C. Daniel Smith

• M.D.
• Managing Director at Esophageal Institute of Atlanta

Introduction Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are commonly performed bariatric procedures in obesity management. Gastroesophageal reflux disease (GERD) in this population has reported rates of 23–100%. GERD after LSG has been noted with recent studies demonstrating de novo reflux or symptom exa...

Background & aims: Regurgitative gastroesophageal reflux disease (GERD) refractive to medical treatment is common and caused by mechanical failure of the anti-reflux barrier. We compared the effects of magnetic sphincter augmentation (MSA) with those of proton-pump inhibitors (PPIs) in a randomized trial. Methods: Patients with moderate to sever...

Background Outcomes are not well studied in patients undergoing remediation for multi-fundoplication failure, that is, two or more prior failed fundoplications. Re-operation must balance reflux control and restoration of the ability to eat with the challenge of reconstructing a distorted hiatus and GE junction. The purpose of this study is to prese...

Introduction: Laparoscopic magnetic sphincter augmentation (MSA) has been shown to be efficacious therapy for gastroesophageal reflux disease (GERD) refractory to maximal medical management. Herein, we present our experience with this procedure and an analysis of our outcomes. Materials and methods: Medical records were retrospectively reviewed...

Background: Only a small percentage of candidates for bariatric surgery ever undergo a procedure for weight loss. Devices duplicating key effects of bariatric surgeries with removable, fully trans-oral implants could extend their benefits to patients unwilling to undergo anatomy-altering abdominal surgeries. Methods: Thirty-two obese subjects (m...

Background and aims: GERD patients frequently complain of regurgitation of gastric contents. Medical therapy with proton-pump inhibitors (PPIs) is frequently ineffective in alleviating regurgitation symptoms, as PPIs do nothing to restore a weak lower esophageal sphincter. Our aim was to compare effectiveness of increased PPI dosing with laparosco...

Aim: To evaluate outcomes of surgical remediation for symptomatic or anatomic failure after a transoral incisionless fundoplication (TIF). Methods: This retrospective study was performed on 11 patients who underwent a remedial operation following TIF failure between June 2011 and September 2016 at the Mayo Clinic in Florida for persistent foregu...

Background: The magnetic sphincter augmentation device continues to become a more common antireflux surgical option with low complication rates. Erosion into the esophagus is an important complication to recognize and is reported to occur at very low incidences (0.1-0.15%). Characterization of this complication remains limited. We aim to describe...

Objective: To report 1-year results from a 5-year mandated study. Summary background data: In 2012, the United States Food and Drug Administration approved magnetic sphincter augmentation (MSA) with the LINX Reflux Management System (Torax Medical, Shoreview, MN), a novel device for the surgical treatment of gastroesophageal reflux disease (GERD...

Background: Repair of giant paraesophageal hernia (PEH) is associated with a favorably high rate of symptom improvement; however, rates of recurrence by objective measures remain high. Herein we analyze our experience with laparoscopic giant PEH repair to determine what factors if any can predict anatomic recurrence. Methods: We prospectively co...

Introduction: Use of the magnetic sphincter augmentation device (MSAD) for gastroesophageal reflux disease (GERD) is increasing. As this innovative treatment for GERD gains widespread use and adoption, an assessment of its safety since U.S. market introduction is presented. Methods: Events were collected from the Manufacturer and User Facility D...

Despite documented success of antireflux surgery in controlling GERD in select patients, there remains a persistent incidence of failure requiring reoperation. Broadly speaking, the need for reoperation can be broken into three general categories, errors in diagnosis or patient selection, intraoperative errors, or the natural history of the antiref...

The aim of this study was to evaluate the current opinion of the individual European surgeons on the use of mesh in large hiatal hernia repair. A Web-based questionnaire was e-mailed to European upper gastrointestinal surgeons identified by the European Association for Endoscopic Surgery. The questionnaire was completed by 165 surgeons. Mesh is rou...

Esophageal disease and dysfunction of the lower esophageal sphincter (LES) manifesting as gastroesophageal reflux disease (GERD) particularly, is the most common of all gastrointestinal conditions impacting patients on a day-to-day basis. LES dysfunction can lead to anatomic changes to the distal esophagus, with GERD-mediated changes being benign s...

Background A new device for mechanical sphincter augmentation (MSA) of the lower esophageal sphincter was approved by the FDA on March 22, 2012. We report early experience with MSA, specifically addressing postoperative management. Study Design Between October 1, 2011 and June 1, 2013, 150 patients were evaluated for MSA. Of these, 66 patients und...

Aims: To prospectively examine the effect of modern bariatric surgery on 24-hour urine parameters in a comprehensive care bariatric practice (CCBP). Materials and methods: 47 consecutive patients in our CCBP underwent serum and 24-hour urine analysis pre-operatively, and 30 returned at 12 months for repeat testing. Paired comparisons for serum m...

Introduction: With an expanding population of patients requiring ventricular assist devices, it is inevitable that these patients will require noncardiac surgery. Ventricular assist devices provide mechanical support for a failing heart either as a bridge to transplant or now as a long-term support if transplant is not available, so-called destina...

Variability in flow of patients through operating rooms has a dramatic impact on a hospital's performance and finances. Natural variation (uncontrollable) and artificial variation (controllable) differ and require different resources and management. The aim of this study was to use variability methodology for a hospital's surgical services to impro...

Patients with gastroesophageal reflux disease who have a partial response to proton-pump inhibitors often seek alternative therapy. We evaluated the safety and effectiveness of a new magnetic device to augment the lower esophageal sphincter. We prospectively assessed 100 patients with gastroesophageal reflux disease before and after sphincter augme...

There is no standard approach to enterotomy management in the setting of a hernia repair. The factors affecting the treatment path include the severity and nature of the injured bowel, presence of gross spillage, and surgeon’s expertise and comfort level, which results in options for both laparoscopic and open repairs. As demonstrated in the litera...

Background: Recent national attention has focused on improving upon the surgical quality of hospitals across the United States. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database includes expected morbidity probability for each surgical patient. We sought to investigate the accuracy of this probabil...

Background: Minimally invasive esophagectomy (MIE) is performed through various approaches, including using video-assisted thoracoscopic surgery for mediastinal esophageal dissection. The prone technique allows for gravity-aided retraction of the lung. The aim of this study was to examine perioperative outcomes after prone MIE in relation to patie...

The objective of this study was to examine whether preoperative recommendation for specific reductions in body mass index (BMI) influenced weight loss in obese surgical patients. We retrospectively reviewed the electronic medical records of 48 patients who enrolled between January 2007 to June 2010 in an 800-calorie per day liquid meal replacement...

Mesh use during hiatal hernia repair (HHR) has been suggested to be safe and effective. Concern has been raised about the risk of mesh-related complications, and the higher risk of complications if revisional hiatal surgery is undertaken after mesh has been used. Available data have not established a clear role for mesh in HHR. To assess surgeons'...

A retained foreign object is a preventable surgical error and has typically been considered a surgical instrument, needle, or sponge. A new retained surgical object is a retained surgical specimen (RSS). This case study outlines the nature of the RSS, the paradigm shift that has led to this becoming a new healthcare error, and steps to prevent this...

Introduction The TEP repair is associated with a learning curve of at least 250 repairs. Expert surgeons' decision-making becomes automated, making it difficult for them to recognize and teach their decision-making process. We sought to deconstruct the intraoperative decision-making of the TEP repair in order to discern the key cognitive and techni...

It is estimated that healthcare associated infections (HAI) account for 1.7 million infections and 99,000 associated deaths each year, with annual direct medical costs of up to $45 billion. Surgical Site Infections (SSI) account for 17% of HAIs, an estimated annual cost of $3.5 to 10 billion for our country alone. This project was designed to pursu...

Transhiatal (two-field) esophagectomy reduces cardiopulmonary complications by avoiding thoracic access, but requires blind mediastinal dissection. The authors developed a minimally invasive esophagectomy (MIE) technique applying single-incision laparoscopy technology to better visualize the thoracic esophageal dissection. This is performed using l...

Component separation technique (CST) enables rectus abdominus medialization, but may cause wound complications. Few published outcomes exist involving laparoscopic CST. Our aim was to examine feasibility and outcomes involving open and laparoscopic (lap) CST during ventral incisional hernia repair (VIHR) and present an algorithm for ventral hernior...

The repair of large congenital diaphragmatic hernia frequently results in patch disruption and recurrence as patients grow in size. Absorbable meshes allow for ingrowth of endogenous tissue as they are degraded, providing a more natural and durable repair. The aim of this study was to compare the characteristics of the new diaphragmatic tissue betw...

Outcomes after ventral incisional hernia (VIH) repair are measured by recurrence rate and subjective measures. No objective metrics evaluate functional outcomes after abdominal wall reconstruction. This study aimed to develop testing of abdominal wall strength (AWS) that could be validated as a useful metric. Data were prospectively collected durin...

Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10 % of patients, most of whom will seek repeat surgical intervention. These reoperations are technically challenging, and as such, there exist only limited reports of reoperation with esophageal preservation. We retrospectively reviewed the records of patients who...

Minimally invasive esophagectomy (MIE) may involve video-assisted thoracoscopic surgery (VATS) for mediastinal esophageal dissection. Usually, VATS requires single-lung ventilation and has associated cardiopulmonary morbidity [1-3]. Alternatively, transhiatal dissection can be performed, although its complications include vocal cord palsy [4], card...

For the critically ill patient, initiation of early enteral nutrition is an important therapeutic strategy which can change their course of hospitalization. If started soon after admission to the Intensive Care Unit (ICU) and if provided with sufficient dosage, early EN can be expected to reduce infectious morbidity, decrease risk for multiorgan fa...

Gastroesophageal reflux disease (GERD) is a significant health concern, with millions of Americans experiencing weekly heartburn and the resulting significant impairment in quality of life. Even more concerning is the increased prevalence of more advanced GERD, as evidenced by rising numbers of patients with Barrett’s esophagus, including an increa...

Non-dysplastic mucosa (ND-) in Barrett's esophagus (BE) shows clonal molecular aberrations, loss of cell cycle control, and other features of "neoplasia." These changes occur prior to morphologic expression of neoplasia (dysplasia). Morphologic evaluation of dysplasia is fraught with error, and, as a result, often leads to false-negative and false-...

The management of nonmalignant esophageal perforations is one of the most challenging situations in esophageal diseases. Traditionally, surgical repair has been the mainstay of therapy. Although endoscopic stenting has traditionally been used for management of malignant stenosis and fistulas, there has been limited information on its role in benign...

Background: Mesh-assisted hiatal closure during foregut surgery is increasing. Our aim was to evaluate the complications that follow revisional foregut surgery. Specifically, we compared surgical indications and perioperative outcomes between patients with and without prior hiatal mesh (PHM). Methods: We conducted an institutional review board (...

Congress and others have called into question the propriety of relationships between professional medical associations (PMAs) and industry. These relationships are critical to the continued development of new and better devices and procedures for patients. Better guidelines are needed to help guide these relationships. Overrestrictive regulatory ov...

This article covers some new areas of development in esophageal surgery. Specific topics include reviews of long-term outcomes after laparoscopic antireflux surgery, the use of surgically placed implantable device for LES augmentation (Linx), the use of mesh for hiatal hernioplasty, and prone and nonthoracic approaches to minimally invasive esophag...

The anterior transabdominal approach was once the standard operative procedure for almost all adrenal lesions. This chapter describes alternative approaches that may provide better exposure for specific types of tumors or permit excision of the adrenal tumor with decreased morbidity. In addition to the anterior abdominal approach, alternative surgi...

To the Editor: In their Special Communication, Dr Rothman and colleagues1 addressed a challenging and important issue. However, important critical elements of the PMA-industry relationship as it relates to surgical PMAs and the medical device industry were not considered.We believe that the medical device industry and pharmaceutical industry are si...

Laparoscopic ventral hernia repair has been shown to offer improved patient recovery, when compared to open repair. It has also been shown to offer a lower complication rate. However, in patients with high body-mass index and large defects, the intraperitoneal on-lay technique of laparoscopic repair is criticized for an increased incidence of failu...

Total pancreatectomy (TP) is associated with significant metabolic abnormalities leading to considerable morbidity. With the availability of modern pancreatic enzyme formulations and improvements in control of diabetes mellitus, the metabolic drawbacks of TP have diminished. As indications for TP have expanded, we examine our results in patients un...

Primary laparoscopic hiatal hernia repair is associated with up to a 42% recurrence rate. This has lead to the use of mesh for crural repair, which has resulted in an improved recurrence rate (0-24%). However, mesh complications have been observed. We compiled two cases, and our senior author contacted other experienced esophageal surgeons who prov...

Background. Laparoscopic ventral hernia repair (LVHR) can be challenging in patients with large abdominal wall defects and loss of domain (LOD). When hernia contents are reduced, the pneumoperitoneum preferentially fills the sac, leaving no space for mesh manipulation. This study presents a modification for LVHR in LOD patients, as well as outcomes...

Gastroesophageal reflux is a very common condition, and surgery remains a reasonable options in select patients. Successful surgical care for GERD depends on proper patient selection, workup and operative technique. This manuscript reviews surgical care for GERD.

Endoluminal therapies have emerged as adjuncts for the treatment of gastroesophageal reflux disease (GERD) in select patients. To compare the effectiveness of endoscopic full-thickness plication and endoscopic radiofrequency treatments for patients with GERD. A total of 126 patients who underwent either endoscopic full-thickness plication (FTP) of...

Antireflux surgery (ARS) is appropriate and effective management for patients who have gastroesophageal reflux disease (GERD) refractory to medical management, who are on lifelong acid suppression, or who are experiencing side effects of the medical management. Over the past 2 decades, the operations have evolved from predominantly open thoracic ap...

The aim of this study was to evaluate the technical feasibility of endosonographically-assisted transesophageal access for vagotomy, esophagomyotomy, and lymphadenectomy in a nonsurvival study with six porcine models in an animal laboratory with general anesthesia. Saline/hydroxypropylmethylcellulose (HPMC) was injected into the submucosa with a su...

Advanced surgical skills such as laparoscopic suturing are difficult to learn in an operating room environment. The use of simulation within a defined skills-training curriculum is attractive for instructor, trainee, and patient. This study examined the impact of a curriculum-based approach to laparoscopic suturing and knot tying. Senior surgery re...

The ideal objective assessment method for laparoscopic technical skills is difficult to achieve in the operating room. Recent "VR2OR" studies have used a blinded, 2-reviewer error-based video tape analysis for intraoperative performance assessment. This study examines the validity of this methodology applied to laparoscopic intracorporeal suturing...

Diffuse esophageal spasm is a motility disorder of undetermined cause. The optimal treatment remains controversial, and evidence-based data are lacking. Several medical treatment modalities have been proposed, but none has emerged as the treatment of choice. Patients who do not respond to medical therapy may be considered for surgical treatment. Th...

Factors regulating the conversion of the interdigestive migrating motor complex (MMC) to postprandial patterns of motility are not completely understood. This study assessed the effects of varying rates of nonnutrient duodenal flow on patterns of interdigestive motility before and after abdominal vagotomy. Six neurally intact dogs were prepared wit...

Background Obese patients with gastroesophageal reflux disease (GERD) refractory to medical therapy are a challenging patient population as obesity is a preoperative predictor of failure after antireflux surgery. We therefore sought to evaluate outcomes using one of two commercially available endoluminal therapies in this population. Methods Consec...

Background: Video game experience (VGE) has been identified as a possible predictive factor for surgical skill. We hypothesized that surgical novices with previous VGE would acquire new surgical skills faster than those without. Methods: Fourth-year medical students (M4) and first-year surgical residents (PG-1) completed a survey asking about st...

The recurrence rate for paraesophageal hernias (PEH) can be as high as 30% following laparoscopic repair. The aim of this study was to determine the severity of symptoms in patients with recurrences and the need for reoperation 10 years after surgery. Consecutive laparoscopic paraesophageal cases performed at a single institution between 1993 and 1...

A number of significant changes have forced surgical educators to re-evaluate the adequacy of traditional forms of surgical skills training. A review of the literature reveals that surgical simulation has emerged as a useful adjunct to help educators adjust to the demands of an ever-changing surgical practice environment. As such, integration of si...

The esophagus is a muscular tube lined with nonkeratinizing squamous epithelium that starts as a continuation of the pharynx and ends as the cardia of the stomach. The esophagus is fixed only at its upper and lower ends, the upper end being firmly attached to the cricoid cartilage and the lower end to the diaphragm. This lack of fixation throughout...

Recurrence of incisional hernia may be as high as 50 per cent. Abnormal collagen I/III ratios have been observed within scar tissue of patients with recurrent incisional hernias. We sought to determine whether collagen composition in primary, nonscarred tissue was similarly affected in these patients. In this prospective, case–control study, nonsca...

Recurrence of incisional hernia may be as high as 50 per cent. Abnormal collagen I/III ratios have been observed within scar tissue of patients with recurrent incisional hernias. We sought to determine whether collagen composition in primary, nonscarred tissue was similarly affected in these patients. In this prospective, case-control study, nonsca...

A small but significant percentage of patients are considered failures after laparoscopic Nissen fundoplication (LNF). We sought to identify preoperative predictors of failure in a cohort of patients who underwent LNF more than 10 years ago. Of 312 consecutive patients undergoing primary LNF between 1992 and 1995, recent follow-up was obtained from...