RESUMEN
There have been many devices and ideas to treat reflux disease endoscopically. Several devices have been tried and even FDA approved but now are no longer used. The push for these therapies is to find effective reflux control with lower risk and faster recovery. In this article we describe an endoscopic suturing device (TIF), radiofrequency device (Stretta) and a newer technique that has a lot of promise called antireflux mucosectomy. All these procedures seem to help control reflux at a minimum of morbidity given current information. As reflux is so prevalent a shift to these techniques for appropriate patients is likely to improve patient care.
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Reflujo Gastroesofágico , Endoscopía , Fundoplicación , Reflujo Gastroesofágico/cirugía , Humanos , Técnicas de SuturaAsunto(s)
Acreditación/normas , Procedimientos Quirúrgicos Robotizados/educación , Especialidades Quirúrgicas/normas , Consejos de Especialidades/normas , Cirujanos/educación , Humanos , Procedimientos Quirúrgicos Robotizados/normas , Procedimientos Quirúrgicos Robotizados/tendencias , Especialidades Quirúrgicas/organización & administración , Cirujanos/normas , Estados UnidosRESUMEN
BACKGROUND: Laparoscopic cholecystectomy (LC), one of the most commonly performed surgical procedures, remains associated with significant major morbidity including bile leak and bile duct injury (BDI). The effect of changes in practice over time, and of interventions to improve patient safety, on morbidity rates is not well understood. The aim of this review was to describe current incidence rates and trends for BDI and other complications during and after LC, and to identify risk factors and preventative measures associated with morbidity and BDI. METHODS: PubMed, MEDLINE, and Web of Science database searches and data extraction were conducted for studies which reported individual complications and complication rates following laparoscopic cholecystectomy in a representative population. Outcomes data were pooled. Meta-regression analysis was performed to assess factors associated with conversion, morbidity, and BDI rates. RESULTS: One hundred and fifty-one studies reporting outcomes for 505,292 patients were included in the final quantitative synthesis. Overall morbidity, BDI, and mortality rates were 1.6-5.3%, 0.32-0.52%, and 0.08-0.14%, respectively. Reported BDI rates reduced over time (1994-1999: 0.69(0.52-0.84)% versus 2010-2015 0.22(0.02-0.40)%, p = 0.011). Meta-regression analysis suggested higher conversion rates in developed versus developing countries (4.7 vs. 3.4%), though a greater degree of reporting bias was present in these studies, with no other significant associations identified. CONCLUSIONS: Overall, trends suggest a reduction in BDI over time with unchanged morbidity and mortality rates. However, data and reporting are heterogenous. Establishment of international outcomes registries should be considered.
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Conductos Biliares/cirugía , Colecistectomía Laparoscópica , Adhesión a Directriz/normas , Seguridad del Paciente/normas , Complicaciones Posoperatorias , Conductos Biliares/lesiones , Colecistectomía Laparoscópica/efectos adversos , Colecistectomía Laparoscópica/métodos , Análisis de Datos , Bases de Datos Factuales , Humanos , Complicaciones Posoperatorias/cirugía , Guías de Práctica Clínica como AsuntoRESUMEN
INTRODUCTION: Barrett's esophagus (BE) has been associated with obesity and metabolic syndrome. Laparoscopic Roux-en-Y gastric bypass (LRYGB) may represent a surgical approach which addresses both severe obesity and BE. LRYGB diverts bile away from the gastric pouch and esophagus due to the long Roux limb, and very little acid is produced in the cardia-based gastric pouch. Furthermore, surgically induced weight loss may diminish systemic inflammation, which may contribute to metaplastic changes in the esophagus. Moreover, improved compliance with proton-pump inhibitor therapy, as a consequence of enrolling in a bariatric program, will decrease acid production further. Decreased duodeno-gastro-esophageal reflux should lead to decreased BE. In this study we examine the effect of LRYGB on regression of BE. METHODS AND PROCEDURES: We performed a review of all patients with biopsy proven BE, who underwent LRYGB at our institution. A total of 19 patients were identified. A subset of those patients was identified who had at least 1 year of clinical, endoscopic, or histological data, comprising a total of 14 patients. Seven of these patients had symptoms of gastroesophageal reflux. All 19 patients had short-segment BE. One patient had low-grade dysplasia. RESULTS: Post-LRYGB, 6 of 14 (42.9%) patients had histologic regression of BE to normal esophageal mucosa, with no evidence of ongoing BE. 13 of 14 patients (92.8%) reported compliance with continuing PPI therapy for at least the first year after surgery. Body mass index for the group of 14 patients improved from 46.6 to 30.3 kg/m2. CONCLUSIONS: We recommend LRYGB as an effective combined bariatric and anti-reflux surgical procedure for patients with severe obesity and BE. In short-term follow-up, LRYGB achieved endoscopic and histologic regression to normal mucosa in a substantial number of the patients in our series. Long-term follow-up for patients with BE according to standard surveillance protocols is still recommended.
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Esófago de Barrett/cirugía , Derivación Gástrica/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/métodos , Obesidad Mórbida/cirugía , Adulto , Esófago de Barrett/complicaciones , Femenino , Estudios de Seguimiento , Reflujo Gastroesofágico/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/complicaciones , Resultado del TratamientoRESUMEN
BACKGROUND: Faculty experts (FE) and crowd workers (CW) can assess technical skill, but assessment of operative technique has not been explored. We sought to evaluate if CW could be taught to assess completion of the critical view of safety (CVS) in laparoscopic cholecystectomy. METHODS: We prepared 160 blinded, surgical videos of laparoscopic cholecystectomy from public domain websites. Videos were edited to ≤60 s, ending when a structure was cut/clipped. CW analyzed videos using Global Objective Assessment of Laparoscopic Skills (GOALS) and CVS criteria assessment tools after watching an instructional tutorial. Ten videos were randomly selected from each performance quartile based on GOALS. Five FE rated the 40 videos using GOALS and CVS. Linear mixed effects models derived average CW and FE ratings for GOALS and CVS for each video. Spearman correlation coefficients (SCC) were used to assess the degree of correlation between performance measures. Satisfactory completion of the CVS was defined as scoring an average CVS ≥ 5. Videos with an average GOALS ≥ 15 were considered top technical performers. RESULTS: A high degree of correlation was seen between all performance measures: CVS ratings between CW and FE, SCC 0.89 (p < 0.001); GOALS and CVS ratings SCC 0.77 (p < 0.001) for CW, and SCC 0.71 (p < 0.001) for FE. Sixteen videos were assigned top technical performer ratings by both CW and FE but the average CVS was inadequate (3.8 and 3.6, respectively), and the percentage of satisfactory CVS ≥ 5 was 12.5%. CONCLUSIONS: A high degree of correlation was found between CW and FE in assessment of the CVS. However, in this video analysis, high technical performers did not achieve a complete CVS in most cases. Educating CW to assess operative technique for the identification of low or average performers is feasible and may broaden the application of this assessment and feedback tool.
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Colecistectomía Laparoscópica/normas , Competencia Clínica/normas , Colaboración de las Masas , Seguridad del Paciente/normas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Grabación en Video , Adulto JovenAsunto(s)
Endoscopía Gastrointestinal , Neoplasias Gastrointestinales/diagnóstico por imagen , Neoplasias Gastrointestinales/cirugía , Tumores del Estroma Gastrointestinal/diagnóstico por imagen , Leiomioma/diagnóstico por imagen , Tumores Neuroendocrinos/diagnóstico por imagen , Algoritmos , Coristoma/diagnóstico por imagen , Resección Endoscópica de la Mucosa , Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico/instrumentación , Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico/métodos , Endosonografía , Tumores del Estroma Gastrointestinal/patología , Tumores del Estroma Gastrointestinal/cirugía , Tumor de Células Granulares/diagnóstico por imagen , Humanos , Leiomioma/cirugía , Lipoma/diagnóstico por imagen , Lipoma/cirugía , Tumores Neuroendocrinos/cirugía , PáncreasAsunto(s)
Profilaxis Antibiótica , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Colangitis/etiología , Colecistitis/etiología , Hemorragia/etiología , Perforación Intestinal/etiología , Pancreatitis/etiología , Colangitis/microbiología , Colangitis/prevención & control , Colecistitis/microbiología , Colecistitis/prevención & control , Duodenoscopios/microbiología , Embolia Aérea/etiología , Hemorragia/prevención & control , Hemorragia/terapia , Humanos , Perforación Intestinal/terapia , Pancreatitis/diagnóstico , Pancreatitis/prevención & control , Factores de Riesgo , Esfinterotomía Endoscópica/efectos adversosRESUMEN
The prevalence of obesity has steadily increased throughout recent decades, and along with it, the costs of caring for the associated comorbid conditions has increased as well. Traditional bariatric surgical procedures generally are safe and effective, but patient acceptance, the risk of minor and sometimes serious complications, costs, and insurance coverage have limited the application of these techniques to the treatment of a minority of patients. Endoluminal techniques represent newer approaches to weight loss that can be used independently or in concert with traditional medical and surgical treatments for obesity, with varying degrees of success. It is anticipated that less invasiveness will increase the appeal across a broader representation of patients, perhaps increasing the number of obese patients who choose an intervention over medical management and possibly resulting in a greater total loss of excess body weight across a population; this may reduce costs involved in treating the complications of weight-related comorbidities. Acceptance of endoluminal bariatric procedures and devices will hinge on proving safety, efficacy, and value.
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Medicina Bariátrica/métodos , Cirugía Bariátrica/métodos , Obesidad/terapia , Medicina Bariátrica/economía , Cirugía Bariátrica/economía , HumanosAsunto(s)
Carcinoma Ductal Pancreático/diagnóstico , Endoscopía del Sistema Digestivo , Linfoma/diagnóstico , Tumores Neuroendocrinos/diagnóstico , Neoplasias Pancreáticas/diagnóstico , Carcinoma Ductal Pancreático/cirugía , Colangiopancreatografia Retrógrada Endoscópica , Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico , Endosonografía , Humanos , Linfoma/cirugía , Imagen por Resonancia Magnética , Tumores Neuroendocrinos/cirugía , Neoplasias Pancreáticas/cirugía , Tomografía de Emisión de Positrones , Tomografía Computarizada por Rayos XAsunto(s)
Enfermedades del Sistema Digestivo/diagnóstico , Dispepsia/etiología , Endoscopía Gastrointestinal , Infecciones por Helicobacter/diagnóstico , Helicobacter pylori , Selección de Paciente , Factores de Edad , Algoritmos , Enfermedades del Sistema Digestivo/complicaciones , Dispepsia/tratamiento farmacológico , Infecciones por Helicobacter/complicaciones , Infecciones por Helicobacter/tratamiento farmacológico , HumanosRESUMEN
We recommend that uncomplicated GERD be diagnosed on the basis of typical symptoms without the use of diagnostic testing, including EGD. We recommend EGD for patients who have symptoms suggesting complicated GERD or alarm symptoms. We recommend that EGD not be routinely performed solely for the assessment of extraesophageal GERD symptoms. We recommend that endoscopic findings of reflux esophagitis be classified according to an accepted grading scale or described in detail. We suggest that repeat EGD be performed in patients with severe erosive esophagitis after at least an 8-week course of PPI therapy to exclude underlying BE or dysplasia. 44BB We recommend against obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude BE in adults. We suggest that endoscopy be considered in patients with multiple risk factors for Barrett's esophagus. We recommend that tissue samples be obtained to confirm endoscopically suspected Barrett's esophagus. We suggest that endoscopic antireflux therapy be considered for selected patients with uncomplicated GERD after careful discussion with the patient regarding potential adverse effects, benefits, and other available therapeutic options.
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Esófago de Barrett/diagnóstico , Esofagoscopía/métodos , Esófago/patología , Reflujo Gastroesofágico/diagnóstico , Adulto , Esófago de Barrett/etiología , Esófago de Barrett/patología , Niño , Endoscopía Gastrointestinal , Reflujo Gastroesofágico/complicaciones , Reflujo Gastroesofágico/cirugía , Humanos , Lactante , Sociedades MédicasRESUMEN
BACKGROUND: Although it has been 25 years since the introduction of laparoscopy to cholecystectomy, outcomes remain largely unchanged, with rates of bile duct injury higher in the modern age than in the era of open surgery. The SAGES Safe Cholecystectomy Task Force (SCTF) initiative seeks to encourage a culture of safety in laparoscopic cholecystectomy (LC) and reduce biliary injury. An expert consensus study was conducted to identify interventions thought to be most effective in pursuit of this goal. METHODS: An initial list of items for safer practice in LC was identified by the SCTF through a nominal group technique (NGT) process. These were put forward to 407 SAGES committee members in two-stage electronically distributed Delphi surveys. Consensus was achieved if at least 80 % of respondents ranked an item as 4 or 5 on a Likert scale of importance (1-5). Additionally, respondents ranked five top areas of importance for the following domains: training, assessment, and research. RESULTS: Thirty-nine initial items were identified through NGT. Response rates for each Delphi round were 40.2 and 34 %, respectively. Final consensus was achieved on 15 items, the majority of which related to non-technical factors in LC. Key domains for training, assessment, and research were identified. Critical view of safety was deemed most important for overall safety, as well as training and assessment of LC. Intraoperative cholangiography was identified as an additional priority area for future research. CONCLUSIONS: Consensus items to progress surgical practice, training, assessment, and research have been identified, to promote safe practice and improve patient outcomes in LC.