GI SURGERY
Selections from Advances in Gastrointestinal and GI Laparoscopic Surgery, presented by the University of
Minnesota Medical School
| LAPAROSCOPIC NISSEN FUNDOPLICATION —Nathaniel J. Soper, MD, Professor and Vice-Chair, Department of
Surgery, and Director of Minimally Invasive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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| Complicating factors: previous upper abdominal surgery (eg, antireflux surgery); obesity; small thin patients; severe
esophagitis and stricture; large hiatal hernias
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| Ensuring successful operation: protect esophagus from harm; perform all dissection under direct vision; ensure 3 cm
of intra-abdominal esophagus; wrap fundus only around esophagus; ensure no tension on fundus (over time, tension will
twist lower esophagus and produce undilatable stricture); speaker routinely uses big dilator and short wrap (2 cm); important
to close hiatus adequately
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| Laparoscopic approach to upper abdomen: place patients in modified lithotomy position (speaker believes regular
lithotomy position invites nerve injury); use angled laparoscope (usually 30°, sometimes 45°); speaker places arc of ports
10 to 15 cm from xiphoid on both sides of abdomen; have access to flexible endoscope; important to have adequate, self-
retaining liver retractor; speaker’s technique—place laparoscope to left of midline (15 cm below xiphoid); place right
hand in subcostal position, with left hand across midline, high up in abdomen; place 2 assisting ports on anatomic right
side; position fundoplication over lower esophagus, not upper stomach, and fix with 2 sutures (speaker uses braided 2.0
polyester sutures and does not use pledgets)
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| Characteristics of Nissen fundoplication: 360° or total fundoplication, with fundus wrapped around distal esophagus;
“short, floppy” wrap performed by most surgeons in United States; in Hell-Rosetti fundoplication, short gastric vessels not divided
(not favored by speaker); speaker advocates closure of crura, even if hiatal hernia not present preoperatively, because mobilization
during operation creates hernia (primary source of procedural failure is fundus wrap passing up into chest); lower
esophagus needs to move independently of diaphragm, so fix fundus to esophagus, not crura; length and orientation of wrap
variable; study—dilator vs no dilator during fundoplication; incidence of postoperative dysphagia higher in patients in whom
dilator not used
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| Partial fundoplications: majority of surgeons in United States who decide against total fundoplication because of motility
issue perform partial posterior fundoplication (Toupet procedure; involves 270° wrap sutured to esophageal wall and crura);
patients with reduced preoperative esophageal motility—Toupet procedure associated with ongoing reflux in up to
50% of patients and higher failure rate than Nissen procedure
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| Indications for Nissen fundoplication: speaker advocates Nissen procedure for all patients (including those with complicated
disease, Barrett’s syndrome, or stricture), unless they have severe preoperative dysphagia in presence of poor
esophageal motility
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| Postoperative procedures: speaker gives clear liquids immediately, admits patients overnight, and administers intravenous
(IV) antinauseants and nonsteroidal anti-inflammatory drugs (NSAIDs); morning after operation, patient placed on
soft diet for 2 wk; 90% of patients discharged first day; speaker advocates no heavy lifting for 6 wk
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| Complications: in speaker’s experience, 4% of patients suffered significant complications and 1 patient died; reoperation
necessary in 1% of patients
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| Predictors of good operative result: typical reflux symptoms, good response to proton pump inhibitors, and positive
24-hr pH test indicate good surgical outcome likely
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| Durability of antireflux operations: in medium-term follow-up, failure rate 2% to 12%; failures related to surgeon inexperience,
large hiatal hernias, vomiting, or injuries causing stress to diaphragm; Dallemagne study—91% of patients
who underwent Nissen fundoplication had no reflux symptoms at 10 yr
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| CHALLENGES IN LAPAROSCOPIC ANTIREFLUX SURGERY —John G. Hunter, MD, MacKenzie Professor and
Chair, Department of Surgery, Oregon Health and Science University, Portland
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Short Esophagus
| Prevalence: existence subject of controversy; however, widely acknowledged that esophageal stricturing results from esophageal
damage; fibroblasts have no orientation and, therefore, if capacity to narrow esophagus exists, so does capacity to
shorten esophagus; speaker’s analysis—group of 57 patients with esophageal shortening included patients with risk factors
for esophageal injury; 8 patients had esophageal shortening that was not predicted
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| Intraoperative diagnosis: mediastinal mobilization as hiatus allows; trial closure of hiatus before suturing; release all
inferior traction on gastroesophageal (GE) junction; drop Penrose drain; distance from GE junction to diaphragm—if
<2.5 cm, take off fat pad and remeasure; if still <2.5 cm, perform lengthening procedure
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| Lengthening procedures: Swanstrom—first lengthening procedure; right chest approach using dilator and Endo-GIA
stapler; Ravitch and Steichen—laparoscopic repair using EEA stapler next to dilator to make hole in stomach (similar
to vertical banded gastroplasty); linear stapler then fired next to dilator to create tube; Filippi—developed left chest approach
using GIA stapler; Champion—wedge gastroplasty used to remove small pouch of stomach (15-30 mm); does
not require additional trocars; requires angulated GIA stapler and 40 F Maloney dilator; highest fundoplication suture
should be around native esophagus, just above GE junction
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| Ensuring successful laparoscopic revision: sharp dissection; Ray-Tec sponge to keep areas dry; define left crus early;
early entry into lesser sac; often necessary to mobilize more short gastric vessels; take down all previous repairs; consider
Collis gastroplasty for short esophagus and second hiatal hernia recurrence; close crura with pledgets; check for intraoperative
perforation with dilute methylene blue (on first day after procedure, speaker performs thin barium swallow to check for
leaks)
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| MULTIMODALITY THERAPY FOR GASTRIC CANCER —Paul F. Mansfield, MD, Professor of Surgery, Department
of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
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| Theoretical advantages of neoadjuvant therapy: downstaging (making unresectable tumors resectable); reduce locoregional
failure; only effective therapy continued; avoid unnecessary resections
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| MD Anderson Cancer Center neoadjuvant therapy trials: first trial (1986)—25 patients received 5-fluorouracil
(5-FU) plus etoposide plus platinum therapy; curative resection rate 72%; laparoscopy not used; major response rate
24%; no pathologic complete responses; moderate toxicity but no mortality; second trial—etoposide plus adriamycin
plus platinum therapy (more toxic regimen than first trial); curative resection rate 77%; major response rate 31%; no
pathologic complete responses; last chemotherapy alone study—5-FU plus interferon plus platinum therapy; curative
resection 80%; major response rate 38%; 3 pathologic complete responses; no treatment-related mortality; prognostic
factors in patients undergoing surgical resection—in univariate analysis, T stage, N stage, and response to therapy
important; in multivariate analysis, only response to therapy significant
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| Neoadjuvant chemoradiation trial: 5-FU (300 mg/m2 continuous infusion) and 45 Gy external beam radiation; patients
restaged after 5-wk recovery, then underwent spleen-preserving D2 lymphadenectomy; all patients underwent staging
laparoscopy and received 10 Gy intraoperative radiation therapy (IORT); combined results of pilot study and phase
2 trials—48 patients (89%) completed full-dose treatment, 98% completed treatment (some had dose reductions); resection
rate 78%; of 54 patients, 6 pathologic complete responses on serial section, 23 partial responses (<10% viable cells
on specimen); 78% of patients had T3 or T4 lesions; 75% of patients had high-grade tumors; survival 60% at 4 yr for resected
patients; response rate >70% in resected patients; mortality rate 2%; conclusions—excellent locoregional control
and should be considered in high-risk patients
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| Neoadjuvant chemo-chemoradiation therapy trial: 2 cycles of 5-FU plus platinum plus leucovorin followed by 5-
FU (300 mg/m2 continuous infusion) and 45 Gy external beam radiation; patients restaged and resected after 5-wk recovery;
results—1 treatment-related death (myocardial infarction after first course of chemotherapy); 1 postoperative death (due to
aspiration); pathologic complete response rate 30%, partial response rate 24%; for responders, median survival >5 yr, for
nonresponders, 1 yr; Taxol-based chemo-chemoradiation therapy trial—multi-institutional phase 2 study; paclitaxel
(Taxol) plus cisplatin plus 5-FU combined with chemoradiation therapy with Taxol; 41 patients (most tumors proximal and
T3); no treatment- or operative-related deaths; 32 R0 resections (resection rate 78%); pathologic complete response rate
20%, partial response rate 15%; treatment toxicity greater and response rates lower
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| Medical Research Council (MRC) Adjuvant Gastric Infusional Chemotherapy (MAGIC) trial: >500 patients
randomized to chemotherapy (etoposide, cisplatin, 5-FU) plus surgery plus chemotherapy or surgery alone; after
initial chemotherapy, 3- to 6-wk recovery before undergoing resection, and 6- to 12-wk recovery before additional chemotherapy;
75% of patients had gastric cancer, 15% had cancer of GE junction, 11% had esophageal cancer; 88% of patients
completed preoperative therapy, 55% began postoperative therapy, and 40% completed all chemotherapy;
results—more patients who underwent preoperative chemotherapy able to undergo potentially curative resection; operative
mortality same for both groups; progression-free survival and overall survival improved significantly in chemotherapy
group
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| Summary of trials: 241 patients entered into 9 trials; 179 patients underwent surgical resection (66 in chemotherapy trials,
42 in chemoradiation plus IORT trials, 71 in chemo-chemoradiation trials); mean patient age, wound infection rate
(40% vs 5% and 10%), and anastomotic leak rate (14%) all higher in chemoradiation plus IORT trials
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| Conclusions: neoadjuvant therapy can be given safely; IORT associated with significant risk for wound infection and
anastomotic leak; patients >70 yr of age at significantly greater risk for mortality after gastrectomy; acceptable operative
morbidity and mortality; response to treatment predictive of survival
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| CURRENT MANAGEMENT OF HEPATIC METASTASES —Todd M. Tuttle, MD, Associate Professor of Surgery, University
of Minnesota Medical School, Minneapolis
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| Curative hepatic resection: D’Angelica et al—outcome determined for 96 patients 5 yr out from hepatic resection;
10-yr survival 78%; indicates some patients cured, not just shift in survival curve
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| Survival after hepatic resection: prognostic factors—presence of extrahepatic disease and margin status most important;
size of metastases; length of disease-free interval (DFI); preoperative carcinoembryonic antigen (CEA) level;
stage of primary tumor (if node-positive, patients fare worse); number of metastases; Memorial Sloan-Kettering Cancer
Center (MSKCC) prognostic scoring system—1 point awarded for each of positive lymph node primary, short DFI,
metastasis size >5 cm, >1 tumor, and preoperative CEA >200 ng/mL; in >1000 hepatic resections, survival correlated
well with prognostic score (if score 0, 5-yr survival 60%; if score 1, 5-yr survival 44%; if score 5, 5-yr survival 14%)
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| Patient staging and evaluation: chest imaging important, as well as liver function tests, international normalized ratio,
complete blood count, CEA level; colonoscopy if not performed within past year; computed tomography of abdomen and
pelvis more commonly performed (hepatic magnetic resonance imaging [MRI] may be more sensitive and provide more
useful anatomic detail); positron emission tomography has role in selected patients; staging in operating room (OR)—
laparoscopy on all patients to identify extrahepatic disease; intraoperative hepatic ultrasonography (US) and laparoscopy
to determine exact number and location of tumors
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| Contraindications for hepatic resection: >4 metastases; inability to obtain negative surgical margin; patient unfit to
tolerate operation due to comorbid conditions or insufficient hepatic reserve; extrahepatic disease—traditionally considered
contraindication; however, studies have shown morbidity and mortality for simultaneous hepatic and extrahepatic
resection no higher than for hepatic resection alone; extrahepatic disease likely not absolute contraindication for all patients
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| Hepatic artery infusional chemotherapy: floxuridine (FUDR)-based chemotherapy administered directly into hepatic
artery; in prospective randomized trial by Kemeny et al, hepatic artery infusional chemotherapy associated with overall survival
benefit; however, improved systemic therapies generally preclude use
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| Systemic therapies: should be integrated into multimodal therapy for patients with colorectal liver metastases; chemotherapy
strategies mandatory for patients undergoing hepatic resection
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| Synchronous resection of liver metastases and primary colorectal cancer: Mayo Clinic study—96 patients
underwent 1- or 2-stage operation with colectomy performed first; no differences in duration of surgery, blood loss,
blood products, morbidity, mortality, DFI, or overall survival; 1-stage procedure associated with shorter hospital stay and
shorter overall recovery
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| Types of hepatic resection: principles of hepatic resection to preserve hepatic function and obtain negative surgical
margin; anatomic liver resections (eg, segmentectomy, lobectomy, trisegmentectomy) preferred; wedge resection—
positive margin rate 20%; often leads to more bleeding; laparoscopic liver resection—>700 now reported in United
States; left lateral segment ideal location; in review by Buell et al, no open conversions, mean OR time 2 hr, no reoperations,
mean hospital stay 3 days, complication rate 23%, and mortality rate 1%; radiofrequency ablation—produces
zone of necrosis in tumor; open approach preferred for ablation of central lesion when open resection performed for other
tumors; percutaneous approach most useful for patients with significant comorbidities or hostile abdomen due to adhesions;
disadvantages of percutaneous approach include no staging of peritoneum and inability to use intraoperative hepatic
US; laparoscopic approach useful for patients unsuitable for open resection; radiofrequency ablation should be
reserved for patients with unresectable tumors; hepatic resection remains standard of care
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Educational Objectives
| The goal of this activity is to educate the listener about developments in gastrointestinal surgery. After hearing and assimilating
this program, the clinician will be better able to:
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 | 1. Identify patients with gastroesophageal reflux disease (GERD) who are good candidates for laparoscopic Nissen fundoplication.
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| 2. Perform laparoscopic Nissen fundoplication.
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| 3. Ensure successful laparoscopic antireflux surgery in patients with a short esophagus.
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| 4. Discuss the role of adjuvant and neoadjuvant chemotherapy in patients with gastric cancer.
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| 5. Manage patients with colorectal liver metastases.
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Discussed on This Program
Cisplatin (CDDP) [Platinol-AQ]
Doxorubicin [Adriamycin PFS, Adriamycin RDF]
Etoposide (VP-16-213) [Etopophos, Toposar, VePesid]
Floxuridine [FUDR]
Flucytosine (5-FC; 5-fluorocytosine) [Ancobon]
Leucovorin calcium (folinic acid; citrovorum factor) [Wellcovorin]
Paclitaxel [Onxol, Paxene, Taxol, Abraxane]
Suggested Reading
Capussotti L et al: Neoadjuvant chemotherapy and resection for initially irresectable colorectal liver metastases. Br J
Surg Epub ahead of print, May 31, 2006; Finlayson SR et al: National trends in utilization and outcomes of antireflux surgery.
Surg Endosc 17:864, 2003; Flum DR et al: The nationwide frequency of major adverse outcomes in antireflux surgery
and the role of surgeon experience, 1992-1997. J Am Coll Surg 195:611, 2002; Gonzalez RJ, Mansfield PF:
Adjuvant and neoadjuvant therapy for gastric cancer. Surg Clin North Am 85:1033, 2005; Heriot AG et al: Hepatic resection
for colorectal metastases—a national perspective. Ann R Coll Surg Engl 86:420, 2004; Higuchi K et al: Gastric cancer:
advances in adjuvant and adjunct therapy. Curr Treat Options Oncol 4:413, 2003; Khaitan L et al: A report on the
Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Outcomes Initiative: what have we learned and what is
its potential? Surg Endosc 17:365, 2003; Khajanchee YS et al: Outcomes of antireflux surgery in patients with normal
preoperative 24-hour pH test results. Am J Surg 187:599, 2004; Macdonald JS: Clinical overview: adjuvant therapy of
gastrointestinal cancer. Cancer Chemother Pharmacol 54:S4, 2004; Melichar B et al: Survival of patients with colorectal
cancer liver metastases treated by regional chemotherapy. Hepatogastroenterology 53:426, 2006; O'Rourke RW et
al: Extended transmediastinal dissection: an alternative to gastroplasty for short esophagus. Arch Surg 138:735, 2003; Patti
MG et al: Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak. J Am Coll
Surg 198:863, 2004; Power C et al: Factors contributing to failure of laparoscopic Nissen fundoplication and the predictive
value of preoperative assessment. Am J Surg 187:457, 2004; Terry ML et al: Stapled-wedge Collis gastroplasty for
the shortened esophagus. Am J Surg 188:195, 2004; Vlastos G et al: Long-term survival after an aggressive surgical approach
in patients with breast cancer hepatic metastases. Ann Surg Oncol 11:869, 2004; Winslow ER et al: Influence of
spastic motor disorders of the esophageal body on outcomes from laparoscopic antireflux surgery. Surg Endosc 17:738,
2003; Yao JC et al: Combined-modality therapy for gastric cancer. Semin Surg Oncol 21:223, 2003.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Soper, Hunter, Mansfield, and Tuttle were recorded at Advances in Gastrointestinal and GI Laparoscopic Surgery,
presented June 15-18, 2005, by the University of Minnesota Medical School, Departments of Surgery and Continuing
Medical Education, and held in Minneapolis, MN. The Audio-Digest Foundation thanks the speakers and the
sponsor for their cooperation in the production of this program.
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