Long-term follow-up evaluation for a canine model of gastroesophageal reflux disease.
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Animals↗
Biomedical subjects
M Gagner
Publications and source records attributed to M Gagner.
Gastrointestinal transit and stress response after laparoscopic vs conventional distal pancreatectomy in the canine model.
BACKGROUND: Several authors have presented the feasibility of laparoscopic pancreatic surgery. However, the pathophysiological effect of laparoscopic pancreatic surgery is not well known. METHODS: Ten mongrel dogs were randomly operated for laparoscopic and conventional distal pancreatectomy. Fed state gastrointestinal transit times were assessed using radiopaque markers. To assess surgical stress, we determined serum IL-1 and cortisol. RESULTS: Postoperative mouth-to-anus transit time in the laparoscopic group was not prolonged while it was significantly prolonged in the conventional group compared with the baseline study, but no significant differences between groups were detected. First defecation was observed significantly earlier in the laparoscopic group. Serum cortisol levels were elevated significantly at 4 h after skin incision in both groups and decreased thereafter. In the laparoscopic group, they returned close to the normal level at 8 h after incision, but were still significantly higher in the conventional group. The level of IL-1 was elevated significantly higher in conventional group at 24 h after the skin incision. CONCLUSION: Thus, we conclude that laparoscopic distal pancreatectomy demonstrated faster recovery of the bowel transit and less stress than conventional distal pancreatectomy in dogs.
Anal Canal↗
Endoscopic approach for carotid artery surgery.
BACKGROUND: Although recent advances in the treatment of carotid artery stenosis have included endovascular angioplasty and stent placement, carotid endarterectomy is still the approach of choice for carotid disease and is one of the most commonly performed operations today. Minimally invasive surgeries involving the neck have recently been performed for thyroid and parathyroid diseases. The purpose of this study was to evaluate the feasibility of an endoscopic approach for carotid artery surgery in a large animal model. METHODS: Eight 25- to 30-kg pigs were used. Animals underwent endoscopic carotid dissection with carbon dioxide insufflation at 10 mmHg. A 1.5- to 2-cm arteriotomy was made in the common carotid artery. Four animals underwent direct arteriotomy closure, and four animals underwent synthetic patch graft placement using intracorporeal suturing techniques. Open examination of the operative site and carotid angiograms were performed at the end of the procedure. Operative time was recorded in the last four cases. RESULTS: All animals tolerated the procedure well and carotid artery repair was successfully performed in all cases using a four-trocar technique. The entire extent of the cervical common and internal carotid arteries was exposed up to the cranial base. Cranial nerves and cervical structures were clearly visualized and preserved. No bleeding occurred at the end of the procedure. Carotid angiograms confirmed patent, nonstenotic vessels in all cases. CONCLUSION: Endoscopic approach for carotid surgery is technically feasible in the porcine model. This approach may represent a valuable option for surgery of the carotid artery since it offers the advantages of minimally invasive techniques while maintaining the benefits of surgical arterial repair.
Angioscopy↗
The metabolic and immune response to laparoscopic versus open liver resection.
BACKGROUND: Laparoscopic liver surgery is a field in its infancy, and scientific evidence of its benefits over those of traditional open techniques has not been shown. Various applications from wedge resections to formal segmental resections have been reported, but the technical ability does not necessarily translate into improved patient outcomes. There is an abundance of evidence reflecting the benefits of laparoscopic cholecystectomy [9, 12, 23], and some of these benefits have been linked to the decreased metabolic and immune responses involved [24, 27]. There is also accumulating evidence that tumor growth may be slower after laparoscopic surgery than after comparable open surgery, and that this is a result of less immune suppression [1]. It is not known whether laparoscopic liver surgery will convey similar benefits. METHODS: In this study, 14 pigs were assigned randomly to undergo a liver resection either by a laparoscopic or an open approach. Operative stress was assessed via cortisol, tumor necrosis factor, interleukin-6, C-reactive protein. The immune response was evaluated through delayed-type hypersensitivity skin antigen testing. Adhesion formation also was assessed at 6 weeks. RESULTS: Immune response as measured by delayed-type hypersensitivity is better preserved after laparoscopic than after open liver resection. The average diameter of induration was 46% greater in the laparoscopic group (20.71 +/- 2.7 mm versus 14.14 +/- 1.5 mm). Interleukin-6 and tumor necrosis factor levels showed a significantly greater rise after open surgery. No difference was observed in the levels of C-reactive protein or cortisol. Adhesion formation was considerably less after laparoscopic resection. CONCLUSIONS: Laparoscopic liver resection results in a diminished stress response, as compared with that of open resection, which translates into greater preservation of immune function. This finding may well have a beneficial effect on infection and tumor growth.
Animals↗
The significance of pH and manometric testing after laparoscopic fundoplication.
Laparoscopic antireflux surgery has become the standard operation for gastroesophageal reflux disease (GERD). This study examined the outcomes of laparoscopic antireflux surgery, hypothesizing that both subjective symptoms and objective pH would correlate with manometric parameters to reflect the absence of reflux after fundoplication. We evaluated 56 patients who underwent laparoscopic antireflux surgery. Preoperative and postoperative symptoms were documented by chart reviews and confirmed by telephone interviews with the patient. Preoperative pH probe and esophageal manometry studies were compared with postoperative studies performed 3 to 6 months after fundoplication. Subjective symptoms were correlated with objective measurements of acid reflux and lower esophageal sphincter pressure (LESP). The follow-up period was 3 to 29 months. Symptomatic improvement was seen in 91% of patients, and good to excellent improvement in preoperative symptoms was cited. Postoperatively, there was significant improvement in percentages of upright supine times when esophageal pH was less than 4 (p <0.001). There was an increase in LESP from an average of 16.9 mmHg preoperatively to 22.7 mmHg postoperatively (p <0.001). There was no correlation between postoperative LESP and symptoms or LESP and 24-h pH results. However, there was a predictive correlation between LESP and postoperative heartburn symptoms (p <0.001). These findings imply that symptom follow-up evaluation is adequate in the asymptomatic patient after laparoscopic fundoplication, and that routine physiologic testing is not necessary.
Adult↗
Evidence-based medicine: open and laparoscopic bariatric surgery.
BACKGROUND: The aim of this study was to perform an evidence-based analysis of the literature on open and laparoscopic surgery for morbid obesity. METHODS: Human studies on surgery for morbid obesity were conducted. Multiple publications of the same studies, abstracts, and case reports were reviewed. Current Contents, MEDLINE, EMBASE, and Cochrane Library databases were investigated. RESULTS: Open Roux-en-Y gastric by pass (RYGB) for morbidly obese patients and long-limb RYGB for superobese patients are highly effective procedures. Randomized controlled trials comparing malabsorptive procedures with other bariatric operations are needed. The long-term efficacy of adjustable silicone gastric banding (ASGB) still is undetermined because of poor evidence. Laparoscopic RYGB is as safe as its open counterpart, although its long-term results are lacking. Laparoscopic ASGB is less invasive than open ASGB, although its efficacy cannot be determined because of poor evidence. Laparoscopic vertical banded gastroplasty (VBG) is becoming unpopular since the decreasing trend of open VBG. Laparoscopic biliopancreatic diversion with duodenal switch is feasible, but needs further studies. CONCLUSIONS: Randomized controlled trials comparing the various laparoscopic operations are strongly needed.
Anastomosis, Roux-en-Y↗
[Laparoscopic hepatectomy].
AIM: To report the current indications and techniques of laparoscopic liver resections, and assess the results of this technique by reviewing international literature. REVIEW OF THE LITERATURE: About 200 laparoscopic hepatectomies have been reported from 1991 to 2001. 102 resections were performed for malignant tumours, and 84 for benign tumours. Global conversion rate was 7% (13/186). Morbidity rate was 16.1% with two cases of possible gas embolisms (1.1%). Mortality rate was 0.54% (1/186 patients). Mean hospital stay was 7.7 days. CONCLUSION: Laparoscopic hepatectomy is feasible, with a morbidity and mortality rate comparable to open procedures according to a careful selection of patients. However, prospective randomized trials are still needed to confirm those results, especially for resection of metastasis or malignant tumors. Evolution of laparoscopic hepatectomies will probably depend on the development of new techniques and instrumentations.
Hepatectomy↗
Transatlantic robot-assisted telesurgery.
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Animals↗
Surgical treatment of type 2 diabetes mellitus.
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Diabetes Mellitus, Type 2↗
Laparoscopic vs open gastrectomy. A retrospective review.
BACKGROUND: The totally laparoscopic approach to partial gastrectomy had not been compared previously with results of the open technique. This study compares the results of a series of laparoscopic cases with matched open cases. METHODS: A retrospective case-matched study was performed in 36 patients (18 laparoscopic surgeries, 18 open surgeries). Each laparoscopic case was matched for patient age and indication for surgery. The intraoperative and postoperative details of the two groups were compared. RESULTS: Laparoscopic surgery resulted in less blood loss, although operative time was increased. Nasogastric tubes were less likely to be used after laparoscopic surgery, and patients in the laparoscopic group had an earlier return to normal bowel function than those in the open group. Length of hospital stay was 2 days shorter in the laparoscopic group. CONCLUSIONS: The totally laparoscopic approach to partial gastrectomy is an excellent alternative to the more traditional open approach. It results in a more rapid return of intestinal function and a shorter hospital stay.
Adult↗
Laparoscopic gastric bypass as a reoperative bariatric surgery for failed open restrictive procedures.
An estimated 2% of men and 6% of women in the United States are morbidly obese. These patients have a mortality rate that is six to twelve times greater than their normal-weight peers. In these extreme cases of overweight, only surgical intervention can produce substantial and sustained weight loss. However, up to 20% of these patients will require reoperation for failure to achieve or maintain an adequate weight loss. Reoperative bariatric surgery can be challenging and has traditionally been performed as an open procedure. We present seven female patients who underwent a laparoscopic Roux-en-Y gastric bypass after failing to achieve their weight-loss goals with prior open restrictive procedures. Their average BMI before surgical revision was 42.2 kg/m2. Mean operative time was 4 h 20 min, and length of hospital stay was 4.1 days. There were three complications in two patients and no deaths. Our initial experience suggests that laparoscopic gastric bypass is a safe and feasible reoperative bariatric procedure. Confirmation awaits a larger series of patients with follow-up data.
Adult↗
Arterial PCO2 and cardiovascular function during endoscopic neck surgery with carbon dioxide insufflation.
BACKGROUND: Endoscopic parathyroidectomy and thyroidectomy were introduced into clinical practice in 1995. Concerns about the use of carbon dioxide insufflation in the neck exist owing to reports of potential adverse metabolic and hemodynamic changes. HYPOTHESIS: Carbon dioxide insufflation in the neck may cause adverse effects on hemodynamic and blood gas levels. These adverse effects may reflect the level of pressure and duration of insufflation. METHODS: Fifteen pigs, 5 per group, underwent endoscopic thyroidectomy at 10, 15, and 20 mm Hg. Partial pressure of carbon dioxide (arterial), pH, cardiac output, central venous pressure, heart rate, and mean arterial pressure (MAP) were measured at baseline, 1 and 2 hours after carbon dioxide insufflation, and 30 minutes after desufflation. RESULTS: At 10 mm Hg, PaCO2 increased slightly but not significantly, and neither acidosis nor adverse hemodynamic changes were observed. Hypercarbia, moderate acidosis, and a slight increase in MAP occurred in pigs undergoing surgery at 15 mm Hg (MAP increased to 88 +/- 2.4 mm Hg from a baseline value of 78 +/- 3.53 mm Hg; P<.05). Pigs undergoing surgery at 20 mm Hg experienced severe hypercarbia and acidosis, as well as a significant decrease in MAP (P<.05). Central venous pressure decreased at 1 hour (P<.05) and increased at 2 hours (P<.05) in pigs undergoing surgery at 15 and 20 mm Hg. After desufflation, PaCO2 and pH levels were normal for the 10 and 15 mm Hg groups, while pigs undergoing surgery at 20 mm Hg developed a higher degree of hypercarbia and acidosis (P =.001). CONCLUSIONS: Carbon dioxide neck insufflation is safe at 10 mm Hg. The use of insufflation pressures higher than 15 mm Hg should be avoided due to the potential risk for metabolic and hemodynamic complications.
Animals↗
The minimally invasive surgical suite enters the 21st century. A discussion of critical design elements.
Most minimally invasive surgical procedures are now performed in operating rooms that were originally designed for traditional open surgery. Laparoscopic instrumentation such as insufflators, light sources, and camera control units must be placed on one or more equipment carts. After the cart has been moved into place, insufflation tubing, video cables, light cords, cautery lines, and foot controls must be positioned and connected. This cart-based paradigm restricts the ergonomic configuration of the operating room and creates potential mechanical, electrical, and biological hazards to the patient and operating room staff. In order to decrease clutter, ease personnel movement, improve ergonomics, maintain the sterile field, and facilitate the use of advanced imaging, communication, and display devices, an appropriately designed operating environment is essential. Herein we detail both the theoretical and practical aspects of the design and describe the implementation and utilization of such a suite in our hospital. These design elements may prove to be critical to the next generation of minimally invasive surgical suites and will facilitate future advanced laparoscopic procedures.
Accident Prevention↗
Laparoscopic necrosectomy for acute necrotizing pancreatitis.
Severe acute pancreatitis (SAP), a disease state that is often complicated by an intricate pathologic process, has remained difficult to manage and is associated with high morbidity and mortality rates. Approximately 80% of patients have a mild form of the disease, while the other 20% develop a severe life-threatening form of the disease. These patients are at great risk for infection, multisystem organ failure, and, possibly, death. Necrotizing or infected pancreatitis requires a multimodal approach and often offers an indication for surgical intervention. The retroperitoneum of the patient with necrotizing pancreatitis should be treated as an abscess cavity, and drainage and debridement of all necrotic tissue should be performed. Over the past several decades, great achievements have been made in the treatment of the patient that presents with acute pancreatitis. However, the morbidity and mortality have remained high, according to recent literature. The laparoscopic era brings new alternatives in the surgical management of pancreatic diseases. Advances in laparoscopic technology and instrumentation allow the utilization of minimally invasive techniques, and lessen the stress of surgery in the already compromised pancreatitic patient.
Female↗
Laparoscopic pancreatic resection: single-institution experience of 19 patients.
BACKGROUND: The number of laparoscopic pancreatic resections reported in the surgical literature has been remarkably low. Few substantive data are available concerning current indications and outcomes after laparoscopic pancreatectomy. The purpose of this article is to review the recent indications, complications, and outcomes after laparoscopic pancreatic resection. STUDY DESIGN: A retrospective analysis of the Mount Sinai hospital records was performed for all patients who underwent laparoscopic distal pancreatectomy or enucleation between the time of the first resection in November 1993 until the time of this study in March 2000. RESULTS: In the 19 patients (6 men) the mean age was 53 years (range 22 to 83 years). In 16 patients (84%) the entire procedure was done by laparoscopy; one operation was converted to a hand-assisted technique; and two cases were converted to open. Median operating time was 4.4 hours (range 1.6 to 6.6 hours), and median intraoperative blood loss was 200 mL. Postoperative complications included three pancreatic leaks (16%), one case of superficial phlebitis, and one prolonged ileus for 7 days (total morbidity of 26%). There were no deaths. The median length of postoperative hospital stay was 6 days (range 1 to 26 days). CONCLUSIONS: This represents the largest single-institution experience with laparoscopic pancreatic resection. The considerable morbidity rate is comparable to recently published open series, and is likely inherent in pancreatic surgery, rather than the technical approach. Laparoscopic pancreatic surgery resulted in shorter hospital stays and appears to be safe for benign diseases.
Adult↗
Endoscopic thyroidectomy for solitary thyroid nodules.
Conventional thyroidectomy often leaves an undesirable scar on the anterior neck. The aim of this study was to assess the feasibility and efficacy of endoscopic thyroidectomy, a new minimally invasive technique for thyroid surgery. Between September 1998 and February 2000, 18 patients with a solitary thyroid nodule underwent endoscopic thyroidectomy utilizing CO2 insufflation. There were 16 females and 2 males with a mean age of 43 years (range 17-66 years). Indications for surgery included indeterminate cytology (n = 8), follicular neoplasm (n = 8), Hürthle cell neoplasm (n = 1), and toxic thyroid nodule (n = 1). The mean nodule diameter was 2.7 cm (0.6-7 cm). Analgesic requirement, return to normal activity, and cosmetic results were compared to 18 consecutive patients who had conventional thyroidectomy. Sixteen of 18 cases were successfully completed endoscopically with a mean operating time of 220 minutes (range, 120-330 minutes). There were no major complications, but 3 patients developed mild hypercarbia and 1 patient had an incidental parathyroidectomy. When compared to conventional thyroidectomy, patients undergoing endoscopic thyroidectomy had a significantly superior cosmetic result (p < 0.005) and a quicker return to normal activity (p < 0.05), but there was no difference in analgesic requirement. Endoscopic thyroidectomy is a technically feasible and safe procedure that leads to an improved cosmetic result and a quicker recovery. Open completion thyroidectomy is recommended for thyroid carcinoma until more data are available.
Adolescent↗
Laparoscopic biliopancreatic diversion with a duodenal switch for morbid obesity: a feasibility study in pigs.
BACKGROUND AND PURPOSE: Biliopancreatic diversion with a duodenal switch is an emerging open procedure that appears as effective as other bariatric operations. Our goal was to determine the safety and feasibility of performing this procedure using a laparoscopic approach in a porcine model. MATERIALS AND METHODS: Six 50-kg pigs underwent surgery. Intake was restricted with a sleeve gastrectomy, and malabsorption was obtained by creating a Roux-en-Y. The Roux limb served as a 150-cm alimentary channel following anastomosis to a transected proximal duodenum, while the other limb, or biliopancreatic channel, transported digestive juices. Where the two limbs joined, a 100-cm common channel was formed. RESULTS: The operation was completed in a mean time of 4.5 hours. Two of the six pigs had an intraoperative duodenoenterostomy anastomotic leak detected on methylene blue testing. This leakage was thought to be related to pig anatomy and is not expected to be a problem in humans. At necropsy, all anastomoses were patent, and there were no enteroenterostomy leaks or mesenteric torsions. CONCLUSION: On the basis of the porcine model, laparoscopic biliopancreatic diversion with a duodenal switch is anticipated to be feasible and safe in humans. Substantial weight loss combined with the benefits of laparoscopic surgery can be expected.
Anastomosis, Roux-en-Y↗
Laparoscopic aortorenal bypass using a PTFE graft: survival study in the porcine model.
PURPOSE: To verify the technical feasibility of laparoscopic aortorenal bypass in a porcine model and to evaluate renal pathologic findings after a short survival time. MATERIALS AND METHODS: Laparoscopic aorta-to-left-renal artery bypass using an interposition Gore-Tex graft was performed in five animals. Renal function was assessed 1 week postoperatively and euthanasia performed after 14 days for histologic examination. RESULTS: The median surgical time was 210 minutes (range 160-260 minutes). The median time needed to perform the aorta-to-graft anastomosis was 65 minutes (range 50-75 minutes), and the median time required to create the graft-to-renal artery anastomosis was 50 minutes (range 45-60 minutes). No conversion to open surgery was needed. Two intraoperative complications were observed: one large-bowel perforation, which was managed laparoscopically, and one obstruction of the aorta-to-graft anastomosis caused by clots, which was managed by removal of clots with a balloon catheter. No major postoperative complications were observed. The mean preoperative and postoperative serum creatinine concentrations were 0.8 +/- 1.2 and 0.7 +/- 1.6 mg/dL, respectively. At autopsy, all but one of the pigs were found to have a patent aortorenal bypass. In one pig, we found a partially clotted graft. Histologic examination demonstrated an unremarkable kidney in four cases and a kidney showing aspects of coagulative necrosis with viable cells in the animal with the partially clotted graft. CONCLUSIONS: Laparoscopic aortorenal bypass is feasible. The short-term effect of the bypass on kidney vascularization seems promising, as demonstrated by pathologic findings. Laparoscopic aortorenal bypass could extend the indications for renal revascularization surgery.
Anastomosis, Surgical↗