Sergey Lyass

Current status of an antireflux procedure in laparoscopic Heller myotomy

Background: Persistent dysphagia and postoperative gastroesophageal reflux (GER) are the most cited reasons for surgical failure of laparoscopic Heller myotomy. Adding an antireflux procedure to Heller myotomy has been proposed to prevent reflux. We hypothesized that an antireflux procedure added to laparoscopic Heller myotomy has little effect on preventing the symptoms or long-term sequelae of GER in achalasia patients. Methods: We performed a meta-analysis of studies on human subjects reported in the English language literature from 1991 to 2001 years. Results: An antireflux procedure accompanied laparoscopic myotomy in 15 studies with 532 patients. In 6 studies of 69 patients, no antireflux procedure was added to laparoscopic myotomy. Follow-up was available on 489 patients (92%) with partial fundoplication. The rate of GER diagnosed in pH studies was 7.9% (18 of 228 patients studied), whereas only 5.9% of patients experienced symptoms of GER (29 of 489 patients followed). Of the 69 patients without fundoplication, 47 (68%) were available for follow-up. Forty patients (85%) were studied with pH monitoring postoperatively, with 4 (10%) demonstrating reflux. Six (13%) of 47 patients had symptoms of GER. The difference in the rate of GER diagnosed in postmyotomy pH studies in wrapped and nonwrapped patients was not significant (7.9 vs 10%, respectively; p = 0.75). There was also no significant difference in the incidence of postmyotomy GER symptoms in wrapped and nonwrapped patients (5.9 vs 13% respectively; p = 0.12). Conclusions: Reflux is not necessarily eliminated with the addition of a partial fundoplication. Based on the published data, recommendations cannot be made regarding the efficacy of adding an antireflux procedure to laparoscopic Heller myotomy. Prospective randomized study is needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.

Leveling the learning curve for laparoscopic bariatric surgery

BackgroundThe learning curve for laparoscopic bariatric surgery is associated with increased morbidity and mortality.MethodsThe study included the first 100 patients undergoing laparoscopic Roux-en-Y gastric bypass (LGB) by a designated surgical team. Surgeon A operated as primary surgeon, with surgeon B assisting (Stage 1). Surgeon B learned LGB in stages: exposure and jejunojejunostomy (stage 2), gastric pouch (stage 3), gastrojejunostomy (stage 4), and sequence all steps (stage 5).ResultsSurgeon A achieved confidence with LGB after 20 cases and surgeon B after 25 cases (stage 2), 18 cases (stage 3), 21 cases (stage 4), and 16 cases (stage 5). Complications (8%) included small bowel obstruction (three); pulmonary embolus (two), and leak, stomal stenosis, and gastrogastric fistula (one each). There was a decreasing trend for operative duration, length of stay, and complications across the five stages (p < 0.05).ConclusionsBy transferring skills in stages, a laparoscopic bariatric program can be established with minimal morbidity and mortality.