Innovations in Minimally Invasive Surgery 2011
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Innovations in Minimally Invasive GI Surgery
C. Daniel Smith, MD
Florida Gastroenterologic SocietyAnnual Meeting
September 25, 2010Lake Buena Vista, Florida
Sunday, November 25, 12
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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Innovations in Minimally Invasive GI Surgery
• Natural Orifice Translumenal Endoscopic Surgery (NOTES)
• Single Incision Laparoscopic Surgery (SILS)
• Minimally Invasive Esophagectomy
• Antireflux Surgery
Sunday, November 25, 12
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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NOTES
• Natural
• Orifice
• Translumenal
• Endoscopic
• Surgery
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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Laparoscopic Surgery
Advanced Imaging & Guidance
Interventional Endoscopy
NOTES
NOTES
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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NOTES
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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NOTES - U.S. Adoption
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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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.”
NOTES - U.S. Adoption
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 11
NOTES - Future ?
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 9
New Treatment Success – Key Elements
Clinical Results
Ease of Use
Patient Demand
Cost
Reimbursement
Other Rx Options
WIDELY ADOPTED
Lap Chole
-
-
+++++
-
+/-
-
YES
Lap Nissen
+++
+/-
+++
+/-
+
+++++
NO
Carotid Stenting
++
-
++++++
-
+/-
-
YES
Lap Colectomy
+++
-
+++
+
++
+
NO
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 10
Clinical Results
Ease of Use
Patient Demand
Cost
Reimbursement
Other Rx Options
WIDELY ADOPTED
Lap Chole
-
-
+++++
-
+/-
-
YES
Lap Nissen
+++
+/-
+++
+/-
+
+++++
NO
Lap Colectomy
+++-
+++
+/-
++
+/-
NO
NOTES
- - -
++
- - -
+++++
NO
New Treatment Success – Key Elements
Lap Colectomy
+++-
+++
+/-
++
+/-
NO
Sunday, November 25, 12
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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
NOTES - Future ?
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Closing Comments
MIS vs. NOTES. SAGES Best of NOTES April 10, 2008
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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NOTES – Impact?
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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NOTES – Impact?
Single Incision Laparoscopic Surgery
Natural Orifice Surgery
Sunday, November 25, 12
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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Single Incision Laparoscopic Surgery
• Less pain
• Faster recovery
• Earlier return to work
• Superior cosmesis
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
14
Single Incision Laparoscopic Surgery
Sunday, November 25, 12
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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Single Incision Laparoscopic Surgery
“The Next Lap Chole”
Over 100,000 hits with Google Search
Laparocopic colectomy - 58,000 hits
Natural Orifice Surgery
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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Single Incision Laparoscopic Surgery
Laparoscopic surgery performed through a single incision: a systematic review of the literature. JACS, Jan 2011, In Press
2007-2010
219 publications4,585 operations
Procedure No. Publications
Cholecystectomy 52
Nephrectomy 34
Appendectomy 28
GYN 19
Colectomy 15
Inguinal Hernia 11
6 institutions - 57 cits1 institution - 26 cits
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
14
Single Incision Laparoscopic Surgery
Laparoscopic surgery performed through a single incision: a systematic review of the literature. JACS, Jan 2011, In Press
2007-2010
219 publications4,585 operations
OUTCOMES
48% perioperative outcomes only
12% compared outcomes to another technique
1 PRCT - Lap chole v. Single incision chole
Improved pain scores
Longer OR time
6 institutions - 57 cits1 institution - 26 cits
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010 10
Clinical Results
Ease of Use
Patient Demand
Cost
Reimbursement
Other Rx Options
WIDELY ADOPTED
Lap Chole
-
-
+++++
-
+/-
-
YES
Lap Nissen
+++
+/-
+++
+/-
+
+++++
NO
Lap Colectomy
+++-
+++
+/-
++
+/-
NO
SILS
--
++
-
+/-+++++
NO
New Treatment Success – Key Elements
Lap Colectomy
+++-
+++
+/-
++
+/-
NO
Sunday, November 25, 12
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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Single Incision Lap Surgery – Impact?
Single Incision Laparoscopic Surgery
“The Next Lap Chole”
????
Sunday, November 25, 12
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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Single Incision Lap Surgery – Impact?
Single Incision Laparoscopic Surgery
Two Field MIE
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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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
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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Minimally Invasive Esophagectomy (MIE)
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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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 0Reoperation 0Mortality 0
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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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 0Reoperation 0Mortality 0
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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GERD
• Most common GI condition
• $ 10 billion healthcare expenditure
• Mechanical defect in valve
• Surgery effective treatment
• Nissen (3600) fundoplication is gold standard
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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Antireflux Surgery - Failure
No. patients
Mortality (%)
Conversion (%)
Intraoperative comp (%)
Early postop comp (%)
Late postop comp (%)
Reoperation (%)
Symptom free 12 months (%)
Continued medical Rx (%)
Satisfied with results (%)
300
0.4
1.3
8
17 (transient)
4
-
93
3
97
1127
0.2
0.7
4
30 (transient)
5
3.5
92
11
95
1690
0.1
0.4
4
35 (transient)
5
2.8
90
18
94
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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Antireflux Surgery - Failure
No. patients
Follow-up (yrs)
Reoperation
Failure** Reoperation, patient dissatisfaction,
severe GERD symptoms
166
11±1.2
26 (16%)
43 (26%)
Surg Endosc (2007) 21:1978–1984 When Fundoplications Fails: Redo? Ann Surg (2005) 241: 861-871
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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Antireflux Surgery – New Device
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
5
Antireflux Surgery – New Device
Sunday, November 25, 12
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
0
12.5
25.0
37.5
50.0
Pre-Implant 3 months 12 month 24 months
Tota
l GER
D H
RQ
L S
core
Baseline
Follow-up
Antireflux Surgery – New Device
0
25
50
75
100
3 months 12 months 24 months
Per
cen
t of
Pat
ien
ts Normalized (Total pH < 5.3)
! Pilot Trial • 44 patients, 4-centers, US and Europe
• Published J of Gastro 2008• To be published Annals of Surgery, November 2010
! Over 160 pts. implanted to date under clinical protocol
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
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
Policlinico San Donat
Academic Medical Center, Amsterdam
Abbott Northwestern
University of California San Diego
University of Rochester Medical Center
Legacy Health, Portland
Mayo Clinic - Jacksonville
Ohio State University
University of Washington
University of Pittsburgh Medical Center
Knox Community, Ohio
Washington University
Phoebe Putney Medical Center
Gunderson Lutheran, Wisconsin
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Innovations in MIS. FGS Annual Meeting. Lake Buena Vista. Sept 25, 2010
5
Antireflux Surgery – New Device - Impact?
0
25
50
75
100
3 months 12 months 24 months
Per
cen
t of
Pat
ien
ts
Normalized (Total pH < 5.3)
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Innovations in Minimally Invasive Surgery
C. Daniel Smith, MD
Sunday, November 25, 12