W.S. Melvin

A prospective analysis of 211 robotic-assisted surgical procedures

Background: The Academic Robotics Group prospectively studied 211 robotically assisted operations to assess the safety and utility of robotically assisted surgery. Methods: All operations took place at one of four member institutions between June 2000 and June 2001 using the recently FDA-approved daVinci robotic system. A variety of procedures were undertaken, including antireflux surgery (69), cholecystectomy (36), Heller myotomy (26), bowel resection (17), donor nephrectomy (15), left internal mammery artery mobilization (14), gastric bypass (seven), splenectomy (seven), adrenalectomy (six), exploratory laparoscopy (three), pyloroplasty (four), gastrojejunostomy (two), distal pancreatectomy (one), duodenal polypectomy (one), esophagectomy (one), gastric mass resection (one), and lysis of adhesions (one). Results: Average operating room time was 188 min (range 45 to 387, SD = 83), surgical time 143 min (range 35 to 462, SD = 63), and robot time 90 min (range 12 to 235, SD = 47). Median length of stay was 1 day (range 0 to 37). There were 8 (4%) technical complications during procedures, five minor (four hook cautery dislodgement, one slipped robotic trocar) and three major (system malfunctions, two of which required conversion to standard laparoscopy). In all cases, technical problems caused only delay, without apparent altered outcome. There were medical/surgical complications in nine patients (4%). Six (3%) were considered major, including one death unrelated to the robotic procedure. Conclusions: The results of robotic-assisted surgery compare favorably with those of conventional laparoscopy with respect to mortality, complications, and length of stay. Robotic-assisted surgery is safe and effective and is a new reality for American surgery. The role of these devices in surgery will expand as the technology evolves.

Endoscopic management of stomal stenosis after Roux-en-Y gastric bypass

Background: In the United States, Roux-en-Y gastric bypass has evolved into the procedure of choice for clinically severe obesity. Stomal stenosis resulting in gastric outlet obstruction is a recognized complication. Endoscopic balloon dilation is often used to treat this condition. To evaluate the safety and efficacy of endoscopic management of stomal stenosis we evaluated our treatment methods and outcomes. Methods: The records of all patients undergoing Roux-en-Y gastric bypass from 1 July 2000 to 30 June 2002 were studied. Stenosis was defined as signs and symptoms of obstruction with inability to cannulate the gastrojejunostomy using an 8.5-mm diagnostic endoscope. Charts were reviewed and demographic data, operative course, symptoms, and outcomes were recorded. Results: A total of 562 patients underwent Roux-en-Y gastric bypass for obesity during the study period. Of these, 38 patients underwent endoscopic balloon dilation for stomal stenosis, for a stenosis rate of 6.8%. The average time from surgery to initial dilation was 7.7 weeks (range 3 to 24). The average number of dilations required was 2.1 (range one to six). The mean initial balloon size was 13 mm and the mean final balloon size was 16 mm. Two patients failed endoscopic dilation and proceeded to surgery, including one patient who developed pneumomediastinum and pneumothorax after dilation. All patients were relieved of their gastric outlet obstruction. The success rate for endoscopic balloon dilation was 95% with a 3% complication rate. Conclusions: In our experience, the rate of gastrojejunostomy stenosis following Roux-en-Y gastric bypass is 6.8%. Endoscopic balloon dilation is a safe and effective therapy for stomal stenosis with a high success rate. It should be considered an appropriate intervention with a low risk for reoperation.

Endoscopic ablation of intestinal metaplasia containing high-grade dysplasia in esophagectomy patients using a balloon-based ablation system.

BackgroundThis study aimed to determine the optimal treatment parameters for the ablation of intestinal metaplasia (IM) containing high-grade dysplasia (HGD) using a balloon-based ablation system for patients undergoing esophagectomy.MethodsImmediately before esophagectomy, patients underwent ablation of circumferential segments of the esophagus containing IM-HGD using the HALO360 system. The treatment settings were randomized to 10, 12, or 14 J/cm2 for two, three, or four applications. After esophagectomy, multiple sections from ablation zones were microscopically evaluated. Histologic end points included maximum ablation depth (histologic layer) and complete ablation of all IM-HGD (yes/no).ResultsEight men with a mean age of 57 years (range, 45–71 years) were treated, and 10 treatment zones were created. There were no device-related adverse events. At resection, there was no evidence of a transmural thermal effect. Grossly, ablation zones were clearly demarcated sections of ablated epithelium. The maximum ablation depth was the lamina propria or muscularis mucosae. The highest energy (14 J/cm2, 4 applications) incurred edema in the superficial submucosa, but no submucosa ablation. Complete ablation of IM and HGD occurred in 9 of 10 ablation zones (90%), defined as complete removal of the epithelium with only small foci of “ghost cells” representing nonviable, ablated IM-HGD and demonstrating loss of nuclei and cytoarchitectural derangement. One focal area of viable IM-HGD remained at the margin of one ablation zone (12 J/cm2, 2 applications) because of incomplete overlap.ConclusionComplete ablation of IM-HGD without ablation of submucosa is possible using the HALO360 system. Ablation depth is dose related and limited to the muscularis mucosae. In one patient, small residual foci of IM-HGD at the edge of the ablation zone were attributable to incomplete overlap, which can be avoided. This study, together with nonesophagectomy IM-HGD trials currently underway, will identify the optimal treatment parameters for IM-HGD patients who would otherwise undergo esophagectomy or photodynamic therapy.

Efficacy of Transoral Fundoplication vs Omeprazole for Treatment of Regurgitation in a Randomized Controlled Trial

BACKGROUND & AIMS Transoral esophagogastric fundoplication (TF) can decrease or eliminate features of gastroesophageal reflux disease (GERD) in some patients whose symptoms persist despite proton pump inhibitor (PPI) therapy. We performed a prospective, sham-controlled trial to determine if TF reduced troublesome regurgitation to a greater extent than PPIs in patients with GERD. METHODS We screened 696 patients with troublesome regurgitation despite daily PPI use with 3 validated GERD-specific symptom scales, on and off PPIs. Those with at least troublesome regurgitation (based on the Montreal definition) on PPIs underwent barium swallow, esophagogastroduodenoscopy, 48-hour esophageal pH monitoring (off PPIs), and high-resolution esophageal manometry analyses. Patients with GERD and hiatal hernias ≤2 cm were randomly assigned to groups that underwent TF and then received 6 months of placebo (n = 87), or sham surgery and 6 months of once- or twice-daily omeprazole (controls, n = 42). Patients were blinded to therapy during follow-up period and reassessed at 2, 12, and 26 weeks. At 6 months, patients underwent 48-hour esophageal pH monitoring and esophagogastroduodenoscopy. RESULTS By intention-to-treat analysis, TF eliminated troublesome regurgitation in a larger proportion of patients (67%) than PPIs (45%) (P = .023). A larger proportion of controls had no response at 3 months (36%) than subjects that received TF (11%; P = .004). Control of esophageal pH improved after TF (mean 9.3% before and 6.3% after; P < .001), but not after sham surgery (mean 8.6% before and 8.9% after). Subjects from both groups who completed the protocol had similar reductions in GERD symptom scores. Severe complications were rare (3 subjects receiving TF and 1 receiving the sham surgery). CONCLUSIONS TF was an effective treatment for patients with GERD symptoms, particularly in those with persistent regurgitation despite PPI therapy, based on evaluation 6 months after the procedure. Clinicaltrials.gov no: NCT01136980.

Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms: a systematic review and meta-analysis.

Purpose: Studies of endoscopic application of radiofrequency energy to the lower esophageal sphincter for gastroesophageal reflux control have produced conflicting reports of its effectiveness. This study aimed to conduct a meta-analysis of randomized controlled trials and cohort studies to assess the impact of this treatment. Methods: Twenty studies were included. Outcomes analyzed included gastroesophageal reflux disease (GERD) symptom assessment, quality of life, esophageal pH, and esophageal manometry. Results: A total of 1441 patients from 18 studies were included. Radiofrequency treatment improved heartburn scores (P=0.001), and produced improvements in quality of life as measured by GERD–health-related quality-of-life scale (P=0.001) and quality of life in reflux and dyspepsia score (P=0.001). Esophageal acid exposure decreased from a preprocedure Johnson-DeMeester score of 44.4 to 28.5 (P=0.007). Conclusions: Radiofrequency ablation of the lower esophageal sphincter produces significant improvement in reflux symptoms and may represent an alternative to medical treatment and surgical fundoplication in select patients.

Heating and humidifying of carbon dioxide during pneumoperitoneum is not indicated: A prospective randomized trial

BackgroundCarbon dioxide (CO2) pneumoperitoneum usually is created by a compressed gas source. This exposes the patient to cool dry gas delivered at room temperature (21°C) with 0% relative humidity. Various delivery methods are available for humidifying and heating CO2 gas. This study was designed to determine the effects of heating and humidifying gas for the intraabdominal environment.MethodsFor this study, 44 patients undergoing laparoscopic Roux-en-Y gastric bypass were randomly assigned to one of four arms in a prospective, randomized, single-blinded fashion: raw CO2 (group 1), heated CO2 (group 2), humidified CO2 (group 3), and heated and humidified CO2 (group 4). A commercially available CO2 heater–humidifier was used. Core temperatures, intraabdominal humidity, perioperative data, and postoperative outcomes were monitored. Peritoneal biopsies were taken in each group at the beginning and end of the case. Biopsies were subjected staining protocols designed to identify structural damage and macrophage activity. Postoperative narcotic use, pain scale scores, recovery room time, and length of hospital stay were recorded. One-way analysis of variance (ANOVA) and the nonparametric Kruskal–Wallis test were used to compare the groups.ResultsDemographics, volume of CO2 used, intraabdominal humidity, bladder temperatures, lens fogging, and operative times were not significantly different between the groups. Core temperatures were stable, and intraabdominal humidity measurements approached 100% for all the patients over the entire procedure. Total narcotic dosage and pain scale scores were not statistically different. Recovery room times and length of hospital stay were similar in all the groups. Only one biopsy in the heated–humidified group showed an increase in macrophage activity.ConclusionsThe intraabdominal environment in terms of temperature and humidity was similar in all the groups. There was no significant difference in the intraoperative body temperatures or the postoperative variable measured. No histologic changes were identified. Heating or humidifying of CO2 is not justified for patients undergoing laparoscopic bariatric surgery.

A cost-effective thoracoscopic treatment strategy for pediatric spontaneous pneumothorax.

AbstractBackground: Recent data suggest that children have a higher incidence of recurrence than adults after nonoperative treatment of primary spontaneous pneumothorax (PSP). Video-assisted thoracoscopic surgery (VATS) allows efficacious therapy with significantly less morbidity. We attempt to define the most cost-effective clinically efficacious strategy using VATS to manage pediatric PSP. Methods: We retrospectively reviewed all admissions to a tertiary care childrens hospital for PSP between January 1, 1991 and June 30, 1996. Results: Fifteen children had 29 primary or recurrent PSPs. Mean patient age was 14.8 ± 1.1 years, boy–girl ratio 4:1, median body mass index 18 (normal, 20–25), and 67% of pneumothoraces left sided. All patients were managed initially nonoperatively: 14 with tube thoracostomy drainage and 1 with oxygen alone. Of the children initially managed nonoperatively, 57% had a recurrent pneumothorax, and 50% of these patients eventually developed contralateral pneumothoraces. Nonoperative treatment for recurrence resulted in a 75% second recurrence rate. In contrast, eight children who underwent operative management had a 9% incidence of recurrence. The total for charges accrued in treating 29 pneumothoraces in these 15 patients was approximately

The laparoscopic management of post-transplant lymphocele. A critical review.

315,000. In the same population, the estimated charges for initial nonoperative therapy followed by bilateral thoracoscopy after a single recurrence would be

Efficacy of percutaneous treatment of biliary tract calculi using the holmium:YAG laser

230,000. Conclusions: A cost-effective treatment strategy for pediatric primary spontaneous pneumothorax is tube thoracostomy at first presentation, followed by VATS with thoracoscopic bleb resection and pleurodesis for patients who experience recurrent pneumothorax.

Radiofrequency Energy Delivery to the Lower Esophageal Sphincter (Stretta Procedure) Does Not Provide Long-term Symptom Control

AbstractBackground: The management of lymphocele in patients following kidney (KT) and kidney pancreas (KPT) transplants is evolving. Open surgery has been the traditional treatment, but some authors have advocated laparoscopic drainage in selected patients. Methods: We retrospectively reviewed our results in lymphocele treatment since developing a laparoscopic program at our institution. Results: Between May 1994 and June 1995, 186 KTs and 48 KPTs were performed, and 1,354 patients are currently being followed. Eight patients developed symptomatic lymphoceles an average of 26 months (range 4–59) following 6 KTs and 2 KPTs. All patients diagnosed were successfully drained laparoscopically, with no conversions to open surgery. Laparoscopic ultrasound was used to help with localization of the fluid collection. Operative time averaged 59 min, median hospital stay was 1 day (range 1–4), and there were no perioperative complications. Follow-up imaging was obtained on six patients, 3–16 months following their procedures, and no recurrences were noted. A review of the literature demonstrates a 5.3% rate of major complications and a 7% incidence of lymphocele recurrence. Conclusions: Intraoperative laparoscopic ultrasound can help localize fluid collections and prevent organ injuries. Laparoscopic drainage of lymphocele following transplantation results in minimal disability and an acceptable complication rate, although it is higher than with open drainage. Therefore, laparoscopic drainage should be considered as primary treatment for all patients with symptomatic post-transplant lymphocele.