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J Ponsky

Publications and source records attributed to J Ponsky.

At least 19 recordsLinked to original sources
PubMed2006

Diaphragm pacing with natural orifice transluminal endoscopic surgery: potential for difficult-to-wean intensive care unit patients.

BACKGROUND: Up to 50% of the patients in the intensive care unit (ICU) require mechanical ventilation, with 20% requiring the use of a ventilator for more than 7 days. More than 40% of this time is spent weaning the patient from mechanical ventilation. Failure to wean from mechanical ventilation can in part be attributable to rapid onset of diaphragm atrophy, barotrauma, posterior lobe atelectasis, and impaired hemodynamics, which are normally improved by maintaining a more natural negative chest pressure. The authors have previously shown that laparoscopic implantation of a diaphragm pacing system benefits selected patients. They now propose that an acute ventilator assist with interventional neurostimulation of the diaphragm in the ICU is feasible and could facilitate the weaning of ICU patients from mechanical ventilation. Natural orifice transluminal endoscopic surgery (NOTES) has the potential to expand the benefits of the diaphragm pacing system to this acute patient population by allowing it to be performed at the bedside similarly to insertion of the common gastrostomy tube. This study evaluates the feasibility of this approach in a porcine model. METHODS: Pigs were anesthetized, and peritoneal access with the flexible endoscope was obtained using a guidewire, needle knife cautery, and balloon dilation. The diaphragm was mapped using a novel endoscopic electrostimulation catheter to locate the motor point (where stimulation provides complete contraction of the diaphragm). An intramuscular electrode then was placed at the motor point with a percutaneous needle. The gastrotomy was managed with a gastrostomy tube. RESULTS: Four pigs were studied, and the endoscopic mapping instrument was able to map the diaphragm to identify the motor point. In one animal, a percutaneous electrode was placed into the motor point under transgastric endoscopic visualization, and the diaphragm could be paced in conjunction with mechanical ventilation. CONCLUSIONS: These animal studies demonstrate the feasibility of transgastric mapping of the diaphragm and implantation of a percutaneous electrode for therapeutic diaphragmatic stimulation.

Animals↗
PubMed2005

SLiC technique. A novel approach to percutaneous gastrostomy.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) has been an invaluable method for obtaining long-term enteral access and represents one of the first forays in the field of minimally invasive surgery. However, the traditional "pull" method for PEG tube placement continues to have some disadvantages, especially in patients with near-obstructive head and neck cancers. METHODS: We describe a new "SLiC" technique for establishing percutaneous gastrostomy using a radially expandable trocar. RESULTS: This technique is initially developed and refined on a porcine model and then successfully implemented on five human patients. CONCLUSION: The SLiC technique can be done safely and efficiently with a pediatric-sized gastroscope and avoids the need for radiation from fluoroscopy. It is a good alternative for obtaining enteral access in patients who would otherwise not be well suited for a traditional PEG tube.

Aged↗
PubMed2003

Anterior gastropexy may reduce the recurrence rate after laparoscopic paraesophageal hernia repair.

BACKGROUND: Although laparoscopic repair of type 3 paraesophageal hernias is safe and results in symptomatic relief, recent data have questioned the anatomic integrity of the laparoscopic approach. The reports document an asymptomatic recurrence rate as high as 42% with radiologic follow-up evaluation for type 3 paraesophageal hernias repaired laparoscopically. This disturbingly high recurrence rate has prompted the addition of an anterior gastropexy to our standard laparoscopic paraesophageal hernia repair. METHODS: A prospective series of 28 patients underwent laparoscopic repair of large type 3 hiatal hernias between July 2000 and January 2002 at the Cleveland Clinic Foundation by one surgeon. All the patients underwent reduction of the hernia, sac excision, crural repair, antireflux procedure, and anterior gastropexy. They all had a video esophagram 24 h after surgery, then at 3-, 6-, and 12-month follow-up visits and annually thereafter. Symptomatic outcomes were assessed with a standard questionnaire at each follow-up visit. RESULTS: In this study, 21 women and 7 men with a mean age of 67 years (range, 35-82 years) underwent successful laparoscopic paraesophageal hernia repair. The mean operative time was 146 min (range, 101-186 min), and the average blood loss was 71 ml (range, 10-200 ml). One intraoperative complication occurred: A small esophageal mucosal tear occurred during esophageal dissection and was repaired laparoscopically. At 24 h, upper gastrointestinal examination identified no leaks. At this writing, all the patients have undergone video esophagram at a 3-month follow-up visit. All were asymptomatic and all examinations were normal. Of the 28 patients, 27 have undergone follow-up assessment at 6 months. At this writing, all the patients have undergone video esophagram at 3, 6, and 12 months follow up visits. All were asymptomatic and all examinations were normal. Ten patients have completed 2 year follow up barium swallows with no recurrences. CONCLUSIONS: With up to 2 years of follow-up evaluation, the addition of an anterior gastropexy to the laparoscopic repair of type 3 hiatal hernias resulted in no recurrences. These encouraging results necessitate further follow-up evaluation to document the long-term effects of anterior gastropexy in reducing postoperative recurrence after laparoscopic repair of paraesophageal hernias.

Adult↗
PubMed2003

Gastric electrical stimulation at proximal stomach induces gastric relaxation in dogs.

Gastric electrical stimulation (GES) improves symptoms in patients with gastroparesis. However, the underlying mechanisms remain unclear. To determine if GES at proximal and distal stomach could affect the biomechanical properties of the stomach, thus contributing to the beneficial effect of GES. Four pairs of electrodes were implanted along the greater curvature of the stomach in seven dogs. Gastric tone and compliance was assessed with a barostat. Measurements were obtained randomly during control and proximal and distal stimulation (4 mA, 375 ms and 6/18 cpm). Data as mean or median (25-75th percentiles). Gastric compliance was not affected by proximal and distal GES. Gastric tone was significantly reduced during proximal GES: 82.0 (66.8, 89.1) mL vs control 49.7 (39.6,75.9) mL at 6 cpm (P = 0.016), and 90.6 (54.5, 117.9) mL vs control 62.8 (39.6, 75.9) mL at 18 cpm (P = 0.031). Tone was not affected by distal GES at 6 cpm: 95.8 (46.3, 106.7) mL vs control 75.2 (49.7, 86.1) mL (P = 0.47) and at 18 cpm: 80.4 (38.1, 170.3) mL vs control 62.8 (44.6, 156.3) mL (P = 0.44). Proximal GES induces gastric relaxation. This effect, if seen also in humans, may explain, in part, the symptomatic improvement associated with GES therapy in patients with gastroparesis.

Animals↗
PubMed2002

Recurrence after laparoscopic ventral hernia repair.

BACKGROUND: Although the early results of laparoscopic ventral hernia repair have shown a low recurrence rate, there is a paucity of long-term data. This study reviews a single institution's experience with laparoscopic ventral hernia repair (LVHR). METHODS: We carried out a retrospective analysis of all LVHR performed at the Cleveland Clinic Foundation from January 1996 to March 2001. Recurrence rates were determined by physical exam or telephone follow-up. Factors predictive of recurrence were determined using Cox regression. RESULTS: Of 100 ventral hernias completed laparoscopically, 96 were available for long-term follow-up (average, 30 months; range 4-65). There were no deaths and major morbidity occurred in seven patients. Recurrences were identified in 17 patients. Nine recurrences occurred in the 1st postoperative year; however, hernia recurrence continued throughout the period of follow-up. Multivariate analysis showed that a prior failed hernia repair was associated with a more likely chance of another recurrence (65% vs 35%, odds ratio (OR) 3.6; p = 0.05) and that an increased estimated blood loss (106 cc vs 51 cc, OR 1.03; p = 0.005) predicted recurrence. Other variables, including body mass index (BMI) (32 vs 31 kg/m2, p = 0.38), defect size (115 cm2 vs 91 cm2; p = 0.23), size of mesh (468 cm2 vs 334 cm2, p = 0.19), type of mesh (p = 0.62), and mesh fixation (p = 0.99), did not predict recurrence. An additional 14 cases required conversion to an open operation, and seven of these cases (50%) had recurrence on long-term follow-up. CONCLUSION: Although LVHR remains the preferred method of hernia repair at our institution, this study documents a higher recurrence rate than many other short-term series. There results underscore the importance of long-term follow-up in assessing hernia surgery outcome.

Adult↗
PubMed2002

The economic impact of flexible endoscopy in a large academic surgical department.

BACKGROUND: There has been considerable controversy concerning the value added to a general surgery practice when flexible gastrointestinal endoscopy is incorporated. The purpose of this study was to assess the economic impact of flexible endoscopy performed by general surgeons in a large academic practice. METHODS: A retrospective review of gross billing charges for a group practice of 11 surgeons over the fiscal year 1999 was performed at the Cleveland Clinic Foundation. The total billing for clinic visits and outpatient and inpatient surgical procedures was compiled, and the percentage attributable to flexible endoscopy was determined. Of the 11 surgeons, three had incorporated flexible endoscopy into their practice. RESULTS: The three endosurgeons generated 33% of the total gross billing for the Department of General Surgery. Flexible endoscopy alone accounted for 12.2% of the total percentage of gross billings for the department. Meanwhile, this revenue was generated from only 8% of the workweek when performing flexible endoscopic procedures were performed. CONCLUSION: Flexible endoscopy can contribute significantly to the financial productivity of the general surgeon.

Academic Medical Centers↗
PubMed2001

Outcome of laparoscopic splenectomy based on hematologic indication.

BACKGROUND: Laparoscopic splenectomy is the procedure of choice for elective splenectomy at the Cleveland Clinic Foundation. Although the literature clearly documents the technical feasibility and safety of laparoscopic splenectomy, little data exists concerning the results of this procedure based on the hematologic indication for splenectomy. We sought to examine the clinical experience with laparoscopic splenectomy in a single institution, with particular attention to morbidity and clinical outcomes based on hematologic disease process. METHODS: This study retrospectively reviewed a consecutive series of laparoscopic splenectomies performed for nontraumatic, splenic pathology at the Cleveland Clinic Foundation from August 1995 to January 2001. Patient demographics, operative indications, morbidity, mortality, and clinical outcome were evaluated. Hematologic diagnostic groups were compared using Fisher's exact tests and Wilcoxon rank-sum tests. RESULTS: A total of 147 laparoscopic splenectomies were performed. Seven patients (5%) required conversion to open splenectomy. Indications for splenectomy included idiopathic thrombocytopenic purpura (ITP) in 65 patients, hematologic malignancy in 43 patients, autoimmune hemolytic anemia (AIHA) in 9 patients, thrombotic thrombocytopenic purpura (TTP) in 9 patients, splenomegaly in 5 patients, splenic cyst in 4 patients, splenic abscess in 3 patients, hereditary spherocytosis in 2 patients, splenic artery aneurysm in 2 patients, Felty's syndrome in 1 patient, myelofibrosis in 1 patient, and other in 3 patients. Accessory spleens were identified in 20 patients (14%). Postoperative complications occurred in 23 (16%) patients. Patients with ITP had significantly shorter operation times (134 vs 163 min; p = 0.001), decreased estimated blood loss (126 vs 307 ml; p = 0.001), decreased length of hospital stay (2.8 vs 4.6 days; p < 0.001), and less chance of conversion (0 vs 7; p = 0.02) than patients with any other diagnosis. A mean follow-up period of 20 +/- 14 months showed an 85% rate of remission for ITP, 89% for TTP, and 89% for AIHA. Patients with malignant disease had significantly larger spleens (822 vs 313 g; p < 0.001), more estimated blood loss (380 vs 168 ml; p = 0.04), and longer operative times (170 vs 142 min; p = 0.009), as compared patients treated for benign disease. However, the length of hospital stay (4.3 vs 3.6 days; p = 0.06) and complication rates (19% vs 14%; p = 0.08) were not significantly different between the two groups. CONCLUSIONS: When performed for ITP, laparoscopic splenectomy resulted in shorter operations, minimal blood loss, earlier discharge, no conversions, and excellent remission rates, as compared with other hematologic indications. Despite larger spleens, more blood loss, and longer operations in patients with hematologic malignancies, morbidity and length of hospital stay still were similar to those associated with benign indications for laparoscopic splenectomy. In conclusion, laparoscopic splenectomy is safe and efficacious for a multitude of benign and malignant hematologic indications, and our data compares favorably to those for open series.

Adolescent↗
PubMed2001

Pancreatic complications following laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) has been widely accepted despite a paucity of outcome data. Therefore, we performed a review of LS to assess the pancreatic complications and outcomes associated with this procedure. METHODS: Ninety-four splenectomies were performed for a variety of hematologic disorders. The patient was placed in the lateral position, and three or four trocars were used. RESULTS: LS was completed successfully in 93 patients. One case was converted to an open splenectomy for suspected gastrotomy. Thirty of 32 patients with splenomegaly underwent successful LS. Fifteen patients (16%) had some evidence of pancreatic injury. Six patients had asymptomatic hyperamylasemia. An injury directly associated with an adverse outcome occurred in nine cases (9.5% overall); six patients had pancreatic collections, one had a pancreatic fistula, and two developed hyperamylasemia and pain altering the length of hospitalization. Four of these nine patients did not have elevated postoperative amylase levels and were readmitted with pancreatic complications. CONCLUSIONS: LS can be performed for most pathologic conditions. Pancreatic injury is the most common morbidity associated with LS. The detection of hyperamylasemia can alert the surgeon to a pancreatic injury and alter postoperative management.

Fungemia↗
PubMed2001

Endoscopic marking: an adjunct to laparoscopic gastrointestinal surgery.

BACKGROUND: In 1975 one of us (J.P.) first described endoscopic marking of the intestinal lumen with india ink to produce a serosal tattoo, thus facilitating the location of lesions during subsequent surgery. The use of the technique in concert with laparoscopic surgery is particularly important because the ability to palpate the bowel is lost. Carbon-based products such as india ink provide permanent marking. An alternative marker is methylene blue, whose mark is only temporary but clearly seen laparoscopically. METHODS: We have used methylene blue for intraoperative marking, reserving India ink for instances in which marking endoscopy occurs before surgery. RESULTS: 15 patients, over a period of 2 years, had endoscopic marking performed preoperatively or intraoperatively. All markings were easily visualized upon laproscopy, assisting identification of the sites of the lesions. Numerous other cases were marked at endoscopy but did not come to surgery. CONCLUSION: Endoscopic marking is an invaluable tool in the performance of laparoscopic gastrointestinal surgery.

Carbon↗
PubMed2001

Minimally invasive surgery.

In 1987, Mouret performed the first laparoscopic cholecystectomy - dramatically changing the history of surgical practice. No other aspect of surgery has developed with such vigor as laparoscopy. Previously, surgeons had attempted to define the maximum level of surgical intervention a patient could withstand - but as laparoscopic surgery developed, this paradigm was turned on its head. Minimally invasive surgeons are continuing to determine and redefine how much can be accomplished through smaller incisions and with minimal surgical stress. Laparoscopy is still only in its infancy. This article reviews current aspects of laparoscopic surgery in 1999-2000 in relation to gallbladder, gastric, colorectal, and splenic disease, as well as reviewing the current role of laparoscopic surgery in the treatment of abdominal wall hernias.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2001

Optical coherence tomography of the esophagus and proximal stomach in health and disease.

OBJECTIVE: Surveillance of Barrett's esophagus is problematic, as high-grade dysplasia cannot be recognized endoscopically. Endoscopic ultrasound lacks the resolution to detect high-grade dysplasia. Optical coherence tomography (OCT) employs infrared light reflectance to provide in vivo tissue images at resolution far superior to endoscopic ultrasound, nearly at the level of histology. We have developed a catheter-based system well suited for study of the GI tract. The purpose of this study was to test this catheter-based OCT system and characterize the OCT appearance of normal squamous mucosa, gastric cardia, Barrett's esophagus, and carcinoma. METHODS: The OCT catheter was passed through the operating channel of the endoscope and placed in contact with the esophageal mucosa. Image acquisition occurred in approximately 3 s. OCT images were correlated with biopsy and/or resection specimens. RESULTS: OCT was used to construct 477 images of the esophagus and stomach in 69 patients. There were unique, distinct OCT appearances of squamous mucosa, gastric cardia, Barrett's esophagus, and carcinoma. Further, these OCT images were accurately recognized by observers unaware of their site of origin. CONCLUSIONS: OCT provides a highly detailed view of the GI wall, with clear delineation of a multiple layered structure. It is able to distinguish squamous mucosa, gastric cardia, Barrett's esophagus, and cancer. This technique holds great potential as an adjunct to the surveillance of patients with Barrett's esophagus, ulcerative pancolitis, and other premalignant conditions.

Adenocarcinoma↗
PubMed2001

The ascendance of laparoscopic splenectomy.

The application of laparoscopic techniques for abdominal procedures has been achieved with varying success. The general acceptance of laparoscopic splenectomy (LS) may be hindered by its infrequent performance and difficulty in manipulating the spleen. A retrospective review of splenectomies performed for primary splenic pathology was done to assess the role and outcome of LS. One hundred fifty LSs were performed from July 1995 through September 1999. Over that time period the proportion of LS performed increased steadily from 17 to 75 per cent of all splenectomies. The primary indications for splenectomy included immune thrombocytopenic purpura in 75 (50%), lymphoma/leukemia 36 (24%), and splenomegaly 19 (13%). There were 86 females and 64 males. Immediately before operation 36 patients (4%) had a platelet count <50,000/ mL, and 24 patients (16%) a hemoglobin <10 mg per cent. The mean operative time was 161 minutes with an average blood loss of 138 cm3 (<50-800). The mean morcellated weight of the entire group was 411 g (33-3300) indicating generally large splenic size. In the 37 patients with splenomegaly the mean weight was 735 g (293-3300). There were two conversions to open splenectomy. Two patients with hematologic malignancy, splenomegaly, and cytopenias died from overwhelming post-splenectomy sepsis (1.3%). Morbidity occurred in 14 (9%) with the most common complication being pancreatitis in seven (5%). The median length of postoperative stay was 2.4 days (range 1-5). In summary LS has rapidly replaced the open approach for nearly all elective splenectomies in adults and children. When performed with the patient in the lateral position it can be accomplished with minimal morbidity, even in complex patients, including those with splenomegaly.

Adolescent↗
PubMed2001

Laparoscopic hernia repair enhances early return of physical work capacity.

Several researchers have documented less postoperative pain and a quicker return to daily activities after laparoscopic herniorrhaphy. However, little objective data that validates this hypothesis exists. This study compares the rate of postoperative physical work capacity with return to preoperative levels, which is measured by a standard treadmill test in patients who underwent laparoscopic and conventional open hernia repair. Patients completed a 6-minute walking test preoperatively and 1 week postoperatively using a nonmotorized treadmill. The distance walked was recorded. If the distance that a patient achieved at 1 week was not within 0.02 miles of the preoperative values of the patient, the patient was asked to return at 1 month for repeat testing. Patients were enrolled prospectively in this study from October 1997 to February 1999. Sixty-six patients participated in the study (27 laparoscopic herniorrhaphies and 39 open herniorrhaphies were performed). There was no significant difference in age, body mass index, or preoperative distance achieved among the two groups. At 1 week, patients who underwent laparoscopic repair demonstrated a mean increase of 18 meters from preoperative distance (P = 0.07). In the open group, patients demonstrated a mean decrease of 90 meters at 1 week (P = 0.001). The change in distance at 1 week between the laparoscopic and the open groups was statistically significant (P = 0.001). However, at 1 month, there was no significant difference among the two groups. Measured using treadmill walking, laparoscopic hernia repair seems to offer an early advantage to open repair in return-to-physical-work capacity.

Exercise Test↗
PubMed1999

A reliable and efficient technique for laparoscopic needle positioning.

Needle positioning can be a difficult, frustrating, and time-consuming step during laparoscopic suturing. Utilizing the reliable and efficient technique described in this article, needle positioning is expedited. This technique is applicable for any type of needledriver or suture.

Humans↗
PubMed1997

Small-bowel diverticulosis: perceptions and reality.

BACKGROUND: Small-bowel diverticulosis is a rare entity that can be discovered incidentally during celiotomy, endoscopy, or radiographic imaging studies. The reported complication rate is low, giving rise to the current recommendation not to treat uncomplicated small-bowel diverticula. STUDY DESIGN: A retrospective review was performed of patients with small-bowel diverticulosis seen during 23 years at three major institutions. RESULTS: Two hundred eight patients were identified. Diverticula were located in the duodenum in 79 percent; in the jejunum or ileum in 18 percent; and in duodenum, jejunum, and ileum in 3 percent. Complications developed in 42 of the 208 patients (20 percent) including bleeding in 14, diverticulitis with perforation and abscess formation in 12, and malabsorption in 8. When assessed by location, jejunoileal diverticula were more likely to have complications than duodenal diverticula: 46 percent compared to 13 percent (p < .01). Bleeding accounted for 52 percent of the duodenal complications compared to 12 percent of the jejunoileal complications (p < 05). Jejunoileal diverticula were more likely to perforate and develop abscesses (21 percent compared to 1.2 percent; p < .001). CONCLUSIONS: The low incidence of complications associated with duodenal diverticula justifies a nonoperative approach. The higher complication rate associated with jejunoileal diverticula will be necessary to define that approach more exactly.

Adult↗