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Laparoscopic Nissen question for Howard
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| Howard,
Please see this site - http://www.lapsurgery.com/nissen.htm
It indicates the article was updated in Jan, 2000. The surgeon indicates
that only a "few surgeons in the United States" perform the laparoscopic
nissen fundoplication, because it requires extensive and highly specialized
training (see second paragraph).
That was approx in the year 2000, when I assume the statement was made,
which indicates it's a relative new procedure and only a handful of people
did it in 2000 in the whole U.S.A.
It is now 2006. Has a lot changed since six years ago, and now it is
considered a relatively common procedure (at least in the bigger cities), or
is it still considered "highly specialized".
Thanks...Pete
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| Howard McCollister 2006-03-22, 1:31 pm |
|
"Pete" <pete@nospam.net> wrote in message
news:121hivr5n507c4@corp.supernews.com...
> Howard,
>
> Please see this site - http://www.lapsurgery.com/nissen.htm
>
> It indicates the article was updated in Jan, 2000. The surgeon indicates
> that only a "few surgeons in the United States" perform the laparoscopic
> nissen fundoplication, because it requires extensive and highly
> specialized training (see second paragraph).
>
> That was approx in the year 2000, when I assume the statement was made,
> which indicates it's a relative new procedure and only a handful of people
> did it in 2000 in the whole U.S.A.
>
> It is now 2006. Has a lot changed since six years ago, and now it is
> considered a relatively common procedure (at least in the bigger cities),
> or is it still considered "highly specialized".
>
> Thanks...Pete
>
Nissen fundoplication was designed in about 1956, so the concept has been
around for a long time. That operation was always held in reserve for the
most severe cases because of gas-bloat, exacerbated by the way Dr. Nissen
advised doing the operation. We've learned a lot since then, and a lot of
that learning came from the resurgence of the Nissen fundoplication in
laparoscopic form over about the last 10 years.
So, here's what happened (and this is not unique in the application of
surgical technique):
Originally, Nissens were hard to do open, and the complication rate (gas
bloat) was high. Prior to 1990, most surgeons, myself included, were only
doing about 2-3 per year because of that. The laparoscopic era starting in
1990 started a whole new level of interest in Nissen fundoplication because
it could be done laparoscopically. At that time, there were no good
specialized tools and ALL surgeons were fumbling around trying to get good
at laparoscopic technique, but some guys like Tom DeMeester really started
looking scientifically into the physiology of the operation and as a result
of his work and a few others, we came to understand more about GERD in a new
years than we had learned in the previous 40 years. The operative technique
became standardized, and some surgeons started jumping on that bandwagon and
learning it, although at the time, it was the hardest laparoscopic operation
there was. I know because my partner and I taught many of those courses for
Ethicon Endo-Surgery. So, some of those surgeons went out and started doing
lap Nissens, but because it is so hard, many of them did it badly because
they just didn't have the laparoscopic skills in those early days of
laparoscopic surgery. Because they did it badly, the recurrence rates are
high - many of those operative failures are the people that we're seeing now
who had a lap Nissen in 1995-2000 and now their GERD is back. As those
recurrences started showing up, gastroenterologists and surgeons became
disenchanted with the lap Nissen and it fell out of popular favor. What that
did was weed out the surgeons who were doing it badly and we now see a core
of laparoscopic surgeons still doing them who are the ones who were always
getting good results because they were doing them right in the first place.
Over the last 5 years, those of us that have always been doing these
operation have learned a lot of new stuff about technique, and results are
better. Unfortunately, the surgeons who were doing the Nissens badly see
this and they start doing Nissens again, but doing them using the same old
concepts that didn't work for them before.
The answer to your question is that it is difficult to do a lap Nissen
properly and it's difficult for patients to find such a surgeon. Many
surgeons claim they can do them, but I can assure you that those that can do
it properly are not nearly as numerous as the number that claim they can. It
is a more common operation than it was, but that doesn't mean that the
surgeons doing them are doing them well. As to "larger cities", the town
where my 3 surgery partners and I practice has a sign that says "Population
2436". We get referrals from all over the upper midwest. We were doing this
operation in 1993, long before Professor Ballantyne. We may very well have
*taught* the guy that taught him.
The best indicator of a surgeon's skill at laparoscopic surgery is for the
patient to as the surgeon if he/she does *revisional* laparoscopic surgery.
Meaning, for example, if they saw a patient who had had a Nissen years ago
and now had GERD again, would that surgeon be confident to do that
operation, or would he/she refer it out? If they respond they'd send the
revisional stuff out rather than do it themselves, then the patient should
find out where they send those recurrences and he should go see *that*
surgeon.
HMc
| |
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| Howard McCollister wrote:
> "Pete" <pete@nospam.net> wrote in message
> news:121hivr5n507c4@corp.supernews.com...
>
> Nissen fundoplication was designed in about 1956, so the concept has
> been around for a long time. That operation was always held in
> reserve for the most severe cases because of gas-bloat, exacerbated
> by the way Dr. Nissen advised doing the operation. We've learned a
> lot since then, and a lot of that learning came from the resurgence
> of the Nissen fundoplication in laparoscopic form over about the
> last 10 years.
> So, here's what happened (and this is not unique in the application of
> surgical technique):
>
> Originally, Nissens were hard to do open, and the complication rate
> (gas bloat) was high. Prior to 1990, most surgeons, myself included,
> were only doing about 2-3 per year because of that. The laparoscopic
> era starting in 1990 started a whole new level of interest in Nissen
> fundoplication because it could be done laparoscopically. At that
> time, there were no good specialized tools and ALL surgeons were
> fumbling around trying to get good at laparoscopic technique, but
> some guys like Tom DeMeester really started looking scientifically
> into the physiology of the operation and as a result of his work and
> a few others, we came to understand more about GERD in a new years
> than we had learned in the previous 40 years. The operative technique
> became standardized, and some surgeons started jumping on that
> bandwagon and learning it, although at the time, it was the hardest
> laparoscopic operation there was. I know because my partner and I
> taught many of those courses for Ethicon Endo-Surgery. So, some of
> those surgeons went out and started doing lap Nissens, but because it
> is so hard, many of them did it badly because they just didn't have
> the laparoscopic skills in those early days of laparoscopic surgery.
> Because they did it badly, the recurrence rates are high - many of
> those operative failures are the people that we're seeing now who had
> a lap Nissen in 1995-2000 and now their GERD is back. As those
> recurrences started showing up, gastroenterologists and surgeons
> became disenchanted with the lap Nissen and it fell out of popular
> favor. What that did was weed out the surgeons who were doing it
> badly and we now see a core of laparoscopic surgeons still doing them
> who are the ones who were always getting good results because they
> were doing them right in the first place.
> Over the last 5 years, those of us that have always been doing these
> operation have learned a lot of new stuff about technique, and
> results are better. Unfortunately, the surgeons who were doing the
> Nissens badly see this and they start doing Nissens again, but doing
> them using the same old concepts that didn't work for them before.
>
> The answer to your question is that it is difficult to do a lap Nissen
> properly and it's difficult for patients to find such a surgeon. Many
> surgeons claim they can do them, but I can assure you that those that
> can do it properly are not nearly as numerous as the number that
> claim they can. It is a more common operation than it was, but that
> doesn't mean that the surgeons doing them are doing them well. As to
> "larger cities", the town where my 3 surgery partners and I practice
> has a sign that says "Population 2436". We get referrals from all
> over the upper midwest. We were doing this operation in 1993, long
> before Professor Ballantyne. We may very well have *taught* the guy
> that taught him.
> The best indicator of a surgeon's skill at laparoscopic surgery is
> for the patient to as the surgeon if he/she does *revisional*
> laparoscopic surgery. Meaning, for example, if they saw a patient who
> had had a Nissen years ago and now had GERD again, would that surgeon
> be confident to do that operation, or would he/she refer it out? If
> they respond they'd send the revisional stuff out rather than do it
> themselves, then the patient should find out where they send those
> recurrences and he should go see *that* surgeon.
>
> HMc
Howard...Thanks for the detailed and fascinating explanation. You are a
gentleman and a scholar :-) . So I guess professor Ballantyne might have
been a little conservative on his estimate of "only a few". I would trust
you to do the lap Nissen, but no one else. I'm sure there are a couple
doc's in Baltimore that might be competent (but like I said it's a XXXXX
even thinking of going back there). Do you know any capable lap Nissen
surgeons at John's Hopkins, or the university of Maryland...Pete
| |
| Howard McCollister 2006-03-22, 1:31 pm |
|
"Pete" <pete@nospam.net> wrote in message
news:121hn8miopaq6eb@corp.supernews.com...
>
> Howard...Thanks for the detailed and fascinating explanation. You are a
> gentleman and a scholar :-) . So I guess professor Ballantyne might have
> been a little conservative on his estimate of "only a few". I would trust
> you to do the lap Nissen, but no one else. I'm sure there are a couple
> doc's in Baltimore that might be competent (but like I said it's a XXXXX
> even thinking of going back there). Do you know any capable lap Nissen
> surgeons at John's Hopkins, or the university of Maryland...Pete
>
I don't offhand, but I'll call around for you. My problem is that time is
tight right now as I'm leaving for Haiti tomorrow early. I'll be there for
about 10 days and communication issues will likely impair my ability to get
this fully investigated within that time period.
HMc
| |
|
| Howard McCollister wrote:
> "Pete" <pete@nospam.net> wrote in message
> news:121hn8miopaq6eb@corp.supernews.com...
>
>
> I don't offhand, but I'll call around for you. My problem is that
> time is tight right now as I'm leaving for Haiti tomorrow early. I'll
> be there for about 10 days and communication issues will likely
> impair my ability to get this fully investigated within that time
> period.
> HMc
Thanks Howard. Take your time, and enjoy Haiti :-) ...Pete
| |
| Howard McCollister 2006-03-22, 1:31 pm |
|
"Pete" <pete@nospam.net> wrote in message
news:121jaf5hf2juvff@corp.supernews.com...
>
> Thanks Howard. Take your time, and enjoy Haiti :-) ...Pete
>
"Enjoy" might not be the right word, exactly, but it's always interesting.
We usually do spend some time at a resort on the north coast after we finish
here, and that is enjoyable.
Starting Monday, my partner and I are teaching a 5 day course in basic
laparoscopy here in Pignon to a group of 14 Haitian surgery residents from
the Univsersity in Port-au-Prince. I just got done making some preliminary
rounds and was presented a 17 year-old with severe GERD and erosive
esophagitis. It rules her life. She can't get PPIs, pH testing isn't
possible. I think we have an old optical endoscope around here, so I plan on
endoscopy on Monday. I am likely going to be faced with the decision as to
whether to go ahead with a laparoscopic Nissen.
HMc
| |
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| Howard McCollister wrote:
> "Pete" <pete@nospam.net> wrote in message
> news:121jaf5hf2juvff@corp.supernews.com...
>
> "Enjoy" might not be the right word, exactly, but it's always
> interesting. We usually do spend some time at a resort on the north
> coast after we finish here, and that is enjoyable.
>
> Starting Monday, my partner and I are teaching a 5 day course in basic
> laparoscopy here in Pignon to a group of 14 Haitian surgery residents
> from the Univsersity in Port-au-Prince. I just got done making some
> preliminary rounds and was presented a 17 year-old with severe GERD
> and erosive esophagitis. It rules her life. She can't get PPIs, pH
> testing isn't possible. I think we have an old optical endoscope
> around here, so I plan on endoscopy on Monday. I am likely going to
> be faced with the decision as to whether to go ahead with a
> laparoscopic Nissen.
> HMc
Interesting...Please keep us informed...Pete
| |
| gonda 2006-03-30, 10:13 am |
| Hi. Don't know how you are doing on this topic but I have recently had an
"open" Nissen fundoplication after having the laparoscopic procedure in
2003. I am only a week out of surgery so it is way too soon to tell how
things will go but the testing and treatment I underwent for this surgery
far out-weighed the lap (open Nissen was done at St. Mary's Hospital which
is connected to Mayo Clinic in Rochester). It didn't even seem close to
the same sort of operation. I really wish I would have gone to Mayo first
and gone ahead with the open method first. Would have saved a lot of time,
anguish and money for extra medication!
P.S. I'm new here so be kind and good luck all!
| |
| Howard McCollister 2006-03-30, 10:13 am |
|
"gonda" <zigzaggypsy@yahoo.com> wrote in message
news:ef89565b2df39e01bc63a059703f6bf7@localhost.talkaboutsupport.com...
> Hi. Don't know how you are doing on this topic but I have recently had an
> "open" Nissen fundoplication after having the laparoscopic procedure in
> 2003. I am only a week out of surgery so it is way too soon to tell how
> things will go but the testing and treatment I underwent for this surgery
> far out-weighed the lap (open Nissen was done at St. Mary's Hospital which
> is connected to Mayo Clinic in Rochester). It didn't even seem close to
> the same sort of operation. I really wish I would have gone to Mayo first
> and gone ahead with the open method first. Would have saved a lot of
> time,
> anguish and money for extra medication!
>
> P.S. I'm new here so be kind and good luck all!
>
There is no one at the Mayo Clinic in Rochester with sufficient skill for
revisional laparoscopic surgery. Was it Dr. Deschamps that did your
operation? He's quite good, although not a laparoscopic surgeon. Likewise
Dr. Sarr.
As to the extensive pre-op testing typically done at the Mayo Clinic -
that's kind of a standing joke in the medical world, especially here in
Minnesota.
HMc
| |
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| gonda wrote:
> Hi. Don't know how you are doing on this topic but I have recently
> had an "open" Nissen fundoplication after having the laparoscopic
> procedure in 2003. I am only a week out of surgery so it is way too
> soon to tell how things will go but the testing and treatment I
> underwent for this surgery far out-weighed the lap (open Nissen was
> done at St. Mary's Hospital which is connected to Mayo Clinic in
> Rochester). It didn't even seem close to the same sort of operation.
> I really wish I would have gone to Mayo first and gone ahead with the
> open method first. Would have saved a lot of time, anguish and money
> for extra medication!
>
> P.S. I'm new here so be kind and good luck all!
Gonda...this is interesting. I'm sure you read our doctor's (Howard's)
response. I believe he is one of the leading lap nissen surgeons in the
U.S. Could you expand a little more please. Did your lap nissen in 2003
fail miserably (ie it just didn't help your symptoms or what). Were you
having any problems swallowing or belching after the lap fundo, and are you
having any problems swallowing or belching after the open procedure you just
had (or is it too early to tell).
Also I assume the "invasion to your body" and the recovery period will be
much greater for the open procedure, so I just don't see your logic on why
you prefer the open procedure, especially since you indicated it has only
been a week and it is too early to tell if it helped your symptoms.
Please get back to us...Pete
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