RESUMEN
A best evidence topic was written according to a structured protocol. In [patients with primary oesophageal achalasia] is [laparoscopic Heller Myotomy] superior to [endoscopic dilatation] with respect to [clinical outcomes]. In total 49 papers were found using the reported search, and eight of these represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Existing evidence shows that LHM is associated with improved post-operative symptoms and reduced clinical relapse rates compared to ED. Satisfactory clinical outcomes with ED often require repeat procedures performed over time and are associated with an increased risk of oesophageal perforation compared to LHM. One prospective randomized study showed no significant difference in post-operative outcomes between LHM and ED but this was limited by lack of standardization in the endoscopic dilatation procedure, limited reporting of complications and poor long-term follow up. Current evidence shows oesophageal perforation during LHM may be successfully managed intra-operatively but in ED usually requires further laparoscopic or open operative intervention. Fundoplication during LHM is associated with reduced incidence of post-operative gastro-oesophageal reflux disease. There is an increased risk of clinical relapse regardless of the treatment in patients with a sigmoid-shaped oesophagus or reduced oesophageal sphincter pressure assessed during pre-treatment manometry. Current studies are limited by study design, variations in operative technique and dilatation regimens, and limited follow up times. Further higher power studies matching patients for disease severity and surgical technique with longer follow up may enable greater understanding of differences in outcomes and improved patient selection for different treatment regimens.
Asunto(s)
Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Acalasia del Esófago/cirugía , Laparoscopía/métodos , HumanosRESUMEN
There are few published data on aldosterone and cortisol co-secreting adrenal tumours. Failure to perform comprehensive preoperative endocrine investigations in patients with adrenal "incidentalomas" or in those thought to be secreting only one hormone may account for this. Clinically patients with such lesions may have evidence of hypertension and hypokalaemia with no features of cortisol excess. Preoperative diagnosis of such lesions with accurate endocrinological work up is essential to prevent adrenal insufficiency and haemodynamic crises following removal of such glands. We present a series of 4 patients with co-secreting tumours treated by laparoscopic adrenalectomy between September 2010 and March 2011. Our experience suggests that dual secretors are more common than originally thought. A high index of suspicion and adequate endocrine work up is paramount in diagnosing such tumours and in experienced hands, laparoscopic adrenalectomy with appropriate substitutive steroid cover is safe, feasible and curative for these functioning adrenal tumours.