RESUMO
BACKGROUND METHODS: The question prompt list content was derived through a modified Delphi process consisting of 3 rounds. In round 1, experts provided 5 answers to the prompts "What general questions should patients ask when given a new diagnosis of Barrett's esophagus" and "What questions do I not hear patients asking, but given my expertise, I believe they should be asking?" Questions were reviewed and categorized into themes. In round 2, experts rated questions on a 5-point Likert scale. In round 3, experts rerated questions modified or reduced after the previous rounds. Only questions rated as "essential" or "important" were included in Barrett's esophagus question prompt list (BE-QPL). To improve usability, questions were reduced to minimize redundancy and simplified to use language at an eighth-grade level (Fig. 1). RESULTS: Twenty-one esophageal medical and surgical experts participated in both rounds (91% males; median age 52 years). The expert panel comprised of 33% esophagologists, 24% foregut surgeons, and 24% advanced endoscopists, with a median of 15 years in clinical practice. Most (81%), worked in an academic tertiary referral hospital. In this 3-round Delphi technique, 220 questions were proposed in round 1, 122 (55.5%) were accepted into the BE-QPL and reduced down to 76 questions (round 2), and 67 questions (round 3). These 67 questions reached a Flesch Reading Ease of 68.8, interpreted as easily understood by 13 to 15 years olds. CONCLUSIONS: With multidisciplinary input, we have developed a physician-derived BE-QPL to optimize patient-physician communication. Future directions will seek patient feedback to distill the questions further to a smaller number and then assess their usability.
Assuntos
Esôfago de Barrett , Médicos , Masculino , Humanos , Pessoa de Meia-Idade , Feminino , Esôfago de Barrett/diagnóstico , Técnica Delphi , Comunicação , Relações Médico-Paciente , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: Screening colonoscopy (SC) is widely accepted and has been shown to decrease the rate of colorectal cancer death. Guidelines and acceptance of screening for Barrett's esophagus (BE) are less established despite the fact that esophageal adenocarcinoma (EA) remains the fastest increasing cancer in the USA. The aim of this study was to assess the timing and frequency of SC in patients ultimately found to have EA and to evaluate the presence of symptoms and risk factors that might have prompted an esophagogastroduodenoscopy (EGD) and potentially earlier diagnosis of the EA. METHODS: A retrospective chart review was performed to identify all patients who were referred to a single center with esophageal cancer between July 2016 and November 2022. Patients with any histology other than adenocarcinoma were excluded. RESULTS: There were 221 patients referred with EA. Of these, a SC had been done prior to the diagnosis of EA in 108 patients (49%): 96 men and 12 women. A total of 203 SC had been done (range 1-7 per patient), and 47% of patients had more than 1 SC. The median interval from the last SC to the diagnosis of EA was 2.9 years. At the time of SC, gastroesophageal reflux disease (GERD) symptoms or chronic acid suppression medication use was reported by 81% of patients, and 80% had an American Society of Gastrointestinal Endoscopy (ASGE) indication for a screening EGD. Only 19 patients (18%) that had a SC had an EGD at any time prior to the diagnosis of EA, and in these patients, 74% had erosive esophagitis or BE. The EA in most patients was stage III or IV and associated with lymph node metastases. CONCLUSIONS: Nearly one-half of patients ultimately diagnosed with EA had one or more SCs, and most of these patients had GERD symptoms, were using acid suppression medications or had an ASGE indication for a screening EGD. Despite this, only 18% had an EGD prior to the EA diagnosis. The addition of an EGD at the time of SC in these patients may have allowed the detection of BE or EA at an early, endoscopically curable stage and represents a missed opportunity to intervene in the natural history of this disease.
Assuntos
Adenocarcinoma , Esôfago de Barrett , Neoplasias Esofágicas , Refluxo Gastroesofágico , Masculino , Humanos , Feminino , Estudos Retrospectivos , Refluxo Gastroesofágico/complicações , Refluxo Gastroesofágico/diagnóstico , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/complicações , Esôfago de Barrett/patologia , Adenocarcinoma/diagnóstico , Adenocarcinoma/complicações , Endoscopia Gastrointestinal , ColonoscopiaRESUMO
BACKGROUND: Tension is an important factor in hernia repairs. Relaxing incisions to reduce tension are common with ventral hernia repairs, and techniques for relaxing incisions also exist for the hiatus. The aim of this study was to update our original experience with a diaphragm relaxing incision (DRI) in a larger group of patients with longer follow-up. METHODS: A retrospective chart review was performed to identify all patients who had a DRI between August 2016 and September 2021 during hiatal hernia repair. All DRI defects were repaired with permanent mesh remote from the esophagus. Objective follow-up was with chest x-ray, upper GI series (UGI) or both. RESULTS: Seventy-three patients had a total of 79 DRI (right in 63, left in 4, and bilateral in 6 patients), during a primary (n = 52) or redo (n = 21) hiatal hernia repair. Concomitant Collis gastroplasty was used in 38 patients (52%). A single intra-operative complication occurred where the right crus tore during a right DRI. At a median of 15 months, 78% of patients had objective follow-up. There was one hernia through a repaired right DRI (1.2%). No patient had evidence of diaphragm paralysis and there were no mesh infections. The 1-year hernia recurrence rate in these patients was 3.9%. CONCLUSIONS: A DRI can be done safely with minimal risk of intra- or post-operative complications. There was a low rate of herniation through the defect when repaired with permanent mesh. No patient developed a mesh infection despite concomitant Collis gastroplasty in 52% of patients, and there was no evidence of diaphragm paralysis on imaging studies. Further, the low rate of hiatal hernia recurrence suggests efficacy of a DRI to reduce crural closure tension. These excellent outcomes should encourage use of a DRI in patients with a difficult hiatus during hernia repair.
Assuntos
Hérnia Hiatal , Laparoscopia , Ferida Cirúrgica , Humanos , Diafragma/cirurgia , Seguimentos , Estudos Retrospectivos , Laparoscopia/métodos , Hérnia Hiatal/cirurgia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Telas Cirúrgicas , Paralisia , Resultado do Tratamento , Fundoplicatura/métodosRESUMO
OBJECTIVE: To evaluate and characterize outcomes of MSA in patients with IEM. SUMMARY BACKGROUND DATA: MSA improves patients with gastroesophageal reflux and normal motility. However, many patients have IEM, which could impact the outcomes of MSA and discourage use. METHODS: An international, multi-institutional case control study of IEM patients undergoing MSA matched to normal patients was performed. Primary outcomes were new onset dysphagia and need for postoperative interventions. RESULTS: A total of 105 IEM patients underwent MSA with matching controls. At 1 year after MSA: GERD-Health Related Quality of Life was similar; DeMeester scores in IEM patients improved to 15.7 and 8.5 in controls ( P = 0.021); and normalization of the DeMeester score for IEM = 61.7% and controls = 73.1% ( P = 0.079).In IEM patients, 10/12 (83%) with preop dysphagia had resolution; 11/66 (17%) had new onset dysphagia and 55/66 (83%) never had dysphagia. Comparatively, in non-IEM patients, 22/24 (92%) had dysphagia resolve; 2/24 (8%) had persistent dysphagia; 7/69 (10%) had new onset dysphagia, and 62/69 (90%) never had dysphagia.Overall, 19 (18%) IEM patients were dilated after MSA, whereas 12 (11%) non-IEM patients underwent dilation ( P = 0.151). Nine (9%) patients in both groups had their device explanted. CONCLUSIONS: Patients with IEM undergoing MSA demonstrate improved quality of life and reduction in acid exposure. Key differences in IEM patients include lower rates of objective GERD resolution, lower resolution of existing dysphagia, higher rates of new onset dysphagia and need for dilation. GERD patients with IEM should be counselled about these possibilities.
Assuntos
Transtornos de Deglutição , Refluxo Gastroesofágico , Laparoscopia , Humanos , Estudos de Casos e Controles , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/cirurgia , Esfíncter Esofágico Inferior/cirurgia , Refluxo Gastroesofágico/cirurgia , Fenômenos Magnéticos , Qualidade de Vida , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: The aim of this study was to provide a full HRM data set in patients with a normal functioning fundoplication. BACKGROUND: The Chicago classification was devised to correlate HRM values to the clinical status of patients with swallowing disorder. However, it is unclear whether those values are applicable after fundoplication as the literature is sparse. METHODS: We identified patients with pre- and postoperative HRM who had a normal functioning primary fundoplication as defined by (1) resolution of preoperative symptoms without significant postoperative side effects, (2) no dysphagia reported on a standardized questionnaire given on the day of the postoperative HRM and (3) normal acid exposure determined objectively by esophageal pH-testing. RESULTS: Fifty patients met inclusion criteria for the study. Thirty-three patients (66%) underwent complete fundoplication and 17 patients (34%) underwent posterior partial fundoplication. Postoperative HRM was performed at a median of 12 months after primary surgery. Lower esophageal sphincter (LES) values significantly increased with the addition of a fundoplication. Median integrated relaxation pressure (IRP) was 14 mm Hg ( P = 0.0001), median resting pressure 19.5 mm Hg ( P = 0.0263), and median total length LES was 3.95 cm ( P = 0.0098). The 95th percentile for IRP in a complete fundoplication was 29 versus 23 mm Hg in a partial fundoplication ( P = 0.3667). CONCLUSION: We offer a new standard manometric profile for a normally functioning fundoplication which provides a necessary benchmark for analyzing postoperative problems with a fundoplication. The previously acceptedupper limit defining esophageal outflow obstruction (IRP >20 mm Hg) is not clinically applicable after fundoplication as the majority of patients in this dysphagia-free cohort exceeded this value. Interestingly, there does not seem to be a significant difference in HRM LES values between complete and partial fundoplication.
Assuntos
Transtornos de Deglutição , Fundoplicatura , Humanos , Fundoplicatura/efeitos adversos , Estudos Retrospectivos , Pressão , Manometria , Esfíncter Esofágico Inferior/cirurgia , Transtornos de Deglutição/diagnóstico , Transtornos de Deglutição/etiologiaRESUMO
Background: Per-oral endoscopic myotomy (POEM) is a valuable tool for the treatment of foregut motility disorders. Hands-on courses are often utilized at the initial means of training in POEM. Whether such training is sufficient to allow individuals to launch an independent practice in POEM is unknown. The purpose of this study was to evaluate the successes and barriers of implementing a POEM practice after attending a hands-on course. Methods: We evaluated participants of a 2-day focused POEM training course. All participants of the course were sent a survey to assess their endoscopic practice before and after the course, concentrating on their ability to implement POEM after returning to their home institution. Results: Between 2012 and 2017, 11 POEM courses were held at our institution, with a total of 102 trainees. Fifty-five individuals responded to our survey (53.9%), most of whom were general surgeons who were already doing some therapeutic endoscopy but had not previously performed POEM. More than half (58.2%) were able to institute a POEM practice at their home institution after the course. Those that were successful in starting a POEM practice were more often those with previous advanced endoscopic experience (90.3%). Success was assisted by high rates of additional explant laboratories (43.6%) and in-person proctoring (52.4%) after completing the course. Those that did not start a POEM practice sited lack of institutional support as the main barrier, followed by problems with insurance approval, and lack of referral volume. Conclusion: Despite the complexity of the POEM procedure, a focused hands-on POEM training course is associated with a high rate of implementation of an independent POEM practice, particularly in individuals with previous advanced endoscopic experience. The largest barriers to POEM adoption are not technical factors, but rather are related to institutional and insurance factors.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório , Acalasia Esofágica , Miotomia , Cirurgia Endoscópica por Orifício Natural , Cirurgiões , Acalasia Esofágica/cirurgia , Humanos , Miotomia/métodos , Cirurgia Endoscópica por Orifício Natural/métodosRESUMO
BACKGROUND: Peroral endoscopic myotomy (POEM) is increasingly used as primary treatment for esophageal achalasia, in place of the options such as Heller myotomy (HM) and pneumatic dilatation (PD) OBJECTIVE: These evidence-based guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) intend to support clinicians, patients and others in decisions about the use of POEM for treatment of achalasia. RESULTS: The panel agreed on 4 recommendations for adults and children with achalasia. CONCLUSIONS: Strong recommendation for the use of POEM over PD was issued unless the concern of continued postoperative PPI use remains a key decision-making concern to the patient. Conditional recommendations included the option of using either POEM or HM with fundoplication to treat achalasia, and favored POEM over HM for achalasia subtype III.
Assuntos
Acalasia Esofágica/cirurgia , Cirurgia Endoscópica por Orifício Natural/métodos , Adulto , Criança , Esfíncter Esofágico Inferior/cirurgia , Esofagoscopia/efeitos adversos , Esofagoscopia/métodos , Fundoplicatura , Miotomia de Heller , Humanos , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controleRESUMO
BACKGROUND: The short-term success of peroral endoscopic myotomy (POEM) is well documented but the durability of the operation is questioned. The aim of this study was to evaluate the clinical outcomes of the POEM procedure for esophageal motility disorders in a large cohort in which all patients had at least 5 years of follow-up. METHODS: All patients from a single center who underwent a POEM between October 2010 and September 2014 were followed for long-term clinical outcomes. Postoperative Eckardt symptom scores of short term and ≥ 5 years were collected through phone interview. Clinical success was defined as an Eckardt score < 3. Overall success was defined as Eckardt score < 3 and freedom from additional interventions. RESULTS: Of 138 patients, 100 patients were available for follow-up (mean age 56, 52% male). The indication for operation was achalasia in 94. The mean follow-up duration was 75 months (range: 60-106 months). Dysphagia was improved in 91% of patients. Long-term overall success was achieved in 79% of patients (80% of achalasia patients, 67% of DES patients). Preoperative mean Eckardt score was 6. At 6 months, it was 1, and at 75 months, it was 2 (p = 0.204). Five-year freedom from intervention was 96%. Overall, 7 patients had additional treatments: 1 balloon dilation (35 mm), 4 laparoscopic Heller myotomy, and 2 redo POEM at a mean of 51 months post-POEM. Ninety-three percent expressed complete satisfaction with POEM. CONCLUSION: A multitude of studies has shown the early benefits of POEM. Here, we show that nearly 80% of patients report clinical success with no significant decrement in symptom scores between their short- and long-term follow-up. Clearly POEM is an effective option for achalasia with durable long-term treatment efficacy.
Assuntos
Transtornos de Deglutição , Acalasia Esofágica , Transtornos da Motilidade Esofágica , Miotomia de Heller , Cirurgia Endoscópica por Orifício Natural , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
BACKGROUND: Esophagectomy is a fundamental step to achieve long-term disease-free survival in esophageal cancer. While various approaches have been described, there is no consensus on the single best technique to optimize operative and oncologic outcomes. We aim to report the modern experience with laparoscopic transhiatal esophagectomy (LTHE) for invasive adenocarcinoma. METHODS: We reviewed all patients who underwent LTHE with extended lymph node dissection for distal esophageal adenocarcinoma (EAC) at our institution between 2007 and 2016. Pre-operative characteristics, operative details, postoperative complications, and long-term outcomes were tracked by review of the electronic medical record and patient surveys. Survival rates were calculated with Kaplan-Meier curves. RESULTS: Eighty-two EAC patients underwent LTHE during the study period (84% male, mean age 65, mean BMI 27.8, large). Most patients were clinical stage III (42.7%) and 68.3% had received neoadjuvant chemoradiation (nCRT). Laparoscopy was successful in 93.9%, with five cases requiring conversion to open (6.1%). The median lymph node harvest was 19. Overall complication rate (major and minor) was 45.5% and ninety-day mortality was 4%. Overall 5-year survival was 52% (77% for stage 1, 57% for stage 2, 37% for stage 3). CONCLUSIONS: Laparoscopic transhiatal esophagectomy has an important role in current esophageal cancer treatment and can be performed with curative intent in patients with distal esophageal tumors. In addition to the well-known advantages of laparoscopy, the increased mediastinal visibility and a modern focus on oncologic principles seem to have a positive impact on cancer survival compared to the open transhiatal approach.
Assuntos
Adenocarcinoma , Neoplasias Esofágicas , Laparoscopia , Adenocarcinoma/cirurgia , Idoso , Neoplasias Esofágicas/cirurgia , Esofagectomia , Feminino , Humanos , Masculino , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Post-operative pain control and narcotic over-utilization are challenging issues for surgeons in all fields. While virtual reality (VR) has been increasingly applied in various fields, its feasibility and efficacy in the peri-operative period has not been evaluated. The aim of this study was to examine the experience of an integrated VR protocol in the perioperative setting. METHODS: Patients undergoing minimally invasive foregut surgery at a single institution were randomized to receive a series of VR meditation/mindfulness sessions (VR) or to standard care after surgery (non-VR). Post-operative pain levels, narcotic utilization and patient satisfaction were tracked. RESULTS: Fifty-two patients were enrolled with 26 in each arm. Post-operative pain scores, total narcotic utilization, and overall satisfaction scores were not significantly different between the two groups. For patients in the VR arm, sessions were able to be incorporated into the perioperative routine with little disruption. Most (73.9 %) were able complete all six VR sessions and reported low pain, anxiety, and nausea scores while using the device. A high proportion responded that they would use VR again (76.2 %) or would like a VR program designed for pain (62.0 %). There were no complications from device usage. CONCLUSION: VR is a safe and simple intervention that is associated with high patient satisfaction and is feasible to implement in the perioperative setting. While the current study is underpowered to detect difference in narcotic utilization, this device holds promise as an adjuvant tool in multimodal pain and anxiety control in the peri-operative period.
Assuntos
Meditação/métodos , Atenção Plena/métodos , Procedimentos Cirúrgicos Minimamente Invasivos , Manejo da Dor/métodos , Realidade Virtual , Idoso , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Satisfação do PacienteRESUMO
BACKGROUND AND AIMS: The objective of this study was to examine expert opinion and agreement on the treatment of distinct GERD profiles from surgical and therapeutic endoscopy perspectives. METHODS: We used the RAND/University of California, Los Angeles Appropriateness Method over 6 months (July 2018 to January 2019) to assess the appropriateness of antireflux interventions among foregut surgeons and therapeutic gastroenterologists. Patients with primary atypical or extraesophageal symptoms were not considered. Patient scenarios were grouped according to their symptom response to proton pump inhibitor (PPI) therapy. The primary outcome was appropriateness of an intervention. RESULTS: Antireflux surgery with laparoscopic fundoplication (LF) and magnetic sphincter augmentation (MSA) were ranked as appropriate for all complete and partial PPI responder scenarios. Transoral incisionless fundoplication was ranked as appropriate in complete and partial PPI responders without a hiatal hernia. Radiofrequency energy was not ranked as appropriate for complete or partial responders. There was lack of agreement between surgery and interventional gastroenterology groups on the appropriateness of LF and MSA for PPI nonresponders. Rankings for PPI nonresponders were similar when results from impedance-pH testing on PPI therapy were available, except that LF and MSA were not ranked as appropriate for PPI nonresponders if the impedance-pH study was negative. CONCLUSIONS: This work highlights areas of agreement for invasive therapeutic approaches for GERD and provides impetus for further interdisciplinary collaboration and trials to compare and generate novel and effective treatment approaches and care pathways, including the role of impedance-pH testing in PPI nonresponders.
Assuntos
Refluxo Gastroesofágico , Laparoscopia , Adulto , Idoso , Endoscopia , Endoscopia Gastrointestinal , Feminino , Fundoplicatura , Refluxo Gastroesofágico/tratamento farmacológico , Refluxo Gastroesofágico/cirurgia , Humanos , Los Angeles , Masculino , Pessoa de Meia-Idade , Inibidores da Bomba de Prótons/uso terapêutico , Resultado do TratamentoRESUMO
INTRODUCTION: Laparoscopic paraesophageal hernia (PEH) is associated with a low morbidity and mortality but an objective hernia recurrence rate in excess of 50% at 5 years. Biologic mesh has not been shown to reduce hernia recurrence rates. Recently, a new bioresorbable mesh made with poly-4-hydroxybutyrate with a Sepra-Technology coating on one side (Phasix-ST mesh) has become available. The aim of this study was to evaluate the feasibility, safety, and short-term efficacy of Phasix-ST mesh for reinforcement of the primary crural closure in patients undergoing elective, laparoscopic PEH repair. METHODS: A prospective database was initiated and maintained for all patients undergoing PEH repair with the use of Phasix-ST mesh. We retrospectively reviewed the records of consecutive patients who had an elective, first-time laparoscopic PEH repair with Phasix-ST mesh and who completed their 1-year objective follow-up study. Patients having a reoperation, non-laparoscopic repair, or who failed to comply with the objective follow-up were excluded. RESULTS: To achieve the desired 50 patients with 1-year objective follow-up, we reviewed the records of 90 consecutive PEH patients. In the final cohort of 50 patients, there were 32 females (64%) and 18 males. The median age of the patients at surgery was 67 years (range 44-84). The operation was PEH repair with fundoplication alone in 29 patients (58%) and PEH repair with Collis gastroplasty and fundoplication in 21 patients (42%). Phasix-ST mesh was used for crural reinforcement in all patients, and there were no intraoperative issues with the mesh or any difficulty placing or fixating the mesh at the hiatus. A diaphragm relaxing incision was performed in 2 patients (4%). The mean length of hospital stay was 2.8 days, and there was no major morbidity or mortality. On the 1-year objective follow-up study (median 12 months) a recurrent hernia was found in 4 patients (8%). No patient that had a Collis gastroplasty or a relaxing incision had a recurrent hernia. No patient had a reoperation. No patient had a mesh infection or mesh erosion. CONCLUSIONS: Phasix-ST mesh reinforcement of the crural closure during laparoscopic primary, elective PEH repair was associated with no adverse mesh-related events such as infection or erosion. Phasix-ST crural reinforcement in combination with tension-reduction techniques when necessary resulted in a very low (8%) objective hernia recurrence rate at a median follow-up of 1 year. These results demonstrate the safety of Phasix-ST mesh for use at the hiatus for crural reinforcement. This safety, along with the encouraging short-term efficacy for reducing hernia recurrence, should encourage further studies using the combination of resorbable biosynthetic mesh crural reinforcement and tension-reducing techniques during repair of paraesophageal hernias.
Assuntos
Hérnia Hiatal , Laparoscopia , Implantes Absorvíveis , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Hérnia Hiatal/cirurgia , Herniorrafia/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Telas Cirúrgicas , Resultado do TratamentoRESUMO
BACKGROUND: Hiatal dissection, restoration of esophageal intra-abdominal length, and crural closure are key components of successful antireflux surgery. The necessity of addressing these components prior to magnetic sphincter augmentation (MSA) has been questioned. We aimed to compare outcomes of MSA between groups with differing hiatal dissection and closure. METHODS: We retrospectively reviewed 259 patients who underwent MSA from 2009 to 2017. Patients were categorized based on hiatal treatment: minimal dissection (MD), crural closure (CC), formal crural repair (FC), and extensive dissection without closure (ED). The primary outcome was normalization of postoperative DeMeester score (≤ 14.72). Univariable and multivariable logistic regression was used to assess which preoperative predictors achieved normalization. RESULTS: Of the 197 patients, MD was used in 81 (41%); FC in 42 (22%); CC in 40 (20%); and ED in 34 (17%). Normalization occurred in 104 (53%) patients, with MD achieving normalization in 45/81 (56%); FC in 25/42 (60%); CC in 21/40 (53%); and ED 13/34 (38%). After regression, FC was most likely to normalize acid exposure. The presence of a hiatal hernia, defective LES, and higher preoperative DeMeester score were less likely to achieve normalization. CONCLUSIONS: Hiatal dissection with restoration of esophageal length and crural closure during MSA increases the likelihood of normalizing acid exposure.
Assuntos
Esfíncter Esofágico Inferior/cirurgia , Refluxo Gastroesofágico/cirurgia , Imãs , Adulto , Doença Crônica , Dissecação , Feminino , Fundoplicatura , Hérnia Hiatal/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Impedance-pH testing (MII-pH) while patients are on acid suppression medications is frequently used to evaluate persistent reflux symptoms. The aim of this study was to determine whether MII-pH on medications can reliably identify patients with gastroesophageal reflux disease (GERD) as defined by pathologic esophageal acid exposure off medications, and to determine if there is a threshold of total reflux episodes on medications where pH testing off medications may be unnecessary. METHODS: A retrospective review identified all patients between 1/2010 and 4/2017 who underwent MII-pH testing on PPI medications and subsequently had pH testing off medications. GERD was defined on pH testing off medications by an abnormal DeMeester Score (DMS) and on MII-pH on medications by ≥ 48 total reflux episodes. Patients with an abnormal DMS by MII-pH on medications were excluded. RESULTS: There were 71 patients, (22 males; 49 females), with a median age of 52 years. Based on ≥ 48 total reflux episodes by MII-pH testing on medications, 42 patients (59%) had GERD. When tested off medications, an abnormal DMS was present in 44 patients (62%). Among those with GERD based on impedance testing on medications, 31% did not have GERD based on pH testing off medications. Further, in the 29 patients with ≤ 48 total reflux episodes on MII-pH (normal test), 15 patients (52%) had pathologic acid exposure off medications. When there were > 73 reflux events with MII-pH on medications, all 15 patients in our series had pathologic acid exposure on pH testing off medications. CONCLUSION: MII-pH testing on medications in patients with refractory GERD symptoms does not reliably correlate with a diagnosis of GERD as defined by pathologic esophageal acid exposure off medications. The commonly used abnormal MII-pH test value of ≥ 48 total reflux episodes is not validated and should not be used. However, in our series, patients with > 73 total reflux episodes had a high likelihood of having pathologic acid exposure off medications. Overall, the preferred strategy to evaluate patients with persistent GERD symptoms on acid suppression therapy should be pH testing off medications.
Assuntos
Monitoramento do pH Esofágico/métodos , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/tratamento farmacológico , Inibidores da Bomba de Prótons/uso terapêutico , Impedância Elétrica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Dysphagia after Nissen fundoplication is challenging for patients. High-resolution manometry (HRM) has rarely been studied preoperatively to determine whether manometry values correlated with postoperative dysphagia after fundoplication. We aim to determine whether HRM criteria could predict dysphagia after Nissen fundoplication. METHODS: A retrospective review of single-institution laparoscopic Nissen fundoplications (LNF) from 2013 to 2015 was completed. Dysphagia was graded using a standard scale. Four groups were: those with new postoperative dysphagia (ND), never had dysphagia (NV), continued dysphagia (CD), and resolved dysphagia (RD). Manometry criteria included distal contractile integral (DCI), contraction front velocity (CFV), distal latency (DL), integrated relaxation pressure (IRP), percent peristalsis (PP), and distal esophageal contraction amplitude (DECA). Statistical bootstrapping was used to power sample sizes for ANOVA analysis. RESULTS: Ninety-four patients were included in the original cohort. Statistical bootstrapping sample size was 2992 patients. Among patients who did not have dysphagia prior to LNF, no HRM metric was associated with developing new dysphagia. Among those with dysphagia prior to LNF, a higher DCI, CFV, DL, PP, and DECA were associated with resolution of dysphagia. The RD group was 2.77 times more likely to have a DCI ≥ 1000 mmHg-s-cm compared with the CD group. CONCLUSIONS: HRM criteria could not predict the development of postoperative dysphagia. However, in those with preoperative dysphagia and strong manometry criteria, dysphagia is more likely to resolve after Nissen fundoplication. Meanwhile, in those with preoperative dysphagia and weak manometry, dysphagia may persist and these patients may be better served with a partial fundoplication.
Assuntos
Transtornos de Deglutição/etiologia , Fundoplicatura/efeitos adversos , Manometria/métodos , Cuidados Pré-Operatórios/métodos , Esôfago/fisiologia , Feminino , Humanos , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Peristaltismo , Complicações Pós-Operatórias , Pressão , Estudos RetrospectivosRESUMO
BACKGROUND: Cost-effectiveness of robotic-assisted surgery is still debatable. Robotic-assisted inguinal hernia repair has no clear clinical benefit over laparoscopic repair. We performed a comprehensive cost-analysis comparison between the two approaches for evaluation of their cost-effectiveness in a large healthcare system in the Western United States. METHODS: Health records in 32 hospitals were queried for procedural costs of inguinal hernia repairs between January 2015 and March 2017. Elective robotic-assisted or laparoscopic unilateral inguinal hernia repairs were included. Cost calculations were done using a utilization-based costing model. Total cost included: fixed cost, which comprises medical device and personnel costs, and variable cost, which comprises disposables and reusable instruments costs. Other outcome measures were length of stay (LOS), conversion to open, and operative times. Statistics were done using t test for continuous variables and χ2 test for categorical variables. A p-value < 0.05 was considered significant. RESULTS: A total of 2405 cases, 734 robotic-assisted (633 Primary: 101 recurrent) and 1671 laparoscopic (1471 Primary: 200 recurrent), were included. The average total cost was significantly higher (p < 0.001) in the robotic-assisted group ($5517) compared to the laparoscopic group ($3269). However, the average laparoscopic variable cost ($1105) was significantly higher (p < 0.001) than the robotic-assisted cost ($933). Whereas there was no significant difference between the two groups for LOS and conversion to open, average operative times were significantly higher in the robotic-assisted group (p < 0.001). Subgroup analysis for primary and recurrent inguinal hernias matched the overall results. CONCLUSIONS: Robotic-assisted inguinal hernia repair has a significantly higher cost and significantly longer operative times, compared to the laparoscopic approach. The study has shown that only fixed cost contributes to the cost difference between the two approaches. Medical device cost plus the longer operative times are the main factors driving the cost difference. Laparoscopic unilateral inguinal hernia repair is more cost-effective compared to a robotic-assisted approach.
Assuntos
Equipamentos e Provisões/economia , Hérnia Inguinal/cirurgia , Herniorrafia , Duração da Cirurgia , Procedimentos Cirúrgicos Robóticos , Análise Custo-Benefício , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Herniorrafia/economia , Herniorrafia/métodos , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/instrumentação , Procedimentos Cirúrgicos Robóticos/métodosRESUMO
OBJECTIVE: To report 1-year results from a 5-year mandated study. SUMMARY BACKGROUND DATA: In 2012, the United States Food and Drug Administration approved magnetic sphincter augmentation (MSA) with the LINX Reflux Management System (Torax Medical, Shoreview, MN), a novel device for the surgical treatment of gastroesophageal reflux disease (GERD). Continued assessment of safety and effectiveness has been monitored in a Post Approval Study. METHODS: Multicenter, prospective study of patients with pathologic acid reflux confirmed by esophageal pH testing undergoing MSA. Predefined clinical outcomes were assessed at the annual visit including a validated, disease-specific questionnaire, esophagogastricduodenoscopy and esophageal pH monitoring, and use of proton pump inhibitors. RESULTS: A total of 200 patients (102 males, 98 females) with a mean age of 48.5 years (range 19.7-71.6) were treated with MSA between March 2013 and August 2015. At 1 year, the mean total acid exposure time decreased from 10.0% at baseline to 3.6%, and 74.4% of patients had normal esophageal acid exposure time (% time pH<4 ≤5.3%). GERD Health-Related Quality of Life scores improved from a median score of 26.0 at baseline to 4.0 at 1 year, with 84% of patients meeting the predefined success criteria of at least a 50% reduction in total GERD Health-Related Quality of Life score compared with baseline. The device removal rate at 1 year was 2.5%. One erosion and no serious adverse events were reported. CONCLUSIONS: Safety and effectiveness of magnetic sphincter augmentation has been demonstrated outside of an investigational setting to further confirm MSA as treatment for GERD.
Assuntos
Deglutição/fisiologia , Esfíncter Esofágico Inferior/cirurgia , Refluxo Gastroesofágico/cirurgia , Imãs , Adulto , Idoso , Esfíncter Esofágico Inferior/fisiopatologia , Monitoramento do pH Esofágico , Feminino , Seguimentos , Refluxo Gastroesofágico/metabolismo , Refluxo Gastroesofágico/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Desenho de Prótese , Inquéritos e Questionários , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Optimal treatment for symptomatic patients with non-achalasia motility disorders (NAD) such as diffuse esophageal spasm, esophagogastric junction outlet obstruction, and hypercontractile disorder is not well established. POEM has been offered to these patients since it is a less invasive and less morbid procedure but long-term outcomes remain undetermined. The aim of this study was to assess long-term outcomes of POEM for patients with NAD. METHODS: Records of 40 consecutive patients undergoing POEM for NAD from May 2011 to January 2016 at a single center were retrospectively reviewed. Preoperative and 6-month postoperative symptom scores, high-resolution manometry, pH testing, and timed barium swallow (TBS) data were collected. Patients were contacted by phone to obtain long-term symptom assessment. Symptoms were assessed using a standardized symptom questionnaire with scores for symptoms graded according to frequency and the Eckardt score. RESULTS: Ten percent had minor complications with no postoperative sequelae. 90% of patients had significant improvement in their mean Eckardt scores (5.02 vs. 1.12, p < 0.001) at early follow-up. Improvements in chest pain (1.02-0.36, p = 0.001) and dysphagia (2.20 vs. 0.40, p = 0.001) were seen. Significant improvements in manometric pressures and esophageal emptying on TBS were observed across groups. 38% (10/26) of patients had a postoperative pH score > 14.72. Long-term (median 48 months) symptom scores were obtained from 29 (72.5%) patients. 82% of patients (24/29) had sustained symptom improvement. A small increase in the dysphagia scores was reported in the long-term follow-up compared to the immediate postoperative period (0.36-0.89, p = 0.046). CONCLUSIONS: Chest pain and dysphagia are effectively palliated with POEM in patients with non-achalasia disorders of the esophagus. Significant improvements are durable in long-term follow-up. Despite earlier reports by our group suggesting possible inferior outcomes from POEM for this difficult group of patients, this study is far more encouraging. POEM should be considered in the treatment of patients with non-achalasia disorders of the esophagus.
Assuntos
Doenças do Esôfago/cirurgia , Miotomia/métodos , Cirurgia Endoscópica por Orifício Natural/métodos , Adulto , Idoso , Transtornos de Deglutição/cirurgia , Junção Esofagogástrica/cirurgia , Feminino , Humanos , Masculino , Manometria/métodos , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
The understanding of esophageal function and dysfunction in a variety of disease states has been driven largely by the introduction of a variety of measurement technologies. Included in these are contrast esophagram, computed tomography, high-resolution manometry, and 24-hour pH monitoring. Two novel measurement technologies, the functional lumen imaging probe (FLIP) and mucosal impedance (MI) catheter have recently introduced and studied. This review will discuss the technological basis of these tools and the evidence behind their application in the measurement of esophageal anatomy, physiology, and histology pertaining to a number of diseases, including gastroesophageal reflux disease, achalasia, and esosinophilic esophagitis.
Assuntos
Doenças do Esôfago/diagnóstico , Doenças do Esôfago/fisiopatologia , Cateterismo/instrumentação , Catéteres , Diagnóstico por Imagem/instrumentação , Impedância Elétrica , Doenças do Esôfago/terapia , Esofagoscopia/instrumentação , Esofagoscopia/métodos , Humanos , Manometria/instrumentaçãoRESUMO
BACKGROUND: Peroral endoscopic myotomy (POEM) is a novel operation for the treatment of achalasia and other esophageal motility disorders. While POEM has shown excellent short-term safety and efficacy, the long-term symptomatic outcomes after the procedure are unknown. METHODS: Patients from a single center that underwent POEM for treatment of esophageal motility orders and were greater than 5 years removed from their operation were studied. Patients were contacted to assess current symptoms and encouraged to undergo repeat endoscopy for objective follow-up. RESULTS: Thirty-six patients underwent POEM from October, 2010 to February, 2012 and current symptom scores were obtained from 29 patients at median 65-month follow-up. In the 23 patients with achalasia, Eckardt scores were significantly improved from preoperative baseline (mean current 1.7 vs. preoperative 6.4, p < 0.001). Nineteen patients (83%) with achalasia had a symptomatic success (Eckardt ≤3) and none required retreatment for symptoms. Eckardt scores were dramatically improved at 6 months and maintained at 2 years; however, there was a small but significant worsening of symptoms between 2 and 5-years. Of the five patients with EGJ outflow obstruction, all had current Eckardt scores ≤3 but two needed reintervention for persistent or recurrent symptoms, one with a laparoscopic Heller myotomy and another with an endoscopic cricomyotomy and proximal esophageal myotomy extension. At 6-month follow-up, repeat manometry showed decreased EGJ relaxation pressures and esophagram demonstrated improved emptying. 24-h pH monitoring showed abnormal distal esophageal acid exposure in 38% of patients. Fifteen patients underwent endoscopy at 5-years, revealing erosive esophagitis in two (13%), new hiatal hernia in two, and new non-dysplastic Barrett's esophagus in one. The patient with Barrett's underwent a subsequent laparoscopic hiatal hernia repair and Toupet fundoplication. CONCLUSIONS: POEM resulted in a successful palliation of symptoms in the majority of patients after 5 years, though these results emphasize the importance of long-term follow-up in all patients.