After his first weight-loss surgery three years ago, Paul Martin considered getting a tattoo designed around the four small surgical scars on his side—say, a golf green.

After a second weight-loss surgery in December, Martin didn’t have any new scars to add to the design. “I woke up with just a slight sore throat,” he says about the procedure, which took about two hours. “There wasn’t any pain because there weren’t any incisions.”

Martin, 53 years old, is among the first patients at Stanford Hospital & Clinics to be treated using what is called natural orifice surgery. In his case, the entire surgery was performed through his throat.

“We went down his throat with a device that looks like a regular endoscope, with a ‘duckbill’ on the end,” the surgeon, John Morton, MD, said. “In the duckbill is a tiny instrument like a sewing machine, with a needle that has plastic sutures.”

Morton, who is also associate professor of surgery, stitched pleats in the stoma, the opening between the patient’s intestine and the small pouch that had been created in the earlier surgery. He then tightened the pleats around the endoscope, reducing the stoma from 20 millimeters to 14, helping to control the amount of food Martin could digest.

Morton described the procedure he performed as part of a continuum of evolving practices. “They’re innovations in what I call ‘minimal access’ surgery,” he said. “We’re moving away from small, multiple incisions, to just one scar or, in some cases, no scar. It’s something we can offer that hopefully will decrease pain and allow for quicker recovery.”

As Morton and other surgeons at Stanford continue to refine no-scar and single-incision procedures, he predicted that more flexible instruments, which will help surgeons work in smaller areas and around corners, will be developed. “That’s a prime direction for the hospital’s Surgical Innovations Program, that we look for new tools and new technologies to help us perform these procedures,” he said.

Other bodily openings that surgeons nationwide have used for natural orifice surgery include the mouth, vagina, rectum and penis. Instead of taking out gall bladders through painful incisions in the abdominal wall, for example, surgeons have removed the organs through these so-called natural orifices, reducing patients’ pain and recovery times.

For another patient who wanted weight-loss surgery, Morton, a specialist in bariatric surgery, chose a different approach. David Pierson, a 32-year-old construction supervisor who had struggled with obesity since he was 12, was a good candidate for lap-band gastric bypass surgery. The twist? The entire procedure was performed through one small incision in the patient’s belly button—the first such surgery in Northern California.

Morton inserted the laparoscopic instruments and camera required for the lap-band procedure through Pierson’s belly button, which he calls an ideal entry point. “The instruments went in one direction—up. The only challenging part was tying knots on the inside. But it was pretty smooth, and looks great,” he said. “We know that one incision is less painful than four or five, and the lower the incision, the less the pain.” By going through the belly button, he avoided making a larger incision closer to the rib cage, which would have caused pain because of the muscles pulling on it.

Pierson said he woke up from the two-hour surgery feeling like his stomach “had been worked on—like I’d been trying to do crunches.” He spent one night in the hospital and returned to work the following week. “I couldn’t see the incision for two days,” because of a bandage, Pierson recalled. “But when it came off, it just looked like little stitches.”

In the operation on Martin—a stomach plication procedure called Stomaphyx—no trace was visible after Morton inserted the instruments down the patient’s throat. Indeed, Martin called it a “tune up” to correct a slight weight gain he experienced after his 2006 gastric bypass surgery. Before that first operation, Martin said, he “huffed and puffed” and had to use an electric cart to get around the construction sites he manages. Now he walks those sites and climbs stairs. Since December, he has lost 17 pounds.

After the operation three years ago, Martin had initially lost more than 150 pounds, before regaining some weight. Such weight regain is rare, noted Morton. Of the 1,200 procedures he has performed, he said, only 20 patients have regained more than five percent of the weight they lost. “But obesity is a chronic disease, and there can be relapses,” he added. “So you find options for patients.”

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The middle school years can be tough. It’s a time of change and sometimes a little awkwardness. So imagine going through those years with a condition that causes your hands or arm pits to sweat so badly that you avoid social situations. It’s called hyperhidrosis, and doctors at Mayo Clinic say a minimally invasive outpatient surgery can stop the sweating.

Every year, thousands of babies are born with spina bifida. It’s a birth defect where the spinal column does not close properly, exposing nerves to the environment. Most babies born with spina bifida in the United States have surgery soon after birth. But some children in other countries aren’t so lucky. A little boy from Algeria suffered terribly for more than two years until his community helped raise money to send him to Mayo Clinic.

Scientists from the University of Alcalá (UAH) have designed a prosthesis made of silicon and polypropylene shaped like an “upside down T” that substantially reduces cases of incisional hernias.

Primary hernias are produced by structural defects in tissues, while the incisional hernias arise from a previous aperture in the abdominal wall, usually the scar of a previous surgery. Irrespective of the techniques used, different types of sutures or medical devices used to hold the abdominal wall, the number of incisional hernias has been constant over the last decade.

One of the most susceptible areas for their appearance is the linea alba, especially when oblique-transverse fibres are sectioned, which is what occurs in the longitudinal laparotomy procedures. The likelihood of a patient developing incisional hernias increases with associated risks, such as advanced age, neoplasia related surgery, obesity and related chronic pathologies.

Presented with these circumstances, a research group from the University of Alcalá managed by Professor Juan Manuel Bellón from the department of surgery of the UAH has developed and patented a new device to prevent the occurrence of incisional hernias. This prevention is carried out by the incorporation of prosthesis into the suture of the abdominal wall which is designed to increase the cohesive forces of the scar. The new design and concept of the prosthesis, named Laparomesh has the shape of a upside down T and is made with silicone and polypropylene, which are biomaterials that will not be absorbed by the body.

The goal of the Laparomesh is to create a reinforcement much like a tendon in the linea alba that would efficiently consolidate the suture of the laparotomy and significantly reduce the cases of incisional hernias. Different to the other prostheses of its type, the design by Professor Bellon and his team is placed neither above nor below, but it encloses both apertures of the abdominal wall, attaching itself to the different anatomical planes by means of a polypropylene suture.

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Professor Bellón, stated that the current average number of cases of incisional hernias is around 15% to 20%, and it is estimated to reduce these numbers to 3%-4% using this newly patented mesh.

Although fewer of them undergo surgery, lung cancer patients in their 80s fare equally well following surgery as their younger counterparts, researchers report. The findings offer doctors potentially valuable guidance in treatment options for elderly patients, according to researchers.

A research team from the Hoag Cancer Center in Newport Beach, California, observed 1,293 patients with lung cancer, 482 of whom underwent surgical treatment. The oldest patients were more likely to be male. Older patients were also more likely to have localized disease.

Overall, the rate of surgery did not differ by age group. However, when primary lung cancer was considered separately, only 31.7 percent of patients older than 80 underwent surgery for their primary lung cancer compared with 38.5 percent of patients younger than 80. For patients with non-small cell lung cancer, the rate of surgery was 64 percent for those older than 80 and 83 percent for those younger than 80. For patients with regionally advanced disease, the rate of surgery for patients age 80 or older was 35 percent compared with 49 percent for those younger than 80 years old.

The five-year survival rate following surgery was 62 percent for those patients older than 80 compared with 53 percent for those aged 70 to 79 years. Among patients age 60 to 69 years and 50 to 59 years, the survival rate was 63 percent. For the youngest patients, those younger than 50, the survival rate was 79 percent.

“Although a smaller proportion of patients over the age of 80 underwent this type of surgery, their survival rate was comparable to the younger age groups,” said lead author Robert O. Dillman, M.D., medical director of the Hoag Cancer Center in Newport Beach, California.

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The removal through endoscopy of tumours that affect only the superficial layers of the oesophagus can avoid complete extirpation of this part of the digestive tract. The technique, carried out at the University Hospital of Navarra for the last three years, was presented at the VI International Course on Therapeutic Endoscopy in the Digestive System, organized by the Digestive System Service at this hospital. Specifically, more than 90% of patients treated for this ailment at the University Hospital of Navarra have not needed the extirpation of the oesophagus.
400 specialists from ten different countries attended the course, focusing on the therapeutic possibilities of endoscopy in the digestive system. Treatment using digestive endoscopy, without having to carry out surgery, is increasing. These applications are less aggressive than surgical operations and are undertaken at out-patient clinics in about 99% of the cases, which usually enables the patient to go home after the walk-in/walk-out treatment, explained Doctor Miguel Ángel Muñoz Navas, Director of the Digestive System Service at the University Hospital of Navarra.

As is known, endoscopy is a technique carried out using a tube-like instrument which contains a light and a lens at its tip. The tube has, moreover, a duct for carrying other instruments with which, amongst other operations. biopsies, extirpation of polyps, injection of contrasting fluids, insertion of prostheses and clips, coagulation of bleedings, extraction of stones from the biliary or pancreatic zone and the draining of abscesses may be undertaken. There are also exists an ecoendoscope, which is one incorporating an ecograph at its end. While in a normal ecography the transducer of the ecograph is outside the body, ecoendoscopy provides better quality images of a lesion that is close to the digestive tract. From the digestive tract we can observe lesions in its vicinity and access them.

Extirpation of oesophageal tumours

As regards the technique for the extirpation of distal tumours of the oesophagus undertaken at the University Hospital of Navarra, Doctor Muñoz explained that this was effective when the carcinoma occurs at surface layers. “The oesophagus is made up of three layers: mucous, sub-mucous and muscular. When the tumour is located in the mucous, we can take it out completely in most cases and thus avoid extirpation of the oesophagus. Until recently patients with this ailment – although affecting only the primary layers – were recommended the total extirpation of the oesophagus, which involved surgery with a high morbidity risk and even death”.

In any case, according to the Director of the Digestive System Service at the University Hospital of Navarra, Doctor Miguel Ángel Muñoz Navas, sometimes a surgical operation is inevitable. “There are times when you have to operate but there are others when a solution with endoscopy can be tried. But, in this case, monitoring of the patient has to be undertaken. It could be the case that we extirpate a tumour with endoscopy and the anatomopathology shows up the fact that the cancer is more infiltrated than had been thought from the biopsies or the ecoendoscopy. In these cases a surgical operation is required. Our experience has shown that more than 90% of patients that we have treated with this technique have not needed subsequent surgery”.

Extirpation of oesophageal tumours using endoscopy is not a very widespread treatment, in part due to its complexity. Nevertheless, it is a real possibility – and scientifically recognised – avoiding the extirpation of the oesophagus. Moreover, the technique can be applied in a walk-in/walk- out manner.

Surgery through natural orifices

Amongst other advances within the sphere of therapeutic digestive endoscopy, on the course organised by the Digestive System Service at the University Hospital of Navarra, surgical operations have been carried out using natural orifices, known as NOTES (natural orifice transluminal endoscopic surgery). Access can be through the buccal cavity, the anus, the vagina and the urinary bladder, the most commonly used routes being oral and vaginal. With the same endoscopy we usually use we can get to the stomach, perforate it and enter the abdominal cavity in order to, for example, extirpate a vesicle or deal with other lesions. Currently in this type of surgery, endoscopy and laparoscopy are being combined.

Endoscopic treatment has also been used in obesity cases. For patients with morbid obesity who do not respond to dietetic treatment, it is common to have recourse to bariatric surgery. This can be aggressive and, from time to time, news stories appear about patients who have died as a consequence of such operations. Such mortality is due, in part, to the fact that these patients are in a bad state of health generally and may have other diseases associated with obesity. They are beginning to work with the possibility of reducing the size of the stomach via endoscopy and of short-circuiting the intestinal loops.

Another novel application presented at the course involves therapeutic endoscopy in the biliary and pancreatic ducts. Despite the small diameter of these ducts, a new technology enables them to be accessed in order to examine them directly and to apply therapeutic techniques.

The Digestive System Service at the University Hospital of Navarra has presented a technique for draining the vesicle directly into the stomach by means of ecoendoscopy; as the Director of the Service explains: when the vesicle is very inflamed it is not possible to carry out surgery and it is less aggressive to access the organ by perforating the stomach and draining the contents of the vesicle into the stomach.

In the session devoted to the diagnostic application of endoscopy, the possibilities of carrying out direct microscopy were considered. Although it does not substitute biopsy, this technique is a complement in deciding where to take samples or in being more certain that a lesion found during examination is a malignant tumour or not.

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Heart surgeons at Washington University School of Medicine in St. Louis report that by adding a simple 10-20 second step to an operative procedure they achieved a significant improvement in the outcome for the surgical treatment of atrial fibrillation (AF).
Reporting in the April issue of the Journal of Thoracic and Cardiovascular Surgery, the surgeons describe an enhancement to the Cox-Maze procedure, a surgical procedure that redirects wayward electrical impulses causing AF by creating precisely placed scars, or ablations, in the heart muscle. The Cox-Maze procedure is highly effective, offering the best long-term cure rate for persistent atrial fibrillation.

The surgeons added one ablation to the series of ablations typically made during the Cox-Maze procedure and that short step improved how well patients did after surgery. As a result, they recommend using this extra ablation in all patients undergoing the procedure.

“The single additional ablation creates what we call a box lesion,” explains Ralph J. Damiano Jr., M.D., the John Shoenberg Professor of Surgery at the School of Medicine. “The box lesion surrounds and electrically isolates the pulmonary veins and the posterior left atrial wall from the rest of the left atrium. Our study shows excellent success when using the box lesion, and we recommend it for any patient with long-standing atrial fibrillation.”

AF is the most common irregular heart rhythm and affects more than 2 million people in the United States. During atrial fibrillation, the upper chambers (atria) of the heart beat rapidly and quiver instead of contracting, drastically reducing the amount of blood they pump. AF can cause fatigue, shortness of breath, exercise intolerance, heart palpitations and stroke.

The area of the heart near the pulmonary veins is a common source of the irregular electrical impulses that can cause AF. Without the box lesion, in some patients this area could still support electrical signals that disrupt the regular contractions of the heart’s upper chambers.

Led by Damiano, also chief of cardiac surgery at the School of Medicine and a cardiac surgeon at Barnes-Jewish Hospital, the Washington University surgeons revolutionized AF treatment in 2002 by helping develop a radiofrequency clamp that creates the ablation lines needed to reroute electrical impulses in the heart. The clamp directs radiofrequency energy into the heart muscle and creates a full-thickness scar.

The radiofrequency clamp procedure is quicker and easier than the original “cut and sew” Cox-Maze procedure, which was developed by James Cox, M.D., at Washington University in 1987. The original procedure relied on a complex series of 10 incisions in the heart muscle, creating a “maze” to channel errant electrical impulses where they should go. In the newer version, called Cox-Maze IV, most of these incisions were replaced by radiofrequency ablations, reducing the operation from an average of 90 minutes to about 30 minutes.

The current study involved two groups of patients with AF. One group underwent radiofrequency ablation-assisted Cox-Maze IV procedures without a box lesion and the other with a box lesion. The box lesion group had a 48 percent lower occurrence of atrial flutter and fibrillation in the first weeks after surgery. These patients also had shorter hospital stays (nine days on average) than patients who had the standard Cox-Maze IV procedure (average stay of 11 days).

Three months after surgery, 95 percent of patients who had the box lesion had no signs of AF, while only 85 percent of the patients who had the standard Cox-Maze IV procedure were free from AF. By six and 12 months postsurgery, all of the patients in the box lesion group were free from AF compared to 90 percent of the other group, although that difference was not statistically significant.

“We also saw that the use of antiarrhythmic drugs was lower after three and six months in those who received a box lesion,” Damiano says. “These drugs can have serious side effects, and if patients can stop using them they often feel better. Overall, the use of the box lesion set was associated with shorter hospitalization, fewer medications and reduced recurrence of atrial fibrillation. We were very pleased with these results.”

Compared to those without atrial fibrillation, people with the disorder are five times more likely to suffer from stroke and have up to a two-fold higher risk of death. For some patients, medications can control the abnormal heart rhythms and the risk of clotting associated with atrial fibrillation, but unlike the Cox-Maze procedure, the drugs usually do not cure the disorder.

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A review of research examining the effectiveness of different obesity treatments has concluded that no matter what other forms of therapy are offered, changes in lifestyle are imperative if patients want to maximise and maintain their weight loss. This review, presented at the annual Society for Endocrinology BES meeting in Harrogate, shows that lifestyle interventions provide benefits at all stages of obesity management and should be encouraged no matter what other forms of therapy are offered.

He found that when weight loss drugs are given on their own, with no other changes in lifestyle, they produce an average weight loss of 5 kg, the same amount of weight you lose if you go on a calorie-controlled diet and take regular exercise. However, if weight loss drugs are offered in combination with behavioural therapies, their effectiveness can be increased by over 100% (from 5 kg to 12 kg average weight loss). He found that the story was the same with bariatric surgery. Patients who exercise and lose weight prior to surgery are less likely to have postoperative complications and lose more weight at a quicker rate after surgery than those who didn’t.

Overall, this review indicates, that when treating obese patients, weight loss drugs and bariatric surgery are significantly more successful if they are offered in conjunction with improvements to diet and exercise.

Full results of the review are:

- Exercise alone produces an average weight loss of 1.8 kg. The more you exercise the more weight you lose.

- Diet alone produces an average weight loss of 5.0 kg. This effect peaks 6-12 months following the start of the diet and wanes after this point. No diet is better than any other in the long term but the greater the reduction in calories, the greater the initial weight loss.

- Behavioural therapies (e.g. cognitive therapy, psychotherapy, relaxation therapy, hypnotherapy) produce an average weight loss of 2.3 kg.

- Exercise plus diet result in an average weight loss of 10.7 kg and helps to maintain weight loss for a longer period.

- Exercise plus diet plus behavioural therapies result in the greatest average weight loss of 12-15 kg.

- Taking weight loss drugs with no changes in lifestyle result in an average weight loss of 5kg. Taking weight loss drugs, in combination with behavioural therapies, leads to an average weight loss of 12 kg.

- Patients that lose more than 10% of their body weight prior to bariatric surgery are 2.12 times more likely to achieve a 70% loss of excess body weight.

Researcher Dr Rob Andrews said:

“People often forget is that there is no quick fix to obesity. Overeating and decreased activity are the fundamental problems underlying the development of obesity. Any therapy aimed at helping obese patients must have a dietary and exercise component in order to be successful. This review shows that patients who are taking weight loss drugs or have bariatric surgery lose significantly more weight if they combine these treatments with regular exercise and a calorie-controlled diet. Maintaining a healthy, balanced lifestyle is the key to maximising and maintaining weight loss.”

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