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ABSTRACT: Diagnostic natural-orifice transluminal endoscopic surgery (NOTES) peritoneoscopy can easily be performed with standard endoscopic equipment in animal studies. The efficacy and optimal transgastric site for NOTES access in humans, however, has not been determined.
To characterize the efficacy of various anterior gastric access locations for diagnostic transgastric NOTES peritoneoscopy in humans.
Prospective clinical study.
Tertiary-care center with experience in NOTES peritoneoscopy.
Patients undergoing planned laparoscopic gastrectomy or gastrotomy involving the anterior aspect of the stomach were eligible.
An anterior gastric site for NOTES gastrotomy was chosen and transgastric NOTES access was independently established after laparoscopic abdominal exploration. Peritoneoscopy was then performed. The site of gastrotomy was closed as part of the intended laparoscopic procedure.
The ability to visualize the abdominal and pelvic organs in all four quadrants was determined. Patients were evaluated postoperatively for complications.
Eight patients requiring 9 procedures were studied. Gastrotomy sites were classified as body (n = 3), lesser curvature (n = 3), greater curvature (n = 1), fundus (n = 1), and antrum (n = 1). Satisfactory navigation could only be performed to the right upper and both lower quadrants. The left upper quadrant, specifically the spleen, was adequately visualized in only 1 case (11%), where the gastrotomy site was at the greater curvature. One patient developed a surgical site infection requiring oral antibiotic therapy. The median postoperative stay was 2 days (range, 0-3 days).
Small number of patients.
NOTES peritoneoscopy with a gastrotomy on the anterior stomach permits adequate visualization of organs in the right upper and both lower quadrants. Visualization of the left upper quadrant and spleen is, however, limited unless access is gained on the greater curvature of the stomach. The accuracy of NOTES in identifying intra-abdominal pathology compared with laparoscopy remains to be determined.
Gastrointestinal endoscopy 08/2010; 72(2):279-83. · 6.71 Impact Factor
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Joseph A Trunzo,
Michael F McGee,
Leandro T Cavazzola,
Steve Schomisch, Mehrdad Nikfarjam,
Jessica Bailey,
Tripurari Mishra,
Benjamin K Poulose,
Young-Joon Lee,
Jeffrey L Ponsky,
Jeffrey M Marks
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ABSTRACT: The immunologic and physiologic effects of natural orifice translumenal endoscopic surgery (NOTES) versus traditional surgical approaches are poorly understood. Previous investigations have shown that NOTES and laparoscopy share similar inflammatory cytokine profiles except for a possible late-phase tissue necrosis factor-alpha (TNF-alpha) depression with NOTES. The local peritoneal reaction and immunomodulatory influence of pneumoperitoneum agents in NOTES also are not known and may play an important role in altering the physiologic insult induced by NOTES.
In this study, 51 animals were divided into four study groups, which respectively underwent abdominal exploration via transgastric NOTES using room air (AIR) or carbon dioxide (CO(2)) or via laparoscopy (LX) using AIR or CO(2) for pneumoperitoneum. Laparotomy and sham surgeries were additionally performed as control conditions. Measurements of TNF-alpha, interleukin-1beta (IL-1beta), and IL-6 were performed for peritoneal fluid collected after 0, 2, 4, and 6 h and on postoperative days (PODs) 1, 2, and 7.
Of the 45 animals assessed, 6 were excluded because of technical operative complications. The findings showed that LX-CO(2) generated the most pronounced response with all three inflammatory markers. However, no significant differences were detected between LX-CO(2) and either NOTES group at these peak points. No differences were encountered between NOTES-CO(2) and NOTES-AIR. Subgroup comparisons showed significantly higher levels of TNF-alpha and IL-6 with NOTES-CO(2) than with LX-AIR on POD 1 (p = 0.022) and POD 2 (p = 0.002). The LX-CO(2) subgroup had significantly higher levels of TNF-alpha than the LX-AIR subgroup at 4 h (p = 0.013) and on POD 1 (p = 0.021). No late-phase TNF-alpha depression occurred in the NOTES animals.
The local inflammatory reaction to NOTES was similar to that with traditional laparoscopy, and the previously described late-phase systemic TNF-alpha depression in serum was not reproduced. At the peritoneal level, NOTES is no more physiologically stressful than laparoscopy. Furthermore, regardless of which gas was used, the role of the pneumoperitoneum agent did not affect the cytokine profile after NOTES, suggesting that air pneumoperitoneum is adequate for NOTES.
Surgical Endoscopy 07/2010; 24(7):1727-36. · 4.01 Impact Factor
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ABSTRACT: Chronic radiation proctitis can be difficult to manage. Radiofrequency ablation has recently been shown to be effective in the management of gastric antral vascular ectasia and Barrett's esophagus, but its utility in the treatment of chronic radiation proctitis is undetermined.
A 77-year-old man with extensive chronic radiation proctitis had continued bleeding despite argon plasma coagulation. The HALO(90) radiofrequency system (BARRX Medical, Sunnyvale, CA) was used for treatment regions of proctitis at an energy density of 12 J/cm(2).
At monthly intervals, over 3 months, radiofrequency ablation was performed with a mean of 7 regions ablated at a time. The mean treatment time was 29 minutes. There was no significant bleeding after the first treatment session. The patient was symptom free at 6 months follow-up with minimal evidence of residual mucosal abnormalities.
Radiofrequency ablation appears feasible for treatment of refractory chronic radiation proctitis, with further studies required.
Surgical Innovation 06/2010; 17(2):92-4. · 2.13 Impact Factor
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The American surgeon 05/2010; 76(5):E17-9. · 1.28 Impact Factor
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ABSTRACT: Evaluation of a potential source for abdominal sepsis in a critically ill patient can be challenging. With flexible endoscopy readily available in this setting, we sought to evaluate the diagnostic efficacy of a transgastric natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy vs. laparoscopic exploration in the identification of intra-abdominal pathology in a porcine model.
In this acute study, 15 pigs were randomized to demonstrate 0 to 4 pathologic lesions: small bowel ischemia (SBI), small bowel perforation (SBP), colon perforation (CP), and gangrenous cholecystitis (GC). Two blinded surgical endoscopists were allowed 60 min to perform NOTES or laparoscopy (LAP) to correctly identify or exclude each lesion. A prototype endoscope (R-scope, Olympus, Inc), which enables independent instrument mobility, was used in the NOTES arm.
When considering all lesions, LAP was more sensitive diagnostically than NOTES (77.4% vs. 61.3%) overall. LAP also displayed a slightly higher NPV compared with NOTES (79.4% vs. 70.7%). However, NOTES was 100% specific with 100% positive predictive value (PPV) compared with 93.1% and 92.3% with LAP, respectively. Individually, NOTES was found most sensitive with CP identification (87.5%) and least sensitive with SBP (37.5%). The sensitivity of NOTES for SBI and GC was 62.5% and 57.1%, respectively.
The utilization of NOTES as a diagnostic tool may have an important role in the critically ill patient when operative intervention is highly morbid. Although it may be overall inferior diagnostically compared with laparoscopy, a positive identification was highly specific with a strong predictive value. Further investigation addressing an improved small bowel evaluation technique would be beneficial. A human trial of NOTES in the ICU utilizing the current technology would still initially mandate laparoscopic or open surgical confirmation and treatment.
Surgical Endoscopy 03/2010; 24(10):2485-91. · 4.01 Impact Factor
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ABSTRACT: Background: Pancreaticoduodenectomy (PD) combined with an en bloc extended right hemicolectomy is required to achieve complete oncological resection of various malignancies. Information regarding the indications and outcomes of this procedure is limited.Study design: Patients requiring PD combined with extended right hemicolectomy for primary tumours from 2002 to 2008 were identified.Results: PD combined with an en bloc extended right hemicolectomy was required in 14 patients, constituting 8% of pancreaticoduodenal resections. Pancreatic adenocarcinoma (8), retroperitoneal sarcoma (2) and colon cancer (2) were the main primary tumours resected. The indication for an extended right hemicolectomy was extensive tumour involvement of the transverse mesentery in seven patients. Clear tumour margins were achieved in 11 individuals. The median operating time was 10 h with intra-operative transfusions required in three patients. One or more complications were noted in eight, with delayed gastric emptying and pancreatic fistula the most common. The median length of hospital stay was 8 days. The overall 2-year survival in this series was 37%, with a median survival of 20 months in pancreatic cancer patients.Conclusions: This series suggests that PD combined with an en bloc extended right hemicolectomy is feasible and can achieve complete tumour clearance with acceptable morbidity.
HPB 10/2009; 11(7):559 - 564. · 1.60 Impact Factor
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ABSTRACT: Patients presenting with large intra-abdominal tumors often require multivisceral organ resection including partial or complete hemidiaphragm excision to achieve complete gross and microscopic tumor resection.
The ideal surgical approach to the repair of major diaphragmatic defects, particularly in a contaminated surgical field, is not well defined, but the use of prosthetic mesh in these situations is contraindicated.
We report our experience using human acellular dermal matrix for the repair of large diaphragmatic defects in these patients.
Human acellular dermal matrix is a safe and effective option in the surgical reconstruction of diaphragmatic defects in patients with large intra-abdominal tumors.
American journal of surgery 10/2009; 199(1):e12-6. · 2.36 Impact Factor
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ABSTRACT: Colocutaneous fistulas are frequently the result of complications related to previous operative procedures and are a major cause of morbidity. Most are initially treated conservatively, with a large percentage eventually requiring further surgery for definitive treatment. The use of a temporary colonic stent for the management of colostomy-related colocutaneous fistula has not been previously described. Two patients with colocutaneous fistula related to end colostomies and opening into midline laparotomy wounds were treated by temporary plastic stenting. A removable Polyflex silicone stent was inserted into the stoma. Stent redeployment was needed on several occasions following partial stent expulsion. Midline wound healing was achieved in both cases by 6 weeks post-stent insertion, and complete fistula closure occurred in 1 case. Temporary stent placement in certain cases may aid in the management of a colocutaneous fistula associated with a colostomy to allow fecal diversion from wounds and aid fistula closure.
Surgical Innovation 09/2009; 16(3):270-3. · 2.13 Impact Factor
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ABSTRACT: Delayed gastric emptying (DGE) continues to be a major cause of morbidity following pancreaticoduodenectomy (PD). A change in the method of reconstruction following PD was instituted in an attempt to reduce the incidence DGE.
Patients undergoing PD from January 2002 to December 2008 were reviewed and outcomes determined. Pylorus-preserving pancreaticoduodenectomy (PPPD) with a retrocolic duodenojejunal anastomosis (n = 79) or a classic PD with a retrocolic gastrojejunostomy (n = 36) was performed prior to January 2008. Thereafter, a classic PD with an antecolic gastrojejunal anastomosis and placement of a retrogastric vascular omental patch was undertaken (n = 36).
A statistically significant decrease in DGE was noted in the antecolic group compared to the entire retrocolic group (14% vs 40%; p = 0.004) and compared to patients treated by classic PD with a retrocolic anastomosis alone (14% vs 39%; p = 0.016). On multivariate analysis, the only modifiable factor associated with reduced DGE was the antecolic technique with an omental patch, odds ratio (OR) 0.3 (confidence interval (CI) 0.1-0.8) p = 0.022. Male gender was associated with an increased risk of DGE with OR 2.3 (CI 1.1-4.8) p = 0.026.
A classic PD combined with an antecolic anastomosis and retrogastric vascular omental patch results in a significant reduction in DGE.
Journal of Gastrointestinal Surgery 07/2009; 13(9):1674-82. · 2.83 Impact Factor
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ABSTRACT: Pancreatic infection is associated with high morbidity and mortality. Drainage of the infection is the usual therapeutic approach. Clostridium perfringens infection can cause fulminant sepsis, but it rarely occurs within the pancreas. The case of a 76-year-old man with cystic pancreatic lesions in which sepsis developed after endoscopic ultrasound with fine-needle aspiration biopsy is described. The sepsis was managed with pancreatic resection and antibiotics. Clostridium perfringens was isolated from blood cultures and microbiologic smears from the pancreas. Invasive intraductal papillary mucinous neoplasm with lymph node involvement was identified on histologic examination. The patient made a complete recovery from surgery without complications.
Archives of surgery (Chicago, Ill.: 1960) 05/2009; 144(4):368-70. · 4.32 Impact Factor
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ABSTRACT: Surgical site infections cause significant postoperative morbidity and may be reduced by pressurized irrigation of high-risk laparotomy wounds before closure. This was a retrospective review (June 2007 to May 2008) from a surgical unit at a tertiary care center.
Patients undergoing laparotomy extending beyond 4 hours, when a standard wound management strategy was instituted by either simple irrigation or pressurized pulsatile lavage (<15 psi) with saline before closure, were included. The outcome measures were the surgical site infections and factors contributing to them.
The median surgical time for the patients was 8 hours, with 34 wounds managed by simple irrigation and 42 wounds managed by pulse irrigation. Both groups had similar characteristics. Overall there were 15 (20%) surgical site infections. Significantly fewer infections occurred in the pulse irrigation group (10% vs 32%; P = .019). The use of a pulse irrigation device was the only factor associated with a reduction in wound infections (P = .019).
Surgical site infections appear to be reduced with pulsatile lavage irrigation of wounds before skin closure in patients undergoing prolonged intra-abdominal surgeries.
American journal of surgery 04/2009; 198(3):381-6. · 2.36 Impact Factor
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ABSTRACT: Ancient schwannomas are degenerate peripheral nerve sheath tumors that very rarely occur in the retroperitoneum. They generally reach large proportions before producing symptoms due to mass effect. We describe three cases of retroperitoneal ancient schwannomas and discuss the diagnosis and management of these tumors.
Three female patients with retroperitoneal ancient schwannomas were reviewed. One patient presented with several weeks of upper abdominal pain and lower chest discomfort, whereas back pain and leg pain with associated weakness were predominant symptoms in the remaining two. Abdominal imaging findings demonstrated heterogeneous masses in the retroperitoneum with demarcated margins, concerning for malignancy. The patients successfully had radical excision of their tumors. Histological examination showed encapsulated tumors that displayed alternating areas of dense cellularity and areas of myxoid matrix consistent with a diagnosis of ancient schwannoma.
A diagnosis of ancient schwannoma should be entertained for any heterogeneous, well encapsulated mass in the retroperitoneum. In these cases less radical surgical resection should be considered as malignant transformation of these tumors is extremely rare and recurrence is uncommon following excision.
World Journal of Surgical Oncology 03/2009; 7:12. · 1.12 Impact Factor
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ABSTRACT: Pancreatic trauma is a common cause of acute pancreatitis in children and is often treated by conservative measures alone. Conservative measures are more likely to fail when there is complete pancreatic duct disruption. We report a case of complete transaction of the pancreatic neck following blunt trauma in a 14-year-old boy. Complete duct disruption was confirmed by endoscopic retrograde pancreatography. The patient was successfully managed by a laparoscopic spleen-preserving distal pancreatectomy and recovered quickly without complications. The merit of a laparoscopic approach to severe pancreatic injury in children is discussed.
Journal of Pediatric Surgery 03/2009; 44(2):455-8. · 1.45 Impact Factor
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ABSTRACT: Roux-en Y gastric bypass surgery is the most common operation for treatment of morbid obesity. The approach to pancreaticoduodenal resection in patients with a history of Roux-en Y gastric bypass is not well described.
Pancreaticoduodenal resection was performed in two patients with distal bile duct strictures, with a past history of Roux-en Y gastric bypass. In both cases the remnant stomach, distal bile duct, duodenum and pancreas were excised. The biliopancreatic limb was divided close to the ligament of Treitz and brought up into the supracolic compartment in a retromesenteric manner and pancreatic and biliary anastomoses performed. The previous enteroenterostomy and gastrojejunal anastomoses were left intact. Both patients had an uncompleted post-operative recovery. The mean operating time was 6.5 hours and mean estimated blood loss was 525 mL. They were discharged home by days 6 and 7 post-operatively.
Pancreaticoduodenal resection can be successfully performed following Roux-en Y gastric bypass with en-bloc excision of the remnant stomach, with the pancreas and bile duct anastomosed to the divided biliopancreatic limb.
JOP: Journal of the pancreas 02/2009; 10(2):169-73.
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ABSTRACT: The mortality associated with pancreaticoduodenectomy (PD) has decreased substantially in recent times, but high morbidity continues to be a significant problem. With reductions in mortality, there is increasing willingness to combine organ resections with PD when indicated. There is, however, a paucity of information regarding the morbidity and mortality of multivisceral resection (MVR) that involves pancreaticoduodenectomy (MVR-PD).
Patients undergoing PD between January 2002 and November 2007 by a single surgeon were reviewed and perioperative outcomes determined. Those treated by PD alone were compared to those undergoing MVR-PD.
There were 105 patients overall who underwent PD during the study period, with MVR-PD performed in 19 patients. Twelve (63%) patients required PD combined with right colectomy, two (11%) underwent PD combined with right nephrectomy, two (11%) required liver resection with PD, and the remaining three (16%) had various combinations of kidney, colon, adrenal and small bowel resection in addition to PD. In both groups, the main indication for surgery was pancreatic cancer; however, there were proportionally more patients in the MVR-PD group with gastrointestinal stromal tumors (two (11%) patients), sarcomas (two (11%) patients) and metastases to the periampullary region (three (16%) patients). The overall complication rate in this study was 60%. Delayed gastric emptying (39%) and pancreatic fistula (16%) were the most common complications. There was no significant difference in complications between the two groups. A non pylorus-preserving PD was more commonly performed in cases of MVR-PD (53% vs 28%; p = 0.007), operating times were longer (9.5 vs 8 h; p = 0.002), and surgical intensive care unit stay was greater (2 vs 1 days; p < 0.001). The overall median length of hospital stay (7 days) and readmission rate were similar between the groups.
MVR-PD can be performed without significant added morbidity compared to PD alone. The main indication for MVR-PD is locally advanced pancreatic cancer requiring PD combined with right hemicolectomy.
Journal of Gastrointestinal Surgery 02/2009; 13(5):915-21. · 2.83 Impact Factor
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ABSTRACT: The outcome of patients with colorectal liver metastases (CLM) undergoing surgical resection in the era of effective chemotherapy is not widely reported. In addition, factors associated with disease-specific survival (DSS) in a contemporary series of patients are not well defined. Clinical, pathologic, and outcome data for 64 patients with CLM treated by a single surgeon in a multidisciplinary setting from February 2002 to October 2007 were examined. Hepatic resection was combined with radiofrequency ablation (RFA) in 23 (36%) cases. Secondary or tertiary resection was undertaken in 12 (19%) patients. Synchronous CLM were noted in 25 (39%) cases. Neoadjuvant chemotherapy was given to 41 (64%) patients. Following hepatic resection, adjuvant chemotherapy was administered in 52 (81%) cases. There was one (2%) operative mortality. One or more complications were noted in 24 (38%) patients. Median length of hospital stay was 7 (2-7) days. Five-year DSS and overall survival were 72% and 69%, respectively. Bilobar disease (p < 0.001), local tumor extension (p = 0.02), response to neoadjuvant chemotherapy (p = 0.005), preoperative portal vein embolization (p = 0.05), number of hepatic lesions (p = 0.03), positive resection margin (p < 0.001), and node-positive primary disease (p = 0.001) were prognostically significant factors on univariate analysis. On multivariate analysis, bilobar disease (p = 0.02) and local tumor extension (p = 0.02) were the only two independent prognostic factors. We conclude that, in patients with CLM, a multidisciplinary approach encompassing an aggressive surgical policy achieves excellent 5-year survival results with acceptable operative morbidity and mortality. Bilobar disease and local extrahepatic extension of cancer appear to be independent prognostic factors for long-term survival.
Annals of Surgical Oncology 12/2008; 16(7):1860-7. · 4.17 Impact Factor
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ABSTRACT: Improvements in the understanding of molecular oncogenesis and mechanisms of drug resistance have presented new opportunities for the treatment of gastrointestinal stromal tumors (GIST). In particular, the discovery of c-kit genomic mutations in GIST and the development of targeted therapy with imatinib mesylate and sunitinib have heralded a new era in the treatment of this disease. Due to its high activity in GIST, imatinib has become the standard of care in treating both advanced disease and localized disease with high-risk features. On the other hand, these developments have provided new challenges in optimizing the use of our drug armamentarium in conjunction with surgery. This review focuses on the molecular oncogenesis of GIST and provides a summary of recent approaches in the management of this disease.
Gastrointestinal cancer research: GCR 10/2008; 2(5):245-50.
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ABSTRACT: The discovery of the c-KIT mutation and the advent of targeted drug therapy with imatinib mesylate have revolutionized the management of gastrointestinal stromal tumors (GISTs). The outcome of patients with surgically treated GISTs treated in the era of targeted drug therapy was assessed and factors associated with adverse outcomes determined.
Patients with GISTs requiring surgery at a tertiary care center from 2002 to 2007 were reviewed and prognostic factors determined.
Forty patients were surgically treated for GISTs. The median age at presentation was 59 years. The stomach (55%) was the main site of primary disease. The median tumor size was 7 cm. Eleven (28%) patients had metastatic disease at presentation. Surgery was undertaken in all patients with curative intent. Multi-organ resection was required in 10 (25%) patients. Imatinib mesylate was administered postoperatively in 68% of cases. Median follow-up was 24 months. There was a 40% recurrence rate with 63% undergoing repeat surgical resection. The peritoneum and liver were the main sites of recurrent disease. The 5-year disease-specific survival and disease-free survival (DFS) were 65% and 35%, respectively. High mitotic rate (P = 0.017) and tumor size greater than 10 cm (P = 0.009) were the only prognostically significant adverse factors of DFS on multivariate analysis, independent of imatinib mesylate treatment.
Aggressive surgical treatment and follow-up of GISTs, combined with targeted drug therapy, leads to long-term DFS survival. Tumor recurrence is independently associated with a high tumor mitotic rate and size greater than 10 cm, despite the use of adjuvant targeted drug therapy.
Journal of Gastrointestinal Surgery 07/2008; 12(11):2023-31. · 2.83 Impact Factor
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ABSTRACT: Nephrectomy and pancreaticoduodenctomy are operations often performed for the treatment of malignancy. However, the combination of both procedures is rarely reported.
The indications and outcomes of combined right nephrectomy and pancreaticoduodenectomy were assessed.
Patients were identified from a prospective operative database between 2002 and 2008.
A tertiary care center.
One-hundred and 80 patients undergoing pancreaticoduodenectomy. There were 5 (2.8%) patients treated by combined right nephrectomy and pancreaticoduodenal resection.
Description of these 5 patients.
Three patients had retroperitoneal sarcomas adherent to the right kidney and duodenum, one patient had a locally advanced transitional-cell carcinoma and the remaining patient presented with an ampullary malignancy and concurrent right renal tumor All patients underwent en bloc resection with clear margins. Median operating time was 13 hours (range: 9-21 hours). There was no perioperative mortality in this series. Complications were noted in 3 (60%) patients related to pancreaticoduodenal resection and all were managed conservatively without significant clinical impact. Median post-operative hospital stay was 8 days (range: 7-11 days). At a median follow-up of 14 months (range: 3-36 months) all patients were alive without evidence of disease recurrence.
En bloc right nephrectomy combined with pancreaticoduodenal resection can be performed in selected patients with malignant tumors with acceptable morbidity to achieve clear resection margins.
JOP: Journal of the pancreas 01/2008; 9(4):449-55.
