Electrical stimulation for gastroparesis. Gastric motility restored.

BACKGROUND: Gastroparesis is a disabling, and sometimes fatal, disease that often does not respond to medical treatment. This single-surgeon prospective study examines the safety and 6-month efficacy of electrical stimulation for the treatment of gastroparesis. METHODS: Sixteen patients with medically refractory gastroparesis underwent laparoscopic implantation of an electrical stimulator device (Enterra Therapy, Medtronic, Minneapolis, MN, USA) consisting of a subcutaneous stimulator and two gastric wall leads. Gastric emptying scans (GES) confirmed the diagnosis of gastroparesis. Patients were evaluated preoperatively using a self-administered GI symptomatology questionnaire and RAND 36 Health Survey. Once patients were >6-months from implantation, a repeat GES was obtained and patients completed a postoperative GI symptomatology questionnaire and RAND 36 Health Survey. Ten of 16 patients in this case series were >6-months from implantation. One was lost to follow-up. An F-test was used to establish equality of standard deviations between the 16 patients evaluated preoperatively and the subset of 10 patients evaluated postoperatively. A Student's t-test was used to evaluate the significance of differences in pre- and postoperative results. RESULTS: Average operating time was 117 min with no intraoperative complications. The majority of patients were discharged on postoperative day 1. There were two complications in the postoperative period. Patients experienced a significant decrease in nausea and vomiting as measured by the GI symptomatology questionnaire. Half of all patients no longer required gastric prokinetic medications and there was a subjective reduction of pyrosis, early satiety, and epigastric pain. A significant increase in quality of life as measured by the RAND 36 Health Survey was seen, and six of eight patients no longer demonstrated gastroparesis on GES. CONCLUSION: Laparoscopic implantation of an electrical stimulation device is a safe and effective treatment by subjective and objective standards for the management of medically refractory gastroparesis.

A biodegradeable membrane from porcine intestinal submucosa to reinforce the gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass: preliminary report.

BACKGROUND: A Silastic ring has been used to prevent dilation of the gastrojejunostomy in Roux-en-Y gastric bypass (RYGBP). The use of a bio-membrane may prevent dilation of the anastomosis without the risks associated with prostheses. The aim of this study was to evaluate the feasibility and safety of applying such a bio-membrane around the gastrojejunostomy in Laparoscopic RYGBP (LRYGBP). METHODS: We used a new bio-membrane, that is derived from porcine small intestinal submucosa (SIS) and acts as a scaffolding for the ingrowth of connective tissue. Over a 4-month period, 14 LRYGBP patients had their proximal anastomosis wrapped with 10 x 2.5 cm SIS by a single surgeon. We compared these patients to a control group of LRYGBP patients matched for BMI. RESULTS: The average age of the patients was 35.0 years (control group: 45.1 years). The patients had a mean initial BMI of 44.7 kg/m2 (+/- 5.9) standard error, and the control subjects had a mean initial BMI of 46.7 kg/m2 (+/- 6.5). SIS application took a mean time of 11 (+/- 3) minutes without any intraoperative complication. The median hospital stay was 3.5 days in the experimental group and 3.7 days in controls. Three patients developed a symptomatic stenosis at the gastrojejunostomy following surgery. In the control group there were two stenoses. At an average follow-up of 87 days (controls: 95 days), the mean reduction in BMI was 7.8 (+/- 0.8) kg/m2 [controls 8.6 kg/m2 (+/- 1.5)]. CONCLUSION: Application of SIS around the gastrojejunostomy in patients undergoing LRYGBP is feasible and safe. Further follow-up is required, however, to evaluate the effectiveness in preventing dilation of the anastomosis.

Laparoscopic exclusion of a splenic artery aneurysm using a lateral approach permits preservation of the spleen.

Splenic artery aneurysms have commonly accepted therapeutic indications. Operative therapy for splenic artery aneurysms has traditionally consisted of aneurysm resection with a possible splenectomy. Recently, laparoscopic splenic artery aneurysm exclusion has been shown to provide adequate therapy without incurring the morbidity associated with aneurysmectomy and splenectomy. However, an anterior approach to exclusion may result in short gastric and left gastroepiploic artery disruption leading to splenic infarction. Preservation of the spleen can best be assured by a lateral approach, which preserves collateral splenic perfusion. A 51-year-old woman with a distal splenic artery aneurysm, who underwent an uncomplicated laparoscopic splenic artery aneurysm exclusion using a lateral approach, is described.

Laparoscopic gastric bypass as a reoperative bariatric surgery for failed open restrictive procedures.

An estimated 2% of men and 6% of women in the United States are morbidly obese. These patients have a mortality rate that is six to twelve times greater than their normal-weight peers. In these extreme cases of overweight, only surgical intervention can produce substantial and sustained weight loss. However, up to 20% of these patients will require reoperation for failure to achieve or maintain an adequate weight loss. Reoperative bariatric surgery can be challenging and has traditionally been performed as an open procedure. We present seven female patients who underwent a laparoscopic Roux-en-Y gastric bypass after failing to achieve their weight-loss goals with prior open restrictive procedures. Their average BMI before surgical revision was 42.2 kg/m2. Mean operative time was 4 h 20 min, and length of hospital stay was 4.1 days. There were three complications in two patients and no deaths. Our initial experience suggests that laparoscopic gastric bypass is a safe and feasible reoperative bariatric procedure. Confirmation awaits a larger series of patients with follow-up data.

Laparoscopic biliopancreatic diversion with a duodenal switch for morbid obesity: a feasibility study in pigs.

BACKGROUND AND PURPOSE: Biliopancreatic diversion with a duodenal switch is an emerging open procedure that appears as effective as other bariatric operations. Our goal was to determine the safety and feasibility of performing this procedure using a laparoscopic approach in a porcine model. MATERIALS AND METHODS: Six 50-kg pigs underwent surgery. Intake was restricted with a sleeve gastrectomy, and malabsorption was obtained by creating a Roux-en-Y. The Roux limb served as a 150-cm alimentary channel following anastomosis to a transected proximal duodenum, while the other limb, or biliopancreatic channel, transported digestive juices. Where the two limbs joined, a 100-cm common channel was formed. RESULTS: The operation was completed in a mean time of 4.5 hours. Two of the six pigs had an intraoperative duodenoenterostomy anastomotic leak detected on methylene blue testing. This leakage was thought to be related to pig anatomy and is not expected to be a problem in humans. At necropsy, all anastomoses were patent, and there were no enteroenterostomy leaks or mesenteric torsions. CONCLUSION: On the basis of the porcine model, laparoscopic biliopancreatic diversion with a duodenal switch is anticipated to be feasible and safe in humans. Substantial weight loss combined with the benefits of laparoscopic surgery can be expected.

Laparoscopic resection of an extraesophageal leiomyoma presenting as an intra-abdominal mass.

Leiomyomas comprise fewer than 1% of esophageal neoplasms. Only 2% of leiomyomas are extraesophageal, and the remainder are intramural or intraluminal. A presumed intra-abdominal mass found at diagnostic laparoscopy was discovered to be an extraesophageal leiomyoma. Esophageal leiomyoma enucleation is most commonly accomplished via a thoracotomy. Increasingly, thoracoscopy has been used. An open transhiatal approach has also been described. Our patient underwent an uncomplicated transhiatal laparoscopic esophageal leiomyoma resection and benefited from the commonly recognized advantages associated with minimally invasive surgery.

When not to give radiation therapy after breast conservation surgery for breast cancer.

BACKGROUND AND OBJECTIVES: A significant proportion of breast cancer patients treated with breast conservation surgery do not receive adjuvant radiation therapy because of advanced age, severe intercurrent disease, or their own preference. We studied patients for whom adjuvant radiation was not performed, to determine whether the rate of local recurrence was acceptable in particular clinical circumstances. METHODS: Patients who had undergone breast conservation surgery for breast cancer were identified. The charts of patients who did not receive adjuvant radiation therapy were reviewed to identify the reason for omitting radiation. Local and distant recurrence rates were examined in relation to radiation and reason for omitting radiation. RESULTS: Forty-three (9%, two bilateral) of the 487 patients did not receive radiation; 9 because of advanced age, 8 refused, 7 had severe intercurrent diseases, 6 developed stage IV disease while getting chemotherapy for stage III disease, 5 patients (1 bilateral) had two reasons for omission (3 cases: age + intercurrent disease; 2 cases: age + stage IV disease; and 1 case: age + small focus of ductal carcinoma in situ) and the remainder for miscellaneous reasons. None of the 13 patients with intercurrent disease or progression to stage IV disease developed local recurrence in their life time; 5 (63%) of 8 patients who refused radiation recurred in the breast; 2 (22%) 9 of the elderly patients developed local recurrences and none of the 6 cases with more than one reason for omission developed local recurrences. CONCLUSIONS: Omission of radiation therapy after breast conservation is appropriate for patients with intercurrent diseases, for those who develop metastases while receiving preoperative chemotherapy and for selected elderly patients. Patients who refuse recommended adjuvant radiation therapy have unacceptably high rates of local recurrence. Omission of radiation for advanced age alone is associated with local recurrence rates comparable to those for younger patients.

Length of transplanted small bowel required for adequate weight gain in rats.

Progress has been made toward developing a clinically successful small-bowel transplant procedure, but there has been little research concerning the functional aspects of the transplanted small bowel. Using a rat model, our study examined the length of transplanted small bowel required to provide adequate weight gain. The rats were divided into six groups; groups 1 and 2 were considered controls. Group 1 (n = 6) underwent a gastrostomy. Group 2 (n = 3) underwent a jejunoile-ectomy followed by re-establishment of intestinal continuity and anastomosis of the native proximal small bowel to an abdominal stoma and the distal portion to the ascending colon. Groups 3 (n = 5), 4 (n = 4), 5 (n = 5), and 6 (n = 4) underwent small-bowel transplantation, receiving 100%, 50%, 25%, and 15% transplants, respectively. The donor small-bowel anastomoses were the same as the native small-bowel anastomoses in group 2. All of the rats began to produce stool within 4 days of becoming dependent upon the transplanted small bowel. By the end of postoperative week 4, there was no significant difference between the percentages of preoperative body weight in groups 1-4 (range 125.7%-130.0%). Although the weight gain in group 5 was significantly less than that in groups 1-4 (P < 0.05), it was adequate (111.8%); group 6 animals lost weight (94.7%). It is concluded that a 50% or more small-bowel transplant with or without an ileocecal valve provides ample weight gain; minimally adequate weight gain is achieved by a 25% transplant without an ileocecal valve; and the graft begins to function soon after transplantation.

Overcoming a kinked peel-away sheath during central line implantation.

In pediatric patients, central line implantation via the subclavian vein can be complicated by the presence of a kink in the peel-away sheath. A technique is described, which has been used on 62 occasions to overcome this problem. Reinserting the catheter through the kinked peel-away sheath in concert with a guidewire that extends 3 to 4 cm beyond the catheter tip can ensure successful placement.

Maintaining long-term central venous access by repetitive hepatic vein cannulation.

Long-term central venous access has become a critical issue in the treatment of pediatric patients. Exhaustion of access sites can lead to superior and inferior vena cava thrombosis, limiting the choices for central line placement. Under such circumstances, hepatic vein cannulation is a viable option. We present the cases of two patients who, combined, have undergone five hepatic vein catheterizations. One patient has received four consecutive central lines via a hepatic vein. This experience suggests that the hepatic vein is a reusable site of cannulation in patients with no other alternative for venous access.