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INTRODUCTION: We report the results of a multicenter trial evaluating a unique, biological mesh (MIROMESH) derived from decellularized porcine liver for hiatal cruralplasty during laparoscopic PEHR. METHODS: 41 subjects underwent a laparoscopic PEHR which included primary crural closure, and MIROMESH onlay. Subjects were assessed at 2-weeks and 6, 12, 18 and 24 months using the SF-36, GERD-HRQL questionnaire, and VAS GERD related symptoms, and UGI. RESULTS: Mean procedure time was 143.0 (±45.2) minutes, 93% had a Type III hiatal hernia and median LOS was 3 days. Of 27 patients available for 2 years follow up, no patients required surgical reintervention for symptomatic hernia recurrence or adverse events. Radiographic follow up revealed a 10% hiatal hernia recurrence rate. GERD HRQL scores were significantly improved from baseline to two years follow up. All the GERD symptoms measured showed significant and sustained improvement at all post-operative time periods. CONCLUSION: The utilization of MIROMESH for crural reinforcement during laparoscopic PEHR resulted in excellent symptomatic improvement in our multicenter trial with a 10% 2 year radiographic recurrence rate.

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BACKGROUND AND OBJECTIVES: Laparoscopic adjustable gastric banding is considered the least invasive surgical option for the treatment of morbid obesity. Its initial popularity has been marred by recent long-term studies showing high complication rates. We sought to examine our experience with gastric banding and factors leading to reoperation. METHODS: We reviewed retrospective data of 305 patients who underwent laparoscopic adjustable gastric banding between 2004 and 2011 at a single institution, 42 patients of whom required a reoperation, constituting 13.8%. Patients undergoing elective reoperations for port protrusion from weight loss as a purely cosmetic issue were excluded (n = 10). Patients' demographic data, weight loss, time to reoperation, and complications were analyzed. RESULTS: Of 305 patients, 42 (13.8%) required reoperations: 26 underwent band removal (8.5%) and 16 underwent port revision (5.2%). The mean weight and body mass index for all patients who underwent reoperations were 122.6 kg and 45.0 kg/m(2), respectively. The most common complication leading to band removal was gastric prolapse (n = 14, 4.6%). The most common indication for port revision was a nonfunctioning port (n = 10, 3.3%). CONCLUSION: Laparoscopic adjustable gastric banding was initially popularized as a minimally invasive gastric-restrictive procedure with low morbidity. Our study showed a 13.8% reoperation rate at 3 years' follow-up. Most early reoperations (<2 years) were performed for port revision, whereas later reoperations (>2 years) were likely to be performed for band removal. Laparoscopic adjustable gastric banding is associated with high reoperation rates; therefore bariatric surgeons should carefully consider other surgical weight-loss options tailored to the needs of the individual patient that may have lower complication and reoperation rates.

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BACKGROUND: Endoscopic submucosal dissection (ESD) offers en bloc resection of early cancer or precancerous lesions, potentially saving patients from major organ resection, such as gastrectomy, colectomy, and esophagectomy. Japan now leads the world in ESD due to its high rate of gastric cancer. Western countries, with their lower gastric cancer rates, do not get as much experience with the technique. Training in ESD utilizing both in vivo and ex vivo porcine stomach has been shown to decrease rates of perforation and operative time. Both models can be prohibitively expensive or not generally available to the majority of endoscopists on a regular basis. This study describes the framework for using human gastric remnants from sleeve gastrectomy patients for ESD training. METHODS: Patients undergoing sleeve gastrectomy for morbid obesity were consented for use of their gastric specimen before surgery. The specimen was weighed and measured by the pathologist and then used for ESD training. The specimen was mounted to a 15-mm laparoscopic port and secured using a pursestring suture. ESD was then performed through this port. RESULTS: We were able to successfully use this model to resect multiple marked out lesions in an en bloc fashion. Training using this model has improved our dissection times from approximately 2 h to 30 min for a 2-cm simulated lesion. CONCLUSIONS: ESD requires the endoscopist to perform a surgical dissection. Until now, development of these skills required intensive training on porcine models that are not widely available. We were able to create a method using the excised portion from sleeve gastrectomy patients, providing a more accessible and cost-effective model for ESD training and potentially other endoscopic therapeutic modalities.

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BACKGROUND: Morbid obesity is associated with increased rates of hiatal and paraesophageal hernias. Although laparoscopic sleeve gastrectomy is gaining popularity as the procedure of choice for morbid obesity, there is little data regarding the management of paraesophageal hernias found intraoperatively. The aim of this study was to evaluate the feasibility and benefits of a combined sleeve gastrectomy and paraesophageal hernia repair in morbidly obese patients. METHODS: From May 2011 to February 2013, 23 patients underwent laparoscopic sleeve gastrectomy combined with the repair of a paraesophageal hernia. Only 4 patients had a large hiatal hernia documented preoperatively on esophagogastroduodenoscopy (EGD). The body mass index (BMI), operative time, length of stay, and complications were evaluated. RESULTS: The average operative time was 165 minutes (115-240 minutes) and length of stay was 2.83 days (2-6 days). All patients were female except for one, with an average age of 53.4 years and a BMI of 41.9 kg/m(2). There were no complications during the procedures. Mean follow-up was 6.16 months (1-19 months), and mean excess weight loss was 39%. The average cost of admission for a combined procedure ($10,056), was slightly higher than a laparoscopic sleeve gastrectomy ($8905) or laparoscopic paraesophageal hernia repair ($8954) done separately. CONCLUSIONS: Laparoscopic sleeve gastrectomy combined with a paraesophageal hernia repair is well-tolerated and feasible in morbidly obese patients. Surgeons should be aware that preoperative EGD is not effective at diagnosing large hiatal or paraesophageal hernias. Surgeons with the skill set to repair paraesophageal hernias should do a combined procedure because it is well-tolerated, feasible, and can reduce the cost of multiple hospital admissions.

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BACKGROUND AND OBJECTIVES: Recent studies have supported minimally invasive techniques as a viable alternative to open surgery in the treatment of gastric cancer. The goal of this study is to review our institution's experience with totally laparoscopic gastrectomy for the treatment of both early- and advanced-stage gastric cancer. METHODS: A retrospective study was conducted to examine the short-term outcomes of laparoscopic gastrectomy performed at Monmouth Medical Center between May 2003 and June 2012. We reviewed postoperative complications, surgical margins, number of resected lymph nodes, estimated blood loss, length of stay, narcotic use, and recurrence rate. RESULTS: Forty patients were included in the study. There were 21 cases of adenocarcinoma, 15 cases of gastrointestinal stromal tumor, 2 cases of carcinoid, 1 case of small cell neuroendocrine tumor, and 1 case of squamous cell carcinoma. The mean operative time was 220 minutes (range, 67- 450 minutes). The median length of stay was 6 days (range, 1-37 days). The mean number of harvested lymph nodes was 11. Early postoperative complications occurred in 7 patients and included anastomotic stricture, wound infection, intra-abdominal abscess, bowel obstruction, and esophageal pneumatosis. There were two deaths. The Kaplan-Meier 5-year overall and recurrence-free survival rate for all cases of adenocarcinoma was 63.2%. CONCLUSIONS: Totally laparoscopic gastrectomy is a reasonable option for the treatment of gastric malignancy, with early data showing acceptable survival rates and perioperative outcomes. Large-scale randomized trials are still needed to confirm oncologic equivalency to open gastrectomy in patients with advanced disease.

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OBJECTIVES: We present 2 patients with free perforation of the anterior wall of the Roux limb due to marginal ulceration after an antecolic laparoscopic gastric bypass and describe the surgical management and laparoscopic repair technique. METHODS: A 15 mm Hg pneumoperitoneum was established with a Veress needle via the left subcostal approach in both patients. Entrance into the abdomen was achieved with the 5 mm Optiview blunt trocar. The Genzyme liver retractor was used to lift the left lobe of the liver and expose the gastrojejunal anastomosis. A 30 degrees 5 mm telescope was used for visualization. In both cases, free fluid and purulent material were noted in the subdiaphragmatic region and along the right paracolic gutter, but the gastrojejunal anastomoses was intact. A 1 cm perforation with surrounding inflammatory exudate was identified on the anterior surface of the Roux limb distal to the gastrojejunostomy. The edges were debrided and intracorporeal 1-layer repair of the ulcer was performed with simple interrupted 2-0 Vicryl sutures. Fibrin glue was applied to the suture line and covered with an omental onlay patch. The anastomosis was tested with air insufflation and methylene blue dye with no evidence of a leak. A Jackson-Pratt drain was placed in the left upper quadrant. RESULTS: Both patients underwent an unremarkable hospital course, and follow-up EGD examination after 3 months revealed no evidence of ulceration. CONCLUSION: Laparoscopic exploration and the repair of the gastrointestinal perforations in patients with a recent history of laparoscopic RYGBP is safe, if patients are hemodynamically stable and present within the first 24 hours of the onset of symptoms.

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