Outcomes of Nissen fundoplication in patients with gastroesophageal reflux disease and delayed gastric emptying

OBJECTIVE

To investigate the effect of delayed gastric emptying (DGE) on subjective and objective outcomes of gastroesophageal reflux disease following Nissen fundoplication with or without pyloroplasty.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Tertiary care teaching hospital.

PATIENTS

A total of 141 consecutive patients considered for Nissen fundoplication who also had suspected DGE based on symptoms.

INTERVENTIONS

Of 141 patients, 63 had a time to 50% emptying (T(1/2)) greater than 90 minutes; 47 of the 63 of these had severe DGE (T(1/2) > 150 minutes) and had Nissen fundoplication and pyloroplasty. Sixteen of the 141 with T(1/2) greater than 90 but less than 150 minutes and 78 with normal gastric emptying findings (n = 78) had Nissen fundoplication only.

MAIN OUTCOME MEASURES

Postoperatively, patients with symptom scores greater than 2 and/or abnormal 24-hour pH values (DeMeester score >14.7) were considered to have had unsuccessful treatment. Gastroesophageal reflux disease outcomes were compared between groups 1 and 2. Finally, the outcomes of both groups were compared with a control cohort of 418 patients with Nissen fundoplication and no DGE symptoms (group 3).

RESULTS

At the mean follow-up of 21 months, there were no differences between the 2 groups regarding relief of reflux symptoms (DGE group, 54 of 63 [85.7%] vs NGE group, 71 of 78 [91%]; P = .47) or objective control of acid reflux (DGE group, 33 of 39 [84.6%] vs NGE group, 41 of 51 [80.3%]; P = .78). Dyspeptic symptoms were improved in the DGE group (P < .001); however, the overall incidence remained higher than the NGE group (P = .01). Postoperatively, T(1/2) normalized in 88.23% (15 of 17) of patients. Postoperative objective outcomes were also no different between these groups and patients with Nissen fundoplication who did not have DGE symptoms (n = 418).

CONCLUSIONS

Delayed gastric emptying does not affect outcomes of gastroesophageal reflux disease following Nissen fundoplication, but patients with DGE have more postoperative gas and bloat and/or nausea compared with patients with normal gastric emptying; this is mostly corrected by addition of a pyloroplasty.

Evaluation of a manually driven, multitasking platform for complex endoluminal and natural orifice transluminal endoscopic surgery applications (with video)

BACKGROUND

The Direct Drive Endoscopic System (DDES) is a multitasking platform developed to overcome the limitations of the currently available rigid and flexible endoscopic systems in application to natural orifice transluminal endoscopic surgery (NOTES), single-port laparoscopy, and advanced endoluminal procedures. The system consists of a 3-channel, steerable guide sheath accepting a 6-mm endoscope and two 4-mm articulating instruments. The system's overall design enables the interventionalist to operate instruments bimanually from a stable platform, conveying a laparoscopic paradigm to the functional working space at the distal end of the flexible guide sheath.

OBJECTIVE

To assess the basic functionality of the DDES device in a series of defined exercises by using ex vivo porcine stomachs and 1 in vivo animal model.

DESIGN

Ex vivo calibration and training exercises, including EMR, full-thickness suturing, and knot tying.

SETTING

Animal laboratory.

INTERVENTIONS

EMR, full-thickness suturing, and knot tying.

MAIN OUTCOME MEASUREMENTS

Successful completion of specified tasks.

RESULTS

Independent instrument movement with a wide range of motion allowed the interventionalist to perform several complex tasks efficiently. The DDES was able to (1) grasp tissue and hold it under tension, (2) cut through layers of porcine stomach in a controlled fashion, (3) suture, and (4) tie knots.

LIMITATION

Ex vivo study.

CONCLUSIONS

This novel multitasking platform demonstrated surgical functionality including triangulation, cutting, grasping, suturing, and knot tying. Preliminary results suggest that the DDES can perform complex endosurgical tasks that have traditionally been challenging or impossible with the standard endoscopic paradigm, and may enable NOTES, single-port laparoscopy, and complex endoluminal procedures.

Patient factors predictive of 24-h pH normalization following endoluminal gastroplication for GERD

BACKGROUND

Endoluminal full-thickness gastroplication has been documented to provide significant and long-lasting improvement of GERD symptoms and health-related quality of life (HRQL) with very little patient morbidity. These treatments, however, are criticized for normalizing esophageal acid exposure in only 30-40% of patients treated. We hypothesize that there are objective criteria that will identify those patients who will have a normal DeMeester score (DMS) following endoluminal treatment.

METHODS

Data from a prospective multicenter trial using the NDO Plicator device to treat GERD were available for statistical analysis. All patients were treated with endoluminal full-thickness gastroplication. All patients had GERD symptoms and abnormal 24-h pH exposure preoperatively. Postoperative objective outcome was assessed by performing 24-h pH studies at 6 months. Univariate and multivariate regression analyses were performed to determine factors predictive of successful treatment (normalized 24-h pH).

RESULTS

A total of 266 patients were included in the study. Mean preoperative DMS was 47.91 (+/-31.34). Postoperatively, mean DMS decreased significantly (37.11 +/- 24.63, p < 0.001), and 31.67% of patients had a DMS within normal range (DMS < 22). Results of multivariate regression analysis demonstrated that the following preoperative patient characteristics were predictive of postoperative success (normal DMS): DMS < 30 (odds ratio [OR] = 4.24, 95% confidence interval [CI] = 1.73, 10.36, p < 0.001), heartburn score < 2 (OR = 3.37, CI = 1.44, 7.89, p = 0.005), and BMI < 30 (OR = 4.93, CI = 1.55, 15.61, p = 0.007).

CONCLUSION

Data analysis from this prospective study indicates that the odds of objective success would be significantly greater if the treatment was restricted to thinner patients with mild reflux disease. This may help define the optimal place for endoluminal therapy in a comprehensive GERD treatment algorithm.

Patient attitudes and expectations regarding natural orifice translumenal endoscopic surgery

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) has theoretical patient advantages. Because public attitude toward NOTES will influence its adoption, this study aimed to assess patients' opinions regarding the NOTES procedure.

METHODS

For this study, 192 patients were surveyed. Both NOTES and laparoscopic surgery (LS) are described together with an example case. Presurgical patients rated the importance of various aspects of surgical procedures and their preference for cholecystectomy via NOTES or LS.

RESULTS

Complication risks, recovery time, and postoperative pain were considered more important than cosmesis, cost, length of hospital stay, or anesthesia type (p < 0.001). In the self-reports, 56% of the respondents preferred NOTES for their cholecystectomy and 44% chose LS. The patients perceived NOTES as having less pain, cost, risk of complications, and recovery time but requiring more surgical skill than open surgery or LS (p < 0.04). College-educated patients were more likely to choose NOTES, whereas patients 70 years of age or older and those who had undergone previous flexible endoscopy were less likely to select NOTES (p < 0.04). Although 80% of the patients choosing NOTES still preferred it even if it carried a slightly greater risk than LS, their willingness to choose NOTES decreased as complications, cost, and hospital distance increased and as surgeon experience decreased (p < 0.001). This study had a limitation in that the survey population was from surgery clinics.

CONCLUSION

A majority of the patients surveyed (56%) would choose NOTES for their cholecystectomy. The deciding characteristics of the patients were more education, youth, and no previous flexible endoscopy. Procedure-related risks, pain, and recovery time were more important than cosmesis, cost, length of hospital stay, and anesthesia type in the choice of a surgical approach. Patients were less willing to accept NOTES as risks and costs increased and as surgeon experience and availability decreased.

Verbal Communication Improves Laparoscopic Team Performance

The impact of verbal communication on laparoscopic team performance was examined. A total of 24 dyad teams, comprisied of residents, medical students, and office staff, underwent 2 team tasks using a previously validated bench model. Twelve teams (feedback groups) received instant verbal instruction and feedback on their performance from an instructor which was compared with 12 teams (control groups) with minimal or no verbal feedback. Their performances were both video and audio taped for analysis. Surgical backgrounds were similar between feedback and control groups. Teams with more verbal feedback achieved significantly better task performance ( P = .002) compared with the control group with less feedback. Impact of verbal feedback was more pronounced for tasks requiring team cooperation (aiming and navigation) than tasks depending on individual skills (knotting). Verbal communication, especially the instructions and feedback from an experienced instructor, improved team efficiency and performance.

Initial experience with a novel endoscopic device allowing intragastric manipulation and plication

BACKGROUND

Current developments in intraluminal and transluminal natural orifice surgery are limited by issues of access, tissue manipulation, and secure tissue approximation/closure. This report describes an initial laboratory experience with a novel tissue approximation and suturing device. The device is deployed via a previously described platform and is 6 mm in diameter. Desirable qualities of this tissue approximation/closure device include robust tissue grasping, minimal tissue trauma, fully visualized anchor placement via off-axis needle and anchor deployment, full reloadability without instrument withdrawal, single-operator operating capability, torque-stable manipulability, and operator-controlled tension setting of tissue anchor pairs.

METHOD

The device was trialed in performing several maneuvers in porcine or canine models. The features of the system allowed bimanual tissue manipulation, full-thickness tissue approximation and plication, and secure closure of an ex vivo gastrotomy hole similar to that used during transluminal surgical interventions.

CONCLUSIONS

This device appears to offer promise in achieving more complex endoluminal and potentially transluminal tasks, including secure suture closure of tissue defects and access holes. As such, devices of this type may prove useful in addressing some of the identified barriers to further development of natural orifice surgical intervention. Further investigation of the qualities and capabilities of this device in these settings is warranted.

Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility.

METHODS

A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions.

RESULTS

In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 +/- 5.2 mmHg (range, 6.0-30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% +/- 8.3% (range, 70-100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett's progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1-46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results.

CONCLUSION

The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360 degrees fundoplication should not be contraindicated for patients with severe esophageal dysmotility.

Desarrollo tecnológico actual de la cirugía endoscópica transluminal a través de orificios naturales

Natural orifice transluminal endoscopic surgery (NOTES) is a novel concept which combines aspects of flexible endoscopy with laparoscopic surgery with the aim of creating a new field of patient friendly "incisionless" surgery. This will require novel advanced technologies to be developed specifically for NOTES. We discuss the technical requirements and the process of creating NOTES instrumentation and illustrate the process with some current enabling devices. The development process is outlined, including the requirements for NOTES, the current technology that can be used, and some prototype devices for access, retraction, and tissue approximation. Endoscopes for NOTES must have high resolution, large instrument channels, some degree of triangulation, and the ability to lock into position inside the abdominal cavity. Instrumentation should echo the capabilities of current laparoscopic tools. They should be large and sturdy, torque-able, and offer the full spectrum of end-effectors. Finally, NOTES technology must permit secure, tailorable tissue approximation. The "R" scope from Olympus and the Transport scope from USGI Medical are possible solutions to the design requirements for access and visualization. Eagle Claw (Olympus), The Swain system (Ethicon), and the G-prox (USGI) are current tissue approximation systems under development and investigation in clinical trials. NOTES is a potential advance in surgical care. This new approach requires the development of new platform devices, tailored to allow the safe and effective practice of this advanced endoscopic approach.

Endoluminal methods for gastrotomy closure in natural orifice transenteric surgery (NOTES)

Natural orifice transenteric surgery (NOTES) is a new and rapidly evolving concept for intra-abdominal operations that offers the potential for a revolutionary advance in patient care. Conceptually, operations that currently require an open or laparoscopic approach could be performed without incisions in the abdomen, with their concomitant pain and scarring. A recent consensus statement by a joint group of gastrointestinal surgeons and gastroenterologists has identified several technical and technologic hurdles that would need to be overcome before NOTES becomes a clinical reality. One of the most significant requirements identified is the need for a very secure closure of the gastrotomy site that is required for scope passage and specimen removal. Although a rapidly expanding variety of transgastric procedures has been reported, only a few reports address the basic problem of gastrotomy closure. Availability of a safe and simple gastrotomy closure device, however, will be essential for the widespread adoption of the new field of NOTES. Unless new safe and simple devices for endoscopic gastrotomy closure are available and have proven efficacy, NOTES will remain in the hands of a few specialists at centers of excellence because the risk of complications due to insufficient gastrotomy closure will not be acceptable for the surgeon and gastroenterologist in general practice. In this article, we describe three new devices in development or newly on the market that are targeted to advance the safe endoscopic closure of gastrotomy from NOTES.

Bringing order to the chaos: developing a matching process for minimally invasive and gastrointestinal postgraduate fellowships

BACKGROUND

Since 1993, there has been an increase in the number of postgraduate fellowships in minimally invasive and gastrointestinal (GI) surgery; from 9 in 1993 to more than 80 in 2004. Early on, there was no supervision or accreditation of these fellowships, and they varied widely in content, structure, and quality. This was widely recognized as being a bad situation for fellow applicants and reflected poorly on the specialties of minimally invasive (MI) and GI surgery. In an effort to bring order to this chaotic situation, the Minimally Invasive Surgery Fellowship Council (MISFC) was founded in 1997.

METHOD

In 2003, the MISFC was incorporated with 77 founding member programs. The goal of the MISFC was to develop guidelines for high-quality fellowship training, to provide a forum for the directors of MI and GI fellowships to exchange ideas, formulate training curricula; to establish uniform application and selection dates; and to create an equitable computerized match system for applicants.

RESULTS

In 2004, the MISFC has increased to 95 members representing 154 postgraduate fellowship positions. The majority of these positions are primarily laparoscopic in focus, but other aspects of GI surgery including bariatric, general GI, flexible endoscopy, and hepatopancreatobiliary are also represented. Uniform application and selection dates were agreed on in 2001; and in 2003, the Council established a computerized Match, administered by the National Resident Match Program, which was used for the 2004 fellowship selection. A total of 113 positions were open for the match. A total of 248 applicants formally applied to MISFC programs and 130 participated in the match. Ninety-nine positions matched on the December 10th match day, and the remaining 14 programs successfully filled on the following scramble day. Seventeen applicants did not match to a program. Post match polling of program directors and applicants documented a high degree of compliance, usability, and satisfaction with the process.

CONCLUSION

The MISFC has been successful at realizing its goals of bringing order to the past chaos of the MIS and GI fellowship situation. Its current iteration, the Fellowship Council, is in the process of introducing an accreditation process to further ensure the highest quality of postgraduate training in the fields of GI and endoscopic surgery.

Beta test results of a new system assessing competence in laparoscopic surgery

BACKGROUND

There is currently a need for objective measures of surgical competence. Such measures should assess knowledge, judgment, and manual skills. The Fundamentals of Laparoscopic Surgery (FLS) program was developed by the Society of American Gastrointestinal and Endoscopic Surgeons to meet these criteria. The FLS assessment includes a multiple-choice cognitive test and a manual skills test. We present the results of validation studies of this novel assessment tool.

STUDY DESIGN

Beta testing of the FLS examination was undertaken at 7 sites by 70 surgeons representing 4 levels of experience and training. Surgeons provided information about their prior experience and indicated a self-assessment of their laparoscopic competence. Results were assessed by ANOVA followed by orthogonal contrasts.

RESULTS

Cognitive performance by training level: There was no difference between fellows and staff in percentage of questions answered correctly, but there was a discrepancy between junior and senior residents and between residents and senior surgeons (p < 0.01). Cognitive performance by laparoscopic experience quartiles: There were notable contrasts between the first and second quartiles of experience (p < 0.02) and between the third and fourth quartiles (p < 0.01). No marked difference was found between the second and third quartiles. Cognitive performance compared with self-assessment: Test results were substantially different (p < 0.01) between test-takers who assessed themselves as "better than average" and those who assessed themselves as "average" or "below average." Manual skills performance by training level: The major difference was found between junior residents versus senior residents, fellows or staff (p < 0.01). Manual skills performance by laparoscopic experience level: Differences were primarily seen between the first two quartiles and the last two quartiles of laparoscopic experience (p < 0.001). Manual skills performance compared with self-assessment: Those who assessed themselves as "above average" in laparoscopic skill performed markedly better than those indicating they had "average" or "below average" skill (p < 0.01).

CONCLUSIONS

Beta test results for the FLS examination demonstrate satisfactory reliability, appropriate psychometric properties, and substantial initial validity. The FLS project is one of the first validated surgical education efforts to assess the competence of surgeons in a specific field.

Forty-eight-hour pH monitoring increases sensitivity in detecting abnormal esophageal acid exposure

Ambulatory 24-hour esophageal pH measurement is the standard for detecting abnormal esophageal acid exposure (AEAE), but it has a false negative rate of 15% to 30%. Wireless 48-hour pH monitoring (Bravo; Medtronic, Shoreview, MN) may allow more accurate detection of AEAE versus 24-hour pH monitoring. Forty-eight-hour wireless data were reviewed from 209 patients at three different tertiary care referral centers between 2003 and 2005. Manometric or endoscopic determination of the lower esophageal sphincter helped place the Bravo probe 5 to 6 cm above the lower esophageal sphincter. A total of 190 studies in 186 patients had sufficiently accurate data. There were 114 women and 72 men with an average age of 51 years. AEAE was defined by a Johnson-DeMeester score greater than 14.7 and was obtained in 115 of 190 studies (61%). Only 64 of 115 patients (56%) demonstrated AEAE for both days of the study, whereas 51 of 115 patients (44%) demonstrated AEAE in a single 24-hour period. There was no difference in the prevalence of AEAE on day 1 versus day 2 only (26% vs. 18%, P = .26). Compared with 24-hour alone data, 48-hour data showed 22% more patients with AEAE. Frequent day-to-day variability in patients with AEAE may be missed by a single 24-hour pH test. Forty-eight-hour pH testing may increase detection accuracy and sensitivity for AEAE by as much as 22%.

Development of a new access device for transgastric surgery

Flexible endoscope-based endoluminal and transgastric surgery for cholecystectomy, appendectomy, bariatric, and antireflux procedures show promise as a less invasive form of surgery. Current endoscopes and instruments are inadequate to perform such complex surgeries for a variety of reasons: they are too flexible and are insufficient to provide robust grasping and anatomic retraction. The lack of support for a retroflexed endoscope in the peritoneal cavity makes it hard to reach remote structures and makes vigorous retraction of tissues and organs difficult. There is also a need for multiple channels in scopes to allow use of several instruments and to provide traction/countertraction. Finally, secure means of tissue approximation are critical. The aim was to develop and test a new articulating flexible endoscopic system for endoluminal and transgastric endosurgery. A multidisciplinary group of gastrointestinal physicians and surgeons worked with medical device engineers to develop new devices and instruments. Needs assessments and design parameters were developed by consensus. Prototype devices were tested using inanimate models until usable devices were arrived at. The devices were tested in nonsurvival pigs and dogs. The devices were accessed through an incision in the wall of the stomach and manipulated in the peritoneal cavity to accomplish four different tasks: right upper quadrant wedge liver biopsy, right lower quadrant cecal retraction, left lower quadrant running small bowel, and left lower quadrant exposure of esophageal hiatus. In another three pigs, transgastric cholecystectomy was attempted. The positions of the device, camera, and endosurgical instruments, with and without ShapeLock technology, were recorded using laparoscopy and endoscopy and procedure times and success rates were measured. Instrument design parameters and their engineering solutions are described. Flexible multilumen guides which could be locked in position, including a prototype which allowed triangulation, were constructed. Features of the 18-mm devices include multidirectional mid body and/or tip angulation, two 5.5-mm accessory channels allowing the use of large (5-mm) flexible endosurgical instruments, as well as a 4-mm channel for an ultraslim prototype video endoscope (Pentax 4 mm). Using the resulting devices, the four designated transgastric procedures were performed in anesthetized animals. One hundred percent of the transgastric endosurgical procedures were accomplished with the exception of a 50% success for hiatal exposure, a 90% success rate for wedge liver biopsy, and a 33.3% success rate for cholecystectomy. A new endosurgical multilumen device and advanced instrumentation allowed effective transgastric exploration and procedures in the abdominal cavity including retraction of the liver and stomach to allow exposure of the gallbladder, retraction of the cecum, manipulation of the small bowel, and exposure of the esophageal hiatus. This technology may serve as the needed platform for transgastric cholecystectomy, gastric reduction, fundoplication, hiatus hernia repair, or other advanced endosurgical procedures.

Manometric abnormalities and gastroesophageal reflux disease in the morbidly obese

BACKGROUND

Obesity is an epidemic in the USA. Many disorders are associated with obesity including gastroesophageal reflux disease (GERD). However, the prevalence of GERD and esophageal motility disorders in the morbidly obese population is unclear.

METHODS

During evaluation for bariatric surgery, 61 morbidly obese patients underwent preoperative 24-hr pH and esophageal manometry. A single reviewer evaluated all 24-hr pH and manometric tracings. Johnson-DeMeester score >14.7 was considered diagnostic of GERD. Manometric criteria for motility disorders were from published values. All values are given as mean +/- SD.

RESULTS

Mean age was 44.4 + 10.3 years. 55 of the patients (90%) were female. Mean BMI was 50.1 +/- 7.2 kg/m(2). 23 patients (38%) complained of GERD symptoms (reflux and/or heartburn). 1 patient (2%) complained of noncardiac chest pain. Mean Johnson-DeMeester score was 19.6 +/- 17.8. Mean intragastric and intrabolus pressures were both elevated (8.3 +/- 1.6 mmHg and 15 +/- 9 mmHg). 33 patients (54%) had abnormal manometric findings: 10 had a mechanically defective LES, 11 had a hypertensive LES, 2 had diffuse esophageal spasm, 3 had nutcracker esophagus,1 had ineffective esophageal disorder and 14 had nonspecific esophageal motility disorder. Some patients had more than one disorder. 20 patients (33%) had significantly elevated (>180 mmHg) contraction amplitudes at the most distal channel (210.0 +/- 28.7 mmHg).

CONCLUSIONS

Prevalence of manometric abnormalities in the morbidly obese is high. Presence of a nut cracker-like distal esophagus in the morbidly obese is significant and warrants further evaluation.

Expression of vascular endothelial growth factor and receptor flk-1 in colon cancer liver metastases

BACKGROUND/PURPOSE

This study investigated vascular endothelial growth factor (VEGF) and flk-1 expression in hepatic metastases from colon carcinoma, and their associations with tumor angiogenesis, proliferation, and apoptosis.

METHODS

Immunohistochemical studies were performed for VEGF/flk-1, Ki-67, p53, and bcl-2 expression, and microvessel density (MVD) in surgical specimens from 35 patients who underwent hepatectomy for colon cancer liver metastases between 1986 and 2001.

RESULTS

VEGF and flk-1 were expressed mainly in the cytoplasm of tumor cells. High VEGF expression was associated with high flk-1 expression (P = 0.043). MVDs of less than 15 and 15 or more were found in 5 (14.3%) and 30 (85.7%) of 35 hepatic metastases, respectively. A Ki-67 index (KI) of 50% or more was detected in 33/35 (94.3%) of tumors, and 23 of these (65.7%) showed a KI of 85% or more. A KI of less than 50% was present in 2/35 (5.7%) of tumors. The expression of VEGF/flk-1 was related to elevated MVD (P < or = 0.026). VEGF was also associated with an increased KI (P = 0.025). Mutant p53 and bcl-2 expressions were detected in 26/35 (74.3%) and 17/35 (48.6%) of liver metastases, respectively. Mutant p53 was not related to VEGF/flk-1 expression, but bcl-2 was highly associated with flk-1 (P = 0.007). The incidences of high flk-1 expression and a KI of 85% or more were significantly higher in tumors which were both p53- and bcl-2-positive (93.3% and 73.3%) than in tumors which were negative for both (42.9% and 14.3%; P < or = 0.021).

CONCLUSIONS

The VEGF-flk-1 system takes part in tumor angiogenesis, proliferation, and apoptosis in colon liver metastases. The bcl-2 pathway may upregulate VEGF activity via the flk-1 receptor. These findings are preliminary, requiring a larger sampling in order to elucidate the role of VEGF/flk-1 in metastatic colon cancer.

Postoperative objective outcomes for upright, supine, and bipositional reflux disease following laparoscopic nissen fundoplication

HYPOTHESIS

Traditionally, patients with gastroesophageal reflux disease fall into 3 categories based on 24-hour pH testing and the clinical occurrence of their acid exposure. Patients with upright reflux are believed to do worse following surgery compared with supine or bipositional reflux patients. We assessed objective postoperative outcomes for patients with upright, supine, and bipositional reflux following laparoscopic Nissen fundoplication to determine if there is a category of refluxing patient who should be counseled against antireflux surgery.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Esophageal physiology laboratory at a tertiary care teaching hospital.

PATIENTS

A total of 225 patients (supine, 45; upright, 92; bipositional, 88) with preoperative and postoperative 24-hour pH measurements, manometry results, and standardized symptom assessment forms were included in the study.

INTERVENTIONS

A Nissen fundoplication was performed based on 24-hour pH and manometry result. Esophageal manometry was performed with a water-perfused system, and 24-hour pH was measured with a digital capture device.

MAIN OUTCOME MEASURES

Preoperative and postoperative symptom correlation, 24-hour pH, and manometric variables.

RESULTS

There was a significant difference in preoperative symptom correlation between groups. Patients with bipositional reflux disease have significantly worst reflux disease (percentage of time with a pH <4, total number of reflux episodes, longest reflux episode, and Johnson-DeMeester score) and the weakest preoperative lower esophageal sphincter pressure. Postoperative symptom correlation was low among all 3 groups. There was no significant difference in postoperative 24-hour pH or manometry among groups. Success following surgery was achieved in 73.3% with supine reflux, 80.4% with upright reflux, and 75.0% with bipositional reflux.

CONCLUSIONS

Patients with bipositional reflux have the most severe disease. Supine, upright, and bipositional reflux patients perform equally well following laparoscopic fundoplication as defined by objective outcome criteria.

Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications

PURPOSE

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for full-thickness excision of benign and malignant rectal neoplasms located 4 to 24 cm above the anal verge. Entrance into the peritoneal cavity during TEM has been regarded as a complication that mandates conversion to open laparotomy for adequate repair of the defect. This study compares the rate of complications arising from TEM with and without intraperitoneal entry.

METHODS

Patients undergoing peritoneal entry were compared to those who did not.

RESULTS

No perioperative deaths occurred. There was no significant difference in the incidence of postoperative complications. No major complications occurred with peritoneal entry, and all peritoneal entries were closed transanally via endoscope.

CONCLUSIONS

Entry into the peritoneum during TEM is not associated with an increased incidence of complication. Entry into the peritoneum during TEM excision does not mandate conversion to open laparotomy but may be safely repaired endoscopically. Lesions likely to be above the peritoneal reflection and within reach of the endoscope (4 to 24 cm) should be considered for TEM excision.

Laparoscopic Placement of Hepatic Artery Infusion Pumps: Technical Considerations and Early Results

BACKGROUND

Laparoscopic hepatic artery infusion pump (LHAIP) placement is a novel treatment option for patients with colorectal liver metastases. This study investigates technical difficulties with regard to variant hepatic arteries and the preliminary outcomes for patients treated with LHAIP placement.

METHODS

Between March 1998 and January 2003, 38 patients with colorectal metastases confined to the liver, 35 (92%) of who had prior systemic chemotherapy that failed, were treated with LHAIP.

RESULTS

Twelve patients (32%) had LHAIP placement only, and 26 (68%) had pump placement combined with laparoscopic radiofrequency ablation (LRFA; 24 patients) and/or liver resection (2 patients). Variant hepatic arterial (HA) anatomy was present in 18 patients (47%). The presence of a variant HA did not increase pump complications, operative time, or blood loss (P >/=.20) or decrease the functional time of pump use (P =.91) in comparison with normal anatomy. In all patients with a variant HA, laparoscopic ligation of the variant vessel and/or cannulation of nongastroduodenal artery resulted in complete hepatic perfusion. Three misperfusions identified intraoperatively with use of methylene blue injection were corrected by laparoscopic ligation (two) or postoperative angioembolization (one). Postoperative pump radionuclide flow studies confirmed isolated hepatic artery infusion in all cases. There was a 13% pump-related complication rate. During a median follow-up of 11 months (0.5 to 35.5 months), the actuarial rate of overall survival was 47% and the estimated median survival time was 17.5 months.

CONCLUSIONS

LHAIP placement is technically feasible, and variant HA is not associated with increased pump complications or decreased pump functional time.

Laparoscopic biliary reconstruction

BACKGROUND

Biliary reconstruction represents a relatively untested frontier in laparoscopy.

METHODS

Retrospective review of all patients who underwent laparoscopic biliary operations at Legacy Health System from 1998 to 2003.

RESULTS

Seven patients underwent laparoscopic biliary reconstruction. Indications included benign calculous disease in 4 patients, benign stricture on 1 patient, choledochal cyst in 1 patient, and malignant biliary obstruction in 1 patient. Operations performed included choledochoduodenostomy, hepaticojejunostomy, stricturoplasty, choledochal cyst excision with hepaticojejunostomy, and cholecystojejunostomy. Median operative time was 300 minutes. Median hospital stay was 4 days. One perioperative complication of a bowel obstruction required reoperation. Median follow-up was 15 months. One patient died of metastatic cancer 8 months after surgery. All other patients are symptom free with no signs of stricture or recurrent biliary obstruction.

CONCLUSIONS

Laparoscopic biliary reconstruction represents a viable treatment option in carefully selected patients.