Steven P. Bowers

Long-term outcome of laparoscopic repair of paraesophageal hernia

BackgroundIt has been reported that the laparoscopic repair of paraesophageal hernias is associated with higher complication and recurrence rates than the open methods of repair.MethodsWe identified 136 consecutive patients who underwent laparoscopic repair of a paraesophageal hernia between 1993 and 1999. Patient demographics and symptom scores for regurgitation, heartburn, chest pain, and dysphagia at presentation and at last follow-up were recorded (0=none, 1=mild, 2=moderate, 3=severe). The operative records were reviewed, and early and late complications were noted. Only patients with a follow-up of 1 were included in the analysis.ResultsThe median age was 64 years, and there was a female preponderance (1.8∶1). Most patients had some medical comorbidity; the American Society of Anesthesiologists (ASA) scores were <2 in eight patients and ≥2 in 117 patients. Three laparoscopic operations were converted to open procedures. There were nine intraoperative complications, five early complications, and three related deaths (morbidity and mortality rates of 10.2% and 2.2%, respectively). Follow-up data were available for 83 patients (66%), and the mean follow-up time was 40 months (range, 12–82). The percentage of patients experiencing chest pain, dysphagia, heartburn, and regurgitation in the moderate to severe range dropped from a range of 34–47% to 5–7% (p<0.05). Three patients underwent repeat laparoscopic repair for symptomatic recurrence.ConclusionThe laparoscopic repair of paraesophageal hernias provides excellent long-term symptomatic relief in the majority of patients and has a low rate of symptomatic recurrence. The complication and death rates may be related in part to the higher incidence of comorbidities in this somewhat elderly patient population.

Clinical and histologic follow-up after antireflux surgery for Barrett's esophagus.

There are few prospective studies that document the histologic follow-up after antireflux surgery in patients with Barrett’s esophagus, as defined by the recently standardized criteria. We report the clinical, endoscopic, and histologic results of patients with Barrett’s esophagus followed postoperatively for at least 2 years. Diagnosis of Barrett’s esophagus required preoperative endoscopic evidence of columnarlined epithelium in the esophagus and a biopsy demonstrating specialized intestinal metaplasia, which stains positively with Alcian blue stain. Between April 1993 and November 1998, a total of 104 patients meeting these criteria underwent fundoplication (laparoscopic [n = 84] or open [n = 6] nissen, laparoscopic Toupet [n = 11], laparoscopic Collis-Nissen [n = 1], Collins-Toupet [n = 1] or open Dor [n = 1]). Short-segment Barrett’s esophagus (length of intestinal metaplasia <3 cm) was found preoperatively in 34% and low-grade dysplasia in 4% of patients. All patients were contacted yearly by mail, phone, or clinic visit. At a mean follow-up of 4.6 years (range 2 to 7.5 years), 81% of patients had stopped taking antisecretory medications and 97% were satisfied with the results of their operations. Eight patients have undergone reoperation for recurrence of symptoms. Two patients have died and two were excluded from endoscopic biopsy because of portal hypertension. Sixty-six patients complied with the surveillance protocol, and their histologic results were returned to our center. Symptomatic follow-up of the 34 patients who refused surveillance esophagogastro and duodenoscopy revealed two patients who were taking medication for reflux symptoms. None of the patients have developed high-grade dysplasia or esophageal carcinoma during surveillance endoscopy (337 total patient-years of follow-up). The incidence of regression of intestinal metaplasia to cardiac-fundic-type metaplasia after successful antireflux surgery is greater than previously reported. We suspect that this is a result of longer follow-up and the inclusion of patients with short-segment Barrett’s esophagus. A substantial number of patients with Barrett’s esophagus who are asymptomatic after antireflux surgery refuse surveillance endoscopy.

Preoperative factors predictive of complicated postoperative management after Roux-en-Y gastric bypass for morbid obesity

Introduction: This study was undertaken to determine preoperative predictive factors of complicated postoperative management after Roux-en-Y gastric bypass (RYGB) for morbid obesity.Methods: Between January 1999 and January 2002, 158 patients who underwent a RYGB received a standardized preoperative evaluation and data were collected prospectively. Complicated postoperative management was defined as patients requiring postoperative ICU admission for ≥48 h, or those needing transfer from the floor to the ICU. Patients with complicated management were compared with those in whom ICU admission was not necessary.Results: Twenty-three patients (14.5%) required prolonged ICU admission (mean stay of 6.3 ± 1.7 days). After multivariate analysis, body mass index (BMI) >50 kg/m2, forced expiratory volume (FEV1) <80% predicted, previous abdominal surgeries, and abnormal EKG were found to be independently associated with an increased likelihood of complicated postoperative care.Conclusion: BMI >50 kg/m2, FEV1 <80% predicted, previous abdominal surgeries, and abnormal EKG increase the likelihood of complicated postoperative management after RYGB for morbid obesity.

Prospective randomized clinical trial comparing nitrous oxide and carbon dioxide pneumoperitoneum for laparoscopic surgery.

BACKGROUND Recent publications demonstrating the safety and advantages of N2O for pneumoperitoneum (PP) prompted us to reconsider N2O as an agent for PP in general surgical laparoscopy. The purpose of this prospective, double-blind, randomized clinical trial was to determine whether N2O PP has any benefits over CO2 PP. STUDY DESIGN One hundred three patients received N2O (group I, n = 52) or CO2 (group II, n = 51) PP for elective laparoscopic surgery. Heart rate, mean arterial blood pressure, end-tidal CO2, minute ventilation, and O2 saturation were recorded before PP, during PP, and in the recovery room. Postoperative pain medication use was recorded. Pain was assessed by means of visual analog scale (VAS) at postoperative hours 2 and 4, and on day 1. RESULTS There were no differences between groups I and II in patient age, gender, weight, anesthesia risk (American Society of Anesthesiologists Score > 2), operative time, duration of PP, or length of hospital stay. Mean end-tidal CO2 increase under anesthesia was greater in group II than group I (3.0 versus 0.5 mmHg, p < 0.001) despite a greater mean intraoperative increase in minute ventilation in group II than group I (0.7 versus -0.2 L/min p < 0.001). The patients who had N2O PP had less pain 2 hours postoperatively (VAS: 4.9 versus 5.7, p <0.05), 4 hours postoperatively (VAS: 3.3 versus 5.1, p < 0.01), and 1 day postoperatively (VAS: 1.7 versus 3.5, p < 0.01) than patients who had CO2 PP. Postoperative narcotic or ketorolac use was not statistically different between groups. There were no adverse events related to either N2O or CO2 pneumoperitoneum. CONCLUSIONS These results suggest that the use of N2O PP has sufficient advantages over CO2 that it should be considered as the standard agent for therapeutic PP.

A Case Series of Laparoscopic Components Separation and Rectus Medialization with Laparoscopic Ventral Hernia Repair

Laparoscopic ventral hernia repair has been shown to offer improved patient recovery, when compared to open repair. It has also been shown to offer a lower complication rate. However, in patients with high body-mass index and large defects, the intraperitoneal on-lay technique of laparoscopic repair is criticized for an increased incidence of failure. In 1990, a study introduced the technique of open-component separation, hence enabling the medialization of the rectus muscle and decreasing the incidence of recurrence associated with primary repair. Open-component separation is associated with increased wound problems due to extensive dissection. Different laparoscopic and endoscopic modifications to the open-component-separation technique have been tried to minimize wound problems. In this article, we present our case series of 4 patients involving the laparoscopic component-separation technique of rectus medialization and, laparoscopic ventral hernia combined. This is one of the first series ever reported to involve both modalities of hernia repair in using an exclusive laparoscopic technique.

Gallbladder function before and after fundoplication

No study has reported an association between gastroesophageal reflux disease (GERD) or its therapies and gallbladder function. We compared pre- and postoperative gallbladder function in patients undergoing fundoplication to determine the following: (1) whether patients with chronic GERD have preexisting gallbladder motor dysfunction; (2) whether medical or surgical therapy alters gallbladder function; and (3) whether division of the hepatic branch of the anterior vagus nerve is detrimental to gallbladder motility. Nineteen patients with documented GERD consented to a preoperative cholecystokinin-stimulated technetium hepatobiliary (CCK-HIDA) scan to quantify the gallbladder ejection fraction (GBEF). All patients underwent laparoscopic Nissen fundoplication. One month after fundoplication, 12 patients completed a repeat CCK-HIDA scan for determination of GBEF, with comparison to the preoperative GBEF. Among patients with preoperative GERD, 11 (58%) of 19 met the scintigraphic criteria for gallbladder dysfunction (GBEF <35%), which is a ratio comparable to that in patients undergoing a CCK-HIDA scan for presumed biliary dyskinesia during the same time period (31 [60%] of 53;P=NS, chi square test) and exceeds the rate of abnormal GBEF reported in healthy volunteers (3%). Six of seven patients with a low preoperative GBEF who underwent repeat evaluation postoperatively had normalization of the GBEF (P=0.05, paired t-test). In the 12 patients who underwent postoperative CCK-HIDA scanning, there was no association between preservation or division of the hepatic branch of the anterior vagus nerve and postoperative gallbladder dysfunction (P=NS, chi-square test). Unexpectedly, 58% of patients with GERD demonstrated gallbladder motor dysfunction prior to fundoplication, with improvement to normal occurring in most of those studied postoperatively. These data support controlled trials to determine the effect of chronic GERD and antisecretory therapy on gallbladder and global gastrointestinal smooth muscle function. Preservation of the hepatic branch of the anterior vagus nerve during fundoplication offered no clear benefit with regard to early postoperative gallbladder function.

Laparoscopic Intraoperative Biliary Ultrasonography: Findings During Laparoscopic Cholecystectomy for Acute Disease

Laparoscopic cholecystectomy (LC) is one of the most commonly performed operations, yet the frequency of bile duct injury remains unacceptably high, and up to 25% of urgent LCs are converted to the open approach. Intraoperative laparoscopic biliary ultrasonography (IOUS) allows identification of portal structures before division of any structure, but the impact of IOUS on LC for acute biliary disease has not been clearly reported. A retrospective review was conducted of all patients who underwent cholecystectomy over a 29-month period. IOUS was performed after release of the medial and lateral peritoneal attachments of the gallbladder. Of the 65 patients, 43 (66%) had an urgent operation. Mean operative time was 89.6 minutes (range 45 to 196 minutes). IOUS was used routinely, when available, in 50 patients (77%). The biliary anatomy was completely observed in 48 patients (96%). IOUS identified significant biliary abnormalities in 20 patients (40%) including presence of a foreshortened cystic duct (CD) (<1 cm) in 7 patients (14%), common bile duct stones in 4 patients (8%), abnormal CD anatomy in 4 patients (8%), and abnormal vascular anatomy in 8 patients (16%). No patient was converted to open operation, no bile duct injury occurred, and no patient required subsequent biliary intervention. IOUS is effective at observing biliary anatomy in the setting of acute disease, and may be a useful tool during these difficult cases.

Contraindications to Laparoscopy

The applications of minimally invasive abdominal surgery continue to grow. As laparoscopic surgery becomes more advanced and more widely applied, the absolute contraindications to laparoscopy are diminishing. However, injuries to patients may occur when surgeons exceed the limitations of laparoscopic surgery and their laparoscopic skill set. This chapter discusses the present limits of laparoscopic access and the situations in which laparoscopy should be used only cautiously. Perhaps the most difficult limitation for surgeons to recognize are the boundaries of their laparoscopic skills. Inadequate training and experience may lead to injuries. In addition, poor equipment and/or inadequate training of surgical assistants or ancillary staff should be thought of as further contraindications to advanced laparoscopic procedures. Although this chapter focuses primarily on the preoperative characteristics of the patient that make laparoscopic surgery prohibitively difficult or dangerous, it also includes a brief discussion regarding surgical judgment. Patient limitations to laparoscopic surgery can be both anatomic and physiologic. Adverse anatomic considerations include difficult access to the abdomen, obliteration of the peritoneal space, organomegaly, intestinal distension, and the potential for dissemination or recurrence of cancer. The major physiologic obstacles to safe laparoscopy include pregnancy, increased intracranial pressure, abnormalities of cardiac output and gas exchange in the lung, and chronic liver disease and coagulopathy. While many of these conditions were formerly considered absolute contraindications to laparoscopy, they are now considered, by many surgeons, to be only relative contraindications.

Tu1173 The Effect of Weak and Failed Peristalsis on Postoperative Dysphagia Following Magnetic Sphincter Augmentation

correlated with weight loss in typeIachalasia (P=0.000). No correlation was found between Eckardt scores and other HRM metrics. Twenty-five patients (10 patients with type I and 15 patients with type II achalasia) were treated with POEM, and their total Eckardt scores and scores of each symptom were decreased after surgery (vs before POEM, all P<0.05). Eckardt scores changes (Eckardt scores before POEM minus Eckardt scores after POEM) were no difference between type I and type II achalasia. Eckardt scores and weight loss changes were positively correlated with IRP at baseline (all P<0.05). No correlation was found between other HRM metrics at baseline and Eckardt scores changes. Twelve patients (4 patients with type I and 8 patients with type II achalasia) underwent HRM after POME. IRP was changed significantly after POEM (vs before POEM, P=0.005), and so were DEP changes in type II achalasia (vs before POEM, P=0.010). IRP changes (IRP before POEM minus IRP after POEM) were positively correlated with Eckardt score changes (P=0.029). CONCLUSION: IRP correlates with symptoms and symptomatic outcomes of POEM in achalasia patients. HRM is an effective way to assess the severity of achalasia, and can be used to predict the efficacy of POEM. Correlation between HRM metrics and Eckardt scores at baseline (P value)

572 Management of Achalasia in a Bariatric Patient Post Sleeve Gastrectomy

Achalasia in the bariatric population is rare, with an incidence described in the literature of 1%. In the post bariatric surgery patient, the incidence is exceedingly rare, limited to a few case studies. To our knowledge, there is only one reported case in the literature, out of Singapore, of achalasia after a sleeve gastrectomy. We present our management of a post sleeve gastrectomy patient who developed achalasia. Our patient was treated with a Heller myotomy and conversion of her sleeve to a roux en y gastric bypass.