Laparoscopic repair of duodenal ulcer and gastroesophageal reflux

Laparoscopic highly selective vagotomy with nissen fundoplication: is there any role?

INTRODUCTION

Nissen fundoplication (NF) has not been a uniformly successful treatment for gastroesophageal reflux disease (GERD). Acid lowering procedures such as highly selective vagotomy (HSV) have not yet been fully evaluated as an adjunctive treatment. NFHSV was evaluated in GERD.

MATERIALS AND METHODS

Between June 2003 and June 2005, 8 women with a history of 6 months of GERD unrelieved by medication, preprandial pain, peptic ulcer disease, or severe gastritis underwent laparoscopic NFHSV. They have been followed for a mean 12 months. Preoperative and postoperative Heartburn Severity scores (HSS) were obtained.

RESULTS

Mean operative time was 110 minutes. There were no complications. One patient needed postoperative proton pump inhibitor, which was discontinued after smoking cessation 5 months after NFHSV. All 8 patients showed marked improvement in symptoms and HSS.

CONCLUSIONS

This series lends credence to the notion that NFHSV was effective. Several studies need to be performed to demonstrate the full efficacy and safety of this approach.

Laparoscopic management of acid peptic disease

BACKGROUND

Despite successful medical treatment to reduce acid hypersecretion and eradicate Helicobacter pylori, surgery still plays an important role in the management of complicated peptic ulcer disease. Almost all types of conventional operations available for ulcer disease have been successfully performed by the laparoscopic approach and this has become the preferred approach in tertiary centers for operative management of acid peptic disease.

METHOD

Between 1995 and 2004, laparoscopic management was offered to refractory or obstructive acid peptic disease patients. For intractable disease, we performed either posterior truncal vagotomy with anterior fundal seromyotomy or posterior truncal vagotomy with anterior proximal gastric vagotomy. For peptic ulcer disease complicated with gastric outlet obstruction, we carried out bilateral truncal vagotomy with gastrojejunostomy.

RESULTS

Two hundred sixty three patients were operated of whom 236 (89.7%) were men and the average age of the patients was 48.4 years. Thirty-two (12.2%) patients underwent posterior truncal vagotomy with anterior seromyotomy, 89 (33.8%) underwent posterior truncal vagotomy with anterior proximal gastric vagotomy, 120 (45.6%) underwent bilateral truncal vagotomy with stapled gastrojejunostomy whereas 22 (8.4%) underwent bilateral truncal vagotomy with hand-sewn gastrojejunostomy. The average operating times were 142, 110, 98, and 72 minutes, respectively. The average postoperative stay was 5.4 days.

CONCLUSIONS

Laparoscopic posterior truncal vagotomy with anterior proximal gastric vagotomy for refractory disease and laparoscopic bilateral truncal vagotomy with stapled gastrojejunotstomy for obstructive disease have become the standard at our institution. Regardless of the preference of individual surgeon, our results have shown that laparoscopic surgery may become the gold standard for surgical management of peptic ulcer disease.

Feasibility of telementoring between Baltimore (USA) and Rome (Italy): the first five cases

BACKGROUND AND PURPOSE

Telemedicine is the use of telecommunication technology to deliver healthcare. Telementoring has been developed to allow a surgeon at a remote site to offer guidance and assistance to a less-experienced surgeon. We report on our experience during laparoscopic urologic procedures with mentoring between Rome, Italy, and Baltimore, USA.

MATERIAL AND METHODS

Over a period of 3 months, two laparoscopic left spermatic vein ligations, one retroperitoneal renal biopsy, one laparoscopic nephrectomy, and one percutaneous access to the kidney were telementored. Transperitoneal laparoscopic cases were performed with the use of AESOP, a robotic for remote manipulation of the endoscopic camera. A second robot, PAKY, was used to perform radiologically guided needle orientation and insertion for percutaneous renal access. In addition to controlling the robotic devices, the system provided real-time video display for either the laparoscope or an externally mounted camera located in the operating room, full duplex audio, telestration over live video, and access to electrocautery for tissue cutting or hemostasis.

RESULTS

All procedures were accomplished with an uneventful postoperative course. One technical failure occurred because the robotic device was not properly positioned on the operating table. The round-trip delay of image transmission was less than 1 second.

CONCLUSION

International telementoring is a feasible technique that can enhance surgeon education and decrease the likelihood of complications attributable to inexperience with new operative techniques.

Laparoscopic Omental Patch Repair for Perforated Duodenal Ulcer

A retrospective review was carried out on 33 consecutive patients with omental patch repair for perforated duodenal ulcer; 13 had laparoscopic repair, and 20 had open repair. Laparoscopic repair was successful in 12 patients, with only one postoperative complication (8%). The morbidity rate for open repair was 15 per cent (3 of 20), and there was one postoperative death in the open group (5%). Overall, it did not take longer to perform the operation laparoscopically than the open method. Patients in the laparoscopic group required less postoperative analgesia (mean doses, 0.2 vs 0.9; P = 0.02). There was no difference in terms of hospital stay and resumption of diet after operation between the two groups. Laparoscopic omental patch repair offers a safe alternative to the open method in the treatment of perforated duodenal ulcer.

Reporting results of laparoscopic procedures. The state-wide registry approach

The rapid development of technology facilitating minimally invasive surgery has challenged the surgical community to evaluate the safety and efficacy of these new techniques even as they were being widely utilized. The publication of retrospective series in a few institutions was followed by widespread adoption of laparoscopic cholecystectomy and subsequent reports of increased complications from the procedure. Other laparoscopic procedures such as antireflux operations and colectomy for cancer require greater technical skill and hold potential for significant morbidity. Because a prospective, randomized clinical trial is unlikely for these procedures, other measures of results need to be examined. A state registry is one such outcome study to be considered. In the state of Oregon we designed and implemented a voluntary registry program for these advanced procedures. Although the antireflux procedures are apparently being done safely, conclusions that can be drawn from such a registry are limited because of incomplete data collection. For a registry to be maximally effective, an automatic method of data accumulation is needed that will capture all cases that are done as well as follow-up information.

Laparoscopic Nissen fundoplication in children

Laparoscopic surgery for the definitive treatment of gastroesophageal reflux (GOR) has become an accepted alternative to conventional techniques in adults. Although relatively rare, GOR in children represents an important clinical entity with symptoms including failure to thrive, nocturnal dyspnea, and vomiting. This paper details our experience in eight children who have undergone a laparoscopic Nissen fundoplication for failed medical treatment of severe GOR. Particular attention is paid to technical aspects of the procedure and the differences between adult and pediatric techniques are emphasized. The preliminary results suggest that a laparoscopic Nissen fundoplication is a safe procedure which significantly improves reflux symptoms in children and that these results are comparable to those obtained with conventional surgery.

Laparoscopic treatment of duodenal ulcer by bilateral truncal vagotomy and endoscopic balloon dilatation

The low morbidity and early recovery associated with laparoscopic procedures have shown a new direction for many types of surgery. We performed a laparoscopic bilateral truncal vagotomy (BTV) with pyloric dilatation (PD) in 20 patients (11 men, 9 women, ranging in age from 32 to 56 years, with a mean age of 42 years). All patients had chronic duodenal ulcer diagnosed endoscopically, with a mean duration of symptoms of 2.6 years (range 2-8 years). The mean length of surgery was 55 min (range 45-90 min). The mean follow-up period was 16 months (range 3-25 months). In 1 patient, esophageal perforation occurred during the dissection of the left vagus nerve and was sutured laparoscopically. Acid secretion tests under basal conditions and pentagastrin stimulation preoperatively and 1 month postoperatively showed a decrease in basal acid output (BAO) of 76% and maximal acid output (MAO) of 84.2%. Endoscopy at the second and sixth postoperative month showed healing of the ulcer in 19 of 20 patients (95%). One patient had partial pyloric stenosis due to chronic duodenal ulcer before BTV and PD and developed complete pyloric stenosis after the surgery. Despite repeated pyloric balloon dilatation, he required an open drainage procedure (gastroduodenostomy, Jaboulay). Three patients (15%) had postoperative diarrhea and responded very well to medical treatment. The preliminary results showed that laparoscopic BTV with PD is a simple and effective procedure for the treatment of chronic duodenal ulcer.

Laparoscopic-assisted vagotomy and distal gastrectomy

This is a report of the techniques used on and outcome for three patients who underwent laparoscopic-assisted vagotomy and distal gastrectomy for complicated peptic ulcer disease. The first patient had a Billroth I anastomosis in 2 h 42 min with an estimated blood loss of 200 ml. Oral fluids were started on day 3 and the diet progressed to a soft food by day 5. The patient was discharged 11 days after his gastrectomy following a transurethal prostatic resection on day 6. The second patient had a Billroth II anastomosis. The operation was completed in 4 h 40 min with an estimated blood loss of 350 ml. Oral fluids were commenced on the 1st postoperative day and the patient was tolerating a soft diet by day 4. The patient was discharged 5 days after his gastrectomy. The third patient had a Billroth I anastomosis with an estimated blood loss of less than 150 ml. The surgery took 2 h 35 min; the patient was tolerating oral fluids on the first postoperative day and was discharged on the 4th postoperative day on soft diet. Laparoscopic-assisted vagotomy and gastrectomy has the advantages of a minimal-access procedure without the risks of an intracorporeal anastomosis.

Laparoscopic excision of a benign gastric tumor

A successful laparoendoscopic excision of a 3-cm leiomyoma of the stomach is reported. Review of related literature and suggested technique and methods for this procedure are described.

Telerobotic assisted laparoscopic surgery: initial laboratory and clinical experience

OBJECTIVES

To assess the feasibility of telerobotic assisted surgery.

METHODS

In a laboratory model, a cholecystectomy, splenectomy, and nephrectomy were performed by an inexperienced surgeon who was being mentored by an experienced surgeon stationed at a remote site. The remote surgeon controlled the laparoscopic camera by utilizing a telerobotic system. In patients, laparoscopic cholecystectomy, varix ligation, and bladder suspension were performed by an experienced team utilizing a robotic system controlled by an experienced surgeon from a remote site.

RESULTS

In both the laboratory and clinical setting, all procedures were successfully completed without complications.

CONCLUSIONS

Current technology is available to successfully allow for telerobotic assisted surgery.

LAPAROSCOPIC SURGERY

The speed of adoption and popularity of laparoscopic cholecystectomy is without precedence in modern surgical history. This has resulted in therapeutic and diagnostic laparoscopy being attempted in almost every field of surgery to substitute open surgical procedures. The list is endless. It will take time to evaluate the safety and advantages of many of these procedures as reports of controlled studies and long term follow up results are awaited. While certain procedures like gall bladder surgery and appendicectomy will establish their many fold advantages over open surgery, many other procedures like repair of hernias, radical resection of bowel for malignancy etc may fail to do so once the initial enthusiasm wanes away. Any way the concept of minimally invasive surgery is going to be a dominant factor in the surgery of this decade and one should prepare to face this fascinating challenge. Further developments in laparoscopic instruments, optical system and video imaging techniques will add to the progress and safety of laparoscopic surgical procedures in the days ahead.

Endoscopic management of peptic ulcer disease

OBJECTIVE

This article reviews the authors' experience with endoscopic management of duodenal ulcer and ulcers occurring after a previous drainage procedure.

SUMMARY BACKGROUND DATA

Patients with complications of duodenal ulcer and ulcers occurring after a previous drainage procedure still require surgical management. Virtually all operations for duodenal ulcer include some form of vagotomy. American surgeons in academic centers prefer highly selective vagotomy in suitable candidates. Video-directed laparoscopic and thoracoscopic operations have been done for all complications of duodenal ulcer except for acute hemorrhage.

METHODS

The authors have performed laparoscopic operation on eight patients with intractable chronic duodenal ulcer, seven patients with gastroesophageal reflux disease combined with duodenal ulcer, one patient with chronic duodenal ulcer and gastric outlet obstruction, and one patient with acute perforation. Operations performed included omentopexy, anterior seromyotomy plus post truncal vagotomy, and highly selective vagotomy. Seven patients had a simultaneous Nissen fundoplication; and the patient with obstruction underwent concomitant pyloroplasty and vagotomy. Six patients with intestinal ulcers occurring after a previous drainage procedure were treated with thoracoscopic vagotomy. Techniques used are shown.

RESULTS

There has been one recurrent ulcer in the laparoscopic group after anterior seromyotomy plus posterior truncal vagotomy. The patient treated by omentopexy for duodenal perforation recovered gastrointestinal function promptly with no further difficulty, but eventually died of primary medical disease. Patients undergoing thoracoscopic vagotomy have all become asymptomatic. Postoperative hospital stay after highly selective vagotomy, anterior seromyotomy plus posterior truncal vagotomy, or thoracoscopic vagotomy was 1-5 days.

CONCLUSIONS

Laparoscopic management of duodenal ulcers is feasible. Larger numbers of patients with longer follow-up are essential. Ulcers occurring after a drainage procedure deserve thoracoscopic vagotomy.