Carlos A. Pellegrini

Systematic use of gastric fundoplication in laparoscopic repair of paraesophageal hernias.

BACKGROUNDnEarly surgical treatment has been recommended in patients with paraesophageal hiatal hernias. Recently, the laparoscopic approach has emerged as an ideal way to perform the operation. But whether or not an antireflux procedure should be done remains controversial.nnnPATIENTS AND METHODSnFour patients with type II and eleven with type III hiatal hernias were treated. Twelve of them manifested symptoms of reflux preoperatively. The operative technique consisted of resection of the sac, closure of the crura and gastric fundoplication, anchored to the diaphragm.nnnRESULTSnAll but two patients were completed laparoscopically. Mean operative time was 320 (+/-49 SD) minutes, and mean hospital stay was 3 (+/-1.2 SD) days. Early postoperative complications were subcutaneous emphysema (two patients) and atrial fibrillation (one patient). At one year all patients were asymptomatic without dysphagia, reflux, or recurrence of the hernia.nnnCONCLUSIONnThe addition of fundoplication to paraesophageal hernia repair restores competency of the sphincter in patients with reflux associated to the hernia and prevents postoperative gastroesophageal reflux that results from the extensive dissection required. In addition, it provides an ideal means of fixing the stomach in the subdiaphragmatic position, decreasing the long term-risk of recurrence.

Robotic surgery: Identifying the learning curve through objective measurement of skill

Background: The incorporation of new devices into surgical practice often requires that surgeons acquire and master new skills. We studied the learning curve for intracorporeal knot tying in robotic surgery. Methods: We developed an objective scoring system to evaluate knot tying and tested eight attending surgeons during 3 weeks of training on a surgical robot. Each performed intracorporeal knot tying tasks both before and after robotic skills training. These performances were compared to their laparoscopic knots and analyzed to determine and define skill improvement. Results: Baseline laparoscopic knot completion took 140 sec (range, 47–432), with a mean composite score of 77 (100 possible), whereas robotic knot tying took 390 sec, with a mean composite score of 40. After initial robotic training, times decreased by 65% to 139 sec and scores increased to 71. With more training, completion times and composite scores were improved and errors were reduced. Conclusion: Like any new technology, surgical robotics requires dedicated training to achieve mastery. Initially, even experienced laparoscopists may register an inferior performance. However, after adequate training, surgeons can exceed their laparoscopic performance, completing intracorporeal knots better and faster using robotics.

A clinical outcome and cost analysis of laparoscopic versus open appendectomy

BACKGROUNDnBenefits of laparoscopic appendectomy are controversial, and the results of recent clinical studies have contradictory conclusions. We performed a cost analysis comparing laparoscopic and open appendectomies to assess potential efficacy of the laparoscopic approach.nnnMETHODSnAll patients operated on for suspected acute appendicitis at the University of Washington Medical Center (UWMC) from January 1, 1991 through January 1, 1995 were analyzed. Potential benefits of the laparoscopic approach were examined in five major categories: hospital length of stay, total hospital charges, operative time, operating room charges, and postoperative complications. Patients were stratified according to the presence or absence of perforation for outcome analysis.nnnRESULTSnThere were 163 appendectomies performed in 82 men and 81 women. Twenty-seven (17%) patients had laparoscopic evaluation, of which 21 underwent attempted laparoscopic appendectomy. Among nonperforated patients, laparoscopic appendectomy did not reduce hospital stay compared with open appendectomy, but did lead to greater hospital charges (

Long-term outcome of esophagectomy for high-grade dysplasia or cancer found during surveillance for barrett’s esophagus

7760 vs

Clinical presentation and evaluation of malignant pseudoachalasia.

5064; P < 0.001). Operating times were longer in the laparoscopic group (104 vs 74 minutes; P < 0.001) compared with open appendectomies. Operating room charges for laparoscopic appendectomies exceeded charges for the open approach (

Pharyngeal pH measurements in patients with respiratory symptoms before and during proton pump inhibitor therapy

4740 vs

Laparoscopic anti-reflux surgery for idiopathic pulmonary fibrosis at a single centre

1870; P < 0.001). Complication rates were similar (laparoscopic, 19% vs open, 16%; NS). The false diagnostic rate for women was four times greater than for men among patients undergoing open appendectomy (31% vs 8%; P < 0.01). Patients with perforation undergoing a midline incision had a longer hospital stay (9.5 vs 5.9; P < 0.02) than patients operated on through a right lower quadrant incision.nnnCONCLUSIONSnIn our analysis, laparoscopic appendectomy, while safe, was more expensive and was not associated with better clinical outcome compared with open appendectomy patients.

Laparoscopy as the initial approach for epiphrenic diverticula

Endoscopic surveillance is recommended for patients with Barrett’s esophagus to detect high-grade dys-plasia (HGD) or cancer. We studied the outcome of esophagectomy in a cohort of patients who devel-oped HGD or cancer between 1995 and 2003 while under surveillance for Barrett’s. Outcomes were measured by analysis of clinical records, symptom questionnaire, and SF-36 (version 2). In 34 patients, mean surveillance time was 48 months (range, 4–132); the mean number of endoscopies was 10 (range, 3–30). Preoperative diagnosis was HGD in 9 patients (26.5%), carcinoma in situ in 16 (47%), and ad-enocarcinoma in 9 (26.5%). There was no esophagectomy-related mortality; 10 patients (29%) had com-plications. At mean follow-up of 46 months (range, 13–108), SF-36 (version 2) results showed quality of life scores equal to or better than those of healthy individuals. Incidence and severity scores (VAS 1–10) for postoperative symptoms were reflux, 59% (2.8); dysphagia, 28% (3.7); bloating, 45% (2.6); nausea, 28% (2.1); and diarrhea, 55% (2.5). Twenty-nine patients (85%) have no clinical, radiographic, or en-doscopic evidence of recurrent esophageal cancer or metastasis. One patient has metastatic disease. En-doscopic surveillance in Barrett’s patients yields malignant lesions at an early, generally curable, stage. Esophagectomy is curative in the great majority and can be accomplished with minimal mortality and excellent quality of life.

Improving accuracy in identifying the gastroesophageal junction during laparoscopic antireflux surgery.

Malignant pseudoachalasia can be indistinguishable from primary achalasia on routine clinical evaluation, often resulting in a delay in diagnosis. To better define the clinical features and appropriate management of this disease, the course of five patients discovered to have pseudoachalasia after being referred for a minimally invasive Heller myotomy was reviewed, as were 67 cases of pseudoachalasia previously reported in the literature. Patients with an occult malignancy tended to present with shorter durations of symptoms, greater weight loss, and at a more advanced age than patients with primary achalasia. Since contrast radiography and endoscopy frequently failed to differentiate these two diseases, persons with presumed achalasia meeting these criteria who are referred for minimally invasivesurgery should undergo additional imaging to rule out an occult malignancy, since this condition can not be reliably detected during the course ofa thoracoscopic or laparoscopic esophagomyotomy.

Will There Be A Good General Surgeon When You Need One

BACKGROUNDnPharyngeal pH monitoring is a diagnostic tool used to identify Gastroesophageal reflux disease (GERD) as an etiology of respiratory symptoms. We performed pharyngeal pH monitoring on 14 patients with respiratory symptoms thought to be induced by GERD.nnnMETHODSnSymptoms and pH monitoring (esophageal and pharyngeal) were assessed prior to and 3 months after the initiation of double-dose proton pump inhibitor therapy.nnnRESULTSnSymptoms included cough, hoarseness, and throat clearing. Ten patients had at least one episode of pharyngeal reflux (PR+) and 4 patients had no pharyngeal reflux (PR-). Pharyngeal reflux episodes in PR+ patients decreased from 3.5 to 0.9 (P <0.05) per day with 8 of 10 (80%) patients having elimination or reduction of such episodes. Eight of 9 PR+ patients (89%) with suppressed pharyngeal reflux on medical therapy had resolution of respiratory symptoms. Three of 4 PR- patients (75%) had persistent symptoms on medical therapy.nnnCONCLUSIONSnProton pump inhibitor therapy improves clinical symptoms and decreases pharyngeal reflux episodes in patients with respiratory symptoms related to GERD. Direct measurement of pharyngeal pH is helpful in the identification of patients likely to respond to antireflux therapy.