Bernard Dallemagne

Clinical results of laparoscopic fundoplication at ten years after surgery

Background:Several studies have demonstrated laparoscopic antireflux surgery (LAS) for the treatment of gastroesophageal reflux disease (GERD) to be efficient at short- and midterm follow-up evaluations. The aim of this study was to evaluate the results for LAS 10 years after surgery.Methods:The 100 consecutive patients who underwent LAS by a single surgeon in 1993 were entered into a prospective database. Nissen fundoplication was performed for 68 patients, and partial posterior fundoplication (modified Toupet procedure) was performed for 32 patients. Evaluations of the outcome were made 5 and 10 years after surgery. A structured symptom questionnaire and upper gastrointestinal barium series were used at 5 years. The same questionnaire and an added quality-of-life questionnaire (the Gastrointestinal Quality of Life Index [GIQLI]) were used at 10 years.Results:Seven patients died of unrelated causes during the 10-year period. Four patients underwent revision surgery: one patient for persistent dysphagia and three patients for recurrent reflux symptoms. Three patients were lost to any follow-up study. At 5 years, 93% of the patients were free of significant reflux symptoms. At 10 years, 89.5% of the patients still were free of significant reflux (93.3% after Nissen, 81.8% after Toupet). Major side effects (flatulence and abdominal distension) were related to “wind” problems. The GIQLI scores at 10 years were significantly better than the preoperative scores of the patients under medical therapy with proton pump inhibitors.Conclusions:Elimination of GERD symptoms improved quality of life and eliminated the need for daily acid suppression in most patients. These results, apparent 5 years after the operation, still were valid at 10 years.

Single-Access Laparoscopic Sigmoidectomy as Definitive Surgical Management of Prior Diverticulitis in a Human Patient

HYPOTHESIS Single-access laparoscopic surgery should offer minimal scarring without compromising surgical outcome. It is enhanced by both innovative port technology and technical expertise learned by developing natural orifice transluminal endoscopic surgery (NOTES). DESIGN Sigmoidectomy in a human via a single laparoscopic port. SETTING University hospital. Patient A 40-year-old woman with previously documented diverticular abscess. INTERVENTIONS The multichannel single port (Triport; Advanced Surgical Concepts, Wicklow, Ireland) was placed at the umbilicus. The sigmoid was retracted by both intraluminal sigmoidoscopy and magnetic anchoring. Mesenteric dissection between the mid-descending colon and the colorectal junction was carried out close to the colon using a Ligasure Advance (Covidien, Valley lab, Norwalk Connecticut). The stapler anvil was passed retrogradely per ano to lie within the descending colon. A linear stapler effected proximal and distal sigmoidal transection. Magnetic attraction then delivered the in situ anvil pike into a colotomy placed adjacent to the proximal staple line. After its position was secured with an endoloop, the pike was mated with its stapler head positioned in the rectal stump. This allowed creation of a double-stapled colorectal anastomosis 10 cm from the anal verge. Specimen retrieval was performed via the umbilical port site. MAIN OUTCOME MEASURES Extent of scarring, occurrence of surgical complications, technical adequacy, and clinical outcome. RESULTS No intraoperative complications occurred during the 90-minute procedure. A total of 40 cm of sigmoid was resected. The patient convalesced without complication and went home 4 days after surgery. At the 1-month review, she was fully recovered and her single umbilical scar was well healed. CONCLUSIONS With advancing surgical technology and technique, truly minimally invasive surgical procedures are feasible. Understanding of NOTES can therefore extend beyond its experimental application into contemporary surgical practice.

Causes of failures of laparoscopic antireflux operations

AbstractBackground: Three factors determine the successful outcome after an antireflux operation for gastroesophageal reflux disease (GERD): indication for surgery, choice of the operative procedure, and quality of the operation. Laparoscopic treatment has not changed these concepts. The factor most likely to have been modified is the technical quality of the operative procedure. We evaluated 26 patients presenting with failure after laparoscopic antireflux surgery to determine the causes. Methods: Nineteen patients came from our series of 503 laparoscopic antireflux procedures and seven patients were referred from other centers. Preoperative, peroperative, and postoperative data were retrospectively reviewed to analyze the responsible factor(s). Results: Nine patients presented with a sphincter mechanism failure to control reflux, 14 patients had severe dysphagia, 3 patients presented with severe epigastric pain. The first operation was a Nissen-Rossetti fundoplication in 17 patients. The technical quality of the operative procedure was the responsible factor in 22/26 patients. The choice of the type of operation was questionable in five patients. Eight patients underwent successful endoscopic treatment, reoperation was necessary in 10 patients. Four patients underwent medical therapy, and four patients had no treatment. Conclusions: The laparoscopic Nissen-Rossetti fundoplication was associated with a higher rate of failures, in terms of recurrent disease or severe dysphagia. The use of this technique was related to the laparoscopic inexperience of the surgeon, leading to a wrong application of the original procedure. Partial posterior fundoplication and total fundoplication with division of the short gastric vessels are obviously associated with a better outcome, if the selection of the operation is based on a strict preoperative physiopathological evaluation of the disease.

Laparoscopic repair of paraesophageal hernia. Long-term follow-up reveals good clinical outcome despite high radiological recurrence rate.

OBJECTIVE The purpose of this report is to evaluate and compare the long-term objective and subjective outcome after laparoscopic paraesophageal hernia repair (LPHR). BACKGROUND Short-term symptomatic results of LPHR are often excellent. However, a high recurrence rate is detected at objective radiographic follow-up. METHODS Retrospective review of a prospectively gathered database of consecutive patients undergoing LPHR with and without reinforced crural repair at a single institution. Subjective and objective outcomes were assessed by using a structured symptoms questionnaire, Gastrointestinal Quality-of-Life Index, satisfaction score, and barium esophagogram. RESULTS From September 1991 to September 2005, LPHR was performed in 85 patients (median age, 66 years) with (25 patients) and without (60 patients) reinforced crural repair. Two patients (3%) underwent laparoscopic reoperation, for severe dysphagia and for symptomatic recurrence, respectively. Subjective outcome, available for 64 patients (75%), improved significantly at median follow-up of 118 months with a postoperative median Gastrointestinal Quality-of-Life Index score of 116. Radiographic recurrence (median follow-up, 99 months) occurred in 23 (66%) of the 35 patients, independently of age at operation, type of paresophageal hiatal hernias, and crural reinforcement, and showed no impact on quality of life. CONCLUSIONS Although providing excellent symptomatic results, long-term objective evaluation of LPHR reveals a high recurrence rate even with reinforced cruroplasty. A tailored, lengthening gastroplasty and reinforced cruroplasty based on objective intraoperative evaluation, and not only on surgeons personal judgment, may be the answer to recurrences.

Natural Orifice Transluminal Endoscopic Surgery: Transgastric Cholecystectomy in a survival porcine model

Beyond doubt, laparoscopic cholecystectomy has changed the focus of surgery and the mind-set of nearly all surgeons. For this reason, the initial natural orifices translumenal endoscopic surgery (NOTES) project focused on cholecystectomy, which seemed to be the most logical and appealing clinical application. The first reports on cholecystectomy confirmed the feasibility of NOTES but identified substantial technical limits because of exposure, endoscope stability issues, and limitations in the control of dissection tools [1, 2]. These limitations led to experimentation with other natural orifice accesses: the colon, the urinary bladder, and combined routes [3, 4]. Although transcolonic cholecystectomy has been reported in survival studies, to date, the feasibility of transgastric cholecystectomy has been described only in nonsurvival animal models [1, 2, 5]. We report the successful performance of transgastric cholecystectomy with survival in a porcine model.

Enhanced-reality video fluorescence: a real-time assessment of intestinal viability.

Objective:Our aim was to evaluate a fluorescence-based enhanced-reality system to assess intestinal viability in a laparoscopic mesenteric ischemia model. Materials and Methods:A small bowel loop was exposed, and 3 to 4 mesenteric vessels were clipped in 6 pigs. Indocyanine green (ICG) was administered intravenously 15 minutes later. The bowel was illuminated with an incoherent light source laparoscope (D-light-P, KarlStorz). The ICG fluorescence signal was analyzed with Ad Hoc imaging software (VR-RENDER), which provides a digital perfusion cartography that was superimposed to the intraoperative laparoscopic image [augmented reality (AR) synthesis]. Five regions of interest (ROIs) were marked under AR guidance (1, 2a-2b, 3a-3b corresponding to the ischemic, marginal, and vascularized zones, respectively). One hour later, capillary blood samples were obtained by puncturing the bowel serosa at the identified ROIs and lactates were measured using the EDGE analyzer. A surgical biopsy of each intestinal ROI was sent for mitochondrial respiratory rate assessment and for metabolites quantification. Results:Mean capillary lactate levels were 3.98 (SD = 1.91) versus 1.05 (SD = 0.46) versus 0.74 (SD = 0.34) mmol/L at ROI 1 versus 2a-2b (P = 0.0001) versus 3a-3b (P = 0.0001), respectively. Mean maximal mitochondrial respiratory rate was 104.4 (±21.58) pmolO2/second/mg at the ROI 1 versus 191.1 ± 14.48 (2b, P = 0.03) versus 180.4 ± 16.71 (3a, P = 0.02) versus 199.2 ± 25.21 (3b, P = 0.02). Alanine, choline, ethanolamine, glucose, lactate, myoinositol, phosphocholine, sylloinositol, and valine showed statistically significant different concentrations between ischemic and nonischemic segments. Conclusions:Fluorescence-based AR may effectively detect the boundary between the ischemic and the vascularized zones in this experimental model.

Challenges and lessons learned from NOTES cholecystectomy initial experience: a stepwise approach from the laboratory to clinical application

BACKGROUND/PURPOSE The initial idea behind natural orifice transluminal endoscopic surgery (NOTES) was that of an incisionless surgery. NOTES cholecystectomy is a good model of human ingenuity and technological advance. NOTES cholecystectomy in a human being was performed at our institution after extensive laboratory work in live pig models. In this process we gained helpful information related to NOTES cholecystectomy. METHODS More than 250 cholecystectomies in pigs have been performed. From May 2007 to November 2008 a total of 10 and 6 transvaginal and transgastric human cholecystectomies, respectively, have been performed. RESULTS The procedure was successful in all patients, with a mean operative time of 120 min. There were no intraoperative or postoperative complications. Patients recovered promptly after surgery and had minor postoperative pain. They were discharged on the second postoperative day. CONCLUSIONS The advantages of laparoscopy appeared to be enhanced by this approach: patients had minor postoperative pain and minimal scarring. This stepwise experience in the cholecystectomy procedure is an important first step in the development of methods and devices to enable the evaluation of potential incisionless NOTES surgery. Additional research and comparison studies are needed for further improvement in order to provide NOTES procedures to a wider range of patients.

EAES recommendations for the management of gastroesophageal reflux disease

BackgroundGastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett’s esophagus, and enteroesophageal and duodenogastroesophageal reflux.MethodsThe European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.ResultsRecommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.ConclusionsSince the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

Transoral endoscopic esophageal myotomy based on esophageal function testing in a survival porcine model

BACKGROUND The most effective treatment of achalasia is Heller myotomy. OBJECTIVE To explore a submucosal endoscopic myotomy technique tailored on esophageal physiology testing and to compare it with the open technique. DESIGN Prospective acute and survival comparative study in pigs (n = 12; 35 kg). SETTING University animal research center. INTERVENTION Eight acute-4 open and 4 endoscopic-myotomies followed by 4 survival endoscopic procedures. MAIN OUTCOME MEASUREMENTS Preoperative and postoperative manometry; esophagogastric junction (EGJ) distensibility before and after selective division of muscular fibers at the EGJ and after the myotomy was prolonged to a standard length by using the EndoFLIP Functional Lumen Imaging Probe (Crospon, Galway, Ireland). RESULTS All procedures were successful, with no intraoperative and postoperative complications. In the survival group, the animals recovered promptly from surgery. Postoperative manometry demonstrated a 50% drop in mean lower esophageal sphincter pressure (LESp) in the endoscopic group (mean preoperative LESp, 22.2 ± 3.3 mm Hg; mean postoperative LESp, 11.34 ± 2.7 mm Hg; P < .005) and a 69% loss in the open procedure group (mean preoperative LESp, 24.2 ± 3.2 mm Hg; mean postoperative LESp, 7.4 ± 4 mm Hg; P < .005). The EndoFLIP monitoring did not show any distensibility difference between the 2 techniques, with the main improvement occurring when the clasp circular fibers were taken. LIMITATIONS Healthy animal model; small sample. CONCLUSION Endoscopic submucosal esophageal myotomy is feasible and safe. The lack of a significant difference in EGJ distensibility between the open and endoscopic procedure is very appealing. Were it to be perfected in a human population, this endoscopic approach could suggest a new strategy in the treatment of selected achalasia patients.

Endoscopic pyloromyotomy: a new concept of minimally invasive surgery for pyloric stenosis.

BACKGROUND AND STUDY AIMS Pyloric stenosis is currently managed using open or laparoscopic pyloromyotomy. However, with recent improvements in flexible endoscopic instrumentation and techniques, totally peroral endoscopic approaches could reduce the invasiveness of myotomic procedures. The aim of the study was to establish the feasibility and efficacy of endoscopic submucosal pyloromyotomy in a porcine model. METHODS Four pigs were included in a preliminary study and a 2-week survival study was performed in another four pigs. An esophagogastroduodenoscope was inserted perorally into the stomach. Saline solution was injected into the submucosal space proximal to the pylorus. The gastric mucosa was incised and a 5-cm submucosal tunnel was created. After exposure of the muscular layer in a submucosal tunnel, myotomy of the circular muscle layer was performed until the longitudinal muscular layer was reached. Once myotomy was completed, endoscopic clips were used to re-approximate the mucosal incision. RESULTS Submucosal dissection, identification of the circular muscular layer, and pyloromyotomy were achieved in all animals. Acute complications such as bleeding and perforation were not observed in any cases. Median pyloric resting pressure was reduced from 16.5 mmHg to 6.1 mmHg immediately after myotomy and 8.4 mmHg at 14 days after myotomy. CONCLUSION Peroral endoscopic submucosal pyloromyotomy appears to be technically feasible and effective. Potential clinical applications, such as for infantile hypertrophic pyloric stenosis or delayed gastric emptying after esophagectomy, could be considered after confirmation of safety in additional survival studies.