Laparoscopy Today

JOURNAL WATCH: JSLS Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy: an Alternative for Recurrent Paraesophageal Hernia in Obese Patients. Cuenca-Abente F et al. 2006;10:86-89 • Cuenca-Abente et al describe their management of a case in which the work up of a morbidly obese, 70-year-old female revealed a recurrent large paraesophageal hernia. They report that a laparoscopic sleeve gastrectomy may be a useful alternative to fundoplication or gastropexy in the treatment of obese patients with complex paraesophageal hernias.

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JOURNAL WATCH: Contemporary Surgery Capsule Endoscopy

Capsule Endoscopy: A New Tool for the Work-up of Occult GI Bleeding • Schmitt TM et al 2004;60(7):312-316. The authors outline two cases in which the use of wireless gastrointestinal endoscopy with a swallowable camera assisted in localizing bleeding in the small intestine beyond the duodenum bulb. Indications, limitations, and complications of capsule endoscopy are discussed, and the authors provide readers with a “When to Use Capsule Endoscopy” flow chart.

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JOURNAL WATCH: JSLS Portal Vein Thrombosis

Portal Vein Thrombosis: An Unusual Complication of Laparoscopic Cholecystectomy • Preventza OA et a 2005;9:87-90. This is a report of portal vein thrombosis following laparoscopic cholecystectomy. The authors explore perioperative measures for thromboprophylaxis in young females on oral contraceptives who require laparoscopic abdominal surgery.

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The Emergence of Flexible Endoscopy as Therapy

ENDOLUMINAL SURGERY

WILLIAM O. RICHARDS, MD, ALFONSO TORQUATI, MD, NIK SEKHAR, MD, YASSAR YOUSSEF, MD

Endoluminal interventions are indeed evolving, and the endoscopic treatment of gastroesophageal reflux disease (GERD) represents the earliest application of this new surgical revolution [1]. Four major technologies have emerged. Although each uses different approaches to augment the barrier function of the lower esophageal sphincter, the mechanisms may be similar. These technologies include endoluminal gastroplication (ELGP) (EndoCinch, Bard, Murray Hill, NJ), the full-thickness plication device (Plicator, NDO-Surgical, Mansfield, MA), radiofrequency energy delivery to the gastroesophageal (GE) junction (Stretta, Curon Medical, Inc., Freemont, CA), and injectable copolymer Enteryx (Boston Scientific, Natick, MA).

The NDO plicator creates a transmural plication that enhances the competency of the GE junction. The recently published results of the North American open-label trial demonstrate significant improvement in GERD-related quality of life and discontinuation of antisecretory drugs in 70% of patients [2].

The Stretta procedure delivers radiofrequency energy to the GE junction and to the cardia of the stomach. Treated patients experience decreasing frequency of transient LES relaxation and increased postprandial lower esophageal sphincter (LES) pressure [3]. A randomized sham versus Stretta clinical trial showed a significant improvement in GERD symptoms 6 months after treatment [4].

Enteryx is a copolymer that is injected under fluoroscopic guidance into the muscularis propria of the lower esophageal sphincter. The material solidifies rapidly in situ and is presumed to alter the distensibility and the compliance of the GE junction [5]. A recent randomized sham-controlled multicenter trial showed a significant reduction in distal esophageal acid exposure and improvement in GERD symptoms [6].

Endoluminal gastroplication (Endocinch) creates several plications at the GE junction that serve as antireflux barriers. Data from ELGP clinical trials are controversial. Although a recent study [7] demonstrated a significant reduction in GERD symptoms after ELGP, another clinical trial [8] showed unchanged heartburn symptoms or persistent use of proton pump inhibitors in 80% of the patients.

Endoscopic mucosal resection (EMR) is another emerging endoluminal application. EMR has been performed in 479 early gastric cancer patients [9]. After resection, the local recurrence rate was 4.6% with a median follow-up period of 38 months. Although endoluminal ablation of Barrett's esophagus (BE) with argon plasma coagulation (APC) and photodynamic therapy (PDT) has been unsatisfactory [10,11], endoluminal ablation with radiofrequency energy is promising. The energy applied through a bougie-balloon device (Barrx Medical, Inc., Sunnyvale, CA) results in a mucosal ablation depth of 600 microns to 700 microns that preserves the muscularis propria layer. An early report about this device demonstrates successful BE ablation in 63% of patients with a 0% stricture rate [12]. Even more amazing is the recent development of a device that performs full-thickness resection (FTR) of the intestine. This device allows resecting the bowel endoluminally without making an abdominal wall incision. Animals that underwent FTR survived for at least 21 days after the procedure [13].

Endoluminal treatment of esophageal leaks has also been successful. Leak closures have been achieved with endoscopic debridement/cleaning, application of fibrin sealant, endoclip placement, plugging, endoscopic suturing, and stenting of the esophagus [14].

A recent report [15] has shown the promise of endoscopic therapy for pancreatic necrosis and pancreatic abscess. Successful pancreas debridement through a gastrotomy was achieved in a small number of patients by using a therapeutic gastroscope. Transgastric gastropexy and hiatal hernia repair were also performed in a pig model [16]. This technique requires endoscopic ultrasound (EUS) guidance. The use of EUS allowed extension to anatomical structures outside the wall of the gastrointestinal tract.

In the field of bariatric surgery, endoscopic restrictive procedures started with the creation of a vertical banded gastroplasty in animal models [17]. Recently, Fogel [18] reported his experience with endoscopic vertical gastroplasty in humans. He demonstrated weight loss in all the 10 treated patients but noted that most sutures were gone 6 months to 9 months after the procedure. Thompson [19] has recently used the endoluminal approach to treat gastric bypass patients who had weight regain secondary to dilated gastrojejunostomy. He has performed endocinch tightening of the dilated gastrojejunostomy in 8 patients that has resulted in additional weight loss.

Another chapter in endoluminal therapies has recently opened, demonstrating the feasibility of the transgastric approach to the peritoneal cavity for diagnostic and therapeutic purposes. Liver biopsies, manipulation of intraabdominal organs, gastrojejunostomy, ligation of fallopian tubes, and transgastric cholecystectomy and cholecysto-gastric anastomosis have been performed in pigs [20,21]. The feasibility of advanced transgastric abdominal surgery has actually been proven by Drs. Rao and Reddy in India (personal communication). They performed transgastric appendectomies in 2 patients.

The search is now on for innovative designs and engineering improvements that have the potential to facilitate these interventions. New endoscopes are being developed. One device, called “Cobra” (USGI Medical), may provide additional benefits, such as a stable platform for triangulation of instruments and camera and the ability to use multiple instruments at the same time (Figure 1). This device should facilitate endoluminal and transgastric surgery [22]. Although all these studies demonstrate the feasibility of the endoluminal approach, they also highlight many limitations of the present techniques. These include difficulty in exerting sufficient forward force and keeping the retroflexion view when the endoscope is in an unsupported position in the peritoneum, not to mention the risks of peritoneal infection from the gastrostomy site, the difficult visual orientation, and the present limits in endoscopic instrumentation.

In summary, it appears that we are at the dawn of a new era or another minimally invasive surgery “revolution,” one in which the surgeon operates in the abdomen with no skin incisions.

Figure 1. USGI Medical’s ShapeLock Endoscopic Guide and ShapeLock Cobra, a multilumen ShapeLock Guide with articulating instrument arms and off-axis visualization.

Address reprint requests to: William O. Richards, MD, Vanderbilt University Medical Center, D5219 MCN, Nashville, TN 37232-001, USA. Tel: 615 322 7555, Fax: 615 343 9485

William O. Richards, MD, is Professor of Surgery and Director of Laparoendoscopic Surgery at Vanderbilt University Medical Center in Nashville, Tennessee. His interests include minimally invasive and endoluminal surgery for GERD, Achalasia, and obesity.

Alfonso Torquati, MD, MSCI, is Assistant Professor of Surgery and Director of Foregut and Bariatric Surgery Research Program at Vanderbilt University Medical Center in Nashville, Tennessee. Minimally invasive and endoluminal surgery for GERD, Achalasia, and obesity are his primary interests.

Nik Sekhar, MD, is an Instructor of Surgery and Laparoscopic Surgery Fellow at Vanderbilt University Medical Center in Nashville, Tennessee. His interests are in minimally invasive and endoluminal surgery.
Yassar Khalil Youssef, MD, is a Laparoscopic Surgery Fellow, Division of GI and Laparoscopic Surgery, at Vanderbilt University Medical Center in Nashville, Tennessee. His interests include minimally invasive and endoluminal transgastric surgery.

References

1. Richards WO, Houston HL, Torquati A, Khaitan L, Holzman MD, Sharp KW. Paradigm shift in the management of gastroesophageal reflux disease. Ann Surg. 2003;237:638-647; discussion 648-639.

2.    Pleskow D, Rothstein R, Lo S, et al. Endoscopic full-thickness plication for the treatment of GERD: 12-month follow-up for the North American open-label trial. Gastrointest Endosc. 2005;61:643-649.

3.    Tam WC, Schoeman MN, Zhang Q, et al. Delivery of radiofrequency energy to the lower oesophageal sphincter and gastric cardia inhibits transient lower oesophageal sphincter relaxations and gastro-oesophageal reflux in patients with reflux disease. Gut. 2003;52:479-485.

4.    Corley DA, Katz P, Wo JM, et al. Improvement of gastroesophageal reflux symptoms after radiofrequency energy: a randomized, sham-controlled trial. Gastroenterology. 2003;125:668-676.

5.    Mason RJ, Hughes M, Lehman GA, et al. Endoscopic augmentation of the cardia with a biocompatible injectable polymer (Enteryx) in a porcine model. Surg Endosc. 2002;6:386-391.

6.    Lehman GA, Chen YK, Mendolia TF, et al. Improved acid exposure and symptom scores 3 months post-ENTERYX: Initial US randomized, controlled trial results. Gastroenterology. 2005;129:371-372.

7.    Chen YK, Raijman I, Ben-Menachem T, et al. Long-term outcomes of endoluminal gastroplication: a U.S. multicenter trial. Gastrointest Endosc. 2005;1:659-667

8.    Schiefke I, Zabel-Langhennig A, Neumann S, Feisthammel J, Moessner J, Caca K. Long term failure of endoscopic gastroplication (EndoCinch). Gut. 2002;54:752-758.

9.    Ono H, Kondo H, Gotoda T, et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut. 2001;48:225-229.

10.    Conio M, Cameron AJ, Chak A, Blanchi S, Filiberti R. Endoscopic treatment of high-grade dysplasia and early cancer in Barrett's oesophagus. Lancet Oncol. 2005;6:311-321.

11.    Kelty CJ, Ackroyd R, Brown NJ, Stephenson TJ, Stoddard CJ, Reed MW. Endoscopic ablation of
Barrett's oesophagus: a randomized-controlled trial of photodynamic therapy vs. argon plasma coagulation. Aliment Pharmacol Ther. 2004;20:1289-1296.

12.    Sharma VK, Moirano M, DePetris G, Fleischer DE. Successful ablation of Barrett's esophagus with low-grade dysplasia (LGD) using BARRX balloon device. Presented at: Digestive Disease Week; May 14-19, 2005; Chicago, IL.

13.    Ikeda K, Fritscher-Ravens A, Mosse CA, Mills T, Tajiri H, Swain CP. Endoscopic full-thickness resection with sutured closure in a porcine model. Gastrointest Endosc. 2005;62:122-129.

14.    Messmann H, Schmidbaur W, Jackle J, Furst A, Iesalnieks I. Endoscopic and surgical management of leakage and mediastinitis after esophageal surgery. Best Pract Res Clin Gastroenterol. 2004;18:809-827.

15.    Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos). Gastrointest Endosc. 2005;62:92-100.

16.    Fritscher-Ravens A, Mosse CA, Mukherjee D, et al. Transgastric gastropexy and hiatal hernia repair for GERD under EUS control: a porcine model. Gastrointest Endosc. 2004;59:89-95.

17.    Hu B, Chung SC, Sun LC, et al. Transoral obesity surgery: endoluminal gastroplasty with an endoscopic suture device. Endoscopy. 2005;37:411-414.

18.    Fogel R. Endoscopic vertical gastroplasty: a novel technique for the treatment of obesity: a preliminary report [abstract]. Gastroenterology. 2005;4. Abstract 40599.

19.    Thompson CC RM, Slattery J, Lautz DB. Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: possible new option for patients with weight regain. Surg Obes Related Dis. 2005;1:223.

20.    Jagannath SB, Kantsevoy SV, Vaughn CA, et al. Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc. 2005;61:449-453.

21.    Park PO, Bergstrom M, Ikeda K, Fritscher-Ravens A, Swain P. Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos). Gastrointest Endosc. 2005;61:601-606.

22.    Pankaj Pasricha M, Kozarek RA, Swain P et al. A next generation therapeutic endoscope: development of a novel endoluminal surgery system with “birds-eye” visualization and triangulating instruments. Gastroenterology. In press.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: Surg Endosc Learning Curves and Psychomotor Training

Learning Curves and Impact of Psychomotor Training on Performance in Simulated Colonoscopy: A Randomized Trial Using a Virtual Reality Endoscopy Trainer • Eversbusch A, Grantcharov TP. 2004;18:1514-1518. This study analyzed the learning curve for the GI Mentor II and looked at whether psychomotor training can contribute to an improvement in the performance of virtual colonoscopy. Assessment of the learning curve was based on three parameters, and assessment of endoscopic skills was based on nine parameters. The study included 28 participants, and showed significant differences in the familiarization curves on the simulator among experienced surgeons, residents, and medical students; and the learning rate was proportional to the endoscopic experience of the participants.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Application of Doppler Technology

Application of Doppler Technology as an Aid in Identifying Vascular Structures During Laparoscopy • Neff M, Cantor B, Koren J, Geis WP, Curtiss S, Rosen S, Konigsberg S. 2004;8:259-261. A laparoscopic Doppler probe was found to provide useful information in identifying the cystic artery during laparoscopic cholecystectomy, to assess mesenteric blood vessels during laparoscopic colectomy, and to identify femoral vessels during laparoscopic preperitoneal hernia repair.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Strategies for Lowering the Rate of Bile Duct Injuries in Laparoscopic Cholecystectomy

REDUCING COMPLICATION RATES

G. KEVIN GILLIAN, MD

Laparoscopic cholecystectomy is the modern “gold standard” for gallbladder extraction, but its level of difficulty and morbidity are often underappreciated by referring physicians and patients. The surgical community is quick to point to the humanistic benefit patients derive from a successful laparoscopic cholecystectomy, but quietly fears the consequences of the infrequent, but devastating, bile duct injury (BDI). These complications reached an incidence of 0.4% to 0.8% during early experiences with laparoscopic cholecystectomy [1]. The transition from open to laparoscopic cholecystectomy has involved the incorporation and evaluation of new instrumentation, changing technology, and surgical technique. Each of these areas has continued to evolve along with our parameters for performing laparoscopic cholecystectomy. It should not be surprising that the mechanisms and decisions that result in bile duct injuries are multiple.

It was a plausible and logical argument that the abrupt rise in bile duct injuries associated with the earliest efforts to perform laparoscopic cholecystectomy could be expected to drop significantly once surgeons and residents progressed beyond their own learning curve for this novel technique. Presumably, with proper surgical education and experience, bile duct injuries from laparoscopic cholecystectomy would rapidly be reduced to or below the historically and contemporarily observed rate of 0.06% to 0.2% seen in open cholecystectomy [2-4]. Unfortunately, the data have demonstrated that the rate of BDI has not dropped below that of open cholecystectomy. In fact, studies indicate that the rate of BDI in laparoscopic surgery is approximately fivefold higher than that in open surgery [5,6]. Some have suggested that this complication rate has leveled off and is no longer improving [7]. Why has this operation resisted our efforts to reach a more acceptable complication rate? Certainly, it has not been for a lack of research on laparoscopic cholecystectomy. A Medline review found more than 20000 articles published on the subject in 2001 alone. Perhaps processes in play, unrecognized by surgeons, have prevented us from making progress in our efforts against the learning curve.

Bile duct injuries resulting from laparoscopic cholecystectomies show patterns not often seen in open cholecystectomy. These injuries present earlier and are associated with higher ductal injuries and more persistent bile leaks than their open counterparts [1,8]. When BDI occurs with a concomitant major vascular injury, the morbidity and lethality is significantly worse [9]. Although many BDIs are managed by therapeutic endoscopy or Roux-en-Y hepaticojejunostomy, end-stage liver disease resulting in liver transplantation is also described. The dramatic nature of therapy required to repair BDIs after laparoscopic cholecystectomy has a prolonged and lasting effect on the surgeon and patient. This is illustrated by the fact that in one review 31% of 89 patients undergoing successful repair of a major BDI pursued legal action afterwards [10]. On a basic level, the fact that bile duct injuries associated with laparoscopic cholecystectomy tend to be more serious when they do occur should suggest that fundamental problems exist with this procedure. Have we been pushed into accepting and providing an operation for our patients that is less safe than the one it proposes to replace? After nearly 15 years of effort, can laparoscopic cholecystectomy be made safer?

To improve our results, we need to accurately identify the cause of our mistakes. A review of cases where BDI occurs has identified 2 areas on which to focus: risks associated with equipment choices and surgeon/human errors of interpretation with respect to information being provided from the surgical field. Once points of risk are accurately identified, alternative instrumentation and techniques can be devised and evaluated to improve our outcomes.

Monopolar cautery is a comfortable surgical workhorse, but in a laparoscopic field unrecognized and delayed injury from thermal damage has been associated with significant morbidity. Strictures and delayed bile duct perforation from cautery induced injury can not be identified with intraoperative inspection or cholangiogram [11,12]. The difficulty in controlling lateral spread of thermal injury puts all structures in the Triangle of Calot in harms way during dissection. Relative to monopolar cautery, ultrasonic dissection has been demonstrated to cause significantly less thermal injury to nontargeted tissues. Surgeons familiar with these devices find them nearly indispensable in advanced laparoscopic cases. The multitasking nature of the instrument allows the surgeon to remain visually focused on his work while dissecting, grasping, cutting, and gaining hemostasis [13].

The use of surgical clips early during the dissection in laparoscopic cholecystectomy has expedited control of vessels and ducts, but they have also been implicated in creating complications. Blind clip placement in an effort to control unexpected bleeding can create unintended ductal injury or stricture. Past pointing of clips can cause injury to structures outside of the visualized field. It is possible to place clips completely across the common bile duct, and, as a consequence, it becomes available for misidentification and transection [14,15]. Control of the cystic duct, the artery, or both of these, after the gallbladder is completely free from the liver bed should improve the accuracy of clip placement. This technique is similar to the “top down” technique of open cholecystectomy (Figure 1). An advantageous 360-degree view of the gallbladder and cystic duct is now available for surgical inspection. If a top down technique is adopted, an endo loop can be placed over the gallbladder and then the cystic duct, eliminating the need for clip application. Such a technique would prevent surgeons from inadvertently capturing a major bile duct in their clips while eliminating most cases of anatomic confusion.

Anatomic variation is a known source of difficulty in this operation. Eighteen percent of patents suffering BDI have aberrant bile duct anatomy on review of cholangiograms [16]. The indications for operative cholangiography have been changing. Most surgeons perform what they consider “selective” cholangiograms. The criteria for application most often reflect the need to evaluate the possibility of clinically suspected common bile duct stones or to clarify anatomic confusion. A small statistical reduction in BDI (0.39 vs 0.58%) has been shown when surgeons use intraoperative cholangiography (IOC) as opposed to not performing it.6 Bile duct injuries are more likely to be discovered and perhaps minimized when IOC is completed than if IOC is omitted [17]. Unfortunately, intraoperative cholangiograms have been interpreted as normal by the surgeon in approximately 80% of cases where BDI was later confirmed [15]. Also, an accurately interpreted IOC offers no protection against delayed perforations and strictures. In short, many of the bile duct injuries are sustained during the dissection that precedes the decision to perform IOC.

Many injuries occur as a consequence of misinterpretation of visual cues in the surgical field. A fascinating study by Way and colleagues15 reviewed 252 major bile duct injuries from a unique perspective. They used the cognitive science concepts of visual perception, judgment, and human error to analyze surgeon performance. They concluded that laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. Once accepted, the misperceptions can be so strongly held by surgeons that irregularities are ignored and corrective feedback does not occur. We tend to stick to our first impressions and discount further information from the field during laparoscopic cholecystectomy. The fallout from a single misinterpretation is magnified as we continue to work [15].

Modifications to current techniques of laparoscopic cholecystectomy are required if we are to further reduce the overall rate of BDI. The operation in its current form creates a number of hazards for the surgeon to negotiate. The combination of imperfect visualization of vital structures, and the ability of our instruments to injure nontargeted tissue is the Achilles’ heel of this operation. A willingness to consider equipment changes and alternative dissection methods is necessary if we are to further progress already made with this operation. The top down dissection as discussed above may be a useful surgical alternative and allow us to avoid the “compelling anatomic illusions” that result in misperception and injury during the performance of laparoscopic cholecystectomy [15].

Figure 1. "Top down" laparoscopic cholecystectomy.

Address reprint requests to: G. Kevin Gillian, MD, 3603 Surrey Dr, Alexandria, VA 22309, USA. Tel: 703 317 0024, Fax: 703 799 4346, E-mail: mounkevin@aol.com

Dr Gillian is a board certified, general surgeon with a private practice in Alexandria, Virginia. His fellowship training in minimally invasive and laparoscopic surgery has resulted in a unique practice that combines both standard and cutting edge techniques for patients. He lectures and preceptors surgeons locally and across the country in advanced laparoscopic and hand-assisted surgery.

Dr Gillian is the director of a multi-specialty center for the diagnosis and treatment of gastroesophageal reflux disease at Inova Alexandria Hospital. He has written about laparoscopic hernia repairs and has spoken extensively about a simpler, more efficient laparoscopic repair of ventral/incisional hernias. Dr Gillian was a featured speaker at the European Hernia Society meeting in London this summer. His latest article, “Laparoscopic Incisional and Ventral Hernia Repair (LIVH): An Evolving Outpatient Technique,” was published in JSLS in October 2003.

References

1.    Richardson MC, Bell G, Fullarton GM. The West of Scotland Laparoscopic Cholecystectomy Audit Group. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. Br J Surg. 1996;83:1356-1360.

2.    Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA. Open cholecystectomy: A contemporary analysis of 42,474 patients. Ann Surg. 1993;218(2):129-137.

3.    Andren-Sandberg A, Alinder G, Bengmark S. Accidental lesions of the common bile duct at cholecystectomy. Pre- and perioperative factors of importance. Ann Surg. 1985;201(3):328-332.

4.    Andren-Sandberg A, Johansson S, Bengmark S. Accidental lesions of the common bile duct at cholecystectomy. II. Results of treatment. Ann Surg. 1985;201(4):452-455.

5.    Johnson SR, Koehler A, Pennington LK, Hanto DW. Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy. Surgery. 2000;128:668-677.

6.    Flum SE, Dullinger EP, Cheadle A, Chan L, Koepsell T. Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. JAMA. 2003;289(13):1639-1644.

7.    Krahenbuhl L, Sclabas G, Wente MN, Achafer M, Schlumpf R, Buchler MW. Incidence, risk factors, and prevention of biliary tract injuries during laparoscopic cholecystectomy in Switzerland. World J Surg. 2001;25(10):1325-1330.

8.    Chaudhary A, Manisegran M, Chandra A, Agarwal AK, Sachdev AK. How do bile duct injuries sustained during laparoscopic cholecystectomy differ from those during open cholecystectomy? J Laparoendosc Adv Surg Tech A. 2001;11(4):187-191.

9.    Buell JF, Cronin DC, Funaki B, et al. Devastating and fatal complications associated with combined vascular and bile duct injuries during cholecystectomy. Arch Surg. 2002;137(6):703-708.

10.    Melton GB, Lillemoe KD, Cameron JL, Sauter PA, Coleman J, Yeo CJ. Major bile duct injuries associated with laparoscopic cholecystectomy: effect of surgical repair on quality of life. Ann Surg. 2002;235(6)888-895.

11.    Gigot JF, Etienne J, Aerts R, et al. The dramatic reality of biliary tract injury during laparoscopic cholecystectomy. Surg Endosc. 1997;11:1171-1178.

12.    Seligman JY, Ragland JJ. Common bile duct injury after laparoscopic cholecystectomy: report of two cases. J Am Osteopath Assoc. 1997;97(4):233-235.

13.    Gillian GK, Geis WP, Grover G. Laparoscopic incisional and ventral hernia repair (LIVH): an evolving outpatient technique. JSLS. 2002;6:315-322.

14.    White T, Hart M. Cholangiography and small duct injury. Am J Surg. 1985;149:641-643.
15.    Way LS, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237(4):460-469.

16.    Suhocki PV, Meyers WC. Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay. Am J Roentgenol. 1999;172(4):955-959.

17.    Slater K, Strong RW, Wall DR, Lynch SV. Iatrogenic bile duct injury: the scourge of laparoscopic cholecystectomy. Aust N Z J Surg. 2002;72(2):83-88.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Gastroesophageal Reflux Disease (GERD) Update

NEW TREATMENTS

J. BARRY MCKERNAN, MD, PhD, CHARLES R. FINLEY, MD

The laparoscopic treatment of GERD continues to enjoy widespread acceptance because laparoscopic fundoplication provides very effective long-term benefits for this patient population. It is interesting to look back on the days prior to the laparoscopic revolution. My own personal experience is likely similar to that of others in that I received approximately 1 referral a year for a patient requiring surgical treatment for GERD prior to the laparoscopic era, and these patients were usually “end-stage” reflux patients. We are now in the second decade of laparoscopic treatment for reflux, and some exciting new modalities are on the horizon as well as some “old” controversies still being bantered about. If one lesson can be learned from the treatment of groin hernias and applied to the treatment of GERD, it is that we should attempt to maintain standardization in the description of the disease itself and its treatment.

One of the common myths about laparoscopic fundoplication is that the short gastric vessels should be sacrificed. A recent prospective, double-blind, randomized trial with a 5-year follow-up showed that division of the short gastric vessels during laparoscopic Nissen fundoplication caused no significant improvement in any measured clinical outcome [1]. Sato et al [2] found that postoperative dysphagia was not significantly affected by division of the short gastric vessels. We would strongly suggest that the true issue is adequate mobilization of the fundus. Adequate mobilization of the fundus to perform a “floppy” fundoplication includes mobilization of the posterior fundus, with particular attention paid to the attachments between the posterior fundus and the pancreas. Although it is said that short gastric vessel division results in a longer operative time, this has not been our experience, and it likely makes adequate posterior mobilization of the fundus as well as creation of the fundoplication itself easier to perform.

Is the Nissen more effective than the modified Toupet fundoplication? Thor and Silander [3] showed with open surgery that modified Toupet is more successful than Nissen fundoplication (95% vs 67% had good or excellent results) in controlling typical reflux symptoms. Laparoscopic Nissen fundoplication has been shown to be 96% successful in relieving the primary symptom for which the surgery is performed [4]. We use Nissen fundoplication most frequently. Although we feel that either procedure results in excellent relief of reflux symptoms, Nissen fundoplication is slightly less time consuming to perform. Modified Toupet fundoplication is performed in patients with documented motility disorders (esophageal body pressures less than 30 mm Hg) or in patients who have difficulty swallowing even in the presence of “normal” manometry. Modified Toupet is also usually performed in association with an esophagomyotomy for achalasia. On the other hand, some would argue that a fundoplication should be applied selectively to patients undergoing Heller myotomy for achalasia [5].

The use of prosthetic materials at the gastroesophageal junction continues to be an active area of discussion. We prefer to avoid the use of pledgets in the creation of the fundoplication. If one chooses to use them, they should certainly not be left in contact with the esophagus, because they have been known to erode into the esophagus and the stomach. Currently, a wide variety of materials are available to either buttress the hiatal hernia closure or for its primary repair.  We have been hesitant to utilize prosthetic mesh in the immediate area of the gastroesophageal junction for fear of erosion. It is widely believed that a hiatal hernia greater than 5 cm in size has an increased rate of recurrence. From the standpoint of standardization, all crural openings are measured intraoperatively. If tension is present on the closure of the crura, we prefer to perform a medial relaxing incision as described by Huntington (Figure 1) [6]. In these cases, the diaphragm is incised just to the right of the right crus, using an angled laparoscope to visualize the right chest, care being taken to avoid the inferior vena cava. The crura are then approximated and the relaxing incision is closed with a biosynthetic material. This material is either sutured or stapled into place.

During Nissen fundoplication, a 50-French bougie dilator is used for calibration of the wrap. Fear is often voiced about possible esophageal perforation during passage of the dilator. An alternate method of calibration would be to use a technique such as the size of a known grasper between the wrap and the esophagus or a bougie that is passed over a previously placed nasogastric (NG) tube. In any event, it is very difficult to “eyeball” the proper diameter of a fundoplication. We have therefore chosen to emphasize a team approach, utilizing anesthesiologists quite familiar with the procedure and who are conscientious about both gently passing the dilator as well as observing its passage with us on our monitors.

Delayed gastric emptying is quite common in patients with GERD. In patients who present with significantly delayed gastric emptying with an intact fundoplication, we have found it helpful to dilate the pylorus endoscopically with a 56-French balloon for 3 minutes. If the patient improves symptomatically, the option of pyloroplasty is then discussed.

We perform intraoperative endoscopy (esophagogastroscopy) on all patients undergoing reoperative fundoplication, repair of paraesophageal hernia, or esophagomyotomy. Intraoperative endoscopy is also performed during any other case in which the exact location of the gastroesophageal junction is at all in question. Chang et al [7] noted that in approximately 10% of patients the GE junction is actually more cephalad than is apparent on laparoscopy.

An interesting new modality on the diagnostic front is the catheterless, 48-hour Bravo pH System (Medtronic, Minneapolis, MN, USA). The preoperative patient with no gross esophagitis on screening esophagogastroduodenoscopy (EGD) (often because by the time patients present for surgical repair they are taking maximum doses of proton pump inhibitors) or spontaneous reflux on upper gastrointestinal series has traditionally been subjected to the 24-hour pH probe as a last resort to confirm diagnosis prior to surgery. This has also been important for diagnosis in patients with principally extraesophageal symptoms, who recently have been receiving more accurate and timely diagnoses as many more internists, ENTs, and pulmonologists are becoming aware of the extraesophageal symptoms of GERD. However, it is difficult for patients to simulate a normal lifestyle and eating habits with the traditional catheter probe, and some are not able to tolerate its placement through the nasopharynx at all. With the Bravo System, a pH probe is placed comfortably and leaves no catheter visible at the patient’s nose to preclude normal activity (due to discomfort or embarrassment). However, some difficulty still exists in obtaining reimbursement for this procedure from some of the health coverage plans.

Lastly, endoscopic treatments of GERD have received much attention of late. These fall into several categories, including endoscopic suturing, submucosal injection of various agents or substrates, and the use of radiofrequency. The latter has received the most attention. The Stretta (Curon Medical, Sunnyvale, CA, USA) procedure delivers radiofrequency energy directly to the gastroesophageal junction through an endoscopic approach. Initial results are somewhat promising. However, many patients are not candidates because of exclusion criteria including the presence of a hiatal hernia greater than 2 cm, Barrett’s esophagus, dysphagia, or severe erosive esophagitis [8]. Little doubt exists that, given the safety and long-term effectiveness of laparoscopic fundoplication, any endoscopic procedure must give predictable results, as well as be durable, cost effective, and relatively easy to perform to be a viable alternative for the patient who can otherwise tolerate general anesthesia.

Figure 1a, 1b, 1c. Relaxing incision is performed for the difficult crural closure utilizing the harmonic scalpel. The crura are closed posteriorly and the relaxing incision is closed with mesh. Reprinted with permission from Huntington TR, Laparoscopic Mesh Repair of the Esophageal Hiatus. J Am Coll Surg. 1997;184:399-400. Copyright 1997, American College of Surgeons.

A captured image from a 3-D animation showing lower esophageal sphincter. From "What Acid Reflux Disease Looks Like" available at www.prevacid.com.

Address reprint requests to: J. Barry McKernan, MD, PhD, 2001 Professional Pkwy, Ste 110, 820 S Wood St, Woodstock, GA 30188, Tel: 770 924 8808, Fax: 770 924 8266, E-mail: videosur@mindspring.com

Clinical Professor of Surgery, Medical College of Georgia, Augusta, Georgia (Dr McKernan).

Clinical Instructor, Emory University School of Medicine, Atlanta, Georgia (Dr Finley).

References

1.    O’Boyle CJ, Watson KI, Jamieson GG, Myers JC, Game PA, Devitt PG. Division of short gastric vessels at laparoscopic Nissen fundoplication. A prospective double-blind randomized trial with 5-year follow-up. Ann Surg. 2002;235(2):165-170.

2.    Sato K, Awad ZT, Filipi CJ, et al. Causes of long-term dysphagia after laparoscopic Nissen fundoplication. JSLS. 2002;6:35-40.

3.    Thor KB, Silander T. A long-term randomized prospective trial of the Nissen procedure versus a modified Toupet technique. Ann Surg. 1989;210(6):719-724.

4.    Peters JH, DeMeester TR, Crookes P, et al. The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: prospective evaluation of 100 patients with “typical” symptoms. Ann Surg. 1998;228:40-50.

5.    Bloomston M, Rosemurgy AS. Selective application of fundoplication during laparoscopic Heller myotomy ensures favorable outcomes. Surg Laparosc Endosc Percutan Tech. 2002;12(5):309-315.

6.    Huntington TR. Laparoscopic mesh repair of the esophageal hiatus. J Am Coll Surg. 1997;184:399-400.

7.    Chang L, Oelschlager B, Barreca M, Pellegrini C. Improving accuracy in identifying the gastroesophageal junction during laparoscopic antireflux surgery. Surg Endosc. 2002;17(3):390-393.

8.    Houston H, Khaitan L, Holzman M, Richards WO. First year experience of patients undergoing the Stretta procedure. Surg Endosc. 2002;17(3):401-404.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

The Status of Laparoscopic Surgery for Colon Cancer: 2002

LAPAROSCOPY UPDATE

ARTHUR P. FINE, MD, FACS

Over the past year, the percentage of colon surgeries performed laparoscopically has increased yet still remains a small fraction of all large bowel procedures performed. It has been estimated that last year 5% of all colon procedures were performed laparoscopically. This year, industry analysts estimate that 8% are accomplished laparoscopically and 7-9% by hand-assisted laparoscopic technique [1]. Despite an increasing body of literature suggesting an equivalency for cancer surgery, feasibility for resection of benign disease, and an improvement of recovery of physical and GI tract activity with a decreased length of hospital stay, most colon surgery is performed by open technique. The reasons may be multiple, including the technical difficulty of the procedure, the fact that most colon resections are performed for malignancy (and that the results of the large multi-institutional studies are pending), and the lack of demand by the public which, as much as any other factor, drove the rapid availability of laparoscopic cholecystectomy. It will be the eventual findings of the effectiveness of laparoscopic surgery for curative resection of colon cancer that will dictate its acceptance.

Multiple studies of laparoscopic colon cancer surgery have been released this year. Most have not been both randomized and prospective nor had sufficient numbers to reach statistical significance. The follow-up periods for these studies have varied between 3 and 5 years.

A study by Franco-Osario [2] of 140 laparoscopic patients showed 3-year survivals for stages I, II, and III of 3.4%, 92.4% and 77.8% respectively. Bertolino [3] also evaluated 3-year survival for curative resection finding survivals of 100% for stage I and 87.7% and 76% for stage II and III. Feliciotti [4] compared 102 rectal cancer patients having both open and laparoscopic surgery. Survival probability for laparoscopic versus open procedures was 80.9% and 75.6% overall, 79% and 75% for stage II, and 69.2% and 66.7% for stage III. The same group [5] also compared 156 colon cancer patients who underwent either laparoscopic surgery or open procedures at 69 months. The cumulative survival probability was 89.7% for laparoscopic surgery and 86.1% open procedures. Lezoche [6] studied a group of 300 patents, still not enough to reach statistical significance; however, there was a trend toward a survival advantage for laparoscopic surgery (cumulative survival probability of 93.4% for laparoscopic versus 86% for open procedures). Lujon’s study [7] of 102 patients, however, compared their results with a benchmark. The results for laparoscopic versus open versus benchmark were 73%, 75%, 70% for stage I; 64%, 65%, 60% for stage II; 55%, 46%, 44% for stage III; and 0%, 11%, 7% for stage IV. While again not statistically significant, there was a trend for improved stage III survival for laparoscopic surgery. A study by Champault [8] also showed equivalence between the two procedures without reaching significance (cumulative survival probability of 63.1% for laparoscopic versus 59.1% for open procedures).

Lezoche’s data broken down by site seems to show a definite benefit for laparoscopic surgery (right colectomy: 86.5% for laparoscopic versus 81.8% for open and left colectomy: 97.1% for laparoscopic versus 88.7% for open). Even more interesting is when this group looked at their stage III survival. In a separate report of stage III patients, survival probability for right colectomy was 81.2% for laparoscopic surgery versus 66.7% for open procedures and was 95.0% for laparoscopic surgery versus 72.3% for open procedures for left colectomy.

The most significant paper of the past year was by Lacy [9]. It was a prospective, randomized study of 219 patients and did reach statistical significance at 43 months. The cancer related mortality for laparoscopic surgery was 9% and for open surgery 21% (p = 0.02). The statistical significance was entirely due to the improved stage III patient survival for laparoscopic patients.

The findings in Lacy’s paper are unique in this year’s significant studies in that they reached statistical significance; however, they are similar to the trends towards improved overall survival at 3-5 years for laparoscopic surgery primarily reflected in the stage III population. Is there significance for this?

Most patients who succumb to malignant disease do so because of metastatic tumor burden. There have been many studies on local or port site recurrences in laparoscopic colon cancer surgery which have as their most consistent finding that surgical technique is the greatest contributor to whether or not local disease recurrence is kept to a minimum. If local and port site recurrence is controlled, and that is painting with a rather broad brush, then these studies at least suggest that laparoscopic surgery may have a more favorable effect on the occult micrometastasis present in stage III malignancy than a comparable open procedure.

Rocca et al [10] evaluated levels of vascular endothelial growth factor (VEGF) in patients undergoing open colon cancer surgery. VEGF is a potent stimulator of tumor angiogenesis [11], without which micrometastasis cannot grow beyond several millimeters in size to become a clinically significant and detectable metastasis. Their data shows circulating levels of VEGF increasing from pre-op levels of 1.32 to 1.61 on postoperative day 2 and 2.43 on postoperative day 5.

A study by Fine (unpublished data) compared an unselected group of patients undergoing colon surgery either by laparoscopic or open technique and evaluated the data for a correlation between total incision length and pre- and postoperative levels of VEGF (The difference in the appearance of the data reflects Rocca’s dividing the VEGF level in pg/cc by the patient’s platelet count). In patients with a total incision length of 12 cm or greater, pre- and postoperative levels were 70 pg/cc and 625 pg/cc respectively. If less than 12 cm, the levels were 44 pg/cc and 90 pg/cc. Data in neither study had sufficient volume to teach statistical significance; however in Fine’s study, multivariate analysis revealed that in the subgroup of patients receiving perioperative blood transfusions, incision length alone accounted for 50% of the pre- and postoperative rise in VEGF.

While the large multi-institutional studies have yet to report what will be regarded as the greatest body of evidence to judge the relative effectiveness of laparoscopic colon cancer surgery, this year, as in the past few years, studies have consistently shown a rough, albeit usually a not significant benefit for this procedure. The consistent finding of improved stage III survival raises the question of whether “wounding” is a factor in how quickly solid tumors and their metastasis recur and whether open surgery hastens the appearance of distant occult metastasis compared to laparoscopic surgery.

This article is a synopsis of Dr Fine’s presentation at Endo Expo 2002.

Address reprint requests to: Arthur P. Fine, MD, FACS, Jefferson Regional Medical Center, South Hills Medical Building, 575 Coal Valley Rd, Ste 372, Jefferson Hills, PA 15025, Telephone: 412 469 7035, Fax: 412 469 7037, E-mail: arthur_fine@msn.com

Arthur P. Fine, MD, trained in general surgery at McKeesport Hospital in Pennsylvania. Before entering private practice, Dr Fine joined the US Air Force where he served as Chief of Surgery at Laughlin Air Force Base until he was discharged, and he began his private practice. He first performed laparoscopic colon surgery in 1992. Since then he has continued clinical research and has reported on the results of laparoscopic surgery in a variety of clinical settings as well as the biochemical changes that may be responsible for the improvements demonstrable to the patient.

References

1.    IHS Health Group (Medical Data International). US Surgical Procedure Volumes: 2001. Englewood, Colo: IHS Health Group (Medical Data International); 2001.

2.    Franco-Osario JD, Garcia-Molina FJ, Dominguez-Adame E, Ortegon-Castellano B, Marquez-Platero R, Mateo-Vallejo F, Gonzalez-Ruiz M, Medina-Diez J. Surg Endosc. 2002;16(suppl):s529.

3.    Zorzi D, Bertolino F, Bima C, Calgaro M, Ribero D, Capussotti L. Curative resection for colorectal cancer: laparoscopy vs. open surgery; preliminary results of a prospective not randomized trial. Surg Endosc. 2002;16(suppl):s178.

4.    Feliciotti F, Guerrieri M, Raganini AM, De Sanctis A, Campagnacci R, Lezoche E. Long-term results of laparoscopic vs. open resection for rectal cancer. Surg Endosc. 2002;16(suppl):s181.

5.    Feliciotti F, Guerrieri M, Paganini AM, De Sanctis A, Campagnacci R, Lezoche E. Laparoscopic vs. open colonic resections for cancer: long-term results on 266 unselected patients. Surg Endosc. 2002;16(suppl):s195.

6.    Lezoche E, Feliciotti F, Paganini AM, Guerrieri M, De Sanctis A, Minervini S, Campagnacci R. Laparoscopic vs. open hemicolectomy for colon cancer. Surg Endosc. 2002;16(4):557-602.

7.    Lujan HJ, Plascencia G, Jacobs M, Viamonte M, Hartman RF. Long-term survival after laparoscopic colon resection for cancer. Dis Colon Rectum. 2002;45(4):291-500.

8.    Champault GG, Barrat C, Raselli R, Elizoldo A, Catheline J-M. Laparoscopic vs. open surgery for colorectal carcinoma. Surg Laparosc Endosc Percutan Tech. 2002;12(2):88-95.

9.    Lacy AM, Garcia-Valdecasa JC, Delgado S, Castelis A, Taura P, Pique JM, Visa J. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial. Lancet. 2002;359:2224-2229.

10.    Rocca A, Lucca F, Sandri MT, Zorzino L. Andrenoni B, de Braud F. Vascular endothelial growth factor: serum levels after surgery for colorectal cancer. Proc AACR. 2001;42.

11.    Retsky M, Demicheli R, Hrushesky W. Premenopausal status accelerates relapse in node positive breast cancer: hypothesis links angiogenesis, screening controversy. Breast Cancer Res and Treatment. 2001;65:217-224.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source