Jamil L. Stetler

Surgical Technique for Laparoscopic Removal of a Magnetic Lower Esophageal Sphincter Augmentation Device

BACKGROUND Nissen fundoplication is the current gold standard for surgical management of gastroesophageal reflux disease; however, a magnetic antireflux device is now an alternative surgical procedure. The early literature shows good reflux control with minimal complications, and therefore placement of these devices is growing in popularity. As more of these devices are placed, there will be cases in which they will need to be removed. A laparoscopic method for removing the device is presented here. MATERIALS AND METHODS We present a case of a 42-year-old female with history of gastroesophageal reflux who underwent a laparoscopic placement of a magnetic lower esophageal sphincter augmentation device and repair of a small hiatal hernia. She had a complicated postoperative course before presenting to our institution with a 2-year history of persistent dysphagia and requesting the device be removed. Laparoscopic removal of the device was performed. RESULTS After laparoscopic removal of the patients magnetic lower esophageal sphincter augmentation device, she had subjective improvement in her dysphagia but is now being medically managed for gastroesophageal reflux and for delayed gastric emptying. CONCLUSIONS Laparoscopic removal of magnetic lower esophageal sphincter augmentation devices will sometimes be necessary and may be challenging if the surgeon encounters significant scar tissue around the gastroesophageal junction. Postoperative complications are similar to those encountered with foregut surgeries and include postoperative delayed gastric emptying.

Laparoscopic Heller Myotomy and Hiatal Hernia Repair After Failed Peroral Endoscopic Myotomy

A 45-year-old female who underwent peroral endoscopic myotomy (POEM) presented to the general surgery clinic with recurrent regurgitation and reflux. She underwent POEM 2 years prior and had symptomatic relief for 8 months. Over the past 6 months, she had frequent respiratory infections suspected to be from aspiration. Upper GI study (Fig. 1b) demonstrates esophageal dilatation, disordered contractions, significant spontaneous gastroesophageal reflux into the upper esophagus both consistent with recurrent achalasia. Highresolution manometry demonstrated normal lower esophageal sphincter pressures but absent peristalsis. Esophageal pH testing was normal. An upper endoscopy demonstrated a dilated and mildly tortuous esophagus, but no hiatal hernia was identified. The patient was taken to the operating room for a laparoscopic Heller myotomy. Upon immediate entry to the abdomen, the patient was found to have a moderate sized hiatal hernia (Fig. 2a). There was significant posterior scarring of the esophagus—likely from the prior myotomy—especially to the left sided pleura. Intra-operative endoscopy confirmed the posterior location of the prior myotomy. The prior myotomy site transilluminated and the edges of the myotomy were readily visible (Fig. 2b). We performed a posterior pledgeted hiatal hernia repair, anterior Heller myotomy, and Toupet fundoplication. The patient underwent an upper GI study on POD#1 that demonstrated significant improvement in esophageal emptying (Fig. 1c). The patient’s diet was quickly advanced and she was discharged on POD#2. POEM has been introduced as a treatment for achalasia over the past decade and has good short-term results. Recurrence of symptoms after 39-month follow-up is less than 10% with the only known risk factor for recurrence being male sex. Though there has been significant recent investigation to utilize POEM as a salvage technique for failed operative myotomy, there is a paucity of data regarding laparoscopic myotomy as a treatment for failed POEM. The largest series of laparoscopic myotomy after failed POEM is 11 patients with five successfully treated (45%). Other treatments for recurrent symptoms after failed POEM are pneumatic dilation and repeat POEM with success rates of 20 and 63%, respectively. However, anatomic considerations such as esophageal diverticula or concomitant hiatal hernia—as was the case in our patient—are best treated surgically. To date, there are no reports of performing a concomitant laparoscopic Heller myotomy and hiatal hernia repair after failed POEM. As POEM can be performed in multiple directions, it is important to read prior operative notes to determine if an anterior or porsterior myotomy was performed. In addition, we recommend intra-operative endoscopy to additionally confirm prior myotomy position before performing surgical myotomy and risking esophageal injury. Furthermore, despite being an endoscopic and minimally invasive procedure, surgeons * Christopher G. Yheulon Christopher.yheulon@emory.edu

Publication patterns and the impact of self-citation among minimally invasive surgery fellowships

INTRODUCTION The h-index is a widely utilized academic metric that measures both productivity and citation impact. The purpose of this study is to define the impact of self-citation among minimally invasive surgery (MIS) fellowship program directors. METHODS Through the Fellowship Councils website, all program directors and associate program directors from the 148 MIS fellowship programs were identified. Using the Scopus database, we calculated the number of publications, citations, self-citations, and h-index for each surgeon. RESULTS A total of 274 surgeons were identified. The mean number±SD of publications, citations, and h-index for the cohort were 60.5 ± 77.2, 1765 ± 4024, and 16.0 ± 15.0, respectively. The self-citation rate for the entire cohort was 3.23%. Excluding self-citations reduces the mean number of citations to 1708 ± 3887 and h-index to 15.8 ± 14.6. The h-index remained unchanged for 77% (210/274) of surgeons. Only 5% (15/274) of surgeons had a change in h-index of greater than one integer and no surgeon had a change greater than three integers. CONCLUSION Self-citation is infrequent and has a minimal impact on the academic profile of program directors of MIS fellowships.

Biliary reconstruction options for bile duct stricture in patients with prior Roux-en-Y reconstruction

Comprehensive description with illustrations of the 4 biliary reconstruction options for bile duct injury in patients with history of Roux-en-Y gastric bypass.