Minimally Invasive "3-Stitch" Modification of the Dor Fundoplication: Simple and Effective.

BACKGROUND: A 180-degree anterior (Dor) fundoplication is usually paired with an esophagogastric myotomy in the surgical treatment of achalasia. The traditional technique, however, is not easily reversible and the execution is variable. This study examined a simplified ''3-stitch'' Dor fundoplication that addressed these challenges and presented the results. METHODS: A prospectively collected, longitudinal surgical achalasia database was queried for patients undergoing a Heller myotomy with '3-stitch 180-degree fundoplication from 2008 to 2019. Preoperative and postoperative Eckardt score, postoperative DeMeester score (24- or 48-hour pH studies), and endoscopic evidence of esophagitis were collected and analyzed to determine the effectiveness and safety of the fundoplication. Length of stay and complications were also considered. RESULTS: The pH testing was performed in 296 patients, with 17% (50 of 296) demonstrating abnormal esophageal acid exposure. Of this group, only 8% (16 of 201) manifested clinical esophagitis on upper endoscopy. A total of 14% (7 of 50) of patients with abnormal esophageal acid exposure were symptomatic. Total postoperative Eckhardt scores for this cohort were 3 or lower in 92% of patients, with a dysphagia-specific score of 0 in 92%. The technical details of a modified 180-degree anterior fundoplication are described. CONCLUSIONS: The 3-stitch Dor fundoplication is an effective addition to a minimally invasive Heller myotomy, with good palliation of symptoms and an acceptable rate of acid reflux. The simplified construction anticipates the potential progression of esophageal dysmotility in patients with achalasia, and the modified technique is reproducible and readily teachable.

Proficiency of Robotic Lobectomy Based on Prior Surgical Technique in The Society of Thoracic Surgeons General Thoracic Database.

BACKGROUND: Robotic lobectomy represents a paradigm shift for many surgeons. It is unknown if a surgeon's prior operative approach influences development of proficiency. We compared outcomes based on prior lobectomy experience and used cumulative sum analysis to assess proficiency. METHODS: Using The Society of Thoracic Surgeons General Thoracic Database we grouped surgeons as de novo, open-to-robotic, or video-assisted thoracoscopic surgery (VATS)-to-robotic. Operative time, blood transfusion, mortality, and major morbidity were primary outcomes. Unacceptable and acceptable thresholds were determined by review of the literature. Proficiency was defined as 20 consecutive cases without crossing an upper control line. Surgeons were assessed individually, and proficiency was assessed by transition group. RESULTS: From 2009 to 2016, 271 surgeons performed 5619 robotic lobectomies for clinical stage I/II non-small cell lung cancer. Of these, 65 surgeons (24%) performed ≥20 lobectomies (4483 cases). Initial proficiency for an operative time target of 250 minutes was 40% for de novo compared with 14% for open-to-robotic and 21% for VATS-to-robotic surgeons, with improvement to 47%, 29%, and 21%, respectively, after 20 cases. Initial and sustained proficiency related to major morbidity was similar for open-to-robotic and VATS-to-robotic but lower for de novo at 40%. After 20 cases most were proficient (de novo, 93%; open-to-robotic, 100%; and VATS-to-robotic, 86%). Proficiency for 30-day mortality and blood transfusion was high in all groups. CONCLUSIONS: Outcomes among all transition groups improved with experience. Operating room duration proficiency was challenging for all groups. Cumulative sum may be useful to monitor proficiency in not only subsequent studies but in clinical practice.

Endoscopic Resection in the Esophagus.

The article is a review of the principles behind endoscopic resection of esophageal dysplasia and early cancers. The techniques of endoscopic mucosal resection and endoscopic submucosal dissection are reviewed, and the supporting literature compared. Endoscopic resection is compared with esophagectomy for the management of these lesions and current areas of controversy with regard to T1b lesions and gastroesophageal reflux following resection are addressed.

Gastric hibernoma: a novel location and presentation of a rare tumor.

We present a case of gastric hibernoma, an unusual tumor with a location novel to the literature. A 39-year-old female presented with one year of upper gastrointestinal bleeding and dysphagia. Gastroenterology performed an esophagogastroduodenoscopy with ultrasound and identified a 6 cm mass within the muscularis propria of the antrum. Computed tomography demonstrated a 9.7 × 7.8 × 4.8 cm3 heterogeneous antral mass with internal septa. A distal gastrectomy with Bilroth I gastroduodenostomy was performed with 4 cm proximal and 2 cm distal margins. Excision was appropriate to make the diagnosis, exclude malignancy, and remove a symptomatic mass. Hibernoma was confirmed by histopathology. These are rare tumors of brown fat named for their resemblance to the thermogenic tissue found in hibernating animals. They typically present as a slowly enlarging mass of the thigh or shoulder. To our knowledge, this is the first presentation of a hibernoma as a submucosal gastric mass.

Theatrical fire pursuant exploratory laparotomy.

Fire in the operating theater is a rare but potentially fatal complication. We report igniting an intraperitoneal fire while preforming an exploratory laparotomy for perforated viscus. Fortunately, the patient suffered no injuries as a result.