Surgery News - October 2008 - (Page 18)

GENERAL SURGERY SURGERY NEWS • O C T O B E R 2 0 0 8 Innovations Offer New Options for General Surgeons B Y J E F F E VA N S Else vier Global Medical Ne ws One- and Two-Port Laparoscopic Appendectomy The third trocar port that is usually reserved for retraction during a laparoscopic appendectomy can be safely replaced with a simple intra-abdominal suture-pulley system, according to Dr. Kurt E. Roberts of the section of surgical gastroenterology in the surgery department at Yale University, New Haven, Conn. Most surgeons use three standard ports for a laparoscopic appendectomy: one 12mm port in the umbilicus, one 5-mm port in the left lower quadrant, and one 5-mm port placed superpubicly or in the right upper quadrant. His two-port procedure, or “puppeteer technique,” creates a 12-mm infraumbilical port, a pneumoperitoneum, and a 5-mm port in the lower left quadrant for the camera. Instead of creating a 5-mm trocar port for retraction, he places a loop suture tied The string-loop pulley system retracts the appendix without a third trocar port. as an air knot to the anterior abdominal wall in the right upper quadrant. A pretied suture is placed around the appendix, through the pulley loop, and then through the 12-mm umbilicus port to the outside of the body, so that pulling on the string on the outside of the body acts like a pulley to adjust the amount of retraction. The technique allows a surgeon to elevate the appendix enough to view its base and the mesoappendix. (See photo.) In his eight-case series, Dr. Roberts averaged 64 minutes of operative time per patient and did not require additional trocar placement or conversion to open appendectomy. There were no intraoperative complications, and only one patient developed periumbilical cellulitis, which resolved with oral antibiotics by 1 week after surgery. The patients had a mean body mass index (BMI) of 25 kg/m2. Dr. Roberts recently completed another 13 laparoscopic appendectomies using only one port through the umbilicus, which contains a 10-mm camera with a 5-mm working channel for an instrument. He still uses his suture-pulley method for obtaining retraction. One of his singleport patients had a BMI of 39 kg/m2. The COURTESY DR. KURT E. ROBERTS GI DYNAMICS INC. COURTESY DR. VIJAY KHATRI ew devices and techniques that are either in development or on the market attest to the innovation at work in general surgery. SURGERY NEWS looks at an intra-abdominal loop suture, a duodenal-jejunal bypass sleeve, and a radiofrequency coagulating device that were presented at the Academic Surgical Congress. N may not be long enough to create malabsorption,” Dr. Gersin said. But the mechanism of the device likely involves more than malabsorption. It may involve some hormonal changes that are yet to be elucidated [and/or] some delays in gastric emptying, Endoscopic Duodenal-Jejunal Bypass giving patients a sense of fullSleeve Early results from a U.S. randomized, pa- ness, and therefore satiety,” he tient-blinded clinical trial for short-term said. Initial implantations and reweight loss prior to bariatric surgery show promise for the EndoBarrier, an endo- movals of the device have all been performed under general The radiofrequency device ablates a plane of the scopic duodenal-jejunal bypass sleeve. The first U.S. patient in the trial to re- anesthesia within about 30 min- liver that is 1 cm wide, 5 cm long, and 6 cm deep. ceive the EndoBarrier was a 263-pound, utes each, but Dr. Gersin said 36-year-old woman with a BMI of 45 that in the future the device will probably but large amounts of blood can still be kg/m2 (Surg. Innov. 2007;14:275-8). She be placed and removed while patients are lost. Attempts to ablate transection planes of the liver with multiple uses of a single had lost 9.2 pounds at week 4, 15 pounds under conscious sedation. Some patients have experienced monopolar device prior to using more at week 8, and 20 pounds at week 12. Two other patients who had undergone the non–life-threatening GI bleeding, most traditional dissection methods has been asprocedure lost 12.8 pounds and 8.4 likely because of an early barb design that sociated with more complications than has since been changed. The bleeding has the InLine bipolar RF linear coagulapounds by week 4. Most U.S. patients have lost about stopped when the device was removed en- tor device (Br. J. Surg. 2007;94:287-91; World J. Surg. 2007;31:2208-12). The In8%-10% of their total body weight so far, doscopically, Dr. Gersin said. About 40-60 patients in the United Line device uses six bipolar electrodes to said Dr. Keith S. Gersin, chief of bariatric surgery at the Carolinas Medical Center, States are currently being enrolled in the coagulate a plane of tissue up to 1 cm wide trial. The device is also being evaluated in by 5 cm long by 6 cm deep. Each ablation Charlotte, N.C., and an ACS Fellow. Two control patients who underwent a clinical trials in Europe and in South takes 3-5 minutes. (See photo.) The InLine device, which is manufacsham procedure (esophagogastroduo- American countries. Early indicators suggest that the device tured by Resect Medical Inc., Fremont, denoscopy) lost 4 pounds and 13.8 pounds improves or resolves diabetes, so “it’s Calif., is approved by the Food and Drug by week 4. “Most of our patients require preoper- probably not just a weight-loss device,” Administration for coagulating tissue durative endoscopy anyway,” said Dr. Gersin, Dr. Gersin said, citing clinical experience ing laparoscopic and intraoperative surgiwho is a paid consultant and member of with 12 patients in Chile who received the cal procedures. Dr. Khatri of the division the advisory board for GI Dynamics, the EndoBarrier to lose weight prior to un- of surgical oncology at the University of dergoing bariatric surgery. The device re- California, Davis, said that he has no condeveloper of the EndoBarrier. After an esophagogastroduodenoscopy, mained in 10 of the 12 patients for a full flicts of interest with Resect Medical. In a study conducted by Dr. Khatri and an over-the-wire catheter system brings 3 months; the other two patients had to the EndoBarrier to the duodenum. Under have the devices explanted 9 days after im- his associates, the first 24 consecutive pafluoroscopic guidance, an inner catheter plantation because of excessive abdominal tients who underwent hepatic ablation deploys the 2-foot sleeve from the capsule pain and discomfort. Type 2 diabetes re- prior to liver transection lost an average of as it moves through the intestine, guided solved in three of four patients who had 240 mL blood and only 2 patients needed the condition prior to the proce- a transfusion. The investigators used indure. Other patients also had dif- traoperative ultrasound to guide the placeferent comorbidities that re- ment of the device in the patients, who solved. The average total weight were undergoing resection for focal noduloss in the 10 patients who com- lar hyperplasia (1), hepatoma (5), or metaspleted the study was about 22 tases to the liver (18). The investigators improved from using pounds (Surg. Obes. Relat. Dis. a median of 16 minutes of portal triad 2008;4:55-9). A total of 55 adverse events clamping in the first 7 cases to a median were linked to the device, in- of 0 in the remaining 17 cases. The last 17 cluding abdominal pain, nausea, cases had a median blood loss of 100 mL, and vomiting. One patient expe- compared with 500 mL in the first 7 casrienced an oral-pharyngeal mu- es. Eleven of these 24 patients had taken cosal tear and another had an multiagent chemotherapy, which can lead esophageal mucosal tear during to postchemotherapy steatohepatitis. The EndoBarrier includes a self-expanding explantation, but these were not Eight patients developed complications, anchor at its proximal end that utilizes barbs considered serious, according to but none died and no bile duct injuries or to prevent movement of the device. abscess formations occurred. the investigators. At the American Hepato-Pancreato“The plan would be in the next 9 by an atraumatic ball. A self-expanding anchor uses barbs to prevent movement of months to a year to begin a pivotal trial in Biliary Association meeting, Dr. Khatri and the United States with over 200 patients,” his associates compared these patients with the device. (See photo.) the prior 24 patients who had undergone The device is designed to prevent contact Dr. Gersin said. hepatic resection without the device. The between chyme and the intestinal wall but first group lost a mean of 804 mL blood, to allow bile and pancreatic secretions to Hepatic Resection With Multichannel but this fell to a mean of 240 mL with the travel on the outside of the sleeve and lat- Radiofrequency Device er mix with the chyme at the sleeve’s end. The amount of blood lost during a hepatic InLine device. Clamping time also signifiOn removal, drawstrings that are attached resection might be significantly reduced by cantly declined from a mean of 30 minutes to the anchor struts collapse the anchor using a multichannel bipolar radiofre- before the device was used to a mean of and retract the barbs from the intestinal quency device to ablate a long, deep, and about 8 minutes after it was introduced. When the device is used in conjunction narrow plane where the liver will be tranwall. The collapsed anchor is then drawn into sected, according to Dr. Vijay Khatri, an with portal triad clamping, the width of the device’s ablation increases from 1 cm a protective hood and the whole system is ACS Fellow. Portal triad clamping (the Pringle ma- to 2 cm because of the lack of rapid blood endoscopically removed from the GI tract. “There are those who would make the neuver) has been the traditional way to re- flow next to it that normally acts as a heat argument, and rightfully so, that 2 feet duce blood loss during hepatic resection, sink, Dr. Khatri said in an interview. ■ single-port appendectomy takes longer to comp

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Surgery News - October 2008 Contents Call to Action Issued to Support DVT, PE Prevention Protocol Changes May Increase Donor Organs CMS Targets 2011 for Switch to ICD-10 Opinion: Election 2008 The 20/20 Vision: Children's Health News From the College: Survival Strategy General Surgery: Innovations

Surgery News - October 2008

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