Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Prospective, randomized clinical trial of laparoscopic totally extraperitoneal inguinal hernia repair using conventional versus custom-made (mosquito) mesh performed in Cameroon: a short-term outcomes

BACKGROUND

Adverse economic conditions often prevent the widespread implementation of modern surgical techniques in third world countries such as in Sub-Sahara Africa.

AIM OF THE STUDY

To demonstrate that a modern technique (laparoscopic totally extraperitoneal inguinal hernioplasty [TEP]) can safely be performed at significantly lower cost using inexpensive mesh material.

SETTINGS

Douala University Hospital Gynecology, Obstetrics and Pediatrics and two affiliated centers, Ayos Regional Hospital and Edéa Regional Hospital in Cameroon.

PATIENTS AND METHODS

Prospective randomized controlled trial (RCT) of consecutive adult patients presenting with primary inguinal hernia treated by TEP, comparing implantation of sterilized mosquito mesh (MM) with conventional polypropylene mesh (CM). Primary endpoints were peroperative, early and midterm postoperative complications and hernia recurrence at 30 months.

RESULTS

Sixty-two patients (48 males) were randomized to MM (n = 32) or CM (n = 30). Groups were similar in age distribution and occupational features. Peroperative and early outcomes differed in terms of conversion rate (2/32 MM) due to external (electrical power supply) factors and mesh removal for early obstruction (1/30 CM). No outcome differences, including no recurrences, were noted after a median follow-up of 21 months.

CONCLUSION

In this RCT with medium-term follow-up, TEP performed with MM appears not inferior to CM.

Defining global benchmarks in elective secondary bariatric surgery comprising conversional, revisional and reversal procedures

Objective

Management of poor response and of long-term complications after bariatric surgery (BS) is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. Benchmarking uses best performance in a given field as reference point for improvement. Our aim was to define ‘‘best possible’’ outcomes for elective secondary BS.

Methods

The establishment of benchmarks in secondary BS followed a standardized methodology, based on recommendations of a Delphi consensus panel of experts. This multicenter study analyzed patients undergoing elective secondary BS in 18 high-volume centers on 4 continents from 06/2013 to 05/2019. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of the centers. Benchmark cases had no: previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI>50kg/m2 or age>65 years. Descriptive statistics, multivariate logistic regression and data visualization were performed using the R software.

Results

Out of 44’884 elective bariatric procedures performed in the participating centers, 5’328 secondary BS cases were identified. The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8±10 years, 8.4±5.3 years after primary BS, with a body mass index 35.2±7kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.57% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.36) and after conversional or revisional procedures with gastrointestinal suture/stapling (OR 1.7). Benchmark cutoffs at 90-days postoperatively were ≤5.8% re-intervention and ≤8.8% re-operation rate. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation.

Conclusion

Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

IFSO Worldwide Survey 2016: Primary, Endoluminal, and Revisional Procedures

BACKGROUND AND AIM

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), being a Federation of 62 national societies, is the ideal network to monitor the number and type of procedures at a global level. The IFSO survey, enriched with a special section on revisional procedures, aims to report the number and types of bariatric procedures performed worldwide in 2016 and analyzes the surgical trends from 2008 to 2016.

METHODS

The 2016 IFSO Survey form was emailed to all IFSO societies. Each Society was requested to indicate the number and type of bariatric procedures performed in the country. Trend analyses from 2008 to 2016 were also performed.

RESULTS

The total number of bariatric/metabolic procedures performed in 2016 was 685,874; 634,897 (92.6%) of which were primary and 50,977 were revisional (7.4%). Among the primary interventions, 609,897 (96%) were surgical and 25,359 (4%) were endoluminal. The most performed primary surgical bariatric/metabolic procedure was sleeve gastrectomy (SG) (N = 340,550; 53.6%), followed by Roux-en-Y gastric bypass (N = 191,326; 30.1%), and one-anastomosis gastric bypass (N = 30,563; 4.8%).

CONCLUSIONS

In 2016, there was an increase in the total number both of surgical and endoluminal bariatric/metabolic procedures. Revisional procedures represent about 7% of the total bariatric interventions. SG remains the most performed surgical procedure in the world.

Medium-Term Outcomes after Reversal of Roux-en-Y Gastric Bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) can be reversed into normal anatomy (NA) or into sleeve gastrectomy (NASG) to address undesired side effects. Concomitant hiatal hernia repair (HHR) may be required. Before reversal, some patients benefit from placement of a gastrostomy, mostly to predict the result of recreating the native anatomy.

METHODS

Retrospective study on mid-term effects of RYGB reversal to NA and NASG, including clinical and weight evolution, surgical complications, and incidence of gastro-esophageal reflux (GERD).

RESULTS

Undesired side effects leading to reversal included early dumping syndrome, hypoglycemia, malnutrition, severe diarrhea and excessive nausea and vomiting. Twenty-five participants to the study, 13 NA, 12 NASG, and 15 HHR. Mean follow-up time was 5.3 ± 2.3 years. Reversal corrected early dumping, malnutrition, diarrhea, and nausea/vomiting. For hypoglycemic syndrome, resolution rate was 6/8 (75%). NA caused significant weight regain (14.2 ± 13.7 kg, (p = .003)). NASG caused some weight loss (4.8 ± 15.7 kg (NS)). Gastrostomy placement gave complications at reversal in five of seven individuals. Eight patients suffered a severe complication, including leaks (one NA vs. three NASGs). Eight out of 14 (57.1%) patients who previously had never experienced GERD developed de novo GERD after reversal, despite HHR.

CONCLUSIONS

RYGB reversal is effective but pre-reversal gastrostomy and concomitant HHR may be aggravating factors for complications and development of de novo GERD, respectively.

A delayed Boerhaave's syndrome diagnosis treated by thoracoscopy in prone position

Boerhaave's syndrome or postemetic rupture of the esophagus, carries a high morbidity and mortality. The authors report a delayed Boerhaave's syndrome diagnosis (3 days), successfully treated by right thoracoscopic debridement in prone position. Thanks to gravity the cardiopulmonary bloc drops back and the access to the esophagus is direct allowing for accurate placement of the chest tubes near the perforation. The procedure is completed by laparoscopic placement of a feeding jejunostomy with the patient supine.

Laparoscopic transhiatal esophago-gastrectomy after corrosive injury

Esophago-gastric necrosis is a surgical emergency associated with high morbidity and mortality. We report a laparoscopic transhiatal esophago-gastrectomy performed on a 43-year-old male, presenting two hours after hydrochloric acid ingestion. A gastroscopy showed several oral mucosal ulcers, a significant edema of the pharynx and larynx, a necrosis of the middle and lower esophagus and of the gastric fundus and antrum. A conservative strategy with intensive care observation was initially followed. After a change of clinical signs, chest-abdominal computed tomography was realized and a pneumoperitoneum with free fluid in the left subphrenic space and bilateral pleural effusions was in evidence. A laparoscopic exploration was proposed to the patient, and confirmed the presence of free peritoneal fluid and necrosis with perforation of the upper part of the stomach. A laparoscopic total gastrectomy with subtotal esophagectomy was performed; the procedure finished with an esophagostomy on the left side of the neck and a laparoscopic feeding jejunostomy (video). Total operative time was 235 minutes. After six months a digestive reconstruction with esophagocoloplasty by laparotomy and cervicotomy was easily realized thanks to the advantages (few adhesions, bloodless, and simple colic mobilization) of the previous minimally invasive surgery.

Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery

BACKGROUND

Reoperations for complications of bariatric surgery are associated with high morbidity and mortality. It is not known whether endoscopic treatment may reduce reoperation rates.

METHODS

Twenty-one patients underwent endoscopic treatment for persisting large anastomotic leaks before considering redo surgery. Eight patients had a gastric bypass, eight had a sleeve gastrectomy combined with a duodenal switch (SDS), four had a sleeve gastrectomy alone, and one had a Scopinaro procedure (biliopancreatic diversion). Fistulas were gastrocutaneous in 15 patients, duodenocutaneous in 2, gastroperitoneal in 3, and gastrobronchial in 1. Partially covered self-expanding metal stents (SEMSs) were used, followed by additional endoscopic procedures if the SEMS failed. SEMSs were removed by traction alone or by insertion of a self-expanding plastic stent (SEPS) followed by extraction of both stents together.

RESULTS

SEMS insertion led to 62 % (13/21) primary closures. Complementary endoscopic treatment led to 4 secondary closures. Total success rate was 81 % (17/21). Three patients in whom SEMSs failed underwent reoperation but died during postoperative follow-up; one patient died from pulmonary embolism before SEMS extraction. The success rates of endotherapy were 100 % (8/8) in the gastric bypass group, 62.5 % (5/8) in the SDS group, 75 % (3/4) in the sleeve gastrectomy group, and 100 % (1/1) for the Scopinaro procedure. Gastrocutaneous fistulas on sleeve sutures were successfully treated in 60 % of cases (6/10), while other anastomotic fistulas were successfully treated in 100 % of cases (11/11) ( P = 0.0351).

CONCLUSIONS

Endoscopic treatment using SEMSs for complications of bariatric surgery is feasible. Healing of severe leaks was obtained in 81 % (17/21) of patients, avoiding high-risk reintervention. Gastrocutaneous fistulas on a sleeve suture are the most difficult condition to treat.

Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery

BACKGROUND

Reoperations for complications of bariatric surgery are associated with high morbidity and mortality. It is not known whether endoscopic treatment may reduce reoperation rates.

METHODS

Twenty-one patients underwent endoscopic treatment for persisting large anastomotic leaks before considering redo surgery. Eight patients had a gastric bypass, eight had a sleeve gastrectomy combined with a duodenal switch (SDS), four had a sleeve gastrectomy alone, and one had a Scopinaro procedure (biliopancreatic diversion). Fistulas were gastrocutaneous in 15 patients, duodenocutaneous in 2, gastroperitoneal in 3, and gastrobronchial in 1. Partially covered self-expanding metal stents (SEMSs) were used, followed by additional endoscopic procedures if the SEMS failed. SEMSs were removed by traction alone or by insertion of a self-expanding plastic stent (SEPS) followed by extraction of both stents together.

RESULTS

SEMS insertion led to 62 % (13/21) primary closures. Complementary endoscopic treatment led to 4 secondary closures. Total success rate was 81 % (17/21). Three patients in whom SEMSs failed underwent reoperation but died during postoperative follow-up; one patient died from pulmonary embolism before SEMS extraction. The success rates of endotherapy were 100 % (8/8) in the gastric bypass group, 62.5 % (5/8) in the SDS group, 75 % (3/4) in the sleeve gastrectomy group, and 100 % (1/1) for the Scopinaro procedure. Gastrocutaneous fistulas on sleeve sutures were successfully treated in 60 % of cases (6/10), while other anastomotic fistulas were successfully treated in 100 % of cases (11/11) ( P = 0.0351).

CONCLUSIONS

Endoscopic treatment using SEMSs for complications of bariatric surgery is feasible. Healing of severe leaks was obtained in 81 % (17/21) of patients, avoiding high-risk reintervention. Gastrocutaneous fistulas on a sleeve suture are the most difficult condition to treat.

Retroperitoneal laparoscopic bilateral lumbar sympathectomy

The first retroperitoneal lumbar sympathectomy was performed in 1924 by Julio Diez. The classic procedure for sympathectomy is open surgery. We report a unilateral laparoscopic retroperitoneal approach to perform bilateral lumbar sympathectomy. This approach was performed for a 43-year-old man with distal arterial occlusive disease and no indication for direct revascularization. His predominant symptoms were intermittent claudication at 100 metres and cold legs. The patient was placed in a left lateral decubitus position. The optical system was placed first in an intra-abdominal position to check that the trocars were well positioned in the retroperitoneal space. The dissection of retroperitoneum was performed by CO2 insufflation. The inferior vena cava was reclined and the right sympathetic chain was individualized. Two ganglia (L3-L4) were removed by bipolar electro-coagulation. The aorta was isolated on a vessel loop and careful anterior traction allowed a retro-aortic pre-vertebral approach between the lumbar vessels. The left sympathetic chain was dissected. Two ganglia (L3-L4) were removed by bipolar electro-coagulation.

Endoluminal fundoplication (ELF)--evolution of EsophyX, a new surgical device for transoral surgery

A novel endoluminal fundoplication (ELF) technique using a trans-oral and fastener-deploying device (EsophyX, EndoGastric Solutions) was developed and evaluated for feasibility, safety and the treatment of gastroesophageal reflux disease (GERD) in a series of bench, animal, human (phase 1, phase 2, commercial registry) studies. The studies verified biological compatibility, durability and non-toxicity of the polypropylene fasteners as well as the feasibility of the ELF technique. The results of the preclinical testing indicated that the EsophyX device was shown to be safe, and capable of deploying fasteners directly into tissue and forming an interrupted suture line at the base of the gastro-esophageal valve (GEV). Moreover, the studies demonstrated that the ELF technique performed using the EsophyX device resulted in the creation of new GEVs of 3-5 cm in length and a circumference of 200 degrees -310 degrees , which maintained their anatomical aspects at six months. The ELF-created GEVs appeared similar to those created by laparoscopic anti-reflux surgery (LARS). The ELF procedure also resulted in reduction of all small hiatal hernias (2 cm in size) and restoration of the angle of His. The ELF procedure provides an anatomical approach similar to that of LARS for the treatment of GERD.

Surgical technique and complications during laparoscopic repair of diaphragmatic hernias

Diaphragmatic hernias can present as retrocostoxiphoid hernias (RCXH) or diaphragmatic dome hernias. The RCXH include the Larrey hernia (LH), the Morgagni hernia (MH), and the Larrey-Morgagni hernia (LMH). These congenital hernias are usually asymptomatic, and the diagnosis is simplified by two exams: chest X-ray, and thoraco-abdominal computed tomography (CT) scan. The potential risk in this condition is small-bowel incarceration in the hernia defect and subsequent obstruction. We report two cases of LH and one case of LMH treated by laparoscopy between February 2004 and October 2005, with a review of the surgical techniques. Two different laparoscopic techniques were used: the tension-free technique, and resection of the hernia sac with closure of the defect and reinforcement by prosthesis. One patient presented a postoperative cardiac tamponade due to a clip-induced bleeding of an epicardial artery at the inferior surface of the heart. Treatment by laparoscopy is feasible, but a consensus regarding the best laparoscopic repair is needed.

Thoracoscopic and laparoscopic oesophagectomy improves the quality of extended lymphadenectomy

BACKGROUND

Oesophagectomy with extended lymphadenectomy carries considerable morbidity due to parietal trauma. It is also technically extremely demanding because the difficult access even through a large thoracotomy requires the use of long instruments to reach the deepest recess in the chest cavity. Since the first thoracoscopic oesophagectomy reported by Cuschieri et al. [1] in 1992, different minimally invasive approaches have been proposed [2-12]. The aim of this video is to show the accurate and relative ease of an entirely thoracoscopic and laparoscopic oesophagectomy with an extended lymph node dissection of mediastinum in prone position (thoracoscopically) and celiac trunk (laparoscopically).

METHODS

Oesophagectomy by thoracoscopy, laparoscopy and cervicotomy was proposed in a 63-year-old man with a lower third oesophageal cancer. General anaesthesia was performed with a double-lumen endotracheal tube and the patient was placed in prone position. Surgeons were positioned at the right side of the patient. Only three trocars were needed. A 10 mm 30-degree angled scope was inserted in the 7th intercostal space on the posterior axillary line and the remaining two 5 mm trocars were inserted in the 5th and 9th intercostal spaces on the posterior axillary line. Prone position allows an excellent visibility of the operative field even in an only partially deflated lung. In order to achieve a good exposure, transitory pneumothorax with CO2 (14 mmHg) was performed. The mediastinal pleura overlying the oesophagus was incised and the arch of azygos vein was isolated, ligated and divided. The oesophagus was circumferentially mobilized from the thoracic inlet down to oesophageal hiatus. Para oesophageal and subcarinal lymph nodes were dissected so as to remain in block with the surgical specimen. A 28 F chest tube was inserted in the 8th intercostal space on the anterior axillary line. In the second stage the patient was placed in supine position and pneumoperitoneum was established. Five trocars were placed along an ideal semicircular line, with the concavity facing the subcostal margin and a 30-degree angled laparoscope was used. The lesser omentum was widely opened up the right pillar of the hiatus. Mobilization of the greater curvature of the stomach was performed preserving the right gastroepiploic artery. A wide Kocher maneuver was performed. Celiac lymphadenectomy started with skeletonization of the hepatic artery until the root of left gastric artery was reached. This artery and the left gastric vein were dissected, clipped and sectioned. All fatty tissue and lymph nodes along hepatic artery, left gastric artery and celiac trunk were resected in block with the surgical specimen. Multiple applications of a linear endoscopic stapler were used to create the gastric tube. Finally the distal oesophagus was dissected, until the thoracoscopic dissection field was joined. In the third stage a left lateral cervicotomy was performed and the cervical oesophagus was dissected down to the thoracoscopic dissection plane. Oesophagus and stomach were delivered through the cervical incision and an oesophagogastric anastomosis was created by a linear stapler technique. Cervical and abdominal drainages were installed.

RESULTS

The total operative time was 271 minutes (thoracoscopy: 106 minutes, laparoscopy 120 minutes and cervicotomy 45 minutes) and blood loss was about 100 ml. Histological examination demonstrated a squamous cell carcinoma. Both margins of resection were free of tumour and 29 lymph nodes were retrieved. The final stage was IIA (pT3N0Mx).

CONCLUSIONS

Thoracoscopic and laparoscopic oesophagectomy with extended lymphadenectomy is technically feasible and safe. Thoracoscopic oesophagectomy in prone position improves the quality of dissection because: The oesophagus and aorto-pulmonary window are reached under excellent visibility, despite a partially deflated lung, which because of gravity will always remain out of harm's way. For the same reason small to moderate bleeding will not obscure the operative field. Dissection with the long endoscopic instruments is more accurate due to the support provided by the entrance site at the parietal level and the ergonomic position of surgeon. This article contains a supplementary video.

Multimedia article. Entirely thoracoscopic pneumonectomy using the prone position: a new technique

BACKGROUND

Reports on video-assisted pneumonectomy have remained scarce, despite early demonstration of its technical feasibility. A totally videothoracoscopic pneumonectomy was first reported by Conlan and Sandor. The patient in this report was positioned in the full lateral position. In this video, we report a totally videothoracoscopic left-side pneumonectomy with the patient in prone position.

METHODS

A 49-year-old man was admitted to our hospital for a bifocal cancer of the left lower lung lobe (LLL) and the cervical esophagus. The preoperative workup included a chest computed tomography (CT) scan showing a 3-cm mass of the laterobasal segment of the LLL, with retrotumoral atelectasis, lymph nodes smaller than 1 cm in diameter at the aortopulmonary window and under the carena, and finally posterolateral adherences between the parietal and the visceral pleura. Flexible bronchoscopy confirmed the presence of a bronchial tumor at the offspring of the apical bronchus of the LLL. Biopsy showed invasive adenocarcinoma, and a CT scan of the neck and head was significant for tumoral infiltration of the cervical esophagus and retropharyngeal space. Gastroscopy showed a stenosis of the cervical esophagus and hypopharynx. Biopsy showed spinocellular epithelioma, but CT scan of the abdomen and bone scintigraphy did not show metastatic disease. A position emission tomography (PET) scan confirmed the findings of the CT scan. Pneumonectomy and esophagectomy by thoracoscopy, laparoscopy, and cervicotomy were proposed. The purpose of this video is to show the details of the thoracoscopic technique with the patient in the prone position.

RESULTS

After induction of general anesthesia, a double-lumen endotracheal tube was placed. The patient was subsequently placed and strapped in a prone position. The surgical team was placed to the left of the patient. A 10-mm trocar was placed in the seventh intercostal space on the posterior axillary line, and a 30 degrees angled videoscope was introduced. Three additional 5-mm trocars were placed at the same level in the 5th, 9th, and 11th intercostal spaces on the posterior axillary line. The mediastinal pleura was opened just ventral to the aorta. The first structure identified was the left main bronchus, which was dissected free and transected with a linear stapler (blue load). The aortopulmonary window became immediately visible. Clearance of this window's lymphoglandular tissue showed, bottom to top, the inferior pulmonary vein, the superior pulmonary vein, and the pulmonary artery. These vascular structures were carefully dissected free with the cautery hook and transected with a vascular linear stapler (white load). The lung was freed entirely tend placed in a retrieval bag for later transhiatal extraction during the laparoscopic phase of the esophagectomy. The intraoperative time for the pneumonectomy was 146 min, and intraoperative blood loss was 30 ml. The pathology report confirmed the presence of invasive, poorly differentiated adenocarcinoma. The bronchial section was free of tumor. One intrapulmonary lymphnode (N1) was positive, whereas all 10 N2 and N3 nodes harvested were free of disease. The tumor was thus staged as IIB (pT2N1Mx). The esophagetomy specimen showed fairly wide differentiated keratinizing of the spinocellular epithelioma with invasion of both pyriform sinuses and both sides of the glottis.

CONCLUSIONS

First described by Cuschieri et al. in 1992, the prone position for thoracoscopy allows for a more direct approach to the aortopulmonary window under excellent visual and ergonomic circumstances. Dissection of the hilar larger vessels and performance of lymphnode sampling appear more straightforward because with this technique, the lung is kept out of harm's way, thanks to gravity.

[Laparoscopic stomach bypass surgery]

Obesity is rapidly becoming a major medical problem in the developed world. Surgery is the only treatment with proven long-term efficiency for morbid obesity. We claim this surgery should be done by laparoscopy, because it is less invasive and morbidity is relatively low in obese patients, who are by definition fragile. Jejunojejunostomy can be performed by different techniques: side-to-side semimechanical, side-to-side entirely mechanical, end-to-side hand-sewn, and side-to-side hand-sewn. Gastrojejunostomy can be performed by different techniques: circular mechanical anastomosis with the anvil inserted through the mouth, gastrostomy, linear mechanical anastomosis, or hand-sewn anastomosis. We report our technique of laparoscopic gastric bypass with different possibilities for the two anastomoses.

Laparoscopic left lateral hepatic lobectomy for metastatic colorectal tumor

BACKGROUND

The growth of experience in laparoscopic surgery, technological improvements in laparoscopic instruments, and the application of laparoscopy to oncology surgery are responsible for the new challenge of laparoscopic liver surgery. Several series of laparoscopic liver resections have been reported, and these series have shown the feasibility of resections. The first anatomical laparoscopic liver resection was a left lateral segmentectomy, reported in 1996 by Azagra et al. due to favorable anatomy of this hepatic segment for a totally laparoscopic approach.

METHODS

This video shows a left lateral hepatic lobectomy (bisegmentectomy 2-3) by a total laparoscopic approach in a 56-year-old woman who presented with a metastatic tumor from operated colorectal cancer. A CO(2) pneumoperitoneum was induced with a Veress needle and abdominal pressure was maintained at 12 mmHg. Five trocars were placed along an ideal semicircular line, with the concavity facing the right subcostal margin, and a 30 degrees angled laparoscope was used. A retraction of round ligament with suture was performed to obtain exposure of the inferior face of liver. The left hepatic pedicle was dissected in close vicinity with the portal branch. Segmental vascular structures and bile ducts of segments 3 and 2 were progressively and intraparenchymatously identified, clipped, and sectioned. A Pringle's maneuver was not necessary. The dissection line was demarcated on the liver with monopolar cautery, and liver parenchymal transection was obtained with an ultrasound scalpel (Ultracision, Ethicon Endosurgery). Finally, the left hepatic vein was sectioned with a linear vascular endostapler (Ethicon Endosurgery). Extraction of specimen was performed using a plastic bag through an enlarged trocar site.

RESULTS

The operative time was 110 min, and blood loss was zero. The postoperative period was uneventful, the length of hospital stay was 5 days, and the patient returned to normal activity 1 week postoperatively. The surgical margins of specimen were free of disease.

CONCLUSIONS

Laparoscopic left lateral lobectomy of the liver is feasible and safe in patients with isolated malignant disease of the left lateral segment. This approach reduces blood loss and postoperative hospital stay, and it has a better cosmetic result.

Laparoscopic resection of colon Cancer: Consensus of the European Association of Endoscopic Surgery (EAES)

BACKGROUND

The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002.

METHODS

A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer.

RESULTS

Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is <1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery.

CONCLUSION

Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.

Totally laparoscopic transhiatal esophago-gastrectomy without thoracic or cervical access. The least invasive surgery for adenocarcinoma of the cardia?

BACKGROUND

The recent progress of minimally invasive surgery has allowed esophagectomy to be performed by both combined laparoscopic/thoracoscopic and totally laparoscopic transhiatal approaches. All these techniques imply a thoracic and/or cervical access for the creation of the esophagogastric anastomosis.

METHODS

Five surgical ports are introduced in the abdomen. The stomach is mobilized, divided, and tubulized, preserving the right arteries. The lymphadenectomy of the celiac trunk and the hepatic pedicle is achieved. The dissection and resection of distal esophagus and a two-fields mediastinal lymphadenectomy are performed by means of harmonic scalpel. The realization of the intrathoracic esophago-gastrostomy is accomplished by means of a circular stapler.

RESULTS

Three patients underwent the procedure. Mean operating time and blood loss were 347 min and 360 cc. There were no intraoperative or postoperative complications. Mean postoperative stay was 9 days.

CONCLUSION

In selected cases, it is possible to perform a distal esophagectomy entirely by laparoscopy, without the need for any thoracic or cervical access.

Surgical revision after failure of laparoscopic adjustable gastric banding

BACKGROUND

This paper reports the outcome of surgical revision for complications following laparoscopic placement of an adjustable silicone gastric band (AGB) to treat morbid obesity.

METHODS

Seventy-three (19.1 per cent) of 382 patients who underwent laparoscopic AGB placement between January 1996 and March 2001 presented with complications within 6 years after operation. Revision was carried out with the intention of reinstating the functional device in all patients.

RESULTS

Successful surgical revision or gradual balloon deflation was performed in 53 patients (29 port-related complications, 14 pouch dilatations, 12 band leakages, three oesophageal dilatations, two symptomatic hernias, one late migration, one intracerebral bleed). Of these patients, 51 (96.2 per cent) had a successful outcome according to the Bariatric Analysis and Reporting Outcome System following significant additional postinterventional weight loss. AGB removal was carried out in 20 patients (13 early or late migrations, five pouch dilatations, three port-related complications, two psychiatric disorders, one band leakage). The final failure rate for complicated AGB procedures was 30.1 per cent.

CONCLUSION

AGB placement is associated with a variety of complications. In most cases surgical complications can be treated with minimally invasive surgery, which should allow further weight loss and improvement of quality of life during long-term follow-up. Alternative bariatric procedures should be reserved for patients with poor outcome after surgical revision of the AGB.

Symptomatic adenomyomatosis of the gallbladder--report of a case

Adenomyomatosis of the gallbladder is a benign and degenerative condition of the gallbladder, characterized by proliferation of the mucosa of the gallbladder wall, forming invaginations and diverticula, penetrating a thickened muscular layer: the so-called Rokitansky-Aschoff sinuses (RAS). Most of the patients with adenomyomatosis remain asymptomatic. Hence adenomyomatosis is usually an incidental finding, either on ultrasonography performed for the detection of stones or by histologic examination of surgical gallbladder specimens. Only occasionally does adenomyomatosis not associated with cholelithiasis cause right upper quadrant pain. We report a case of symptomatic adenomyomatosis of the gallbladder. Clinical findings, etiology, diagnosis and therapy are discussed.

Laparoscopic right posterior hepatic bisegmentectomy (Segments VII-VIII)

The role of laparoscopy in liver surgery is still a subject of debate. Up to now, isolated hepatic lesions requiring a segmental (or bisegmental) resection have been considered to be an indication for laparoscopic surgery only when they are located in the left lobe or in the right lower lobe, whereas an open approach by laparotomy or thoracotomy is still preferred for lesions of the upper right lobe. Here we report a case of a right posterior hepatic bisegmentectomy (segments VII-VIII) performed for a hepatic hemangioma that was carried out entirely laparoscopically. In our opinion, there is not an a priori contraindication to the laparoscopic resection of any hepatic benign lesion, wherever it is located in the liver parenchyma. Nevertheless, major hepatic resections still have to be performed by expert surgeons in specialized centers.

An adjustable silicone gastric band for laparoscopic treatment of morbid obesity--technique and results

The laparoscopic application of an adjustable silicone gastric band (Lap-Band System, Bioenterics, Carpinteria, CA) (Fig. 1), based on a similar device introduced by Kuzmak in 1986, is gaining widespread acceptance as a gastric restrictive procedure in treatment of morbid obesity. The advantage of an operation that does not open the gastrointestinal tract and can be performed laparoscopically is obvious. This procedure, using the laparoscopic approach , has been performed in our institutions since 1992. The goals of this article are to describe both our standardized surgical technique that minimized the morbidity rate and its results.

Laparoscopic adjustable gastric banding

The introduction of laparoscopic adjustable silicone gastric banding (LASGB) has recently revolutionized gastric restrictive procedures in the treatment of morbid obesity. We analysed the short and long term results of this minimally invasive bariatric procedure. A total of 652 patients with a body mass of (median) 45 kg/m(2) were treated. There were only minor preoperative incidents. One patient died more than one month after the procedure. Early postoperative complications included 2 gastric perforations caused by a nasogastric tube and one early slipping of the band. Late complications occurred in 7% of the patients: 25 patients suffered a pouch dilation, 2 patients had gastric erosion by the band; 18 patients had port complications requiring reoperation. Loss of excess weight was 62% at 2 years. Laparoscopic adjustable gastric banding is a safe and effective treatment for morbid obesity. The most frequent complication is pouch dilation. Further study is warranted for the evaluation of long term results.

Laparoscopic banding: selection and technique in 830 patients

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) with the Lap-Band has been our first choice operation for morbid obesity since September 1993. Results in terms of complications and weight loss are analyzed.

METHODS

830 consecutive patients (F 77.9%) underwent LAGB. Initial body weight was 127.9 +/- SD 23.9 kg, and body mass index (BMI) was 46.4 +/- 7.2 kg/m2. Mean age was 37.9 (15-65). Steps in LAGB were: 1) establishment of reference points for dissection (equator of the balloon inflated with 25 cc air and left crus); 2) creation of a retrogastric tunnel above the bursa omentalis; 3) creation of "virtual" pouch; 4) embedding the band.

RESULTS

Mortality was 0, conversion 2.7%, and follow-up 97%. Major complications requiring reoperation developed in 3.9% (36 patients). Early complications were 1 gastric perforation (requiring band removal) and 1 gastric slippage (requiring repositioning). Late complications included 17 stomach slippages (treated by band repositioning in 12 and band removal in 5), 9 malpositions (all treated by band repositioning), 4 gastric erosions by the band (all treated by band removal), 3 psychological intolerance (requiring band removal), and 1 HIV positive (band removed). A minor complication requiring reoperation in 91 patients (11%) was reservoir leakage. 20% of patients who had % excess weight loss < 30 had lost compliance to dietetic, psychological and surgical advice. BMI declined significantly from the initial 46.4 +/- 7.2 to 37.3 +/- 6.8 at 1 year, 36.4 +/- 6.9 at 2 years, 36.8 +/- 7.0 at 3 years, and 36.4 +/- 7.8 at 5 years.

CONCLUSION

LAGB is a relatively safe and effective procedure.

Laparoscopic pyloric exclusion after endoscopic retrograde cholangiopancreatography perforation

We describe a laparoscopic technique of pyloric exclusion with gastroenterostomy and common bile duct T tube insertion for obvious perforation at endoscopic retrograde cholangiopancreatography with papillotomy. The patient was operated on immediately after diagnosis of the lesion. The postoperative sequellae were very comparable to those of elective laparoscopic common bile duct exploration. We believe this approach is interesting, especially in the current era of frequent litigation.

Feasibility of robotic laparoscopic surgery: 146 cases

Theoretically, in laparoscopic surgery, a computer interface in command of a mechanical system (robot) allows the surgeon: (1) to recover a number a number of lost degrees of freedom, thanks to intraabdominal articulations; (2) to obtain better visual control of instrument manipulation, thanks to three-dimensional vision; (3) to modulate the amplitude of surgical motions by downscaling and stabilization; (4) to work at a distance from the patient. These advances improve the quality of surgical tasks in a perfect ergonomic position. The purpose of this paper is to evaluate the feasibility of utilizing a robot in laparoscopic surgery. The first robot-assisted procedure in humans was performed in March 1997 by our team. One hundred forty-six patients underwent robot-assisted laparoscopic surgery. Between March 1997 and February 2001 a nonconsecutive series was performed of 39 antireflux procedures, 48 cholecystectomies, 28 tubal reanastomoses, 10 gastroplasties for obesity, 3 inguinal hernias, 3 intrarectal procedures, 2 hysterectomies, 2 cardiac procedures, 2 prostactectomies, 2 arteriovenous fistulas, 1 lumbar sympathectomy, 1 appendectomy, 1 laryngeal exploration, 1 varicocele ligation, 1 endometriosis cure, 1 neosalpingostomy, 1 deferent canal. The robot (Da Vinci system, Intuitive Surgical, Mountain View, CA), consists of a console and a cart with three articulated robot arms. The surgeon sits in front of the console, manipulating joysticklike handles while observing the operative field through binoculars that provide a three-dimensional picture. This computer is capable of modulating these data by eliminating physiologic tremor and by downscaling the amplitude of motions by a factor 5 or 3 to one. This study has demonstrated the feasibility of several laparoscopic robotic procedures. There is no morbidity related to the system. Operating time and the hospital stay were within acceptable limits. The system seems most beneficial in intra-abdominal microsurgery or for manipulations in a very small space. Optimized ergonomics and increased mobility of the instrument tips are beneficial in many steps of abdominal surgical procedures.

Causes of dissatisfaction in some patients after adjustable gastric banding

BACKGROUND

The laparoscopic application of the adjustable gastric band has gained widespread acceptance as a gastric restrictive procedure. The weight loss been well documented. This paper evaluates the patients' satisfaction.

METHODS

Between April 1995 and July 1999, 82 consecutive patients underwent the Lap-Band procedure.

RESULTS

Follow-up is 100%. The satisfaction index is high. 80% of all patients are extremely pleased or pleased. 15% of patients are displeased or extremely displeased. 5% have no opinion. The reason for low satisfaction differ, but 3 groups can be distinguished: 1) patients who suffered surgical complications; 2) patients who did not benefit from the procedure; 3) most importantly, patients who suffered psychological complications.

CONCLUSION

Gastric Banding is a safe, standardized and effective operation, with good acceptance by the patients. More efforts have to be made to improve patient selection and to avoid surgical complications. Most importantly, more focus is needed on the psychological aspect of the procedure and its consequences.

Evaluation of telesurgical (robotic) NISSEN fundoplication

BACKGROUND

The laparoscopic surgical approach has proven its benefit for the patient. There are however several shortcomings, which have triggered considerable research for improvement. One improvement may be the introduction of telesurgery by the interposition of a computer interface between surgeon and patient.

MATERIAL AND METHODS

A prospective randomized study was conducted in an advanced laparoscopic procedure, Nissen fundoplication. The control group underwent the conventional laparoscopic approach, while the investigational group underwent the telesurgical approach.

RESULTS

Feasibility was 100%. The procedure was more time consuming in the Telesurgical group, at all stages of the operation. Mortality was nil and morbidity was comparable in both groups.

CONCLUSION

The telesurgical approach is feasible in advanced laparoscopic procedures like Nissen fundoplication. At the present time there is however no obvious added benefit from this new technique.

Endoscopic retroperitoneal surgery

A minimally invasive approach to the retroperitoneum is described. Basic anatomy, techniques of access and pitfalls related to the technique are discussed. Available procedures are outlined. Extended retroperitoneoscopy is an expanding field and constitutes a safe alternative to the more debilitating open approach in selected indications.

Laparoscopic gastroplasty (adjustable silicone gastric banding)

Until now, for treatment of morbid obesity in the long term, surgery remained as the final option. For 40 years, surgeons looked at the best procedure. Among the restrictive procedures (gastroplasty), the laparoscopic adjustable silicone banding is the least invasive surgical treatment of morbid obesity. Between October 1992 and January 1998, we performed this procedure on 652 patients. Median body mass index was 45 (range, 35-65). Median hospital stay was 3 days (range, 2-10 days). The mean operative time was 80 minutes (range, 40-240 minutes). Four patients (0.6%) presented early complications: bleeding (1 patient), gastric perforation (2 patients), and pneumonia (1 patient). Forty-seven (7.2%) patients presented late complications and needed to be reoperated. There is one case of mortality. Loss of mass body weight was 62% in 2 years. According to these results, laparoscopic adjustable silicone gastric banding seems to be a safe and efficient technique.

Laparoscopic highly selective vagotomy

BACKGROUND/AIMS

Ten percent of our population has had a gastroduodenal ulcer. Medical treatment heals ulcers in 90% of the cases but they recur in 50-70% of the patients. We present a proposal of surgical treatment for patients with recurrent ulcer after a long-term medical treatment or whose ulcer reappears as soon as medical treatment ceases.

METHODOLOGY

Thirty-three patients underwent highly selective vagotomy (HSV) laparoscopic between April 1992 and March 1993. There were 26 male patients and 7 female patients aged 19-65 years (mean age: 38 years). Twenty-six patients were operated electively and preliminary medical treatment lasted an average 5.4 years (range: 0.5-26 years) and the disease had lasted 1-30 years (mean duration: 8.4 years). For patients with a chronic peptic ulcer disease, pre-operative assessment involved a recent gastroscopy, isotopic gastric study and a selection test.

RESULTS

HSV proved feasible in 100% of the cases in spite of a history of previous surgery and peritonitis in patients with a perforated ulcer. There were neither conversions nor intra-operative complications. There was no mortality or morbidity. The mean hospital stay was 2 days (range: 1-5 days) for selectively operated patients and 7 days (range: 6-10 days) for patients operated for a perforated ulcer. Twenty-two patients were rated Visick I and II and 3 with Visick III after re-examining. The BAO had decreased by 61% to 89% and the MAO by 60% to 80%.

CONCLUSIONS

The treatment of choice for gastro-duodenal ulcer is highly selective vagotomy. The laparoscopic approach shortens the hospital stay and improves patient's comfort.

The world's first obesity surgery performed by a surgeon at a distance

BACKGROUND

In recent years, laparoscopic procedures have gained popularity. The laparoscopic technique is, however, more difficult than the conventional approach, especially in obese patients. The purpose of this article is to demonstrate a solution to these difficulties.

METHOD

On September 16, 1998, a laparoscopic gastric banding procedure was performed by a surgeon while he was actually sitting at a distance from his patient. The surgeon's assistant was scrubbed and gowned and stood at the patient's side. The surgeon manipulated handles that were connected to a computer in command of robotic arms mounted on the operating table near the patient. The robotic arms contained surgical tools with articulated tips, well inside the abdominal cavity. The system constituted a master-slave construction called Mona (Intuitive Surgical, Mountain View, CA). The entire procedure (adjustable silicone gastric banding) was performed solely by this system without any other intervention.

RESULTS

The entire procedure lasted 90 minutes. The blood loss was 25 mL. The patient left the hospital on the second postoperative day.

CONCLUSION

This procedure demonstrates that telesurgical procedures are feasible, can be performed safely even in obese patients, and improve the surgeon's comfort by restoring ergonomically acceptable conditions, by increasing the number of degrees of freedom, and by recreating the eye-hand connection lost in videoendoscopic procedures.

[Nissen fundoplication done by remotely controlled robotic technique]

Two Nissen fundoplications were performed by a minimally invasive robotic technique on May 19, 1998. The Mona robot, was placed to the left of the patient. It held and activated surgical tools. The surgeon was placed some 3 meters from the patient and was seated at a console. He was not scrubbed. He commanded the 3 robotic arms by manipulating two handles, while observing a 3 dimensional picture recreated by a binocular system. Manipulations of the handles were translated into digital information by a computer. This information was modified by the computer with downscaling of the amplitude of motion by a factor 1 to 3 or 1 to 5. Physiologic tremor was eliminated. The computer delivered an impulse in command of the articulated robot arms via a 5 m long cable. Operating time was 4.30 hours, and 1.30 hours respectively. Blood loss was estimated at 20 and 30 ml. The two patients were discharged on the first postoperative day after a gastrograffin swallow had been performed in order to check the position of the wrap and its patency. Our experience with the Mona device may suggest that surgical robotics could have an increasingly important role in tomorrow's operating theatres. It should allow for more precise procedures, performed under better circumstances.

Laparoscopic rectopexy according to Wells

BACKGROUND

The laparoscopic approach usually reduces the morbidity of procedures performed by laparotomy. The aim of this study was to demonstrate the usefulness of laparoscopic rectopexy.

METHODS

A total of 37 patients were included in this prospective study. The indication was true rectal prolapse in all patients. Incontinence was seen in 33% of the patients. A slightly modified Wells procedure was performed laparoscopically. Postoperatively, the patients were evaluated for resolution of the prolapse and incontinence. They were also questioned about their satisfaction with the procedure.

RESULTS

Laparoscopy was successful in all but one case. Follow-up is available in 32 of 37 patients. Prolapse was cured in all patients, and the incontinence resolved in 11 of 12. In addition, 38% of the patients experienced significant constipation preoperatively versus 5% postoperatively.

Video-assisted thoracoscopic repair of an intercostal pulmonary hernia

Pulmonary hernias are extremely rare. They are usually treated with open surgical procedures. We describe a case in which a large, spontaneously acquired intercostal pulmonary hernia was successfully repaired by video-assisted thoracoscopic surgery (VATS).

Laparoscopic rectopexy according to Wells

BACKGROUND

The laparoscopic approach usually reduces the morbidity of procedures performed by laparotomy. The aim of this study was to demonstrate the usefulness of laparoscopic rectopexy.

METHODS

A total of 37 patients were included in this prospective study. The indication was true rectal prolapse in all patients. Incontinence was seen in 33% of the patients. A slightly modified Wells procedure was performed laparoscopically. Postoperatively, the patients were evaluated for resolution of the prolapse and incontinence. They were also questioned about their satisfaction with the procedure.

RESULTS

Laparoscopy was successful in all but one case. Follow-up is available in 32 of 37 patients. Prolapse was cured in all patients, and the incontinence resolved in 11 of 12. In addition, 38% of the patients experienced significant constipation preoperatively versus 5% postoperatively.