Motion – Laparoscopic Nissen Fundoplication Is More Cost Effective Than Oral PPI Administration: Arguments for the Motion

Gastroesophageal reflux disease is a mechanical disorder of the foregut. While medications can only provide symptom relief, surgery can correct the pathophysiological abnormality of the lower esophageal sphincter. The costs of medical and surgical therapy are much greater than the costs of medication or hospitalization alone. In the case of medical therapy, one must consider the costs of serial monitoring and of failed treatment. The effectiveness of treatment also depends on patient-related factors, including weight, socioeconomic factors, smoking, alcohol use, dietary habits and the use of nonsteroidal anti-inflammatory drugs. Surgical results depend on the experience and skill of the surgeon, as well as the attributes of the institution in which the procedure is undertaken. Therefore, studies that come from specialized centres may not be applicable to the community. Data from the author’s facility indicate that laparoscopic Nissen fundoplication is the most cost effective option when it is undertaken by experienced surgeons on otherwise healthy patients who have documented gastroesophageal reflux disease

The Modern Age of POEM: the Past, Present and Future of Per-Oral Endoscopic Myotomy.

BACKGROUND: Per-oral endoscopic myotomy (POEM) has gained widespread enthusiasm amongst foregut specialists since its introduction in the mid 2000s as an effective and less invasive treatment option for achalasia. As more than 6000 POEM procedures have been performed to date throughout the world, we aim to summarize the history and current state of POEM in the treatment of esophageal motility disorders. METHODS: We performed a comprehensive review of the published literature focusing on the history and development of the POEM procedure, and its most current applications and outcomes. RESULTS: Multiple favorable long-term studies have been published advocating for the use of POEM as a valid and perhaps the most valid treatment option for achalasia. The procedure is also increasingly being applied to a wider spectrum of esophageal motility disorders including type III achalasia, spastic esophageal disease or isolated lower esophageal sphincter (LES) dysfunction, as well as new endoluminal procedures such as submucosal tumor endoscopic resection (STER), endoscopic fundoplications (POEM-F) and peroral pyloromyotomy (POP or G-POEM). CONCLUSIONS: While POEM is a proved and valid procedure, its further adoption is being threatened by external factors: challenges related to teaching, institutional support (politics) and insurance reimbursement. While this technique has come an incredible distance in its relatively short lifespan, the future of POEM in the USA will depend on the support from surgical societies to validate it as a valuable tool in the esophageal specialist\u27s armamentarium, and to encourage a commitment to training in endoluminal surgery

Enabling single-site laparoscopy : the SPORT platform

BACKGROUND: The Single Port Orifice Robotic Technology (SPORT) Surgical System by Titan Medical Inc. is designed to overcome the inherent challenges of minimally invasive single-access procedures. The aim of this preclinical study was to evaluate the feasibility of various digestive surgery procedures using this novel surgical robotic platform. METHODS: A total of 12 minimally invasive procedures were performed on six pigs (5 cholecystectomies, 3 Nissen fundoplications, 1 splenectomy and 1 hepatic pedicle dissection) and on one human cadaver (1 cholecystectomy and 1 Nissen fundoplication), by four laparoscopic surgeons. The usability of the device was assessed by means of the modified objective structured assessment of technical skills (OSATS) score that was calculated and analyzed by two independent observers on the recorded videos. Surgeon feedback and recommendations were systematically recorded. RESULTS: All procedures were successfully completed with the SPORT system. In general, surgeons reported to appreciate the intuitive interface and controls, the high-resolution 3D imaging, the dexterity of the end-effectors, and the ergonomic open control platform. Some features requiring optimization were also identified. The modified OSATS score demonstrated a learning curve effect for all device-related tasks. CONCLUSIONS: A variety of abdominal procedures could be safely completed with the current SPORT prototype, in the preclinical setting. This preliminary feasibility experience is promising and encourages further development of single-port robotically assisted surgery

Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders.

BACKGROUND: Peroral endoscopic myotomy (POEM) is a novel operation for the treatment of achalasia and other esophageal motility disorders. While POEM has shown excellent short-term safety and efficacy, the long-term symptomatic outcomes after the procedure are unknown. METHODS: Patients from a single center that underwent POEM for treatment of esophageal motility orders and were greater than 5 years removed from their operation were studied. Patients were contacted to assess current symptoms and encouraged to undergo repeat endoscopy for objective follow-up. RESULTS: Thirty-six patients underwent POEM from October, 2010 to February, 2012 and current symptom scores were obtained from 29 patients at median 65-month follow-up. In the 23 patients with achalasia, Eckardt scores were significantly improved from preoperative baseline (mean current 1.7 vs. preoperative 6.4, p \u3c 0.001). Nineteen patients (83%) with achalasia had a symptomatic success (Eckardt ≤3) and none required retreatment for symptoms. Eckardt scores were dramatically improved at 6 months and maintained at 2 years; however, there was a small but significant worsening of symptoms between 2 and 5-years. Of the five patients with EGJ outflow obstruction, all had current Eckardt scores ≤3 but two needed reintervention for persistent or recurrent symptoms, one with a laparoscopic Heller myotomy and another with an endoscopic cricomyotomy and proximal esophageal myotomy extension. At 6-month follow-up, repeat manometry showed decreased EGJ relaxation pressures and esophagram demonstrated improved emptying. 24-h pH monitoring showed abnormal distal esophageal acid exposure in 38% of patients. Fifteen patients underwent endoscopy at 5-years, revealing erosive esophagitis in two (13%), new hiatal hernia in two, and new non-dysplastic Barrett\u27s esophagus in one. The patient with Barrett\u27s underwent a subsequent laparoscopic hiatal hernia repair and Toupet fundoplication. CONCLUSIONS: POEM resulted in a successful palliation of symptoms in the majority of patients after 5 years, though these results emphasize the importance of long-term follow-up in all patients