Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the Esophageal Diagnostic Advisory Panel

BACKGROUND

Gastroesophageal reflux disease (GERD) is a very prevalent disorder. Medical therapy improves symptoms in some but not all patients. Antireflux surgery is an excellent option for patients with persistent symptoms such as regurgitation, as well as for those with complete symptomatic resolution on acid-suppressive therapy. However, proper patient selection is critical to achieve excellent outcomes.

STUDY DESIGN

A panel of experts was assembled to review data and personal experience with regard to appropriate preoperative evaluation for antireflux surgery and to construct an evidence and experience-based consensus that has practical application.

RESULTS

The presence of reflux symptoms alone is not sufficient to support a diagnosis of GERD before antireflux surgery. Esophageal objective testing is required to physiologically and anatomically evaluate the presence and severity of GERD in all patients being considered for surgical intervention. It is critical to document the presence of abnormal distal esophageal acid exposure, especially when antireflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach.

CONCLUSIONS

Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. Additional studies with long-term follow-up are required to evaluate the diagnostic and therapeutic benefit of new technologies, such as oropharyngeal pH testing, multichannel intraluminal impedance, and hypopharyngeal multichannel intraluminal impedance, in the context of patient selection for antireflux surgery.

Subxyphoid thyroidectomy: a feasibility study

OBJECTIVE

The cultural desire to avoid cervical incisions and increasing concern for cosmetic outcomes has motivated surgeons to develop alternative approaches to thyroid surgery. The Direct Drive Endoscopic System (DDES) platform combines a flexible endoscope with a pair of separately controlled articulating instruments through a single, flexible, access system. We hypothesized that the DDES platform would permit single-incision minimally invasive thyroid lobectomy without robotic assistance.

METHODS

This is a single-cadaver feasibility study. A single, 2.2-cm subxyphoid incision was used for access. The platform's 55-cm flexible sheath was secured to the operating table rails and introduced into the subcutaneous space. A flexible pediatric endoscope was simultaneously introduced with 2 interchangeable 4-mm instruments. Blunt dissection and electrocautery were used to create the tunnel in the otherwise free central plane. The thyroid was dissected using a superior to inferior technique while maintaining the critical steps of traditional thyroid surgery. A Veress needle introduced through the lateral neck provided additional retraction.

RESULTS

The total operating time was 2.5 hours. The subcutaneous tunnel was safe and accommodated the DDES well. Visualization was adequate. Graspers, scissors, and hook cautery were used to complete the lobectomy. The ergonomics, articulation, and strength of the instrumentation were sufficient.

CONCLUSIONS

Subxyphoid thyroidectomy is technically possible and avoids the difficulties inherent to a transaxillary approach while still avoiding cosmetically unappealing cervical scars. Continued technological refinement will only expand the therapeutic possibilities of flexible endoscopy while minimizing the physical insult to patients and maximizing aesthetics for patients.

Endoscopic suture fixation of gastrointestinal stents: proof of biomechanical principles and early clinical experience

BACKGROUND AND STUDY AIMS

Gastrointestinal stents have become an important therapeutic option for several indications. However, migration in up to 40 % of cases represents a significant drawback, especially when covered prostheses are used. We hypothesized that a novel endoscopic suturing device could enable endoluminal stent fixation, which might increase attachment and thereby potentially reduce migration.

PATIENTS AND METHODS

In an initial ex vivo porcine model, stents were attached to the esophageal wall with either endoscopic hemoclips or by endoscopic suture stent fixation (ESSF). The distal tension force required to induce dislocation was measured in Newtons (N) by a digital force gauge and was compared with conventional stent placement. ESSF was then performed clinically in five patients, in whom self-expanding metal stents were sutured in place for endoscopic treatment of gastrointestinal fistulas or strictures.

RESULTS

Esophageal ESSF was achieved in all experiments and significantly increased the force needed to displace the stent (n = 12; mean force 20.4 N; 95 % confidence interval [CI]: 15.4 - 25.4; P < 0.01) compared with clip fixation (n = 8; mean 6.1 N; 95 %CI 4.7 - 7.6) or stent placement without fixation (n = 16; mean 4.8 N; 95 %CI 4.0 - 5.6). All clinical cases of ESSF were performed successfully (5 /5) and took a median of 15 minutes. Elective stent removal was achieved without complications. One stent migration (1 /5) due to sutures being placed too superficially was observed. More loosely tied sutures remained intact, with the stent attached in place.

CONCLUSION

Endoscopic suture fixation of gastrointestinal stents provided significantly enhanced migration resistance in an ex vivo setting. In addition, early clinical experience found ESSF to be technically feasible and easy to accomplish.

A randomized multiinstitution comparison of the laparoscopic Nissen and Hill repairs

BACKGROUND

Laparoscopic Hill repair (LHR) and laparoscopic Nissen fundoplication (LNF) are established surgical antireflux procedures but have never been compared in a prospective trial. This trial was designed to compare the effectiveness of LHR against the gold-standard LNF.

METHODS

Patients with uncomplicated gastroesophageal reflux from two esophageal centers were randomly assigned and blinded from 2003 to 2007. Preoperative and postoperative evaluation included two quality of life metrics--Quality of Life in Reflux and Dyspepsia, and Dysphagia--as well as endoscopy, video esophogram, manometry, and pH testing.

RESULTS

Of 121 patients who consented to the trial, 102 underwent surgery; 46 LNF and 56 LHR were performed, with a mean follow-up of 12 months. Postoperatively, the DeMeester score normalized for both repairs, with no difference between them (LNF 6.8, LHR 11.1, p=0.26). Postoperative medication use was 4%, and the groups were equivalent. Lower esophageal sphincter pressure increased significantly for LNF (14.93 to 24.10, p=0.001) but not for LHR (19.91 to 20.25, p=0.87). Quality of life scores improved significantly for both repairs (LNF 3.77 to 6.65; LHR 3.84 to 6.54, p<0.001), and postoperative results were equivalent (p=0.99). Dysphagia scores preoperative/postoperative were LNF 33.88 to 38.33 and LHR 35.44 to 38.72, and were equivalent postoperatively (p=0.94). Two LNF and two LHR required reoperation for failed repair.

CONCLUSIONS

The LHR and the LNF both yield excellent and equivalent results for uncomplicated gastroesophageal reflux at 12 months. Their mechanisms of action may be different.

Laparoscopic paraesophageal hernia repair: defining long-term clinical and anatomic outcomes

OBJECTIVE

We recently reported in a multi-institutional, randomized study of laparoscopic paraesophageal hernia repair (LPEHR) that the anatomic recurrence rate at a median of approximately 5 years was >50%. This study focuses exclusively on the symptomatic response to LPEHR and its relationship with the development of a recurrent hernia.

METHODS

During 2002 to 2005, 108 patients underwent LPHER with or without biologic mesh. A standardized symptom severity questionnaire, SF-36 health survey, and upper gastrointestinal series were performed at baseline, 6 months, and during 2008-2009.

RESULTS

Of 108 patients, 72 (average age of 68 ± 10 years) underwent clinical assessment, and 60 of them also had radiologic studies at a median follow-up of 58 (40-78) months. Radiographic recurrence (≥ 20 mm) was 14% at 6 months and 57% at the time of follow-up, and the average recurrence size was 40 ± 10 mm. All symptoms were significantly improved at long-term follow-up and, with the exception of heartburn, were unaffected by the presence or size of the recurrence. Two patients (3%) with recurrent symptoms related to their hernia underwent reoperation.

CONCLUSION

Despite frequent radiologic recurrences after LPEHR, symptoms remain well controlled, patient satisfaction is high, and the need for reoperation is low.

A natural orifice transrectal approach for oncologic resection of the rectosigmoid: an experimental study and comparison with conventional laparoscopy

BACKGROUND

A transrectal (TR) approach for natural orifice translumenal endoscopic surgery (NOTES) makes sense for colorectal surgery because the colotomy can be incorporated into subsequent anastomosis. Because cancer is a primary indication for left-sided colon resection, oncologic standards will have to be met by a NOTES procedure. This study aimed to assess whether pure TR rectosigmoidectomy can be performed with strict adherence to oncologic principles compared with a conventional laparoscopically assisted approach (LAP).

METHODS

Human male cadavers were allocated to either TR (n = 4) or LAP (n = 2). A simulated sigmoid lesion was created at 25 cm. Transrectal retrograde mobilization of the rectosigmoid was performed using conventional transanal endoscopic microsurgery (TEM) instrumentation. After ligation of the superior hemorrhoidal artery and further mobilization, the specimen was delivered transanally and divided extracorporeally. Using a circular stapler, NOTES colorectal anastomosis was performed. Lymph node yield, adequate resection margins, and operative time were compared with LAP.

RESULTS

Transrectal retrograde rectosigmoid dissection was achieved in all attempts (4/4) and showed numbers of lymph nodes (median, 5; range, 3-6) similar to the LAP group (median, 4.5; range, 2-7). One pure TR approach failed to resect the lesion. Three TR procedures required additional mobilization via an abdominal approach to provide adequate margins. The mean length of TR specimens was 16 ± 4 cm compared with 31 ± 9 cm achieved by LAP (p < 0.01). The TR operative time was significantly longer (247 ± 15 vs 110 ± 14 min).

CONCLUSION

Lymph node yield during TR rectosigmoidectomy was similar to that achieved by the LAP approach. However, conventional TEM instrumentation alone did not permit adequate colon mobilization. This indicates a need for flexible instrumentation or other technical solutions to perform true NOTES colectomies.

Surgeon volume versus morbidity and cost in patients undergoing pancreaticoduodenectomy in an academic community medical center

BACKGROUND

Despite trends toward regionalization of care, the majority of pancreaticoduodenectomies (PD) are performed in community hospitals by surgeons with varying degrees of experience. We analyzed the impact of several variables, including surgeon volume, on outcomes following PD within a high-volume community-based teaching hospital system.

METHODS

Patients who underwent PD from 2005 to 2008 were reviewed retrospectively. Perioperative data, complications, and hospital financial data was queried. A high-volume (HV) surgeon was defined as an average of 10 or more PD per year.

RESULTS

Ninety-four patients underwent PD with an overall operative mortality rate of 9.6% (HV 2.2%, LV 16.0%), major complication rate of 32% (HV 18%, LV 44%), and median cost of $30,860 (HV $27,185, LV $33,007). Factors predictive of death were age (p < 0.02), body mass index (p < 0.01), and surgeon volume (p < 0.05). Factors predictive of major complication were surgeon volume (p < 0.01) and body mass index (p < 0.01). Factors predictive for increased length of stay for patients discharged from the hospital were surgeon volume (p < 0.02) and preoperative ASA classification (p < 0.05).

CONCLUSIONS

Surgeon volume and patient body mass index have a significant impact on perioperative morbidity following PD in a community teaching hospital.

Advances in cancer surgery: natural orifice surgery (NOTES) for oncological diseases

Natural orifice transluminal endoscopic surgery (NOTES) is a new concept that attempts to reduce the impact of surgery on the patient. In surgical oncology several studies have already revealed that a minimally invasive approach provides at least the same, if not a better, long-term outcome. One could hypothesize that a less invasive approach such as NOTES could further enhance such advantages. Since its initial description, NOTES has become clinical reality and today nearly every organ is accessible by a transluminal approach, in at least the experimental setting. Subsequent to published research, first clinical studies on NOTES in oncology were reported and the accuracy of transgastric peritoneoscopy for staging of pancreas cancer was shown to be similar to laparoscopy in humans. A NOTES gastro-jejunostomy via transgastric access has also been proposed to decrease invasiveness of palliative treatment of duodenal, biliary and pancreatic cancers. Colorectal cancer resection via transanal access would offer a clear-cut patient advantage over laparoscopic and would not be subject to the frequent criticism of violating an innocent second organ, as the colon or rectum is always breached in a colectomy. Natural orifice endoluminal therapies, such as endoscopic submucosal dissection, already have been clinically applied for several years. Improved techniques or instruments evolving from NOTES technology might enhance its widespread use for the treatment of early malignancies and thereby again will provide a tremendous benefit for the patient. Although still somewhat controversial, the subject of natural orifice surgery in oncological disease indicates that current laboratory efforts to introduce NOTES into cancer surgery could be ready for cautious clinical investigations. The final determination of patient benefit will need well-constructed prospective study.

How should we establish the clinical case numbers required to achieve proficiency in flexible endoscopy?

BACKGROUND

Recommended procedure numbers for upper endoscopy (UE) and colonoscopy (C) are 35 and 50 for surgical residents, and 130 and 140 for gastroenterology fellows, respectively. The purpose of this study was to challenge the methods used to determine proficiency in flexible endoscopy.

METHODS

Global assessment of gastrointestinal endoscopic skills (GAGES) was used to evaluate 139 procedures. Scores for UE were compared using self-reported case numbers and grouped according to requirements for each discipline. C scores were compared using the requirements to define novice and experienced endoscopists. Procedure volumes were plotted against GAGES scores.

RESULTS

Three groups were compared for UE based on case volumes: fewer than 35 cases (group 1), 35 to 130 cases (group 2), and more than 130 cases (group 3). There was no difference between group 2 (17.8 +/- 1.8) and group 3 (19.1 +/- 1.1), but both scored higher than group 1 (14.4 +/- 3.7; P < .05). For C, the scores were 11.8 +/- 3.8 (novices) and 18.8 +/- 1.34 (experienced; P < .001) at a 50-case minimum and 12.4 +/- 4.2 and 18.8 +/- 1.3 (P < .001) for a 140-case proficiency cut-off level, respectively. The curve of procedures versus GAGES plateaued at 50 (UE) and 75 (C).

CONCLUSIONS

The surgical and gastroenterology case recommendations may not represent the experience needed to achieve proficiency. GAGES scores could help define proficiency in basic endoscopy.