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1.
World J Surg ; 48(6): 1448-1457, 2024 06.
Artículo en Inglés | MEDLINE | ID: mdl-38629870

RESUMEN

INTRODUCTION: The use of prosthetic mesh in laparoscopic repair of large hiatus hernias remains controversial. Clinical and quality of life outcomes from a randomized controlled trial of mesh versus suture repair previously showed few differences at early follow-up. This study evaluated longer-term quality of life outcomes from that trial. METHODS: A prospective, multicentre, double blind randomized controlled trial assessed three methods of repair for large hiatus hernias: sutures-only versus absorbable mesh versus non-absorbable mesh. Quality of life was assessed using the Short-Form 36 (SF-36) questionnaire which was completed preoperatively and then at 3, 6, 12 months following surgery and annually thereafter. SF-36 outcomes were compared across the three repair techniques at longer-term follow-up (3-6 years), and to earlier baseline and 12-month outcomes. RESULTS: 126 patients were randomized; 43-suture-only, 41-absorbable mesh and 42-non-absorbable mesh. Questionnaires were completed by 118 patients preoperatively, 115 at 12 months and 98 at longer-term follow-up (median 5 years). There were no significant differences between the repair techniques for the subscale and composite scores at longer-term follow-up. The mental component score improved significantly after surgery and was sustained across follow-up for all techniques. The physical component score also improved significantly but was lower at longer-term follow-up compared to the 12-month follow up in both mesh groups. CONCLUSION: Surgical repair of large hiatus hernias provides sustained long-term improvement in quality of life. The addition of mesh does not improve quality of life. TRIAL REGISTRATION: This trial is registered with the Australia and New Zealand Clinical Trials Registry ACTRN12605000725662.


Asunto(s)
Hernia Hiatal , Herniorrafia , Laparoscopía , Calidad de Vida , Mallas Quirúrgicas , Humanos , Hernia Hiatal/cirugía , Femenino , Masculino , Herniorrafia/métodos , Herniorrafia/instrumentación , Método Doble Ciego , Estudios Prospectivos , Estudios de Seguimiento , Persona de Mediana Edad , Anciano , Laparoscopía/métodos , Resultado del Tratamiento , Encuestas y Cuestionarios , Adulto
2.
Ann Surg ; 275(1): 39-44, 2022 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-33214480

RESUMEN

OBJECTIVE: To determine very late clinical outcomes at up to 20 years follow-up from a randomized controlled trial of Nissen versus anterior 180-degree partial fundoplication. SUMMARY BACKGROUND DATA: Nissen fundoplication for gastroesophageal reflux can be followed by troublesome side effects. To address this, partial fundoplications have been proposed. Previously reports from a randomized controlled trial of Nissen versus anterior 180-degree partial fundoplication at up to 10 years follow-up showed good outcomes for both procedures. METHODS: One hundred seven participants were randomized to Nissen versus anterior 180-degree partial fundoplication. Fifteen to 20 year follow-up data was available for 79 (41 Nissen, 38 anterior). Outcome was assessed using a standardized questionnaire with 0 to 10 analog scores and yes/no questions to determine reflux symptoms, side-effects, and satisfaction with surgery. RESULTS: After anterior fundoplication heartburn (mean score 3.2 vs 1.4, P = .001) and proton pump inhibitor use (41.7% vs 17.1%, P = .023) were higher, offset by less dysphagia for solids (mean score 1.8 vs 3.3, P = .015), and better ability to belch (84.2% vs 65.9%, P = .030). Measures of overall outcome were similar for both groups (mean satisfaction score 8.4 vs 8.0, P = .444; 86.8% vs 90.2% satisfied with outcome). Six participants underwent revision after anterior fundoplication (Nissen conversion for reflux - 6), and 7 underwent revision after Nissen fundoplication (Nissen to partial fundoplication for dysphagia - 5; redo Nissen for reflux - 1; paraesophageal hernia -1). CONCLUSIONS: At 15 to 20 years follow-up Nissen and anterior 180-degree partial fundoplication achieved similar success, but with trade-offs between better reflux control versus more side-effects after Nissen fundoplication.


Asunto(s)
Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/métodos , Trastornos de Deglución/etiología , Trastornos de Deglución/prevención & control , Estudios de Seguimiento , Fundoplicación/efectos adversos , Reflujo Gastroesofágico/complicaciones , Pirosis/etiología , Pirosis/prevención & control , Humanos , Laparoscopía/efectos adversos , Satisfacción del Paciente , Complicaciones Posoperatorias , Inhibidores de la Bomba de Protones/uso terapéutico , Reoperación , Resultado del Tratamiento
3.
Health Qual Life Outcomes ; 19(1): 233, 2021 Oct 02.
Artículo en Inglés | MEDLINE | ID: mdl-34600554

RESUMEN

AIM: This study assessed the responsiveness and convergent validity of two preference-based measures; the newly developed cancer-specific EORTC Quality of Life Utility Measure-Core 10 dimensions (QLU-C10D) relative to the generic three-level version of the EuroQol 5 dimensions (EQ-5D-3L) in evaluating short-term health related quality of life (HRQoL) outcomes after esophagectomy. METHODS: Participants were enrolled in a multicentre randomised controlled trial to determine the impact of preoperative and postoperative immunonutrition versus standard nutrition in patients with esophageal cancer. HRQoL was assessed seven days before and 42 days after esophagectomy. Standardized Response Mean and Effect Size were calculated to assess responsiveness. Ceiling effects for each dimension were calculated as the proportion of the best level responses for that dimension at follow-up/post-operatively. Convergent validity was assessed using Spearman's correlation and the level of agreement was explored using Bland-Altman plots. RESULTS: Data from 164 respondents (mean age: 63 years, 81% male) were analysed. HRQoL significantly reduced on both measures with large effect sizes (> 0.80), and a greater mean difference (0.29 compared to 0.16) on QLU-C10D. Both measures had ceiling effects (> 15%) on all dimensions at baseline. Following esophagectomy, ceiling effects were observed with self-care (86%), mobility (67%), anxiety/depression (55%) and pain/discomfort (19%) dimensions on EQ-5D-3L. For QLU-C10D ceiling effects were observed with emotional function (53%), physical function (16%), nausea (35%), sleep (31%), bowel problems (21%) and pain (20%). A strong correlation (r = 0.71) was observed between EQ-5D-3L anxiety and QLU-C10D emotional function dimensions. Good agreement (3.7% observations outside the limits of agreement) was observed between the utility scores. CONCLUSION: The QLU-C10D is comparable to the more widely applied generic EQ-5D-3L, however, QLU-C10D was more sensitive to short-term utility changes following esophagectomy. Cognisant of requirements by policy makers to apply generic utility measures in cost effectiveness studies, the disease-specific QLU-C10D should be used alongside the generic measures like EQ-5D-3L. TRIAL REGISTRATION: The trial was registered with the Australian New Zealand Clinical Trial Registry (ACTRN12611000178943) on the 15th of February 2011.


Asunto(s)
Esofagectomía , Calidad de Vida , Australia , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Persona de Mediana Edad , Psicometría , Reproducibilidad de los Resultados , Encuestas y Cuestionarios
4.
Ann Surg ; 272(2): 241-247, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32675536

RESUMEN

OBJECTIVE: To determine whether absorbable or nonabsorbable mesh repair of large hiatus hernias is followed by less recurrences at late follow-up compared to sutured repair. SUMMARY OF BACKGROUND DATA: Radiological recurrences have been reported in up to 30% of patients after repair of large hiatus hernias, and mesh repair has been proposed as a solution. Earlier trials have revealed mixed outcomes and early outcomes from a trial reported previously revealed no short-term advantages for mesh repair. METHODS: Multicentre prospective double-blind randomized controlled trial of 3 methods of hiatus hernia repair; sutures versus absorbable mesh versus nonabsorbable mesh. Primary outcome - hernia recurrence assessed by barium meal X-ray and endoscopy at 3-4 years. Secondary outcomes - clinical symptom scores at 2, 3, and 5 years. RESULTS: 126 patients were enrolled - 43 sutures, 41 absorbable mesh, and 42 nonabsorbable mesh. Clinical outcomes were obtained at 5 years in 89.9%, and objective follow-up was obtained in 72.3%. A recurrent hernia (any size) was identified in 39.3% after suture repair, 56.7% - absorbable mesh, and 42.9% - nonabsorbable mesh (P = 0.371). Clinical outcomes were similar at 5 years, except chest pain, diarrhea, and bloat symptoms which were more common after repair with absorbable mesh. CONCLUSIONS: No advantages were demonstrated for mesh repair at up to 5 years follow-up, and symptom outcomes were worse after repair with absorbable mesh. The longer-term results from this trial do not support mesh repair for large hiatus hernias.


Asunto(s)
Hernia Hiatal/cirugía , Herniorrafia/métodos , Laparoscopía/métodos , Mallas Quirúrgicas/efectos adversos , Técnicas de Sutura , Implantes Absorbibles , Adulto , Análisis de Varianza , Australia , Distribución de Chi-Cuadrado , Método Doble Ciego , Femenino , Estudios de Seguimiento , Hernia Hiatal/diagnóstico por imagen , Herniorrafia/efectos adversos , Humanos , Laparoscopía/efectos adversos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recurrencia , Reoperación/métodos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de Heridas/fisiología
5.
Ann Surg ; 268(2): 228-232, 2018 08.
Artículo en Inglés | MEDLINE | ID: mdl-29303805

RESUMEN

OBJECTIVE: To evaluate late outcomes from a randomized trial of division versus no division of short gastric vessels during laparoscopic Nissen fundoplication at up to 20 years follow-up. BACKGROUND: Nissen fundoplication is an established procedure for the treatment of gastroesophageal reflux disease. Controversy about whether side effects such as dysphagia could be reduced by division of the short gastric vessels led to the establishment of a randomized trial in 1994. Early results showed equivalent reflux control and dysphagia, but more bloating after vessel division. METHODS: A total of 102 patients underwent a laparoscopic Nissen fundoplication between May 1994 and October 1995, and were randomized to short gastric vessel division (50) versus nondivision (52). Follow-up was obtained yearly to 20 years using a standardized questionnaire administered by a blinded investigator. Clinical outcomes at 20 years or most recent follow-up were determined. RESULTS: No significant differences for heartburn symptom and satisfaction scores or medication use were found between treatment groups. At 15 to 20 (mean 19.6) years follow-up, significant differences persisted for epigastric bloating: 26% versus 50% for nondivision versus division groups (P = 0.046). Heartburn symptom scores were low and not different for nondivision versus division groups (mean analog scores 1.4 vs 2.1/10, P = 0.152). Overall satisfaction after surgery was high in both groups (mean analog scores 8.1 vs 8.6/10, P = 0.989). CONCLUSIONS: Although laparoscopic Nissen fundoplication has durable efficacy for heartburn symptom control at up to 20 years follow-up, division of short-gastric vessels failed to confer any reduction in side effects, and was associated with persistent epigastric bloat symptoms at late follow-up in this trial.


Asunto(s)
Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/métodos , Estómago/irrigación sanguínea , Procedimientos Quirúrgicos Vasculares , Estudios de Seguimiento , Reflujo Gastroesofágico/diagnóstico , Humanos , Método Simple Ciego , Estómago/cirugía , Resultado del Tratamiento
6.
Ann Surg ; 266(6): 1000-1005, 2017 12.
Artículo en Inglés | MEDLINE | ID: mdl-27735829

RESUMEN

OBJECTIVE: To assess the long-term efficacy of antireflux surgery on Barrett's esophagus (BE) using BRAVO wireless pH monitoring. BACKGROUND: BE is associated with chronic gastroesophageal reflux and esophageal cancer. Till date, studies have failed to demonstrate that preventing gastroesophageal reflux with antireflux surgery halts the progression of BE, often because of difficulties in objectively proving an effective antireflux barrier. METHODS: Since 1991, all patients undergoing antireflux surgery across 2 hospital sites have been followed in a prospective database. Patients with BE and at least 5 years follow up after antireflux surgery were identified. All patients completed a clinical outcome questionnaire and underwent endoscopic assessment and histological evaluation of their BE. Fourty-eight hours pH monitoring was then performed with the wireless BRAVO system. RESULTS: A total of 50 patients (40 males:10 females) were included in the study, with an average follow up of 11.9 years. Approximately, 92% (46/50) reported their outcome of surgery as "excellent" or "good" and 86% (43/50) reported "none" or "mild" symptoms. Histological regression of BE was seen in 41% (20/49). Lower esophageal acid exposure (percentage time pH < 4) was significantly greater in those with no pathological regression (P = 0.008). Moreover, 64% (32/50) showed endoscopic reduction in the length of BE. Acid exposure was also significantly less in the group showing endoscopic reduction of BE (%time pH < 4, 0.2 vs 3.6, P = 0.007). CONCLUSIONS: Antireflux surgery is safe and effective in patients with Barrett's esophagus. An intact fundoplication, as assessed with BRAVO wireless pH monitoring, suggests that antireflux surgery may halt the progression of Barrett's esophagus, and this might reduce the risk of cancer development.


Asunto(s)
Esófago de Barrett/cirugía , Reflujo Gastroesofágico/cirugía , Laparoscopía , Esófago de Barrett/patología , Esófago de Barrett/fisiopatología , Progresión de la Enfermedad , Monitorización del pH Esofágico , Esofagoscopía , Femenino , Reflujo Gastroesofágico/prevención & control , Humanos , Masculino , Estudios Prospectivos
7.
J Surg Oncol ; 114(6): 719-724, 2016 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-27792238

RESUMEN

BACKGROUND AND OBJECTIVES: In 1975, a modification of popular two-stage Ivor-Lewis oesophagectomy was published with synchronous resection in chest and abdomen. As data on this technique are rare and inconsistent, we aimed to investigate safety, feasibility, and outcome of this approach. METHODS: Outcome of 201 patients undergoing synchronous oesophagectomy from 2000 to 2013 was analysed retrospectively. Two groups (early: 2000-2006; late: 2007-2013) were analysed to allow comparison of outcome over time. RESULTS: Patients in the later period had fewer respiratory comorbidities (P = 0.010), median blood loss decreased significantly over time while lymph node yield increased (P < 0.001). Overall complications occurred in 58.9 (early) versus 51.7% (late) of patients (P = 0.320), anastomotic leaks in 14.3 versus 6.7% (P = 0.112), respiratory complications in 48.2 versus 34.8% (P = 0.063). Thirty-day/90-day mortality was 2.7% versus 3.4, respectively, 8.1% versus 6.8% (P ≤ 0.793). Long-term survival was better in the later cohort (P = 0.004). CONCLUSIONS: Our data of 201 patients over a period of 14 years suggests that this technique is a quick, feasible, safe, and reasonable alternative to standard two-stage Ivor-Lewis oesophagectomy. Quality of this approach and ultimate outcomes have improved over time, with similar complication rates/outcomes to literature accepted standards for two-stage approach, especially in the later time period. J. Surg. Oncol. 2016;114:719-724. © 2016 Wiley Periodicals, Inc.


Asunto(s)
Adenocarcinoma/cirugía , Carcinoma de Células Escamosas/cirugía , Neoplasias Esofágicas/cirugía , Esofagectomía/métodos , Mejoramiento de la Calidad/tendencias , Adenocarcinoma/mortalidad , Adulto , Anciano , Carcinoma de Células Escamosas/mortalidad , Neoplasias Esofágicas/mortalidad , Esofagectomía/mortalidad , Esofagectomía/normas , Estudios de Factibilidad , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Mejoramiento de la Calidad/estadística & datos numéricos , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del Tratamiento
8.
World J Surg ; 39(6): 1465-73, 2015 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-25651955

RESUMEN

INTRODUCTION: Laparoscopic surgery is the treatment of choice for repair of large hiatus hernia, but can be followed by recurrence. Repair with prosthetic mesh has been recommended to prevent recurrence, although complications following mesh repair have generated disagreement about whether or not mesh should be used. The early objective and clinical results of a randomized trial of repair with mesh versus sutures have been reported, and revealed few differences. In the current study, we evaluated quality of life outcomes within this trial at follow-up to 2 years. METHODS: In a multicenter prospective double-blind randomized trial three methods for repair of large hiatus hernia were compared: sutures versus repair with absorbable mesh (Surgisis) versus non-absorbable (Timesh). Quality of life assessment using the Short-Form 36 (SF-36) questionnaire was undertaken at 3, 6, 12 and 24 months after surgery. SF-36 outcomes (8 individual scales and 2 composite scales) were determined for each group, and compared between groups, and across different follow-up points. RESULTS: 126 patients were enrolled-43 sutures, 41 absorbable mesh and 42 non-absorbable mesh. 115 (91.3%) completed a preoperative questionnaire, and 113 (89.7%) completed the post-operative questionnaire at 3 months, 116 (92.1%) at 6 months, 114 (90.5%) at 12 months, and 91 (72.2%) at 24 months. The SF-36 Physical and Mental Component Scores (PCS and MCS) improved significantly following surgery, and this improvement was sustained across 24 months follow-up (p < 0.001 for PCS and MCS at each follow-up point). There were no significant differences between the groups for the component scores or the eight SF-36 subscale scores at each follow-up time. 29 individuals had a recurrence at 6 months follow-up, of which 9 were symptomatic. The PCS were higher in patients with recurrence versus without (p < 0.01), and in patients with a symptomatic recurrence versus asymptomatic recurrence versus no recurrence (p = 0.001). CONCLUSION: SF-36 measured quality of life improved significantly after repair of large hiatal hernia at up to 2 years follow-up, and there were no differences in outcome for the different repair techniques. The use of mesh versus no mesh in repair of large hiatal hernia did not influence quality of life.


Asunto(s)
Hernia Hiatal/cirugía , Herniorrafia/instrumentación , Laparoscopía/instrumentación , Calidad de Vida , Mallas Quirúrgicas , Anciano , Método Doble Ciego , Femenino , Estudios de Seguimiento , Herniorrafia/métodos , Humanos , Laparoscopía/métodos , Masculino , Periodo Posoperatorio , Estudios Prospectivos , Recurrencia , Encuestas y Cuestionarios , Suturas
9.
ANZ J Surg ; 85(9): 668-72, 2015 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-24286198

RESUMEN

BACKGROUND: Previous trials show good outcomes following anterior and posterior partial versus Nissen fundoplication for gastro-oesophageal reflux. However, it is unclear which partial fundoplication performs best. This study compared anterior 180° versus posterior 270° fundoplication. METHODS: At three hospitals, patients were randomized to anterior 180° versus posterior 270° partial fundoplication, and clinical outcomes were determined using a structured questionnaire at 3, 6 and 12 months. Heartburn, dysphagia and satisfaction were assessed using 0-10 analoue scales, and adverse outcomes and side effects were determined. Endoscopy, manometry and pH monitoring were performed 6 months after surgery. RESULTS: Forty-seven patients were randomized to anterior (n = 23) versus posterior (n = 24) fundoplication. Clinical outcomes for 93-98% of patients were available at each follow-up point. At 12 months, the mean heartburn score was higher following anterior fundoplication (2.7 versus 0.8, P = 0.045), although differences were not significant at earlier follow-up. Conversely, following posterior fundoplication, patients were less able to belch at 3 (56% versus 16%, P = 0.013) and 6 months (43% versus 9%, P = 0.017). No significant differences were demonstrated for dysphagia. Both groups had high rates of satisfaction with the outcome - 85% versus 86% satisfied at 12 months follow-up. CONCLUSION: Both partial fundoplications are effective treatments for gastro-oesophageal reflux. Posterior partial fundoplication is associated with less reflux symptoms offset by more side effects.


Asunto(s)
Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/métodos , Satisfacción del Paciente , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Encuestas y Cuestionarios , Resultado del Tratamiento
10.
Ann Surg ; 261(2): 282-9, 2015 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-25119120

RESUMEN

OBJECTIVE: Determine whether absorbable or nonabsorbable mesh in repair of large hiatus hernias reduces the risk of recurrence, compared with suture repair. BACKGROUND: Repair of large hiatus hernia is associated with radiological recurrence rates of up to 30%, and to improve outcomes mesh repair has been recommended. Previous trials have shown less short-term recurrence with mesh, but adverse outcomes limit mesh use. METHODS: Multicentre prospective double blind randomized controlled trial of 3 methods of repair: sutures versus absorbable mesh versus nonabsorbable mesh. Primary outcome-hernia recurrence assessed by barium meal radiology and endoscopy at 6 months. Secondary outcomes-clinical symptom scores at 1, 3, 6, and 12 months. RESULTS: A total of 126 patients enrolled: 43 sutures, 41 absorbable mesh, and 42 nonabsorbable mesh. Among them, 96.0% were followed up to 12 months, with objective follow-up data in 92.9%. A recurrent hernia (any size) was identified in 23.1% after suture repair, 30.8% after absorbable mesh, and 12.8% after nonabsorbable mesh (P = 0.161). Clinical outcomes were similar, except less heartburn at 3 and 6 months and less bloating at 12 months with nonabsorbable mesh; more heartburn at 3 months, odynophagia at 1 month, nausea at 3 and 12 months, wheezing at 6 months; and inability to belch at 12 months after absorbable mesh. The magnitudes of the clinical differences were small. CONCLUSIONS: No significant differences were seen for recurrent hiatus hernia, and the clinical differences were unlikely to be clinically significant. Overall outcomes after sutured repair were similar to mesh repair.


Asunto(s)
Hernia Hiatal/cirugía , Herniorrafia/instrumentación , Laparoscopía/instrumentación , Mallas Quirúrgicas , Suturas , Anciano , Método Doble Ciego , Femenino , Estudios de Seguimiento , Hernia Hiatal/prevención & control , Herniorrafia/métodos , Humanos , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recurrencia , Resultado del Tratamiento
11.
Ann Surg ; 259(3): 464-8, 2014 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-23732271

RESUMEN

OBJECTIVE: To perform long-term histopathological and clinical assessment of patients who have previously undergone cardiomyotomy for achalasia. BACKGROUND: There are few studies on long-term outcome for patients treated by cardiomyotomy for achalasia. Recent publications suggest that these patients may be at high risk of both squamous cell carcinoma and adenocarcinoma of the esophagus. METHODS: All patients, in whom at least 5 years had elapsed since laparoscopic cardiomyotomy for achalasia, were identified from a prospective database. Patients were invited to attend for endoscopy and clinical outcome was assessed by questionnaire. RESULTS: Out of 171 patients identified, 2 had died from esophageal carcinoma. Of the remainder, 68 were recruited [mean age 52 years (range 26-72)]. Fifty-six percent reported minimal symptoms and 6% experienced frequent reflux symptoms. Almost all patients (93%) reported some dysphagia, but dysphagia scores remained significantly lower than preoperatively (P < 0.0001). Quality of life was comparable to normal subjects, and 97% of patients indicated they had made the correct decision to undergo surgery. At endoscopy 83% had evidence of chronic inflammation in the distal esophagus on histopathology, including 22% with moderate to severe esophagitis and 7% with Barrett's esophagus. Five patients showed esophageal candidiasis, and 2 had eosinophilic esophagitis. No dysplasia or malignancy was identified. CONCLUSIONS: The clinical outcome remains excellent in most patients at long-term follow-up after cardiomyotomy for achalasia. Surveillance endoscopy might identify high-risk patients but routine endoscopy in all patients is probably not necessary, particularly early after surgery.


Asunto(s)
Cardias/cirugía , Acalasia del Esófago/cirugía , Esofagoscopía/métodos , Fundoplicación/métodos , Adulto , Anciano , Esófago de Barrett/diagnóstico , Esófago de Barrett/epidemiología , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Estudios Prospectivos , Medición de Riesgo/métodos , Factores de Riesgo , Australia del Sur/epidemiología , Encuestas y Cuestionarios , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del Tratamiento
12.
World J Surg ; 38(6): 1431-43, 2014 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-24366275

RESUMEN

BACKGROUND: Antireflux surgery is effective for the treatment of gastroesophageal reflux, but not all patients benefit equally from it. The challenge is to identify the patients who will ultimately benefit from antireflux surgery. The aim of this study was to identify preoperative factors that predict clinical outcome after antireflux surgery, with special interest in the influence of socioeconomic factors. METHODS: Preoperative clinical and socioeconomic data from 1,650 patients who were to undergo laparoscopic fundoplication were collected prospectively. Clinical outcome measures (persistent heartburn, dysphagia, satisfaction) were assessed at short-term (1 year) and longer-term (≥ 3 years) follow-up. RESULTS: At early follow-up, male gender (relative risk [RR] 1.091, p < 0.001) and the presence of a hiatus hernia (RR 1.065, p = 0.002) were independently associated with less heartburn. Male gender was also associated with higher overall satisfaction (RR 1.046, p = 0.034). An association was found between postoperative dysphagia and age (RR 0.988, p = 0.007) and the absence of a hiatus hernia (RR 0.767, p = 0.001). At longer-term follow-up, only male gender (RR 1.125, p < 0.001) was an independent prognostic factor for heartburn control. Male gender (RR 0.761, p = 0.001), the presence of a hiatus hernia (RR 0.823, p = 0.014), and cerebrovascular comorbidities (RR 1.306, p = 0.019) were independent prognosticators for dysphagia at longer-term follow-up. A hiatus hernia was the only factor associated with better overall satisfaction. Socioeconomic factors did not influence any clinical outcomes at short- and longer-term follow-up. CONCLUSION: Male gender and hiatus hernia are associated with a better clinical outcome following laparoscopic fundoplication, whereas socioeconomic status does not influence outcome.


Asunto(s)
Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Hernia Hiatal/cirugía , Laparoscopía/métodos , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Australia , Estudios de Cohortes , Esofagoscopía/métodos , Femenino , Estudios de Seguimiento , Fundoplicación/efectos adversos , Reflujo Gastroesofágico/diagnóstico , Hernia Hiatal/diagnóstico , Humanos , Laparoscopía/efectos adversos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/cirugía , Valor Predictivo de las Pruebas , Cuidados Preoperatorios/métodos , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Factores Socioeconómicos , Factores de Tiempo , Resultado del Tratamiento , Adulto Joven
13.
J Gastrointest Surg ; 17(7): 1173-80, 2013 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-23653375

RESUMEN

BACKGROUND: There is a learning curve associated with laparoscopic antireflux surgery which has an impact on patient outcomes. It is unclear, however, whether this can be eliminated by supervision of early cases by experienced surgeons. The aim of this study was to evaluate the impact of training under supervision on outcomes for laparoscopic fundoplication. METHOD: Patients undergoing primary laparoscopic antireflux surgery from 1995 to 2009 were identified from a prospective database. Patients were classified according to whether they were operated on by an experienced consultant or supervised trainee, and sub-categorised according to the presence of a very large hiatus hernia. A standardised questionnaire was used to assess outcomes for heartburn, dysphagia and satisfaction at 1 and 5 years follow-up. Outcomes for the study groups were compared. RESULTS: One thousand seven hundred and ten patients underwent surgery; 1,112 were operated on by consultants and 598 by trainees. The peri-operative complication rate was not different between the groups, although in patients operated on by trainees, there were increased rates of endoscopic dilatation (9 vs. 5 % p = 0.014) and re-operation (9 vs. 6 %, p = 0.031), and a lower satisfaction rate (76 vs. 82 %, p = 0.044) within 5 years of surgery. All other outcomes were similar for trainees vs. consultants. CONCLUSION: The learning curve for laparoscopic fundoplication had a small, but statistically significant, impact on patient outcomes, with slightly lesser outcomes when surgery was undertaken by trainees, even when supervised by experienced surgeons. Although the differences were not large, they raise questions about equipoise and highlight ethical dilemmas with teaching new generations of surgeons.


Asunto(s)
Competencia Clínica , Fundoplicación/educación , Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/educación , Femenino , Hernia Hiatal/cirugía , Humanos , Curva de Aprendizaje , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del Tratamiento
14.
Ann Surg ; 258(2): 233-9, 2013 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-23207247

RESUMEN

OBJECTIVE: To investigate late objective outcomes 14 years after laparoscopic anterior 180-degree partial versus Nissen fundoplication. BACKGROUND: Clinical outcomes from randomized clinical trials suggest good outcomes for anterior 180-degree partial fundoplication, with similar control of reflux symptoms and less side effects, compared with Nissen fundoplication. However, objective outcomes at late follow-up have not been reported. METHODS: A subset of participants from a randomized trial of anterior 180-degree versus Nissen fundoplication underwent stationary esophageal high-resolution manometry and ambulatory 24-hour impedance-pH monitoring at 14 years' follow-up. The subset and other patients in the trial also completed a standardized clinical questionnaire to ensure that they were representative of the overall trial. RESULTS: Eighteen patients (8 anterior, 10 Nissen) underwent objective testing and had a symptom profile similar to those who did not (n = 59) have testing. Total esophageal acid exposure time and the total number of acid and weakly acidic reflux episodes per 24 hours were higher after anterior fundoplication than after Nissen fundoplication. Proximal, midesophageal and distal reflux were proportionately increased after anterior 180-degree fundoplication. The number of liquid and mixed reflux episodes was also higher after anterior fundoplication, which was accompanied by higher clinical heartburn scores. There were no differences in gas reflux, gastric belches, and supragastric belches, which is in line with the observation that gas-related symptoms were similar for both groups. Mean LES resting and relaxation nadir pressure were lower after anterior fundoplication, which was reflected by lower dysphagia scores. Patient satisfaction was similar after both procedures. CONCLUSIONS: At 14 years after randomization, this study demonstrated that acid, weakly acidic, liquid and mixed reflux episodes are more common after anterior 180-degree fundoplication than after Nissen fundoplication. On the contrary, gas reflux and gastric belching and patient satisfaction are similar for both procedures. Mean LES resting and relaxation nadir pressure are lower after anterior fundoplication. Overall, these findings suggest less effective reflux control after anterior 180-degree partial fundoplication, offset by less dysphagia, leading to a clinical outcome that is equivalent to Nissen fundoplication at late follow-up.


Asunto(s)
Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/métodos , Adulto , Anciano , Monitorización del pH Esofágico , Femenino , Estudios de Seguimiento , Reflujo Gastroesofágico/diagnóstico , Humanos , Masculino , Manometría , Persona de Mediana Edad , Satisfacción del Paciente/estadística & datos numéricos , Estudios Prospectivos , Encuestas y Cuestionarios , Resultado del Tratamiento
15.
J Gastrointest Surg ; 17(5): 997-1001, 2013 May.
Artículo en Inglés | MEDLINE | ID: mdl-23233272

RESUMEN

INTRODUCTION: The standard of care for achalasia is laparoscopic Heller's cardiomyotomy. This procedure achieves satisfactory and long-standing results in over 85 % of patients. However, in 10-15 % of patients, esophageal function will progressively deteriorate, and up to 5 % will develop end-stage achalasia. Options in these difficult patients are limited, and include redo cardiomyotomy, repeat dilatation, and in severe cases, esophagectomy. METHODS: In this report, we describe an alternate approach, a cardioplasty, which was originally described by Heyrovsky in 1913. RESULTS: The development of an angulated stapling device now makes this operation feasible by a laparoscopic approach. CONCLUSION: This report highlights our technique for laparoscopic cardioplasty in patients with end-stage achalasia.


Asunto(s)
Cardias/cirugía , Acalasia del Esófago/cirugía , Laparoscopía/métodos , Grapado Quirúrgico/instrumentación , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento
16.
J Gastrointest Surg ; 16(9): 1653-8, 2012 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-22639376

RESUMEN

INTRODUCTION: Nissen fundoplication can be followed by side effects, and this has driven modifications, including partial fundoplications. We previously reported early outcomes from a randomised trial of Nissen vs anterior 90° partial fundoplication. This paper reports 5-year follow-up outcomes to determine whether anterior 90° fundoplication achieves a satisfactory longer-term outcome. METHODS: From February 1999 to August 2003, 79 patients were randomised to Nissen vs anterior 90° fundoplication. Patients were followed yearly using a standardized clinical questionnaire which included symptom scores to assess heartburn, dysphagia, other post-fundoplication side effects and overall satisfaction with the outcome. Five-year clinical outcomes were analysed. RESULTS: Seventy-four patients were available for follow-up at 5 years. There were no significant differences for heartburn or satisfaction, although more patients used antisecretory medication after anterior 90° fundoplication (29.7 vs 8.1 %). Dysphagia was greater after Nissen fundoplication when measured by an analogue score for solid food and a composite dysphagia score. Symptoms of bloating were more common following Nissen fundoplication (80.0 vs 32.4 %), and less patients could eat a normal diet (78.4 vs 94.6 %). Re-operation was undertaken in four patients after Nissen fundoplication (dysphagia, three; hiatus hernia, one) vs three after anterior 90° fundoplication (recurrent reflux, three). CONCLUSIONS: At 5 years, anterior 90° partial fundoplication was associated with less side effects, offset by greater use of antisecretory medication. Reflux symptoms and overall satisfaction were similar to Nissen fundoplication. Laparoscopic anterior 90° partial fundoplication is an effective treatment for gastro-esophageal reflux.


Asunto(s)
Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Adulto , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento
17.
World J Surg ; 36(5): 1089-95, 2012 May.
Artículo en Inglés | MEDLINE | ID: mdl-22374537

RESUMEN

BACKGROUND: Positron emission tomography (PET) is an integral part of tumor staging for patients with esophageal cancer. Recent studies suggest a role for PET scan in predicting survival in these patients, but this relationship is unclear in the setting of neoadjuvant therapy. We examined pretreatment maximum standard uptake value (SUV(max)) of the primary tumor in patients treated with and without neoadjuvant therapy. METHODS: All patients undergoing esophagectomy with a preoperative PET scan over a nine-year period (2001-2010) were identified from a prospectively maintained database. Positron emission tomography data were obtained from computers housing the original PET scans. Overall survival was correlated with SUV(max) of the primary tumor. RESULTS: A total of 191 patients were identified, and 103 patients met inclusion criteria. Eighty-two had an adenocarcinoma (80%), and 21 (20%) had a squamous cell carcinoma. Fifty-seven (55%) patients received neoadjuvant therapy. In the surgery alone group, a SUV(max) of > 5.0 in the primary tumor was associated with poor prognosis [Hazard Ratio (HR) 0.32; p = 0.007], but this factor did not retain its significance on multivariate analysis (HR 0.65; p = 0.43). Pretreatment SUV(max) in patients who underwent neoadjuvant therapy was not significant in predicting overall survival (p = 0.10). CONCLUSIONS: This study does not support the use of SUV(max) on pretreatment PET scans as a prognostic tool for patients with esophageal cancer, especially in those who have received neoadjuvant therapy. Lymph node status is a more accurate predictor of outcome, and efforts to improve pretreatment staging should focus on this factor.


Asunto(s)
Adenocarcinoma/diagnóstico por imagen , Carcinoma de Células Escamosas/diagnóstico por imagen , Neoplasias Esofágicas/diagnóstico por imagen , Imagen Multimodal , Tomografía de Emisión de Positrones , Tomografía Computarizada por Rayos X , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Adenocarcinoma/terapia , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/terapia , Neoplasias Esofágicas/mortalidad , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/terapia , Esofagectomía , Femenino , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Análisis Multivariante , Terapia Neoadyuvante , Estadificación de Neoplasias , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Sensibilidad y Especificidad , Tasa de Supervivencia
18.
Ann Surg ; 255(4): 637-42, 2012 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-22418004

RESUMEN

OBJECTIVE: To compare longer term (5-year) outcomes for reflux control and postsurgery side effects after laparoscopic anterior (90° and 180°) partial versus Nissen fundoplication for gastroesophageal reflux. BACKGROUND: Laparoscopic Nissen fundoplication is the most frequently performed surgical procedure for gastroesophageal reflux. It achieves excellent control of reflux, but in some patients it is followed by troublesome side effects. To reduce the risk of side effects laparoscopic anterior partial fundoplication variants have been advocated, although some studies suggest poorer reflux control. METHODS: From 1995 to 2003, 461 patients with gastroesophageal reflux were enrolled in 4 randomized controlled trials comparing anterior partial versus Nissen fundoplication. Two trials evaluated anterior 180° and 2 anterior 90° partial fundoplication. The original trial data were combined, and a reanalysis from original data was undertaken to determine outcomes at 5 years follow-up. Reflux symptom control and side effects were evaluated in a blinded fashion using standardized questionnaires, including 0 to 10 analog scores (0 = no symptoms, 10 = severe symptoms). RESULTS: At 5 years, patients who underwent an anterior 90° or 180° partial fundoplication had less side effects than those who underwent Nissen fundoplication and were equally satisfied with the overall outcome. Reflux control, measured by heartburn scores and antisecretory medication use, was similar for anterior 180° partial versus Nissen fundoplication, but inferior after anterior 90° partial versus Nissen fundoplication. CONCLUSIONS: Anterior 180° partial fundoplication achieves durable control of reflux symptoms and fewer side effects compared with Nissen fundoplication. Reflux control after anterior 90° partial fundoplication appears less effective than after Nissen fundoplication. This data supports the use of anterior 180° partial fundoplication for the surgical treatment of gastroesophageal reflux.


Asunto(s)
Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía , Adolescente , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Satisfacción del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Método Simple Ciego , Resultado del Tratamiento , Adulto Joven
19.
J Gastrointest Surg ; 16(3): 475-85, 2012 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-21913039

RESUMEN

BACKGROUND: Esophageal peristalsis and basal gastroesophageal junction (GEJ) pressure correlate poorly with dysphagia. AIM: To determine intraluminal pressures that reflect GEJ function and to determine manometric correlates for dysphagia before and after fundoplication. METHODS: The relationships between maximal intrabolus pressure, residual GEJ relaxation pressure and peak peristaltic pressure for water swallows were determined in normal volunteers and patients with reflux disease before and after fundoplication. GEJ anatomy was assessed by radiological, endoscopic and surgical criteria, whilst dysphagia was measured with a validated composite dysphagia score. RESULTS: Dysphagia was significantly associated with lower peak peristaltic pressure in the distal esophagus and the presence of a hiatus hernia preoperatively, as well as higher residual pressure on GEJ relaxation postoperatively. Peak distal peristaltic pressure and residual GEJ relaxation pressure were predictors of intrabolus pressure after total fundoplication (p<0.002). Residual GEJ relaxation pressure was four times higher after 360° fundoplication (N=19) compared to 90° fundoplication (N=14, p<0.0001). Similarly, intrabolus pressure was elevated 2.5 times after 360° fundoplication and nearly doubled after 90° fundoplication and both were significantly different from controls (N=22) and reflux disease patients (N=53, p<0.0001). CONCLUSIONS: Gastroesophageal junction impedance to flow imposed by fundoplication is associated with dysphagia when there is suboptimal distal esophageal contraction strength and relatively high residual GEJ relaxation pressure.


Asunto(s)
Trastornos de Deglución/etiología , Unión Esofagogástrica/fisiopatología , Fundoplicación/efectos adversos , Reflujo Gastroesofágico/cirugía , Peristaltismo/fisiología , Adolescente , Adulto , Anciano , Trastornos de Deglución/fisiopatología , Endoscopía Gastrointestinal , Femenino , Estudios de Seguimiento , Fundoplicación/métodos , Reflujo Gastroesofágico/fisiopatología , Humanos , Masculino , Manometría , Persona de Mediana Edad , Complicaciones Posoperatorias , Presión , Resultado del Tratamiento , Adulto Joven
20.
Arch Surg ; 146(10): 1164-9, 2011 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-22006875

RESUMEN

BACKGROUND: Previous research suggests that females have a poorer outcome than do males after surgery for gastroesophageal reflux. OBJECTIVE: To evaluate reflux and esophageal symptoms in males and females in a community sample and in patients undergoing antireflux surgery. DESIGN: Face-to-face interview. SETTING: A South Australian community. PARTICIPANTS: Random sample of 2973 individuals from the community and 2153 patients presenting for antireflux surgery. MAIN OUTCOME MEASURES: In a random sample of 2973 individuals from the community, the prevalence of reflux and other esophageal symptoms was determined and compared with symptoms in 2153 patients presenting for antireflux surgery. Identical questions were used to assess frequency and severity of heartburn and dysphagia and medication use. Analog scales assessed heartburn and dysphagia (0 indicating no symptoms and 10, severe symptoms). Outcomes for males vs females were compared across both groups. RESULTS: In the community, females were more likely to report heartburn, and when reported, symptom severity was higher. The prevalence of dysphagia was similar for males and females, although females reported higher dysphagia scores for solid foods. A similar proportion of males and females took antireflux medications. Females presenting for antireflux surgery were, on average, 7 years older than males, had a higher body mass index, and had higher heartburn and dysphagia symptom scores. At endoscopy, men were more likely to have ulcerative esophagitis and Barrett esophagus, and at surgery they were less likely to have a hiatal hernia. CONCLUSIONS: Significant differences were noted between males and females in the frequency and severity of gastroesophageal reflux-associated symptoms in the community and in patients presenting for surgery. These might reflect differences in symptom perception, which explain previously reported better outcomes in men undergoing antireflux surgery.


Asunto(s)
Trastornos de Deglución/epidemiología , Reflujo Gastroesofágico/complicaciones , Pirosis/epidemiología , Factores Sexuales , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Reflujo Gastroesofágico/diagnóstico , Reflujo Gastroesofágico/cirugía , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Índice de Severidad de la Enfermedad , Australia del Sur , Adulto Joven
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