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Abstract: Purpose: This study was designed to evaluate whether neoadjuvant therapy is a risk factor for anastomotic leakage after rectal cancer surgery. Methods: A retrospective review of 220 patients who underwent tumor-specific mesorectal excision for rectal cancer from 2000 to 2005 was performed. Risk factors for leak were identified by using a multivariable regression model. Results: A total of 54 patients received neoadjuvant chemoradiation therapy and surgery, whereas 166 received surgery alone. No difference in clinically significant leaks was observed between the two groups (5.6 vs. 6.6 percent, P = 1). A diverting ileostomy was performed in 26.4 percent of patients who received neoadjuvant therapy compared with 9.7 percent for surgery alone (P = 0.0021). Neoadjuvant patients were more likely to have ultralow anastomoses (17.6 vs. 2.5 percent, P < 0.0001). On multivariate analysis, smoking (odds ratio, 6.37 (1.8, 22.2), P = 0.004), difficult anastomosis (odds ratio, 7.66 (1.8, 31.5), P = 0.0048), and low level of anastomosis (≤4 cm from the verge; odds ratio, 5.28 (1.05, 26.6), P = 0.044) were independently associated with anastomotic leakage. Conclusions: Significant predictors of anastomotic leak include smoking, difficult anastomosis, and level of anastomosis (≤4 cm). Neoadjuvant chemoradiation therapy was not found to be significantly associated with leakage after tumor-specific mesorectal excision for rectal cancer.

Background: A quality improvement opportunity was identified to de-adopt the low-value care practice of routinely performing bloodwork for all patients undergoing elective bariatric surgery. While these patients are typically discharged on postoperative day 1 (POD1) after bloodwork is performed, it is uncommon for the discharge plan to change due to unexpected laboratory abnormalities alone. Methods: Patients undergoing bariatric surgery between September 2020 and April 2021 only had POD1 bloodwork if there were perioperative clinical concerns, they had insulin-dependent diabetes, or they were therapeutically anticoagulated. Thirty-day Emergency Department (ED) visits and readmissions were monitored as balancing measures. Outcomes were compared to a control group that underwent bariatric surgery prior to September 2020 when POD1 laboratory testing was routinely performed. Financial and environmental costs were estimated based our institutional standards. Results: The intervention group consisted of 303 patients: 248 (82%) Roux-en-Y gastric bypasses and 55 (18%) sleeve gastrectomies. Most patients (n= 256, 84.5%) did not have POD1 bloodwork. Twelve (3.9%) had bloodwork performed in violation of our protocol, of which none had a change in management based on the results. Of the 35 (12%) who had appropriately ordered bloodwork, 6 (2%) required a transfusion and 2 (0.7%) required a second surgery on the same admission for hemorrhage. Forty-four (14.5%) had 30-day ED visits of which 17 (5.6%) were within 7 days. Sixteen (5.3%) were readmitted. There were no significant differences between intervention and control groups in the rate of transfusion, second surgery, or 30-day ED visits. The avoidance of POD1 bloodwork saved approximately $6602.24 in lab processing fees alone and 512 test tubes. Conclusion: POD1 bloodwork can be safely avoided in the absence of clinical concerns. In addition to not significantly increasing postoperative complications, there were benefits from a financial cost, environmental impact, and patient discomfort perspective. Graphical abstract:

Background: It is not yet clear where laparoscopic procedures will fit into the armamentarium of the surgeon. Over the past decade, there has been a clear trend toward minimally invasive procedures for palliation of inoperable cancer. Traditionally, when duodenal obstruction occurs secondary to a disease process, gastric bypass through laparotomy is required. Patients and Methods: Between November 13, 1992 and September 13, 1994, 10 patients underwent laparoscopic gastroenterostomy for duodenal obstruction. In 9 patients, the procedure was carried out for malignant obstruction; in 1 patient, duodenal obstruction was secondary to chronic scarring from benign peptic ulcer disease. Eight of these, patients already had biliary decompression through radiologic or endoscopic means. One patient underwent laparoscopic cholecystenterostomy for biliary obstruction in addition to the laparoscopic gastroenterostomy. Results: Laparoscopic gastroenterostomy was successfully completed in 8 of the 10 patients. In 2, conversion to open surgery was necessary. There was no mortality related to this operative approach. Conclusions: Laparoscopic gastroenterostomy is a safe procedure for treatment of duodenal obstruction. Good palliation can be expected in patients with obstruction of the duodenum secondary to advanced malignancies.

The decision tree with the highest overall accuracy and sensitivity for diagnosis of internal hernia in patients who have undergone laparoscopic Roux-en-Y gastric bypass surgery included the mesenteric swirl sign and small bowel obstruction, the model with the highest specificity included superior mesenteric vein “beaking” and small bowel obstruction, and the remaining CT signs showed lower diagnostic accuracy and/or higher levels of interobserver agreement, which may limit their clinical utility.

To review surgical-site infection (SSI) and retrieval-site tumor recurrence rates in laparoscopic colorectal procedures when using a plastic freezer bag as a wound protector.

The risks of adverse obstetric outcomes among young women survivors of colorectal cancer (CRC) are uncertain.This Western Australian, whole-jurisdictional linked-data, retrospective cohort study compared maternal and neonatal outcomes of first postcancer pregnancies among women CRC survivors against randomly selected pregnancies of women with no cancer history. Logistic regression models were used to investigate a range of adverse outcomes independently associated with CRC and its surgical and adjunctive treatments.Among 627,762 deliveries during the study period (1983–2007), 232 were first pregnancies following CRC. Whether following laparoscopic or open cancer surgery, these pregnancies were independently associated with a significantly increased risk of antepartum hemorrhage [odds ratios (ORs): 1.25; 2.13 for the respective procedures], postpartum hemorrhage (ORs: 1.61; 3.31), Cesarean delivery (ORs: 2.42; 4.24), infant low Apgar score (ORs: 1.32; 2.64), need for neonatal resuscitation (ORs: 1.49; 3.20), and special care admission (ORs: 1.42; 2.87). A history of open (but not laparoscopic) cancer surgery was associated with increased risk of gastrointestinal obstruction during pregnancy (OR 1.17) and prolonged postpartum hospitalization (OR 3.11). Neither was significantly associated with perinatal death. Among women with previous CRC, rectal (versus colonic) malignancy was independently associated with a significantly higher risk of overall maternal and neonatal adverse outcomes (ORs: 3.73 and 2.73, respectively), as was radiotherapy (ORs: 4.24 and 2.81, respectively). Chemotherapy was independently associated with a marginally but significantly higher risk of overall maternal but not neonatal outcomes (ORs: 1.11; 0.98). Open versus laparoscopic cancer surgery was associated with a significantly higher risk of antepartum and postpartum hemorrhage, low Apgar score, need for neonatal resuscitation, and neonatal special care admission.Previous CRCs, particularly rectal and radiation-treated tumors, appear to confer an increased likelihood of adverse outcomes in subsequent pregnancies. Laparoscopic technique for CRC surgery may reduce adverse gestational outcomes.

Previous research in colorectal cancer has focused on survival, recurrence, and functional outcomes. Few have assessed the decisional needs of patients or the information patients are retaining from the informed consent process.

Abstract: Background: Surgery is increasingly reserved for complicated diverticulitis. The role of laparoscopy in this context is ill defined. This study aimed to evaluate the safety, feasibility, and outcomes associated with the application of laparoscopy to an unrestricted spectrum of diverticular pathologies, with an emphasis on complicated disease. Methods: Consecutive patients who underwent elective, urgent, or emergent laparoscopic colectomy for diverticular disease from 1991 to 2007 were analyzed from a prospectively collected database. Laparoscopy was offered to all patients presenting for surgical attention, thus minimizing selection bias. Complicated cases had abscesses, perforations, fistulas, or strictures. Uncomplicated cases had chronic or recurrent diverticulitis. Summary statistics and univariate comparisons were generated. Results: A total of 183 patients were analyzed, including 39 complicated cases. The complicated cohort included 12 abscesses or perforations (31%), 18 fistulas (46%), and 11 strictures (28%). Intraoperative complications were comparable between the two groups (7.7 vs. 9.7%), although the complicated cases resulted in more conversions (23 vs. 4.2%; p = 0.0007). More than 79% of the complicated patients and 96% of the uncomplicated patients underwent unprotected primary anastomosis. Medical (23 vs. 1.4%; p < 0.0001) and surgical (28 vs. 14%; p = 0.035) complications were more frequent in the complicated group. Leak rates were acceptably low (6.5 vs. 2.2%; p = 0.23). There were no recorded deaths. Finally, the time until discharge from hospital was significantly longer in the complicated group by a median of 1 day. Conclusions: The laparoscopic management of complicated diverticular disease is feasible and appears to be safe in the hands of experts. Despite a high rate of conversion to open surgery, laparoscopy was the sole operative intervention for the majority of patients with complicated diverticular disease. Further studies are needed to allow rigorous comparison with an open control group.

Abstract: Background: This study aimed to seek the opinions of academic surgical chairs on minimally invasive surgery (MIS) education for general surgery residents and to identify perceived gaps and trends in educational strategies. Methods: A national survey on attitudes toward MIS was sent to the chairs of departments of surgery and divisions of general surgery across the 16 Canadian academic centers. The survey contained 34 questions consisting of Likert scales, single answers, and multiple-choice questions. Nonresponders were contacted directly. At the time of the survey, two department chair positions were vacant. Results: The response rate was 87% (26/30). The majority of the centers used early operating room exposure to basic MIS cases (92%) and animal labs (85%). Two-thirds of the institutions used early operating room exposure to advanced MIS cases (69%) and didactic lectures (65%). Half of the academic centers used MIS video (54%) and the laparoscopic virtual reality simulator (54%). The least used method was computer software (19%). The surgical division and department chairs believed the most effective teaching method was early operating room exposure to basic MIS cases (100%), followed by the laparoscopic virtual reality simulator (91%) and animal labs (88%). Computer software was considered 42% useful, and the least useful method was didactic lectures (16%). In the next 5 years, 62% of academic centers plan to add laparoscopic virtual reality simulators to their MIS curriculum. Conclusion: The chairs’ opinion on the most effective MIS teaching method for residents is basic MIS cases followed by laparoscopic virtual reality simulators. The majority of academic institutions plan to add laparoscopic virtual reality simulators to the curriculum in the next 5 years.

The purpose was to determine if the perioperative benefits associated with laparoscopic colectomies are maintained as operative time increases.

Abstract: Background: The recent introduction of hand-assist devices in laparoscopic colorectal surgery has renewed interest in the influence of incision length. This study aimed to define the impact of extraction incision length on the postoperative outcomes of laparoscopic left-sided colon and rectal resections. Methods: Consecutive patients undergoing laparoscopic left-sided colorectal resection from 1991 to 2007 were retrieved from a prospectively collected database. The association between incision length and patient characteristics, diagnosis, and perioperative outcomes were analyzed using logistic regression, Spearman correlation, Wilcoxon test, and chi-square test. Results: A total of 494 laparoscopic colorectal resections (left, sigmoid, anterior, and low anterior resections) were retrieved. Patients with conversions to open surgery (n = 59) and missing data (n = 53) were excluded. As a result, 382 cases were included in the study. A slight majority of the patients had malignant disease (n = 202, 53%). The median incision length was 5 cm (interquartile range, 4–6 cm). Increasing weight was positively correlated with incision length (p = 0.0001). Male patients had modestly larger mean incisions than female patients (5.5 vs. 5.0 cm; p = 0.0075). Age, previous surgery, diagnosis, days to resumption of normal diet, and days to discharge from hospital showed no significant relationship with incision length. No association was observed between the incision length and intraoperative or postoperative complications. Conclusions: Patients undergoing laparoscopic colorectal surgery appear to achieve the same perioperative outcomes irrespective of their extraction incision lengths. To maintain the short-term benefits of laparoscopy, surgeons should consider pursuing a minimally invasive technique, even when a larger extraction incision will ultimately be required.

Abstract: Background: This study aimed to define the management and risk factors for intraoperative complications (IOC) and conversion in laparoscopic colorectal surgery, and to assess whether surgeon experience influences intraoperative outcomes. Methods: Consecutive patients undergoing laparoscopic colorectal procedures from 1991 to 2005 were analyzed from a longitudinal prospectively collected database. All patients referred to the four surgeons involved in this study were offered a minimally invasive approach. Patient characteristics, perioperative variables, and surgeon experience data were analyzed and compared. Results: A total of 991 consecutive laparoscopic colorectal procedures were studied. The majority of operations were performed for malignant disease (n = 526, 53%), and most frequently consisted of segmental colonic resections (n = 718, 72%). A total of 85 patients (8.6%) had an IOC. Patients experiencing an IOC had a significantly higher median body weight (75 versus 68 kg, p = 0.0047) and had a higher proportion of previous abdominal surgery (31% versus 20%, p = 0.029). Only 39% of patients suffering an IOC required conversion to open surgery. A total of 126 (13%) cases were converted to open surgery. On multivariable analysis, previous abdominal surgery [odds ratio (OR) 3.40, 95% confidence interval (CI) 1.39–8.35, p = 0.0076] was independently associated with having an IOC and a conversion to open within the same procedure. With increasing experience, individual surgeons were found to operate on heavier patients (p = 0.025), and on patients who had a higher rate of previous intra-abdominal surgery (p < 0.0001). Despite these risk factors, the early and late experience demonstrated no significant difference in terms of IOCs (p = 0.54) and conversion to open surgery (p = 0.40). Conclusions: The majority of IOCs can be managed laparoscopically. With increasing experience surgeons can perform laparoscopic colorectal surgery on a patient population with a greater proportion of previous abdominal surgery and a higher mean body weight without adversely affecting their rates of intraoperative complications or conversion.

Abstract: Background: The large randomized trials reporting on laparoscopic versus open colon surgery for cancer have all excluded patients with transverse colon cancer lesions. This study was undertaken to review our experience with surgery for curable transverse colon cancer. Methods: A database of 938 laparoscopic colon resections performed between April 1991 and September 2004 was reviewed. Of 514 procedures for cancer, stage IV disease, mid to low rectal cancers, and total colectomies were excluded. On an intent-to-treat basis, outcomes of surgery for transverse colon lesions (TC) were compared with outcomes of segmental colon resections for other lesions (OC). Results: A total of 22 TC were resected compared with 285 OC. Patients with TC were similar to patients with OC in age, gender, weight, and body mass index (BMI). Cancer stage was equivalent between patients with TC (9 Stage I, 7 Stage II, 6 Stage III) and OC (66 Stage I, 126 Stage II, 93 Stage III, p = 0.170) as was tumor size. Patients with TC underwent 9 transverse colectomies, 12 extended right hemicolectomies, and 1 extended left hemicolectomy. Patients with OC underwent 126 right hemicolectomies, 24 left hemicolectomies, and 135 sigmoid colectomies or anterior resections. There were no differences in conversion rate (18.2% vs. 13.3%, p = 0.752) or in intraoperative (9% vs. 8%, p = 0.814) or postoperative (41% vs. 30%, p = 0.418) complications. Operating time was longer with TC (209 ± 63 min vs. 176 ± 60 min, p = 0.042) and lymph node harvest was higher (15.3 ± 11.6 vs. 10.8 ± 7.6, p = 0.011). At a median followup of 17.2 months and 17.1 months, respectively, there were two (9%) recurrences after resection of TC and 17 (6%) recurrences after resection of OC. Conclusions: Laparoscopic resection of transverse colon cancers is technically feasible and not associated with a significantly higher rate of complications or conversions or with impaired oncologic outcomes compared with patients having segmental laparoscopic resections for other colon cancers. Operating time is longer.

Background and Purpose: Laparoscopic donor nephrectomy (LapDN) offers donors more rapid postoperative recovery and recipients equivalent graft function when compared with open donor nephrectomy (OpenDN). Nonetheless, costs are less favorable for LapDN than for OpenDN. We compared LapDN and OpenDN with cost-utility analysis.Methods: A decision analysis modeling approach was performed: utilities derived using time trade-off and quality-adjusted life year (QALY) techniques; probabilities derived from a systematic review of the literature. All costs were included from a societal perspective using actual cost data from OpenDN and LapDN patients performed contemporaneously between July 1, 2000 and December 31, 2000. Costs of lost employment were estimated using mean provincial annual earnings. Incremental cost-effectiveness ratio (ICER) was calculated with "best-case" and "worst-case" scenarios for confidence intervals; sensitivity analyses were used to assess robustness.Results: LapDN costs are higher ($10,317.40 vs. $9,853.70), while quality of life (QOL) is superior (0.7683 vs. 0.7062). The ICER from a societal perspective was C$7,471.11/QALY. If all donor nephrectomies nationally were performed laparoscopically, there would be an additional annual cost of C$665,240 with a societal gain of 24.84 QALYs.Conclusions: LapDN offers improved QOL at marginally higher cost. A societal ICER of $7,471.11/QALY compares favorably to many accepted health-care interventions. By potentially increasing organ donor rates, LapDN may be cost saving by decreasing the number of patients on dialysis.

Pheochromocytoma during pregnancy is a very rare condition; fewer than 200 cases have been reported in the literature. We present the case of a 24-year-old pregnant woman found to have a pheochromocytoma during investigation of abdominal pain. This is the second reported case of laparoscopic adrenalectomy for pheochromocytoma detected during pregnancy. After appropriate radiologic investigation and medical management, a laparoscopic left adrenalectomy was performed at the beginning of the second trimester. There were no complications, and she was delivered of a healthy baby at term. We review the management of pheochromocytoma in pregnant patients and discuss the role of laparoscopy.

A technique for laparoscopic excision of benign retroperitoneal tumors, including a teratoma and two cystic lesions, is described. Laparoscopic resection of a 12-cm retroperitoneal teratoma was accomplished with the patient in the left lateral decubitus position. Medial mobilization of the ascending colon and the duodenum was required for access to the lesion. Resections of two cystic lesions (measuring 20 cm and 12 cm) were performed with the patients in the lithotomy position. The colon required medial mobilization in both cases to gain access to the cysts. Once the cysts were dissected from surrounding structures, they were punctured, and the aspirated fluid was sent for cytologic analysis. There were no complications or conversions. Mean operating time was 122 minutes (range, 80–190). Patients were discharged 1 day after surgery, requiring only nonsteroidal anti-inflammatory medications for analgesia. Retroperitoneal tumors can be resected laparoscopically with careful preoperative investigation and meticulous laparoscopic technique. A major advantage of laparoscopic resections is that the patient recovers rapidly with minimal morbidity.

Splenic preservation and conservative management are now accepted norms when dealing with splenic pathologic conditions. This case report describes the technique of laparoscopic partial splenectomy for an undiagnosed splenic lesion. A thorough understanding of splenic anatomy permits laparoscopic partial splenectomy with the resultant benefits, including a decreased risk of postsplenectomy sepsis, short hospital stay, and superior cosmesis. The success and relative ease of performing this procedure will pave the way for its future use in other selective cases involving splenic pathology.

The overall prognosis of patients afflicted with cancer of the esophagus is dismal and has not changed greatly over the last few decades. Improvements have largely been due to better perioperative care rather than new surgical techniques. There remain, however, philosophical differences in the surgical community about the optimal treatment of these patients, and these differences are summarized in this article. The principal elements required to make an appropriate surgical decision also are outlined. Until new markers for early detection and effective systematic therapy emerge, improvement is likely to occur only in subsets of patients referred early and treated in an environment that guarantees low operative mortality.

Benign peptic stricture of the esophagus is a complex disorder which results from persistent gastroesophageal reflux. Its successful management depends on an accurate preoperative evaluation of the stricture and the patient. Surgical management of peptic strictures can be quite effective in relieving the symptoms and halting the pathologic gastroesophageal reflux that accompanies this disorder. This article reviews the general principles of evaluation and surgical treatment of benign peptic esophageal strictures.

In recent years, several accounts have reported a proximal migration of colorectal cancer. To determine the experience at the Jewish General Hospital in Montreal, 1044 cases of large-bowel cancer that presented between the years 1955 and 1978 were analyzed. The colon was arbitrarily divided into five anatomic regions, and the distribution of cancer in each region for each of eight three-year periods was calculated. An increase in right-sided lesions ocurred from 15.6 per cent in the first three-year period to 37.6 per cent in the final three-year period (P<0.01). No significant change occurred in transverse and left-colon lesions. An increase in sigmoid carcinomas occurred from 14 per cent to 35 per cent (P<0.01). A dramatic decrease in rectal carcinoma from 53 per cent to 2.1 per cent occurred (P<0.001). These findings imply that methods for the early detection and screening of large-bowel carcinoma should be directed at the entire colon rather than the distal 25 cm.In recent years, several accounts have reported a proximal migration of colorectal cancer. To determine the experience at the Jewish General Hospital in Montreal, 1044 cases of large-bowel cancer that presented between the years 1955 and 1978 were analyzed. The colon was arbitrarily divided into five anatomic regions, and the distribution of cancer in each region for each of eight three-year periods was calculated. An increase in right-sided lesions ocurred from 15.6 per cent in the first three-year period to 37.6 per cent in the final three-year period (P<0.01). No significant change occurred in transverse and left-colon lesions. An increase in sigmoid carcinomas occurred from 14 per cent to 35 per cent (P<0.01). A dramatic decrease in rectal carcinoma from 53 per cent to 2.1 per cent occurred (P<0.001). These findings imply that methods for the early detection and screening of large-bowel carcinoma should be directed at the entire colon rather than the distal 25 cm.

A 39-year-old woman presented with abdominal wall mass 9 years after she underwent laparoscopic cholecystectomy for symptomatic gallstones. After surgical resection, a pathologic examination identified an abscess cavity within the abdominal wall that was surrounded by a wide, diffuse, poorly defined wall of dense fibrous tissue. An examination did not show neoplastic tissue. The cavity was bile-stained and contained a 2.5-cm gallstone. This case shows a complication of laparoscopic cholecystectomy. Gallstones spilled during the extraction of the gallbladder through the abdominal wall incision may lead to a reactive process that clinically and microscopically may resemble a fibro-proliferative disorder, including a neoplastic process. This complication of laparoscopic cholecystectomy is rare. Pathologists must be aware of its occurrence because examination of the solid fibrous wall may lead to diagnoses of reactive or neoplastic fibro-proliferative processes.

Acute mesenteric vascular accidents are being diagnosed more commonly as a consequence of an aging population and often result in emergency bowel resection for ischemia. Because predicting postoperative intestinal viability remains difficult, second-look laparotomy has been advocated to improve outcomes. Recently, laparoscopy has emerged as an alternative to laparotomy for the diagnosis and treatment of ongoing postoperative ischemia. A review of the literature since 1994 reveals that, to date, 19 procedures have been reported to prevent 13 (68) unnecessary laparotomies. We describe our laparoscopic second-look technique and review the literature. Second-look laparoscopy has been shown repeatedly to be a safe alternative to laparotomy. It is simple and reduces negative second-look laparotomy in critically ill patients.

As technology and surgeon experience expand, laparoscopic surgery is playing a larger role in the treatment of gastric conditions. We present our technical approach to various laparoscopic gastric resections and outline our preliminary results. Contrary to the majority of publications on laparoscopic gastric resection, we believe gastric mobilization should be carried out by incising the avascular plane between the greater omentum and transverse colon. This gives easy access to the origin of the left gastric artery and permits an acceptable D1 oncologic resection. For small lesions, tumor localization and resection margins should be mapped with the aid of routine intraoperative endoscopy. Nine patients underwent formal gastric resections, six of which were done for malignancy. Median time to discharge and length of follow-up were 4.5 days (range 3–10) and 25 months (range 24–35), respectively. One patient died postoperatively, and the remaining five patients operated for malignancy are alive and well with no evidence of recurrent disease or port site metastases.

Most operations in the abdominal cavity and chest can be performed using minimally invasive techniques. As yet it has not been determined which laparoscopic procedures are preferable to the same operations done through conventional laparotomy. However, most surgeons who have completed the learning curves of these procedures believe that most minimally invasive techniques will be scientifically recognized soon. The evolution, validation and justification of advanced laparoscopic surgical methods seem inevitable. Most believe that the trend towards procedures that minimize or eliminate the trauma of surgery while adhering to accepted surgical principles is irreversible. The functional results of laparoscopic antireflux surgery in the seven years since its inception have been virtually identical to the success curves generated with open fundoplication in past years. Furthermore, overall patient outcomes with laparoscopic procedures have been superior to outcomes with the traditional approach. Success is determined by patient selection and operative technique. Patient evaluation should include esophagogastroduodenoscopy, barium swallow, 24 h pH study and esophageal motility study. Gastric emptying also should be evaluated. Patients who have abnormal propulsion in the esophagus should not receive a complete fundoplication (Nissen) because it adds a factor of obstruction. Dor or Toupet procedures are adequate alternatives. Prokinetic agents, dilation or pyloroplasty are used for pyloric obstruction ranging from little to more severe. Correcting reflux laparoscopically is more difficult in patients with obesity, peptic strictures, paraesophageal hernias, short esophagus, or a history of previous upper abdominal or antireflux surgery.