William S. Richardson

SURGICAL MANAGEMENT OF ACHALASIA

Although achalasia is not a common illness in the United States and Europe, there continues to be a need for surgical therapy for treatment. Laparoscopic Heller myotomy and partial fundoplication has, for the most part, replaced open surgery (abdominal or thoracic) as the surgical treatment of choice. In order to perform this procedure well, one must select patients carefully, evaluate them fully, and adhere to the technical principles required to achieve consistently good results.

Laparoscopic repair of superior mesenteric artery syndrome

BACKGROUND Superior mesenteric artery syndrome is duodenal obstruction by the superior mesenteric artery. It is caused by decreasing the angle between the aorta and superior mesenteric artery causing compression of the third part of the duodenum and usually occurs after a period of weight loss. METHODS Between September 1999 and April 2000, 2 patients with superior mesenteric artery syndrome were treated laparoscopically. The laparoscope was placed in the umbilicus; the surgeon operated through two trochars on the left side of the abdomen, and an assistant retracted through one trochar on the right side of the abdomen. The dilated duodenum was seen below the transverse mesocolon and to the right of the superior mesenteric artery. A proximal loop of jejunum was anastamosed to the duodenum using the endoscopic gastrointestinal anastomotic (GIA) stapler. RESULTS Average operating time was 113 minutes and average hospital length of stay was 3 days. There were no complications and both patients were pleased with their results. CONCLUSIONS Laparoscopic duodenojejunal bypass is feasible with laparoscopic techniques. The operating time is acceptable and the postoperative length of stay is short.

Outpatient laparoscopic cholecystectomy. Outcomes of 847 planned procedures.

BackgroundCholecystectomy is now being performed on an outpatient basis at many centers. The purpose of this study was to review the results of our large experience with this procedure.MethodsBetween 1990 and 1997, 2288 patients underwent laparoscopic cholecystectomy at our clinic. A total of 847 (37%) were scheduled as outpatients. The selection criteria for planned outpatient laparoscopic cholecystectomy called for nonfrail patients with an ASA <4 who were living <2 h from the hospital. All patients received detailed preoperative instruction about outpatient laparoscopic cholecystectomy. A questionnaire was sent to 309 patients to sample their opinions.ResultsSince 1993, we have increased the number of planned outpatient cholecystectomies performed at our clinic, but the percentage of cholecystectomies completed on an outpatient basis has remained≈60%. A total of 547 of 847 operations scheduled as outpatient procedures (74.5%) were completed as planned, and 204 patients (24%) were kept in the hospital overnight. Twenty-seven (3%) were converted to open procedures. Eighteen laparoscopic patients (2%) stayed>1 day (range, 2–20). None of the patients died. Of the 142 patients (46%) who completed our opinion survey, 66% were happy with their experience, 32% would like to have stayed in the hospital, and 2% were undecided.ConclusionSuccessful same-day surgery requires proper patient instruction, appropriate patient selection, and a low threshold to convert patients to inpatient status when the situation warrants. No major complications occurred as a result of same-day discharge, and two-thirds of the patients said that they preferred outpatient surgery.

LAPAROSCOPIC ANTIREFLUX SURGERY

Gastroesophageal reflux disease is very common, and there continues to be a need for gastroesophageal reflux surgery despite improved medical therapy. With the relatively new option of laparoscopic antireflux surgery, many more of these procedures are now being performed. In order to perform these well, one must select patients carefully, evaluate them fully, and adhere to the technical principles required to achieve consistently good results.

Nissen and Toupet fundoplications effectively inhibit gastroesophageal reflux irrespective of natural anatomy and function

AbstractBackground: The physiology of Nissen fundoplication (NF) and Toupet fundoplication (TF) is controversial. The aim of this study was to determine the contribution of elevated intragastric pressure to the antireflux mechanism after surgically created fundoplication in explanted porcine stomachs. Methods: The stomachs and 6–8 cm of distal esophagus were removed from 15 pigs and placed in anatomic position. Five NF, 2 cm in length with three interrupted sutures, were performed, taking full-thickness bites of stomach and partial-thickness bites of esophagus around a 60 French dilator. Five 270° TF 2 cm in length with six interrupted sutures were performed taking full-thickness bites of stomach and partial-thickness bites of esophagus around a 60 French dilator. Each stomach served as its own control. The pylorus was tied off and the stomach was inflated with Ringers lactate while the pressure was monitored. Results: Before NF, reflux could be easily induced with a mean intragastric pressure of 5.5 ± 3.7 mmHg. After NF reflux could not be induced but the sutures pulled out of the stomach at a mean pressure of 36.8 ± 11.7 mmHg (p < 0.01 vs control). Before TF, reflux could easily be induced with a mean intragastric pressure of 3.0 ± 3.0 mmHg. After TF, reflux could not be induced and the sutures pulled out of the esophagus or stomach with a mean pressure of 30.8 ± 9.0 mmHg (p < 0.01 vs control). Porcine stomachs in vivo are resistant to reflux, but when explanted they reflux easily. NF and TF are so effective at interrupting reflux that the sutures tear out instead of allowing reflux. Conclusions: While not yet statistically significant, it appears that sutures tear out of the esophagus (TF) more readily than they tear out of the stomach (NF). TF and NF prevent reflux in the absence of anatomic or functional components of the lower esophageal sphincter.

Laparoscopic floppy Nissen fundoplication

Good results for antireflux surgery are obtained when proper patients are selected, trained surgeons perform the operation, and proper techniques are used. As our prior results showed higher rates of dysphagia without fundus mobilization (Nissen-Rossetti fundoplication), we now perform complete mobilization on all patients. Full fundus mobilization requires take-down of the short gastric vessels to reveal the base of the left crus, take-down of all posterior gastropancreatic adhesions and the peritoneal fold that is cauded to the crus and superior to the pancreas. Proper division of these attachments will allow an untethered fundoplication and may reduce the risk of dysphagia and slip of the fundoplication onto the stomach.

Esophageal resection for cancer.

Currently, relatively safe, reliable resection techniques are available for most patients with esophageal carcinoma who present with nonmetastatic disease. For optimal results, the surgeon must be familiar with both transhiatal and transthoracic approaches and must individualize the approach depending on the tumor size and location and the patients functional status. Whereas post-resection survival rates are good for patients with early-stage disease (Stage I or IIa), most patients present with locally advanced, Stage III disease. Although some progress has been made in the past decade in regard to early diagnosis among patients with Barretts metaplasia undergoing endoscopic surveillance and additional progress has been made in adapting multimodality treatment programs successfully to patients with locally advanced disease, the overall cure rate for patients with esophageal carcinoma remains low.

Fundoplications resist reflux independent of in vivo anatomic relationships

BACKGROUND Antireflux operations restore lower esophageal sphincter (LES) function and hiatal anatomy; however, the relative contributions are unclear. METHODS We measured the competency of fundoplications, exclusive of in vivo variables, in gastroesophageal explants from 8 cadavers. Using a multichannel manometer, esophageal, LES, and intragastric pressures were recorded during transpyloric distension. Data were compared at baseline, and after Nissen (360 degrees) and Toupet (270 degrees) fundoplications. RESULTS Before fundoplication, stomachs refluxed immediately upon distension. Nissen fundoplications never refluxed before gastric rupture (46.8 +/- 15.0 mm Hg). LES pressure averaged 2.0 +/- 0.5 times intragastric pressure during distension. Toupet fundoplications refluxed at intragastric pressure <2 mm Hg, then became competent until gastric rupture (49.9 +/- 15.0 mm Hg). LES pressure averaged 2.4 +/- 1.0 times intragastric pressure during distension. CONCLUSIONS Nissen and Toupet fundoplications increase LES pressure linearly at 2 to 2.5 times intragastric pressure, independent of in vivo variables. Toupet fundoplication lacks the competency of Nissen fundoplication at low intragastric pressures.

Laparoscopic repair of congenital diaphragmatic hernias.

Most Morgagni and Bochdalek hernias are found and repaired in children, but 5% are found in adults. Symptoms of these hernias are attributable to the involved viscera. Both hernias require repair on presentation because of the risk of incarceration. We describe a laparoscopic method of repairing these hernias that allows shorter recovery than open surgery.

Teflon buttress inhibits recanalization of uncut stapled bowel

The uncut Roux limb operation is designed to have the benefits of a Roux limb but still have electrical continuity from proximal to distal bowel, thus eliminating the risk of Roux stasis syndrome. The main complication has been recanalization of the uncut staple line leading to bile reflux. This study aims to employ a new technique, which will not allow recanalization of an uncut staple line but will not interfere with normal bowel myoelectric activity. Fourteen mongrel dogs, 25 to 35 kg, underwent a midline laparotomy under general anesthesia. An uncut staple line was placed 25 cm from the ligament of Treitz. In seven animals an uncut staple line alone was placed, and in the other seven animals the bowel was stapled between a sandwich of Teflon reinforcing strips such that the staples were held on both sides of the bowel by the Teflon. A jejunojejunostomy was placed 6 cm proximal to the staple line. Insulated bipolar electrical leads were placed around the staple line. After the electrical leads were monitored 2 days to 3 months postoperatively for bowel myoelectric activity, the animals were killed and the operative sites inspected. No animal suffered morbidity or mortality from the procedure. All seven unreinforced staple lines recanalized and all seven reinforced staple lines remained competent. The duodenal pacemaker potentials were transmitted through the staple line in five animals (3 controls and 2 with Teflon reinforcement) within 1 week postoperatively. The uncut staple line does not reliably transmit the duodenal pacemaker potentials. The staple line does not recanalize when it is reinforced with a permanent material, increasing the utility of the “uncut” Roux limb operation.