Innovations in Minimally Invasive Surgery 2011

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Innovations in Minimally Invasive Surgery 2011

  1. 1. Innovations in Minimally Invasive GI Surgery Florida Gastroenterologic Society Annual Meeting September 25, 2010 Lake Buena Vista, Florida C. Daniel Smith, MD 2Sunday, November 25, 12
  2. 2. Innovations in Minimally Invasive GI Surgery • Natural Orifice Translumenal Endoscopic Surgery (NOTES) • Single Incision Laparoscopic Surgery (SILS) • Minimally Invasive Esophagectomy • Antireflux Surgery Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 3Sunday, November 25, 12
  3. 3. NOTES • Natural • Orifice • Translumenal • Endoscopic • Surgery Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 6Sunday, November 25, 12
  4. 4. NOTES Laparoscopic Surgery NOTES Advanced Interventional Imaging & Endoscopy Guidance Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 7Sunday, November 25, 12
  5. 5. NOTES Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 6Sunday, November 25, 12
  6. 6. NOTES - U.S. Adoption Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 10Sunday, November 25, 12
  7. 7. NOTES - U.S. Adoption NOTES Surgery - Elsewhere Dr. Christine Ren, an associate professor of surgery at New York University’s school of medicine, called the vaginal procedure “repulsive” and said: “As a woman I find it very invasive, physically and emotionally. To me it’s quite distasteful. You will really have to prove to me that there is a benefit.” Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 11Sunday, November 25, 12
  8. 8. NOTES - Future ? Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 11Sunday, November 25, 12
  9. 9. New Treatment Success – Key Elements Carotid Lap Lap Chole Lap Nissen Stenting Colectomy Clinical Results - +++ ++ +++ Ease of Use - +/- - - Patient Demand +++++ +++ ++++++ +++ Cost - +/- - + Reimbursement +/- + +/- ++ Other Rx Options - +++++ - + WIDELY ADOPTED YES NO YES NO Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 9Sunday, November 25, 12
  10. 10. New Treatment Success – Key Elements Lap Lap Chole Lap Nissen NOTES Colectomy Clinical Results - +++ +++ Ease of Use - +/- - --- Patient Demand +++++ +++ +++ ++ Cost - +/- +/- --- Reimbursement +/- + ++ Other Rx Options - +++++ +/- +++++ WIDELY ADOPTED YES NO NO NO Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 10Sunday, November 25, 12
  11. 11. NOTES - Future ? Which would you rather have: A lap chole by a skilled surgeon OR A transgastric/vaginal cholecystectomy Innovations in MIS. FGS Annual Meeting. September 24-26, 2010 12Sunday, November 25, 12
  12. 12. Closing Comments MIS vs. NOTES. SAGES Best of NOTES April 10, 2008 13Sunday, November 25, 12
  13. 13. NOTES – Impact? Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 14Sunday, November 25, 12
  14. 14. NOTES – Impact? Natural Orifice Surgery Single Incision Laparoscopic Surgery Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 14Sunday, November 25, 12
  15. 15. Single Incision Laparoscopic Surgery • Less pain • Earlier return to work • Faster recovery • Superior cosmesis Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 14Sunday, November 25, 12
  16. 16. Single Incision Laparoscopic Surgery Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 14Sunday, November 25, 12
  17. 17. Single Incision Laparoscopic Surgery “The Next Lap Chole” Natural Orifice Surgery Over 100,000 hits with Google Search Laparocopic colectomy - 58,000 hits Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 14Sunday, November 25, 12
  18. 18. Single Incision Laparoscopic Surgery Laparoscopic surgery performed through a single incision: a systematic review of the literature. JACS, Jan 2011, In Press 2007-2010 Procedure No. Publications Cholecystectomy 52 219 publications Nephrectomy 34 4,585 operations Appendectomy 28 GYN 19 6 institutions - 57 cits Colectomy 15 1 institution - 26 cits Inguinal Hernia 11 Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 14Sunday, November 25, 12
  19. 19. Single Incision Laparoscopic Surgery Laparoscopic surgery performed through a single incision: a systematic review of the literature. JACS, Jan 2011, In Press 2007-2010 OUTCOMES 219 publications 48% perioperative outcomes only 4,585 operations 12% compared outcomes to another technique 1 PRCT - Lap chole v. Single incision chole 6 institutions - 57 cits Improved pain scores 1 institution - 26 cits Longer OR time Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 14Sunday, November 25, 12
  20. 20. New Treatment Success – Key Elements Lap Lap Chole Lap Nissen SILS Colectomy Clinical Results - +++ +++ - Ease of Use - +/- - - Patient Demand +++++ +++ +++ ++ Cost - +/- +/- - Reimbursement +/- + ++ +/- Other Rx Options - +++++ +/- +++++ WIDELY ADOPTED YES NO NO NO Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 10Sunday, November 25, 12
  21. 21. Single Incision Lap Surgery – Impact? Single Incision Laparoscopic Surgery “The Next Lap Chole” ???? Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 14Sunday, November 25, 12
  22. 22. Single Incision Lap Surgery – Impact? Single Incision Two Field MIE Laparoscopic Surgery Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 14Sunday, November 25, 12
  23. 23. Esophagectomy Outcomes Transthoracic Transhiatal Operative mortality (%) 4 2 Blood loss 1402 847 LOS 19 15 Respiratory complications (%) 57 27 Cardiac complications (%) 26 16 Anastomotic leak (%) 15 14 Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 16Sunday, November 25, 12
  24. 24. Minimally Invasive Esophagectomy (MIE) Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 16Sunday, November 25, 12
  25. 25. Minimally Invasive Esophagectomy (MIE) 2-Field Technique No. patients 8 (3 low risk, 5 high risk) EBL (cc) 63 (25-400) Operative time (min) 292 (194-375) Lymph nodes harvested 23 (13-29) LOS in ICU (days) 1 (1-5) LOS overall (days) 7 (5-16) Use of chest tubes 0 Reoperation 0 Mortality 0 Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 16Sunday, November 25, 12
  26. 26. Two-Field MIE - Impact? Two Field MIE No. patients 8 (3 low risk, 5 high risk) EBL (cc) 63 (25-400) Operative time (min) 292 (194-375) Lymph nodes harvested 23 (13-29) LOS in ICU (days) 1 (1-5) LOS overall (days) 7 (5-16) Use of chest tubes 0 Reoperation 0 Mortality 0 Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 16Sunday, November 25, 12
  27. 27. GERD • Most common GI condition • $ 10 billion healthcare expenditure • Mechanical defect in valve • Surgery effective treatment • Nissen (3600) fundoplication is gold standard Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 4Sunday, November 25, 12
  28. 28. Antireflux Surgery - Failure No. patients 300 1127 1690 Mortality (%) 0.4 0.2 0.1 Conversion (%) 1.3 0.7 0.4 Intraoperative comp (%) 8 4 4 Early postop comp (%) 17 (transient) 30 (transient) 35 (transient) Late postop comp (%) 4 5 5 Reoperation (%) - 3.5 2.8 Symptom free 12 months (%) 93 92 90 Continued medical Rx (%) 3 11 18 Satisfied with results (%) 97 95 94 Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 4Sunday, November 25, 12
  29. 29. Antireflux Surgery - Failure No. patients 166 Follow-up (yrs) 11±1.2 Reoperation 26 (16%) Failure* 43 (26%) * Reoperation, patient dissatisfaction, severe GERD symptoms Surg Endosc (2007) 21:1978–1984 When Fundoplications Fails: Redo? Ann Surg (2005) 241: 861-871 Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 4Sunday, November 25, 12
  30. 30. Antireflux Surgery – New Device Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 5Sunday, November 25, 12
  31. 31. Antireflux Surgery – New Device Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 5Sunday, November 25, 12
  32. 32. Antireflux Surgery – New Device 50.0 Baseline ! Pilot Trial • 44 patients, 4-centers, US andTotal GERD HRQL Score Follow-up 37.5 Europe • Published J of Gastro 2008 25.0 • To be published Annals of Surgery, November 2010 12.5 0 Pre-Implant 3 months 12 month 24 months 100 Normalized (Total pH < 5.3) Percent of Patients 75 ! Over 160 pts. implanted to date under clinical 50 protocol 25 Innovations in MIS. FGS Annual Meeting. 0 Lake Buena Vista. Sept 25, 2010 3 months 12 months 24 monthsSunday, November 25, 12
  33. 33. Antireflux Surgery – New Device ! FDA Pivotal Trial • 100 pt, 15-center, USA and Europe • Jan 09 – Sept 09 (data pending completion of follow-up Sept 10) University of Southern California Ohio State University Policlinico San Donat University of Washington Academic Medical Center, Amsterdam University of Pittsburgh Medical Center Abbott Northwestern Knox Community, Ohio University of California San Diego Washington University University of Rochester Medical Center Phoebe Putney Medical Center Legacy Health, Portland Gunderson Lutheran, Wisconsin Mayo Clinic - Jacksonville Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010Sunday, November 25, 12
  34. 34. Antireflux Surgery – New Device - Impact? 100 Normalized (Total pH < 5.3) Percent of Patients 75 50 25 0 3 months 12 months 24 months Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 5Sunday, November 25, 12
  35. 35. Innovations in Minimally Invasive Surgery C. Daniel Smith, MD smith.c.daniel@mayo.edu 404-323-4615 36Sunday, November 25, 12

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