Dr. James Wall is a practicing Pediatric Surgeon at Stanford University. He is an alumnus of the Stanford Biodesign program and holds a Master's degree in Bioengineering. His current research interest is in the design, development and analysis of health technology as well as the emerging field of surgical endoscopy. James currently leads the surgical endoscopy program at Lucile Packard Children’s Hospital and is the Assistant Director of the Biodesign Innovation Fellowship for Stanford Biodesign. Lucile Packard is one of the only Children's Hospitals in the world to offer advanced surgical endoscopic procedures including the Per-Oral Endoscopic Myotomy (POEM) for Achalasia.
- Pediatric Surgery
- Neonatal Surgery
- Minimally Invasive Pediatric Surgery
- Endoscopic Gastrointestinal Surgery
- Anorectal Malformations
- Congenital Diaphragmatic Hernia
- Hirschsprung's Disease
- Congenital Pulmonary Airway Malformations
- Pectus Excavatum
- Pectus Carinatum
Chairman Value Based Selection Committee, Lucile Packard Children's Hospital (2015 - Present)
Assistant Director, Biodesign Innovation Fellowship, Stanford Byers Center for Biodesign (2014 - Present)
Honors & Awards
Pediatric Surgery Fellowship Teaching Award, Division of Pediatric Surgery (2016)
Fellowship:Stanford University School of Medicine Registrar (2003) CA
Residency:UCSF Dept of General Surgery (2003) CA
Internship:UCSF Dept of General Surgery (2003) CA
Board Certification: Pediatric Surgery, American Board of Surgery (2015)
Board Certification: General Surgery, American Board of Surgery (2010)
Medical Education:University of Pennsylvania (2003) PA
Biodesign Fellowship, Stanford Byers Center for Biodesign (2007)
Masters of Bioengineering, Stanford University (2008)
Current Research and Scholarly Interests
Health Technology Innovation
- Biodesign Fundamentals
MED 275B (Spr)
Independent Studies (6)
- Bioengineering Problems and Experimental Investigation
BIOE 191 (Aut, Win, Spr, Sum)
- Directed Reading in Surgery
SURG 299 (Win, Spr, Sum)
- Directed Study
BIOE 391 (Aut, Win, Spr)
- Graduate Research
SURG 399 (Win, Spr, Sum)
- Medical Scholars Research
SURG 370 (Win, Spr, Sum)
- Undergraduate Research
SURG 199 (Win, Spr, Sum)
- Bioengineering Problems and Experimental Investigation
Prior Year Courses
Graduate and Fellowship Programs
Pediatric Surgery (Fellowship Program)
Trends and surgical outcomes of laparoscopic versus open pyloromyotomy.
Hypertrophic pyloric stenosis (HPS) is one of the most common pediatric illnesses necessitating surgical intervention. Controversy remains over the optimal surgical approach between laparoscopic pyloromyotomy (LP) and open pyloromyotomy (OP). LP has gained acceptance for management of HPS in an era of expanding minimal access surgical approaches to pediatric conditions. Several studies suggest advantages of LP over OP; however, selection bias and small sample sizes remain a concern. This study compares the outcomes of LP versus OP using propensity score methods.The 2013-2015 ACS NSQIP Pediatric PUF was queried for all infants undergoing pyloromyotomy. The trend in the proportion of infants undergoing LP was described and perioperative outcomes between the OP and LP cohorts were compared using propensity score weighted regression models.4847 infants were identified to have undergone surgical pyloromyotomy. The proportion of LP performed increased significantly from 59% in 2013 to 65.5% in 2015 (p < 0.001). LP was associated with lower overall complications (1.4% vs 2.9%) (ORadj 0.52, 95% CI 0.34-0.80), surgical site-related complications (1.1% vs 2.1%) (ORadj 0.52, 95% CI 0.32-0.84), and post-operative length of stay (1.5 days vs 1.9 days) (ORadj 0.89, 95% CI 0.81-0.98) without significant differences in related re-operation (0.9% vs 0.9%) (ORadj 1.01, 95% CI 0.52-1.93) or readmissions (1.4% vs 2.1%) (ORadj 0.73, 95% CI 0.46-1.17).Our study demonstrates that LP is increasingly utilized for management of hypertrophic pyloric stenosis and is associated with shorter length of stay, and lower odds of surgical site-specific and overall complications without differences in related re-operations. This study supports LP as a safe and effective method for management of HPS.
View details for PubMedID 29340829
Advanced minimal access surgery in infants weighing less than 3kg: A single center experience.
Journal of pediatric surgery
Minimal access surgery (MAS) has gained popularity in infants less than 5kg, however, significant challenges still arise in very low weight infants.A retrospective chart review was performed to identify all infants weighing less than 3kg who underwent an advanced MAS or equivalent open procedure from 2009 to 2016. Advanced case types included Nissen fundoplication, duodenal atresia repair, Ladd procedure, congenital diaphragmatic hernia repair, esophageal atresia/tracheoesophageal fistula repair, diaphragmatic plication, and pyloric atresia repair. A comparative analysis was performed between the MAS and open cohorts.A total of 45 advanced MAS cases and 17 open cases met the inclusion criteria. Gestational age and age at operation were similar between the cohorts, while infants who underwent open procedures had significantly lower weight at operation (p=0.003). There were no deaths within 30days related to surgery in either group. Only 3 MAS cases required unintended conversion to open. There were 2 (4.4%) postoperative complications related to surgery in the MAS cohort and 2 (11.8%) in the open cohort.Advanced MAS may be performed in infants weighing less than 3kg with low mortality, acceptable rates of conversion, and similar rates of complications as open procedures.Prognosis study.Level III.
View details for DOI 10.1016/j.jpedsurg.2017.05.006
View details for PubMedID 28549685
Initial experience with peroral endoscopic myotomy for treatment of achalasia in children.
Journal of pediatric surgery
Achalasia is a primary esophageal motility disorder characterized by aperistalsis of the esophagus and failed relaxation of the lower esophageal sphincter that presents rarely in childhood. The peroral endoscopic myotomy (POEM) procedure is an emerging treatment for achalasia in adults that has recently been introduced into pediatric surgical practice.This is a prospective case series of all children referred to Stanford University Lucile Packard Children's Hospital with manometry-confirmed achalasia who underwent a POEM procedure from 2014 to 2016.We enrolled 10 subjects ranging in age from 7 to 17years (M=13.4). The mean pre- and 1-month post-procedure Eckardt scores were 7 (SD=2.5) and 2.4 (SD=2) (p<0.001), respectively. The median procedure time for the entire cohort was 142min (range 60-259min) with ongoing improvement with increased experience (R2=0.6, p=0.008). There were no major adverse events.The POEM procedure can be successfully completed in children for the treatment of achalasia with demonstrated short-term post-operative improvement in symptoms. The adoption of advanced endoscopic techniques by pediatric surgeons may enable development of unique intraluminal approaches to congenital anomalies and other childhood diseases.Treatment Study - Level IV.
View details for PubMedID 28827050
Endoscopic Division of Duodenal Web Causing Near Obstruction in 2-Year-Old with Trisomy 21
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
2016; 26 (5): 413-417
Surgical intervention for duodenal atresia most commonly entails duodenoduodenostomy in the neonatal period. Occasionally, type I duodenal atresia with incomplete obstruction may go undiagnosed until later in life. Endoscopic approach to dividing intestinal webs has been reported as successful in patients as young as 7 days of age, and can be a useful modality particularly in patients with comorbidities who may not tolerate open or laparoscopic surgery.A 2-year-old female with a history of trisomy 21 and tetralogy of Fallot underwent laparoscopic and endoscopic exploration of intestinal obstruction as seen on upper gastrointestinal series for symptoms of recurrent emesis and weight loss. After laparoscopy confirmed a duodenal web as the cause of intestinal obstruction, endoscopic division of the membrane was carried out with a triangle tip electrocautery knife and 15 mm radially dilating balloon.The patient tolerated the procedure well, and also tolerated full age-appropriate diet by time of discharge on postoperative day 2. She remains asymptomatic as of 6 months postoperatively.This report describes a successful endoscopic approach for definitive treatment of a duodenal web in a 2-year-old girl with trisomy 21, and laparoscopy confirmed no intraabdominal obstructive process or complication from endoscopy. Endoscopy enables minimal recovery time and suggests an improved method of duodenal web division over pure surgical intervention.
View details for DOI 10.1089/lap.2015.0462
View details for Web of Science ID 000376469600014
View details for PubMedID 26913816
- Endoscopic Submucosal Dissection of a Large Hamartoma in a Young Child. Journal of pediatric gastroenterology and nutrition 2016; 62 (1): e5-7
Biodesign process and culture to enable pediatric medical technology innovation
SEMINARS IN PEDIATRIC SURGERY
2015; 24 (3): 102-106
Innovation is the process through which new scientific discoveries are developed and promoted from bench to bedside. In an effort to encourage young entrepreneurs in this area, Stanford Biodesign developed a medical device innovation training program focused on need-based innovation. The program focuses on teaching systematic evaluation of healthcare needs, invention, and concept development. This process can be applied to any field of medicine, including Pediatric Surgery. Similar training programs have gained traction throughout the United States and beyond. Equally important to process in the success of these programs is an institutional culture that supports transformative thinking. Key components of this culture include risk tolerance, patience, encouragement of creativity, management of conflict, and networking effects.
View details for DOI 10.1053/j.sempedsurg.2015.02.005
View details for Web of Science ID 000355070600002
View details for PubMedID 25976143
Initial Results of Endoscopic Gastrocutaneous Fistula Closure in Children Using an Over-the-Scope Clip.
Journal of laparoendoscopic & advanced surgical techniques. Part A
2015; 25 (1): 69-72
Gastrocutaneous fistula (GCF) occurs commonly in pediatric patients after removal of long-term gastrostomy tubes. Although open repair is generally successful, endoscopic approaches may offer benefits in terms of incisional complications, postoperative pain, and procedure time. In addition, endoscopic approaches may offer particular benefit in patients with varied degrees of skin irritation or erosion surrounding a GCF, making surgical repair difficult, or patients with significant comorbidities, making minimal intervention and anesthesia time preferable. Over-the-scope (OSC) clips are a new technology that enables endoscopic closure of intestinal fistulas up to 2 cm in diameter. Six pediatric patients underwent endoscopic GCF closure using OSC clips under Institutional Review Board approval. The procedure was technically successful in 5 of 6 cases with an average operating time of 29 minutes. The technical failure required an open revision, whereas all other patients reported full healing of the GCF site at 1 month. All successful cases were performed as outpatients without postoperative narcotics. In addition, all patients reported high satisfaction with the procedure and cosmetic results. Endoscopic GCF closure using an OSC clip is technically feasible in the pediatric population. Based on limited cases with a 1-month follow-up, the functional and cosmetic results of technically successful cases are excellent. Endoscopic GCF closure is a potential alternative to standard surgical closure in patients with skin irritation or erosion and/or significant comorbidities.
View details for DOI 10.1089/lap.2014.0379
View details for PubMedID 25531644
Prenatal imaging and postnatal presentation, diagnosis and management of congenital lung malformations.
Current opinion in pediatrics
2014; 26 (3): 315-319
Congenital lung malformations (CLMs) vary in their clinical presentation and severity. Increases in prenatal diagnosis, observed regression of certain lesions, and prognostic uncertainty are driving an evolution in management.There has been an increase in the early diagnosis of these malformations, a change that is attributable to the routine use of prenatal ultrasound. Although prenatal diagnosis of CLMs using ultrasound and MRI has increased, chest radiography and computed tomography still play important roles in diagnosis. The management of these lesions depends on the type of malformation and symptoms. The treatment of asymptomatic patients with lung malformations is controversial, because the prognosis of these lesions is largely unknown. Proponents of early intervention argue that the complications of CLM, which may include infection, pneumothorax, bleeding and malignant transformation, justify surgery. Advocates of conservative management note that some CLMs disappear postnatally, and that the long-term complication rate following surgery is unknown. There is a need to obtain natural history data regardless of the therapeutic recommendations.This article reviews the prenatal radiographic features and postnatal clinical findings of various CLMs and the dilemmas regarding treatment.
View details for DOI 10.1097/MOP.0000000000000091
View details for PubMedID 24739492
Introduction of the per-oral endoscopic myotomy technique to pediatric surgical practice
Journal of Pediatric Surgery Case Reports
View details for DOI 10.1016/j.epsc.2014.06.009
A Prospective Randomized Trial of Ultrasound- vs Landmark-Guided Central Venous Access in the Pediatric Population.
Journal of the American College of Surgeons
2013; 216 (5): 939-943
The purpose of this prospective randomized study was to compare landmark- to ultrasound-guided central venous access when performed by pediatric surgeons. The American College of Surgeons advocates for use of ultrasound in central venous catheter placement; however, this is not universally embraced by pediatric surgeons. Complication risk correlates positively with number of venous cannulation attempts.With IRB approval, a randomized prospective study of children under 18 years of age undergoing tunneled central venous catheter placement was performed. Patient accrual was based on power analysis. Exclusion criteria included known nonpatency of a central vein or coagulopathy. After randomization, the patients were assigned to either ultrasound-guided internal jugular vein access or landmark-guided subclavian/internal jugular vein access. The primary outcomes measure was number of attempts at venous cannulation. Secondary outcomes measures included: access times, number of arterial punctures, and other complications. Continuous variables were compared using 2-tailed Student's t-test. Discrete variables were analyzed with chi-square. Significance was defined as p < 0.05.There were 150 patients enrolled between April 2008 and September 2011. There was no difference when comparing demographic data. Success at first attempt was achieved in 65% of patients in the ultrasound group vs 45% in the landmark group (p = 0.021). Success within 3 attempts was achieved in 95% of ultrasound group vs 74% of landmark group (p = 0.0001).Ultrasound reduced the number of cannulation attempts necessary for venous access. This indicates a potential to reduce complications when ultrasound is used by pediatric surgeons.
View details for DOI 10.1016/j.jamcollsurg.2013.01.054
View details for PubMedID 23478546
Virtual Neck Exploration for Parathyroid Adenomas A First Step Toward Minimally Invasive Image-Guided Surgery
2013; 148 (3): 232-238
To evaluate the performance of 3-dimensional (3D) virtual neck exploration (VNE) as a modality for preoperative localization of parathyroid adenomas in primary hyperparathyroidism and assess the feasibility of using augmented reality to guide parathyroidectomy as a step toward minimally invasive imageguided surgery.Enhanced 3D rendering methods can be used to transform computed tomographic scan images into a model for 3D VNE. In addition to a standard imaging modality, 3D VNE was performed in all patients and used to preoperatively plan minimally invasive parathyroidectomy. All preoperative localization studies were analyzed for their sensitivity, specificity, positive predictive value, and negative predictive value for the correct side of the adenoma(s) (lateralization) and the correct quadrant of the neck (localization). The 3D VNE model was used to generate intraoperative augmented reality in 3 cases.Tertiary care center.A total of 114 consecutive patients with primary hyperparathyroidism were included from January 8, 2008, through July 26, 2011.The accuracy of 3D VNE in lateralization and localization was 77.2% and 64.9%, respectively. Virtual neck exploration had superior sensitivity to ultrasonography (P.001), sestamibi scanning (P=.07), and standard computed tomography (P.001). Use of the 3D model for intraoperative augmented reality was feasible.3-Dimensional VNE is an excellent tool in preoperative localization of parathyroid adenomas with sensitivity, specificity, and diagnostic accuracy commensurate with accepted first-line imaging modalities. The added value of 3D VNE includes enhanced preoperative planning and intraoperative augmented reality to enable less-invasive image-guided surgery.
View details for DOI 10.1001/jamasurg.2013.739
View details for Web of Science ID 000316682000005
View details for PubMedID 23682370
- Algorithm for Calculating Haller Index for Pectus Excavatum Using 3-Dimensional Optical Scanning ELSEVIER SCIENCE INC. 2018: S192
A Simplified Method for Three-Dimensional Optical Imaging and Measurement of Patients with Chest Wall Deformities.
Journal of laparoendoscopic & advanced surgical techniques. Part A
BACKGROUND: Pectus excavatum and carinatum are two of the most commonly observed chest wall deformities in pediatrics. The standard diagnostic evaluation for these conditions includes either chest radiograph (CXR) or computed tomography (CT). Our research aims to develop a novel and reliable way of quantifying chest wall deformities in the clinic setting without radiation exposure.METHODS: Using a handheld structured light scanner, we created three-dimensional (3D) models of patients with chest wall deformities through an IRB-approved protocol. Raters from a variety of backgrounds were then asked to take measurements based on the 3D model utilizing commercially available 3D graphical software. The standard deviation of the measurements and intraclass correlation coefficient (ICC) were then calculated to quantify inter-rater reliability.RESULTS: Sixty patients with pectus excavatum (Haller index range 2.0-6.38) and pectus carinatum were enrolled and imaged in our outpatient clinic using a structured light scanner. Five patients were used to verify interuser reliability. The standard deviation of all the measurements was 2.2mm. The ICC for absolute agreement was 0.99139, with 1.0 being perfect correlation.CONCLUSION: Structured light scanners provide an alternative approach to quantifying chest wall deformities in pediatric patients without radiation exposure. Our method is highly reliable, even among users with minimal image processing or 3D modeling experience. Our protocol can potentially be used to track treatment progress in children with chest wall deformities.
View details for PubMedID 30207836
- Dilation of Esophageal Stricture in a Pediatric Patient Using Functional Lumen Imaging Probe Technology Without the Use of Fluoroscopy. Journal of pediatric gastroenterology and nutrition 2018
A multidisciplinary approach to laparoscopic sleeve gastrectomy among multiethnic adolescents in the United States.
Journal of pediatric surgery
Childhood obesity has become a serious public health problem in our country with a prevalence that is disproportionately higher among minority groups. Laparoscopic sleeve gastrectomy (LSG) is gaining attention as a safe bariatric alternative for severely obese adolescents.A retrospective study on morbidly obese adolescents that underwent LSG at our institution from 2009 to 2017. Primary outcomes were weight loss as measured by change in BMI and percent excess weight loss (%EWL) at 1 year after surgery, resolution of comorbidities and occurrence of complications.Thirty-eight patients, of whom 71% were female and 74% were ethnic minorities, underwent LSG between 2009 and 2016. Mean age was 16.8years, mean weight was 132.0kg and mean BMI was 46.7. There were no surgical complications. Mean %EWL was 19.4%, 27.9%, 37.4%, 44.9%, and 47.7% at 1.5, 3, 6, 9, and 12month follow up visits, respectively. Comorbidity resolution rates were 100% for hypertension and nonalcoholic fatty liver disease, 91% for diabetes, 44% for prediabetes, 82% for dyslipidemia and 89% for OSA.LSG is an effective and safe method of treatment of morbid obesity in adolescents as it can significantly decrease excess body weight and resolve comorbid conditions. Further studies are needed to investigate the long-term effects of LSG in adolescents.Descriptive case series with prospective database.IV.
View details for PubMedID 28697852
- Ultrasound-Guided Percutaneous Vein Access for Placement of Broviac Catheters in Extremely Low Birth Weight Neonates: A Series of 3 Successful Cases JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES 2015; 25 (11): 958-960
Long-term follow-up of laparoscopic transcutaneous inguinal herniorraphy with high transfixation suture ligature of the hernia sac.
Journal of pediatric surgery
2015; 50 (10): 1767-1771
Laparoscopic transcutaneous inguinal hernia repair in children may reduce postoperative pain, improve cosmesis, allow for less manipulation of the cord structures, and offer easy access to the contralateral groin. However, there is concern for unacceptably high recurrence rates when the procedure is generalized. To address this increase in recurrence, in 2011 we described in this journal a modification of the laparoscopic transcutaneous technique that replicates high transfixation ligature of the hernia sac with the aim of inducing more secure healing, preventing suture slippage, and distributing tension across two suture passes. We now describe our long-term follow-up of this novel repair.After obtaining IRB approval, a retrospective chart review and phone follow-up were performed on all patients who underwent laparoscopic transfixation ligature hernia repair between October 2009 and August 2014 (including further follow-up of the 21 patients reviewed in the 2011 report of this technique). Data collection included demographics, laterality of hernia, evidence of recurrence, complications, and time to follow-up.Median follow-up was 24months (range 2-52months). Three pediatric surgeons performed 216 laparoscopic transfixation ligature repairs on 166 patients. Demographics: mean age 29.5months (range 1-192months); male 67.2% and female 32.8%; 4.2% of patients were premature at operation. Repairs were bilateral in 42% of patients, right sided in 34%, and left sided in 24%. Three patients together experienced 4 recurrences, for an overall recurrence rate of 1.8%. Two of the recurrences occurred in a 2-month old syndromic patient with severe congenital heart disease who recurred twice after laparoscopic transfixation ligature repair then subsequently failed an attempt at open repair. Excluding this one outlier patient, the recurrence rate was 0.9%. The complication rate was 1.7% (3 hydroceles and 1 inguinal hematoma; all resolved spontaneously).Laparoscopic high transfixation ligature hernia repair can be adopted by surgeons with basic laparoscopic skills, and result in excellent outcomes with acceptable recurrence rates.
View details for DOI 10.1016/j.jpedsurg.2015.06.006
View details for PubMedID 26201542
Challenges and climate of business environment and resources to support pediatric device development
SEMINARS IN PEDIATRIC SURGERY
2015; 24 (3): 107-111
The incidence of pediatric disease conditions pales in comparison to adult disease. Consequently, many pediatric disorders are considered orphan diseases. Resources for the development of devices targeting orphan diseases are scarce and this poses a unique challenge to the development of pediatric devices. This article outlines these challenges and offers solutions.
View details for DOI 10.1053/j.sempedsurg.2015.02.006
View details for Web of Science ID 000355070600003
View details for PubMedID 25976144
Congenital peribronchial myofibroblastic tumor: case report of an asymptomatic infant with a rapidly enlarging pulmonary mass and review of the literature.
Annals of clinical and laboratory science
2015; 45 (1): 83-89
Congenital peribronchial myofibroblastic tumor (CPMT) is a rare, benign lung tumor of infants, with only 19 reported cases worldwide. It is often diagnosed by prenatal imaging or in the immediate postnatal period due to co-morbidities like polyhydramnios, fetal hydrops, respiratory distress, and heart failure.We report the oldest known infant (8 weeks old) diagnosed with CPMT, and present his clinical course including the relevant radiographic and histopathologic findings.CPMT is a rare tumor that should be considered among other primary lung tumors of infancy (developmental, benign, and malignant) even if not detected prenatally or in the immediate postnatal period.
View details for PubMedID 25696016
Complete resection of a rare intrahepatic variant of a choledochal cyst
JOURNAL OF PEDIATRIC SURGERY
2013; 48 (3): 652-654
The vast majority of choledochal cysts occur as either saccular or diffuse fusiform dilatation of the extrahepatic bile duct. We describe the complete resection of a rare single intrahepatic choledochal cyst communicating with the extrahepatic biliary tree. While previous reports describe partial resection with enteral drainage, we performed a complete resection of this rare choledochal cyst.
View details for DOI 10.1016/j.jpedsurg.2012.12.016
View details for Web of Science ID 000316470100037
View details for PubMedID 23480926
Successful extracorporeal membrane oxygenation treatment for pheochromocytoma-induced acute cardiac failure
AMERICAN JOURNAL OF EMERGENCY MEDICINE
2012; 30 (6)
The aim of this study is to report the case of a catecholamine-induced cardiogenic shock bridged to curative adrenalectomy using extracorporeal membrane oxygenation (ECMO) and medical management. A 37-year-old woman presented an acute cardiogenic shock due to a left-sided pheochromocytoma. Echocardiography revealed a severe global hypokinesia with a left ventricular ejection fraction of 15%. Despite maximal ionotropic support, adequate perfusion could not be achieved; and ECMO was used to bridge the patient during medical management with calcium-channel blockers. The left ventricular ejection fraction improved to 65%, and ECMO was discontinued after 11 days. An open left adrenalectomy was performed 10 days after ECMO. At 1-year follow-up, the patient is in good health with normal cardiac function. Pheochromocytomas can present with dramatic cardiovascular collapse. With timely diagnosis and medical therapy, followed by surgical resection, the cardiovascular effects can be reversed; and the condition, cured. Young patients with catecholamine-induced cardiac failure refractory to medical therapy are ideal candidates for short-term ECMO support, as the underlying cause is imminently reversible.
View details for DOI 10.1016/j.ajem.2011.05.006
View details for Web of Science ID 000305811600046
View details for PubMedID 21741786
Prospective evaluation of peritoneal fluid contamination following transabdominal vs. transanal specimen extraction in laparoscopic left-sided colorectal resections
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2012; 26 (6): 1495-1500
Natural orifice specimen extraction (NOSE) in colorectal surgery prevents the need for an enlarged port site or minilaparotomy to extract the surgical specimen. The downside of this technique may be an increased risk of bacterial contamination of the peritoneal cavity from the external milieu. The aim of this study was to prospectively analyze the peritoneal bacterial contamination in NOSE and non-NOSE laparoscopic colorectal procedures.Consecutive patients operated for sigmoid diverticulitis with laparoscopic approach and transanal extraction of the specimen from January to December 2010 at our university hospital were enrolled. Patients who underwent a laparoscopic sigmoidectomy in the same study period with conventional specimen extraction were used as reference. Peritoneal fluid samples were collected under sterile conditions at the end of the procedure and sent for gram stain as well as anaerobic, aerobic, and fungal cultures.Twenty-nine patients underwent laparoscopic sigmoidectomy for diverticulitis with transanal NOSE, while 9 patients underwent laparoscopic sigmoidectomy with conventional specimen extraction during the same period. The two groups were successfully matched 1:2 (17 NOSE and 9 non-NOSE) according age, sex, ASA, and Charlson comorbidity score. The contamination rate of peritoneal fluid was 100% vs. 88.9% in NOSE and non-NOSE procedures, respectively (P = 0.23). Overall and major complications rates were 27.6% vs. 11.10% (P = 0.41) and 5.08% vs. 11.1% (P = 1) in NOSE vs. non-NOSE procedures, respectively. In the NOSE group there was a statistically significant lower consumption of oral paracetamol (P = 0.007) and of oral tramadol (P = 0.02).Although a higher peritoneal contamination was found in the NOSE procedures, there were no significant differences in clinical outcomes relative to standard approach. Avoiding a minilaparotomy to extract the specimen resulted in a significantly lower postoperative analgesic requirement in the NOSE group.
View details for DOI 10.1007/s00464-011-2066-6
View details for Web of Science ID 000304161500001
View details for PubMedID 22179455
Submucosal Endoscopic Myotomies for Esophageal Lengthening: A Novel Minimally Invasive Technique with Feasibility Study
EUROPEAN JOURNAL OF PEDIATRIC SURGERY
2012; 22 (3): 217-221
Replacement conduits carry significant morbidity in long gap esophageal atresia. Surgical myotomies can lengthen the esophagus, but have not gained widespread adoption due to long-term dilatation. The aim of this study is to assess the feasibility of an emerging minimally invasive technique of submucosal endoscopic myotomy for esophageal lengthening.Bilateral submucosal lengthening endoscopic myotomies (BSLEM) were performed in three swine. Circular esophageal muscle fibers were selectively divided in a bilateral 3 cm longitudinal pattern. Ex-vivo tensile testing was performed on the BSLEM and compared with three circular myotomies, three spiral myotomies, and three controls.BSLEM was completed in all cases with one esophageal microperforation. The mean operating time was 38 minutes. Over physiologic force ranges of 0 to 100 g, the percentage esophageal elongation was significantly different among the four groups (p<0.05). Spiral myotomy enabled the maximal lengthening among the techniques. BSLEM enabled lengthening significantly greater than controls, but less than both types of surgical myotomy.BSELM is feasible and allows significant esophageal lengthening. Unlike surgical myotomies, BSELM enables selective division of circular fibers to potentially preserve perfusion near the anastomosis and prevent long-term dilatation. Studies are ongoing to characterize the ideal pattern of selective endoscopic myotomy and long-term effects.
View details for DOI 10.1055/s-0032-1308711
View details for Web of Science ID 000306110600008
View details for PubMedID 22576306
An Original Endoluminal Magnetic Anastomotic Device Allowing Pure NOTES Transgastric and Transrectal Sigmoidectomy in a Porcine Model: Proof of Concept
2012; 19 (2): 109-116
While experimental natural orifice transluminal endoscopic surgery (NOTES) sigmoid colectomies have been reported, pure NOTES anastomoses are restricted by the limited reach of commercially available circular staplers. MAGNAMOSIS is a set of self-orienting magnetic rings that can be delivered endoluminally throughout the colon to generate a compression anastomosis. Aim. To assess the feasibility of a pure NOTES transrectal (TR) and transgastric (TG) approach to perform any segmental colectomy.One pig (50 kg) underwent the experimental procedure as follows: (a) creation of the TG access to the peritoneal cavity, (b) precise transluminal placement of the proximal MAGNAMOSIS ring, (c) creation of the TR access with the TEO and transrectal dissection of the sigmoid mesentery, (d) resection of the surgical specimen, (e) transrectal extraction of the specimen, (f) delivery and mating of the distal MAGNAMOSIS ring, and (g) closure of the TG and TR viscerotomies. The animal survived for 14 days at which time burst pressure and histology were performed.A pure NOTES TR and TG segmental colectomy was performed in 139 minutes. The postoperative course was uneventful. The animal had a formed bowel movement including the magnetic rings on postoperative day 5. Endoscopic examination at postoperative day 14 revealed a patent anastomosis. Necropsy revealed no abscess or signs of peritonitis. Burst pressure was >198 mm Hg. The histology showed a sealed anastomosis with mild inflammation.MAGNAMOSIS enabled a totally NOTES partial colectomy with combined TG and TR access. The flexible delivery options and low cost of manufacturing could make MAGNAMOSIS an attractive alternative to circular staplers.
View details for DOI 10.1177/1553350611429029
View details for Web of Science ID 000304822100001
View details for PubMedID 22143749
Totally Endoscopic Magnetic Enteral Bypass by External Guided Rendez-Vous Technique
2011; 18 (4): 317-320
This study aimed to assess the feasibility of a totally endoscopic enteral bypass using a self-orienting, dual ring, magnetic anastomosis system (MAGNAMOSIS) guided by a magnetic tracking system (3D METRIS).In an anesthetized pig, 2 endoscopes were advanced, one each into the stomach and the colon. Both endoscopes were equipped with a MAGNAMOSIS ring secured with an endoscopic snare and a 3D METRIS within one working channel. The whole procedure was followed laparoscopically. The tracking system guided tips of endoscopes to a "rendez-vous" location between the colon and stomach.MAGNAMOSIS magnets automatically joined in the correct configuration when guided to within 2 cm of each other. At necropsy, magnetic rings were secure without entrapment of excess bowel or mesentery.An endoscopic enteral bypass with magnetic anastomosis and magnetic tracking device was feasible. More accurate tracking and advanced techniques could enable endoscopic bypasses at multiple sites in the gastrointestinal tract.
View details for DOI 10.1177/1553350611409761
View details for Web of Science ID 000299896100004
View details for PubMedID 21742664
Two novel endoscopic esophageal lengthening and reconstruction techniques
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2011; 25 (10): 3440-3440
Esophageal reconstruction presents a significant clinical challenge in patients ranging from neonates with long-gap esophageal atresia to adults after esophageal resection. Both gastric and colonic replacement conduits carry significant morbidity. As emerging organ-sparring techniques become established for early stage esophageal tumors, less morbid reconstruction techniques are warranted. We present two novel endoscopic approaches for esophageal lengthening and reconstruction in a porcine model.Two models of esophageal defects were created in pigs (30-35 kg) under general anesthesia and subsequently reconstructed with the novel techniques. The first model was a segmental defect of the esophagus created by thoracoscopically transecting the esophagus above the gastroesophageal (GE) junction. The first reconstruction technique involved bilateral submucosal endoscopic lengthening myotomies (BSELM) with a magnetic compression anastomosis (MAGNAMOSIS™). The second model was a wedge defect in the anterior esophagus created above the GE junction through a laparotomy. The second reconstruction technique involved an inverted mucosal-submucosal sleeve transposition graft (IMSTG) that crossed the esophageal gap and was secured in place with a self-expandable covered esophageal stent.Both techniques were feasible in the pig model. The BSELM approach lengthened the esophagus 1 cm for every 2 cm length of myotomy. The myotomy targeted only the inner circular fibers of the esophagus, with preservation of the longitudinal layer to protect against long-term dilation and pouching. The IMSTG approach generated a vascularized mucosal graft almost as long as the esophagus itself.Emerging endoscopic capabilities are enabling complex endoluminal esophageal procedures. BSELM and IMSTG are two novel and technically feasible approaches to esophageal lengthening and reconstruction. Further survival studies are needed to establish the safety and efficacy of these techniques.
View details for DOI 10.1007/s00464-011-1711-4
View details for Web of Science ID 000294964600048
View details for PubMedID 21556998
Original Technique to Close the Transrectal Viscerotomy Access in a NOTES Transrectal and Transgastric Segmental Colectomy
2011; 18 (3): 193-200
Segmental colectomy is an ideal procedure for natural orifice transluminal endoscopic surgery (NOTES). Transanal endoscopic approaches have enabled rectosigmoid colectomy through a viscerotomy that is resected with the specimen. To extend NOTES segmental colectomy to the entire colon and beyond, a rectal viscerotomy will have to be safely and effectively closed at the end of the procedure. A new technique for rectal viscerotomy closure using a circular EEA hemorrhoid and prolapse stapler with DST series technology (Covidien) is described.
View details for DOI 10.1177/1553350611411490
View details for Web of Science ID 000297596400004
View details for PubMedID 21727099
- Robotic Gastrectomy Is Safe and Feasible, but Real Benefits Remain Elusive ARCHIVES OF SURGERY 2011; 146 (9): 1092-1092
Laparo-Endoscopic Single-Site (LESS) with Transanal Natural Orifice Specimen Extraction (NOSE) Sigmoidectomy: A New Step before Pure Colorectal Natural Orifices Transluminal Endoscopic Surgery (NOTES (R))
JOURNAL OF GASTROINTESTINAL SURGERY
2011; 15 (8): 1488-1492
We present the first human case of laparo-endoscopic single-site sigmoidectomy with transanal natural orifice specimen extraction.This technical achievement is a new step toward pure colorectal Natural Orifices Transluminal Endoscopic Surgery. It is the product of a gradual development with critical steps being conceived and standardised in years of experimental and clinical procedures.
View details for DOI 10.1007/s11605-011-1557-z
View details for Web of Science ID 000293243200035
View details for PubMedID 21584823
- Intellectual property and royalty streams in academic departments: Myths and realities SURGERY 2008; 143 (2): 183-191
Impact of multiple lymphatic channel drainage to a single nodal basin on outcomes in melanoma
78th Annual Meeting of the Pacific-Coast-Surgical-Association
AMER MEDICAL ASSOC. 2007: 753–56
To determine the impact of multiple lymphatic channels (MLCs) on outcome in melanoma.Retrospective cohort study.Academic tertiary care center.Of 1198 consecutive selective sentinel lymphadenectomies performed from 1995 to 2000 for primary invasive melanoma, 502 patients were identified with extremity or truncal melanoma that drained to a single nodal basin. Three cohorts were formed based on lymphatic channels (none, single, and multiple). Tumors with drainage to multiple nodal basins as well as all head and neck tumors were excluded.Multiple variables, including patterns of lymphatic drainage, were analyzed for impact on disease-free and overall survival.Demographics were similar among groups, with a median follow-up of 5.6 years. Univariate analysis revealed MLCs as an independent risk factor for both disease-free (P = .04) and overall survival (P = .003). Multivariate analysis confirmed that tumor depth, sentinel lymph node status, and MLCs were risk factors for both disease-free and overall survival. Kaplan-Meier analysis showed worse survival in the MLCs group.Our study reveals that MLCs are an independent risk factor for recurrence and mortality in melanoma. Multiple lymphatic channels may facilitate the process of metastasis.
View details for Web of Science ID 000248721200013
View details for PubMedID 17709729