The Extended Learning Curve for Laparoscopic Fundoplication: A Cohort Analysis Of 400 Consecutive Cases

Many studies have looked at the learning curve associated with laparoscopic Nissen fundoplication (LNF) in a given institution. This study looks at the learning curve of a single surgeon with a large cohort of patients over a 10-year period. Prospective data were collected on 400 patients undergoing laparoscopic fundoplication for over 10 years. The patients were grouped consecutively into cohorts of 50 patients. The operating time, the length of postoperative hospital stay, the conversion rate to open operation, the postoperative dilatation rate, and the reoperation rate were analyzed. Results showed that the mean length of operative time decreased from 143 min in the first 50 patients to 86 min in the last 50 patients. The mean postoperative length of hospital stay decreased from 3.7 days initially to 1.2 days latterly. There was a 14% conversion to open operation rate in the first cohort compared with a 2% rate in the last cohort. Fourteen percent of patients required reoperation in the first cohort and 6% in the last cohort. Sixteen percent required postoperative dilatation in the first cohort. None of the last 150 patients required dilatation. In conclusion, laparoscopic fundoplication is a safe and effective operation for patients with gastroesophageal reflux disease. New techniques and better instrumentation were introduced in the early era of LNF. The learning curve, however, continues well beyond the first 20 patients

Experimental study of effect of embolism of different laparoscopy insufflation gases

Background and purposeWhilst carbon dioxide is the gas generally used for insufflation during laparoscopy, several studies have reported adverse effects specifically associated with its use. These effects may be attributable to chemical, metabolic, or immunologic effects specific to CO2. Because helium is chemically, physiologically, and pharmacologically inert, it has been suggested as a possible substitute insufflation gas. However, there has been concern about the potential implications of venous gas embolism during helium insufflation. The aim of this study was to examine the physiological effect of the intravenous injection of He and CO2 in an experimental model.Materials and methodsEleven domestic white pigs were randomly allocated to receive multiple intravenous injections of increasing volumes of either CO2 or He gas. Cardiorespiratory function was measured, and the intravenous volumes of gas that resulted in cardiac arrest were determined.ResultCardiorespiratory functional measures returned to normal quicker after CO2 than after He injection. Helium injection quickly overwhelmed the animal's ability to compensate and resulted in death at a lower volume than did CO2 injection.ConclusionsGas embolism during He insufflation is more likely to be lethal than is CO2 embolism. This scenario is most likely following Veress needle insertion into a large vein. Therefore, if He is to be used for insufflation during clinical laparoscopy, the possibility of venous injection should be minimized by avoiding Veress needle use. Further investigation of the safety of He insufflation is warranted before a role during clinical laparoscopy can be recommended

Efficacy of a 90 anterior fundoplication vs a total fundoplication in an experimental model

BACKGROUND:The surgical treatment of gastroesophageal reflux disease (GERD) has improved greatly, so that excellent long-term control of symptoms can now be achieved. At present, the gold standard for treatment is the Nissen fundoplication. However, this procedure produces side effects in some patients, including persistent dysphagia, epigastric bloating, and excessive flatulence. As a result, some surgeons who have recommended the use of a partial fundoplication to lessen the occurrence of these side effects. The aim of this study was to determine the efficacy of a laparoscopically constructed 90 degree anterior fundoplication and to compare this method with the Nissen fundoplication. METHODS:Twelve domestic white pigs underwent initial esophageal myotomy to ensure an incompetent lower esophageal sphincter. These animals were then randomized to undergo either a total fundoplication or a 90 degree wrap. All procedures were completed laparoscopically. Resting lower esophageal sphincter pressures were measured immediately and at 2 weeks postoperatively with a water-perfused esophageal manometry catheter incorporating a Dent sleeve. The efficacy of the antireflux barrier was determined at 2 weeks after surgery by fundoplication yield studies. RESULTS:Both the total fundoplication and the 90 degree wrap produced an increase in resting lower esophageal sphincter pressure and restored adequate competence to the gastroesophageal junction in the early postoperative period. CONCLUSION:A laparoscopically completed 90 degree anterior fundoplication restores lower esophageal sphincter competence in the early postoperative period. Clinical studies examining the long-term results and significant side effects of this procedure are required to establish the place for this procedure in the antireflux surgery armamentarium.Yau, P. ; Watson, D. I. ; Ascott, N. ; Lafullarde, T. ; Jamieson, G. G

Metabolic and immunologic consequences of laparoscopy with helium or carbon dioxide insufflation: A randomized clinical study

Background: Previous studies using animal models have demonstrated that carbon dioxide (CO2) pneumoperitoneum during laparoscopy is associated with adverse physiological, metabolic, immunological and oncological effects, and many of these problems can be avoided by the use of helium insufflation. The present study was performed in patients to compare the effect of helium and CO2 insufflation on intraperitoneal markers of immunological and metabolic function. Methods: Eighteen patients undergoing elective upper gastrointestinal laparoscopic surgery were randomized to have insufflation achieved by using either helium (n = 8) or CO2 (n = 10) gas. Intraperitoneal pH was monitored continuously during surgery, and peritoneal macrophage function was determined by harvesting peritoneal macrophages at 5 min and 30 min after commencing laparoscopy, and then assessing their ability to produce tumour necrosis factor-α (TNF-α), and their phagocytic function. Results: Carbon dioxide laparoscopy was associated with a lower intraperitoneal pH at the commencement of laparoscopy, although this difference disappeared as surgery progressed. The production of TNF-α was better preserved by CO2 laparoscopy, but the insufflation gas used did not affect macrophage phagocytosis. Patients undergoing helium laparoscopy required less postoperative analgesia. Conclusion: The choice of insufflation gas can affect intraperitoneal macrophage function in the clinical setting, and possibly acid–base balance. The present study suggested no immunological advantages for the clinical use of helium as an insufflation gas. The outcomes of the present study, however, are different to those obtained from previous laboratory studies and further research is needed to confirm this outcome.Susan J. Neuhaus, David I. Watson, Tanya Ellis, Thierry Lafullarde, Glyn G. Jamieson and W. John Russel