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Nathaniel J Soper

Publications and source records attributed to Nathaniel J Soper.

16 recordsLinked to original sources
PubMed2006

Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients.

BACKGROUND: This study examines the impact of age and comorbidities on complications and outcomes of laparoscopic (Lap) paraesophageal hernia (PEH) repair. METHODS: Data were collected prospectively on all patients who underwent Lap PEH repair from January 1995 through June 2005. Pre- and postoperative variables including complications were analyzed. Patients were stratified by age (Group [Gr.] 1, <65 years; Gr. 2, 65 to 74 years; Gr. 3, >/=75 years) and American Society of Anesthesiology (ASA) class (1 and 2 vs 3 and 4). Statistical analysis was performed using 1-way ANOVA, chi-square, and Fisher exact test. RESULTS: Overall, 171 patients underwent Lap PEH repair. Mean patient age was 65 +/- 15 years, mean ASA class 2.4 +/- 0.5, gender 72% female, and mean operating time 173 +/- 49 min. Patients in Gr. 3 had a significantly higher ASA class (Gr. 1, 2.3 +/- 0.6; Gr. 2, 2.5 +/- 0.5; Gr. 3, 2.6 +/- 0.5) and longer postoperative length of stay (LOS) compared with Gr. 1 (P < 0.05). Esophageal lengthening was required in 10.4% of patients in Gr. 3 versus 2.6% in Gr. 1 and 2.1% in Gr. 2 (P = 0.079). Total complication rates were 17.1% in Gr. 1, 22.4% in Gr. 2, and 27.7% in Gr. 3 (P = not significant [NS]). Most complications were minor; grade 2 or higher complications occurred in 10.5% of patients in Gr. 1, 8.3% in Gr. 2, and 8.5% in Gr. 3 (P = NS). There was 1 death (Gr. 2) on postoperative day 18 due to a myocardial infarction (mortality rate = 0.6%). Mean follow-up was 25.3 +/- 20.6 months. Postoperative symptoms of heartburn and regurgitation were similar between groups as was antisecretory medication use. Anatomic failure of the repair occurred in 23.7% of patients with adequate follow-up: 26.7% in Gr. 1, 15.4% in Gr. 2, and 27.8% in Gr. 3 (P = NS). Reoperation was performed in 1 of 32 (3.1%) failures. CONCLUSIONS: Lap PEH repair is safe in elderly and properly selected high-risk patients, although complication rates are higher than in younger patients. Most patients have a good symptomatic outcome irrespective of their age, but the anatomic recurrence rates remain a concern for all age groups.

Adult↗
PubMed2006

Beta test results of a new system assessing competence in laparoscopic surgery.

BACKGROUND: There is currently a need for objective measures of surgical competence. Such measures should assess knowledge, judgment, and manual skills. The Fundamentals of Laparoscopic Surgery (FLS) program was developed by the Society of American Gastrointestinal and Endoscopic Surgeons to meet these criteria. The FLS assessment includes a multiple-choice cognitive test and a manual skills test. We present the results of validation studies of this novel assessment tool. STUDY DESIGN: Beta testing of the FLS examination was undertaken at 7 sites by 70 surgeons representing 4 levels of experience and training. Surgeons provided information about their prior experience and indicated a self-assessment of their laparoscopic competence. Results were assessed by ANOVA followed by orthogonal contrasts. RESULTS: Cognitive performance by training level: There was no difference between fellows and staff in percentage of questions answered correctly, but there was a discrepancy between junior and senior residents and between residents and senior surgeons (p < 0.01). Cognitive performance by laparoscopic experience quartiles: There were notable contrasts between the first and second quartiles of experience (p < 0.02) and between the third and fourth quartiles (p < 0.01). No marked difference was found between the second and third quartiles. Cognitive performance compared with self-assessment: Test results were substantially different (p < 0.01) between test-takers who assessed themselves as "better than average" and those who assessed themselves as "average" or "below average." Manual skills performance by training level: The major difference was found between junior residents versus senior residents, fellows or staff (p < 0.01). Manual skills performance by laparoscopic experience level: Differences were primarily seen between the first two quartiles and the last two quartiles of laparoscopic experience (p < 0.001). Manual skills performance compared with self-assessment: Those who assessed themselves as "above average" in laparoscopic skill performed markedly better than those indicating they had "average" or "below average" skill (p < 0.01). CONCLUSIONS: Beta test results for the FLS examination demonstrate satisfactory reliability, appropriate psychometric properties, and substantial initial validity. The FLS project is one of the first validated surgical education efforts to assess the competence of surgeons in a specific field.

Aptitude↗
PubMed2005

Perioperative outcomes and complications of laparoscopic ventral hernia repair.

BACKGROUND: Laparoscopic techniques are being used increasingly in the repair of ventral hernias and offer the potential benefits of a shorter hospital stay, decreased wound complications, and possibly a lower recurrence rate. Despite good results from high-volume centers, significant complications may occur with this approach and the morbidity of incisional hernia repair may be underestimated. The purpose of this study was to review our experience with laparoscopic ventral hernia repair (LVHR) since its inception at our institution. METHODS: Medical records of all patients who underwent LVHR at a single institution from May 2000 through December 2003 were reviewed. Preoperative and postoperative variables including complications were analyzed. Follow-up evaluation was by office visit and phone survey with assessment of patient satisfaction scores. Data are expressed as mean +/- SD. RESULTS: A total of 121 LVHR were performed in 116 patients (52 men, 64 women; mean age, 57 +/- 13 y; mean body mass index, 35 +/- 8). Hernias were recurrent in 35 cases (28.9%), with a mean of 1.4 prior repairs (range, 1-7). The mean defect size was 109 +/- 126 cm2 and the average mesh size used was 256 +/- 192 cm2. Operating time was 147 +/- 45 minutes, and the hospital stay averaged 1.7 +/- 1 days. Twelve cases (9.9%) were converted to open operation, most commonly because of extensive adhesions. Extensive laparoscopic adhesiolysis was necessary in 29 cases (26.6%). Overall, perioperative complications occurred in 33 cases (27.3%), 13 of which (39.3%) were persistent seromas. Major complications were seen in 9 cases (7.4%). There were 4 enterotomies (3.3%): 3 occurred as a result of adhesiolysis and 1 resulted from a trocar injury; 2 were detected intraoperatively and were converted to open operation and 2 presented postoperatively. One of these patients developed sepsis and died. Follow-up evaluation was available for 83.6% of cases at a mean interval of 22 +/- 16 months after repair. The hernia recurrence rate was 9.3% (9 cases) and was detected at a median of 6 months postoperatively. The overall patient satisfaction score was high at 4.3 +/- 1.1 (scale, 1-5). CONCLUSIONS: Laparoscopic repair is effective for the vast majority of patients with primary or recurrent ventral hernias and results in hernia recurrence rates of less than 10%, with high patient satisfaction scores. Although seroma is the most common complication, major morbidity occurred in 7.4% of the patients in our series. Enterotomy is the most common serious complication and may result in sepsis and death.

Adult↗
PubMed2004

Laparoscopic management of idiopathic esophageal achalasia.

INTRODUCTION: Idiopathic esophageal achalasia was described in 1682 as a motor disorder of smooth muscle. In 1913 transabdominal cardiomyotomy was introduced and in 1958 this technique was popularized via a left thoracotomy, in 1991 laparoscopic cardiomyotomy was introduced since then many surgeons have adopted this technique as the primary treatment of esophageal achalasia. OBJECTIVE: Evaluate usefulness and recent advances in endoscopic surgery for the management of esophageal achalasia, as well as general issues in clinical presentation and diagnosis. METHODS: We did a review of the medical literature and of our series of patients treated between 1996 and 2004. RESULTS: Between 1996 and 2004, 84 patients underwent laparoscopic Heller myotomy and partial funduplication (78 Toupet and 6 Dor) for the treatment of achalasia. Operative time ranged from 2 to 3 hours with a mean of 2.5 hours. Mucosal perforation (esophageal/gastric) occurred in 3 patients and was repaired with primary closure. During follow-up 3 patients required postoperative endoscopic dilation and one required reoperation due to adhesions causing angulation of the g-e-junction. CONCLUSIONS: Laparoscopic Heller myotomy provided marked reduction in dysphagia, with minimal complaints of regurgitation, heartburn and chest pain at a mean follow-up of 2 years.

Clinical Trials as Topic↗
PubMed2003

Efficacy of laparoscopic antireflux surgery in patients with Barrett's esophagus.

BACKGROUND: Laparoscopic antireflux surgery (LARS) corrects significant physiologic and anatomic abnormalities in patients with gastroesophageal reflux disease (GERD); however, debate exists whether LARS prevents recurrent symptoms and malignant transformation in patients with Barrett's esophagus (BE). This study compared clinical outcomes after LARS in patients with and without BE. METHODS: From 1994 to 2001, 448 patients who underwent LARS were studied. Of these, 68 (15%) had preoperative evidence of BE with low-grade dysplasia in 3 (4%), and 380 (85%) were without BE. Mean postoperative follow-up was more than 30 months in each group. RESULTS: After LARS, there was equivalent reduction in acid reduction medication use and typical GERD symptoms in both groups. Anatomic failures developed in 12% of patients with BE and in 5% of those without BE (P = 0.05). Upper endoscopy with biopsies was obtained in 50 of 68 patients (74%) with BE at 37 +/- 22 months postoperatively. Intestinal metaplasia was no longer present in 7 of 50 (14%) BE patients, and low-grade dysplasia regressed to nondysplastic Barrett's in 2 of 3 patients. New low-grade dysplasia developed in 1 BE patient (2%) at postoperative endoscopic surveillance. No BE patients developed high-grade dysplasia or adenocarcinoma. CONCLUSIONS: After LARS, patients with BE have symptomatic relief and reduction in medication use equivalent to non-BE patients. Regression of intestinal metaplasia and the absence of progression to high-grade dysplasia or adenocarcinoma suggest that LARS is an effective approach for the management of patients with Barrett's esophagus. The higher failure rate of LARS in BE is of concern and mandates ongoing follow-up of these patients.

Barrett Esophagus↗
PubMed2003

Clinical outcomes after laparoscopic antireflux surgery in patients with and without preoperative endoscopic esophagitis.

A wide spectrum of endoscopic findings exists in patients with gastroesophageal reflux disease (GERD). This study compared clinical outcomes after laparoscopic antireflux surgery (LARS) in patients who had GERD with and without preoperative endoscopic esophagitis. From 1992 to 2001, a total of 414 patients who underwent LARS with 6 months or more of follow-up were prospectively entered into a database. Among these patients, 84 (20%) had no endoscopic evidence of esophagitis on preoperative endoscopy (group 1), whereas 330 (80%) did have esophagitis (group 2). Perioperative outcomes, GERD symptom relief, and the use of acid-reducing medication were assessed. Preoperative DeMeester scores in groups 1 and 2 were 44 +/- 29 and 61 +/- 62 (P < 0.05) and mean esophageal peristaltic amplitude was 86 +/- 32 mm Hg vs. 60 +/- 42 mm Hg, respectively (P < 0.05). Although procedure time was significantly shorter in group 1, other perioperative outcomes were similar. At postoperative follow-up, the use of proton pump inhibitors was reduced in both groups (86% to < or =14%). With the exception of postoperative dysphagia, there was no difference in GERD symptom relief between groups 1 and 2. The presence or absence of preoperative esophagitis has minimal effect on favorable symptomatic outcomes after LARS. Thus LARS is an effective treatment option for patients, irrespective of endoscopic evidence of esophagitis, leading to excellent symptom relief and a marked reduction in the use of proton pump inhibitors.

Barrett Esophagus↗
PubMed2003

Laparoscopic paraesophageal hernia repair, a challenging operation: medium-term outcome of 116 patients.

Laparoscopic paraesophageal hernia repairs performed in 116 patients between 1992 and 2001 were prospectively analyzed. Perioperative outcomes were assessed and follow-up was performed under protocol. There were 85 female and 31 male patients who had a mean (+/- SD) age of 65 +/- 13 years and an American Society of Anesthesiology score of 2.3 +/- 0.6. All but two patients underwent an antireflux procedure. Gastropexy was performed in 48 patients, an esophageal lengthening procedure in six patients, and prosthetic closure of the hiatus in six patients. Major complications occurred in five patients (4.3%) with two postoperative deaths (1.7%). Mean follow-up was 30 +/- 25 months; 96 patients (83%) have been followed for more than 6 months. Among these patients, 73 (76%) are asymptomatic, 11 (11%) have mild symptoms, and 12 (13%) take antacid medications. Protocol barium esophagograms were obtained in 69% of patients at 6 to 12 months' follow-up. Recurrence of hiatal hernia was documented in 21 patients (22% overall and in 32% of those undergoing contrast studies). Reoperation has been performed in three patients (3%). When only the patients with recurrent hiatal hernias are considered, 13 (62%) are symptomatic but only six (28%) require medication for symptoms. Laparoscopic paraesophageal hernia repair is generally safe, even in this high-risk group. This study confirms a relatively high incidence of recurrent hiatal abnormalities after paraesophageal hernia repair; however, most recurrent hiatal hernias are small and only 3% have required reoperation. Protocol esophagograms detect recurrences that are minimally symptomatic. Improved techniques must be devised to improve the long-term outcomes of laparoscopic paraesophageal hernia repair.

Adult↗
PubMed2002

The effect of robotic assistance on learning curves for basic laparoscopic skills.

BACKGROUND: We hypothesized that laparoscopic tasks performed with ZEUS robotic assistance would be done with greater precision and with a different learning curve than when performed in a standard laparoscopic trainer. METHODS: Participants were divided into the surgically experienced (n = 11) and the surgically naive (n = 17). Two laparoscopic tasks (bead transfer and rope pass) were repeated for five repetitions. RESULTS: For all drills and participants, completion time and error rate decreased across the five repetitions for each platform. Precision averaged 97% for both platforms over all drills. For both groups, completion time for tasks was shorter on the laparoscopic platform. ZEUS allowed for greater consistency in performance. CONCLUSIONS: Compared with performance on a standard laparoscopic trainer, robotic assistance allows for increasing speed and consistency while maintaining precision over multiple repetitions. Understanding how robotics affects learning curves will allow for modifications in the training experience with this new technology.

Adult↗
PubMed2002

Portal vein thrombosis after splenectomy.

BACKGROUND: Portal vein thrombosis (PVT) has been described after splenectomy, but the factors associated with its development and the clinical outcomes are poorly characterized. METHODS: Case logs of four surgeons from 1996 to 2001 were retrospectively reviewed to identify cases of postsplenectomy PVT. RESULTS: Eight cases of PVT (8%) among 101 splenectomies were identified. Indications for splenectomy in patients with PVT were myeloproliferative disease (n = 4), hemolytic anemia (n = 3), and myelodysplastic disorder (n = 1). All patients had splenomegaly (mean 1698 g, range 360 to 3150 g). Among 10 patients with myeloproliferative disease (MP), 4 patients (40%) developed PVT, compared with 4 of 12 patients (25%) with hemolytic anemia. Three of 4 patients (75%) with MP disease and spleen weight greater than 3,000 g developed PVT. Five patients developed PVT despite receiving prophylactic subcutaneous heparin postoperatively. Presenting symptoms included anorexia in 7 (88%), abdominal pain in 6 (75%), and both elevated leukocyte and platelet counts in 8 patients (100%). All diagnoses were made by contrast-enhanced computed tomography scan, and anticoagulation was initiated immediately. One patient died of intraabdominal sepsis; the others are alive with no clinical sequelae at 38 months of follow-up. CONCLUSIONS: PVT is a relatively common complication of splenectomy in patients with splenomegaly. A high index of suspicion, early diagnosis by contrast-enhanced computed tomography, and prompt anticoagulation are key to a successful outcome.

Adult↗
PubMed2002

Utility of staging laparoscopy in subsets of peripancreatic and biliary malignancies.

OBJECTIVE: To determine the relative benefit of staging laparoscopy in peripancreatic and biliary malignancies. SUMMARY BACKGROUND DATA: Staging laparoscopy has been used in a variety of peripancreatic and biliary malignancies. The utility of the technique in subsets of these types of cancer has not been systematically compared. METHODS: One hundred fifty-seven patients underwent laparoscopy after conventional tumor staging; 89 were also staged with laparoscopic ultrasonography. Diagnostic categories were cancer of the pancreatic head and uncinate process, cancer of the body and tail of pancreas, cancer of the extrahepatic bile duct, cancer of the gallbladder, and cancer of the ampulla of Vater/duodenum. RESULTS: In patients with cancer of the head of the pancreas, metastatic disease or vascular invasion was discovered frequently by laparoscopy (31%), whereas in ampullary/duodenal cancer it was never found. The laparoscopic findings in cancer of the head of the pancreas had an important influence on treatment decisions, whereas in cancer of the ampulla/duodenum, laparoscopy had no effect on clinical decisions. Laparoscopy also substantially influenced the treatment of gallbladder cancer; in other tumor types, results were intermediate. Laparoscopic ultrasonography was valuable in cancer of the head of the pancreas. CONCLUSIONS: The utility of staging laparoscopy depends on diagnosis. It is recommended for continued use in pancreatic head and gallbladder cancers but not in ampullary malignancies.

Adult↗
PubMedDate not supplied

Patients with upright reflux have less favorable postoperative outcomes after laparoscopic antireflux surgery than those with supine reflux.

The aim of this study was to compare symptomatic outcomes after laparoscopic antireflux surgery in patients with upright vs. supine reflux. A prospective database was used to assess postoperative clinical outcomes in relation to positional patterns of reflux in 117 patients. Supine reflux was present in 31%, upright in 24%, and the remaining 44% had bipositional reflux. Preoperatively there were no differences in the frequency of typical or atypical symptoms between groups. At a mean follow-up of 18 +/- 11 months postoperatively, there were marked differences in symptoms between groups. Patients with upright reflux noted significantly more heartburn, chest pain, odynophagia, and bloating postoperatively when compared to patients with supine and bipositional reflux (P < 0.05). According to visual analog scales, patients with upright reflux expressed less satisfaction with operative results, ascribing more symptoms to the esophagus and stomach, when compared to those with supine reflux (P < 0.05). Although all patients reported improvement, the extent of the relief from preoperative symptoms was less in patients with upright reflux (P < 0.05). When asked if, in retrospect, they favored operative therapy, the patients with upright reflux were less enthusiastic (P < 0.05). Although antireflux surgery eliminates reflux in nearly all patients, postoperative symptomatic outcome is related to the preoperative pattern of reflux. Although all patients showed symptomatic improvement, the extent of that improvement was significantly less in patients with upright reflux. These patients should be carefully counseled preoperatively regarding expected symptomatic outcomes.

Adult↗