RESUMEN
BACKGROUND AIMS: The TIF procedure has emerged as an endoscopic treatment for patients with refractory gastro-esophageal reflux disease (GERD). Previous systematic reviews of the TIF procedure conflated findings from studies with modalities that do not reflect the current 2.0 procedure technique or refined data-backed patient selection criteria. A meta-analysis was conducted using data only from randomized studies that assessed the TIF 2.0 procedure compared to a control. The purpose of the meta-analysis was to determine the efficacy and long-term outcomes associated with performance of the TIF 2.0 procedure in patients with chronic long-term refractory GERD on optimized PPI therapy, including esophageal pH, PPI utilization and quality of life. Methods: Three prospective research questions were predicated on the outcomes of the TIF procedure compared to patients who received PPI therapy or sham, concomitant treatment for GERD, and the patient-reported quality of life. Event rates were calculated using the random effect model. Since the time of follow-up post-TIF procedure was variable, analysis was performed to incorporate the time of follow-up for each individual patient at the 3-year time point. Results: Results from this meta-analysis, including data from 233 patients, demonstrated that TIF subjects at 3 years had improved esophageal pH, a decrease in PPI utilization, and improved quality of life. Conclusions: In a meta-analysis of randomized, controlled trials (RCTs), the TIF procedure data for patients with GERD refractory to PPI's produces significant changes, compared with sham or PPI therapy, in esophageal pH, decreased PPI utilization, and improved quality of life.
Asunto(s)
Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Cirugía Endoscópica por Orificios Naturales , Esofagoplastia/métodos , Reflujo Gastroesofágico/tratamiento farmacológico , Humanos , Boca , Cirugía Endoscópica por Orificios Naturales/métodos , Inhibidores de la Bomba de Protones/uso terapéutico , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
GERD has become one of the most frequent pathology of the upper GI tract. It is a spectrum disease and is a progressive disease as well. Serious and severe complications are possible. The mainstream therapy in most of the patients is the medical therapy with PPI's. The most severe cases with an impaired LES (Lower Esophageal Sphincter) function as well as important anatomical disruptions are of surgical indication, the gold standard being laparoscopic fundoplication, an elective therapy with long term follow up outcomes at the expense of de novo symptoms associated with fundoplications in general. 30% to 40% of the patients are PPI refractory with partial symptom control, but they are not willing to go for the laparoscopic fundoplication because of the invasive character and because of potential postfundoplications syndromes. There is a "treatment gap" for these patients with GERD. For a well selected patient population with GERD, with mild forms of the disease, without complications and without major anatomical disruptions (patients with small hiatal hernias), patients who are refractory on PPI medication, there are today new alternative therapies, minimally invasive. These therapies are less aggressive and basically with no side effects or new onset symptoms that Laparoscopic Fundoplications will give. These are endoscopic therapies which improve the LES function: Stretta utilizes radiofrequence therapy, a novel technique describes mucosal resection at the level of the cardia, while a partial fundoplication from within the stomach can be realized with EsophyX, Muse or Gerd-X. Form all these procedures, EsophyX is the most advanced with more than 20,000 patients treated worldwide, with good clinical outcomes and with no de novo symptoms. The laparoscopic techniques treat hiatal hernias larger than 2 cm. Linx utilizes a magnetic ring at the LES level. EndoStim utilizes electrodes in order to stimulate the LES muscle. These procedures are effective on short term and there are few patients treated with Linx or EndoStim. More research for Linx and EndoStim is necessary with randomized clinical trials, with improvement of the devices and with long term follow up.
Asunto(s)
Fundoplicación , Reflujo Gastroesofágico/cirugía , Gastroscopía , Laparoscopía , Calidad de Vida , Medicina Basada en la Evidencia , Fundoplicación/métodos , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos , Resultado del TratamientoRESUMEN
Transoral Incisionless Fundoplication (TIF) with EsophyX device for a well selected GERD patient population has proven its efficacy, safety and durability. We present a case report of a male, 63 y old, with typical and atypical GERD symptoms started 15 years ago. The esophagogastroduodenoscopy (EGD) showed a Hiatal Hernia (HH) of 3 cm and an erosive esophagitis Los Angeles Grade B. The first surgery was performed 7 years ago, in March 2009: a TIF with the EsophyX 2® device (EndoGastric Solution, Inc., Redmond, WA, United States). Post-surgery the symptoms were controlled, completely eliminated, the EGD showing the healing of the esophagitis. Six years after the surgery the sore throat re-appears, while the EGD shows a 2 cm hiatal hernia and erosive esophagitis Los Angeles Grade A. The Impedance pH-metry confirms GERD with a DeMeester score of 44.5. In 2016 (7 years after first procedure) a second and new TIF 2.0 procedure, this time with EsophyX Z device is performed. The EsophyX Z device is an automatic stapler-like fastener delivery system, easier of use, faster, safer and more reproducible (standardized fastener delivery). The time of the procedure was significantly reduced, compared to first procedure. The patient is now symptom free, EGD is normal, the impendance ph metry at 13 months post-surgery showed a normal DeMeester score at 8. This is a World's first case report of a TIF 2.0 procedure with EsophyX Z device 7 years after a first TIF procedure with EsophyX 2 device, with excellent results and a significant reduction of the time for the procedure.
Asunto(s)
Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Cirugía Endoscópica por Orificios Naturales/instrumentación , Estudios de Seguimiento , Fundoplicación/instrumentación , Humanos , Masculino , Persona de Mediana Edad , Calidad de Vida , Resultado del TratamientoRESUMEN
PURPOSE: Robotics in surgery is a recent innovation. This technology offers a number of attractive features in laparoscopy. It overcomes the difficulties with fixed port sites by restoring all 6 degrees of freedom at the instrument tips, provides new possibilities for miniaturization of surgical tasks and allows remote controlled surgery. We investigated the applicability of remote controlled robotic surgery to laparoscopic radical prostatectomy. MATERIALS AND METHODS: Our previous experience with laparoscopic prostatectomy served as a basis for adapting robotic surgery to this procedure. A surgeon at a different location who activated the tele-manipulators of the da Vinci∗ robotic system performed all steps of the intervention. A scrub nurse and second surgeon who stood at patient side had limited roles to port and instrument placement, exposure of the operative field, assistance in hemostasis and removal of the operative specimen. Our patient was a 63-year-old man presenting with a T1c tumor discovered on 1 positive sextant biopsy with a 3+3 Gleason score and 7 ng./ml. preoperative serum prostate specific antigen. RESULTS: The robot provided an ergonomic surgical environment and remarkable dexterity enhancement. Operating time was 420 minutes, and the hospital stay lasted 4 days. The bladder catheter was removed 3 days postoperatively, and 1 week later the patient was fully continent. Pathological examination showed a pT3a tumor with negative margins. CONCLUSIONS: Robotically assisted laparoscopic radical prostatectomy is feasible. This new technology enhances surgical dexterity. Further developments in this field may have new applications in laparoscopic tele-surgery.
Asunto(s)
Laparoscopía/métodos , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Procedimientos Quirúrgicos Robotizados/métodos , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Estudios de Factibilidad , Humanos , Laparoscopía/efectos adversos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Tempo Operativo , Próstata/patología , Próstata/cirugía , Prostatectomía/efectos adversos , Neoplasias de la Próstata/patología , Procedimientos Quirúrgicos Robotizados/efectos adversosRESUMEN
BACKGROUND: Over the past decades, staging laparoscopy evolved as a useful tool in multimodality treatment of patients with abdominal malignancies, especially for detection of incurable peritoneal and liver metastasis. Natural orifice translumenal endoscopic surgery (NOTES) is a new, evolving technique which represents the next logical progression in minimally invasive surgery and has theoretical advantages in comparison with standard laparoscopic surgery. A review of the current literature revealed a continuous increasing number of fundamental and clinical studies addressing NOTES approach in multimodal management of oncologic patients. Technical possibility to use this new minimally invasive approach for oncological resection of abdominal malignancies was proved by some investigators. HYPOTHESIS: NOTES can be used as an alternative method for staging patients with limited peritoneal carcinomatosis and may have better results compared to current imaging techniques for small diameter metastatic disease. CONCLUSIONS: With the continuous development of the NOTES techniques and technology, the second-look peritoneoscopy by NOTES may become an alternative method for staging in patients with peritoneal carcinomatosis. Nevertheless, NOTES is at a very early stage of its development, and its implementation in oncologic surgery should be made very caution, and only after careful evaluation.
Asunto(s)
Carcinoma/patología , Laparoscopía/métodos , Cirugía Endoscópica por Orificios Naturales/métodos , Neoplasias Peritoneales/patología , Humanos , Estadificación de Neoplasias/métodosRESUMEN
PURPOSE: We developed and assessed the feasibility of extraperitoneal laparoscopic radical prostatectomy performed using the da Vinci (Intuitive Surgical, Mountain View, California) robotic system. MATERIALS AND METHODS: In June 2002, 4 consecutive patients with clinically localized prostate cancer underwent extraperitoneal, robotic assisted laparoscopic radical prostatectomy. After development of the extraperitoneal space the surgeon performed laparoscopic prostatectomy from the remote control unit. The assistant aligned and exchanged robotic instruments and used conventional laparoscopic instruments to facilitate prostatectomy. Perioperative data and pathological results were recorded. RESULTS: No difficulties were noted when developing the extraperitoneal space. All additional steps were successfully performed with telerobotics. More distal placement of the robotic ports appeared to improve the feasibility of the extraperitoneal approach. The peritoneum acted as a natural bowel retractor and the distal port placement facilitated use of the assistant ports. Mean operative time was 274 minutes (range 124 to 360). Mean catheterization time and hospital stay were 2.7 and 5.3 days, respectively. A positive margin was observed in 1 patient and pathological stage was pT2 in 3 and pT3 in 1. No postoperative complications or open conversions were observed. CONCLUSIONS: The extraperitoneal approach was feasible with the da Vinci robotic system. Distal port placement for the robot appeared to create an ergonomic environment for the surgeon and assistant and more direct prostatic access. While additional clinical experience is required, the extraperitoneal approach may ultimately provide advantages for robotic and nonrobotic laparoscopic radical prostatectomy.
Asunto(s)
Laparoscopía/métodos , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Robótica , Anciano , Estudios de Factibilidad , Humanos , Masculino , Persona de Mediana EdadRESUMEN
PURPOSE: The use of robotics is a recent innovation in surgery. In addition to dexterity enhancement and motion scaling, this new technology opens the horizon of remote surgery. This latter advancement has potential use during surgery involving a high risk of patient-to-professional or professional-to-patient virus transmission. We investigated the feasibility of robotic assisted kidney transplantation. MATERIALS AND METHODS: A right cadaveric kidney was transplanted into a 26-year-old male patient who has been on hemodialysis for 11 years. Surgery was done with the help of the da Vinci robot (Intuitive Surgical, Inc., Mountain View, California) by a remote surgeon, who completely performed vascular dissection and anastomosis as well as ureterovesical anastomosis. The role of the assistant by the side of the patient was limited to access creation, exposure, hemostasis and maintaining traction on the running sutures performed by the robot. RESULTS: Operative time was 178 minutes. Robotic assistance made anastomosis possible by its unique ability of stereoscopic magnification and ultra-precise suturing techniques due to the flexibility of the robotic wristed instruments. Renal perfusion was excellent with immediate diuresis. Postoperative acute tubular necrosis started to resolve after 1 week. CONCLUSIONS: This study demonstrates that robotic assisted kidney transplantation is feasible. Currently technical and cost hindrances limit the routine use of robots. However, with ongoing improvement and future availability of this technology the prevention of patient-to-professional and professional-to-patient viral transmission may become a potential field of application.