Ellen Morrow

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

We sought to assess whether laparoscopic anti-reflux surgery (LARS) is associated with decreased rates of disease progression in patients with idiopathic pulmonary fibrosis (IPF). The study was a retrospective single-centre study of IPF patients with worsening symptoms and pulmonary function despite antacid treatment for abnormal acid gastro-oesophageal reflux. The period of exposure to LARS was September 1998 to December 2012. The primary end-point was a longitudinal change in forced vital capacity (FVC) % predicted in the pre- versus post-surgery periods. 27 patients with progressive IPF underwent LARS. At time of surgery, the mean age was 65 years and mean FVC was 71.7% pred. Using a regression model, the estimated benefit of surgery in FVC % pred over 1 year was 5.7% (95% CI −0.9–12.2%, p=0.088) with estimated benefit in FVC of 0.22 L (95% CI −0.06–0.49 L, p=0.12). Mean DeMeester scores decreased from 42 to 4 (p<0.01). There were no deaths in the 90 days following surgery and 81.5% of participants were alive 2 years after surgery. Patients with IPF tolerated the LARS well. There were no statistically significant differences in rates of FVC decline pre- and post-LARS over 1 year; a possible trend toward stabilisation in observed FVC warrants prospective studies. The ongoing prospective randomised controlled trial will hopefully provide further insights regarding the safety and potential efficacy of LARS in IPF. Laparoscopic anti-reflux surgery is well tolerated in IPF, with a nonsignificant trend towards decreased FVC decline http://ow.ly/BspI300pbJh

Laparoscopic gastric bypass during left ventricular assist device support and ventricular recovery

The prevalence of obesity and heart failure is increasing in the United States. Heart transplant is contraindicated in morbidly obese patients due to poor outcomes. Bariatric surgery may increasingly be considered for patients with heart failure to achieve transplant eligibility and improve cardiac function. A 54-year-old man with non-ischemic dilated cardiomyopathy underwent left ventricular assist device (LVAD) placement with a HeartMate II (Thoratec Corp, Pleasanton, CA) in December 2010 for New York Heart Association Class IV heart failure symptoms and inotrope dependence. The patient was not eligible for heart transplant due to morbid obesity, with a body mass index (BMI) of 41 kg/m. Other

Laparoscopic paraesophageal hernia repair.

Laparoscopic paraesophageal hernia repair is an operation that allows for relief of gastrointestinal and respiratory symptoms with a minimal recovery time and a high degree of satisfaction. It is a difficult and complex operation; however, if the important tenets are adhered to by surgeons with a lot of experience in laparoscopic PEH repair, the results are good. Patient selection is important. Older or frail patients who are asymptomatic should not have an operation, and some who are very symptomatic should probably consider just a reduction of their gastric volvulus and gastropexy. Still, most of the patients will be symptomatic and will be able to tolerate a laparoscopic definitive repair. The important aspects of repair include: complete resection of the hernia sac from the mediastinum, adequate esophageal mobilization, adequate closure of the hiatus, and fundoplication. The most troublesome aspect of the operation is the recurrence rate, which is up to 50% at 5 years of follow-up. Fortunately, most recurrences are asymptomatic and the vast majority of patients still have greatly improved quality of life.

Laparoscopic anti-reflux surgery for the treatment of idiopathic pulmonary fibrosis (WRAP-IPF): a multicentre, randomised, controlled phase 2 trial

BACKGROUND Abnormal acid gastro-oesophageal reflux (GER) is hypothesised to play a role in progression of idiopathic pulmonary fibrosis (IPF). We aimed to determine whether treatment of abnormal acid GER with laparoscopic anti-reflux surgery reduces the rate of disease progression. METHODS The WRAP-IPF trial was a randomised controlled trial of laparoscopic anti-reflux surgery in patients with IPF and abnormal acid GER recruited from six academic centres in the USA. We enrolled patients with IPF, abnormal acid GER (DeMeester score of ≥14·7; measured by 24-h pH monitoring) and preserved forced vital capacity (FVC). We excluded patients with a FVC below 50% predicted, a FEV1/FVC ratio of less than 0·65, a history of acute respiratory illness in the past 12 weeks, a body-mass index greater than 35, and known severe pulmonary hypertension. Concomitant therapy with nintedanib and pirfenidone was allowed. The primary endpoint was change in FVC from randomisation to week 48, in the intention-to-treat population with mixed-effects models for repeated measures. This trial is registered with ClinicalTrials.gov, number NCT01982968. FINDINGS Between June 1, 2014, and Sept 30, 2016, we screened 72 patients and randomly assigned 58 patients to receive surgery (n=29) or no surgery (n=29). 27 patients in the surgery group and 20 patients in the no surgery group had an FVC measurement at 48 weeks (p=0·041). Intention-to-treat analysis adjusted for baseline anti-fibrotic use demonstrated the adjusted rate of change in FVC over 48 weeks was -0·05 L (95% CI -0·15 to 0·05) in the surgery group and -0·13 L (-0·23 to -0·02) in the non-surgery group (p=0·28). Acute exacerbation, respiratory-related hospitalisation, and death was less common in the surgery group without statistical significance. Dysphagia (eight [29%] of 28) and abdominal distention (four [14%] of 28) were the most common adverse events after surgery. There was one death in the surgery group and four deaths in the non-surgery group. INTERPRETATION Laparoscopic anti-reflux surgery in patients with IPF and abnormal acid GER is safe and well tolerated. A larger, well powered, randomised controlled study of anti-reflux surgery is needed in this population. FUNDING US National Institutes of Health National Heart, Lung and Blood Institute.

Laparoscopic simulation for surgical residents in Ethiopia: course development and results

BACKGROUND We aimed to develop and implement a laparoscopic skills curriculum in an Ethiopian surgical residency program. We hypothesized that residents would improve with practice. METHODS We developed a laparoscopic curriculum by adapting existing training models. Six courses were conducted during 2012 and 2013 in a teaching hospital in Ethiopia. Eighty-eight surgical residents participated. Main outcome measures were laboratory task completion times and student survey responses. RESULTS Students showed improvement in time needed to complete skills tasks with practice. Mean times improved for all 5 tasks (P ≤ .01). Students uniformly reported that the course was valuable. The curriculum is now taught and sustained by local faculty. CONCLUSIONS The development and implementation of a collaborative and sustainable laparoscopic curriculum is possible in a low-resource environment. Such a curriculum can result in improved laparoscopic expertise, surgical trainee satisfaction, and may increase utilization of laparoscopy.

Dual Ring Wound Protector Reduces Circular Stapler Related Surgical Site Infections in Patients Undergoing Laparoscopic Roux-En-Y Gastric Bypass

BackgroundWhile there are various techniques to create the gastrojejunostomy during a laparoscopic Roux-en-Y gastric bypass (LRYGB), many surgeons prefer using a circular stapler. One drawback of this method, however, is the higher incidence of surgical site infections (SSIs). To investigate the effect of a dual ring wound protector on SSIs during LRYGB.MethodsIn April 2016, our bariatric surgical group implemented an intervention whereby a dual ring wound protector in conjunction with a conical EEA stapler introducer was used when creating the gastrojejunostomy. SSIs from pre- and post-intervention were compared using Fisher’s exact test. Only LRYGBs performed with a circular stapler were included in our analysis. Student’s t test and χ2 were used to compare pre- and post-intervention groups with respect to demographics and co-morbidities.ResultsBetween April 2015 and January 31st, 2017, our surgeons performed 158 LRYGBs using a circular stapler for the gastrojejunostomy. There were 84 patients (53%) in the pre-intervention group and 74 (47%) in the post-intervention group. The pre- and post-intervention groups were not statistically different. The SSI rate for the pre-intervention group was 9.5% while the SSI rate was 1.35% in the post-intervention group (p = 0.0371). The use of a dual ring wound protector for LRYGBs with circular stapled gastrojejunostomy was associated with an 86% relative risk reduction in SSIs.ConclusionUsing a dual ring wound protector in conjunction with a conical EEA introducer for LRYGBs with circular stapled gastrojejunostomy significantly decreased SSIs.

General Issues of Hiatal Hernias

The esophagogastric junction and the esophageal hiatus represent an anatomic unit which functionally resembles the lower esophageal sphincter (LES) [6, 7]. Furthermore, the LES must also be regarded as one functional unit together with the tubular esophagus and the upper esophageal sphincter (UES). Acknowledgment of these functional units seems of crucial importance for hiatal hernia surgery, due to the important effects on esophageal function, i.e., esophageal emptying and antireflux mechanisms.

Hiatal Hernia Repair in Difficult Pathologic-Anatomic Situations at the Hiatus

Laparoscopic fundoplication is safe and effective and currently is considered as the “gold standard” surgical treatment for GERD with a success rate of about 80–95%. Due to lack of proper definition, different criteria like relief of GERD symptoms, improvement in quality of life, avoidance of postoperative complications, and patient satisfaction were considered. Patients sometime report symptoms strongly suggesting that of recurrence but with no objective evidence of reflux by pH study. There are various mechanisms described for recurrence, transdiaphragmatic herniation of wrap being the most common mechanism after laparoscopic repair. If symptoms are not effectively managed by PPIs or affecting quality of life, redo surgery is advisable and can be completed laparoscopically with results comparable to primary surgery with little increase in risk of recurrence.

Hiatushernienoperation bei schwierigen pathologisch-anatomischen Situationen am Hiatus

Das nachfolgende Kapitel beschreibt mit der Rezidivhiatushernie und mit der Hiatushernie bei adiposen Patienten den Umgang mit pathologisch-anatomisch schwierigen Situationen am Hiatus. Der Fokus liegt in beiden Fallen auf geeignetem chirurgischem Management. Fur Rezidivhernien werden zusatzlich noch Risikofaktoren (z. B. verkurzter Osophagus), klinische Symptomatik (z. B. Aufstosen und Schluckbeschwerden) und mogliche Mechanismen der Rezidiventstehung (haufig aufgrund von Problemen mit der Manschette) erlautert.

Watchful waiting versus elective repair for asymptomatic and minimally symptomatic paraesophageal hernias: A cost-effectiveness analysis

OBJECTIVE To evaluate the decision of watchful waiting (WW) versus elective laparoscopic hernia repair (ELHR) for minimally symptomatic paraesophageal hernias (PEH) with respect to cost-effectiveness. BACKGROUND The current recommendation for minimally symptomatic PEHs is watchful waiting. This standard is based on a decision analysis from 2002 that compared the two strategies on quality-adjusted life-years (QALYs). Since that time, the safety of ELHR has improved. A cost-effectiveness study for PEH repair has not been reported. METHODS A Markov decision model was developed to compare the strategies of WW and ELHR for minimally symptomatic PEH. Input variables were estimated from published studies. Cost data was obtained from Medicare. Outcomes for the two strategies were cost and QALYs. RESULTS ELHR was superior to the WW strategy in terms of quality of life, but it was more costly. The average cost for a patient in the ELHR arm was 11,771 dollars while for the WW arm it was 2207. CONCLUSION This study shows that WW and ELHR both have benefits in the management of minimally symptomatic paraesophageal hernias.