Ryan C. Broderick

Magnetic lower esophageal sphincter augmentation device removal

Implantation of a magnetic lower esophageal sphincter augmentation device is now an alternative to fundoplication in the surgical management of gastroesophageal reflux disease (GERD). Although successful management of GERD has been reported following placement of the device, there are instances when device removal is needed. The details of the technique for laparoscopic magnetic lower esophageal sphincter device removal are presented to assist surgeons should device removal become necessary.

Intraoperative Endoscopic Botox Injection During Total Esophagectomy Prevents the Need for Pyloromyotomy or Dilatation

BACKGROUND Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage. MATERIALS AND METHODS We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality. RESULTS From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P < .05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P < .05). CONCLUSION Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy.

Training and Credentialing in Robotics

Since the introduction of robotics in minimally invasive surgery in the 1990s, many new devices and advances in technique have been developed. In addition, access and exposure have been increasing, with currently more than 3266 da Vinci Surgical Systems (dVSS, Intuitive Surgical, Sunnyvale, CA) in hospitals worldwide accounting for 570,000 procedures in 2014 [1]. Overall, the use of robotics in minimally invasive surgery has reportedly produced significant improvement in many aspects of surgery, including decreased postoperative pain, decreased physiologic insult, faster recovery times, and improved cosmesis [2–4]. Compared to laparoscopic surgery, robotic surgery provides better visualization and dexterity in many situations. Patient demand, physician demand, and industry involvement have driven the advancement of both laparoscopic and robotic surgery. The trend toward minimally invasive techniques in general, and robotics in particular, has significantly altered the focus and characteristics of surgical training programs. Open surgical training, and the Fundamentals of Laparoscopic Surgery (FLS) curriculum, is now required by governing bodies such as the Accreditation Council for Graduate Medical Education (ACGME) to obtain board certification and has been vetted as safe and effective surgical training [5–13]. With the rapid expansion of robotics in general surgery and surgical subspecialties, the education and certification materials are not as well developed nor as well regulated as earlier surgical techniques (e.g., laparoscopic surgery). Similar to laparoscopic surgery training, the future of robotic surgery training should feature objective metrics in a curriculum that can be broadly applied across training institutions and also allow for specific subspecialty training.

Erratum to: Reoperation rates after laparoscopic fundoplication

There is a shared first authorship between the first two authors, T. Zhou and C. Harnsberger, as both contributed equally to this paper. The affiliation for T. Zhou should be: Department of General Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, San Diego, CA, USA The affiliation for C. Harnsberger, R. Broderick, H. Fuchs, G. Jacobsen, S. Horgan, D. Chang, B. Sandler should be: Department of General Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, San Diego, CA, USA The affiliation for M. Talamini should be: Department of Surgery, Health Sciences Center T19-020, Stony Brook Medicine, Stony Brook, NY 11794-8191, USA