The role of diagnostic laparoscopy for chronic abdominal conditions: an evidence-based review.

BACKGROUND: Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for chronic intraabdominal conditions. METHODS: A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. The search identified and reviewed six main categories that have received attention in the literature: pelvic pain and endometriosis, primary and secondary infertility, nonpalpable testis, and liver disease. RESULTS: The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. CONCLUSIONS: The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.

The role of staging laparoscopy for intraabdominal cancers: an evidence-based review.

Diagnostic laparoscopy is minimally invasive surgery for the diagnosis of intraabdominal diseases. The aim of this review is a critical examination of the available literature on the role of laparoscopy for the staging of intraabdominal cancers. A systematic literature search of English-language articles on MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects was performed for the period 1995-2006. The level of evidence in the identified articles was graded. The search identified and reviewed seven main categories that have received attention in the literature: esophageal cancer, gastric cancer, pancreatic cancer, hepatocellular carcinoma, biliary tract cancer, colorectal cancer, and lymphoma. The indications, contraindications, risks, benefits, diagnostic accuracy of the procedure, and its associated morbidity are discussed. The limitations of the available literature are highlighted, and evidence-based recommendations for the use of laparoscopy to stage intraabdominal cancers are provided.

Midterm follow-up evaluation after a novel approach to anterior fundoplication for achalasia.

BACKGROUND: This study aimed to compare the outcomes for Heller myotomy alone and combined with different partial fundoplications. METHODS: The authors retrospectively reviewed their experience with 69 laparoscopic myotomies and 14 Heller myotomies, 80% of which were performed with partial fundoplication including 20 Toupet, 18 Dor, and 17 modified Dor procedures, in which the fundoplication is sutured to both sides of the crura and not the myotomy. RESULTS: The mean age of the study patients was 69 years (range, 15-80 years). Four mucosal perforations were repaired intraoperatively. There was one small bowel fistula in an area of open hernia repair distant from the myotomy. One patient with severe chronic obstructive pulmonary disease died of pneumonia. Phone follow-up evaluation was achieved in 68% of the cases at a mean of 37 months (range, 2-97 months). The results for no dysphagia and for heartburn requiring proton pump inhibitors, respectively, were as follows: Heller myotomy (85.7%, 28.5%), Toupet (66.6%, 33.3%), Dor (83.3%, 20%), and modified Dor (84.6%, 15.3%). Two patients with reflux strictures required annual dilation (Toupet, Dor). Two patients required revisions: one redo Heller myotomy (Dor) and one esophageal replacement (Toupet). CONCLUSION: Heller myotomy provides excellent dysphagia relief with or without fundoplication. Heartburn is a significant problem for a minority of patients. In the authors' hands, Toupet had the worst results and modified Dor was most protective for heartburn.

Laparoscopic hand-assisted versus open transhiatal esophagectomy: a case-control study.

BACKGROUND: This case-control study evaluated and compared the outcomes of laparoscopically assisted (LTE) and open transhiatal esophagectomy (OTE). METHODS: In this study, 17 patients who underwent LTE during this period August 1999 through June 2003 were compared with 14 matched control patients who underwent OTE during this period December 1989 through September 2001. The groups had stage I esophageal cancer or lesser disease at the preoperative evaluation. Patients with prior upper abdominal or thoracic surgery were excluded. RESULTS: There was no significant difference between the groups with respect to age, body mass index, American Society of Anesthesiology (ASA) classification, or operating time. The estimated blood loss was 331 (+/- 220) ml for LTE and 542 (+/- 212) ml for OTE (p = 0.01). The hospital stay was 9.1 (+/- 3.2) days for LTE and 11.6 (+/- 2.9) days for OTE (p = 0.04). Comparing only the last six LTE with the OTE, the operating time was 311 (+/- 31) min for LTE and 388 (+/- 14) min for OTE (p = 0.02). CONCLUSIONS: The findings showed shorter operative time, less blood loss, and a shorter hospital stay with LTE than with OTE.

Burst strength of laparoscopic and open hernia repair.

BACKGROUND: There are few reports of overall strength of laparoscopic and open incisional hernia repair. METHODS: After anesthesia, a 2-inch circular defect was made in the abdominal wall of 28 female swine. Gore-Tex DualMesh Biomaterial (W. L. Gore & Associates, Flagstaff, AZ) was used for all repairs. Sixteen animals underwent open repair and 12 underwent laparoscopic repair. Burst strength was detected within 2 weeks and at 6 weeks by euthanizing the animals and insufflating the abdominal cavity with water while measuring the intraabdominal pressure until it could no longer be pressurized. RESULTS: Three events occurred after insufflation: rupture around patch (R), dissection from insufflation or pressure monitoring sites (D), or rectal prolapse (P). Failure after open early repair occurred at 289 (range 219-388) mmHg with 7-R, 1-P and late 289 (196-343) mmHg with 1-R, 6-P. Failure after laparoscopic early repair occurred at 259 (191-388) mmHg with 4-R, 1-P, 1-D and late 291 (140-330) mmHg with 2-R, 1-P, 3-D. Late groups were less likely to rupture. CONCLUSION: Both hernia repairs are durable at early and late periods. Tissue ingrowth adds to repair strength. We could not show that one repair was stronger than the other. Nonetheless, laparoscopic repair tended to degrade by dissection, which was our highest pressure event.

Evaluation of scar formation after botulinum toxin injection or forced balloon dilation to the lower esophageal sphincter.

BACKGROUND: It has been postulated that nonsurgical treatments for achalasia cause fibrosis, increasing the risk of surgical Heller myotomy. The goal of this study was to evaluate fibrosis, muscle fracture, and esophageal inflammation after these treatments. METHODS: Eighteen female swine were divided into three groups: 6 were euthanized and their lower esophageal sphincters were harvested (group 1); 6 underwent botulinum toxin injection (group 2); and 6 underwent forced balloon dilatation (group 3). Groups 2 and 3 were euthanized 30 days later and LESs harvested. LESs, were evaluated with trichrome and hematoxylin and eosin (H&E) preparations. RESULTS: Results for both trichrome and H&E slides were the same: severe inflammation in groups 2 and 3 but only minimal inflammation in group 1 (p <0.05) and mild fibrosis in groups 2 and 3 and none in group 1 (p <0.05). CONCLUSIONS: Botulinum toxin injection and forced balloon dilatation caused significant inflammation in the esophagus of the swine, which would be consistent with the injury caused by reflux. Forced balloon dilatation and botulinum toxin caused fibrosis and may increase surgical risk.

Risk factors for gallstone disease in the laparoscopic era.

BACKGROUND: The risk factors for gallstone disease are well known, but they have not been updated to take the development of better ultrasound technology and the advent of laparoscopic surgery into consideration. METHODS: We compared two groups of patients who underwent ultrasound-one group (n = 100) who underwent cholecystectomy after ultrasound revealed the presence of gallstones and a control group (n = 107) in whom no gallstones were shown on ultrasound. RESULTS: Seven patients in the control group refused to participate in the study; otherwise, the groups are sequential. Age in the surgery group was 51 years (+/- 16) vs 50 (+/- 16) for the control group. The percentage of female patients was 59% and 52%, respectively (p = ns). Body mass index was 32 (+/- 8) and 28 (+/- 6), respectively (p = 0.013). Parity > 2 was 0.49% and 0.37%, respectively (p = 0.000001). The number who breast-fed at least one child was 17 (24%) and eight (12%), respectively (p = 0.03). Oral contraceptive use was 37 (52%) and 17 (22%), respectively (p = 0.0005). Primary relatives who had had gallbladder surgery was 0.68 (+/- 1) and 0.35 (+/- 0.6), respectively (p = 0.02). CONCLUSION: Body mass index, breast-feeding, oral contraceptives, parity > 2, and family history were found to be risk factors for gallstone disease. Age and female sex were not, probably due to selection bias.

Response of atypical symptoms of gastro-oesophageal reflux to antireflux surgery.

BACKGROUND: Atypical manifestations of gastro-oesophageal reflux (GOR) include asthma, chest pain, cough and hoarseness. The effectiveness of antireflux surgery for these symptoms is uncertain. The present study compared symptomatic response rates for typical and atypical GOR symptoms after fundoplication. METHODS: Between October 1991 and January 1998, 324 patients underwent laparoscopic fundoplication at Emory University Hospital and returned postoperative questionnaires. Severity of typical (heartburn) and atypical (asthma, chest pain, cough and hoarseness) GOR symptoms was reported by patients on a 0-4 scale before surgery, and at 6 and 52 weeks after operation. Patients were stratified based on preoperative symptoms into three groups: group 1 (severe heartburn/minimal atypical symptoms), group 2 (severe heartburn/severe atypical symptoms) and group 3 (minimal heartburn/severe atypical symptoms). RESULTS: In group 1 (n = 173) heartburn improved in 99 per cent and resolved in 87 per cent. In group 2 (n = 95) heartburn improved in 95 per cent and resolved in 76 per cent, and atypical symptoms improved in 94 per cent and resolved in 42 per cent. In group 3 (n = 56) atypical symptoms improved in 93 per cent and resolved in 48 per cent. Although all symptoms were improved by fundoplication, resolution was more likely for heartburn than for atypical symptoms. CONCLUSION: Atypical symptoms of GOR are improved by fundoplication, but symptom resolution occurs in fewer than 50 per cent of patients.

Laparoscopic repair of superior mesenteric artery syndrome.

BACKGROUND: Superior mesenteric artery syndrome is duodenal obstruction by the superior mesenteric artery. It is caused by decreasing the angle between the aorta and superior mesenteric artery causing compression of the third part of the duodenum and usually occurs after a period of weight loss. METHODS: Between September 1999 and April 2000, 2 patients with superior mesenteric artery syndrome were treated laparoscopically. The laparoscope was placed in the umbilicus; the surgeon operated through two trochars on the left side of the abdomen, and an assistant retracted through one trochar on the right side of the abdomen. The dilated duodenum was seen below the transverse mesocolon and to the right of the superior mesenteric artery. A proximal loop of jejunum was anastamosed to the duodenum using the endoscopic gastrointestinal anastomotic (GIA) stapler. RESULTS: Average operating time was 113 minutes and average hospital length of stay was 3 days. There were no complications and both patients were pleased with their results. CONCLUSIONS: Laparoscopic duodenojejunal bypass is feasible with laparoscopic techniques. The operating time is acceptable and the postoperative length of stay is short.

Nissen fundoplication improves gastric motility in patients with delayed gastric emptying.

BACKGROUND: Fundoplication hastens gastric emptying in pediatric patients with gastroesophageal reflux disease (GERD). However, among adult GERD patients with impaired gastric emptying, the degree of improvement offered by fundoplication and the value of pyloroplasty are less well defined. Therefore, we compared outcomes in GERD patients with delayed gastric emptying after fundoplication alone or fundoplication with pyloroplasty. METHODS: Of 616 consecutive GERD patients who submitted to primary fundoplication (601 laparoscopic) between October 1991 and October 1997, 82 underwent preoperative solid-phase nuclear gastric emptying analysis. Of these, 25 had delayed gastric emptying (half-time >100 min). Of 12 patients with emptying half-times between 100 and 150 min, one underwent pyloroplasty at the time of Nissen fundoplication. Of 13 patients with emptying half-times >150 min, 11 had pyloroplasty at the time of Nissen fundoplication. Patients were asked to use a 0 ("none") to 4 ("incapacitating") scale to describe the severity of their symptoms of heartburn, regurgitation, dysphagia, bloating and diarrhea preoperatively and at 6 weeks and 1 year postoperatively. Eight patients consented to a postoperative analysis of gastric emptying. RESULTS: One year after fundoplication, patients with delayed gastric emptying and controls reported a similar improvement in heartburn, regurgitation, and dysphagia, with no increase in undesirable side effects such as bloating and diarrhea. Among the patients with delayed gastric emptying who consented to undergo a repeat gastric emptying study after their operation, fundoplication alone provided a 38% improvement (p < 0.05) in gastric emptying, whereas fundoplication with pyloroplasty resulted in a 70% improvement in gastric emptying (p < 0.05). CONCLUSION: Fundoplication improves gastric emptying. The addition of pyloroplasty results in even greater improvement and may have particular value for patients with severe gastric hypomotility.

Outpatient laparoscopic cholecystectomy. Outcomes of 847 planned procedures.

BACKGROUND: Cholecystectomy is now being performed on an outpatient basis at many centers. The purpose of this study was to review the results of our large experience with this procedure. METHODS: Between 1990 and 1997, 2288 patients underwent laparoscopic cholecystectomy at our clinic. A total of 847 (37%) were scheduled as outpatients. The selection criteria for planned outpatient laparoscopic cholecystectomy called for nonfrail patients with an ASA < 4 who were living < 2 h from the hospital. All patients received detailed preoperative instruction about outpatient laparoscopic cholecystectomy. A questionnaire was sent to 309 patients to sample their opinions. RESULTS: Since 1993, we have increased the number of planned outpatient cholecystectomies performed at our clinic, but the percentage of cholecystectomies completed on an outpatient basis has remained approximately 60%. A total of 547 of 847 operations scheduled as outpatient procedures (74.5%) were completed as planned, and 204 patients (24%) were kept in the hospital overnight. Twenty-seven (3%) were converted to open procedures. Eighteen laparoscopic patients (2%) stayed > 1 day (range, 2-20). None of the patients died. Of the 142 patients (46%) who completed our opinion survey, 66% were happy with their experience, 32% would like to have stayed in the hospital, and 2% were undecided. CONCLUSION: Successful same-day surgery requires proper patient instruction, appropriate patient selection, and a low threshold to convert patients to inpatient status when the situation warrants. No major complications occurred as a result of same-day discharge, and two-thirds of the patients said that they preferred outpatient surgery.

Teflon buttress inhibits recanalization of uncut stapled bowel.

The uncut Roux limb operation is designed to have the benefits of a Roux limb but still have electrical continuity from proximal to distal bowel, thus eliminating the risk of Roux stasis syndrome. The main complication has been recanalization of the uncut staple line leading to bile reflux. This study aims to employ a new technique, which will not allow recanalization of an uncut staple line but will not interfere with normal bowel myoelectric activity. Fourteen mongrel dogs, 25 to 35 kg, underwent a midline laparotomy under general anesthesia. An uncut staple line was placed 25 cm from the ligament of Treitz. In seven animals an uncut staple line alone was placed, and in the other seven animals the bowel was stapled between a sandwich of Teflon reinforcing strips such that the staples were held on both sides of the bowel by the Teflon. A jejunojejunostomy was placed 6 cm proximal to the staple line. Insulated bipolar electrical leads were placed around the staple line. After the electrical leads were monitored 2 days to 3 months postoperatively for bowel myoelectric activity, The animals were killed and the operative sites inspected. No animal suffered morbidity or mortality from the procedure. All seven unreinforced staple lines recanalized and all seven reinforced staple lines remained competent. The duodenal pacemaker potentials were transmitted through the staple line in five animals (3 controls and 2 with Teflon reinforcement) with in 1 week postoperatively. The uncut staple line does not reliably transmit the duodenal pacemaker potentials. The staple line does not recanalize when it is reinforced with a permanent material, increasing the utility of the "uncut" Roux limb operation.

Users' Guides to the Medical Literature: XXV. Evidence-based medicine: principles for applying the Users' Guides to patient care. Evidence-Based Medicine Working Group.

This series provides clinicians with strategies and tools to interpret and integrate evidence from published research in their care of patients. The 2 key principles for applying all the articles in this series to patient care relate to the value-laden nature of clinical decisions and to the hierarchy of evidence postulated by evidence-based medicine. Clinicians need to be able to distinguish high from low quality in primary studies, systematic reviews, practice guidelines, and other integrative research focused on management recommendations. An evidence-based practitioner must also understand the patient's circumstances or predicament; identify knowledge gaps and frame questions to fill those gaps; conduct an efficient literature search; critically appraise the research evidence; and apply that evidence to patient care. However, treatment judgments often reflect clinician or societal values concerning whether intervention benefits are worth the cost. Many unanswered questions concerning how to elicit preferences and how to incorporate them in clinical encounters constitute an enormously challenging frontier for evidence-based medicine. Time limitation remains the biggest obstacle to evidence-based practice but clinicians should seek evidence from as high in the appropriate hierarchy of evidence as possible, and every clinical decision should be geared toward the particular circumstances of the patient.

Users' guides to the medical literature: XXIV. How to use an article on the clinical manifestations of disease. Evidence-Based Medicine Working Group.

Clinicians rely on knowledge about the clinical manifestations of disease to make clinical diagnoses. Before using research on the frequency of clinical features found in patients with a disease, clinicians should appraise the evidence for its validity, results, and applicability. For validity, 4 issues are important-how the diagnoses were verified, how the study sample relates to all patients with the disease, how the clinical findings were sought, and how the clinical findings were characterized. Ideally, investigators will verify the presence of disease in study patients using credible criteria that are independent of the clinical manifestations under study. Also, ideally the study patients will represent the full spectrum of the disease, undergo a thorough and consistent search for clinical findings, and these findings will be well characterized in nature and timing. The main results of these studies are expressed as the number and percentages of patients with each manifestation. Confidence intervals can describe the precision of these frequencies. Most clinical findings occur with only intermediate frequency, and since these frequencies are equivalent to diagnostic sensitivities, this means that the absence of a single finding is rarely powerful enough to exclude the disease. Before acting on the evidence, clinicians should consider whether it applies to their own patients and whether it has been superseded by new developments. Detailed knowledge of the clinical manifestations of disease should increase clinicians' ability to raise diagnostic hypotheses, select differential diagnoses, and verify final diagnoses. JAMA. 2000;284:869-875

Users' guides to the medical literature: XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group.

Clinical experience provides clinicians with an intuitive sense of which findings on history, physical examination, and investigation are critical in making an accurate diagnosis, or an accurate assessment of a patient's fate. A clinical decision rule (CDR) is a clinical tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in a patient. Clinical decision rules attempt to formally test, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. Existing CDRs guide clinicians, establish pretest probability, provide screening tests for common problems, and estimate risk. Three steps are involved in the development and testing of a CDR: creation of the rule, testing or validating the rule, and assessing the impact of the rule on clinical behavior. Clinicians evaluating CDRs for possible clinical use should assess the following components: the method of derivation; the validation of the CDR to ensure that its repeated use leads to the same results; and its predictive power. We consider CDRs that have been validated in a new clinical setting to be level 1 CDRs and most appropriate for implementation. Level 1 CDRs have the potential to inform clinical judgment, to change clinical behavior, and to reduce unnecessary costs, while maintaining quality of care and patient satisfaction. JAMA. 2000;284:79-84