Tommy H. Lee

Applicability and Feasibility of Incorporating Minimally Invasive Esophagectomy at a High Volume Center

Esophageal resection remains an integral part of treatment for esophageal cancer. Traditionally, the two open operative techniques which incorporate a cervical esophago-gastric anastomosis have been transhiatal esophagectomy (THE) and transthoracic esophagectomy, with en bloc lymphadenectomy (TTE). The clinical decision as to which of these two procedures would best serve the patient often rests on the following notion: the goal of THE is to reduce early postoperative morbidity and mortality by avoiding a thoracotomy, whereas the goal of TTE is to increase longterm survival by employing wide excision and extensive node dissection in the mediastinum and abdomen. En bloc esophagectomy has been shown to increase survival by decreasing locoregional disease recurrence related to micrometastatic disease. Transhiatal esophagectomy is often associated with increased locoregional failure rates in the absence of extended lymphadenectomy and has the potential to cause significantly more bleeding than other approaches because of the blunt mediastinal dissection. Despite these concerns, THE is a valid option for patients with or at risk for respiratory disorders, as it significantly decreases perioperative pulmonary complications. Esophageal resections are associated with a morbidity and mortality of up to 70% and 14%, respectively. Minimally invasive esophagectomy (MIE) has been proposed as a method of esophageal resection for malignant esophageal diseases. Some of the proposed benefits of MIE as compared with open techniques include decreased time to recovery and shorter hospital stays, benefits that are deemed important especially in patients with poor prognosis who may spend a significant proportion of their survival recovering from the procedure itself. Other benefits may include decreased blood loss, fewer wound and pulmonary complications, and less postoperative pain. Additionally, superior laparoscopic visualization may enhance mediastinal dissection. The procedure is not met with universal acceptance amongst surgeons, however, because of a steep learning curve, longer operative duration, perceived inadequate oncological integrity, and increased risk of gastric conduit ischemia with a minimally invasive technique. Minimally invasive esophagectomies have been incorporated into our operative armamentarium since 2005. The aim of this study is to assess a high volume centers experience with MIE and to compare the morbidity and mortality associated with different techniques.

Endoscopic assessment of failed fundoplication: A case for standardization

BackgroundPreoperative endoscopic assessment of the failed fundoplication is instrumental in diagnosis and surgical management. Endoscopy is a routine and essential part of the workup for a failed fundoplication, but no clear guidelines exist for reporting endoscopic findings. This study aimed to compare endoscopic findings reported by community physicians (gastroenterologists and surgeons) with the findings of the authors (esophageal center) for patients who underwent reoperative intervention after a previous antireflux procedure.MethodsRetrospective review of a prospectively maintained database was performed to identify patients who underwent reoperation after a failed antireflux operation between 1 December 2003 and 30 June 2010. Endoscopic findings as reported by the outside physician and by the esophageal center endoscopist were reviewed and compared.ResultsDuring the study period, 229 patients underwent reoperation. Of these patients, 20 did not have endoscopy performed by an outside physician and were excluded from the study, leaving 208 patients. The endoscopic reports of the esophageal center physician included 97 cases of hiatal hernia (64 type 1 and 33 types 2 and 3), 52 slipped fundoplications, 61 disrupted fundoplications, 30 intrathoracic fundoplications, 25 twisted fundoplications, 14 two-compartment stomachs, and 27 cases of Barrett’s esophagus. Outside physicians identified 68% of the hiatal hernias and 61% of the paraesophageal hernias reported by the authors. Only 32% of the outside reports mentioned a previous fundoplication. Furthermore, only 17% of the slipped fundoplications and 30% of the disrupted fundoplications were so described. Outside physicians identified 19 of the 27 patients with Barrett’s esophagus.ConclusionFundoplication changes described by the general endoscopist are inadequate. With an increasing population of patients who have undergone prior antireflux surgery, incorporation of fundoplication assessment in an endoscopic curriculum may be helpful.

High‐resolution impedance manometry findings in patients with nutcracker esophagus

Background and Aim:  The objective of this study was to evaluate the association between high‐resolution manometry (HRM) and impedance findings and symptoms in patients with nutcracker esophagus (NE).

A proposed classification for uniform endoscopic description of surgical fundoplication.

BackgroundObjective assessment of postfundoplication anatomy is of utmost importance especially if reoperative intervention is being planned. There is a lack of uniformity in the description of endoscopic findings in these patients. The purpose of this study was to propose a classification for standardized endoscopic reporting of postfundoplication anatomy.MethodsAfter institutional review board approval, preoperative endoscopic findings of patients who underwent reoperative intervention from 1992 to 2011 were reviewed and classified. The classification included four factors: E (distance of GEJ to crus), S (amount of gastric tissue between the GEJ and fundoplication), F (fundoplication configuration), and P (paraesophageal hernia).ResultsThe endoscopic findings of 310 patients who underwent reoperative antireflux surgery were classified using the newly proposed classification model. A significant increase in the number of procedures was noted over the years. There was no change in presenting symptoms and patterns of failure over the years. The classification model was easily applicable to previous endoscopy reports. There was good symptom association with our classification model.DiscussionAn endoscopic anatomical classification is proposed for description of failed fundoplication. With this classification, we hope to fill the gap in developing a uniform classification of failed fundoplications. Further studies addressing widespread applicability and outcome analysis are needed.

Trangastric endo-organ resection of a proximal gastric lesion

IntroductionGastric tumors confined to mucosa and submucosa can be resected with endoscopic resection techniques. They include endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) [1, 2]. These techniques can be challenging when the tumor is large or is near the gastroesophageal (GE) junction. Transgastric resection is a novel technique of removing gastric tumors that are unresectable by endoscopy due to their size and location.Materials and MethodsWe present a case of a 41-year-old male where a suspicious appearing lesion near the GE junction was removed using combined trans-gastric laparoscopic and endoscopic technique. The stomach was inflated using endoscopy, and three 5-mm balloon-tipped trocars were inserted directly into the stomach. The lesion was lifted with submucosal injection of saline and was resected using ultrasonic dissection device. The specimen was retrieved using Rothnet through the endoscope. The mucosal defect was closed with absorbable sutures. Trocars were removed and gastrostomy sites were closed with Endostitch device. Swallow study done on post-op day 2 did not show any signs of leak. Patient was discharged home on post-op day 5. Final pathology was consistent with hyperplastic polyp.ConclusionProximal Gastric lesions can be safely removed with combined Laparoscopic trans-gastric and endoscopic approach.

Long-term follow-up of a novel anastomotic device in a canine model.

Construction of intestinal anastomosis is a fundamental general surgery skill. New constraints in creating safe, effective anastomoses are faced, however, even as minimally invasive surgery techniques continue to gain popular and scientific support. We present our experience in developing and testing a novel anastomotic device (AD) constructed of a shape memory metal, with long-term follow-up in a canine model. This device has the potential for both laparoscopic and endoscopic delivery because of its unique design and adaptable deployment system. Eight canines had gastroduodenal and jejunojejunal anastomoses formed with the AD: the gastroduodenal anastomosis by transecting the stomach immediately distal to the pylorus and forming a side-to-side functional end-to-end anastomosis and the jejunojejunal anastomosis similarly following transection in the mid-jejunum. Four animals were survived for 6 months, and 4 for 12 months. At the study’s end, the animals were euthanized and the anastomotic sites harvested for both gross and microscopic pathology. Two animals developed postoperative complications: one a mechanical bowel obstruction from bedding ingestion that required laparotomy, and one an ileus that conservative management resolved. All animals survived to their endpoints, displaying normal growth and development. All jejunojejunal anastomoses had AD passage and microscopic evidence of complete healing. Meanwhile, none of the gastroduodenal devices passed, with microscopy demonstrating incomplete mucosalization. This AD is highly effective in forming jejunojejunal anastomoses. Gastroduodenal anastomoses, while highly functional, retained the device without complete healing. Future studies using a more human-like animal model and an anastomotic technique avoiding the thick pylorus muscle should yield better results.