J. H. Peters

Risk factors and the prevalence of trocar site herniation after laparoscopic fundoplication

Background: Although there have been case reports describing trocar site herniation after laparoscopic fundoplication, its overall prevalence and the risk factors for its development are unclear. Methods: The records of 320 patients undergoing primary laparoscopic fundoplication as treatment for gastroesophageal reflex disease (GERD) or hiatal hernia between 1991 and 1999 were reviewed retrospectively. Placement of the initial supraumbilical trocar was by the open Hassan technique in all patients. Results: Nine patients (five male) with a mean age 54 years (range, 37-75) developed trocar site herniation, for an overall prevalence of 3%. The mean interval between surgery and diagnosis was 12 months (range, 4-21). In all patients, the hernia occurred at the supraumbilical camera port site. Patients with trocar hernias tended to have a higher body mass index (BMI) than those without hernias (mean BMI, 29.4 kg/m2 vs 27.2 kg/m2, p = 0.13). None of the patients developed intestinal obstruction as a consequence of herniation. To date, all but one of the hernias have been repaired. Six of them required the insertion of a prosthetic mesh. Conclusions: The prevalence of trocar site herniation after laparoscopic fundoplication was minimal at 3%. All hernias occurred at the midline supraumbilical port, the only site where open trocar insertion was employed. As a consequence of these observations, we have developed a new method of open trocar placement. This method utilizes a paramedian skin incision and separate fascial incisions through anterior and posterior rectus sheathes, with retraction of the rectus abdominis muscle laterally.

Predictive factors of coexisting cancer in Barrett’s high-grade dysplasia

BackgroundIdentification of high-grade dysplasia (HGD) in Barrett’s esophagus has been considered an indication for esophagectomy because of the high risk for coexisting cancer. However, rigorous endoscopic surveillance programs recently have been recommended, reserving esophagectomy for patients whose cancer is identified on biopsy. This approach risks continued surveillance for patients who already have cancer unless reliable markers for the presence of occult cancer are identified. This study aimed to determine the endoscopic, histologic, and demographic features associated with the presence of occult cancer in patients with HGD.MethodsEndoscopic, histologic, and demographic findings for 31 patients who underwent esophagectomy for HGD were reviewed. The presence of an ulcer, nodule, stricture, or raised area on preoperative endoscopy was noted. The results of endoscopic biopsies taken before resection every 1 to 2 cm along the Barrett’s segment were reviewed. The HGD was categorized as unilevel if the dysplasia was limited to one level of biopsy and as multilevel if more than one level was involved. Patients were divided into two groups according to the presence or absence of cancer in the resected specimens, and these variables were compared.ResultsThe prevalence of coexisting cancer in patients with HGD was 45% (14/31). Of the 31 patients in this study, 9 had a visible lesion. Cancer was found in the resected specimens from 7 (78%) of 9 patients with a visible lesion and 7 (32%) of 22 patients without a visible lesion (p = 0.019). Of 22 patients without a visible lesion, 10 had multilevel and 12 had unilevel HGD. The findings showed that 6 (60%) of 10 patients with multilevel HGD and 1 (8.3%) of 12 patients with unilevel HGD had cancer in the resected esophagus (p = 0.009).ConclusionFor patients with HGD, a lesion visible on endoscopy and/or HGD at multiple biopsy levels is associated with an increased risk for coexisting cancer. These patients should be considered for early esophagectomy.

Endoscopic augmentation of the cardia with a biocompatible injectable polymer (Enteryx) in a porcine model

Background: Endoscopic approaches to restore the gastroesophageal barrier in patients with gastroesophageal reflux disease (GERD) are presently undergoing clinical trial. The aim of the study was to demonstrate the feasibility, durability, safety, and antireflux efficacy following augmentation of the cardia with a biocompatible injectable polymer (Enteryx). Methods: Augmentation was performed in 12 Yucatan mini-pigs. The cardia was injected circumferentially with 1–1.5 ml of Enteryx at three or four sites. Four groups of three animals each were killed at 2, 6, 12, and 24 weeks following augmentation. Gastrointestinal endoscopy and esophageal manometry were performed preoperatively and postoperatively. Competency was determined as the intragastric pressure (yield pressure) and volume (yield volume) needed during gastric distension with air and water to result in equalization of gastric and esophageal pressure. Comparisons were made with a group of noninjected animals (n = 6). Results: All animals had a normal eating pattern; none showed any evidence of vomiting or regurgitation. The median injection volume was 4 ml (range, 1–8). At autopsy, implants were found in 83% of the animals. Intramuscular placement of the implant was durable, whereas sloughing occurred if the implant was placed submucosally. The mechanical properties of sphincter length and pressure were unaffected by the injection. The median yield pressure of the animals that survived for >6 weeks (21.4 mmHg) was significantly greater (p = 0.049) than the animals that survived for <6 weeks (4.5 mmHg) and greater (p = 0.054) than the control animals (9.1 mmHg), suggesting that the healing process was associated with reduced distensibility of the cardia. Conclusions: Augmentation of the cardia with an injectable polymer (Enteryx) is simple, safe, and durable. Early studies suggest that alteration in the distensibility and geometry of the gastroesophageal junction may provide antireflux protection.

Endoscopic grading of the gastroesophageal valve in patients with symptoms of gastroesophageal reflux disease (GERD).

AbstractBackground: It has been suggested that endoscopic grading of the gastroesophageal flap valve is a good predictor of the reflux status. Methods: To test this hypothesis, 268 symptomatic patients underwent endoscopic grading of the gastroesophageal valve using Hills classification, with grades I through IV. Esophageal acid exposure, lower esophageal sphincter characteristics, and the degree of esophageal mucosal injury were compared among the groups. Results: The prevalence of a mechanically defective sphincter, abnormal esophageal acid exposure, erosive esophagitis, and Barretts esophagus increased with increasing alteration of the gastroesophageal valve. The presence of a grade IV valve indicated increased esophageal acid exposure in 75% of patients. As a predictor, this is similar to lower esophageal sphincter pressure but not as good as the presence of esophageal mucosal injury. Conclusions: Endoscopic grading of the gastroesophageal valve provides useful information about the reflux status but is less useful as an indicator of gastroesophageal reflux disease (GERD) than the presence of esophageal mucosal injury.

A contemporaneous comparison of hospital charges for laparoscopic and open Nissen fundoplication

Surgical treatment of gastroesophageal reflux disease is increasingly recognized as a costeffective alternative to long-term medical therapy. This fact, coupled with the advent of laparoscopic fundoplication as a safe and efficacious alternative to open surgery, underscores the importance of determining the costs associated with laparoscopic treatment.Hospital costs and charges of patients undergoing open (N=9) and laparoscopic (N=11) fundoplication were retrospectively analyzed. Both procedures were performed during the same time period (6/91–6/93), at the same hospital, and by the same surgical team. Operative time, and hospital stay, were recorded in addition to total, operating room, anesthesia, sterile supplies, and hospital room charges. Figures are reported as mean values ± standard error of the mean. The Wilcoxon signed rank test was used for comparison of groups.Operative time (221±18 vs 165±12 min, P=0.033) was longer in the laparoscopic group, while hospital stay (5.8±02 vs 8.8±04 days, P<0.001) was significantly shorter. Total hospital costs were similar for both groups of patients (

Inferior vena caval blood flow and cardiac hemodynamics during carbon dioxide pneumoperitoneum

14,615±863 vs

The safety and usefulness of endoscopy for evaluation of the graft and anastomosis early after esophagectomy and reconstruction

15,891±921, P=0.247). Overall hospital charges were nearly identical (

An intraluminal surgical approach to the management of gastric bezoars

26,634±1376 vs

Ultrasonic epithelial ablation of the lower esophagus without stricture formation. A new technique for Barrett's ablation.

27,189±1753, P=0.803). A detailed analysis demonstrated cost shifting, with laparoscopic fundoplication resulting in significantly higher charges associated with events in the operating room. Operating room (

Redefining gastroesophageal reflux (GER).

6,064±252 vs