Quantification of acute parasympathetic denervation during cryoballoon ablation by using extracardiac vagal stimulation.

AIMS: The purpose of this study was to systematically quantify the level of acute parasympathetic denervation in a stepwise fashion by means of extracardiac vagal stimulation (ECVS) by positioning a quadripolar catheter in the internal jugular vein, in a cohort of patients undergoing second-generation cryoballoon ablation for paroxysmal atrial fibrillation. METHODS: Fifty patients with symptomatic paroxysmal atrial fibrillation, having undergone extracardiac vagal stimulation before and after ablation by means of second-generation cryoballoon second-generation cryoballoon ablation, were included. RESULTS: The extracardiac vagal stimulation performed preablation provoked cardioinhibitory responses in all patients with mean pause duration of 10130.6 ± 3280.0 ms. At the end of the procedure, the VRs were significantly diminished with mean pause of 1687.5 ms ± 2183.7 ms (P = 0.00 compared with the pause before the procedure). CONCLUSION: The ECVS proved to be a reproducible, feasible and reliable method to quantify the degree of parasympathetic denervation during CB-A. In all patients, significant cardiac parasympathetic denervation could be observed at the end of the procedure. Responses to ECVS were more specific to quantify the vagal denervation than the increase in the heart rate. However larger studies are needed to confirm this observation.

Vagal blocking improves glycemic control and elevated blood pressure in obese subjects with type 2 diabetes mellitus.

BACKGROUND: An active device that downregulates abdominal vagal signalling has resulted in significant weight loss in feasibility studies. OBJECTIVE: To prospectively evaluate the effect of intermittent vagal blocking (VBLOC) on weight loss, glycemic control, and blood pressure (BP) in obese subjects with DM2. METHODS: Twenty-eight subjects were implanted with a VBLOC device (Maestro Rechargeable System) at 5 centers in an open-label study. Effects on weight loss, HbA1c, fasting blood glucose, and BP were evaluated at 1 week to 12 months. RESULTS: 26 subjects (17 females/9 males, 51 ± 2 years, BMI 37 ± 1 kg/m(2), mean ± SEM) completed 12 months followup. One serious adverse event (pain at implant site) was easily resolved. At 1 week and 12 months, mean excess weight loss percentages (% EWL) were 9 ± 1% and 25 ± 4% (P < 0.0001), and HbA1c declined by 0.3 ± 0.1% and 1.0 ± 0.2% (P = 0.02, baseline 7.8 ± 0.2%). In DM2 subjects with elevated BP (n = 15), mean arterial pressure reduced by 7 ± 3 mmHg and 8 ± 3 mmHg (P = 0.04, baseline 100 ± 2 mmHg) at 1 week and 12 months. All subjects MAP decreased by 3 ± 2 mmHg (baseline 95 ± 2 mmHg) at 12 months. CONCLUSIONS: VBLOC was safe in obese DM2 subjects and associated with meaningful weight loss, early and sustained improvements in HbA1c, and reductions in BP in hypertensive DM2 subjects. This trial is registered with ClinicalTrials.gov NCT00555958.

Selective ganglionated plexi ablation for paroxysmal atrial fibrillation.

BACKGROUND: Selective ganglionated plexi (GP) ablation guided by high-frequency stimulation has been proposed for the treatment of paroxysmal atrial fibrillation (AF), but the efficacy of the method is not established. OBJECTIVE: This study sought to compare selective ablation of GP identified by high-frequency stimulation with extensive regional ablation targeting the anatomic areas of GP in patients with paroxysmal AF. METHODS: Eighty patients with paroxysmal AF (age 53 +/- 9 years) were randomized to undergo selective GP ablation or regional left atrial ablation at the anatomic sites of GP. For selective GP ablation (n = 40), ablation targets were the sites where vagal reflexes were evoked by high-frequency stimulation. Vagal reflexes were defined as prolongation of the R-R interval by >50% and a concomitant decrease in blood pressure (>20 mm Hg) during AF. The end point of the procedure was failure to reproduce vagal reflexes with repeated high-frequency stimulation. For anatomic ablation, lesions were delivered at the sites of GP clustering. RESULTS: At 13.1 +/- 1.9 months, 42.5% of patients with selective GP and 77.5% of patients with anatomic ablation were free of symptomatic paroxysmal AF (PAF) (P = .02). Parasympathetic denervation was more prominent in patients with anatomic than selective GP ablation, and in patients free of AF compared to these with AF recurrence immediately after ablation, but this trend was abolished at 6 months. CONCLUSION: Selective GP ablation directed by high-frequency stimulation does not eliminate paroxysmal AF in the majority of patients. An anatomic approach for regional ablation at the sites of GP confers better results.

An improved technique for laparoscopic highly selective vagotomy using harmonic shears.

BACKGROUND: Results from classic highly selective vagotomy (HSV) are technique dependent because an incomplete operation will result in early recurrence of duodenal ulcer. Few reports describe laparoscopic completion of the procedure. All techniques use clips for division of neurovascular branches, making the laparoscopic approach tedious and thus the results, uncertain. METHODS: Ten patients with intractable duodenal ulcer and negative Helicobacter pylori status underwent an extended HSV. All procedures were performed laparoscopically using a new surgical tool, the harmonic shears. RESULTS: All procedures were completed laparoscopically and took approximately 1 h. There were no deaths and no postoperative complications. Patients were discharged the next day. Follow-up endoscopy at 2 months showed healing of duodenal ulcer in all cases, and postoperative acid secretion studies demonstrated a decrease in basal acid output (BAO) by 74% (8.2 meq/h to 2.16 meq/h) and maximal acid output (MAO) by pentagastrin stimulation by 79.2% (40 to 8.32). CONCLUSIONS: Harmonic shears expedite laparoscopic HSV. The operation can be taught safely, yields good results in early follow-up, and represents an acceptable option in patients with intractable duodenal ulcers who are H. pylori negative.

Laparoscopic Hill's vagotomy by the abdominal wall lifting method.

We performed laparoscopic Hill's vagotomy by the abdominal wall lifting method in nine patients with intractable duodenal ulcer. Our original I-type lifting bar is a curved stainless-steel rod 5 mm in diameter. One I-type lifting bar is inserted intraperitoneally into each of the right and left hypochondrial regions. An incision is made in the lesser omentum near the gastroesophageal junction, and the right esophageal wall and right crus of the diaphragm are dissected and exposed. The posterior trunk of the vagus nerve is identified and divided. Then the neurovascular bundle is dissected and divided repeatedly along the lesser curvature of the stomach from the first branch of the crow's foot to the gastroesophageal junction. The mean operating time was 163 min, with little blood loss. The reduction rate of basal acid output and maximal acid output was, respectively, 73.7 +/- 0.1 and 63.7 +/- 0.1%. Four weeks after surgery, gastroduodenoscopy revealed ulcer healing to a scar.

Laparoscopic highly selective vagotomy using CO2 laser: experimental study in dogs.

We attempted to establish a modified laparoscopic highly selective vagotomy using CO2 laser in dogs and evaluated its effectiveness and feasibility. After the laser dose based on gross and histologic measurements was determined, five dogs underwent anterior CO2 laser vagotomy with posterior truncal vagotomy under laparoscopy (lap-laser vagotomy) and five others underwent anterior selective vagotomy with posterior truncal vagotomy in the standard fashion via laparotomy (open surgical vagotomy). No complications such as gastric perforation were observed in any of the dogs subjected to lap-laser vagotomy, and the operating time was approximately half of that required for open surgical vagotomy. After surgery, acid secretion significantly decreased versus preoperative values in both groups of animals and remained stable for 6 months. We conclude that anterior CO2 laser vagotomy with posterior truncal vagotomy is as effective as conventional vagotomy and easier to perform; thus, we recommend it as a method of laparoscopic highly selective vagotomy.

Vagotomies--laparoscopic or thoracoscopic approach.

The complications and sequelae of truncal vagotomy have been overemphasized in the surgical literature. With the introduction of minimally invasive techniques, the indications for vagotomy have to be reconsidered. The procedure can be performed either by laparoscopy or by thoracoscopy. The techniques for these approaches are outlined. In an experience of twenty-one vagotomies no major complication occurred, and the immediate results are fair.

Laparoscopic gastric vagotomies.

Recurrent duodenal ulcer remains a continuing challenge for medical care. Once popular, operations have almost vanished from surgical wards due to efficient medical treatment. The onset of laparoscopy and minimal invasive surgery has caused several teams to reconsider the position of surgical treatment in the disease. Various procedures are actually used, and, as no long-term follow-up is available, it is difficult to estimate which technique would be advisable. The authors compare the different procedures and the theoretical advantages and disadvantages of each one. The best technique has to be applicable in laparoscopy and achieve the best results for the patient.

Wittmoser's technique of thoracoscopic sympathectomy and vagotomy.

His extensive developmental and clinical work made Raimund Wittmoser a major trailblazer in endoscopic surgery from the 1950s on. His single-puncture technique for operative thoracoscopy permitted surgical interventions of peerless quality on the sympathetic and vagal nerves. His basic surgical principle was to achieve the greatest possible selectivity by a segmental approach to the sympathetic rami communicantes or the individual branches of the vagus nerve. Besides his extraordinary surgical skills, his particular achievement was the development of new instrumental and ancillary technologies for endoscopic surgery. In addition to the development of new endoscopes and imaging systems, his pressure-regulated CO2 insufflation system and low frequency cautery technique had major impact on the further development of endoscopic surgery. Finally, Wittmoser's surgical interventions in the autonomic nervous system were of outstanding quality and set standards still observed by thoracoscopic surgeons today.

[Use of laser technique in the surgical treatment of peptic ulcer]. / Primenenie lazernoi tekhniki pri khirurgicheskom lechenii iazvennoi bolezni.

The results of surgical treatment of 275 patients with gastric and duodenal ulcer disease with the use of the laser CO2-scalpel are analysed. The use of laser technique permits to improve the results of surgical interventions, and extends the possibilities for the performance of the organ-preserving operations.

[Use of lasers in gastroenterology]. / Primenenie lazerov v gastroenterologii.

Under analysis were results of the surgical treatment of 120 patients with different gastroenterological diseases. It was shown that laser scalpel can be successfully used not only at key steps of the operation, but also for the dissection of other tissues but the skin and fatty tissue. Using laser scalpels gives better functional results of the abdominal surgery.

Complete vagotomy. The evolution of an effective technique.

In the 36 years since the reintroduction of truncal vagotomy for the treatment of duodenal ulcer, recurrent ulcer at a rate of between 7% and 12% has become accepted as the most serious long-term postoperative complication. Although techniques for performance of complete vagotomy have been described, many of these principles of technique have been either forgotten or discarded. The new techniques of vagotomy, that is, selective and highly selective vagotomy, have realerted us to the necessity of performing a careful and wide anatomic dissection of all periesophageal tissue of the esophagogastric junction.