RESUMEN
BACKGROUND: In recent years, multiple guidelines on bariatric and metabolic surgery were published, however, their quality remains unknown, leaving providers with uncertainty when using them to make perioperative decisions. This study aims to evaluate the quality of existing guidelines for perioperative bariatric surgery care. METHODS: A comprehensive search of MEDLINE and EMBASE were conducted from January 2010 to October 2022 for bariatric clinical practice guidelines. Guideline evaluation was carried out using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. RESULTS: The initial search yielded 1483 citations, of which, 26 were included in final analysis. The overall median domain scores for guidelines were: (1) scope and purpose: 87.5% (IQR: 57-94%), (2) stakeholder involvement: 49% (IQR: 40-64%), (3) rigor of development: 42.5% (IQR: 22-68%), (4) clarity of presentation: 85% (IQR: 81-90%), (5) applicability: 6% (IQR: 3-16%), (6) editorial independence: 50% (IQR: 48-67%), (7) overall impressions: 48% (IQR: 33-67%). Only six guidelines achieved an overall score >70%. CONCLUSIONS: Bariatric surgery guidelines effectively outlined their aim and presented recommendations. However, many did not adequately seek patient input, state search criteria, use evidence rating tools, and consider resource implications. Future guidelines should reference the AGREE II framework in study design.
Asunto(s)
Cirugía Bariátrica , Guías de Práctica Clínica como Asunto , Humanos , Cirugía Bariátrica/normasRESUMEN
BACKGROUND: Endoscopic mucosal resection (EMR) is an effective treatment for esophageal intramucosal adenocarcinoma (IMC), with similar recurrence and mortality rates versus esophagectomy in up to 5 years of follow-up. Long-term outcomes to 10 years have not been studied. This retrospective study investigates IMC eradication, recurrence, morbidity and mortality at 10 years following EMR versus esophagectomy in a single Canadian institution. METHODS: Patients with IMC treated via esophagectomy or EMR from 2006 to 2015 were included. Post-EMR endoscopic follow-up occurred every 3 months for 1 year, every 6 months for 2 years and every 12 months thereafter. Categorical variables were expressed as percentages and continuous variables as mean with standard deviation or median and interquartile range. The student's t-test and Fischer's exact test were used for comparisons. Survival analysis utilized the Kaplan-Meier estimator and log-rank test. RESULTS: Twenty-four patients were included. Patient and tumor characteristics were similar between groups. Median follow-up for EMR and esophagectomy were 85.2 months [IQR 64.8] and 126 months [IQR 54] respectively. A mean of 1.3 EMR (SD 1.1) were required for eradication, which was seen in 12 patients (12/14, 86%). No EMR-related complications occurred. Disease progression was seen in two patients (2/14, 14%); local recurrence was seen in 1 patient (1/14, 7%). Esophagectomy eradicated IMC in 10 patients (10/10, 100%); recurrence was seen in 2 (2/10, 20%, metastatic). Major, early esophagectomy-related morbidity affected 3 patients (3/10, 30%), and late morbidity was documented for 9 (9/10, 90%). Esophagectomy and EMR had similar recurrence rates (p = 0.554). Esophagectomy was associated with significantly more procedure-related morbidity (p < 0.001). There was no difference in mortality (p = 0.442) or disease-free survival (p = 0.512) between treatment groups. CONCLUSION: EMR and esophagectomy for the treatment of IMC are associated with comparable recurrence rates and disease-free survival in 10-year follow-up. EMR is associated with significantly lower procedure-associated morbidity. EMR can be used to treat T1a distal esophageal adenocarcinoma with minimal procedure-related morbidity, and acceptable oncologic outcomes in long-term follow-up.
Asunto(s)
Adenocarcinoma , Esófago de Barrett , Resección Endoscópica de la Mucosa , Neoplasias Esofágicas , Humanos , Esófago de Barrett/patología , Estudios Retrospectivos , Estudios de Seguimiento , Esofagectomía/efectos adversos , Esofagoscopía , Canadá , Neoplasias Esofágicas/patología , Adenocarcinoma/patología , Resultado del TratamientoRESUMEN
BACKGROUND: Prophylactic ursodeoxycholic acid (UDCA) may be beneficial in reducing gallstone disease after bariatric surgery. The American Society for Metabolic and Bariatric Surgery (ASMBS) 2019 guidelines recommend a 6-month course of UDCA for patients undergoing laparoscopic sleeve gastrectomy (LSG). This has not been adopted broadly. This study intends to assess the effect of routine UDCA administration following LSG on symptomatic gallstone disease. METHODS: We performed a retrospective chart review of patients who underwent LSG, between 2009 and 2019, at two tertiary care centers in Atlantic Canada. At one center, UDCA 250 mg oral twice daily was routinely prescribed following LSG for 6 months to patients with an intact gallbladder. At the other center, UDCA was not prescribed. Primary and secondary outcomes were cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) rates. Compliance with and side effects of UDCA therapy were analyzed. RESULTS: A total of 751 patients were included in the study. Patients who had prior cholecystectomy or were lost to follow up were excluded. After exclusion criteria were applied, 461 patients were included for analysis: 303 in the UDCA group and 158 in the group who did not receive UDCA. Cholecystectomy rate was not significantly associated with UDCA administration, however there was a trend towards less cholecystectomy in patients who received UDCA (8.3% vs. 13.9%, p = 0.056). ERCP rate was significantly lower in patients who received UDCA (0.3% vs 2.5%, p = 0.031). Rate of gallstone disease requiring intervention, either cholecystectomy or ERCP, was significantly decreased in patients who received UDCA (8.9% vs 15.8%, p = 0.022). The most common barriers to compliance with UDCA were cost (45.4%) and nausea (18.1%). CONCLUSION: This is the first study to demonstrate lower rates of ERCP in patients receiving routine UDCA following LSG. Our findings support the ASMBS 2019 guidelines for administering UDCA after LSG for preventing gallstone disease.
Asunto(s)
Cálculos Biliares , Gastrectomía , Ácido Ursodesoxicólico , Humanos , Cálculos Biliares/etiología , Cálculos Biliares/prevención & control , Cálculos Biliares/cirugía , Gastrectomía/efectos adversos , Laparoscopía/efectos adversos , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Ácido Ursodesoxicólico/uso terapéuticoRESUMEN
BACKGROUND: There are limited prospective data, and conflicting retrospective data, providing guidance on how to optimally manage patients with morbid obesity and severe knee osteoarthritis. This study sought to review the effect of bariatric surgery on knee pain and knee surgery 30-day outcomes, as well as assess whether the sequence of bariatric and knee surgery has any effect on 30-day complications. METHODS: A retrospective chart review of all patients undergoing laparoscopic sleeve gastrectomy (LSG) from July 2006 to July 2016 at a university hospital was performed. Patients with knee pain or knee surgery (pre- or post-LSG) were identified using bariatric and orthopedic clinic notes. Those who had improvement in knee pain following LSG resulting in removal from orthopedic surgery waitlist were identified. We also assessed surgical outcomes in patients undergoing knee arthroscopy or total knee arthroplasty (TKA) followed by LSG compared to patients undergoing LSG followed by knee arthroscopy or TKA. RESULTS: During our study timeframe, 355 patients underwent LSG. Knee pain was documented in 150 (42.2%) patients, and orthopedic surgery consultation was completed for 57 (38.0%) patients with knee pain. Orthopedic intervention was performed prior to LSG for 24 patients and after LSG for 27 patients. Procedures were a combination of arthroscopy (18) and TKA (33). Six patients were removed from the waitlist for TKA following LSG due to resolution of symptoms. Order of interventions did not affect 30-day complications for patients undergoing LSG and arthroscopy (16% arthroscopy first, 0% LSG first, p = 0.43). A higher rate of LSG complications was noted in patients who underwent TKA prior to LSG (25% vs 0%, p = 0.04). There were no differences in TKA complications (8.3% TKA first, 4.8% LSG first, p = 1.00). CONCLUSION: In a small number of patients with morbid obesity and severe knee osteoarthritis, orthopedic intervention can be delayed and potentially avoided by undergoing LSG. In our study, 6/57 (10.5%) of patients with orthopedic consultation prior to LSG saw resolution of symptoms of knee pain. Referral to bariatric surgery should be considered for patients with morbid obesity and severe knee osteoarthritis.
Asunto(s)
Cirugía Bariátrica , Laparoscopía , Obesidad Mórbida , Osteoartritis de la Rodilla , Cirugía Bariátrica/efectos adversos , Gastrectomía/métodos , Humanos , Laparoscopía/métodos , Obesidad Mórbida/complicaciones , Obesidad Mórbida/cirugía , Osteoartritis de la Rodilla/complicaciones , Osteoartritis de la Rodilla/cirugía , Dolor/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Estudios Prospectivos , Estudios Retrospectivos , Resultado del Tratamiento , Pérdida de PesoRESUMEN
BACKGROUND: Global trend has seen management shift towards selective conservatism in penetrating abdominal trauma (PAT). The purpose of this study is to compare the presentation; management; and outcomes of patients with PAT managed operatively versus non-operatively. METHODS: Prospective cohort study of all patients Ùpresenting with PAT to Groote Schuur Hospital, Cape Town from 01 May 2015 to 30 April 2017. Presentation; management; and outcomes of patients were compared. Univariate predictors of delayed operative management (DOM) were explored. RESULTS: Over the 2-year study period, 805 patients with PAT were managed. There were 502 (62.4%); and 303 (37.6%) patients with gunshot (GSW) and stab wounds (SW), respectively. The majority were young men (94.7%), with a mean age of 28.3 years (95% CI 27.7-28.9) and median ISS of 13 (IQR 9-22). Successful non-operative management was achieved in 304 (37.7%) patients, and 501 (62.5%) were managed operatively. Of the operative cases, 477 (59.3%) underwent immediate laparotomy and 24 (3.0%) DOM. On univariate analysis, number; location; and mechanism of injuries were not associated with DOM. Rates of therapeutic laparotomy were achieved in 90.3% in the immediate, and 80.3% in the DOM cohorts. The mortality rate was 1.3, 11.3 and 0% in the in the NOM, immediate laparotomy and DOM subgroups, respectively. The rate of complications was no different in the immediate and DOM cohorts (p > 0.05). CONCLUSION: Patients with PAT in the absence of haemodynamic instability; peritonism; organ evisceration; positive radiological findings, or an unreliable clinical examination, can be managed expectantly without increased morbidity or mortality.
Asunto(s)
Traumatismos Abdominales , Heridas por Arma de Fuego , Heridas Penetrantes , Heridas Punzantes , Traumatismos Abdominales/epidemiología , Traumatismos Abdominales/cirugía , Adulto , Humanos , Laparotomía , Masculino , Estudios Prospectivos , Estudios Retrospectivos , Sudáfrica/epidemiología , Centros Traumatológicos , Heridas por Arma de Fuego/complicaciones , Heridas por Arma de Fuego/epidemiología , Heridas por Arma de Fuego/terapia , Heridas Penetrantes/epidemiología , Heridas Penetrantes/cirugía , Heridas Punzantes/epidemiología , Heridas Punzantes/cirugíaRESUMEN
Summary: Peripancreatic fluid collections (PFCs) occur as a consequence of pancreatitis. Most PFCs resolve spontaneously, although 1%-2% persist and may require intervention. Conventional transluminal endoscopic drainage methods require the PFC to be bulging into the gastric wall; however, it is not uncommon for this to be absent. Imaging guidance for transluminal endoscopic PFC drainage allows the endoscopist to localize nonbulging pseudocysts that cannot be localized using endoscopy alone, to identify and avoid vascular structures between the cyst and the gastric lumen, and to reveal solid or necrotic components within the pseudocyst cavity. Although endoscopic ultrasound (EUS) has been used to meet this need, timely access to therapeutic EUS remains a limiting factor at many centres. We report our technique and experience performing transgastric endoscopic drainage of PFCs under computed tomography (CT) interventional radiology guidance.
Asunto(s)
Drenaje/métodos , Endoscopía del Sistema Digestivo/métodos , Pancreatitis/cirugía , Radiología Intervencionista/métodos , Cirugía Asistida por Computador/métodos , Tomografía Computarizada por Rayos X/métodos , Endosonografía/métodos , Humanos , Pancreatitis/diagnóstico , Estudios Retrospectivos , EstómagoRESUMEN
BACKGROUND: In Canada, bariatric surgery continues to remain the most effective treatment for severe obesity and its comorbidities. As the number of bariatric surgeries continues to grow, the need for consensus guidelines for optimal perioperative care is imperative. In colorectal surgery, enhanced recovery after surgery (ERAS) protocols were created for this purpose. The objective of this review is to develop evidence-based ERAS guidelines for bariatric surgery. METHODS: A literature search of the MEDLINE database was performed using ERAS-specific search terms. Recently published articles with a focus on randomized controlled trials, systematic reviews, and meta-analyses were included. Quality of evidence and recommendations were evaluated using the GRADE assessment system. RESULTS: Canadian bariatric surgeons from six provinces and ten bariatric centers performed a review of the evidence surrounding ERAS in bariatric surgery and created consensus guidelines for 14 essential ERAS elements. Our main recommendations were (1) to encourage participation in a presurgical weight loss program; (2) to abstain from tobacco and excessive alcohol; (3) low-calorie liquid diet for at least 2 weeks prior to surgery; (4) to avoid preanesthetic anxiolytics and long-acting opioids; (5) unfractionated or low-molecular-weight heparin prior to surgery; (6) antibiotic prophylaxis with cefazolin ± metronidazole; (7) reduced opioids during surgery; (8) surgeon preference regarding intraoperative leak testing; (9) nasogastric intubation needed only for Veress access; (10) to avoid abdominal drains and urinary catheters; (11) to prevent ileus by discontinuing intravenous fluids early; (12) postoperative analgesia with acetaminophen, short-term NSAIDS, and minimal opioids; (13) to resume full fluid diet on first postoperative day; (14) early telephone follow-up with full clinic follow-up at 3-4 weeks. CONCLUSIONS: The purpose of addressing these ERAS elements is to develop guidelines that can be implemented and practiced clinically. ERAS is an excellent model that improves surgical efficiency and acts as a common perioperative pathway. In the interim, this multimodal bariatric perioperative guideline serves as a common consensus point for Canadian bariatric surgeons.
Asunto(s)
Cirugía Bariátrica/rehabilitación , Cirugía Bariátrica/normas , Vías Clínicas/normas , Recuperación Mejorada Después de la Cirugía/normas , Obesidad Mórbida/cirugía , Canadá , Consenso , HumanosRESUMEN
BACKGROUND: There currently is no consensus on how to accurately predict early rebleeding and death after a major variceal bleed. This study investigated the relative predictive performances of the original Child-Pugh (CP), model for end-stage liver disease (MELD) and a four-category recalibrated Child-Pugh (rCP). METHODS: This prospective study included all adult patients admitted to Groote Schuur Hospital with acute esophageal variceal bleeding secondary to alcoholic cirrhosis, between January 2000 and December 2017. CP and rCP grades and MELD score were calculated on admission, and the predictive ability in discriminating in-hospital rebleeding and death was compared by area under receiver-operating characteristic (AUROC) curves. RESULTS: During the study period, 403 consecutive adult patients were treated for bleeding esophageal varices of whom 225 were secondary to alcoholic cirrhosis. Twenty-four (10.6%) patients were CP grade A, 88 (39.1%) grade B and 113 (50.2%) grade C on hospital admission. MELD scores ranged from 6 to 40. Thirty-one (13.8%) patients rebleed, and 41 (18.2%) patients died. There was no difference in the discriminatory capacity of the CP (AUROC 0.59, 95% CI 0.50-0.670) and MELD (AUROC 0.62, 95% CI 0.51-0.73) to predict rebleeding (p = 0.72), or between the Child-Pugh (AUROC 0.75, 95% CI 0.71-0.81) and MELD (AUROC 0.71, 95% CI 0.62-0.80) to predict death (p = 0.35). The rCP classification (A-D) had a significantly improved discriminatory capacity (AUROC 0.83 95% CI 0.77-0.89) compared to the CP score (A-C) and MELD to predict death (p = 0.004). CONCLUSION: A recalibrated Child-Pugh score outperforms the original Child-Pugh grade and MELD score in predicting in-hospital death in patients with bleeding esophageal varices secondary to alcoholic cirrhosis.
Asunto(s)
Enfermedad Hepática en Estado Terminal/mortalidad , Várices Esofágicas y Gástricas/complicaciones , Hemorragia Gastrointestinal/mortalidad , Mortalidad Hospitalaria , Cirrosis Hepática Alcohólica/complicaciones , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Summary: The Canadian Association of Chairs of Surgical Research was created in 2014, with representation from every departmental surgical research committee across Canada, to establish Canadian surgical research as a beacon for health care innovation and to propose solutions for the daily challenges facing surgeon-researchers. Our key mandate has been to identify challenges for surgeons and scientists performing research to prevent further erosion of this vital area of activity that benefits patients, health care service providers and Canadian society. This article outlines the findings of a nationwide survey sent to all members of departments of surgery across Canada, seeking input on current threats and potential solutions. The results suggest that surgical research in Canada is experiencing a decline in funding and an increase in challenges affecting research productivity of academic surgeons, such as pressures to be clinically active, unpredictable surgical schedules, growing administrative demands, and increasing complexity of patient populations. Although surgeons are productive in their research endeavours, institutional changes and sharing of best practices are needed to ensure sustainable growth of research programs.
Asunto(s)
Actitud del Personal de Salud , Investigación Biomédica , Cirugía General , Canadá , Humanos , Encuestas y CuestionariosRESUMEN
Summary: Comparisons with other high-income countries suggest that Canada has been slower to adopt laparoscopic colectomy (LC). The Canadian Association of General Surgeons sought to evaluate the barriers to adoption of laparoscopic colon surgery and to propose potential intervention strategies to enhance the use of the procedure. Given the clinical benefits of laparoscopic surgery for patients, the increasing needs for surgical care and the desire of Canadian general surgeons to advance their specialty and enhance the care of their patients, it is an important priority to improve the utilization of LC.
Asunto(s)
Colectomía/tendencias , Neoplasias del Colon/cirugía , Procedimientos Quirúrgicos Electivos/tendencias , Implementación de Plan de Salud/tendencias , Laparoscopía/tendencias , Canadá , Competencia Clínica , Colectomía/métodos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Implementación de Plan de Salud/estadística & datos numéricos , Humanos , Laparoscopía/métodos , Aceptación de la Atención de Salud/estadística & datos numéricos , Cirujanos/organización & administraciónRESUMEN
Obesity and weight loss have complex effects on respiratory physiology, but these have been insufficiently studied, particularly at early time points following weight loss surgery and in the supine position. We evaluated 15 female participants with severe obesity before and 5 wk and 6 mo after bariatric surgery using the Pittsburgh Sleep Quality Index (PSQI), spirometry, plethysmography, and oscillometry to measure respiratory system mechanics. Oscillometry and spirometry were conducted in the upright and supine position and before and after bronchodilation with 200 µg of salbutamol. At 5 wk postsurgery, weight loss was 11.9 kg (SD 2.7) with no effect on spirometric outcomes and a slight effect on oscillometric outcomes. However, at 6 mo weight loss was 21.4 kg (SD 7.1) with a 14.1% (SD 6.1) and 17.8 (5.4)% reduction in upright and supine respiratory system resistance (Rrs),6, respectively. Respiratory system elastance also decreased by 25.7% (SD 9.4) and 20.2 (SD 7.2)% in the upright and supine positions. No changes were observed in spirometry, but sleep quality improved from PSQI of 8.4 (SD 3.5) to 4.1 (SD 2.9). Bronchodilator responsiveness was low at baseline but increased significantly after surgery, and this response was comparable to the improvement in Rrs produced by weight loss. Modeling the impedance spectra with a two-compartment model demonstrated that improvements in lung mechanics with weight loss begin in the upper or central compartment of the lungs and progress to include the peripheral compartment. Respiratory mechanics are impaired in individuals with severe obesity and is associated with poor sleep quality, but these improved substantially with weight loss. Our data provide new evidence that individuals with severe obesity may have poor sleep quality because of abnormal respiratory mechanics that weight loss improves.NEW & NOTEWORTHY This is the first study to quantify the degree of weight loss-induced improvements in respiratory system mechanics in both upright and supine positions, and its association with bronchodilator responsiveness and sleep quality at multiple time points. Weight loss induced large improvements in upright and supine respiratory system mechanics with corresponding improvements in bronchodilator responsiveness and sleep quality. Using mathematical modeling, we demonstrate that these improvements begin in the central airways and progress to include the lung periphery.
RESUMEN
BACKGROUND: Achalasia is a chronic disease affecting the myenteric plexus of the esophagus and lower esophageal sphincter. Treatment is aimed at palliating symptoms to improve quality of life. Treatment options for symptom relapse after esophagomyotomy include botox injection, repeat myotomy, per-oral endoscopic myotomy, or pneumatic balloon dilation (PBD). Data demonstrating the safety and efficacy of PBD for recurrence are scarce. With a lack of published data, guidelines have suggested avoiding PBD for recurrent achalasia because of concern for a high risk of perforation. METHODS: A retrospective review of patients who underwent PBD for recurrent symptoms of achalasia after esophagomyotomy between 2007 and 2017 was conducted. PBD was performed at 30 mm and held for 60 s under fluoroscopic guidance. Patients with residual symptoms had subsequent dilations at increasing 5 mm increments to a maximum of 40 mm. Patient demographics, Eckardt scores, presence of hiatal hernia, time from myotomy to recurrence, and diagnostic modalities were reported. The primary outcome was need for further endoscopic or surgical intervention. Complications are reported as secondary outcomes. RESULTS: One-hundred eight esophagomyotomies were done during the study period. Fourteen patients underwent PBD for recurrent symptoms. The median time to symptom recurrence after esophagomyotomy was 28 months. The median Eckardt score was 6. Ten of 14 patients had an intervention between the initial surgery and PBD (9 standard dilations and 1 botox injection). A total of 23 PBD were done. Seven patients required dilation at 35 mm and two patients required dilation at 40 mm. Eleven patients required no further intervention at a median follow-up of 27.7 months. There were three treatment failures: one required repeat esophagomyotomy and two had no further treatments. There were no periprocedural complications. CONCLUSION: Serial PBD is safe and effective in treatment of recurrent symptoms of achalasia after esophagomyotomy.
Asunto(s)
Dilatación/métodos , Acalasia del Esófago/terapia , Miotomía de Heller , Adulto , Dilatación/instrumentación , Femenino , Fluoroscopía , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Estudios RetrospectivosRESUMEN
BACKGROUND: Endoscopic mucosal resection (EMR) is increasingly being used as a first-line treatment for Barrett esophagus (BE) with high-grade dysplasia (HGD) and intramucosal adenocarcinoma (IMC). We reviewed our experience with endoscopic treatment of BE with HGD and IMC at our institution with respect to eradication rates, complications and long-term recurrence. METHODS: We performed a single-centre retrospective review of all patients referred between October 2010 and August 2014 for EMR with dysplastic BE or IMC. We performed EMR using a cap-fitted endoscope, and the procedure was repeated every 3 months until eradication or progression of disease. RESULTS: A total of 28 patients were identified: 16 with dysplastic BE (14 HGD, 1 low-grade dysplasia, 1 intermediate dysplasia) and 12 with IMC. Complete eradication of HGD was achieved in 11 of 14 (79%) patients. Three of 12 (25%) patients initially referred with suspected IMC were found to have invasive adenocarcinoma on EMR. Eradication was successful in 8 of 9 (89%) patients with true IMC, with 1 patient progressing to salvage esophagectomy. Complications occurred in 2 of 28 (7%) patients; both had esophageal strictures managed with dilatation. Median duration of follow-up was 371 days. CONCLUSION: Our experience supports the safety of EMR as a first-line treatment for patients with BE with dysplasia and IMC in early short-term follow-up.
CONTEXTE: La mucosectomie endoscopique est de plus en plus utilisée en première intention pour l'oesophage de Barrett avec dysplasie de haut grade (DHG) et pour l'adénocarcinome intramuqueux. Nous avons passé en revue notre expérience du traitement endoscopique de l'oesophage de Barrett avec DHG et de l'adénocarcinome intramuqueux dans notre établissement aux plans des taux d'éradication, des complications et des récurrences à long terme. MÉTHODES: Nous avons procédé à une revue rétrospective de tous les cas d'oesophage de Barrett dysplasique ou d'adénocarcinome intramuqueux d'un seul centre adressés pour mucosectomie endoscopique entre octobre 2010 et août 2014. Nous avons effectué les mucosectomies endoscopiques à l'aide d'un endoscope muni d'un capuchon, et les interventions étaient répétées tous les 3 mois jusqu'àéradication ou progression de la maladie. RÉSULTATS: En tout, 28 patients ont été recensés : 16 présentaient un oesophage de Barrett dysplasique (14 DHG, 1 dysplasie de bas grade, 1 dysplasie intermédiaire) et 12 présentaient un adénocarcinome intramuqueux. Une éradication complète de la DHG a été obtenue chez 11 patients sur 14 (79 %). Chez 3 patients sur 12 (25 %) initialement adressés pour un adénocarcinome intramuqueux, la mucosectomie a révélé un adénocarcinome envahissant. Huit patients sur 9 (89 %) atteints d'un adénocarcinome intramuqueux avéré ont subi le traitement d'éradication avec succès, et 1 patient a dû subir une oesophagectomie de sauvetage. Des complications sont survenues chez 2 patients sur 28 (7 %); les 2 patients ont présenté des sténoses oesophagiennes corrigées par dilatation. La durée médiane du suivi a été de 371 jours. CONCLUSION: Notre expérience confirme l'innocuité de la mucosectomie endoscopique comme traitement de première intention chez les patients présentant un oesophage de Barrett dysplasique ou un adénocarcinome intramuqueux dans le contexte d'un suivi à court terme.
Asunto(s)
Adenocarcinoma/cirugía , Esófago de Barrett/cirugía , Resección Endoscópica de la Mucosa/métodos , Neoplasias Esofágicas/cirugía , Evaluación de Resultado en la Atención de Salud , Anciano , Anciano de 80 o más Años , Canadá , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Esophagectomy has been the standard of care for patients with intramucosal adenocarcinoma (IMC) in the setting of Barrett's esophagus. It is, however, associated with significant post-operative morbidity and mortality. Endoscopic mucosal resection (EMR) offers a minimally invasive approach with lesser morbidity. This study investigates the transition from esophagectomy to EMR for IMC with respect to eradication rates, post-operative morbidity, and long-term survival. METHODS: Patients diagnosed with IMC from 2005 to 2013 were identified retrospectively. Beginning in 2009, preferred initial therapy for IMC transitioned from esophagectomy to EMR. Esophagectomy was performed either through a transthoracic or transhiatal technique. EMR was repeated until resolution of IMC on pathology or progression of disease. Continuous data are expressed as mean (SD) and analyzed using Student's t test. Categorical data are presented as number (%) and analyzed using Fisher's exact test. RESULTS: We identified 23 patients; 12 patients underwent esophagectomy and 11 patients underwent EMR as initial therapy. Patients were similar with respects to age, gender, and comorbidity index. Most tumors arose from short segment (vs long segment) Barrett's (esophagectomy: 9 (75%) vs. EMR: 10 (91%), p = 0.59) and one patient in each group had superficial invasion into the submucosa (T1sm1), the remainder having mucosal disease. Esophagectomy was associated with 7 (58%) minor complications and 2 (17%) major complications (respiratory failure, anastomotic leak), whereas there were no complications related to EMR (p < 0.01). EMR successfully eradicated IMC in 10 patients (91%) with one progressing to esophagectomy. Patients required 2 (1) endoscopies to achieve eradication. There was one mortality in each group on long-term follow-up (log-rank test, p = 0.62). CONCLUSIONS: EMR was successful in eradicating IMC in 10/11 patients with similar long-term recurrence and mortality to esophagectomy patients. Patients with IMC may benefit from EMR as initial therapy by obviating the need for a complex and morbid operation.
Asunto(s)
Adenocarcinoma/patología , Esófago de Barrett/patología , Resección Endoscópica de la Mucosa , Neoplasias Esofágicas/patología , Esofagectomía , Recurrencia Local de Neoplasia/cirugía , Adenocarcinoma/cirugía , Anciano , Esófago de Barrett/complicaciones , Esófago de Barrett/cirugía , Progresión de la Enfermedad , Resección Endoscópica de la Mucosa/métodos , Neoplasias Esofágicas/cirugía , Esofagectomía/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Obesity is associated with respiratory symptoms that are reported to improve with weight loss, but this is poorly reflected in spirometry, and few studies have measured respiratory mechanics with oscillometry. We investigated whether early changes in lung mechanics following weight loss are detectable with oscillometry. Furthermore, we investigated whether the changes in lung mechanics measured in the supine position following weight loss are associated with changes in sleep quality. Nineteen severely obese female subjects (mean body mass index, 47.2 ± 6.6 kg/m(2)) were evaluated using spirometry, oscillometry, plethysmography, and the Pittsburgh Sleep Quality Index before and 5 weeks after bariatric surgery. These tests were conducted in both the upright and the supine position, and pre- and postbronchodilation with 200 µg of salbutamol. Five weeks after surgery, weight loss of 11.5 ± 2.5 kg was not associated with changes in spirometry and plethysmography, with the exception of functional residual capacity. There were also no changes in upright respiratory system resistance (Rrs) or reactance following weight loss. Importantly, however, in the supine position, weight loss caused a substantial reduction in Rrs. In addition, sleep quality improved significantly and was highly correlated with the reduction in supine Rrs. Prior to weight loss, subjects did not respond to the bronchodilator when assessed in the upright position with either spirometry or oscillometry; however, with modest weight loss, bronchodilator responsiveness returned to the normal range. Improvements in lung mechanics occur very early after weight loss, mostly in the supine position, resulting in improved sleep quality. These improvements are detectable with oscillometry but not with spirometry.
Asunto(s)
Cirugía Bariátrica , Pulmón/fisiopatología , Obesidad Mórbida/cirugía , Oscilometría , Trastornos Respiratorios/diagnóstico , Mecánica Respiratoria , Adulto , Índice de Masa Corporal , Peso Corporal , Femenino , Volumen Espiratorio Forzado , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Obesidad Mórbida/complicaciones , Pletismografía , Trastornos Respiratorios/complicaciones , Trastornos Respiratorios/fisiopatología , Pruebas de Función Respiratoria , Higiene del Sueño/fisiología , Espirometría , Encuestas y Cuestionarios , Circunferencia de la CinturaRESUMEN
This 2014 roundtable discussion, hosted by the Canadian Association of General Surgeons, brought together general surgeons and gastroenterologists with expertise in endoscopy from across Canada to discuss the state of endoscopy in Canada. The focus of the roundtable was the evaluation of the competence of general surgeons at endoscopy, reviewing quality assurance parameters for high-quality endoscopy, measuring and assessing surgical resident preparedness for endoscopy practice, evaluating credentialing programs for the endosuite and predicting the future of endoscopic services in Canada. The roundtable noted several important observations. There exist inadequacies in both resident training and the assessment of competency in endoscopy. From these observations, several collaborative recommendations were then stated. These included the need for a formal and standardized system of both accreditation and training endoscopists.
Asunto(s)
Endoscopía/normas , Gastroenterología , Cirugía General/organización & administración , Canadá , Competencia Clínica , Humanos , Sociedades MédicasRESUMEN
BACKGROUND: Obesity is associated with increased mortality. Bariatric surgery is becoming an important treatment modality for obesity, with an associated reduction in mortality. There are few data available on the incidence and cause of death in referred patients while they are waiting for bariatric surgery. METHODS: We retrospectively examined all cases of death in patients who were referred for bariatric surgery assessment but who had not yet undergone bariatric surgery at a tertiary care centre in Halifax, Nova Scotia. The wait list comprised patients referred for surgery between March 2008 and May 2013. All cases of death were reviewed to determine age, sex, time of referral, time spent on the wait list, cause of death, comorbidities and body mass index (BMI). RESULTS: Of the 1399 patients referred, 22 (1.57%) died before receiving surgery. The mean age of these patients was 62.7 (range of 32-70) years. The average time from referral to death was 21.6 months, and the average BMI was 51.5. The most frequent cause of death was cancer, followed by cardiac and infectious causes. CONCLUSION: This study provides useful information about mortality and causes of death among patients awaiting bariatric surgery at our centre. Our results will help guide the development of a judicious system for triage in light of long wait times.
CONTEXTE: L'obésité est associée à une mortalité accrue. La chirurgie bariatrique devient une modalité thérapeutique importante pour traiter l'obésité et elle est associée à une réduction de la mortalité. On dispose de peu de données sur l'incidence et la cause du décès chez les patients référés qui sont en attente d'une chirurgie bariatrique. MÉTHODES: Nous avons examiné rétrospectivement tous les cas de patients référés qui sont décédés en attente d'une chirurgie bariatrique dans un centre de soins tertiaires de Halifax (Nouvelle-Écosse). La liste d'attente comprenait des patients référés pour chirurgie entre mars 2008 et mai 2013. Nous avons passé en revue tous les décès pour déterminer l'âge, le sexe, la date de la référence, le temps passé sur la liste d'attente, la cause du décès, les comorbidités et l'indice de masse corporelle (IMC). RÉSULTANTS: Parmi les 1399 patients référés, 22 (1,57 %) sont décédés avant de subir leur chirurgie. L'âge moyen de ces patients était de 62,7 ans (entre 32 et 70 ans). L'intervalle moyen entre la référence et le décès a été de 21,6 mois et l'IMC moyen était de 51,5. La cause de décès la plus fréquente était le cancer, suivi des causes cardiaques et infectieuses. CONCLUSION: Cette étude procure des renseignements utiles sur la mortalité et les causes de décès chez les patients en attente d'une chirurgie bariatrique dans notre établissement. Ces résultats permettront de mieux orienter la création d'un système de triage adéquat, compte tenu de la longueur des temps d'attente.
Asunto(s)
Cirugía Bariátrica , Obesidad Mórbida/mortalidad , Listas de Espera , Adulto , Distribución por Edad , Anciano , Enfermedades Cardiovasculares/mortalidad , Causas de Muerte , Comorbilidad , Femenino , Humanos , Infecciones/mortalidad , Masculino , Persona de Mediana Edad , Neoplasias/mortalidad , Nueva Escocia/epidemiología , Obesidad Mórbida/epidemiología , Derivación y Consulta , Estudios Retrospectivos , Distribución por SexoRESUMEN
BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an increasingly performed operation for morbid obesity worldwide. To date there has been limited experience in Canada. We report our intermediate results, assessing whether LSG can be safely performed at a Canadian academic teaching hospital and whether it is effective as a bariatric procedure and as metabolic therapy for type 2 diabetes mellitus. METHODS: We performed a retrospective review of all patients who underwent LSG at our institution from Sept. 1, 2007, to June 30, 2011. RESULTS: We included 166 patients (mean age 44 yr, 82% female) in our study. The mean preoperative body mass index was 49.61. At baseline, 87 (52%) patients had type 2 diabetes. For this subgroup, mean preoperative HbA1c and AC glucose were 7.6% and 8.3 mmol/L, respectively. The mean duration of surgery was 93 minutes. Major complications included 1 staple line leak (0.6%), and 2 patients required reintervention for bleeding (1.2%). The mean hospital stay was 2.6 days. Two patients required readmission (1.2%). Seven minor complications occurred (4%). Postoperative excess weight loss was 49.3% at 6 months, 54.2% at 12 months and 64.4% at 24 months. In the type 2 diabetes subgroup, resolution occurred in 78% and improvement in 7% of patients at 12 months. CONCLUSION: Laparoscopic sleeve gastrectomy can be safely performed at Canadian teaching hospitals. It is effective both as a bariatric procedure and as a therapeutic intervention for type 2 diabetes mellitus.
CONTEXTE: La gastrectomie verticale par laparoscopie (GVL) est une intervention de plus en plus utilisée pour traiter l'obésité morbide partout dans le monde. À ce jour, au Canada, l'expérience en a été limitée. Nous faisons état de nos résultats intérimaires et nous évaluons si la GVL peut être effectuée de manière sécuritaire dans un hôpital d'enseignement universitaire canadien et si elle est efficace en tant qu'intervention bariatrique et comme traitement métabolique du diabète de type 2. MÉTHODES: Nous avons procédé à une revue rétrospective des dossiers de tous les patients qui ont subi une GVL dans notre établissement entre le 1er septembre 2007 et le 30 juin 2011. RÉSULTATS: Nous avons ainsi inclus 166 patients (âge moyen 44 ans, 82 % de femmes) dans notre étude. L'indice de masse corporelle préopératoire moyen était de 49,61. Au départ, 87 patients (52 %) souffraient de diabète de type 2. Pour ce sous-groupe, l'HbA1c et la glycémie à jeun préopératoires moyennes étaient respectivement de 7,6 % et de 8,3 mmol/L. La durée moyenne de la chirurgie a été de 93 minutes. Les complications majeures ont inclus une fuite au niveau de la ligne d'agrafage (0,6 %) et on a dû réintervenir chez 2 patients en raison de saignements (1,2 %). Le séjour hospitalier moyen a été de 2,6 jours. Deux patients ont dû être réadmis (1,2 %). Sept complications mineures sont survenues (4 %). La perte de poids excédentaire postopératoire a été de 49,3 % à 6 mois, de 54,2 % à 12 mois et de 64,4 % à 24 mois. Dans le sousgroupe atteint de diabète de type 2, la résolution est survenue chez 78 % des patients et une amélioration, chez 7 % des patients à 12 mois. CONCLUSION: La gastrectomie verticale par laparoscopie peut être effectuée de façon sécuritaire dans les hôpitaux universitaires canadiens. Il s'agit à la fois d'une intervention bariatrique et d'un traitement pour le diabète de type 2.
Asunto(s)
Diabetes Mellitus Tipo 2/prevención & control , Gastrectomía , Laparoscopía , Obesidad Mórbida/cirugía , Pérdida de Peso , Adulto , Glucemia/metabolismo , Índice de Masa Corporal , Canadá , Diabetes Mellitus Tipo 2/complicaciones , Femenino , Hemoglobina Glucada/metabolismo , Hospitales de Enseñanza , Humanos , Masculino , Obesidad Mórbida/sangre , Obesidad Mórbida/complicaciones , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: In the United States, 37.5 % of adults (78 million) are obese. The direct medical costs of treating obesity-related disease account for more than 6 % of the national health expenditure. Robotic bariatric surgery is becoming more common, but it is unclear whether robotic procedures result in lower complication rates. Additionally, some evidence is conflicting regarding the costs of robotic Roux-en-Y gastric bypass (RYGB) compared with those of laparoscopic RYGB. This study aimed to compare complication rates, operative characteristics, and expected costs between robotic and laparoscopic RYGB. METHODS: A systematic review of the literature was performed with searches of five databases and grey literature, hand searches, and reference and forward citation searches. Studies comparing robotic versus laparoscopic RYGB involving patients ages 18-65 years who met the National Institutes of Health (NIH) criteria for bariatric surgery were included in the study if they reported overall or major complication rates. Outcomes were pooled using random-effects metaanalysis. A decision-tree economic analysis was performed to calculate expected costs associated with each technique. RESULTS: The systematic search strategy returned 1,374 potentially relevant studies. The inclusion criteria were met by 10 of these studies, which included results from 2,557 patients. The overall major and minor complications did not differ significantly between the robotic and laparoscopic groups. The rates for anastomotic leak, bleeding, stricture, and reoperation did not differ significantly. An economic analysis found that the expected costs for robotic RYGB ($15,447) were higher than for laparoscopic RYGB ($11,956). Sensitivity analyses produced similar results. CONCLUSION: The complication rates did not differ significantly between robotic and laparoscopic RYGB, but the expected costs were greater for robotic RYGB. Further cost effectiveness analyses are recommended before adoption of a robotic approach to RYGB.
Asunto(s)
Derivación Gástrica/métodos , Gastos en Salud , Laparoscopía/economía , Obesidad Mórbida/cirugía , Robótica/economía , Análisis Costo-Beneficio , Humanos , Obesidad Mórbida/economíaRESUMEN
BACKGROUND: Transabdominal ultrasonography (TAUS) is the most commonly used modality to diagnose gallbladder (GB) disease. GB polyps are reported in 1-5.6 % of TAUS studies. Histopathologic studies suggest that there is a relationship between GB polyps and GB cancer. Previous literature suggests GB polyps reported on TAUS do not correlate well with histological findings. There have been recent advances in TAUS technology. We hypothesize the recent advances in TAUS technology have improved the accuracy of TAUS for diagnosing GB polyps. METHODS: Radiology and pathology databases at our tertiary care center were retrospectively searched between January 1, 2000, and December 31, 2010. Ultrasound reports that suggested a GB polyp was present on TAUS were correlated to histopathology in cases where a cholecystectomy was performed. The pathology reports where a GB polyp was found were correlated with preoperative TAUS reports. RESULTS: There were 102,740 TAUS reports referring to the GB, of which 6,612 (6.4 %) contained search terms suggesting a GB polyp was present. There were 13,278 cholecystectomy pathology reports, of which 159 (1.2 %) included a diagnosis of GB polyp. TAUS detected only 50 % of the polyps identified on histopathology. The sensitivity and specificity of TAUS for diagnosing GB polyps were 50.0 and 98.3 %, respectively. The positive and negative predictive values were 10.5 and 99.8 %. CONCLUSIONS: Despite improvement in TAUS technology, the accuracy for GB polyps remains poor. This needs to be considered when managing patients with TAUS-detected GB polyps. We recommend that the decision to operate on TAUS-detected GB polyps be largely based on symptoms, and following GB polyps with TAUS should be discouraged.