Carlos Galvani

Robotic-assisted heller myotomy versus laparoscopic heller myotomy for the treatment of esophageal achalasia: multicenter study

Laparoscopic Heller myotomy (LHM) has become the standard treatment option for achalasia. The incidence of esophageal perforation reported is about 5%–10%. Robotically assisted Heller myotomy (RAHM) is emerging as a safe alternative to LHM. Data comparing the two approaches are scant. The aim of this study was to compare RAHM with LHM in terms of efficacy and safety for treatment of achalasia. A total of 121 patients underwent surgical treatment of achalasia at three institutions. A retrospective review of prospectively collected perioperative data was performed. Patients were divided into two groups: group A (RAHM), 59 patients, and group B (LHM), 62 patients. All the operations were completed using minimally invasive techniques. There were 63 women and 58 men, with a mean age of 45 ±19 years (14–82 years). Fifty-one percent of patients in group A and 95% of patients in group B reported weight loss. Duration of symptoms was equal for both groups. Dysphagia was the main complaint in both groups (P = NS). There was no difference in preoperative endoscopic treatment in both groups (44% versus 27%, P = NS). Operative time was significantly shorter for LHM in the first half of the experience (141 ± 49 versus 122 ± 44 minutes, P < .05). However, in the last 30 cases there was no difference in operative time between the groups (P = NS). Intraoperative complications (esophageal perforation) were more frequent in group B (16% versus 0%). The incidence of postoperative heartburn did not differ by group. There were no deaths. At 18 and 22 months, 92% and 90% of patients had relief of their dysphagia. This study suggests that RAHM is safer than LHM, because it decreases the incidence of esophageal perforation to 0%, even in patients who had previous treatment. At short-term follow-up, relief of dysphagia was equally achieved in both groups.

Decreased serum hepcidin and improved functional iron status 6 months after restrictive bariatric surgery

Excess adiposity is associated with low‐grade inflammation and decreased iron status. Iron depletion in obesity is thought to be mediated by an inflammation‐induced increase in the bodys main regulator of iron homeostasis, hepcidin. Elevated hepcidin can result in iron depletion as it prevents the release of dietary iron absorbed into the enterocytes, limiting replenishment of body iron losses. Weight reduction is associated with decreased inflammation; however, the impact of reduced inflammation on iron status and systemic hepcidin in obese individuals remains unknown. We determined prospectively the impact of weight loss on iron status parameters, serum hepcidin, inflammation, and dietary iron in 20 obese premenopausal females 6 months after restrictive bariatric surgery. At baseline, the presence of iron depletion was high with 45% of the women having serum transferrin receptor (sTfR) >28.1 nmol/l. Differences between baseline and 6 months after surgery for BMI (47.56 vs. 39.55 kg/m2; P < 0.0001), C‐reactive protein (CRP) (10.83 vs. 5.71 mg/l; P < 0.0001), sTfR (29.97 vs. 23.08 nmol/l; P = 0.001), and serum hepcidin (111.25 vs. 31.35 ng/ml; P < 0.0001) were significantly lower, whereas hemoglobin (Hb) (12.10 vs. 13.30 g/dl; P < 0.0001) and hematocrit (Hct) (36.58 vs. 38.78%; P = 0.001) were significantly higher. Ferritin and transferrin saturation (Tsat) showed minimal improvement at follow‐up. At baseline, hepcidin was not correlated with sTfR (r = 0.02); however, at follow‐up, significant correlations were found (r = −0.58). Change in interleukin‐6 (IL‐6) from baseline was marginally associated with decreased log serum hepcidin (Δ IL‐6: β = −0.22; P = 0.15), whereas change in BMI or weight was not. No significant difference in dietary iron was noted after surgery. Weight loss in obese premenopausal women is associated with reduced serum hepcidin and inflammation. Reduction in inflammation and hepcidin likely allow for enhanced dietary iron absorption resulting in an improved functional iron profile.

Laparoscopic adjustable gastric band versus laparoscopic Roux-en-Y gastric bypass: ends justify the means?

BackgroundIn the United States, the most frequently performed bariatric procedure is the Roux-en-Y gastric bypass (RYGB). Worldwide, the most common operation performed is the laparoscopic adjustable gastric band (LAGB). The expanding use of LAGB is probably driven by the encouraging data on its safety and effectiveness, in contrast to the disappointing morbidity and mortality rates reported for RYGB. The aim of this study was to evaluate the results of LAGB versus RYGB at a single institution.MethodsBetween November 2000 and July 2004, 590 bariatric procedures were performed. Of these, 120 patients (20%) had laparoscopic RYGB and 470 patients (80%) had LAGB. A retrospective review was performed.ResultsIn the LAGB group, 376 patients (80%) were female, and the mean age was 41 years (range, 17–65). In the RYGB group, 110 patients (91%) were female, and the mean age was 41 years (range, 20–61). Preoperative body mass index was 47 ± 8 and 46 ± 5, respectively (p = not significant). Operative time and hospitalization were significantly shorter in LAGB patients (p < 0.001). Complications and the need for reoperation were comparable in both groups. Weight loss at 12, 18, 24, and 36 months for LAGB and RYGB was 39 ± 21 versus 65 ± 13, 39 ± 20 versus 62 ± 17, 45 ± 25 versus 67 ± 8, and 55 ± 20 versus 63 ± 9, respectively.ConclusionsThe current study demonstrates that LAGB is a simpler, less invasive, and safer procedure than RYGB. Although mean percentage excess body weight loss (%EBWL) in RYGB patients increased rapidly during the first postoperative year, it remained nearly unchanged at 3 years. In contrast, in LAGB patients weight loss was slower but steady, achieving satisfactory %EBWL at 3 years. Therefore, we believe that LAGB should be considered the initial approach since it is safer than RYGB and is very effective at achieving weight loss.

Short-term outcome in the first 10 morbidly obese adolescent patients in the FDA-approved trial for laparoscopic adjustable gastric banding

Background: We received the LAP-BAND Investigational Device Exemption (IDE) from the US Food and Drug Administration in December 2004 to conduct a prospective longitudinal trial examining the safety and efficacy of laparoscopic adjustable gastric banding (LAGB) in morbidly obese adolescents ages 14 to 17 years. Objectives: To report the short-term results of LAGB in the first 10 adolescents with complete 9 months of follow-up. Patients and Methods: Baseline characteristics and outcome data were analyzed in 10 patients enrolled between March 2005 and February 2006. Results: All of the patients were girls. Their mean body mass index (±SD) was 50 ± 13 kg/m2, and excess weight was 171 ± 79 pounds. Comorbidities included depression (3 patients), sleep apnea (3), hypertension (6), dyslipidemia (7), insulin resistance (9), metabolic syndrome (9), and steatohepatitis (in 4 of 5 patients with liver biopsy). Operative time was 45 ± 9 minutes, and discharges were within 23 hours of surgery. Band-related complications were as follows: 2 dehydration, 1 pouch dilation, and 1 port revision. All of the patients lost weight, with a 9-month excess weight loss of 30% ± 16% (range 14%–57%). Hypertension and the metabolic syndrome were resolved in 100% of patients (P = 0.04) and 80% of the patients (P = 0.01), respectively, along with significant improvement in the Pediatric Quality of Life and Beck Depression Inventory scores and a trend toward improvement in high-density lipoprotein cholesterol abnormalities (P = 0.08). Conclusions: At short-term follow-up, weight loss occurred with minimal complications, leading to early resolution of major obesity-related comorbidities. Continued evaluation of the long-term safety and efficacy of LAGB as a surgical adjunct to a comprehensive obesity treatment program is warranted.

Laparoscopic Heller myotomy for achalasia facilitated by robotic assistance

BackgroundLaparoscopic Heller myotomy is the standard operation for achalasia. The incidence of esophageal perforation is approximately 5% to 10%. Data about the safety and utility of robotically assisted Heller myotomy (RAHM) are scarce. The aim of this study was to assess the efficacy and safety of RAHM for the treatment of esophageal achalasia.MethodsFrom a prospectively maintained database, demographic data, symptoms, esophagograms, manometries, and perioperative data from all the RAHMs performed between September 2002 and February 2004 were analyzed.ResultsA total of 54 patients underwent RAHM, including 26 men. The mean age of these patients was 43 years (range, 14–75 years). Dysphagia was present in 100% of the patients. Of the 54 patients, 26 (48%) had undergone previous treatment including pneumatic dilation (17 patients), Botox injections (4 patients), or both of these treatments (5 patients). The dissection was performed laparoscopically, and the myotomy was performed with robotic assistance. The operative time, including the robot setup time, averaged 162 min (range, 62–210 min). Blood loss averaged 24 ml. No mucosal perforations were observed. The hospital length of stay was 1.5 days. There were no deaths. At 17 months, 93% of the patients had relief of their dysphagia.ConclusionsThe findings showed RAHM to be safe and effective, with a 0% incidence of perforation and relief of symptoms for 91% of the patients.

Routine left robotic‐assisted laparoscopic donor nephrectomy is safe and effective regardless of the presence of vascular anomalies

The classic approach to donor nephrectomy consists of preferential procurement of the kidney without vascular anomalies. We studied the effect of routine procurement of the left kidney regardless the presence of multiple arteries on the outcomes of robotic‐assisted laparoscopic living donor nephrectomy (LLDN) with particular reference to the incidence of urological complications. From August 2000 to July 2005, 209 left LLDNs were performed. We analyzed the outcomes of donors and recipients in relation to the presence of multiple vessels versus normal anatomy. We divided the patients into two groups: group A (n = 148) with normal vascular anatomy and group B (n = 61) with vascular anomalies. In the donors, no significant difference in conversion to open surgery rate, blood loss, length of stay, was noted between the two groups; operative time and warm ischemia time were slightly higher in group B. One‐year patient survival was 98% in both groups while the 1‐year graft survival was 96.6% in group A and 96% in group B. Only one urological complication was noted in the group with normal anatomy (0.7%) versus none in the group with multiple arteries. Left kidney procurement using robotic‐assisted laparoscopic technique is safe and effective, even in the presence of vascular anomalies.

Single-incision sleeve gastrectomy using a novel technique for liver retraction.

Single incision laparoscopic access appears to be a safe, feasible technique for performing laparoscopic sleeve gastrectomy.

Initial experience with the adjustable gastric band in morbidly obese US adolescents and recommendations for further investigation.

Background: The public health crisis of obesity has spread to the pediatric population. In morbidly obese (MO) adolescents, early weight loss intervention can reduce and prevent obesity-related comorbidities and mortality and improve quality of life. The present study was performed to evaluate weight loss efficacy and safety of “off-label” laparoscopic adjustable gastric banding (LAGB) procedures performed in MO adolescents by our adult bariatric program. Patients and Methods: We retrospectively reviewed data from 716 LAGB procedures performed on an off-label basis in adults and 24 adolescent patients ages 14 to 20 years by the adult bariatric program at our institution between 2001 and 2006. Results: There was no mortality. Average operative time was 45 minutes, length of stay for adolescents was 15 hours, and weight loss outcome and overall surgical complication rates are comparable between adolescents and adults. For adolescent subjects, baseline mean preoperative body mass index was 49 kg/m2 and average excess weight loss rates were 22%, 34%, 52%, 42%, and 42% at 3, 6, 12, 24, and 36 months, respectively. The overall complication rate was 29%, with a 25% incidence of pouch enlargement in adolescents (vs 18% in adult patients; P = ns). Two of 24 adolescent patients (8.4%) required laparoscopic band repositioning (vs 1.5% of adult patients; P = 0.06). Conclusions: LAGB is an effective and safe surgical weight loss modality for MO adolescent subjects. Vigilant follow-up for LAGB-related complications and intensive postoperative behavioral management are important for improving long-term success. We recommend continued investigation of long-term efficacy and safety of LAGB in this population.

Fully Robotic-Assisted Technique for Total Pancreatectomy with an Autologous Islet Transplant in Chronic Pancreatitis Patients: Results of a First Series

Received November 7, 2013; Revised December 3, 2 December 9, 2013. From the Section of Minimally Invasive and Robotic Su Samame), Institute for Cellular Transplantation (Rilo), a Transplantation and Hepatopancreaticobiliary Surgery (P Gruessner), Department of Surgery, University of Arizona, Correspondence address: Carlos A Galvani, MD, Section Invasive and Robotic Surgery, Department of Surgery, Arizona, College of Medicine, 1501 N Campbell Ave, PO Tucson, AZ 85724-5066. email: cgalvani@surgery.arizona.e

Intensive laparoscopic training course for surgical residents: program description, initial results, and requirements

IntroductionThe Department of Surgery at the University of Arizona has created an intensive laparoscopic training course for surgical residents featuring a combined simulation laboratory and live swine model. We herein report the essential components to design and implement a rigorous training course for developing laparoscopic skills in surgical residents.Materials and methodsAt our institution, we developed a week-long pilot intensive laparoscopic training course. Six surgical residents (ranging from interns to chief residents) participate in the structured, multimodality course, without any clinical responsibilities. It consists of didactic instruction, laboratory training, practice in the simulation laboratory, and performance (under the direction of attending laparoscopic surgeons) of surgical procedures on pigs. The pigs are anesthetized and attended by veterinarians and technicians, and then euthanized at the end of each day. Three teams of two different training-level residents are paired. Daily briefing, debriefing, and analysis are performed at the close of each session. A written paper survey is completed at the end of the course.ResultsThis report describes the results of first 36 surgical residents trained in six courses. Preliminary data reveal that all 36 now feel more comfortable handling laparoscopic instruments and positioning trocars; they now perform laparoscopic surgery with greater confidence and favor having the course as part of their educational curriculum.ConclusionA multimodality intensive laparoscopic training course should become a standard requirement for surgical residents, enabling them to acquire basic and advanced laparoscopic skills on a routine basis.