2005 SAGES Abstracts

POSTER ABSTRACTS
SAGES 2005
P245–Esophageal/Gastric Surgery
LAPAROSCOPIC TREATMENT OF POST-DILATION ESOPHAGIC
ENDOSCOPIC PERFORATION IN A PATIENT WITH IDIOPATHIC
ACHALASIA BY THAL ESOPHAGOGASTROPLASTY WITH DOR
ANTIREFLUX VALVE, Gustavo L Carvalho PhD, Gildo O Passos
Jr,Frederico P Santos,Frederico W Silva MD,Carlos H Ramos
MD,Gilvan Loureiro MD,Carlos T Brandt PhD, Clínica Cirúrgica
Videolaparoscópica Gustavo Carvalho, UPE - Universidade de
Pernambuco, UFPE - Universidade Federal de Pernambuco,
Recife ? BRAZIL
BACKGROUND: The most serious complication of forced dilation
of the esophagus is rupture of the thoracic esophagus
with mediastinitis. This leads to a surgical emergency and usually
requires a thoractomy or laparatomy approach, or both,
for it to be repaired and possibly to the need for a cervicotomy
to re-route the esophageal passage. There has been a recent
report of the repair of these lesions by laparoscopy through
suture of the lesion. However, the repair of this severe injury
using Thal´s esophagogastroplasty with Dor?s anterior fundoplication
(Thal-Dor) fully performed by laparoscopy has not
previously been reported.
OBJECTIVE: To report the case of a female patient with idiopathic
achalasia who suffered post-dilation endoscopic rupture
of the esophagus and received treatment exclusively by
laparascopic means using Thal-Dor Procedure.
PATIENT: A 52 year-old female patient suffering from idiopathic
achalasia, with strong symptoms, suffered an approximately
6cm rupture in the distal esophagus while undergoing endoscopic
balloon dilation. The lesion was identified immediately
and the patient referred for emergency surgical treatment by
laparoscopy.
METHOD: After performing the pneumoperitoneum, a phrenotomy
was undertaken on the anterior part of the diaphragmatic
hiatus which allowed a better view of the mediastinum and
complete identification of the esophageal injury. By using
ultrasonic scissors 4 cm of the stomach adjacent to the lesion
were sectioned longitudinally from the cardia.
Esophagogastroplasty was carried out using transverse suture
to repair the injury. After testing with instilation of methylene
blue, an antireflux Dor valve was made to cover up the gastroesophageal
suture.
RESULTS: An esophagogram taken on the 1st POD showed no
leakages and the esophageal passage without abnormalities,
with the patient being fed in sequence. Three weeks after surgery,
endoscopy showed the esophagogastric region without
signs of esophagitis or stenosis; and from a rear view, the
antireflux valve well adjusted to the endoscope. The patient
was satisfied with the procedure and to date has not mentioned
any eating restrictions.
CONCLUSION: It is being increasingly demonstrated that the
resources of minimally invasive surgery are safe and effective
in conducting complex procedures, even in emergency situations,
as long as patient clinical adequacy, level of technical
skill of the surgical team and availability of instruments are
respected.
P246–Esophageal/Gastric Surgery
LAPARASCOPIC RE-FUNDOPLICATION IN THE TREATMENT OF
GERD - AN ANALYSIS OF 18 CASES., Gustavo L Carvalho PhD,
Marco Antônio C Melo MD,Frederico P Santos,Gildo O Passos
Jr.,Gilvan Loureiro MD,Frederico W Silva MD,Roberto Pabst
MD, Clínica Cirúrgica Videolaparoscópica Gustavo Carvalho,
UFPE-Universidade Federal de Pernambuco, UPE -
Universidade de Pernambuco, Recife - BRAZIL
BACKGROUND: Antireflux surgeries have a low rate of reoperations,
varying from 2 to 10%. Nevertheless, when this is
necessary, it is common to opt for open surgery under the
belief that this will be safer. However, various centers have
observed the efficiency of re-operations by laparascopic
means in antireflux surgeries, so demonstrating that the rate
of complications is small, apart from the good long-term
results.
OBJECTIVE: To assess the effectiveness and safety of laparascopic
re-fundoplication in a series of 18 patients.
PATIENTS: In the period from 1992 to 2004, a study was made
of 18 patients (11 men and 7 women; whose average age was
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46 years old) who underwent antireflux surgery by the Nissen
procedure and who needed a second fundoplication. In all of
them, endoscopy was carried out, from which 11 patients were
shown to have esophagitis of varying degrees, 9 presented
accessory gastric chamber due to migration of the valve, 8
presented other problems in the valve whether associated with
migration or not (3 incomplete, 2 twisted, 2 tightened and 1
partially undone) and in 2 patients it was associated with
Barrett´s esophagus. The main indications of the second operation
were migration (9), undoing (4), tightening (3) and torsion
(2) of the valve.
METHOD: In one patient, the surgery consisted of removing a
stitch which was tightening the lower esophagus. In the other
cases, fundoplication was again carried out and was associated
with a new hiatoplastia in 13 of these. The patients were
later assessed by endoscopy and biopsy.
RESULTS: There was no conversion to open surgery. The average
hospital stay was 3.37 ±5,36 days. One female patient presented
sudden thoracic pain on the 12th POD and needed
another laparascopic operation in which a perforation of the
valve was diagnosed and treated. One male patient had postoperative
discomfort for some time. There were no other complications
from the operations and 15 patients have shown
themselves to be asymptomatic since then. An endoscopy for
control was carried out on the 30th and 60th post-operative
days from which it was shown that 15 patients remained free
of esophagitis and GERD.
CONCLUSION: Laparoscopic re-fundoplication are not only
technically feasible but also clinically effective with low rates
of complications and conversions.
P247–Esophageal/Gastric Surgery
LAPAROSCOPIC RESECTION OF A TUBULOVILLOUS ADENO-
MA ARISING IN THE DUODENAL BULB, Kuo-Hsin Chen MD,
Shih-Horng Huang PhD, Department of Surgery, Far-Eastern
Memorial Hopital, Taipei,Taiwan
LAPAROSCOPIC RESECTION OF A TUBULOVILLOUS ADENO-
MA ARISING IN THE DUODENAL BULB
Kuo-Hsin Chen MD, Shih-Horng Huang PhD, Department of
Surgery, Far-Eastern Memorial Hospital, Taipei, Taiwan
Tubulovillous adenoma arising in the duodenum is rare. Most
of the lesions are found during endoscopic examination and
removed by endoscopic cauterization.
We report a 74 y/o male patient with a tubulovillous adenoma
of the duodenum bulb, which caused duodenal obstruction
and intermittent bleeding. The patient had a history of previous
laparotomy for cholecystectomy, vagotomy and pyloroplasty
6 years before this admission. Endoscopic polypectomy
was attempted but failed to remove it completely due to the
large size.
Laparoscopic duodenotomy is performed under CO2 pneumoperitoneam.
The pedunculated lesion is exposed and lifted
with an Endoloop. An EndoGIA is applied and the lesion is
removed completely. The duodenotomy is closed by interrupted
intracorporeal sutures.
The postoperative course is uneventful. The patient remained
symptoms free 22 months after the surgery.
The laparoscopic resection of the duodenal bulb tubulovillous
adenoma is feasible. To hold the lesion with an Endoloop
helps to avoid tissue trauma during surgery. Any bleeding
from the base of the lesion could be checked and controlled
through laparoscopic approach. The patient recovered faster
when compared with traditional open resection.
P248–Esophageal/Gastric Surgery
LAPAROSCOPIC NISSEN FUNDOPLICATION AFTER FAILED
STRETTA PROCEDURE, S S Davis MD, M I Goldblatt MD,D J
Mikami MD,W S Melvin MD, The Ohio State University
Medical Center, Center for Minimally Invasive Surgery
OBJECTIVE: Radiofrequency energy delivery to the GE junction
(the Stretta procedure) has been shown to be a safe and
effective short-term treatment for GERD. Studies show
improvements in GERD symptom scores, patient satisfaction
and distal esophageal acid exposure. Laparoscopic Nissen
Fundoplication may still be required for symptom control in
patients who do not respond to Stretta. No literature exists
describing the feasibility or efficacy of LF after failed Stretta.