Letters to the Editors Laparoscopic robot-assisted distal splenorenal shunt
To the Editors: Surgical shunts are highly effective in the prevention of recurrence of bleeding from esophagogastric varices, but are associated with significant morbidity.1 Should the morbidity associated with surgical shunts be reduced, their role in the treatment of selected patients with portal hypertension and bleeding varices could be revisited. Robotic assistance improves surgical dexterity and permits laparoscopic operations that were previously considered impossible or exceedingly difficult.2,3 Two patients suffering from noncirrhotic portal fibrosis developed severe portal hypertension and bled from esophagogastric varices. Liver tests were practically normal in both patients, anticipating long-term preservation of good liver function. After multidisciplinary evaluation both patients were selected for laparoscopic robot-assisted distal splenorenal shunt (DSRS). Patients were placed supine with the legs parted. The table was placed 20° in the reverse Trendelenburg position and tilted to the right side. The tower of the da Vinci Surgical System SiHD (Intuitive Surgical, Inc, Sunnyvale, CA) was docked over the head of the patient, with 2 operating arms on the patient’s right side. A total of 5 ports were placed. The robotic surgeon operated from the da Vinci console, and the laparoscopic surgeon stood between the patient’s legs. The left renal vein was exposed first, and widely mobilized. The splenic vein was also exposed, but extensive mobilization was avoided because of the presence of severe portal hypertension. Splenorenal anastomosis was created end-to-side in both patients, according to the standard technique. With the DSRS open, all the veins connecting portal and esophagogastrosplenic compartments were ligated, eventually making the shunt selective. Surgery lasted 410 minutes in patient 1 and 385 minutes in patient 2. The intraoperative and postoperative courses were uneventful in both patients. Estimated blood loss was negligible in patient 1 and 150 mL in patient 2. No transfusion of blood or fresh frozen plasma was required. The amount of ascites was negligible in both patients, and drains were removed 48 hours after the operation. Both patients were discharged on postoperative day 5. At the longest follow-up of 20 and 14 months, patients are alive and well. Both DSRS are patent, esophagogastric varices are decompressed, and liver function is unchanged with respect to preoperative values. Noncirrhotic portal fibrosis is a disease of uncertain etiology characterized by periportal fibrosis causing portal hypertension at a presinusoidal level. Hepatic function is usually preserved long term, even though the liver slowly atrophies. Bleeding from esophagogastric varices is frequent and, although mortality is less than in
patients with cirrhosis, repeat hemorrhage may promote hepatic insufficiency. Therefore, prevention of recurrent bleeding is a priority.4 DSRS is a valid treatment option in patients diagnosed with noncirrhotic portal fibrosis because of its ability to selectively decompress the gastoesophageal compartment while maintaining hepatopetal flow.1 Disincentives to DSRS include the operative risk associated with major surgery and concerns on patient suitability for subsequent liver transplantation. We have shown the feasibility of laparoscopic robotassisted DSRS in patients with noncirrhotic portal fibrosis. Should this procedure be validated in larger series, it could expand the therapeutic armamentarium of hepatologists and liver surgeons. Ugo Boggi, MD, FEBS Mario Antonio Belluomini, MD Linda Barbarello, MD Fabio Caniglia, MD Division of General and Transplant Surgery University of Pisa, Pisa, Italy Maurizia Brunetto, MD Division of Hepatology University of Pisa, Pisa, Italy Gabriella Amorese, MD Division of Anesthesia and Intensive Care University of Pisa, Pisa, Italy E-mail: [email protected]
References 1. Boggi U, Signori S, Vistoli F, D’Imporzano S, Amorese G, Consani G, et al. Laparoscopic robot-assisted pancreas transplantation: first world experience. Transplantation 2012;93:201-6. 2. Boggi U, Signori S, De Lio N, Perrone VG, Vistoli F, Belluomini M, et al. Feasibility of robotic pancreaticoduodenectomy. Br J Surg 2013;100:917-25. 3. Sarin SK, Kumar A, Chawla YK, Baijal SS, Dhiman RK, Jafri W, et al. Noncirrhotic portal fibrosis/idiopathic portal hypertension: APASL recommendations for diagnosis and treatment. Hepatol Int 2007;1:398-413. 4. Livingstone AS, Koniaris LG, Perez EA, Alvarez N, Levi JU, Hutson DG. 507 Warren-Zeppa distal splenorenal shunts: a 34-year experience. Ann Surg 2006;243:884-92. http://dx.doi.org/10.1016/j.surg.2014.07.012
Biofeedback and electrostimulation: Last chance or first choice for obstructed defecation?
To the Editors: We read with interest the article published by Hicks et al1 on the efficacy of biofeedback (BFB) treatment in more than 90 patients with symptoms of rectocele and
SURGERY 405
406 Letters to the Editors
obstructed defecation (ODS; 70% of patients experienced improvement in their symptoms after BFB). The authors underlined the efficacy of BFB therapy in patients with rectocele, expecially in those with rectocele plus internal rectal prolapse. According to several authors, operative repair of rectocele does not always alleviate symptoms related to difficulty in defecation, and some patients have impaired fecal continence after operative treatment.2 The mechanism of action of BFB therapy is also not known. Although various parameters of colonic and anorectal function improve,3-6 and one study showed improvement in distal colonic blood flow, the precise alterations are unclear. Recent studies using bidirectional cortical evoked potentials and transcranial magnetic stimulation suggest significant bidirectional brain-gut dysfunction in patients with dyssynergic defecation. Electrical stimulation has been shown to alleviate spasm conditions such as spasticity complicating spinal cord injuries and detrusor hyperactivity.7,8 Recently, Halstead et al7 found that rectal probe electrostimulation administered to improve fertility in men with spinal cord injury also relieved their spasticity for many hours. Nissenkorn et al8 found that electrostimulation of the pelvic floor muscles delivered by a para-urethral electrode decreased greatly stress incontinence and reduced the frequency, urgency, and urge incontinence in patients with overactive bladder. Jung et al9 evaluated the efficacy of electrostimulation to treat pelvic floor dyssinergia in 147 patients refractory to biofeedback. The overall response to electrostimulation was 59.2%. In the electrostimulation-responsive group, overall satisfaction improved substantially (from 7.3 ± 3.0 to 4.3 ± 2.5, P < .05). Recently we successfully treated 40 patients with pelvic floor dyssynergia with BFB plus transanal elettrostimulation. Eighteen (46%) of had previous operation for ODS (rectal prolapse and/or rectocele): 16 with laparoscopic ventral mesh rectopexies and 2 with STARR (ie, stapled transanal rectal resection). The Wexner score decreased from 16.7 ± 4 to 10 ± 3.5 (P < .01) and ODS decreased from 18.3 ± 5.5 to 5.7 ± 1.8 (P < .0001). Although BFB should be the first-line treatment of ODS, our experience suggests that surgery of the ODS could achieve better outcomes with the use of BFB therapy combined with transanal electrostimulation. Federica Cadeddu, MDa Franco Salis, MDb Carolina Ilaria Ciangola, MDc Giovanni Milito, MDc From the Departments of Surgerya and Surgery, Plastic and Reconstructive Surgeryb San Francesco Hospital, Nuoro; and Department of Surgeryc University Hospital Tor Vergata Rome, Italy
Surgery February 2015
References 1. Hicks CW, Weinstein M, Wakamatsu M, Savitt L, Pulliam S, Bordeianou L. In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort. Surgery 2014;155:659-67. 2. Maria G, Brisinda G, Bentivoglio AR, Albanese A, Sganga G, Castagneto M. Anterior rectocele due to obstructed defecation relieved by botulinum toxin. Surgery 2001;129:524-9. 3. Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol 2007;5:331-8. 4. Rao SSC, Valestin J, Brown CK, et al. Long term efficacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial. Am J Gastroenterol 2010;105:890-6. 5. Heymen S, Scarlett Y, Jones K, et al. Randomized, controlled trail shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type constipation. Dis Colon Rectum 2007;50:428-41. 6. Chiarioni G, Whitehead WE, Pezza V, et al. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology 2006;130: 657-64. 7. Halstead LS, Seager SW, Houston JM, Whitesell RPT, Dennis M, Nance PW. Relief of spasticity in SCI men and women using rectal probe electrostimulation. Paraplegia 1993;31:715-21. 8. Nissenkorn I, Shalev M, Radziszewski P, Dobronski P, Borkowski A, De Jong PR. Patient adjusted intermittent electrostimulation in the treatment of stress and urge urinary incontinence. BJU Int 2004;94:105-9. 9. Jung KW, Myung SJ, Byeong J. Combined therapy with electrical stimulation and biofeedback in pelvic floor dyssynergia. Neurogastroenterol Motil 2007;19:74. http://dx.doi.org/10.1016/j.surg.2014.09.019
Morbidity and mortality after total gastrectomy for gastric malignancy: Do not forget about geriatric frailty and nutrition
To the Editors: With great interest we read the paper in Surgery entitled ‘‘Morbidity and mortality after total gastrectomy for gastric malignancy’’ by Bartlett et al.1 Using the data from the American College of Surgeons National Surgical Quality Improvement Program database, the authors studied 1,165 patients undergoing total gastrectomy. The reported morbidity and 30-day mortality rates (36% and 4.7%, respectively) are in line with other reports on outcome after gastric cancer surgery. Using a multivariate model it was shown that age >70 years, weight loss, albumin
To the Editors: Surgical shunts are highly effective in the prevention of recurrence of bleeding from esophagogastric varices, but are associated with significant morbidity.1 Should the morbidity associated with surgical shunts be reduced, their role in the treatment of selected patients with portal hypertension and bleeding varices could be revisited. Robotic assistance improves surgical dexterity and permits laparoscopic operations that were previously considered impossible or exceedingly difficult.2,3 Two patients suffering from noncirrhotic portal fibrosis developed severe portal hypertension and bled from esophagogastric varices. Liver tests were practically normal in both patients, anticipating long-term preservation of good liver function. After multidisciplinary evaluation both patients were selected for laparoscopic robot-assisted distal splenorenal shunt (DSRS). Patients were placed supine with the legs parted. The table was placed 20° in the reverse Trendelenburg position and tilted to the right side. The tower of the da Vinci Surgical System SiHD (Intuitive Surgical, Inc, Sunnyvale, CA) was docked over the head of the patient, with 2 operating arms on the patient’s right side. A total of 5 ports were placed. The robotic surgeon operated from the da Vinci console, and the laparoscopic surgeon stood between the patient’s legs. The left renal vein was exposed first, and widely mobilized. The splenic vein was also exposed, but extensive mobilization was avoided because of the presence of severe portal hypertension. Splenorenal anastomosis was created end-to-side in both patients, according to the standard technique. With the DSRS open, all the veins connecting portal and esophagogastrosplenic compartments were ligated, eventually making the shunt selective. Surgery lasted 410 minutes in patient 1 and 385 minutes in patient 2. The intraoperative and postoperative courses were uneventful in both patients. Estimated blood loss was negligible in patient 1 and 150 mL in patient 2. No transfusion of blood or fresh frozen plasma was required. The amount of ascites was negligible in both patients, and drains were removed 48 hours after the operation. Both patients were discharged on postoperative day 5. At the longest follow-up of 20 and 14 months, patients are alive and well. Both DSRS are patent, esophagogastric varices are decompressed, and liver function is unchanged with respect to preoperative values. Noncirrhotic portal fibrosis is a disease of uncertain etiology characterized by periportal fibrosis causing portal hypertension at a presinusoidal level. Hepatic function is usually preserved long term, even though the liver slowly atrophies. Bleeding from esophagogastric varices is frequent and, although mortality is less than in
patients with cirrhosis, repeat hemorrhage may promote hepatic insufficiency. Therefore, prevention of recurrent bleeding is a priority.4 DSRS is a valid treatment option in patients diagnosed with noncirrhotic portal fibrosis because of its ability to selectively decompress the gastoesophageal compartment while maintaining hepatopetal flow.1 Disincentives to DSRS include the operative risk associated with major surgery and concerns on patient suitability for subsequent liver transplantation. We have shown the feasibility of laparoscopic robotassisted DSRS in patients with noncirrhotic portal fibrosis. Should this procedure be validated in larger series, it could expand the therapeutic armamentarium of hepatologists and liver surgeons. Ugo Boggi, MD, FEBS Mario Antonio Belluomini, MD Linda Barbarello, MD Fabio Caniglia, MD Division of General and Transplant Surgery University of Pisa, Pisa, Italy Maurizia Brunetto, MD Division of Hepatology University of Pisa, Pisa, Italy Gabriella Amorese, MD Division of Anesthesia and Intensive Care University of Pisa, Pisa, Italy E-mail: [email protected]
References 1. Boggi U, Signori S, Vistoli F, D’Imporzano S, Amorese G, Consani G, et al. Laparoscopic robot-assisted pancreas transplantation: first world experience. Transplantation 2012;93:201-6. 2. Boggi U, Signori S, De Lio N, Perrone VG, Vistoli F, Belluomini M, et al. Feasibility of robotic pancreaticoduodenectomy. Br J Surg 2013;100:917-25. 3. Sarin SK, Kumar A, Chawla YK, Baijal SS, Dhiman RK, Jafri W, et al. Noncirrhotic portal fibrosis/idiopathic portal hypertension: APASL recommendations for diagnosis and treatment. Hepatol Int 2007;1:398-413. 4. Livingstone AS, Koniaris LG, Perez EA, Alvarez N, Levi JU, Hutson DG. 507 Warren-Zeppa distal splenorenal shunts: a 34-year experience. Ann Surg 2006;243:884-92. http://dx.doi.org/10.1016/j.surg.2014.07.012
Biofeedback and electrostimulation: Last chance or first choice for obstructed defecation?
To the Editors: We read with interest the article published by Hicks et al1 on the efficacy of biofeedback (BFB) treatment in more than 90 patients with symptoms of rectocele and
SURGERY 405
406 Letters to the Editors
obstructed defecation (ODS; 70% of patients experienced improvement in their symptoms after BFB). The authors underlined the efficacy of BFB therapy in patients with rectocele, expecially in those with rectocele plus internal rectal prolapse. According to several authors, operative repair of rectocele does not always alleviate symptoms related to difficulty in defecation, and some patients have impaired fecal continence after operative treatment.2 The mechanism of action of BFB therapy is also not known. Although various parameters of colonic and anorectal function improve,3-6 and one study showed improvement in distal colonic blood flow, the precise alterations are unclear. Recent studies using bidirectional cortical evoked potentials and transcranial magnetic stimulation suggest significant bidirectional brain-gut dysfunction in patients with dyssynergic defecation. Electrical stimulation has been shown to alleviate spasm conditions such as spasticity complicating spinal cord injuries and detrusor hyperactivity.7,8 Recently, Halstead et al7 found that rectal probe electrostimulation administered to improve fertility in men with spinal cord injury also relieved their spasticity for many hours. Nissenkorn et al8 found that electrostimulation of the pelvic floor muscles delivered by a para-urethral electrode decreased greatly stress incontinence and reduced the frequency, urgency, and urge incontinence in patients with overactive bladder. Jung et al9 evaluated the efficacy of electrostimulation to treat pelvic floor dyssinergia in 147 patients refractory to biofeedback. The overall response to electrostimulation was 59.2%. In the electrostimulation-responsive group, overall satisfaction improved substantially (from 7.3 ± 3.0 to 4.3 ± 2.5, P < .05). Recently we successfully treated 40 patients with pelvic floor dyssynergia with BFB plus transanal elettrostimulation. Eighteen (46%) of had previous operation for ODS (rectal prolapse and/or rectocele): 16 with laparoscopic ventral mesh rectopexies and 2 with STARR (ie, stapled transanal rectal resection). The Wexner score decreased from 16.7 ± 4 to 10 ± 3.5 (P < .01) and ODS decreased from 18.3 ± 5.5 to 5.7 ± 1.8 (P < .0001). Although BFB should be the first-line treatment of ODS, our experience suggests that surgery of the ODS could achieve better outcomes with the use of BFB therapy combined with transanal electrostimulation. Federica Cadeddu, MDa Franco Salis, MDb Carolina Ilaria Ciangola, MDc Giovanni Milito, MDc From the Departments of Surgerya and Surgery, Plastic and Reconstructive Surgeryb San Francesco Hospital, Nuoro; and Department of Surgeryc University Hospital Tor Vergata Rome, Italy
Surgery February 2015
References 1. Hicks CW, Weinstein M, Wakamatsu M, Savitt L, Pulliam S, Bordeianou L. In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort. Surgery 2014;155:659-67. 2. Maria G, Brisinda G, Bentivoglio AR, Albanese A, Sganga G, Castagneto M. Anterior rectocele due to obstructed defecation relieved by botulinum toxin. Surgery 2001;129:524-9. 3. Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol 2007;5:331-8. 4. Rao SSC, Valestin J, Brown CK, et al. Long term efficacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial. Am J Gastroenterol 2010;105:890-6. 5. Heymen S, Scarlett Y, Jones K, et al. Randomized, controlled trail shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type constipation. Dis Colon Rectum 2007;50:428-41. 6. Chiarioni G, Whitehead WE, Pezza V, et al. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology 2006;130: 657-64. 7. Halstead LS, Seager SW, Houston JM, Whitesell RPT, Dennis M, Nance PW. Relief of spasticity in SCI men and women using rectal probe electrostimulation. Paraplegia 1993;31:715-21. 8. Nissenkorn I, Shalev M, Radziszewski P, Dobronski P, Borkowski A, De Jong PR. Patient adjusted intermittent electrostimulation in the treatment of stress and urge urinary incontinence. BJU Int 2004;94:105-9. 9. Jung KW, Myung SJ, Byeong J. Combined therapy with electrical stimulation and biofeedback in pelvic floor dyssynergia. Neurogastroenterol Motil 2007;19:74. http://dx.doi.org/10.1016/j.surg.2014.09.019
Morbidity and mortality after total gastrectomy for gastric malignancy: Do not forget about geriatric frailty and nutrition
To the Editors: With great interest we read the paper in Surgery entitled ‘‘Morbidity and mortality after total gastrectomy for gastric malignancy’’ by Bartlett et al.1 Using the data from the American College of Surgeons National Surgical Quality Improvement Program database, the authors studied 1,165 patients undergoing total gastrectomy. The reported morbidity and 30-day mortality rates (36% and 4.7%, respectively) are in line with other reports on outcome after gastric cancer surgery. Using a multivariate model it was shown that age >70 years, weight loss, albumin
