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Sharata A.M.,Foundation for Surgical Innovation and Education | Dunst C.M.,Foundation for Surgical Innovation and Education | Dunst C.M.,Providence Portland Medical Center | Pescarus R.,Providence Portland Medical Center | And 5 more authors.
Journal of Gastrointestinal Surgery | Year: 2014

Introduction Peroral endoscopic myotomy (POEM) is a flexible endoscopic approach to the lower esophageal sphincter (LES) providing access for a myotomy to relieve dysphagia. The technique has been adopted worldwide due to reports of excellent short-term clinical outcomes. We report on a consecutive patient cohort with clinical and objective outcomes representing the establishment of a POEM program within a busy esophageal surgical practice. Methods Comprehensive data was collected prospectively on all patients undergoing POEM from October 2010 to November 2013 at a single institution. Patients were classified based on high-resolution manometry (HRM). Operative data and immediate outcomes were reviewed. Symptom scores, HRM, and timed barium swallow (TBS) were performed prior to the procedure. Patients were asked to undergo routine postoperative testing 6-12 months after surgery with the addition of standard 24-h pH to the preoperative protocol. Morbidity was defined as requiring additional procedures or prolonged hospital stay >2 days. Results One hundred POEM patients were included in the final analysis. The mean age was 58 years (18-83 years). Primary presenting symptoms included dysphagia 81, chest pain 10, and regurgitation 9. The mean follow-up was 16 months. HRM diagnoses were 75 achalasia (30 type I, 43 type II, 2 type III), 12 nutcracker esophagus, 5 diffuse esophageal spasm (DES), and 8 isolated hypertensive non-relaxing LES.The mean operative time was 128 min. The median hospital length of stay (LOS) was 1 day. The overall morbidity was 6 %; all were treated endoscopically or with conservative management without further sequelae (three had intra-tunnel leak diagnosed on routine esophagram and one developed a postoperative intra-tunnel hemorrhage, one developed Ogilvie's, and one required prolonged intubation for CO2 retention).The average LES resting/residual pressure significantly decreased (44.3/22.2 to 19.6/11.7 in millimeters of mercury). Esophageal emptying improved from 40 to 90 % on TBS with 93 % patients demonstrating >90 % emptying at 1 min. Of the achalasia patients, 36 % (17/47) showed some return of normal peristalsis (≥70 % peristalsis) on post-op HRM.Abnormal acid exposure was present on postoperative testing in 38 % (26/68). Of these, 14 were asymptomatic. No reflux patient required additional antireflux procedure.Eckardt scores decreased from 6 to 1. Dysphagia was improved or eradicated in 97 % with a complete resolution accomplished in 89 %. Complete dysphagia relief was better for achalasia patients (46/47 patients; 97.8 %) vs. non-achalasia patients (17/24; 70.8 %). Of those with preoperative chest pain, 91.5 % reported complete relief.Four patients have refractory dysphagia. Two non-achalasia patients underwent subsequent laparoscopic Heller myotomy and two are improved following serial endoscopic dilatations. Conclusion This study represents the largest POEM series to date that includes objective data. Despite reflux in one/three of patients, POEM provides excellent relief of dysphagia (97 %) and chest pain (91.5 %) for patients with esophageal spastic disorders with acceptable procedural morbidity. © 2014 The Society for Surgery of the Alimentary Tract.


Speer E.,Providence Portland Medical Center | Speer E.,Foundation for Surgical Innovation and Education | Dunst C.M.,Providence Portland Medical Center | Dunst C.M.,Foundation for Surgical Innovation and Education | And 7 more authors.
Surgical Endoscopy and Other Interventional Techniques | Year: 2016

Introduction: Anastomotic complications after esophagectomy are relatively frequent. The off-label use of self-expanding covered metal stents has been shown to be an effective initial treatment for leaks, but there is a paucity of literature regarding their use in cervical esophagogastric anastomoses. We reviewed our outcomes with anastomotic stenting after esophagectomy with cervical esophagogastric reconstruction. Methods: All stents placed across cervical anastomoses following esophagectomy from 2004 to 2014 were retrospectively reviewed. Indications for surgery and stent placement were collected. For patients with serial stents, each stent event was evaluated separately and as part of its series. Success was defined as resolution of indicated anastomotic problem for at least 90 days. Complications were defined as development of stent-related problems. Results: Twenty-three patients had a total of 63 stents placed (16 % prophylactic, 38 % leak, 46 % stricture). Sixty percent of patients had successful resolution of their initial anastomotic problem; 67 % required more than one stent. Strictures and leaks healed in 27 and 70 % of patients, respectively, at a median of 55.5 days. Stent-related complications occurred in 78 % of patients. Complications (per stent event) included 62 % migration, 11 % clinically significant tissue overgrowth, 8 % minor erosion (ulcers), and 8 % major erosion. Stents placed for stricture were more likely to result in complications, especially migration (76.7 vs. 48.5 %, p = 0.02). Preoperative chemoradiation was a significant risk factor for erosion (22.5 vs. 4.3 %, p = 0.05), but not for overall complications. Patients with major erosions had longer stent duration compared to those without (92 vs. 36 days, p = 0.14). Discussion: Although stents are effective at controlling post-esophagectomy anastomotic leaks, they are not effective for treating strictures. Stents have high complication rates, but most are minor. Chemoradiation is a risk factor for stent erosion. Caution should be used when stent duration exceeds 2–3 months due to the risk of erosion. © 2015, Springer Science+Business Media New York.


Pescarus R.,Providence Portland Medical Center | Sharata A.M.,Foundation for Surgical Innovation and Education | Dunst C.M.,Foundation for Surgical Innovation and Education | Dunst C.M.,Providence Portland Medical Center | And 5 more authors.
Surgical Endoscopy and Other Interventional Techniques | Year: 2016

Background: Roux-en-Y gastric bypass (RYGB) is considered to be an optimal surgical treatment option for GERD in the morbidly obese patient. Nevertheless, a subgroup of patients suffer from recurrent or persistent GERD after their gastric bypass. Unfortunately, limited treatment options are available in these patients. Fundoplication via mobilization of the remnant stomach and radiofrequency treatment of the lower esophageal sphincter have been described with some success. Our objective is to illustrate a safe and durable surgical option in the treatment of patients with medically refractory GERD post-RYGB. Methods: After placing five trocars in the usual position for a foregut laparoscopic surgery, a lysis of adhesions and standard dissection of the hiatus is performed. The anterior and posterior vagal nerves associated phrenoesophageal tissue bundles are identified. A primary crural repair with interrupted nonabsorbable sutures is performed. Four full-length nonabsorbable sutures are placed sequentially through the anterior and posterior phrenoesophageal bundle, posterior fundus and finally through the pre-aortic fascia. The repair is calibrated on a 44 French bougie. The sutures are tied from medial to lateral in the order of their placement under endoscopic guidance. Results: No peri-procedural complications were encountered. Standard post-antireflux surgery clinical follow-up with the patient completing a validated GERD clinical questionnaire at 1 and 6 months after the surgery demonstrated excellent GERD symptom control without any dysphagia. A pH study and EGD performed at 6 months post-Hill procedure show the absence of pathological reflux with an intact Hill mechanism. Conclusion: The Hill procedure is a valid treatment for the post-bariatric surgical patient with GERD in which the gastric fundus is absent or inaccessible thus eliminating standard fundoplication as a reasonable option. This also represents a safe and durable treatment of GERD in this uniquely challenging patient population. © 2015, Springer Science+Business Media New York.


Speer E.A.,Providence Portland Medical Center | Chow S.C.,Legacy Good Samaritan Hospital | Dunst C.M.,Providence Portland Medical Center | Dunst C.M.,Foundation for Surgical Innovation and Education | And 10 more authors.
Journal of Gastrointestinal Surgery | Year: 2016

Introduction: Feeding jejunostomies (J tubes) provide enteral nutrition when oral and gastric routes are not options. Despite their prevalence, there is a paucity of literature regarding their efficacy and clinical burden. Methods: All laparoscopic J tubes placed over a 5-year period were retrospectively reviewed. Clinical burden was measured by number of clinical contact events (tube-related clinic visits, phone calls, ED visits) and morbidity (dislodgement, clogging, tube fracture, infection, other). Tube replacements were also recorded. Results: One hundred fifty-one patients were included. Fifty-nine percent had associated malignancy, and 35 % were placed for nutritional prophylaxis. Mean time to J tube removal was 146 days. J tubes were expected to be temporary in >90 % but only 50 % had sufficient oral intake for removal. Tubes were removed prematurely due to patient intolerance in 8 %. Mortality was 0 %. Morbidity was 51 % and included clogging (12 %), tube fracture (16 %), dislodgement (25 %), infection (18 %) and “other” (leaking, erosion, etc.) in 17 %. The median number of adverse events per J tube was 2(0–8). Mean number of clinic phone calls was 2.5(0–22), ED visits 0.5(0–7), and clinic visits 1.4(0–13), with 82 % requiring more than one J tube-related clinic visit. Unplanned replacements occurred in 40 %. Conclusion: While necessary for some patients, J tubes are associated with high clinical burden. © 2016, The Society for Surgery of the Alimentary Tract.


Pescarus R.,Hopital Sacre Coeur | Shlomovitz E.,University of Toronto | Sharata A.M.,Providence Portland Medical Center | Cassera M.A.,The Oregon Clinic | And 6 more authors.
Surgical Endoscopy and Other Interventional Techniques | Year: 2016

Introduction: Obtaining an adequate mucosal closure is one of the crucial steps in per-oral endoscopic myotomy (POEM). Thus far, there have been no objective data comparing the various available closure techniques. This case-controlled study attempts to compare the application of endoscopic clips versus endoscopic suturing for mucosotomy closure during POEM cases. Methods: A retrospective review of our prospective POEM database was performed. All cases in which endoscopic suturing was used to close the mucosotomy were matched to cases in which standard endoclips were used. Overall complication rate, closure time and mucosal closure costs between the two groups were compared. Results: Both techniques offer good clinical results with good mucosal closure and the absence of postoperative leak. Closure time was significantly shorter (p = 0.044) with endoscopic clips (16 ± 12 min) when compared to endoscopic suturing (33 ± 11 min). Overall, the total closure cost analysis showed a trend toward lower cost with clips (1502 ± 849 USD) versus endoscopic suturing (2521 ± 575 USD) without reaching statistical significance (p = 0.073). Conclusion: The use of endoscopic suturing seems to be a safe method for mucosal closure in POEM cases. Closure time is longer with suturing than conventional closure with clips, and there is a trend toward higher overall cost. Endoscopic suturing is likely most cost-effective for difficult cases where conventional closure methods fail. © 2015, Springer Science+Business Media New York.


PubMed | Foundation for Surgical Innovation and Education and Providence Portland Medical Center
Type: Journal Article | Journal: Surgical endoscopy | Year: 2016

Roux-en-Y gastric bypass (RYGB) is considered to be an optimal surgical treatment option for GERD in the morbidly obese patient. Nevertheless, a subgroup of patients suffer from recurrent or persistent GERD after their gastric bypass. Unfortunately, limited treatment options are available in these patients. Fundoplication via mobilization of the remnant stomach and radiofrequency treatment of the lower esophageal sphincter have been described with some success. Our objective is to illustrate a safe and durable surgical option in the treatment of patients with medically refractory GERD post-RYGB.After placing five trocars in the usual position for a foregut laparoscopic surgery, a lysis of adhesions and standard dissection of the hiatus is performed. The anterior and posterior vagal nerves associated phrenoesophageal tissue bundles are identified. A primary crural repair with interrupted nonabsorbable sutures is performed. Four full-length nonabsorbable sutures are placed sequentially through the anterior and posterior phrenoesophageal bundle, posterior fundus and finally through the pre-aortic fascia. The repair is calibrated on a 44 French bougie. The sutures are tied from medial to lateral in the order of their placement under endoscopic guidance.No peri-procedural complications were encountered. Standard post-antireflux surgery clinical follow-up with the patient completing a validated GERD clinical questionnaire at 1 and 6months after the surgery demonstrated excellent GERD symptom control without any dysphagia. A pH study and EGD performed at 6months post-Hill procedure show the absence of pathological reflux with an intact Hill mechanism.The Hill procedure is a valid treatment for the post-bariatric surgical patient with GERD in which the gastric fundus is absent or inaccessible thus eliminating standard fundoplication as a reasonable option. This also represents a safe and durable treatment of GERD in this uniquely challenging patient population.


Riva P.,Institute of Image Guided Surgery | Perretta S.,Institute of Image Guided Surgery | Swanstrom L.,Institute of Image Guided Surgery | Swanstrom L.,Foundation for Surgical Innovation and Education
Surgical Endoscopy and Other Interventional Techniques | Year: 2016

Background: Obesity is a leading cause of morbidity and healthcare utilization. At the moment, the best treatment for obesity has shown to be laparoscopic gastric bypass. However, about a quarter of the patients experience substantial weight regain, which is difficult to treat, as revision surgery has higher risks than primary procedures. Endoscopic procedures, such as endoscopic suturing, are effective, safe and less invasive in addressing weight regain. Methods: We conducted a retrospective analysis on 22 consecutive patients operated between 2011 and 2013 who had a significant weight regain after RYGB (mean follow-up 22 months), in order to evaluate the long-term outcomes of endoscopic gastro-jejunal revision after weight regain post-bypass surgery. Mucosal ablation around the anastomosis was performed in all patients, and the endoscopic suturing device was used to perform suture stoma reduction. We also evaluated, in a group of 11 patients, the effect of combining sclerotherapy and endoscopic suturing. Results: We showed good efficacy of the endoluminal procedure, with 100 % of patients achieving weight loss. Maximum weight loss was noted at a mean of 18-month follow-up (average of 60.3 % excess weight loss; n = 19), while the mean weight loss regained percentage was 5 % ± 39. 4/22 patients (all four in non-sclerotherapy group, all of them had an anastomosis >10 mm) regained some of this lost weight by the time of the longest follow-up. There was an actual correlation between final stoma diameter (<10 mm) and weight loss. Conclusions: A larger randomized sample of patients with a longer follow-up would be needed to support the effectiveness of the combination of the two therapies. Although almost 20 % of the patients regained weight during the follow-up period, the endoluminal approach offers the advantage of being repeatable after weight regain without adding morbidity risks. © 2016 Springer Science+Business Media New York


Robinson B.,Foundation for Surgical Innovation and Education | Dunst C.M.,Foundation for Surgical Innovation and Education | Dunst C.M.,Providence Cancer Center | Cassera M.A.,Providence Cancer Center | And 5 more authors.
Surgical Endoscopy and Other Interventional Techniques | Year: 2015

Background: Laparoscopic surgery for gastrointestinal reflux disease was introduced in 1991. Early safety, efficacy, and 5–10-year durability have been amply documented, but long-term patient outcomes have been criticized. This study presents 20-year outcomes after laparoscopic fundoplication (LF) in a consecutive patient cohort. Methods: Patients who underwent primary LF procedures for gastroesophageal reflux disease (GERD) were identified from a prospectively collected IRB-approved database (1991–1995). A phone symptom questionnaire was administered using a 5-point validated GERD scoring system (heartburn, regurgitation, and dysphagia). Symptomatic success was defined by a lack of surgical re-intervention and a low symptom score. Results: One-hundred and ninety-three patients were identified during the time period. Fifty-one patients completed the survey (100 lost to follow-up, 40 deceased, 2 declined to answer). Respondents had a median follow-up of 19.7 years. Overall, 38/51 (74.5 %) of patients reported complete control of heartburn and regurgitation. Ten patients reported only occasional heartburn. Eight of fifty-one (16 %) reported daily dysphagia, and 22/51 (43 %) of respondents were using proton pump inhibitors at the time of telephone interview. Nine of fifty-one (18 %) underwent revision of the original surgery which did not negatively impact the satisfaction rating, with 8/9 (89 %) of these patients reporting the highest satisfaction rating. Overall, 46/51 (90 %) were satisfied with their choice of surgery. Conclusion: Long-term results from the early experience with LF are excellent with 94 % of patients reporting only occasional or fewer reflux symptoms at 20-year follow-up. However, 18 % required surgical revision surgery to maintain their results. There is a relatively high rate of daily dysphagia but 90 % of patients are happy to have had LF. © 2014, Springer Science+Business Media New York.


PubMed | Foundation for Surgical Innovation and Education
Type: Journal Article | Journal: Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract | Year: 2015

Peroral endoscopic myotomy (POEM) is a flexible endoscopic approach to the lower esophageal sphincter (LES) providing access for a myotomy to relieve dysphagia. The technique has been adopted worldwide due to reports of excellent short-term clinical outcomes. We report on a consecutive patient cohort with clinical and objective outcomes representing the establishment of a POEM program within a busy esophageal surgical practice.Comprehensive data was collected prospectively on all patients undergoing POEM from October 2010 to November 2013 at a single institution. Patients were classified based on high-resolution manometry (HRM). Operative data and immediate outcomes were reviewed. Symptom scores, HRM, and timed barium swallow (TBS) were performed prior to the procedure. Patients were asked to undergo routine postoperative testing 6-12 months after surgery with the addition of standard 24-h pH to the preoperative protocol. Morbidity was defined as requiring additional procedures or prolonged hospital stay >2 days.One hundred POEM patients were included in the final analysis. The mean age was 58 years (18-83 years). Primary presenting symptoms included dysphagia 81, chest pain 10, and regurgitation 9. The mean follow-up was 16 months. HRM diagnoses were 75 achalasia (30 type I, 43 type II, 2 type III), 12 nutcracker esophagus, 5 diffuse esophageal spasm (DES), and 8 isolated hypertensive non-relaxing LES. The mean operative time was 128 min. The median hospital length of stay (LOS) was 1 day. The overall morbidity was 6%; all were treated endoscopically or with conservative management without further sequelae (three had intra-tunnel leak diagnosed on routine esophagram and one developed a postoperative intra-tunnel hemorrhage, one developed Ogilvies, and one required prolonged intubation for CO2 retention). The average LES resting/residual pressure significantly decreased (44.3/22.2 to 19.6/11.7 in millimeters of mercury). Esophageal emptying improved from 40 to 90% on TBS with 93% patients demonstrating >90% emptying at 1 min. Of the achalasia patients, 36% (17/47) showed some return of normal peristalsis (70% peristalsis) on post-op HRM. Abnormal acid exposure was present on postoperative testing in 38% (26/68). Of these, 14 were asymptomatic. No reflux patient required additional antireflux procedure. Eckardt scores decreased from 6 to 1. Dysphagia was improved or eradicated in 97% with a complete resolution accomplished in 89%. Complete dysphagia relief was better for achalasia patients (46/47 patients; 97.8%) vs. non-achalasia patients (17/24; 70.8%). Of those with preoperative chest pain, 91.5% reported complete relief. Four patients have refractory dysphagia. Two non-achalasia patients underwent subsequent laparoscopic Heller myotomy and two are improved following serial endoscopic dilatations.This study represents the largest POEM series to date that includes objective data. Despite reflux in one/three of patients, POEM provides excellent relief of dysphagia (97%) and chest pain (91.5%) for patients with esophageal spastic disorders with acceptable procedural morbidity.


PubMed | Foundation for Surgical Innovation and Education
Type: Journal Article | Journal: Surgical endoscopy | Year: 2015

Laparoscopic surgery for gastrointestinal reflux disease was introduced in 1991. Early safety, efficacy, and 5-10-year durability have been amply documented, but long-term patient outcomes have been criticized. This study presents 20-year outcomes after laparoscopic fundoplication (LF) in a consecutive patient cohort.Patients who underwent primary LF procedures for gastroesophageal reflux disease (GERD) were identified from a prospectively collected IRB-approved database (1991-1995). A phone symptom questionnaire was administered using a 5-point validated GERD scoring system (heartburn, regurgitation, and dysphagia). Symptomatic success was defined by a lack of surgical re-intervention and a low symptom score.One-hundred and ninety-three patients were identified during the time period. Fifty-one patients completed the survey (100 lost to follow-up, 40 deceased, 2 declined to answer). Respondents had a median follow-up of 19.7 years. Overall, 38/51 (74.5%) of patients reported complete control of heartburn and regurgitation. Ten patients reported only occasional heartburn. Eight of fifty-one (16%) reported daily dysphagia, and 22/51 (43%) of respondents were using proton pump inhibitors at the time of telephone interview. Nine of fifty-one (18%) underwent revision of the original surgery which did not negatively impact the satisfaction rating, with 8/9 (89%) of these patients reporting the highest satisfaction rating. Overall, 46/51 (90%) were satisfied with their choice of surgery.Long-term results from the early experience with LF are excellent with 94% of patients reporting only occasional or fewer reflux symptoms at 20-year follow-up. However, 18% required surgical revision surgery to maintain their results. There is a relatively high rate of daily dysphagia but 90% of patients are happy to have had LF.

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