In an attempt to identify those patients who would benefit from palliative resection of the colon or rectum and those who would not, an analysis of ten years of resections was undertaken. For the 81 patients who underwent palliative resection, the operative mortality was 10 per cent and the postoperative morbidity was 50 per cent. The mean survival was 11.4 months and the median survival nine months. Poor prognostic factors deduced were patients with extensive liver metastases, those over the age of 75 years, and a previous history of cardiovascular disease. It is believed that patients with a combination of these factors may not benefit from palliative resection. Otherwise, resections satisfactorily relieve patients of the symptoms of impending obstruction and rectal bleeding and are, therefore, believed to be worthwhile.
This study was done to determine the factors contributing to laparoscopic failure (conversion to open surgery or early reoperation) during the learning curve for laparoscopic Nissen fundoplication in a 228-bed nonteaching community hospital. Data were gathered prospectively for the first 100 consecutive patients booked for elective laparoscopic Nissen fundoplication by the four general surgeons at the hospital. All complications were recorded contemporaneously, and particular note was taken of the factors surrounding conversion to open surgery and reoperation within 100 days of surgery. There were no deaths. The conversion rate was 20% and the early reoperation rate 6%. There were two late recurrences. The average operative time was 117 minutes and the average length of stay 1.8 days; 37 operations were performed on outpatients. The laparoscopic failure rate was 26% (18/68) during a surgeon's first 20 operations and 11% (3/28) thereafter (P < 0.09); the corresponding conversion rates were 22% and 4% (P < 0.05). During a surgeon's first 20 operations, the laparoscopic failure rate rose from 21% (12/57) to 55% (6/11) (P < 0.04) if a second surgeon did not assist. After 20 operations, this difference lost its significance. Intrathoracic herniation of the stomach was found preoperatively in 11 (44%) of 25 operations followed by laparoscopic failure and (8%) 6 of 75 without (P < 0.0002). Laparoscopic failure had no correlation with patient age, sex, ASA classification, duration of symptoms, or referring physician's specialty. The individual learning curve for laparoscopic Nissen fundoplication requires about 20 operations to surmount. Factors leading to laparoscopic failure during the learning curve are the surgeon's inexperience, absence of experienced help, and the presence of intrathoracic herniation.
The JOVO procedure is safe and reproduces laparoscopically the early weight loss of open VBG with much shorter hospital stay and low complication and failure rates. Longer follow-up and larger numbers are needed.
Results from a low-volume community hospital general surgical practice are similar to those from specialized series. Obesity is so common, its non-surgical treatment so ineffective and the VBG so well established, that excluding this intervention from community hospitals is untenable.
A simple technique for laparoscopic vertical banded gastroplasty is described. With the surgeon to the patient’s left, four trochars are placed as cephalad as possible. Short gastric vessels are divided and the posterior wall of the stomach mobilized. The ETS-Flex with Articulating Head (Ethicon Endosurgery Inc.) is used to divide the stomach close to a 42-french bougie against the lesser curvature. An additional stapler bite abuts directly against a 28-french bougie to obtain correct stoma size. A ribbon of Prolene mesh is pulled through a tunnel behind the stomach at the apex of the divided gastroplasty and sutured around the distal end of the gastroplasty. To date we have used this method successfully in 5 patients with 1–11 months of follow-up. Although we lack a sufficient number of patients or follow-up for definitive conclusions, we believe this technique will produce good results, as it reproduces exactly that used successfully in open surgery and our early results parallel those following open surgery.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.