Laparoscopic ischemic conditioning of the stomach prior to esophagectomy.

Several complications after esophagectomy with gastric pull-up are associated with ischemia within the gastric conduit. The aim of this study is to assess the feasibility of laparoscopic ischemic preconditioning of the stomach prior to thoracotomy, esophagectomy, and gastric pull-up with an intrathoracic anastomosis. A retrospective review of 24 consecutive patients between October 2008 and July 2011 with esophageal adenocarcinoma (stage I-III) undergoing laparoscopic gastric ischemic conditioning prior to esophagectomy was conducted. Conditioning included laparoscopic ligation of the left and short gastric arteries, celiac node dissection, and jejunostomy tube placement. Formal resection and reconstruction was then performed 4-10 days later. Of the 24 patients, 88% received neoadjuvant chemotherapy/radiation therapy. Twenty-three of the 24 patients underwent successful laparoscopic ischemic conditioning and subsequent esophagectomy. Total mean number of lymph nodes harvested was 21.8 (±8.0), and a mean of 5.3 (±2.4) celiac lymph nodes identified. There were no conversions to an open procedure. Length of stay was 3.8 (±4.8) days with a median length of stay of 2 (1-24) days. Three patients experienced anastomotic leak, six patients experience delayed gastric emptying, and two patients developed anastomotic stricture. There were no surgical site infections. R0 resection was achieved in all patients who underwent laparoscopic ischemic conditioning followed by esophagectomy. Laparoscopic ischemic conditioning of the gastric conduit has been shown to be feasible and safe.

Robotic Heller myotomy: a safe operation with higher postoperative quality-of-life indices.

INTRODUCTION: Achalasia is a primary motility disorder of the esophagus that is treated most effectively with operative myotomy. Excellent outcomes with laparoscopic myotomy and fundoplication are well known. Heller myotomy utilizing a computer-enhanced (robotic) laparoscopic platform allows for a more precise dissection by utilizing the superior optics of a 3-dimensional camera and greater degrees of freedom provided by robotic instrumentation. How this affects outcome and quality of life is unknown. METHODS: We assessed patients' health perceptions using a standardized, validated, health-related, disease-specific quality-of-life metric. Sixty-one consecutive patients undergoing laparoscopic or robotic myotomy over a 6-year period were evaluated prospectively. All operations were performed using intraoperative manometric and endoscopic guidance and all except 5 patients had a fundoplication. The effects of the operation on health-related quality of life were evaluated with the Short Form (SF-36) Health Status Questionnaire and a disease-specific gastroesophageal reflux disease activity (GERD) activity index (GRACI) preoperatively and postoperatively. All patients completed the questionnaire at both time points. Patient scores were compared using 2-way repeated measures analyses of variance followed by the Tukey test. Operative time, estimated blood loss, duration of stay, intraoperative complication, and postoperative complications were analyzed. RESULTS: Thirty-seven patients had laparoscopic and 24 patients had robotic Heller myotomy. There was an increase in SF-36 overall evaluation of health postoperatively compared with preoperatively in both groups (P < .05). The robotic myotomy patients had better SF-36 Role Functioning (emotional) and General Health Perceptions (P < .05) compared with the laparoscopic group. The GRACI showed an equivalent improvement in severity of symptoms in both groups (P < .05). Operative time was 287 +/- 9 minutes for laparoscopic cases and 355 +/- 23 minutes for robotic cases. Estimated blood loss and duration of stay were not different between groups. There were 3 operative esophageal perforations (8%) during laparoscopic myotomy and all were repaired immediately. There were no perforations or operative complications in the robotic group. Neither group had any additional complications. CONCLUSIONS: Minimally invasive operative myotomy improves functional status and overall evaluation of health in patients with achalasia. Robotic myotomy had no intraoperative esophageal perforations compared with an 8% intraoperative rate during laparoscopic myotomy. Heller myotomy with partial fundoplication using a robotic platform appears to be a more precise and safer operation than laparoscopic myotomy with improved quality-of-life indices postoperatively compared with laparoscopic myotomy with fewer complications; this suggests that, in skilled hands, the robotic platform may be safer, with improved quality-of-life outcomes.

"General surgical pearls" for the anterior exposure of vertebral fractures.

Recently interest has been increasing in the anterior surgical approach for spinal cord decompression and bony stabilization of vertebral compression fractures. Our neurosurgical spine service routinely consults us to provide anterior operative exposure and wound closure for all levels of the thoracic and lumbar vertebral spine. Averaging about 30 exposures per year we have developed an excellent operative experience with these vertebral exposures. With no complete general surgery reference on anterior vertebral identified this summary of our "general surgical pearls" that we have learned and/or have developed should significantly aid other general and trauma surgeons who may be asked by their neurosurgical and/or orthopedic surgical colleagues for assistance with these operations.

Prognostic factors in patients with surgically resected stages I and II non-small cell lung cancer.

BACKGROUND: About one-third to one-half of patients with early stages of non-small cell lung cancer (NSCLC) succumb to their disease. In this study, we attempted to identify prognostic factors that predict outcome in patients with stages I and II NSCLC. METHODS: A retrospective evaluation of 454 patients with surgically resected stages I and II NSCLC was performed to determine the impact of various clinical, laboratory, and pathological factors on patient outcome such as overall survival (OS) and event-free survival (EFS). RESULTS: Patients older than 65 years had shorter EFS and OS than younger patients (p = 0.002). Patients with preoperative hemoglobin less than or equal to 10 g% had shorter EFS and OS compared to patients with a hemoglobin greater than 10 g% (p = 0.001). Expectedly, OS and EFS were shorter in patients with stage II as compared to stage I patients (p < 0.001). In a multivariate analysis, age, hemoglobin level, and stage remain significant predictors for EFS and OS. CONCLUSIONS: Older age, anemia, and higher stage are important prognostic factors in patients with surgically resected stage I and II NSCLC.