RESUMO
BACKGROUND: Surgical treatment options of gastroesophageal reflux disease have changed significantly in the last 50 years. Magnetic Sphincter Augmentation (MSA) and Anti-reflux Mucosectomy (ARMs) are gaining traction but there is a paucity of literature comparing these novel options to Toupet fundoplication and gold standard Nissen fundoplication. METHODS: This is a retrospective review of a prospectively maintained database, evaluating patients undergoing Nissen, Toupet, MSA, and ARMs. Pre-operative, intra-operative, and post-operative variables including Reflux symptom index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life questionnaire (GERD-HRQL), and Dysphagia scores were compared between groups. RESULTS: During the study period, 649 patients underwent anti-reflux surgery. Patients who underwent Nissen or Toupet were younger than those undergoing MSA or ARMs (65 ± 12 and 67 ± 14 years vs 56 ± 14 and 56 ± 18 years, P < 0.01). Average operative time for Nissen was 127 ± 40 min which was similar to a Toupet at 122 ± 32 min. These durations were significantly longer than for MSA, averaging 79 ± 29, and ARMs, at a mean 35 ± 3 min (all P < 0.001). Length of stay was significantly different among all four groups with Nissen, Toupet, MSA, and ARMs patients staying a median of 31, 24, 7, and 3 h post operatively, respectively (all P < 0.001). Complications and re-admissions were similarly low among all groups. Despite minor differences in RSI and GERD-HRQL scores at isolated follow-up time points, quality of life scores seems to be similar overall at up to 5 years follow-up. Gas bloat and dysphagia did not differ among groups at any time point. CONCLUSIONS: Novel anti-reflux surgery options provide similar GERD-related quality of life compared to traditional full or partial fundoplications with the added benefit of shorter operative time and faster recovery.
Assuntos
Transtornos de Deglutição , Refluxo Gastroesofágico , Laparoscopia , Humanos , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/cirurgia , Qualidade de Vida , Resultado do Tratamento , Refluxo Gastroesofágico/cirurgia , Refluxo Gastroesofágico/complicações , Fundoplicatura , Fenômenos MagnéticosRESUMO
BACKGROUND AND AIMS: A small percentage of patients with esophageal dysmotility disorders (EDDs) fail to improve or relapse after management by laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). In this study, we aimed to describe the role of functional luminal imaging probe (FLIP) in identifying patients who might benefit from lower esophageal sphincter (LES)-directed retreatment. METHODS: This was a retrospective study at 6 tertiary care centers (United States, 4; Europe, 1; Asia, 1) between January 2015 and April 2021 involving patients with prior failed myotomy. The primary outcome was the impact of the use of FLIP on the management of patients with prior failed myotomy. RESULTS: One hundred twenty-three patients (62 women [50%]; mean age, 53 ± 21.1 years) who underwent LHM (n = 53, 43%) or POEM (n = 70, 57%) for the management of achalasia (n = 98) or other EDDs (n = 25) had clinical failure at a median time of 10.8 months (interquartile range, .8-17.3) postprocedure. Twenty-nine patients had apposing "abnormal" diagnoses in terms of integrated relaxation pressure (IRP) >15 mm Hg on HRM and distensibility index (DI) <2.8 mm2/mm Hg on FLIP, with ultimate change in management noted in 15 patients (10 directed toward conservative management, 5 directed toward LES-directed retreatment). The impact of FLIP on both diagnosis and management was noted in 15 of 29 patients (52%). In the subgroup analysis of 44 patients who underwent LES-directed retreatment, clinical success was highest among patients with both abnormal IRP and DI (21/25 [84%]) versus patients with only abnormal IRP (8/14 [57%]) or only abnormal DI (3/5 [60%], P = .04), with DI at 40-mL distension volume on FLIP identified as an independent predictor of clinical success (odd ratio, 1.51; 95% confidence interval, 1.02-2.1; P = .03). CONCLUSIONS: The finding of this study further suggests the important role of using FLIP in addition to HRM in evaluating patients with clinical failure postmyotomy.
Assuntos
Acalasia Esofágica , Transtornos da Motilidade Esofágica , Cirurgia Endoscópica por Orifício Natural , Adulto , Idoso , Transtornos da Motilidade Esofágica/etiologia , Esfíncter Esofágico Inferior/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/métodos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The endoluminal functional lumen imaging probe (FLIP) can be used to obtain real-time measurements of the diameter (Dmin), cross-sectional area (CSA), and distensibility of the pylorus before and after peroral pyloromyotomy (POP), an emerging endoscopic treatment for delayed gastric emptying. Our study aims to report our single-center experience in performing POP with FLIP measurements before and after pyloromyotomy. METHODS: A retrospective review of a prospectively maintained gastroesophageal database was performed. Demographic and perioperative data, including intraoperative FLIP measurements of the pylorus before and after POP, were analyzed. Measurements were compared using paired t tests. RESULTS: Thirty-four patients underwent POP between February 2017 and July 2020. Twenty-three (67.7%) patients were male and the average age was 59 years. The etiology of delayed gastric emptying was post-vagotomy in 22 patients, idiopathic gastroparesis in 7 patients, and diabetic gastroparesis in 5 patients. There were no significant differences in pre-myotomy or post-myotomy FLIP measurements when comparing the post-vagotomy versus the gastroparesis groups. There were significant increases in Dmin, CSA, and distensibility index when comparing pre-myotomy and post-myotomy readings for all patients (all p < 0.001). At follow-up, 64.7% of patients reported resolution of all symptoms. CONCLUSION: POP is an effective intervention in patients with delayed gastric emptying. Significant changes in FLIP measurements before and after POP suggest that FLIP may be a useful adjunct in guiding the management of delayed gastric emptying.
Assuntos
Gastroparesia , Miotomia , Piloromiotomia , Impedância Elétrica , Esvaziamento Gástrico , Gastroparesia/diagnóstico por imagem , Gastroparesia/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Miotomia/efeitos adversos , Piloromiotomia/métodos , Piloro/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION: The esophagogastric junction (EGJ) is a complex anti-reflux barrier whose integrity relies on both the intrinsic lower esophageal sphincter (LES) and extrinsic crural diaphragm. During hiatal hernia repair, it is unclear whether the crural closure or the fundoplication is more important to restore the anti-reflux barrier. The objective of this study is to analyze changes in LES minimum diameter (Dmin) and distensibility index (DI) using the endoluminal functional lumen imaging probe (FLIP) during hiatal hernia repair. METHODS: Following implementation of a standardized operative FLIP protocol, all data were collected prospectively and entered into a quality database. This data were reviewed retrospectively for all patients undergoing hiatal hernia repair. FLIP measurements were collected prior to hernia dissection, after hernia reduction, after cruroplasty, and after fundoplication. Additionally, subjective assessment of the tightness of crural closure was rated by the primary surgeon on a scale of 1 to 5, 1 being the loosest and 5 being the tightest. RESULTS: Between August 2018 and February 2020, 97 hiatal hernia repairs were performed by a single surgeon. FLIP measurements collected using a 40-mL volume fill without pneumoperitoneum demonstrated a significant decrease in LES Dmin (13.84 ± 2.59 to 10.27 ± 2.09) and DI (6.81 ± 3.03 to 2.85 ± 1.23 mm2/mmHg) after crural closure (both p < 0.0001). Following fundoplication, there was a small, but also statistically significant, increase in both Dmin and DI (both p < 0.0001). Additionally, subjective assessment of crural tightness after cruroplasty correlated well with DI (r = - 0.466, p < 0.001) and all patients with a crural tightness rating ≥ 4.5 (N = 13) had a DI < 2.0 mm2/mmHg. CONCLUSION: Cruroplasty results in a significant decrease in LES distensibility and may be more important than fundoplication in restoring EGJ competency. Additionally, subjective estimation of crural tightness correlates well with objective FLIP evaluation, suggesting surgeon assessment of cruroplasty is reliable.
Assuntos
Refluxo Gastroesofágico , Hérnia Hiatal , Esfíncter Esofágico Inferior/cirurgia , Junção Esofagogástrica/cirurgia , Fundoplicatura/métodos , Refluxo Gastroesofágico/cirurgia , Hérnia , Hérnia Hiatal/cirurgia , Humanos , Estudos RetrospectivosRESUMO
Background. There are growing interests from practicing endoscopists to implement the functional lumen imaging probe (FLIP) impedance planimetry system. We present a simulation-based curriculum using an "into the fire" approach with hands-on pre- and post-tests to teach the use of this technology. Methods. The curriculum consists of a series of pre-tests, didactic content, mentored hands-on instructions, and post-tests. Pre- and post-testing included a knowledge-based written test, a confidence survey, and an assessment form specific to the hands-on performance of FLIP. Result. Twenty-two practicing physicians completed the curriculum. After course completion, participants had improved knowledge-based written test scores from 6.8±1.7 to 8.9±0.9 (P<0.001), confidence scores from 10.0±5.9 to 22.1±2.6 (P<0.001), and hands-on performance score from 11.4±3.4 to 23.1±2.0 (P<0.001) with significant improvement in all components of the hands-on skills. Conclusion. Our simulation curriculum is effective in improving confidence, knowledge, and technical proficiency when teaching the use of FLIP to practicing physicians.
Assuntos
Currículo , Médicos , Competência Clínica , Impedância Elétrica , HumanosRESUMO
BACKGROUND & AIMS: Endoscopic submucosal dissection (ESD) is a widely accepted treatment option for superficial gastric neoplasia in Asia, but there are few data on outcomes of gastric ESD from North America. We aimed to evaluate the safety and efficacy of gastric ESD in North America. METHODS: We analyzed data from 347 patients who underwent gastric ESD at 25 centers, from 2010 through 2019. We collected data on patient demographics, lesion characteristics, procedure details and related adverse events, treatment outcomes, local recurrence, and vital status at the last follow up. For the 277 patients with available follow-up data, the median interval between initial ESD and last clinical or endoscopic evaluation was 364 days. The primary endpoint was the rate of en bloc and R0 resection. Secondary outcomes included curative resection, rates of adverse events and recurrence, and gastric cancer-related death. RESULTS: Ninety patients (26%) had low-grade adenomas or dysplasia, 82 patients (24%) had high-grade dysplasia, 139 patients (40%) had early gastric cancer, and 36 patients (10%) had neuroendocrine tumors. Proportions of en bloc and R0 resection for all lesions were 92%/82%, for early gastric cancers were 94%/75%, for adenomas and low-grade dysplasia were 93%/ 92%, for high-grade dysplasia were 89%/ 87%, and for neuroendocrine tumors were 92%/75%. Intraprocedural perforation occurred in 6.6% of patients; 82% of these were treated successfully with endoscopic therapy. Delayed bleeding occurred in 2.6% of patients. No delayed perforation or procedure-related deaths were observed. There were local recurrences in 3.9% of cases; all occurred after non-curative ESD resection. Metachronous lesions were identified in 14 patients (6.9%). One of 277 patients with clinical follow up died of metachronous gastric cancer that occurred 2.5 years after the initial ESD. CONCLUSIONS: ESD is a highly effective treatment for superficial gastric neoplasia and should be considered as a viable option for patients in North America. The risk of local recurrence is low and occurs exclusively after non-curative resection. Careful endoscopic surveillance is necessary to identify and treat metachronous lesions.
Assuntos
Ressecção Endoscópica de Mucosa , Neoplasias Gástricas , Ressecção Endoscópica de Mucosa/efeitos adversos , Mucosa Gástrica/cirurgia , Humanos , Recidiva Local de Neoplasia , Estudos Retrospectivos , Neoplasias Gástricas/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION: The Endoluminal Functional Lumen Imaging Probe (Endoflip™) is a balloon-based catheter that provides real-time, objective feedback regarding the distensibility of any sphincter in the gastrointestinal tract. Usage of the Functional Lumen Imaging Probe (FLIP) has not been standardized, which has limited the interpretation and generalizability of published data. The purpose of this consensus statement is to provide a standardized protocol for obtaining FLIP measurements in order to create a more uniform approach to data collection. METHODS: Five expert foregut surgeons, all of whom utilize the FLIP system in their daily practice, convened on March 19, 2019, to create a standardized protocol for obtaining FLIP measurements during hiatal hernia repair and fundoplication, magnetic sphincter augmentation, laparoscopic Heller myotomy, and peroral endoscopic myotomy. Existing literature was presented and reviewed. Each step of the protocol was discussed in detail until a unanimous consensus was reached. RESULTS: A standardized protocol was developed for obtaining FLIP measurements during hiatal hernia repair and fundoplication, magnetic sphincter augmentation, laparoscopic Heller myotomy, and peroral endoscopic myotomy. CONCLUSION: The FLIP impedance planimetry system is the only technology available that provides surgeons an objective way to assess the tightness of a fundoplication or adequacy of a myotomy during an operation. While considerable research remains to correlate FLIP measurements to patient outcomes, this consensus statement will provide standardization of data collection among FLIP users that will enhance the understanding of future study results.
Assuntos
Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Miotomia , Consenso , Impedância Elétrica , Acalasia Esofágica/cirurgia , Fundoplicatura , Humanos , Resultado do TratamentoRESUMO
INTRODUCTION: Peroral endoscopic myotomy (POEM) is a minimally invasive treatment for achalasia. Considerable evidence demonstrates a high incidence of gastroesophageal reflux disease (GERD) after POEM. The endoluminal functional lumen imaging probe (FLIP) uses impedance planimetry to obtain objective measurements of the gastroesophageal junction. This study aims to determine whether FLIP measurements collected at the time of POEM are associated with the development of reflux esophagitis postoperatively. METHODS: Patients who underwent POEM between 2012 and 2019 who subsequently had esophagogastroduodenoscopy (EGD) were included. Intraoperative FLIP measurements before and after myotomy, clinical data from EGD, and reflux specific quality of life questionnaires were collected. Comparisons between groups were made using the Wilcoxon rank-sum and Fisher's exact tests. Receiver operating characteristic (ROC) curves were used to determine optimal cutoffs of measurements to classify patients into those with high risk of postoperative esophagitis and those with lower risk. RESULTS: A total of 43 patients were included. Of those, 25 (58.1%) were found to have esophagitis on postoperative EGD: four patients (16%) with LA Grade A, five (20%) with LA Grade B, 11 (44%) with LA Grade C and two (8%) with LA grade D esophagitis. Patients with a final distensibility index ≥ 2.7 and a final cross-sectional area ≥ 83 were significantly more likely to develop esophagitis on postoperative EGD (p = 0.016 and p = 0.008, respectively). Gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and reflux symptom index (RSI) scores were not significantly different in patients who developed esophagitis and those who did not. CONCLUSION: Reflux affects some patients after POEM. We show that FLIP measurements collected during POEM may help predict which patients are more likely to develop reflux esophagitis postoperatively. Subjective symptoms on quality of life questionnaires are not reliable in determining which patients are at risk for esophagitis.
Assuntos
Acalasia Esofágica , Esofagite Péptica , Miotomia , Cirurgia Endoscópica por Orifício Natural , Impedância Elétrica , Acalasia Esofágica/cirurgia , Esofagite Péptica/diagnóstico , Esofagite Péptica/epidemiologia , Esofagite Péptica/etiologia , Esofagoscopia , Humanos , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Qualidade de Vida , Resultado do TratamentoRESUMO
BACKGROUND: Although peroral endoscopic myotomy (POEM) has emerged as a highly efficacious procedure in the treatment of a variety of esophageal motility disorders, currently no standard pathway for postprocedural care exists. Our study aims to report institutional outcomes in performing POEM as an outpatient procedure with same-day discharge. Additionally, we seek to determine factors associated with admission. METHODS: Demographic, perioperative, and postoperative outcome data of 115 patients who underwent POEM between June 2014 and January 2020 on a same-day discharge pathway were analyzed. Cohorts were compared using the t test, Wilcoxon rank-sum, or chi-square test. Multivariable logistic regression with a manual backward selection method was used to identify factors associated with admission. RESULTS: Fifty-five patients (48%) were successfully discharged same-day. The most common primary reasons for admission were delay in obtaining an esophagram (25%), intraoperative complication (13.3%), and pain (10%). There were no differences in 30-day ED visit rate (12.7% vs 15.0%, p = 0.725) or 30-day readmission rate (9.1% vs 16.7%, p = 0.373) between patients who were discharged same-day versus patients who were admitted. Patients discharged same-day had fewer intraoperative complications (1 vs 9, p = 0.017), shorter OR time (69 vs 100 min, p < 0.001), and earlier cessation of narcotic use (day 0 vs day 1, p = 0.001). On multivariable analysis, intraoperative complication (p = 0.048) was associated with overnight admission. CONCLUSION: Patients did not experience additional morbidity with same-day discharge after POEM. A delay in obtaining an esophagram was the most common reason that patients were admitted and those who suffered an intraoperative complication are more likely to require admission.
Assuntos
Acalasia Esofágica , Transtornos da Motilidade Esofágica , Miotomia , Cirurgia Endoscópica por Orifício Natural , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior , Esofagoscopia , Hospitalização , Humanos , Alta do Paciente , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Anti-reflux mucosectomy (ARMS) is a new endoscopic procedure involving a hemi-circumferential endoscopic mucosal resection (EMR) around the gastroesophageal junction. We aim to compare perioperative and quality of life outcomes of patients with reflux who underwent ARMS to a comparable group who underwent laparoscopic Nissen fundoplication (NF). METHODS: A retrospective review of a prospectively maintained quality database was performed. All patients who underwent ARMS (n = 33) were matched with patients who underwent NF (n = 67). Clinical and quality of life (QOL) outcomes were collected preoperatively and up to two years postoperatively, measured by the Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), and Dysphagia Score. Outcomes were compared using the Wilcoxon rank-sum and Fisher's exact test. RESULTS: While 10 patients (30.3%) who underwent ARMS required additional laparoscopic anti-reflux operations, the ARMS group had shorter OR time (p<0.001), less estimated blood loss (p<0.001), shorter hospital stay (p<0.001), less pain at discharge (p = 0.007), earlier narcotic discontinuation (p<0.001), and earlier return to activities of daily living (p<0.001) compared to the NF group. There was no difference in 30-day complication rates, emergency room visits, or readmission rates between the groups. There was no difference between ARMS and NF groups in terms of GERD-HRQL, RSI, or Dysphagia scores at 3 weeks, 6 months, 1 year, or 2 years postoperatively. However, the ARMS group reported less symptoms of gas and bloating postoperatively at all time points (all p<0.05). Both groups reported increased dysphagia at 3 weeks postoperatively (p<0.01) but this did not persist at 6 months, 1 year, or 2 years. CONCLUSION: While ARMS had better perioperative outcomes compared to NF, reflux quality of life outcomes were comparable. ARMS can be an effective endoscopic intervention for GERD when performed on appropriately selected patients without limiting future laparoscopic anti-reflux interventions.
Assuntos
Refluxo Gastroesofágico , Laparoscopia , Atividades Cotidianas , Fundoplicatura , Refluxo Gastroesofágico/cirurgia , Humanos , Qualidade de Vida , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The purpose of this study was to analyze non-dysplastic Barrett's esophagus (NDBE) biopsy tissue and compare the rate of somatic DNA copy number alterations (CNAs) in patients who subsequently progressed to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) to those patients who did not. METHODS: A retrospectively collected database of Barrett's esophagus (BE) patients spanning a 16-year period was queried. Patients who progressed from NDBE to HGD or EAC were identified and compared to patients who did not. Initial biopsy specimens were microdissected and extracted DNA underwent Multiplex Ligation-dependent Probe Amplification (MLPA) for CNAs. Comparisons between progressors and non-progressors were made with Fisher's exact and two-sample t tests. Logistic regression assessed factors associated with progression. RESULTS: Of the 2459 patients in the BE database, 36 patients progressed from NDBE to either HGD or EAC. There were eight progressors who had biopsy specimens with adequate DNA for analysis. The progressor and non-progressor cohort had similar demographic information and medical history. The progressor group trended towards being older at diagnosis (72 ± 10 vs. 64 ± 13 years, p = 0.097) and fewer progressors reported reflux symptoms (50 vs. 94.7%, p < 0.001). Progressor specimens had more overall CNAs (75% vs. 33.6%, p = 0.026). On univariable analysis, there was an association between progression and absence of GERD symptoms (OR 16.54 [3.42-80.03], p = 0.001), any CNA (OR 5.10 [1.18-23.30], p = 0.035), and CNA in GATA6 or ERBB2 (OR 6.72 [1.18-38.22], p = 0.032). CONCLUSIONS: Patients who progressed from NDBE to HGD or EAC were older at first diagnosis of BE and fewer of the progressors reported symptoms of reflux when compared to non-progressors. Progression was associated with the presence of any CNA and specific CNAs in GATA6 or ERBB2.
Assuntos
Esôfago de Barrett , Esôfago de Barrett/genética , DNA , Variações do Número de Cópias de DNA , Progressão da Doença , Humanos , Estudos RetrospectivosRESUMO
INTRODUCTION: The Endoluminal Functional Lumen Imaging Probe (Endoflip) can be used to provide objective measurements of the gastroesophageal junction during fundoplication, and recent publications have suggested that this device could improve surgical outcomes. However, the impact of operative variables has not been clearly reported. The aim of this study is to determine the effect of these variables on functional lumen imaging probe (FLIP) measurements. METHODS: Following implementation of a standardized operative FLIP protocol, all data were collected prospectively and entered into a quality database. This database was queried for patients undergoing hiatal hernia repair and fundoplication. The protocol utilized various balloon volumes (30 and 40 ml), patient positions (flat and reverse Trendelenburg) and amounts of insufflation (15 mmHg pneumoperitoneum and no pneumoperitoneum). RESULTS: Between August 2018 and February 2020, 97 fundoplications were performed by a single surgeon. Multivariable analysis without interactions demonstrated that a 40 ml volume fill resulted in significantly higher minimum diameter (Dmin), cross-sectional area (CSA), intra-balloon pressure (IBP) and distensibility index (DI) compared to a 30 ml volume fill (p < 0.001). While reverse Trendelenburg positioning resulted in a significantly higher Dmin, IBP and CSA compared to the flat position (all p < 0.05), there was little impact of positioning on DI. Lastly, pneumoperitoneum significantly increased IBP (p < 0.001) but did not affect Dmin (p = 0.697) or CSA (p = 0.757), which resulted in a significant decrease in DI (p < 0.001) when compared to measurements without pneumoperitoneum. Multivariable analysis allowing for interactions demonstrated significant two-way interactions between balloon volume and pneumoperitoneum (p = 0.047), as well as patient position and pneumoperitoneum (p < 0.001). CONCLUSION: Surgeons should consider balloon volume and the presence or absence of pneumoperitoneum when interpreting distensibility during or after fundoplication. Additionally, we suggest a formal standardized protocol for FLIP measurements to utilize a 40 ml volume fill in reverse Trendelenburg without pneumoperitoneum.
Assuntos
Esofagoplastia , Insuflação , Junção Esofagogástrica , Esôfago , Fundoplicatura , HumanosRESUMO
BACKGROUND: The study aim is to determine if patients who have undergone endoscopic gastrojejunostomy revision (EGJR) maintain weight loss up to 5 years postoperatively. METHODS: This is a retrospective review of patients who underwent EGJR with a full-thickness endoscopic suturing device between April 2009 and June 2018. Percent of excess body weight loss (%EBWL) was calculated using the weight on day of EGJR consult as baseline. The paired t test and McNemar's test were used to compare weight and comorbidities between preoperative and postoperative time points. RESULTS: A total of 70 patients regained a mean of 42.8 ± 18.7% of the weight lost after gastric bypass. On day of EGJR consult, average was 116.1 ± 25.2 kg and BMI of 42.3 ± 8.5. Weight loss and %EBWL at follow-up was as follows: 10.7 ± 11.6 kg and 18.5 ± 18.2% at 6 months, 8.5 ± 11.5 kg and 14.9 ± 20.6% at 1 year, 6.9 ± 10.7 kg and 12.2 ± 19.8% at 2 years, 5.3 ± 9.1 kg and 8.7 ± 14.9% at 3 years, 3.1 ± 12.0 kg and 3.2 ± 21.6% at 4 years, and 3.9 ± 13.1 kg and 7.0 ± 23.8% at 5 years. The percentage of patients with obstructive sleep apnea, hypertension, hyperlipidemia, and diabetes did not change over time. Patients who received a pursestring revision or had a greater percent reduction in stoma diameter had more significant %EBWL. CONCLUSIONS: Weight loss after EGJR is sustained up to 5 years after revision with little effect on medical comorbidities. Patients with a greater reduction in stoma diameter experienced superior weight loss.
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Endoscopia/métodos , Derivação Gástrica/efeitos adversos , Obesidade Mórbida/cirurgia , Aumento de Peso/fisiologia , Feminino , Derivação Gástrica/métodos , Humanos , Masculino , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: We hypothesized that practicing surgeons would successfully achieve a better and more frequent Critical View of Safety (CVS) during laparoscopic cholecystectomy (LC) after participation in a structured Safe CVS Curriculum. METHODS: All surgeons performing LC at a regional health system had four LC cases recorded: twice before and twice after a curriculum focused on the CVS, which was led by a member of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Safe LC Task Force. Videos were then de-identified and randomly ordered for grading on a 6-point CVS assessment tool by two expert surgeons, who were blinded to the operator and whether the surgeries were performed before or after the curriculum. Confidence surveys and performance on a CVS identification video quiz were also compared pre- and post-curriculum. RESULTS: Twelve surgeons (five general, four acute care, and three minimally invasive) with an average experience of 17.9 ± 6.3 years participated in the study. After the curriculum, surgeons achieved all three CVS criteria in more cases (1/24 (4%) versus 10/24 (42%), p < 0.004). There was also significant improvement in correctly identifying whether the CVS was achieved in 10 video clips from the Internet (7.9 ± 1.5 vs. 9.3 ± 0.8, p = 0.006) and increased confidence on a 5-point Likert scale in accurately identifying the CVS (4.5 ± 0.5 vs. 4.9 ± 0.3, p = 0.017). CONCLUSION: A structured curriculum on achieving a quality CVS for practicing, experienced surgeons improved their confidence and frequency of obtaining the Critical View of Safety during LC. We recommend that the Safe CVS Curriculum be considered for widespread use in order to increase the quality and frequency of attaining the Critical View of Safety.
Assuntos
Colecistectomia Laparoscópica/educação , Colecistectomia Laparoscópica/normas , Currículo , Educação Médica Continuada , Cirurgia Geral/educação , Cirurgia Geral/normas , Ductos Biliares/lesões , Colecistectomia Laparoscópica/efeitos adversos , Competência Clínica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Melhoria de Qualidade , Inquéritos e Questionários , Gravação em VídeoRESUMO
INTRODUCTION: The purpose of this study is to evaluate the utility of using a functional lumen imaging probe (EndoFLIP™) intra-operatively during hiatal hernia repair and fundoplication. Additionally, we hypothesize that these measurements correlate with long-term outcomes. METHODS: A prospectively maintained quality database was queried. Between 2013 and 2018, 175 patients underwent laparoscopic fundoplication, the majority of which also had a hiatal hernia repair. The EndoFLIP™ was used to measure minimum diameter (Dmin), balloon pressure, and distensibility index (DI) at different timepoints throughout the operation. Clinical outcomes were measured up to 2 years after treatment. RESULTS: Crural closure and fundoplication resulted in a significant increase in balloon pressure and decrease in DI when compared to initial measurements as well as measurements taken after hernia reduction. After 1 year, patients with a final DI < 2.0 mm2/mmHg reported significantly more gas bloat and dysphagia than those with a final DI ≥ 2.0 mm2/mmHg (p = 0.040 and p = 0.025, respectively). This disparity became even more dramatic at 2 years (p = 0.006 and p = 0.004, respectively), with a final DI < 2.0 mm2/mmHg being significantly associated with higher prevalence of daily gas bloat (43.8% vs. 12.0%; p = 0.03). Additionally, patients with a final DI between 2.0 and 3.5 mm2/mmHg reported significantly lower Reflux Symptom Index scores at one year compared to those with a final DI < 2.0 or > 3.5 mm2/mmHg (p = 0.042). CONCLUSION: EndoFLIP™ measurements correlate well with patient outcomes, with a final DI between 2 and 3.5 mm2/mmHg potentially being ideal. The EndoFLIP™ can be a useful adjunct in the operating room by providing objective measurements of esophageal distensibility after crural closure and fundoplication.
Assuntos
Impedância Elétrica/uso terapêutico , Junção Esofagogástrica/cirurgia , Fundoplicatura/métodos , Salas Cirúrgicas/normas , Idoso , Feminino , Humanos , Masculino , Estudos ProspectivosRESUMO
Surveillance of Barrett's esophagus (BE) is a clinical challenge; metaplasia of the distal esophagus increases a patient's risk of esophageal adenocarcinoma (EAC) significantly but the actual percentage of patients who progress is low. The current screening recommendations require frequent endoscopy and biopsy, which has inherent risk, high cost, and operator variation. Identifying BE patients genetically who are at high risk of progressing could deemphasize the role of endoscopic screening and create an opportunity for early therapeutic intervention. Genetic alterations in germline DNA have been identified in other disease processes and allow for early intervention or surveillance well before disease develops. The genetic component of BE remains mostly unknown and only a few genome-wide association studies exist on this topic. This review summarizes the current literature available that examines genetic alterations in BE and EAC with a particular emphasis on clinical implications.
Assuntos
Adenocarcinoma/genética , Esôfago de Barrett/genética , Neoplasias Esofágicas/genética , Predisposição Genética para Doença/genética , Mutação em Linhagem Germinativa/genética , Polimorfismo de Nucleotídeo Único/genética , Detecção Precoce de Câncer , Estudo de Associação Genômica Ampla , Humanos , Fatores de RiscoRESUMO
BACKGROUND: Obtaining a clear Critical View of Safety helps prevent bile duct injuries during laparoscopic cholecystectomy, which can be improved with a structured Safe Critical View of Safety curriculum. We aimed to determine whether the improvement in obtaining Critical View of Safety postcurriculum is retained long-term. METHODS: A safe Critical View of Safety curriculum was previously implemented for all surgeons who perform laparoscopic cholecystectomy at a regional health system. Recordings of laparoscopic cholecystectomy cases were collected 1 year after completion of the curriculum, deidentified and randomly ordered, and then graded by 2 blinded expert surgeons using a 6-point Critical View of Safety assessment tool. RESULTS: A total of 12 surgeons with average experience of 17.9 ± 6.3 years in practice participated in the study. The majority (83%) had performed >700 laparoscopic cholecystectomies, and 4 surgeons (33%) reported 2 or more bile duct injuries in their career. Controlling for gallbladder pathology, Critical View of Safety scores improved from 1.7 ± 0.4 to 4.0 ± 0.4 (P < .001) immediately after completion of the curriculum. However, there was a small decrease in Critical View of Safety score after 1 year (3.2 ± 0.3 from 4.0 ± 0.4, P = .055), while still significantly higher compared to precurriculum (3.2 ± 0.3 vs 1.7 ± 0.4, P < .001). Acute care surgeons had lower Critical View of Safety retention scores compared to general surgeons (1.8 ± 0.5 vs 3.3 ± 0.4, P = .01) and minimally invasive surgeons (1.8 ± 0.5 vs 3.8 ± 0.5, P < .01). CONCLUSION: A structured curriculum helped improve practicing surgeons' attainment of obtaining the Critical View of Safety during laparoscopic cholecystectomy. However, this improvement decreased after 1 year, suggesting some decay in knowledge retention over time. Therefore, continued educational interventions on Critical View of Safety and safe laparoscopic cholecystectomy may be needed to enhance long-term retention.
Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/educação , Currículo , Complicações Intraoperatórias/prevenção & controle , Retenção Psicológica , Segurança , Adulto , Ductos Biliares/lesões , Competência Clínica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Fatores de TempoRESUMO
BACKGROUND: Esophageal dysmotility is a common finding in patients being evaluated for antireflux surgery, although its implication remains unclear. We aimed to evaluate outcomes of patients with esophageal dysmotility after fundoplication. METHODS: A retrospective review of a prospective quality-database was performed. All patients who underwent laparoscopic Nissen (NF) or Toupet (TF) fundoplication were included. Esophageal dysmotility was defined using the Chicago Classification v4.0 and conventional metrics, creating three sub-groups: ineffective esophageal motility (IEM), distal/diffuse esophageal spasm (DES), and hypercontractile esophagus (HE). Quality of life (QOL) outcomes were measured by the Reflux Severity Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), and Dysphagia Scores. RESULTS: Of 487 patients included, 99 (20.3%) had esophageal dysmotility (49 IEM, 40 DES, 10 HE). While a majority in the dysmotility group (81.8%) underwent TF, most patients in the normal group (76.5%) underwent NF (p < 0.001). On multivariable analysis controlling for sex, age, BMI, hiatal hernia, and surgery type, the normal group had higher Dysphagia Scores at 3 weeks (2.2 ± 0.9 vs. 1.7 ± 0.8, p < 0.001), but not at 6-month, 1-year, 2-year, or 5-year follow-up. There were no differences between normal and dysmotility groups in terms of RSI or GERD-HRQL scores at any time point. Patients with different sub-types of esophageal dysmotility had similar QOL outcomes at all time points. CONCLUSION: Patients with esophageal dysmotility had similar outcomes compared to those with normal motility after fundoplication, suggesting the tailored approach favoring partial fundoplication for patients with dysmotility as part of an appropriate treatment algorithm.
Assuntos
Transtornos de Deglutição , Transtornos da Motilidade Esofágica , Refluxo Gastroesofágico , Laparoscopia , Humanos , Recém-Nascido , Fundoplicatura/efeitos adversos , Qualidade de Vida , Transtornos de Deglutição/etiologia , Estudos Prospectivos , Manometria , Transtornos da Motilidade Esofágica/etiologia , Transtornos da Motilidade Esofágica/cirurgia , Refluxo Gastroesofágico/complicações , Refluxo Gastroesofágico/cirurgia , Laparoscopia/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: The use of mesh in hernia repair has faced intense scrutiny, leading patients to become fearful of its use, despite its benefits in reducing hernia recurrence. We report a single institutional experience in performing hernia repair with mesh in terms of hernia-specific outcomes, mesh-related complications, and patient-reported quality of life. STUDY DESIGN: Patients who underwent abdominal wall hernia repair with mesh at a single institution were identified from a prospectively maintained quality database. Demographic, perioperative, and postoperative outcomes data were analyzed. Surgical Outcomes Measurements System (SOMS) and Carolinas Comfort Scale (CCS) surveys were administered pre- and postoperatively at 3 weeks, 6 months, 1, 2, and 5 years. RESULTS: Between 2010 and 2020, a total of 6,387 patients underwent abdominal hernia repair with mesh. Inguinal hernia repairs made up the majority (65%) of the operations. Rates of mesh infection varied by hernia type, with lower rates after umbilical (0.0%) and inguinal (0.4%) repair, and highest after incisional repair (1.3%). Similarly, mesh explantation rates were low after umbilical and inguinal repair (0.0% and 0.4%, respectively) and highest after incisional repair (3.0%). Scores on all SOMS domains were significantly improved from baseline (all p < 0.05). On CCS, 2.9%, 3.3%, and 4.4% of patients reported severe or disabling symptoms postoperatively at 1, 2, and 5 years, respectively. CONCLUSIONS: Rates of mesh-related complications vary by hernia type. A majority of patients report excellent long-term quality of life, although a relatively large percentage of patients experience severe or disabling symptoms at long-term follow-up.
Assuntos
Hérnia Abdominal/cirurgia , Herniorrafia/métodos , Telas Cirúrgicas , Bases de Dados Factuais , Remoção de Dispositivo , Procedimentos Cirúrgicos Eletivos , Herniorrafia/efeitos adversos , Humanos , Hérnia Incisional/cirurgia , Medidas de Resultados Relatados pelo Paciente , Reoperação , Telas Cirúrgicas/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Peroral endoscopic pyloromyotomy, or gastric peroral endoscopic myotomy, is a novel endoscopic procedure for the treatment of refractory gastroparesis. We present a simulation-based curriculum using an "into-the-fire" approach with hands-on pre- and post-tests to teach this procedure. METHODS: Six, 1-day peroral endoscopic pyloromyotomy courses were taught by an expert surgical endoscopist in 2018 to 2019. The curriculum is composed of a series of pretraining tests, lectures, mentored hands-on instruction, and post-training tests using porcine models. Both pre- and post-testing included a confidence survey, a knowledge-based written test, and a specific assessment form for the peroral endoscopic pyloromyotomy procedure. Participants' scores were analyzed using paired t tests. RESULTS: Twenty-eight practicing physicians participated. After completing the curriculum, participants had improved confidence scores (10.5 ± 5.2 vs 19.4 ± 3.6; P < .001), written test scores (6.8 ± 1.6 vs 8.0 ± 1.1; P < .001), and hands-on performance scores (23.6 ± 3.4 vs 29.3 ± 1.4; P < .001) with marked improvement in all components of the peroral endoscopic pyloromyotomy procedure. Postcourse surveys showed 93% of participants had performed or intended to perform the peroral endoscopic pyloromyotomy procedure within the next year. CONCLUSION: Our simulation curriculum with an into-the-fire approach to teach peroral endoscopic pyloromyotomy is effective in improving practitioner knowledge, confidence, and technical skills, leading to an increase in the adoption of this procedure.