RESUMEN
INTRODUCTION: Traditional treatment for the esophageal motility disorder, achalasia, ranges from endoscopic botulinum toxin (Botox) injections or balloon dilatation, to laparoscopic or open surgical myotomy. Recent advances in endoscopic therapy have led to peroral endoscopic myotomy (POEM) as a viable alternative to traditional techniques for myotomy. Uncertainty exists as to whether the procedure is feasible for patients who have already received prior endoscopic or surgical procedures for therapy, as these groups experience higher failure rates as well as intraoperative mucosal perforations and technical difficulty during Heller myotomy. We describe our first 40 patients who have undergone POEM and compare outcomes between patients who have or have not received previous treatment for achalasia. METHODS AND PROCEDURES: We evaluated our prospectively collected database of POEM procedures performed by two surgeons (JLP and JMM) at a single institution. Perioperative data was collected for operative and hospital outcomes. Patients completed pre- and postoperative GERD-Health-Related Quality of Life Questionnaires (GERD-HRQL) and SF-12 surveys for symptom scoring. RESULTS: Forty patients received a POEM procedure between 2011 and 2013. Of these, 40% (n = 16) had had at least one prior endoscopic or surgical procedure. Nine had prior Botox injections, 7 had balloon dilations, 3 had both Botox and dilations, and 3 received prior laparoscopic Heller myotomy (two with Dor fundoplication). Mean operative time was 102 min for patients with prior procedures (Prior Tx) and 118 min for patients without any prior procedure (No Tx) (p = 0.07). Intraoperative complication rates for the Prior Tx group were 12.5 versus 16.7% for the No Tx group. Mean follow-up was 10 months. Both groups independently demonstrated clinical improvement in both the GERD-HRQL and SF-12 scores following POEM. There were no statistical differences between the two groups for GERD-HRQL reflux and dysphagia subset scores, or SF-12 mental component summary. CONCLUSION: We found favorable outcomes following POEM in patients who have had prior endoscopic or surgical treatments for achalasia, as well as for patients without prior intervention. There were no significant differences between these two groups with regards to operative times, GERD-HRQL scores, and mental component SF-12 scores. One complication requiring intervention occurred in a patient that had received multiple prior Botox injections and balloon dilatations. POEM appears to be a viable alternative for treatment of achalasia compared to traditional techniques, however, long-term data are needed to establish the durability of this technique and to determine whether symptoms will recur necessitating re-intervention.
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Trastornos de la Motilidad Esofágica/cirugía , Fundoplicación/métodos , Complicaciones Intraoperatorias/prevención & control , Cirugía Endoscópica por Orificios Naturales/métodos , Complicaciones Posoperatorias/prevención & control , Anciano , Femenino , Humanos , Incidencia , Complicaciones Intraoperatorias/epidemiología , Masculino , Boca , Complicaciones Posoperatorias/epidemiología , Encuestas y Cuestionarios , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Minimally invasive techniques have become an integral part of general surgery with recent investigation into single-incision laparoscopic cholecystectomy (SILC). This study presents the final 1-year results of a prospective, randomized, multicenter, single-blinded trial of SILC vs multiport cholecystectomy (4PLC). STUDY DESIGN: Patients with biliary colic and documented gallstones or polyps or with biliary dyskinesia were randomized to SILC vs 4PLC. Data measures included operative details, adverse events, and conversion to 4PLC or laparotomy. Patients were followed for 12 months. RESULTS: Two hundred patients underwent randomization to SILC (n = 119) or 4PLC (n = 81). Enrollment ranged from 1 to 50 patients with 4 sites enrolling >25 patients. Total adverse events were not significantly different between groups (36% 4PLC vs 45% SILC; p = 0.24), as were severe adverse events (4% 4PLC vs 10% SILC; p = 0.11). Incision-related adverse events were higher after SILC (11.7% vs 4.9%; p = 0.13), but all of these were listed as mild or moderate. Total hernia rates were 1.2% (1 of 81) in 4PLC patients vs 8.4% (10 of 119) in SILC patients (p = 0.03). At 1-year follow-up, cosmesis scores continued to favor SILC (p < 0.0001). CONCLUSIONS: Results of this trial show SILC to be a safe and feasible procedure when compared with 4PLC, with similar total adverse events but with an identified significant increase in hernia formation. Cosmesis scoring and patient preference at 12 months continue to favor SILC, and more than half of the patients were willing to pay more for a single-site surgery over a standard laparoscopic procedure. Additional longer-term population-based studies are needed to clarify if this increased rate of hernia formation as compared with 4PLC will continue to hold true.
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Colecistectomía Laparoscópica/métodos , Enfermedades de la Vesícula Biliar/cirugía , Hernia Ventral/epidemiología , Hernia Ventral/prevención & control , Laparoscopios , Adolescente , Adulto , Anciano , Diseño de Equipo , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Método Simple Ciego , Resultado del Tratamiento , Estados Unidos/epidemiología , Adulto JovenRESUMEN
INTRODUCTION: Flank hernias represent a challenging problem to reconstructive surgeons. Their anatomic proximity to the bony prominence and major neurovascular structures limits fixation options and restricts mesh overlap. We present our technique and outcomes of a preperitoneal repair with wide mesh overlap. METHODS: This study is a retrospective analysis of patients undergoing open flank hernia repair with a retromuscular preperitoneal approach. RESULTS: Between September 2007 and April 2011, 16 patients, mean age 55 years (range 34-80) and BMI 33 kg/m² (range 26-46), underwent open flank hernia repair. Eight were recurrent hernias; six previously had mesh placed; nine were incarcerated. Mean hernia defect size was 232 cm² (range 25-800). Mean operative time was 178 min (range 105-245). One intraoperative complication, ureteral injury in a transplant recipient, occurred and was primarily repaired without sequela. Two patients developed wound complications, one requiring superficial debridement and another requiring partial excision (<5 %) of the mesh with secondary healing. With a mean follow-up of 16.8 months (range 2-49), no recurrent hernias were noted. CONCLUSION: Open retromuscular preperitoneal repair of flank hernias with iliac bone fixation is technically feasible, allowing wide mesh overlap for a durable repair. This approach may offer advantages of treating abdominal wall laxity and repair of larger defects when compared to laparoscopic approaches.
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Hernia Abdominal/cirugía , Herniorrafia/métodos , Peritoneo/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Hernia Abdominal/etiología , Hernia Abdominal/patología , Herniorrafia/instrumentación , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Mallas Quirúrgicas , Resultado del TratamientoRESUMEN
BACKGROUND: The ideal method to secure biologic mesh during laparoscopic hiatal hernia repair remains uncertain. Suture or tack fixation can be technically difficult, and serious cardiovascular complications have been reported. Fibrin sealant (FS) offers a potential solution to this problem. We hypothesized that FS provides comparable mesh fixation to suture repair during laparoscopic mesh hiatoplasty. STUDY DESIGN: Using a porcine model, laparoscopic hiatal hernia repair was performed with suture reapproximation of the crura and reinforcement with an acellular porcine dermal matrix. Prior to repair, animals were randomized to mesh fixation with sutures (S) or FS. After 30-day survival, an esophagram was performed, the diaphragm harvested, and mesh position, fixation, and incorporation were evaluated histologically and biomechanically using a T-peel test. RESULTS: Twenty (10 S and 10 FS) laparoscopic hiatal hernia repairs were performed. Total operative time was significantly less in the FS group (74.7 versus 127.0 min, p < 0.01). There were no instances of mesh migration in any animal. Mean peel force did not differ significantly between the S and FS groups (0.21 vs. 0.18 N/mm, respectively; p = 0.49). There was no significant difference in cellular repopularization or inflammatory changes around the mesh. CONCLUSIONS: Fibrin sealant offers a reasonable alternative to suturing biologic mesh during laparoscopic hiatal hernia repair with equivalent mesh fixation. At 30 days it provides adhesive strength similar to suture fixation, while significantly reducing operative time.
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Adhesivo de Tejido de Fibrina , Hernia Hiatal/cirugía , Herniorrafia/métodos , Laparoscopía , Mallas Quirúrgicas , Adhesivos Tisulares , Animales , Modelos Animales , PorcinosRESUMEN
BACKGROUND: Minimally invasive techniques have become an integral part of general surgery, with recent investigation into single-incision laparoscopic cholecystectomy (SILC). This study presents a prospective, randomized, multicenter, single-blind trial of SILC compared with four-port cholecystectomy (4PLC) with the goal of assessing safety, feasibility, and factors predicting outcomes. METHODS: Patients with biliary colic and documented gallstones or polyps or with biliary dyskinesia were randomized to SILC or 4PLC. Data measures included operative details, adverse events, and conversion to 4PLC or laparotomy. Pain, cosmesis, and quality-of-life scores were documented. Patients were followed for 12 months. RESULTS: Two hundred patients were randomized to SILC (n = 117) or 4PLC (n = 80) (3 patients chose not to participate after randomization). Patients were similar except for body mass index (BMI), which was lower in the SILC patients (28.9 vs. 31.0, p = 0.011). One SILC patient required conversion to 4PLC. Operative time was longer for SILC (57 vs. 45 min, p < 0.0001), but outcomes, including total adverse events, were similar (34% vs. 38%, p = 0.55). Cosmesis scores favored SILC (p < 0.002), but pain scores were lower for 4PLC (1 point difference in 10-point scale, p < 0.028) despite equal analgesia use. Wound complications were greater after SILC (10% vs. 3%, p = 0.047), but hernia recurrence was equivalent for both procedures (1.3% vs. 3.4%, p = 0.65). Univariate analysis showed female gender, SILC, and younger age to be predictors for increased pain scores, while SILC was associated with improved cosmesis scores. CONCLUSIONS: In this multicenter randomized controlled trial of SILC versus 4PLC, SILC appears to be safe with a similar biliary complication profile. Pain scores and wound complication rates are higher for SILC; however, cosmesis scores favored SILC. For patients preferring a better cosmetic outcome and willing to accept possible increased postoperative pain, SILC offers a safe alternative to the standard 4PLC. Further follow-up is needed to detail the long-term risk of wound morbidities, including hernia recurrence.
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Enfermedades de las Vías Biliares/cirugía , Colecistectomía Laparoscópica/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Factibilidad , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios/métodos , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Calidad de Vida , Método Simple Ciego , Ombligo , Adulto JovenRESUMEN
The importance of adequate nutrition has long been established in the surgical patient population. Enteral nutrition provides the safest, most cost-effective approach with endoscopic and surgical options for permanent access. Parenteral nutrition should be reserved for patients in whom enteral nutrition is contradicted. This article summarizes the routes of access for both enteral and parenteral nutrition as well as the indications, procedural pearls, and complications associated with each approach.
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Nutrición Enteral/métodos , Nutrición Parenteral/métodos , Contraindicaciones , Endoscopía Gastrointestinal , Nutrición Enteral/efectos adversos , Humanos , Intubación Gastrointestinal/efectos adversos , Nutrición Parenteral/efectos adversosRESUMEN
BACKGROUND AND AIM: Partially covered self-expanding metal stents (PCMS) have been extensively used for palliation of malignant distal biliary stricture. Many centers have been using them as a bridge to surgery (BTS) regardless of resectability with or without eventual neoadjuvant therapy. We analyzed the outcome of all patients receiving PCMS and subsequently referred for surgery in our institution. METHODS: Our prospectively established pancreaticobiliary database was retrospectively analyzed to retrieve all patients with malignant biliary stricture who underwent PCMS placement and subsequently went for curative surgical attempt at our institution. Cancer type and staging, adverse events related to stent placement or surgery, type of surgery performed, time between stenting and surgery, length of postoperative hospitalization, and postoperative follow-up were recorded. RESULTS: 27 patients (21 men; median age 66 years, range 39-82 years) received PCMS. Indications for placement included biliary stricture related to pancreatic cancer (n=23) or other malignancies (n=4). Median time between stenting and surgery was 32 days (range 6-569 days). Median time of hospitalization post surgery was 7 days (1-40 days). All patients underwent exploratory laparoscopy, followed in 9 (33.3%) by Whipple procedure with uneventful removal of the PCMS. Eighteen patients (66.6%) had their attempted curative resection terminated early due to intraoperative evidence of metastatic spread, with 8 (30%) patients undergoing peritoneal or liver metastasis biopsy. PCMS were left in place in those 18 patients. Complications related to PCMS in the bridge-to-surgery period included migration (n=2, 7.4%) and tissue overgrowth (n=1, 3.4%), all of them managed by endoscopic removal and replacement with PCMS. Median follow-up post surgery was 210 days (range 9-1,642 days). CONCLUSION: PCMS are an appropriate BTS option. For resectable patients, PCMS results in biliary drainage and allows for neoadjuvant treatment without portending subsequent curative resection (Whipple). For unresectable patients, long-term biliary drainage is provided by PCMS.
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Colestasis/terapia , Endoscopía del Sistema Digestivo/instrumentación , Stents , Listas de Espera , Adulto , Anciano , Anciano de 80 o más Años , Colestasis/patología , Colestasis/cirugía , Materiales Biocompatibles Revestidos , Bases de Datos Factuales , Endoscopía del Sistema Digestivo/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Metales , Cuidados Preoperatorios/métodos , Diseño de Prótesis , Calidad de Vida , Estudios Retrospectivos , Medición de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: Partially covered metal stents have been extensively used for palliation of obstructive jaundice in malignant distal biliary strictures and can be removed in cases of malfunction or need for tissue diagnosis. We investigated independent predictors of mortality in patients undergoing partially covered metal stents revision (i.e., removal and replacement). METHODS: Patients with a distal malignant biliary obstruction palliated with a partially covered metal stent were followed-up prospectively over 5 years until malfunction or death. All patients who required removal of their partially covered metal stents were captured in a specific database. Multivariate analysis was performed on non-surgical patients to assess for independent predictors of death using known risk factors including type of malignancy (adenocarcinoma versus all others), age greater than 55, gender, and exposure to adjuvant chemotherapy and/or radiotherapy. RESULTS: Forty-two patients (28 men, mean age of 62±12 years) underwent partially covered metal stents removal. Of these, biliary drainage was achieved in 38 patients by placement of a new partially covered metal stent (n=32) or plastic stent (n=6). The remaining 4 patients did not undergo stent replacement because of refusal (2), resolution of obstruction (1) and unrelated death (1). Long-term follow-up post removal in patients who were not surgical candidates (n=31) was 35 weeks (95% CI 28-40), with a survival rate of 29% at 10 months. Logistic regression analysis in the 31 patients with unresectable disease showed that a histologic diagnosis of adenocarcinoma was associated with increased mortality post partially covered metal stents revision. CONCLUSIONS: Partially covered metal stents revision should be undertaken especially when dealing with a non-adenocarcinoma type cancer.
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Adenocarcinoma , Colestasis/terapia , Remoción de Dispositivos , Neoplasias Pancreáticas , Stents/efectos adversos , Adenocarcinoma/complicaciones , Adenocarcinoma/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Colestasis/etiología , Remoción de Dispositivos/instrumentación , Remoción de Dispositivos/mortalidad , Análisis de Falla de Equipo , Estudios de Seguimiento , Humanos , Ictericia Obstructiva/etiología , Ictericia Obstructiva/terapia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Cuidados Paliativos/métodos , Cuidados Paliativos/estadística & datos numéricos , Neoplasias Pancreáticas/complicaciones , Neoplasias Pancreáticas/mortalidad , Estudios Prospectivos , Estados UnidosRESUMEN
BACKGROUND: Benign biliary strictures (BBS) have been endoscopically managed with placement of multiple plastic stents. Uncovered metal stents have been associated with mucosal hyperplasia and partially covered self-expandable metal stents with migration. Recently, fully covered self-expandable metal stents (CSEMSs) with anchoring fins have become available. OBJECTIVE: Our purpose was to analyze the efficacy and complication rates of CSEMSs in the treatment of BBS. DESIGN: CSEMSs (10-mm diameter) were placed in 44 patients with BBS. CSEMSs were left in place until adequate biliary drainage was achieved, confirmed by resolution of symptoms, normalization of liver function tests, and imaging. SETTING: Tertiary care center with long-standing experience with metal stents. PATIENTS: A total of 44 patients with BBS (28 men, median age 53.5 years) were included. The preprocedure diagnoses included chronic pancreatitis (n = 19), gallstone-related strictures (n = 14), post liver transplant (n = 9), autoimmune pancreatitis (n = 1), and primary sclerosing cholangitis (n = 1). INTERVENTION: ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or rat tooth. MAIN OUTCOME MEASUREMENTS: Stricture resolution and morbidity. RESULTS: The median time of CSEMS placement was 3.3 months (interquartile range 3.0-4.8). Resolution of the BBS was confirmed in 34 of 41 patients (83%) after a median postremoval follow-up time of 3.8 months (interquartile range 1.2-7.7). Complications were observed in 6 (14%) patients after CSEMS placement and in 4 (9%) after CSEMS removal. LIMITATION: Pilot study from a single center. CONCLUSION: Temporary placement of CSEMSs for BBS may offer an alternative to plastic stenting. Further investigation is required to further assess safety and long-term efficacy.
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Colestasis/cirugía , Stents , Constricción Patológica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Factores de Tiempo , Grabación en VideoAsunto(s)
Implantación de Prótesis Vascular/métodos , Obstrucción de la Salida Gástrica/terapia , Fístula Intestinal/etiología , Pancreaticoduodenectomía/efectos adversos , Stents/efectos adversos , Fístula Vascular/etiología , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Resultado Fatal , Femenino , Obstrucción de la Salida Gástrica/diagnóstico por imagen , Obstrucción de la Salida Gástrica/etiología , Humanos , Fístula Intestinal/diagnóstico por imagen , Fístula Intestinal/cirugía , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Pancreatoyeyunostomía/efectos adversos , Pancreatoyeyunostomía/métodos , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/terapia , Reoperación , Medición de Riesgo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Fístula Vascular/diagnóstico por imagen , Fístula Vascular/cirugíaRESUMEN
BACKGROUND: Current management of malignant gastric outlet obstruction (GOO) includes surgical diversion or enteral stent placement for unresectable cancer. We analyzed the long-term results, predictive factors of outcomes, and complications associated with enteral stents with focus on their management. METHODS: Between 1997 and 2007, 46 patients with malignant GOO underwent placement of self-expandable metal stents (SEMS) for palliation. Patients were captured prospectively after 2001 and followed until complication or death. Patency, management of complications, and long-term survival were analyzed. RESULTS: Forty-six patients had a mean survival of 152 +/- 235 days and a mean SEMS patency rate of 111 +/- 220 days. SEMS patency rates of 98%, 74%, and 57% at 1, 3, and 6 months were seen. Thirteen patients presented with obstruction and included two SEMS migration, two early occlusion, one fracture, four malignant ingrowth, and four with delayed clinical failure. Interventions included seven endoscopic revisions with three SEMS replacements. Six had percutaneous endoscopic gastrostomy with jejunal arm placed. Two patients eventually underwent surgical bypass. Two patients required surgery for complications including delayed duodenal perforation and aortoenteric fistula. CONCLUSIONS: SEMS effectively palliate gastric outlet obstructions that result from upper gastrointestinal malignancies. Their benefits offset potential complications or malfunctions, when a pluridisciplinary approach is adopted.
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Cateterismo/instrumentación , Obstrucción de la Salida Gástrica/cirugía , Cuidados Paliativos/métodos , Calidad de Vida , Stents , Adulto , Anciano , Anciano de 80 o más Años , Cateterismo/métodos , Estudios de Cohortes , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Obstrucción de la Salida Gástrica/mortalidad , Obstrucción de la Salida Gástrica/patología , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Retrospectivos , Medición de Riesgo , Sensibilidad y Especificidad , Análisis de SupervivenciaRESUMEN
BACKGROUND: Bilomas have traditionally been treated by either percutaneous drainage or surgery. However, percutaneous drainage is associated with discomfort and infection, whereas surgery, which is usually reserved for refractory cases, has high morbidity and mortality rates. Recently, endoscopic drainage of bilomas adjacent to the GI lumen has been reported in isolated reports. OBJECTIVE: We analyzed our 4 years' experience with this innovative technique. DESIGN: Patients with symptomatic bilomas were offered EUS-guided drainage and were followed up prospectively for clinical and radiologic responses. SETTING: Tertiary care center with long-standing experience in EUS-guided drainage. PATIENTS: A total of 5 patients underwent EUS-guided transenteric drainage of symptomatic bilomas. INTERVENTION: The technique included transenteric EUS-guided puncture, placement of a guidewire into the biloma, and creation of an enteral-biloma fistula with placement of a plastic endoprosthesis after balloon dilation. In 4 cases, the stents were removed at a mean of 6.8 +/- 4.3 weeks. In one patient with malignancy, the stent was left in place for palliation. MAIN OUTCOME MEASUREMENTS: Efficacy and safety of EUS-guided drainage of bilomas. RESULTS: EUS-guided transenteric biloma drainage was successfully performed in 5 patients without any significant morbidity. Biloma resolution was confirmed in all 5 patients, and none of the 4 patients relapsed after stent removal (mean follow-up of 12.8 +/- 6.1 months). CONCLUSIONS: EUS-guided drainage of bilomas is technically feasible, appears safe, and provides an attractive alternative to percutaneous or surgical drainage.