Surgical management of gastroesophageal reflux disease in the obese patient

BACKGROUND

Gastroesophageal reflux disease (GERD) affects two thirds of the American population. Obesity is also a disease that affects two thirds of the population. The pathophysiology of reflux disease is reasonably understood, however, the degree to which obesity affects this disease remains poorly defined. Therefore the approach to GERD in the obese patient requires special attention and its own algorithm.

METHODS

A literature search was conducted to consolidate the current available literature on GERD and its management in the obese. In addition, the authors reviewed the literature and present expert opinion on controversial topics.

RESULTS

It is well established that GERD is increased in obesity and the pathophysiology is reviewed. Management options for GERD are discussed, with a focus on the obese population. Management strategies including fundoplication and gastric bypass are discussed. In addition, bariatric surgery in the setting of GERD is also reviewed.

CONCLUSIONS

Currently this is an extremely controversial topic and this white paper presents a strong review of the literature to help guide the management of this challenging disease in this population. Expert recommendations are given throughout the paper based upon the current available data.

Laparoscopic parastomal hernia repair using a nonslit mesh technique

BACKGROUND

The management of parastomal hernia is associated with high morbidity and recurrence rates (20-70%). This study investigated a novel laparoscopic approach and evaluated its outcomes.

METHODS

A consecutive multi-institutional series of patients undergoing parastomal hernia repair between 2001 and 2005 were analyzed retrospectively. Laparoscopy was used with modification of the open Sugarbaker technique. A nonslit expanded polytetrafluoroethylene (ePTFE) mesh was placed to provide 5-cm overlay coverage of the stoma and defect. Transfascial sutures secured the mesh, allowing the stoma to exit from the lateral edge. Five advanced laparoscopic surgeons performed all the procedures. The primary outcome measure was hernia recurrence.

RESULTS

A total of 25 patients with a mean age of 60 years and a body mass index of 29 kg/m2 underwent surgery. Six of these patients had undergone previous mesh stoma revisions. The mean size of the hernia defect was 64 cm2, and the mean size of the mesh was 365 cm2. There were no conversions to open surgery. The overall postoperative morbidity was 23%, and the mean hospital length of stay was 3.3 days. One patient died of pulmonary complications; one patient had a trocar-site infection; and one patient had a mesh infection requiring mesh removal. During a median follow-up period of 19 months (range, 2-38 months), 4% (1/25) of the patients experienced recurrence.

CONCLUSION

On the basis of this large case series, the laparoscopic nonslit mesh technique for the repair of parastomal hernias seems to be a promising approach for the reduction of hernia recurrence in experienced hands.

Radiofrequency energy delivery to the lower esophageal sphincter (Stretta procedure) in patients with recurrent reflux after antireflux surgery: can surgery be avoided?

BACKGROUND

Recurrent reflux following antireflux surgery (ARS) can be difficult to manage, especially in patients who also fail medical management. In these patients, redo ARS remains the only treatment option. Endoscopic radiofrequency energy delivery to the lower esophageal sphincter (the Stretta procedure; Stretta, Curon, Sunnyvale, CA) has been shown to significantly decreased symptom scores and improve quality of life in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the use of the Stretta procedure in treating patients with recurrent reflux after fundoplication.

METHODS

Between March 2002 and December 2003, eight patients with recurrent reflux following ARS underwent the Stretta procedure. All patients were asked to complete an institutional symptom survey pre-Stretta and at 1, 6, and 12 months after the procedure. Patients rated 7 reflux-related symptoms (heartburn, dysphagia, regurgitation, cough, voice changes/hoarseness, asthma, chest pain) on a 0 (none) to 3 (severe) scale. Data were analyzed using a Wilcoxon matched pairs signed rank test where appropriate.

RESULTS

Complete data were obtained for seven of the eight patients, with a median follow-up of 253 days (range, 67-378 days). One patient was lost to follow-up and not included in our analysis. Symptom scores decreased significantly, with six patients noting both improved typical and atypical symptoms. Overall, six patients (85%) were satisfied with their results.

CONCLUSIONS

Based on this small series, the Stretta procedure significantly reduces subjective symptoms of GERD. The Stretta procedure may serve an important role as an additional management strategy to help manage recurrent GERD after ARS.

A research agenda for gastrointestinal and endoscopic surgery

BACKGROUND

Development of a research agenda may help to inform researchers and research-granting agencies about the key research gaps in an area of research and clinical care. The authors sought to develop a list of research questions for which further research was likely to have a major impact on clinical care in the area of gastrointestinal and endoscopic surgery.

METHODS

A formal group process was used to conduct an iterative, anonymous Web-based survey of an expert panel including the general membership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). In round 1, research questions were solicited, which were categorized, collapsed, and rewritten in a common format. In round 2, the expert panel rated all the questions using a priority scale ranging from 1 (lowest) to 5 (highest). In round 3, the panel re-rated the 40 questions with the highest mean priority score in round 2.

RESULTS

A total of 241 respondents to round 1 submitted 382 questions, which were reduced by a review panel to 106 unique questions encompassing 33 topics in gastrointestinal and endoscopic surgery. In the two successive rounds, respectively, 397 and 385 respondents ranked the questions by priority, then re-ranked the 40 questions with the highest mean priority score. High-priority questions related to antireflux surgery, the oncologic and immune effects of minimally invasive surgery, and morbid obesity. The question with the highest mean priority ranking was: "What is the best treatment (antireflux surgery, endoluminal therapy, or medication) for GERD?" The second highest-ranked question was: "Does minimally invasive surgery improve oncologic outcomes as compared with open surgery?" Other questions covered a broad range of research areas including clinical research, basic science research, education and evaluation, outcomes measurement, and health technology assessment.

CONCLUSIONS

An iterative, anonymous group survey process was used to develop a research agenda for gastrointestinal and endoscopic surgery consisting of the 40 most important research questions in the field. This research agenda can be used by researchers and research-granting agencies to focus research activity in the areas most likely to have an impact on clinical care, and to appraise the relevance of scientific contributions.

Surgeon-initiated screening colonoscopy program based on SAGES and ASCRS recommendations in a general surgery practice

BACKGROUND

This study aimed to determine the utility of a screening colonoscopy program initiated by general surgeons in an academic center.

METHODS

New patients presenting to three general surgeons who met screening colonoscopy indications were asked whether they had undergone colorectal cancer (CRC) screening. The patients who had not undergone CRC screening were offered screening colonoscopies or referred to their gastroenterologists.

RESULTS

In the first 9-month period of the program, 200 patients who met the Society of American Gastrointestinal and Endoscopic Surgeons/American Society of Colon and Rectal Surgeons indications for CRC screening were asked whether they had undergone screenings. Only 46% (n = 92) reported any prior appropriate screenings. Of the patients who elected CRC screening by the surgeons, 55 underwent full colonoscopies (2 concurrently with hemorrhoidectomies), and 2 had flexible sigmoidoscopies. As a result of screening, 10 patients (18%) required treatment: 7 had polypectomies, 2 had partial colectomies, and 1 with an indication for surgery deferred treatment.

CONCLUSIONS

Most of the patients presenting to the general surgeon likely have not had CRC screening, and diligence in making appropriate recommendations should be routine. Colonoscopic findings requiring intervention are not insignificant.

Heller myotomy vs Heller myotomy plus Dor fundoplication: cost-utility analysis of a randomized trial

BACKGROUND

The addition of a Dor antireflux procedure reduces the risk of pathologic gastroesophageal reflux (GER) by ninefold following laparoscopic Heller myotomy for achalasia. It is not clear, however, how these benefits compare with the increased cost of the fundoplication. The objective of this study was to estimate the cost-effectiveness of Heller myotomy plus Dor fundoplication compared with Heller alone in patients with achalasia.

METHODS

We conducted a cost-utility analysis using the Markov simulation model to examine the two treatment alternatives. The model estimated the total expected costs of each strategy over a 10-year time horizon. Data for the model were derived from our randomized clinical trial. The strategies were compared using the method of incremental cost-effectiveness analysis.

RESULTS

The incidence of pathologic GER was 47.6% (10 of 21 patients) in the Heller group and 9.1% (2 of 22 patients) in the Heller plus Dor group using an intention-to-treat analysis (p = 0.005). Heller plus Dor was associated with a significant reduction in the risk of GERD (relative risk 0.11; 95% confidence interval 0.02-0.59; p = 0.01). The cost of surgery was significantly higher for Heller plus Dor than for Heller alone (mean difference $942; p = 0.04), secondary to a longer operating room time (mean difference 40 min; p = 0.01). At a time horizon of 10 years, when proton pump inhibitor (PPI) therapy costs are considered, the cost-utility analysis demonstrates that Heller plus Dor surgery is associated with a total cost of $6,861 per patient and a quality-adjusted life expectancy of 9.9 years, whereas Heller-alone surgery is associated with a cost of $9,541 per patient and a quality-adjusted life expectancy of 9.5 years.

CONCLUSIONS

In achalasia patients, Heller myotomy plus Dor fundoplication is preferred to Heller alone because it is both more effective in preventing postoperative GERD and more cost-effective at a time horizon of 10 years.

Analysis of the SAGES Outcomes Initiative groin hernia database

BACKGROUND

In 1999, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) introduced the SAGES Outcomes Initiative as a way for its members to track their own outcomes. It contains perioperative and postoperative data on nearly 20,000 operations. This report provides a descriptive analysis of the groin hernia database.

METHODS

The SAGES Outcomes Initiative database was accessed for all groin hernia cases from September 1999 to February 2005. The data from the preoperative, intraoperative, and postoperative entries were summarized. These data are purely descriptive and no statistical analysis was done.

RESULTS

The hernia registry contains 1,607 entries, with 1,070 follow-up entries. Males comprised 85% of patients, 63% were employed, 62% had at least one comorbidity, with 84% ASA class I or II. Primary, unilateral hernia accounted for 86% of cases, whereas 14% were recurrent, 11% bilateral, 6% incarcerated, and 3% required emergency repair. The operating surgeon was the attending surgeon in 83% of cases. Anesthetic techniques were general anesthesia in 74% of cases, regional in 7%, and local in 34%, with only 16% of cases local only. Most patients had symptomatic hernias and symptoms were improved in more than 95% of patients. Most repairs were open, although 45% were endoscopic. The most frequently cited postoperative event was significant bruising (6%), with more than 99% of complications being class I or II. More than 95% of patients were able to return to work by the first postoperative visit. Patients who underwent endoscopic repair were reported to have fewer days of narcotic use than patients undergoing open repairs (0 vs 3).

CONCLUSIONS

First analysis of the SAGES Outcomes Initiative groin hernia database demonstrates that (a) this is one of the largest prospective; voluntary hernia registries; (b) missing data are infrequent; and (c) the data are similar to published data from national, mandatory registries and randomized trials. Although the SAGES Outcomes Initiative is a voluntary registry, initially designed for surgeon self-assessment, and it therefore has the potential for methodological concerns inherent to voluntary registries, the findings from this first analysis are encouraging. Efforts are ongoing to simplify data entry (PDA), refine data parameters, increase surgeon participation, and determine the role of data audit and thereby the potential for clinical research.

Comparison of patient satisfaction after redo and primary fundoplications

BACKGROUND

Although much has been written about the results and patient satisfaction with fundoplication for the treatment of gastroesophageal reflux disease, the reports have focused primarily on surgical successes. With the growing number of fundoplications being performed, more patients are requiring reoperation because of recurrent symptoms or side effects. Reports of success rates for reoperation are available, but information regarding patient satisfaction is limited.

METHODS

All the patients undergoing fundoplication at our institution were sent short-form health surveys (SF-12), Gastroesophageal reflux disease-specific quality-of-life questionnaires (QOLRAD), and queries regarding long-term satisfaction.

RESULTS

Between November 1992 and July 2000, 221 patients (198 primary and 23 redo) underwent fundoplication. There were 19 open cases (3 primary and 16 redo). In the primary group, 173 patients underwent Nissen, 23 underwent Toupet, and 2 underwent Collis fundoplications. In the redo group, 12 patients underwent Nissen, 9 underwent Toupet, 1 underwent Collis, and l underwent Belsey fundoplications. Follow-up surveys were completed for 130 patients (112 primary and 18 redo) at a mean of 32.6 months (range, 0.8-98 months). In the primary group, 87% of the patients were satisfied with their operation, as compared with 75% in the redo group. There was a trend toward higher SF-12 mental scores (46 +/- 12 vs 40 +/- 14; p = 0.07) and QOLRAD scores (6.2 +/- 1.3 vs 5.2 +/- 2.0; p = 0.07) in the primary fundoplication group. There was a significant difference in the SF-12 physical scores between the groups (32 +/- 13 for the primary group vs 18.5 +/- 11 for the redo group; p = 0.0002). Additionally, 61% of the patients in the redo group were again using antireflux medications, whereas only 24% of the patients in the primary group were using medications again.

CONCLUSION

Gastroesophageal reflux disease symptom scores and quality-of-life scores for patients undergoing redo fundoplication are lower than the scores of patients having primary fundoplication. Quality of life is similar between primary and redo fundoplication patients in the mental component. However, redo patients do not do as well physically more than 2 years after surgery.

First year experience of patients undergoing the Stretta procedure

BACKGROUND

The Stretta procedure is a new, totally endoscopic treatment for GERD, where radiofrequency energy is delivered to the smooth muscle of the gastroesophageal junction.

METHODS

Forty-one patients undergoing the Stretta procedure between August 2000 and August 2001 were prospectively evaluated. Under an IRB-approved protocol, patients were studied preoperatively and postoperatively with esophageal manometry, 24-h pH testing, SF12 surveys, and GERD-specific questionnaires (QOLRAD).

RESULTS

Results are reported as mean +/- SEM. All procedures were performed on an outpatient basis; 33 were under conscious sedation and 8 were under general anesthesia. Prior to treatment, patients had a mean LES pressure of 25 +/- 2.4 mmHg, Johnson-Demeester score of 32.8 +/- 4.6 mmHg, and % time reflux 8.4 +/- 0.9%. The quality-of-life scores were significantly improved at 6 months: QOLRAD score increased from 3.7 +/- 0.2 to 5.1 +/- 0.2 (p = 0.002), SF12 mental score increased from 44.3 +/- 2.0 to 51.8 +/- 1.7 (p = 0.001), and SF12 physical score increased from 26.2 +/- 2.4 to 33.1 +/- 3.8 (p = 0.001). Eighteen patients returned for esophageal manometry and 24-h pH testing at a mean of 6.8 +/- 0.5 months. There was a significant decrease in esophageal acid exposure time (8.4 +/- 0.9% to 4.4 +/- 1.3%, p = 0.03) and Johnson-Demeester score (32.8 +/- 4.6 to 22.9 +/- 5.3, p = 0.04). There was no significant change in mean LES pressure (25.3 +/- 2.4 mmHg to 26.8 +/- 2.6 mmHg, p = 0.63). Twenty of 31 patients (65%) available for 6 months follow-up were completely off proton pump inhibitors. The only complication related to Stretta was a case of gastroparesis 10 days post-operatively that resolved completely.

CONCLUSIONS

The Stretta procedure is a promising new endoscopic treatment for GERD. It significantly improves GERD symptoms and quality of life while eliminating the need for proton pump inhibitors in the majority of patients.

A report on the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Outcomes Initiative: what have we learned and what is its potential?

INTRODUCTION

The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Outcomes Initiative established a national database in 1999. The goal was to provide a vehicle whereby surgeons could accumulate meaningful data about their surgical activity and procedure outcomes.

METHODS

Through a secure Internet site, participants entered core data at the time of operation on all patients undergoing any laparoscopic or open procedure. Procedure-specific data was accumulated for cholecystectomy, inguinal hernia, and fundoplication. A second data set was collected at the time of follow-up evaluation. Individual data and a summary of national data were available through the Web site for contemporaneous review.

RESULTS

Between May 1999 and December 2001, 4,100 cases were entered by 73 surgeons, including data for 1070 cholecystectomies, 1,070 antireflux procedures, and 300 hernias. The remaining cases encompassed all other procedures. Perioperative and follow-up data showed many interesting findings. For example, 30% of cholecystectomies were first-assisted by a nonphysician. The rate of conversion from laparoscopic cholecystectomy to open surgery was 3%. In the gastroesophageal reflex disease (GERD) report on fundoplications, 21% of the patients had a previous fundoplication. This report contains a summary of the data collected during this period in the national database.

CONCLUSIONS

The SAGES Outcomes Initiative allows surgeons to be involved in data collection about their practice. It provides data on the general practice of surgery, which are more useful for setting benchmarks than published data from the surgical elite.

Results after laparoscopic lysis of adhesions and placement of seprafilm for intractable abdominal pain

BACKGROUND

The surgical treatment of patients with chronic abdominal pain resulting from intraabdominal adhesions is controversial. We report our experience with treatment of this challenging patient population using laparoscopic lysis of adhesions (LOA) and placement of Seprafilm (Genzyme, Cambridge, MA, USA).

METHODS

The participants in this study were 19 consecutive patients (2 men and 17 women) who underwent laparoscopic LOA and placement of Seprafilm between July 1998 and July 2001. Patients with abdominal pain resulting from irritable bowel syndrome, hernias, or endometriosis were excluded. The patients had undergone a mean of 6.4 previous abdominal procedures (range, 1-14) and 2.3 previous LOAs (range, 0-10). They had experienced chronic, intractable abdominal pain for at least 4 months (range, 4-180). Eight patients had preoperative obstructive symptoms.

RESULTS

A completely laparoscopic procedure was used to treat 16 patients, whereas the procedure for 3 patients was converted to open surgery because of dense adhesions. Perioperative complications included two patients in whom enterocutaneous fistulae developed and one patient with intraabdominal hematoma. At follow-up (mean, 9.6 months; range, 1-32 months), 14 patients (73.7%) had completely discontinued all pain medications. At this writing, 12 of these patients are completely symptom free. Two patients are taking nonsteroidal antiinflammatory drugs (NSAIDs) as needed, and three patients require round-the-clock narcotics. Three patients were readmitted with small bowel obstruction, which was managed nonoperatively. One patient had diagnostic laparoscopy for recurrent pain 6 months postoperatively, but had no adhesions.

CONCLUSION

Chronic intractable abdominal pain is relieved in most patients via this approach. Repeat laparoscopy in two patients showed no intraabdominal adhesions. Laparoscopic LOA and placement of Seprafilm is an excellent approach to this challenging patient population with symptoms caused by intraabdominal adhesions.

Initial experience with the stretta procedure for the treatment of gastroesophageal reflux disease

BACKGROUND

The Stretta device (Curon Medical, Sunnyvale, CA) is a balloon-tipped four-needle catheter that delivers radiofrequency (RF) energy to the smooth muscle of the gastroesophageal junction. It can be used for the endoscopic treatment of gastroesophageal reflux disease (GERD).

PATIENTS AND METHODS

Data prospectively collected on the first 25 consecutive patients undergoing the Stretta procedure at Vanderbilt University Medical Center between August 2000 and March 2001 are reported. Patient evaluation included esophageal manometry, ambulatory 24-hour pH testing, a standard GERD-specific quality-of-life survey (QOLRAD), a general quality-of-life survey (SF12), and endoscopy. Stretta surgery was performed following a standardized protocol. Thermocouple-controlled RF energy was delivered to the lower esophageal sphincter (LES) after endoscopic location of the z-line. Patients were followed up 3 months after endoscopic treatment. Results are presented as mean +/- SEM.

RESULTS

Prior to treatment, patients had a mean DeMeester score of 31.0+/-11.4, an LES pressure of 24+/-2 mm Hg, and normal esophageal peristalsis. Of the 25 outpatient procedures, 19 were done under conscious sedation and 6 under general anesthesia. There was a small learning curve (76+/-8 min for the first three procedures; 50+/-2 min for the subsequent 22). The mild to moderate pain during the first 24 postoperative hours was controlled with over-the-counter medication. Two complications were noted: one patient presented with ulcerative esophagitis and gastroparesis 10 days after the Stretta treatment, and one patient developed pancreatitis on postoperative day 27, which was probably unrelated to the Stretta procedure. Eight of the thirteen patients (62%) available for 3-month follow-up were off all antisecretory medication. The other five patients were still taking medications but had been able to reduce the amount considerably. The average daily dose of proton pump inhibitors was 43.0+/-5.0 mg/preoperatively and 6.4+/-2.2 mg/3 months postoperatively (P < 0.001). Other classes of GERD treatment such as metoclopramide had been completely abandoned. In all patients, QOLRAD scores improved (3.5+/-0.4 to 5.5+/-0.5; P < 0.001) as did SF12 physical (23.7+/-3.0 to 31.0+/-3.4; P < 0.008) and mental (40.5+/-2.9 to 47.7+/-3.2, P < 0.017) scores. All patients would undergo a Stretta procedure again except one 78-year-old man with progressive Alzheimer's disease.

CONCLUSION

The Stretta procedure is a promising new modality in the management of GERD. It can be safely performed in one short session with gastroesophageal endoscopy under conscious sedation in an outpatient setting. It improves GERD symptoms and quality-of-life scores in patients at 3 months and eliminates or significantly reduces the need for antisecretory drugs.

Coronary artery bypass grafting in patients who require long-term dialysis

BACKGROUND

Should coronary artery bypass grafting (CABG) be performed in patients on long-term dialysis? This subject has been debated for several years. We retrospectively reviewed the charts of all patients who had CABG from August 1989 to October 1997.

METHODS

We identified 70 patients who were on long-term dialysis and had CABG during that time period. Patients were evaluated by chart review and telephone survey. Forty-nine patients (70%) had unstable angina and 37 patients (52%) had triple vessel disease. Patient risk factors included 60 patients with hypertension (85%), 40 patients with diabetes mellitus (57%), 35 patients who had congestive heart failure (50%), 35 patients who had a previous myocardial infarction (50%), and 31 smokers (44%). Operative procedures included 49 patients who had CABG only and 21 patients who had concomitant CABG with valve replacement or repair. During the postoperative period, complications developed in 50% of patients.

RESULTS

Review of these complications showed that 25% of patients required prolonged mechanical ventilation, and 10% of patients had septicemia. Operative mortality was high, with 10 patient deaths (14.3%) within 30 days of the procedure. Six (60%) of these deaths occurred in patients who had CABG and valve repair or replacement. Long-term follow up at 50.3 months showed no improvement in survival in patients who had CABG compared with the known mortality rate of 22% per year in dialysis patients regardless of comorbid conditions. Quality of life subjectively improved in only 41% of patients in follow-up telephone survey.

CONCLUSIONS

Patients requiring long-term dialysis with coexistent severe cardiac disease should be thoroughly evaluated preoperatively. One must weigh the high morbidity and mortality risk against the limited long-term resolution of angina and ultimate survival.

Simultaneous carotid endarterectomy and coronary revascularization

BACKGROUND

Combined cardiac operation and carotid endarterectomy using our technique is an acceptable approach to simultaneous correction of both carotid and cardiac disease.

METHODS

From August 1989 to March 1998, 121 consecutive patients underwent combined operations. Of these patients, 112 had coronary artery bypass grafting and carotid endarterectomy, and 9 had coronary artery bypass grafting, carotid endarterectomy, and valve repair or replacement. All patients had a critical stenosis of 85% or more of the carotid artery. Mean age of the patients was 69.2 years; 80 patients were 65 years old or older. There were 88 men and 33 women. Notable risk factors included chronic obstructive pulmonary disease (19.8%), congestive heart failure (28%), preoperative myocardial infarction and unstable angina (66.9%). Of the patients, 20.7% had a stenosis of greater than 50% of the left main coronary artery. The technique used was correction of both the carotid and coronary lesions during a single aortic cross-clamp period using retrograde continuous blood cardioplegia for myocardial protection. Systemic hypothermia to 25 degrees C was used for cerebral protection.

RESULTS

Mean cross-clamp time was 118 minutes. Seven patients (5.8%) sustained perioperative cerebrovascular accidents. Two patients had transient ischemic attacks. The procedure-related mortality rate was 5.8%.

CONCLUSIONS

The described technique is a good method for simultaneous repair of coronary and carotid lesions in a high-risk group of patients with concomitant disease. We will continue to use it.

A laparoscopic approach to ventriculoperitoneal shunt placement in adults

BACKGROUND

Ventriculoperitoneal shunts have been used for the treatment of hydrocephalus for years. In the past, the abdominal portion of this technique has required mini-laparotomy. We present a series of 10 consecutive patients in which ventriculoperitoneal (VP) shunts were placed with laparoscopic assistance.

MATERIALS AND METHODS

At Lankenau Medical Center for July 1996 to January 1998, 10 patients (aged 22-81) with normopressure hydrocephalus underwent laparoscopic VP shunt placement. The neurologic portion of the procedure is begun simultaneously with the abdominal procedure. After pneumoperitoneum is established using a miniport disposable 2-mm introducer at the umbilicus, a 2-mm camera is introduced into the peritoneal cavity through the same port. A needle is introduced into the peritoneal cavity under direct visualization. Once the catheter is placed ventricularly, it is tunneled subcutaneously to the abdomen. Using the Seldinger technique, the VP catheter is introduced under direct visualization through a sheath into the peritoneal cavity toward the pelvis. Positioning and function are also confirmed under direct visualization.

RESULTS

All patients tolerated this procedure well, and there were no complications. The benefits of this procedure include direct visualization of catheter placement and smaller incisions than necessary for an open procedure.

CONCLUSION

We recommend laparoscopic-assisted placement of the VP shunt in normopressure hydrocephalus patients as a good alternative to the open technique.

Diagnostic laparoscopy outside of the operating room

Laparoscopy is increasingly being used as a diagnostic technique to characterize intraperitoneal processes. This technique can be highly informative when applied in settings such as the intensive care unit, the emergency room, the trauma bay, and the office. Diagnostic laparoscopy is an excellent method to evaluate intraperitoneal processes and should be part of the general surgeon's armamentarium of skills. In this paper, the technique of diagnostic laparoscopy and its role outside of the operating room setting is reviewed. Diagnostic laparoscopy is also compared with other diagnostic modalities.

Effects of chronic treatment with valproate on serotonin-1A receptor binding and function

Valproate is effective in treating bipolar disorder characterized by rapid cycling or acute mania, although the mechanism of action is unclear. In contrast to other treatments for depression, 21 days of treatment in rats with valproate (1,, 200 or 400 mg/kg) did not significantly alter the hypothermia induced by 8-hydroxy-2-(di-n-propyl)aminotetralin (8-OH-DPAT), an agonist at serotonin-1A receptors. Treatment with valproate also had no effect on radioligand binding to serotonin-1A, serotonin-2 or beta-adrenergic receptors. Based on these animal studies in frontal cortex and hippocampus, the therapeutic benefit of valproate in mood disorders does not appear to involve adaptive changes in serotonin-1A, serotonin-2 or beta-adrenergic receptor number.

Delayed desensitization of alpha 2-adrenoceptor-mediated platelet aggregation in depressed patients

After prolonged exposure to epinephrine, platelets are observed to desensitize alpha 2-adrenoceptor-mediated aggregation responses in vitro. Herein, this phenomenon was studied as a possible in vitro model for alpha 2-adrenoceptor dysregulation in depression. Platelet-rich plasmas obtained from 22 unipolar depressed patients and 25 healthy subjects were preincubated with 20 mumol/L of epinephrine for various lengths of time prior to stirring. By comparing the subsequent extents of aggregation, we observed significantly less desensitization at 4, 20, 30, or 60 minutes postepinephrine exposure (p < or = .05) in depressed patients as compared to healthy controls. This blunted desensitization appeared to be due to a delayed onset of desensitization during the first 0.5 to 2 minutes after epinephrine exposure, since thereafter, the monoexponential desensitization rate did not differ in depressed patients, but the extent of desensitization remained less as compared to healthy subjects. The extent of desensitization was correlated (r = -0.48, p = .02) with the density (Bmax) of the alpha 2-adrenoceptor high-affinity state, as detected in undesensitized platelet membranes by p125I-clonidine binding. An elevation was also observed in the density of nonadrenergic p125I-clonidine-binding sites (putative imidazoline I1 sites) in platelet membranes from depressed patients compared to healthy control subjects. Following treatment with desipramines, the patients (n = 15) displayed more normal (nonblunted) extents of desensitization of aggregation, and the Bmax values for the putative I1 sites were at the levels of healthy controls. If similar aberrations exist in neurons of depressed patients, this may explain a dysregulation of the noradrenergic system believed to underlie depression.