2005 SAGES Abstracts

POSTER ABSTRACTS
Introduction
Radical total gastrectomy is a technically difficult
procedure.Since the anastomosis is to the abdominal esophagus
a lot of retraction is needed in open sugery.The magnification
offered by laparoscopy facilitates the dissection as well as
the anstomosis.The abdominal incision is considerably small
and so is the morbidity.
Methods
We have done 15 total gastrectomies laparoscopically in the
last 15 months.A total of five ports are used.The port placement
is the same as in fundoplication except the camera port
which is below the umbilicus in the midline.The complete
stomach along with omentum is dissected.All the vessels are
ligated at the origin and nodal clearance is achieved..The duodenum
is transected with stapler.An additional 2-0 vicryl
suture is taken on the duodenal stump.A purse string suture
with 1-0 proline is taken on the lower end of esophagus and
the anvil of stapler is inserted.A loop of jejunum is delivered
through the transverse mesocolon..A small abdominal incision
is taken and the specimen is removed.The EEA stapler is then
fired through the jejunum.
Results
The average time taken is 180 minutes.The average blood loss
is 100 ml.None of our patients had anastomotic leak.No conversion
to open surgery was needed.There was no
mortality.The average hospitalisation was 6 days.3 patients
have completed one year follow up.
Conclusion.
Total gastrectomy with esophagojejunostomy can be done
laparoscopically.The oncological clearance is the same as in
open surgery but there is a definate decrease in the morbidity
and hospitalisation.
P271–Esophageal/Gastric Surgery
EVALUATION OF LAPAROSCOPIC ANTI-REFLUX SURGERY
WITHOUT A BOUGIE USING A POSTOPERATIVE VALIDATED
SYMPTOM SCORE, K Ramkumar, M Deakin,C V N Cheruvu,
University Hospital of North Staffordshire, Stoke-on-Trent, UK
Introduction
Traditionally Laparoscopic Anti-reflux Surgery (LARS) was performed
with the insertion of a bougie blindly through the gastro
oesophageal junction to prevent a tight fundoplication. The
bougie insertion is associated with oesophageal and gastric
perforations. The aim of this study is to assess whether LARS
without a bougie is safe and effective documenting the postoperative
symptom of dysphagia, recurrent reflux and gas
bloat as the main outcome measures.
Methods
Data was collected prospectively in 68 consecutive patients
who underwent LARS without a bougie between January 2000
and July 2004 in a tertiary care university hospital. 8 patients
were excluded due to additional procedures. All these patients
had preoperative 24hr pH studies, manometry and upper GI
endoscopy. Patients were seen for follow-up at six weeks then
at four months interval upto one year. A validated Modified
Visick Symptom Score (MVSS) questionnaire to assess recurrent
reflux, dysphagia and gas bloat was sent by post and
results were collected by post / telephone interview.
Results
Of the 60 patients, 43 were male and the mean age was 39.7
yrs (range 15 ? 61 yrs). 42 (70%) patients had a floppy 360 fundoplication
and 18 (30%) patients had partial fundoplication. 3
(5%) patients had an open conversion. Median length of hospital
stay was two days. There was no mortality and postoperative
morbidity was seen in 4 (6.7%) patients, of whom two had
chest infections, one developed acute pulmonary oedema and
one had acute gas bloat with a prolonged hospital stay. Longterm
follow up assessment was achieved in 55 (91.6%)
patients with a mean follow-up of 16.35 months. Modified
Visick Symptom Score (MVSS) for heartburn and regurgitation
was good and excellent (Visick 1 or 2) in 96.6% of patients.
Similarly MVSS for dysphagia and gas bloat was good and
excellent (Visick 1 or 2) in 95% and 91.6% of patients respectively.
We had a 91.6% patient satisfaction and all said that
they would recommend surgery to others. Long-term side
effects occurred in 8 (13%) patients of whom five patients had
gas bloat, two had recurrent reflux and one patient had dysphagia.
Conclusions
These results demonstrate that Laparoscopic Anti-reflux
Surgery without a bougie is a safe and effective therapy for
Gastro oesophageal reflux disease avoiding the risks of
oesophageal and gastric injury.
P272–Esophageal/Gastric Surgery
USE OF A LEFT HEMIDIAPHRAGM RELAXING INCISION FOR A
TENSION FREE CRURAL CLOSURE IN THE REPAIR OF LARGE
HIATAL HERNIAS., Patrick R Reardon MD, Wiljon Beltre
MD,Ajay K Chopra MD,Michael J Reardon MD, Department of
Surgery, University of Texas Health Sciences Center at
Houston, The Methodist Hospital. Houston, Texas.
Introduction: Repair of a large hiatal or paraesophageal hernia
with simple cruroplasty is associated with a high recurrence
rate. The tension on the suture line renders it prone to disruption.
To achieve a tension free repair, prosthetic materials have
been utilized as bridging materials for the repair of the large
hiatus. We report the use of a relaxing incision in the central
tendon in the left hemidiaphragm to achieve a tension free
crural closure.
Methods: From July 1995 to August 2004, a total of 123
patients underwent laparoscopic repair of a hiatal hernia with
or without fundoplication in a single surgeon?s practice. Six of
them presented with large symptomatic hernias (five type III/IV
and one large type II hiatal hernia). There were 3 males and 3
females in this group. The average age was 65.3 years (range
42-84 years). The average BMI was 30.94 (range 27.4-38.4). The
size of the hiatal defect ranged from 8 to 9 cm. Attempt at closure
of such a large defect resulted in undue tension.
Therefore, a vertical relaxing incision was made in the central
tendon of the left hemidiaphragm. The hiatus was then closed
with Teflon pledgeted Dacron sutures. The resulting defect in
the left diaphragm was patched with Gore-Tex Dual Mesh
using 0 braided Dacron sutures utilizing the Endo Stitch
device. The mean duration for the procedure was 348 minutes
(range 325-365 minutes). Patients have been followed up from
7 to 44 months (average 31.5 months). All patients are asymptomatic
and recent contrast studies obtained in 3 of the
patients are normal.
Conclusion: A relaxing incision in the left hemidiaphragm
achieves an effective and tension free repair of a large hiatal
hernia. There are no adverse effects noted with this technique.
Longer follow-up is needed regarding recurrence rates.
P273–Esophageal/Gastric Surgery
MIDTERM FOLLOW UP AFTER LAPAROSCOPIC HELLER
MYOTOMY ALONE VERSUS TOUPET, DOR AND MODIFIED
DOR FUNDOPLICATION, William S Richardson MD, Colleen I
Kennedy MD,John S Bolton MD, Ochsner Clinic Foundation,
New Orleans, LA, USA
Our aim was to compare outcomes of Heller myotomy alone
(H) and with different partial fundoplications.
We retrospectively reviewed our experience of 69 laparoscopic
Heller myotomies. 80% were performed with partial fundoplication
(20 Toupet (T), 18 Dor (D), and 17 modified Dor (MD)
where the fundoplication is sutured to both sides of the crura
and not the myotomy).
Age was 69 (range 15-80) years. There were 4 mucosal perforations
repaired intraoperatively. There was one small bowel
fistula at an area of open hernia repair distant from the myotomy.
There was one death from pneumonia in a patient with
severe COPD. Phone follow-up was achieved in 68% (7-H, 12-T,
12-D, 13-MD) of cases at a mean of 37 (range2-97) months.
Results are in %. D=Dysphagia.
In addition, there were two patients with reflux strictures
requiring annual dilation (T, D), one redo Heller myotomy (D),
and one esophageal replacement (T).
Heller myotomy provides excellent relief of dysphagia with
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