Patients with complicated gastroesophageal re flux problems are sometimes considered to be marginal surgical candidates, but with recent advances in laparoscopic techniques, that thinking should change, according to general surgeon Ted Trus, M.D., FRCS, a specialist in laparoscopic surgery at MUSC’s Digestive Disease Center.

“Many physicians think patients with problems like short esophagus, Barrett esophagus, esophageal strictures or poor esophageal motility should stay away from surgery,” Trus said.

“But with minimally invasive surgery, we’ve found that outcomes are very good. Laparoscopic procedures can give excellent results without all the pain and recovery time associated with their open-procedure counterparts.”

Trus said they’ve been doing anti-reflux surgery laparoscopically for some time. “Unlike with open procedures, the patient is usually home within a couple of days,” he said. “Patient satisfaction is very high and it stays that way over time -- about 95 percent in three-year follow-up studies.”

Before coming to MUSC, Trus trained with Emory University’s John Hunter, M.D., a pioneer in the development of laparoscopic surgical techniques and instrumentation. Thanks to that fellowship, Trus offers a minimally invasive surgical option for a wide range of nonmalignant reflux and esophageal motility problems, as well as the more “routine” laparoscopic surgeries such as cholecytectomy, and common bile duct explorations, splenectomy, etc.

He also performs hernia surgery in which the repair is managed with laparoscopic techniques. A mesh is placed using a pre-peritoneal approach, so the abdominal cavity is never entered at all.

Esophageal achalasia

One disease for which minimally invasive surgery is especially effective is esophageal achalasia, a problem characterized by the inability to swallow due to nonrelaxation of the lower esophageal sphincter muscle. Standard therapy involves the use of either botulism toxin to relax the muscle, balloon dilation to expand it, or an open surgical procedure to divide the muscle—a procedure involving a surgical approach that includes a large abdominal or thoracic incision.

“That surgery is now easily performed laparoscopically with very good results, less pain and rapid recovery,” Trus said.

Adrenal tumors

David Adams, M.D., head of the MUSC section of general and gastrointestinal surgery, has performed laparoscopic adrenalectomies with excellent success.

“We get hypertension patients whose disease is secondary to small, benign adrenal tumors,” he said. “This presents the ideal situation for a minimally invasive approach—the target is a small area that is difficult to reach using an open technique. In addition, hypertensive patients may not be good surgical candidates in general. In this type of situation, minimally invasive surgery offers an attractive option.”

In a laparoscopic adrenalectomy, Adams makes only very small incisions, they cuts a few adhesions to let the colon (or liver if the gland is on the right side) gently fall away, exposing the tumor for examination and removal.

Instead of a week’s inpatient stay and a month’s recovery (the normal course following an open adrenalectomy), laparoscopic surgery patients are usually back at work in a few days. “We’ve even had physical laborers who are back on the job in four or five days,” Adams said. “This would be impossible following an open procedure.” MUSC surgical teams are also performing laparoscopic spinal fusions. The general surgeons handle the exposure, then teams from neurosurgery and orthopaedics do the rest. With much less dissection needed, patients experience less pain and recover much faster.

Horizons

The possibilities for laparoscopic approaches seem endless: biliary bypass, gastric jejunostomy, partial adrenalectomy, colon surgeries. In the near future, MUSC teams may also be doing laparoscopic living-donor nephrectomies for transplantation.

The university’s work with laparoscopic development has also led to research opportunities. Trus and surgical resident Gloria Rios, M.D., recently received a grant to compare outcomes for laparoscopic cholecystectomy patients whose procedures involved either standard instruments (5 millimeters) or new, 2 millimeter devices. The grant was awarded by the Association of Women in Surgery.

Laparoscopic Surgeries

Adrenalectomy; Anti-Reflux Surgery; Achalasia Surgery; Cholecystectomy and bile duct exploration; Colon resection; Hernia repair; Jejunostomy; Spinal fusion; Splenectomy

For consultation or referrals, call MUSC Health Connection at 792-1414.

Editor's note: The article is reprinted from MDialogue newsletter, a physician liaison program publication.