2005 SAGES Abstracts

POSTER ABSTRACTS
SAGES 2005
pathophysiology of this phenomenon remains unclear and it
will require further research to establish it. Preoperative manometric
evaluation for fundoplication is a controversial issue
but it is also the gold standard to recognize esophageal motor
disorders. It also helps identify esophageal motor disorders
whether they were, or not present preoperatively for legal purpose.
P252–Esophageal/Gastric Surgery
THE ROLE OF SELECTIVE VAGOTOMY DURING NISSEN FUN-
DOPLICATION, S Dissanaike MD, K O Shebani MD,E E Frezza
MD, Texas Tech University Health Sciences Center
After Laparoscopic Nissen fundoplication, some patients continued
to experience symptoms related to high acid output. To
alleviate this problem, we decided to perform selective vagotomy
on those patients who complained of epigastric pain, a
pain consistent with peptic ulcer disease, or who have had a
history of peptic ulcer disease.
METHODS We prospectively studied all patients who came to
see us with gastroesophageal reflux disease GERD, a history
of peptic ulcer disease or associated gastritis. The patients
were assigned to two treatment groups: 1) Nissen fundoplication
(NF) only and 2) NF with highly selective vagotomy (HSV).
Patients were selected for HSV based on: 1) high acid output,
2) pre-prandial pain, 3) history of peptic ulcer, 4) high dose
protein pump inhibitor therapy and 5) failure of anti-acid therapy
after 6 months. Prior to the operation, an upper endoscopy
was performed to rule out acute peptic ulcer or gastritis. A 24
hour pH study and manometry were also performed.
RESULTS Three patients in each group were considered in our
initial series. The mean age was 41 +/- 8 in the first group and
44 +/- 9 in the second. Patients were on anti-acid therapy for
an average of 12 +/- 4 months in the first group and 10 +/- 3
months in the second group. There were no active peptic
ulcers or active gastritis in either group. Esophagitis was present
in both groups. Manometry was normal. The DeMeester
score was slightly higher in the second group. Operative time
was 90 +/- 20 minutes for group 1 and 110 +/- 15 minutes for
group 2. None of the patients complained of reflux. In group 1,
2 out of 3 patients were re-started on anti-acid therapy, with
some relief of symptoms. In group 2, no patients complained
of stomach pain or required anti-acid therapy.
CONCLUSION Adding HSV to the Nissen fundoplication
decreased the symptomatology of high acid production. More
studies are needed before a final conclusion can be drawn.
From our preliminary data, we feel that performing HSV can
be advantageous to the patient, adding only 15 to 20 minutes
to the procedure.
P253–Esophageal/Gastric Surgery
LAPAROSCOPIC GASTRIC BYPASS ? AN EFFECTIVE TREAT-
MENT FOR COMPLICATED GERD. A CASE REPORT., Piotr
Gorecki MD, Kevin Cho MD,Katherine Martone MD,Leslie Wise
MD, Department of Surgery, New York Methodist Hospital,
Brooklyn, NY
Introduction: Surgical treatment of severe complicated gastroesophageal
reflux disease (GERD) associated with a large
hiatal hernia remains a challenging problem. High incidence of
symptoms recurrence has been reported after laparoscopic
repair.
Case report: A 29 year- old morbidly obese female suffering
from severe heartburn, regurgitation and dysphagia presented
for evaluation for weight reduction surgery. Her weight was
234 lbs and BMI was 40 kg/m2. Her quality of life was significantly
impaired because of her symptoms. Her preoperative
evaluation revealed esophagitis with a 6 cm hiatal hernia and
stricture of the distal esophagus. A 24-h pH testing revealed a
significant acid exposure of the distal esophagus with
DeMeester score of 177. Esophageal manometry revealed
hypotensive low esophageal sphincter (LES) with LES pressure
of 1 mm Hg. The patient underwent endoscopic balloon dilatation
of the esophageal stricture followed by a course of
aggressive treatment of esophagitis with proton pump
inhibitors for three months. Her dysphagia improved. She
underwent a laparoscopic reduction of a large hiatal hernia
with high mediastinal dissection to establish intraabdominal
192 http://www.sages.org/
segment of the short esophagus and a Roux-en Y gastric
bypass. Her recovery was uneventful and she was discharged
home on a fourth postoperative day. At four-month follow up
visit she reported complete resolution of her reflux and dysphagia
symptoms and no need for acid suppresion medications.
She enjoyed weight loss of 47 lbs and her quality of life
improved from not acceptable to excellent. Radiograms and
endoscopy photographs will be presented.
Conclusion: Aggressive treatment of esophagitis and preoperative
balloon dilatation of peptic stricture followed by laparoscopic
repair of hiatal hernia and Roux Y gastric bypass is feasible
and may be considered as the most definite surgical
treatment of severe GERD complicated by esophageal stricture.
P254–Esophageal/Gastric Surgery
LESSONS LEARNED FROM LAPAROSCOPIC TREATMENT OF
ESOPHAGEAL AND GASTRIC SPINDLE CELL TUMORS, Steven
R Granger MD, Michael D Rollins MD,Sean J Mulvihill
MD,Robert E Glasgow MD, Department of Surgery, University
of Utah Medical Center, Salt Lake City, Utah, USA
Introduction: Gastric and esophageal spindle cell tumors are
rare neoplasms that have been traditionally resected for negative
margins through an open approach. The aim of this study
was to evaluate the efficacy and lessons learned from laparoscopic
resection of gastric and esophageal spindle cell tumors.
Methods and Procedures: This was a retrospective review of
all patients who underwent laparoscopic resection of gastric or
esophageal spindle cell tumors at a tertiary referral center
between December 2002 and August 2004. Medical records
were reviewed with regard to patient demographics, preoperative
evaluation, operative approach, tumor location and
pathology, length of operation, complications, and length of
hospital stay.
Results: Ten consecutive patients (6 men and 4 women) with a
mean±SEM age of 51±6.2 years (range, 21-72) were treated.
Preoperative endoscopic ultrasound (EUS) was performed in
all patients with a diagnostic accuracy of 100% for predicting
spindle cell neoplasm, while EUS-guided FNA had a diagnostic
accuracy of 55% in correctly predicting the final pathology. R0
laparoscopic resection was achieved in all patients. Four
patients with symptomatic distal esophageal leiomyomas were
treated with enucleation and Nissen fundoplication. Six
patients were treated with laparoscopic wedge resection of
gastric lesions which included leiomyoma (1), GIST (3), and
heterotopic pancreas (2). Intraoperative endoscopy was performed
in 4 patients and was associated with shorter operative
times (161±21.7 versus 196±24.2 without intraoperative
endoscopy). Operative time for this whole series was 182±17
minutes, 197±28 minutes for the first 5 cases and 167±19 minutes
for the last 5 cases. The mean length of hospital stay was
2.1±0.25 days. One patient with esophageal leiomyoma had
persistent dysphagia at 12 month follow-up. There were no
other complications and no deaths in this series of patients.
Conclusions: Laparoscopic resection of esophageal and gastric
spindle cell tumors may be performed safely with low patient
morbidity. This approach can accomplish adequate surgical
margins and lead to short hospital stays. Improvements in
technique have led to shorter operative times.
P255–Esophageal/Gastric Surgery
SYMPTOMATIC OUTCOMES AFTER LAPAROSCOPIC MODI-
FIED HELLER MYOTOMY AND DOR FUNDOPLICATION
(MHMDF) FOLLOWING FAILED MEDICAL MANAGEMENT OF
ACHALASIA., Mohammad K Jamal MD, Eric J DeMaria
MD,Alfredo M Carbonell DO,Jason M Johnson DO,Brennan J
Carmody MD, Department of Surgery, Virginia Commonwealth
University, Richmond, Virginia.
Patients with failed non-operative management of achalasia
may have suboptimal outcomes after MHMDF. We report a single
surgeon experience in 30 patients with achalasia who
underwent a MHMDF between 1998 and 2004. The aim of the
study was to determine the impact of pre-operative treatment
on a detailed symptom assessment. Pre- and post-operative
symptom scoring (SS) was obtained using a standard questionnaire.
Patients were asked to quantitate their symptoms in
6 categories on a scale of 0 to 3 (0=none, 1=mild, 2=moderate,