Outcomes of minimally invasive esophagectomy without pyloroplasty: analysis of 109 cases.

Pyloroplasty is performed during esophagectomy to avoid delayed gastric emptying. However, studies have shown that gastric function is minimally impaired even without a pyloroplasty when a gastric tube rather than the whole stomach is used for reconstruction. The aim of this study was to evaluate outcomes of minimally invasive esophagectomy without performance of a pyloroplasty. We performed a retrospective review of 145 patients who underwent a minimally invasive esophagectomy. The 30-day mortality was 2.1 per cent with an in-hospital mortality of 3.4 per cent. Of the 140 patients with more than 90 days follow-up, 31 patients had a pyloroplasty and 109 patients did not. One (3.2%) of 31 patients with pyloroplasty versus six (5.5%) of 109 patients without pyloroplasty developed delayed gastric emptying. There was no significant difference in the leak rate between the two groups (9.7% vs. 9.6%, respectively). Total operative time was significantly shorter in the group without pyloroplasty (360 vs. 222 minutes with a pyloroplasty, P < 0.01). Patients with delayed gastric emptying responded well to endoscopic pyloric dilation or Botox injection. The routine performance of a pyloroplasty during minimally invasive esophagectomy can be safely omitted with a reduction in operative time and minimal adverse effects on postoperative gastric function.

The use of endoscopic stent in management of leaks after sleeve gastrectomy.

Gastric leak after sleeve gastrectomy can lead to significant morbidity and mortality. The aim of this study was to examine the safety and efficacy of endoscopic deployment of a covered esophageal stent in the management of leaks after sleeve gastrectomy. Three consecutive patients who underwent sleeve gastrectomy at outside institutions presented with leaks. All three patients underwent endoscopic placement of a covered stent. Additional procedures included laparoscopic or percutaneous drainage of abdominal collection(s). The patients were two women and one man, with a mean age of 34 years. One patient presented acutely at day 7 after the index operation and two patients presented late at 6 and 9 months, respectively. Two patients had proximal gastric leaks and one patient had a proximal gastric leak with a concomitant obstruction at the mid-aspect of the gastric sleeve. Endoscopic deployment of a covered stent was successful in all cases. There were no complications relating to the stent placement. The stent was removed at 6 weeks in two patients and at 4 months in one patient. The use of endoscopic stent was a safe and effective option in the management of leaks after sleeve gastrectomy.

Component separation in the treatment of incisional hernias.

Incisional hernia repair following open laparotomy or laparoscopic abdominal surgery is a significant challenge for the general surgeon. Primary suture closure results in high rates of recurrence, and permanent mesh reinforcement is not routinely used in contaminated surgical fields. The use of component separation to allow for low-tension, prosthetic-free incisional hernia repair has improved outcomes in these challenging surgical circumstances.

Robotic implantation of gastric electrical stimulation electrodes for gastroparesis.

BACKGROUND: Gastric electrical stimulation (GES) is a low-morbidity treatment option that may be effective for refractory symptoms in patients with gastroparesis of diabetic or idiopathic etiology. During surgery to initiate GES, two electrodes are tunneled in the gastric antrum in a precise location. If these electrodes pass through the mucosa and into the gastric lumen (determined by endoscopy) they must be repositioned, often multiple times. During this procedure, extensive suturing to anchor the electrodes is necessary once properly placed. Robotic surgical systems may provide surgeons with several technical and ergonomic advantages during this procedure when compared with a standard laparoscopic approach. METHODS: Over a 26-month period, 22 GES systems were implanted. The initial procedures were performed laparoscopically. After the first 15 laparoscopic cases, a technique for robotically implanting leads was developed and employed for the remainder of the series. Demographics, operative time, and endoscopically confirmed electrode mucosal perforations were quantified and compared based on operative approach. RESULTS: Patients were similar demographically. Total operative time did not differ based on technique (152 +/- 40 min laparoscopic versus 158 +/- 38 min robotic placement; p = 0.6). Mucosal perforations on first attempt at electrode placement occurred more frequently with the laparoscopic than with the robotic technique (15/30 laparoscopic versus 1/14 robotic; p = 0.006). There were no procedure-related complications. CONCLUSIONS: The robotic approach to GES electrode implantation is feasible and safe. Compared with standard laparoscopic techniques, the accurate insertion and anchoring of these leads can be accomplished more efficiently and comfortably using robotic techniques. Whether robotic GES electrode placement will result in significant clinical advantages for patients will require long-term follow-up.

Minimally invasive resection of gastrointestinal stromal tumors.

Gastrointestinal stromal tumors (GISTs) are rare neoplasms. The advent of electron microscopy and immunohistochemistry has led to the realization that these tumors originate from a pleuropotential cell known as the interstitial cell of Cajal (ICC). The morphologic features demonstrated as most predictive of recurrence or metastases are tumor size and mitotic rate. There is oncologic justification for minimally invasive resection techniques with gross margins for GISTs. Minimally invasive resection provides advantages to patients in terms of morbidity and recovery. A variety of endoscopic, laparoscopic, and hybrid techniques are described for surgically excising GISTs in different anatomic locations.

The impact of perioperative dexmedetomidine infusion on postoperative narcotic use and duration of stay after laparoscopic bariatric surgery.

Dexmedetomidine (Precedex, Hospira, Lake Forest, IL) is an alpha-2 receptor agonist with sedative and analgesic sparing properties. This medication has not been associated with respiratory suppression, despite occasionally high levels of sedation. For 10 months, all patients undergoing a laparoscopic bariatric procedure received a dexmedetomidine infusion 30 min before the anticipated completion of the procedure (n = 34). A control group was comprised of a similar number of patients to have had laparoscopic bariatric surgery in the time period immediately before these 10 months (n = 37). All pathways and discharge criteria were identical for patients in each group. A total of 73 patients were included in this retrospective chart review. Two gastric bypass patients were excluded for complications requiring additional surgery (one bleed and one leak). Gastric bypass patients who received a dexmedetomidine infusion required fewer narcotics (66 vs 130 mg of morphine equivalents) than control patients and met discharge criteria on post-op day (POD) 1 more often (61% discharged POD 1 vs 26% discharged POD 1, p = 0.02). Vital signs and pain scores were similar in all groups. Dexmedetomidine infusion perioperatively is safe and may help to minimize narcotic requirements and decrease duration of stay after laparoscopic bariatric procedures. This may have important patient safety ramifications in a patient population with a high prevalence of obstructive sleep apnea. A well-organized prospective, randomized, double-blinded trial is necessary to confirm the benefits of dexmedetomidine suggested by this study.