Single-port laparoscopic Heller myotomy and Dor fundoplication: initial experience with a new approach for the treatment of pediatric achalasia

Achalasia

Achalasia is a rare neurogenic motility disorder of the esophagus, occurring in approximately 0.11 cases per 100,000 children. The combination of problems (aperistalsis, hypertensive lower esophageal sphincter (LES), and lack of receptive LES relaxation) results in patients having symptoms of progressive dysphagia, weight loss, and regurgitation. Treatment modalities have evolved over the past few decades from balloon dilation and botulinum toxin injection to laparoscopic Heller myotomy and endoscopic myotomy. Most data on achalasia management is extrapolated to children from adult experience. This article describes understanding of the pathogenesis and discusses newer therapeutic techniques as well as controversies in management.

Laparoscopic esophagomyotomy for achalasia in children: A review

Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy (LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multi-institutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term (> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care.

Short-term surgical outcomes of reduced port surgery for esophageal achalasia

PURPOSE

To clarify the feasibility and utility of reduced port surgery (RPS) for achalasia.

METHODS

Between September 2005 and June 2013, 359 patients with esophageal achalasia, excluding cases of reoperation, underwent laparoscopic Heller myotomy and Dor fundoplication (LHD) according to our clinical pathway. Three-hundred and twenty-seven patients underwent LHD with five incisions (conventional approach), while the other 32 patients underwent RPS, including eight via SILS. The clinical data were collected in a prospective fashion and retrospectively reviewed. We selected 24 patients matched for gender, age and morphologic type with patients in the RPS group from among the 327 patients (C group). The surgical outcomes were compared between the C and RPS groups.

RESULTS

There were no significant differences between the two groups in the duration of symptoms, dysphagia score, chest pain score, shape of the distal esophagus and esophageal clearance. The operative time was significantly longer in the RPS group than in the C group (p < 0.001). There were no significant differences between the two groups in the length of postoperative hospital stay or rates of bleeding, mucosal injury of the esophagus and/or stomach and postoperative complications. The symptom scores significantly improved after surgery in both groups (p < 0.001). Furthermore, there were no significant differences between the C group and RPS group in terms of the postoperative symptom scores or satisfaction scores after surgery.

CONCLUSIONS

The surgical outcomes of RPS for achalasia are comparable to those obtained with the conventional method.

Advances in minimally invasive surgery in pediatric patients

Surgery has changed dramatically over the last several decades. The emergence of MIS has allowed pediatric surgeons to manage critically ill neonates, children, and adolescents with improved outcomes in pain, postoperative course, cosmesis, and return to normal activity. Procedures that were once thought to be too difficult to attempt or even contraindicated in pediatric patients in many instances are now the standard of care. New and emerging techniques, such as single-incision laparoscopy, endoscopy-assisted surgery, robotic surgery, and techniques yet to be developed, all hold and reveal the potential for even further advancement in the management of these patients. The future of MIS in pediatrics is exciting; as long as our primary focus remains centered on developing techniques that limit morbidity and maximize positive outcomes for young patients and their families, the possibilities are both promising and infinite.

The international experience of single-incision pediatric endosurgery: current state of the art

PURPOSE

As application and awareness of single-incision pediatric endosurgery (SIPES) are increasing, various techniques and indications have been independently described by select centers around the world. In order to facilitate a cooperative approach toward advancing and investigating the practice of SIPES, we conducted a survey among members of the International Pediatric Endosurgery Group (IPEG), asking them about their experience and attitudes toward single-incision endosurgery.

MATERIALS AND METHODS

After institutional review board approval, an invitation to participate in an online survey was sent to all IPEG members. Questions focused on demographic information, practice patterns, indications, and equipment used regarding SIPES.

RESULTS

Of the 560 contacted active IPEG members, 115 completed the survey (recall 21%). The respondents represented pediatric surgeons from 32 countries on six continents. Of respondents, 97% had heard of, while 71% had performed, SIPES. Reasons for not having performed SIPES included disbelief in benefit (59%), lack of proficiency (34%), and inadequate resources (28%). The most commonly performed SIPES procedures were appendectomy (85%), cholecystectomy (66%), splenectomy (42%), pyloromyotomy (35%), and intestinal surgery (13%), as well as Nissen fundoplication and gynecologic adnexal pathology (7%). The equipment and techniques utilized showed large variation and included some self-devised, innovative, low-resource approaches. Complications with SIPES reported by the survey participants included technical difficulties, wound infection, and prolonged operating time.

CONCLUSIONS

SIPES is being performed worldwide for a large spectrum of common indications in pediatric surgery. The equipment and techniques used vary with geographic location and resources. Some encountered complications are common to those seen with conventional minimally invasive surgery, whereas others may be SIPES-specific. Different respondents reported diverging views on pain, operating time, and cost.

Long-term results of laparoscopic treatment of esophageal achalasia in children: a multicentric survey

BACKGROUND

This report describes three Italian centers' experience in the treatment of children with esophageal achalasia.

PATIENTS AND METHODS

Between June 2000 and June 2012, 31 children (13 girls and 18 boys, with a median age of 8.4 years) affected by esophageal achalasia were treated in three different institutions with an esophagomyotomy according to Heller's procedure via laparoscopy associated with a Dor antireflux procedure. Between 2000 and 2005 (for 14 patients) we used mono- or bipolar coagulation to perform myotomy; after 2005 (for 17 patients) we used the new hemostatic devices to perform it.

RESULTS

Median length of surgery was 120 minutes. Median hospital stay was 4 days. We recorded eight complications in our series: 3 patients (9.6%) had a mucosal perforation, and 5 children (16.1%) presented dysphagia after surgery. When comparing the data before and after 2005, it seems that the new hemostatic devices statistically shortened the length of surgery (P<.01, Student's t test).

CONCLUSIONS

On the basis of our experience, laparoscopic Heller's myotomy associated with an antireflux procedure is a safe and effective method for the treatment of achalasia in the pediatric population. Intraoperative complications were <10%, and they occurred mostly at the beginning of our experience. Residual dysphagia occurred in about 16% of cases. The use of the new hemostatic devices seems to reduce the length of surgery and intraoperative bleeding. Considering the rarity of this pathology, we believe that patients with achalasia have to be treated only at centers with a strong experience in the treatment of this pathology.

Single-port versus multiport laparoscopic resection for gastric gastrointestinal stromal tumors: a case-matched comparison

PURPOSE

The aim of this study was to compare the outcomes of single-port laparoscopic gastric resection (SPLGR) with multiport laparoscopic gastric resection (MPLGR) for gastric gastrointestinal stromal tumors (GISTs).

METHODS

Between April 2009 and December 2012, 16 consecutive patients with gastric GISTs underwent SPLGR. The patients undergoing the SPLGR were case-matched for age, sex, body mass index and tumor location with those undergoing MPLGR. The demographic and surgical outcomes were analyzed and compared from the review of a prospectively collected database of 16 patients who underwent MPLGR.

RESULTS

All 16 patients underwent complete SPLGR without any intraoperative complications. No significant differences were observed in the mean length of the operation (91.4 vs. 94.1 min), blood loss (6.3 vs. 10.1 ml) and length of postoperative hospital stay (4.7 vs. 5.4 days) between the SPLGR and MPLGR groups. The tumor size was similar (37.8 vs. 32.1 mm) and negative surgical margins were achieved in all patients. At a mean follow-up of 27 months, all 16 SPLGR patients were disease-free.

CONCLUSIONS

Our initial comparison demonstrated that SPLGR, when performed by experienced surgeons, is a safe and feasible procedure for patients with gastric GISTs, resulting in good surgical and oncological outcomes.

Laparoendoscopic single site adrenalectomy: initial results of cosmetic satisfaction and the potential for postoperative pain reduction

Background

Recent reports have suggested that laparoendoscopic single site (LESS) surgery is technically feasible. The aim of this study was to describe our initial experience with LESS adrenalectomy for benign adrenal tumors, focusing the attention about cosmetic satisfaction and reduction of postoperative pain.

Methods

Medical records of consecutive patients undergoing LESS adrenalectomy were analyzed. All procedures were performed through a single multichannel port. Demographic and operative data were assessed. A visual analog scale (VAS) was used with a 10-point scale for an objective assessment of incisional pain and incisional cosmesis.

Results

Between January 2010 and July 2012, 14 consecutive patients with benign adrenal tumors underwent LESS adrenalectomies. Of the planned LESS adrenalectomies, 12 (86%) were completed with a single-port, whereas two required an additional port placement. Mean operating time was 128.1 ± 31.5 min and mean blood loss 10.5 ± 12.1 ml. Mean pain scores using the VAS on postoperative days 1, 3, and 14 were 2.3, 1.0, and 0.3 points, respectively. The rate of analgesic use was also lower within 12 hours after surgery (14%). The patient was highly satisfied with the single small wound procedure, and mean cosmesis scores of postoperative days 3 and 14 were 9.4 and 9.8 points, respectively. The postoperative course was uneventful with no morbidity within one month of follow-up.

Conclusions

LESS adrenalectomy is a safe and technically feasible procedure for patients with benign adrenal tumors, and offers cosmetic benefit and the potential for postoperative pain reduction. However, surgeons with lack of experience as LESS surgery should be comprehended that the assistance of the needlescopic instrument does not compromise the cosmetic outcomes for difficult cases and the obese patients may not always be suitable candidates for pure LESS technique.

Single-incision pediatric endosurgery: a systematic review

BACKGROUND

Single-incision pediatric endosurgery (SIPES) is defined as minimally invasive surgery performed through a unique incision in the abdomen, chest, or retroperitoneum. Several publications exist, but no previous systematic review has been made to evaluate the real benefits of this approach in terms of feasibility and clinical outcomes.

MATERIALS AND METHODS

We performed an electronic search in PubMed up to March 2012 with the terms "single AND incision OR site OR port OR trocar AND children" including related articles and obtained 197 articles. After applying our inclusion criteria, 78 articles were reviewed.

RESULTS

We identified prospective controlled trials (n=1), case-control studies (n=12), case series (n=49), and case reports (n=16). In total, 4212 patients had been operated on by SIPES and were separated by systems: gastrointestinal (n=2888), urologic (n=390), gynecologic (n=27), other abdominal (n=874), and thoracic (n=33) procedures. The most common procedure was SIPES appendectomy, and a unique prospective controlled trial supports its safety and effectiveness. Technically demanding surgeries such as hepatojejunostomy and colonic surgeries were described. Multichannel ports and multiple ports, standard and articulated instruments, transparietal instruments, retraction sutures, and magnets were used. Operative times, length of stay, and complications similar to standard laparoscopic surgery were described. A low conversion rate (to a reduced port, standard laparoscopy and open procedures) was also mentioned. No comparable measure for pain and cosmesis assessment was used.

CONCLUSIONS

A wide experience in SIPES and feasibility has already been described with good clinical outcomes and low rate of conversion. Appendectomy is the unique procedure in which SIPES has been demonstrated to be safe and effective. It is pending the execution of prospective controlled trials for other operations to demonstrate, with objective evidence, the real benefits of this less invasive approach.

Single incision laparoscopic approach for esophageal achalasia: A case report

INTRODUCTION

Esophageal achalasia is an uncommon, benign, neurodegenerative disease that induces a transit disorder characterized by incomplete lower esophageal sphincter relaxation.

PRESENTATION OF CASE

A 56-year-old woman with dysphagia was admitted to our hospital. An esophagography revealed flask-type achalasia. Endoscopy revealed a dilated esophagus and some resistance at the esophagogastric junction. We used a capped wound protector, common straight forceps, and hook-type electrocautery to perform transumbilical single incision laparoscopic Heller myotomy with Dor fundoplication (SILHD). The left liver lobe and cardia were pulled by a thread. A 6-cm Heller myotomy of the esophagus was performed with an additional 2-cm myotomy of the gastric wall. Dor fundoplication was performed to cover the exposed submucosa. Intraoperative endoscopy confirmed the adequacy of the myotomy and Dor fundoplication. There were no postoperative complications. An esophagography and an endoscopic examination did not reveal stenosis or reflux at 1-year follow-up, and the patient has been satisfactorily symptom free.

DISCUSSION

LHD is the most accepted surgical treatment for achalasia and has low invasiveness and long-term efficacy. SILHD for achalasia is a new approach and may provide improved cosmetics and less invasiveness compared with those by conventional LHD. The 1-year follow-up results in the present case are the longest reported to date. The evaluation of long-term results in a large-scale study is necessary in future.

CONCLUSION

SILHD can be safe, widely accepted, mid-term minimal invasive and cosmetically superior surgical procedure for achalasia.

Single-port laparoscopic adrenalectomy for a right-sided aldosterone-producing adenoma: a case report

Introduction

Single-port laparoscopic adrenalectomy is one of the most interesting surgical advances. Here, we evaluate the safety and feasibility of single-port laparoscopic adrenalectomy as treatment for a right-sided aldosterone-producing adenoma.

Case presentation

A 39-year-old Japanese woman presented with hypertension and hypokalemia. Abdominal computed tomography and an endocrinological workup revealed a 19mm right adrenal tumor with primary aldosteronism. Our patient was informed of the details of the surgical procedure and our efforts to reduce the number of incisions needed - ideally, to a single incision - when removing her adrenal gland. A single-port laparoscopic adrenalectomy was attempted. A multichannel port was inserted through a 2.5cm umbilical incision. A 5mm flexible laparoscope, articulating laparoscopic dissector and tissue sealing device were the primary tools used in the operation. The right liver lobe was evaluated using a percutaneous instrument, providing good visualization of the operative field surrounding her right adrenal gland. The single-port laparoscopic adrenalectomy was successfully completed without any intraoperative complications. The operating time was 76 minutes, and her blood loss was 5mL. Oral intake was resumed on the first postoperative day, and the length of her hospital stay was three days. Her postoperative course was uneventful with no morbidity within one month of follow-up, and our patient had excellent cosmetic results.

Conclusions

Single-port laparoscopic adrenalectomy is a safe and feasible procedure for patients with a right-sided adrenal tumor when performed by a surgeon experienced in laparoscopic and adrenal surgery. However, more surgical experience using this technique is required to confirm our initial impressions.