RESUMEN
BACKGROUND: Median arcuate ligament syndrome (MALS) is a condition characterized by chronic abdominal symptoms associated with median arcuate ligament compression of the celiac artery. The selection of patients is difficult in the management of MALS. This study aimed to identify factors that predict outcomes of surgical and nonoperative treatment in these patients. METHODS: Patients referred with a possible diagnosis of MALS between 1998 and 2013 were identified retrospectively. Only patients with chronic symptoms and radiologically confirmed celiac artery compression were included. The clinical features, investigations, and management were documented. Outcome was assessed using the Visick score, Gastrointestinal Symptom Rating Scale, and 12-Item Short Form Health Survey by telephone interview and review of medical records. RESULTS: There were 67 patients, 43 (64%) treated surgically and 24 (36%) managed without surgery, with a median follow-up of 25 months and 24 months, respectively. After surgical treatment, 16 (37%) were asymptomatic, 24 (56%) were partially improved, 3 (7%) had no changes in symptoms, and none had worsening of symptoms. Postexertional pain predicted improvement after surgery (P = .022). Vomiting (P = .046) and unprovoked pain (P = .006) were predictors of poor surgical outcome. After nonoperative management, 1 (4%) was asymptomatic, 7 (29%) were partially improved, 12 (50%) had no changes in symptoms, and 4 (17%) had worsening of symptoms. No outcome predictors of nonoperative treatment were identified. CONCLUSIONS: MALS was more likely to respond to decompression if patients had postexertional pain. Patients who presented with vomiting and unprovoked pain were unlikely to respond to surgery. In contrast with previous studies, postprandial pain was not found to be predictive of outcome.
Asunto(s)
Arteria Celíaca/anomalías , Arteria Celíaca/cirugía , Constricción Patológica/terapia , Descompresión Quirúrgica/métodos , Laparoscopía , Procedimientos Quirúrgicos Vasculares , Dolor Abdominal/etiología , Adulto , Anciano , Arteria Celíaca/diagnóstico por imagen , Arteria Celíaca/fisiopatología , Constricción Patológica/complicaciones , Constricción Patológica/diagnóstico por imagen , Constricción Patológica/cirugía , Descompresión Quirúrgica/efectos adversos , Femenino , Humanos , Laparoscopía/efectos adversos , Masculino , Síndrome del Ligamento Arcuato Medio , Persona de Mediana Edad , Selección de Paciente , Queensland , Estudios Retrospectivos , Factores de Riesgo , Encuestas y Cuestionarios , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversos , Vómitos/etiología , Adulto JovenRESUMEN
BACKGROUND: This study compares long-term outcomes between intention-to-treat laparoscopic and open approaches to colorectal liver metastases (CLM), using inverse probability of treatment weighting (IPTW) based on propensity scores to control for selection bias. METHOD: Patients undergoing liver resection for CLM by 5 surgeons at 3 institutions from 2000 to early 2014 were analysed. IPTW based on propensity scores were generated and used to assess the marginal treatment effect of the laparoscopic approach via a weighted Cox proportional hazards model. RESULTS: A total of 298 operations were performed in 256 patients. 7 patients with planned two-stage resections were excluded leaving 284 operations in 249 patients for analysis. After IPTW, the population was well balanced. With a median follow up of 36 months, 5-year overall survival (OS) and recurrence-free survival (RFS) for the cohort were 59% and 38%. 146 laparoscopic procedures were performed in 140 patients, with weighted 5-year OS and RFS of 54% and 36% respectively. In the open group, 138 procedures were performed in 122 patients, with a weighted 5-year OS and RFS of 63% and 38% respectively. There was no significant difference between the two groups in terms of OS or RFS. CONCLUSION: In the Brisbane experience, after accounting for bias in treatment assignment, long term survival after LLR for CLM is equivalent to outcomes in open surgery.
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Neoplasias Colorrectales/patología , Hepatectomía/métodos , Laparoscopía , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Metastasectomía/métodos , Neoplasias Colorrectales/mortalidad , Supervivencia sin Enfermedad , Femenino , Hepatectomía/efectos adversos , Hepatectomía/mortalidad , Humanos , Análisis de Intención de Tratar , Estimación de Kaplan-Meier , Laparoscopía/efectos adversos , Laparoscopía/mortalidad , Neoplasias Hepáticas/mortalidad , Modelos Logísticos , Masculino , Metastasectomía/efectos adversos , Metastasectomía/mortalidad , Persona de Mediana Edad , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Queensland , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: Prevalences of bile duct injury (BDI) following laparoscopic cholecystectomy (LC) remain unacceptably high. There is no standardized method for performing an LC. This study aims to describe a standardized technique for LC that will allow for the development of a concept LC checklist, the use of which, it is hoped, will decrease the prevalence of BDI. METHODS: A standardized method for LC was developed based on previously published expert analysis supplemented by video error analysis of operations in which BDI occurred. Established checklist methodology was then used to construct an LC-specific concept checklist. RESULTS: A five-step technique for the safe establishment of the critical view was created to guide the development of the checklist. The five steps are: (i) confirm the gallbladder lies in the hepatic principal plane and is retracted to the 10 o'clock position; (ii) confirm Hartmann's pouch is lifted up and toward the segment IV pedicle; (iii) identify Rouvière's sulcus; (iv) confirm the release of the posterior leaf of the peritoneum covering the hepatobiliary triangle, and (v) confirm the critical view with or without intraoperative cholangiography. CONCLUSIONS: A standardized approach to LC would allow for the creation of an LC-specific checklist that has the potential to lower the prevalence of BDI.
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Lista de Verificación/normas , Colecistectomía Laparoscópica/normas , Enfermedades de los Conductos Biliares/etiología , Enfermedades de los Conductos Biliares/prevención & control , Conductos Biliares/lesiones , Colangiografía , Colecistectomía Laparoscópica/efectos adversos , Colecistectomía Laparoscópica/métodos , Competencia Clínica/normas , Humanos , Seguridad del Paciente , Análisis y Desempeño de Tareas , Resultado del Tratamiento , Grabación en VideoRESUMEN
Laparoscopic fundoplication (LF) is a surgical treatment for gastroesophageal reflux disease (GERD) that has been performed for more than 20 years. High-volume centers of excellence report long-term success rates greater than 90% with LF. On the other hand, general population-based outcomes are reported to be markedly worse, leading to a nihilistic perception of the procedure on the part of the medical referral population. The lack of standardization of the technique and the lack of tools to calibrate objectively the repairs are probably among the causes of variability in the outcomes and may explain the decline in the number of LF procedures in recent years. The functional lumen imaging probe (EndoFLIP(®)) device is essentially a "smart bougie" in the form of a balloon catheter that measures shape and compliance of the gastroesophageal junction (GEJ) during surgery using impedance planimetry. With approximately 3 years of international experience gained with this tool, a symposium was convened in October 2012 in Strasbourg, France, with the aim of determining if intraoperative EndoFLIP use could provide standardization of surgical treatment of GERD through the understanding of physiological changes occurring to the GEJ during fundoplication. This article provides a brief history of the EndoFLIP system and reviews data previously published on the use of EndoFLIP to characterize the GEJ in normal subjects. It then summarizes the data from the 5 high-volume international sites with expert surgeons performing LF presented in Strasbourg to objectively profile the characteristics of a normal postoperative GEJ.
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Esofagoscopía/métodos , Fundoplicación/métodos , Cirugía Asistida por Computador , Esofagoscopía/instrumentación , Fundoplicación/instrumentación , Reflujo Gastroesofágico/cirugía , Humanos , Estudios RetrospectivosRESUMEN
BACKGROUND: Increased esophagogastric junction distensibility occurs with esophageal reflux. The EndoFLIP(®) is now available as a clinical tool to measure this. Control data for patients without reflux has to date only been available for a handful of patients evaluated under sedation during endoscopy. This study explores the baseline data for patients who undergo laparoscopy using general anesthesia with pneumoperitoneum. METHODS: Patients who require surgery in the absence of a history of esophageal reflux underwent EndoFLIP(®) evaluation of pressure, cross-sectional area, and distensibility with bag fills of 30 and 40 ml. This was performed after induction of anesthesia, during pneumoperitoneum, and just before extubation. RESULTS: Baseline levels were established and were noted to be significantly affected by the impact of pneumoperitoneum, with negligible effects from general anesthesia, patient gender, age, body mass index, or muscle relaxation. CONCLUSIONS: These data provide a guide for more accurate intraoperative EndoFLIP(®) calibration of crural hiatal repair during surgery.
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Unión Esofagogástrica/patología , Esofagoscopía/instrumentación , Reflujo Gastroesofágico/patología , Adolescente , Adulto , Anciano , Anestesia General , Calibración , Dilatación Patológica/diagnóstico , Diseño de Equipo , Unión Esofagogástrica/cirugía , Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Humanos , Cuidados Intraoperatorios/instrumentación , Persona de Mediana Edad , Neumoperitoneo Artificial/métodos , Presión , Adulto JovenRESUMEN
HYPOTHESIS: Laparoscopic 90 degrees anterior partial fundoplication for gastroesophageal reflux disease achieves equivalent results to laparoscopic Nissen fundoplication. DESIGN: A multicenter, prospective, double-blind randomized clinical trial with a minimum of 5 years' follow-up. SETTING: Nine university teaching hospitals in 6 major cities throughout Australia and New Zealand. PARTICIPANTS: One hundred twelve patients undergoing primary antireflux surgery were randomized to undergo either laparoscopic Nissen fundoplication (52 patients) or anterior 90 degrees partial fundoplication (60 patients). INTERVENTIONS: Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication. MAIN OUTCOME MEASURES: Blinded assessment at 1 and 5 years' follow-up of clinical outcome for postoperative heartburn, dysphagia, gas-related symptoms, and satisfaction with the surgical outcome. Analog scales ranging from 0 to 10 were used to assess symptom severity. RESULTS: Ninety-seven patients underwent follow-up at 5 years. Three others died during follow-up, 4 refused follow-up, and 8 were lost to follow-up; 89% remained at 5-years' follow-up. At 5 years' follow-up, mean analog scores for heartburn were 2.2 for anterior fundoplication vs 0.9 for Nissen fundoplication (P=.003). There were no significant differences between the groups for dysphagia scores. The mean score for outcome satisfaction was 7.1 after anterior fundoplication vs 8.1 after Nissen fundoplication (P=.18). Eighty-eight percent reported a good or excellent outcome following Nissen fundoplication vs 77% following anterior fundoplication. CONCLUSIONS: Laparoscopic Nissen and anterior 90 degrees partial fundoplication achieve similar levels of patient satisfaction at 5 years' follow-up, with similar adverse effect profiles. However, at 5 years' follow-up, laparoscopic Nissen fundoplication achieves superior control of reflux symptoms. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Register Identifier: ACTRN12607000298415.
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Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/métodos , Adulto , Anciano , Método Doble Ciego , Femenino , Estudios de Seguimiento , Fundoplicación/efectos adversos , Reflujo Gastroesofágico/diagnóstico , Pirosis/diagnóstico , Pirosis/epidemiología , Humanos , Laparoscopía/efectos adversos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/fisiopatología , Estudios Prospectivos , Recurrencia , Valores de Referencia , Medición de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
Although polyps of the extrahepatic biliary system are rare, an awareness of their potential existence is important as they may closely mimic choledocholithiasis clinically and radiologically but require distinct measures for successful management. This report describes the presentation and successful laparoscopic transcystic management of this infrequently encountered condition. It also explores the literature and discovers the numerous potential presenting features of common bile duct calculi and the spectrum of possible management options.
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Coledocolitiasis/diagnóstico , Enfermedades del Conducto Colédoco/diagnóstico , Enfermedades del Conducto Colédoco/cirugía , Laparoscopía , Pólipos/diagnóstico , Pólipos/cirugía , Anciano de 80 o más Años , Enfermedades del Conducto Colédoco/patología , Diagnóstico Diferencial , Humanos , Laparoscopía/métodos , MasculinoRESUMEN
BACKGROUND: The short-term clinical outcomes from a multicenter prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees partial fundoplication have been reported previously. These demonstrated a high level of satisfaction with the overall outcome following anterior 90 degrees fundoplication. However, the results of postoperative objective tests and specific clinical symptoms are not always consistent with an individual patient's functional status and general well being following surgery, and quality of life (QOL) is also an important outcome to consider following surgery for reflux. Hence, QOL information was collected in this trial to investigate the hypothesis: improvements in QOL following laparoscopic antireflux surgery are greater after anterior 90 degrees partial fundoplication than after Nissen fundoplication. METHODS: Patients undergoing a laparoscopic fundoplication for gastro-esophageal reflux at one of nine university teaching hospitals in six major cities in Australia and New Zealand were randomized to undergo either laparoscopic Nissen or anterior 90 degrees partial fundoplication. Quality of life before and after surgery was assessed using validated questionnaires - the Short Form 36 general health questionnaire (SF36) and an Illness Behavior Questionnaire (IBQ). Patients were asked to complete these questionnaires preoperatively and at 3, 6, 12 and 24 months postoperatively. RESULTS: One hundred and twelve patients were randomized to undergo a Nissen fundoplication (52) or a 90 degrees anterior fundoplication (60). Patients who underwent anterior fundoplication reported significant improvements in eight of the nine SF36 scales compared to four of the nine following a Nissen fundoplication. The majority of these improvements occurred early in the postoperative period. With respect to the illness behavior data, there were no significant differences between the two procedures. Both groups had a significant improvement in disease conviction scores at all time points compared to their preoperative scores. CONCLUSIONS: Patients undergoing laparoscopic anterior 90 degrees partial fundoplication reported more QOL improvements in the early postoperative period than patients undergoing a Nissen fundoplication. However, the QOL outcome for both procedures was similar at later follow-up.
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Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/métodos , Calidad de Vida , Australia , Estudios de Seguimiento , Reflujo Gastroesofágico/psicología , Estado de Salud , Humanos , Nueva Zelanda , Satisfacción del Paciente , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
OBJECTIVE: Prospectively evaluate whether for patients having laparoscopic cholecystectomy with failed trans-cystic duct clearance of bile duct (BD) stones they should have laparoscopic choledochotomy or postoperative endoscopic retrograde cholangiography (ERCP). SUMMARY BACKGROUND DATA: Clinical management of BD stones found at laparoscopic cholecystectomy in the last decade has focused on pre-cholecystectomy detection with ERCP clearance in those with suspected stones. This clinical algorithm successfully clears the stones in most patients, but no stones are found in 20% to 60% of patients and rare unpredictably severe ERCP morbidity can result in this group. Our initial experience of 300 consecutive patients with fluoroscopic cholangiography and intraoperative clearance demonstrated that, for the pattern of stone disease we see, 66% of patients' BD stones can be cleared via the cystic duct with dramatic reduction in morbidity compared to the 33% requiring choledochotomy or ERCP. Given the limitations of the preoperative approach to BD stone clearance, this trial was designed to explore the limitations, for patients failing laparoscopic trans-cystic clearance, of laparoscopic choledochotomy or postoperative ERCP. METHODS: Across 7 metropolitan hospitals after failed trans-cystic duct clearance, patients were intraoperatively randomized to have either laparoscopic choledochotomy or postoperative ERCP. Exclusion criteria were: ERCP prior to referral for cholecystectomy, severe cholangitis or pancreatitis requiring immediate ERCP drainage, common BD diameter of less than 7 mm diameter, or if bilio-enteric drainage was required in addition to stone clearance. Drain decompression of the cleared BD was used in the presence of cholangitis, an edematous ampulla due to instrumentation or stone impaction and technical difficulties from local inflammation and fibrosis. The ERCP occurred prior to discharge from hospital. Mechanical and extracorporeal shockwave lithotripsy was available. Sphincter balloon dilation as an alternative to sphincterotomy to allow stone extraction was not used. Major endpoints for the trial were operative time, morbidity, retained stone rate, reoperation rate, and hospital stay. RESULTS: From June 1998 to February 2003, 372 patients with BD stones had successful trans-cystic duct clearance of stones in 286, leaving 86 patients randomized into the trial. Total operative time was 10.9 minutes longer in the choledochotomy group (158.8 minutes), with slightly shorter hospital stay 6.4 days versus 7.7 days. Bile leak occurred in 14.6% of those having choledochotomy with similar rates of pancreatitis (7.3% versus 8.8%), retained stones (2.4% versus 4.4%), reoperation (7.3% versus 6.6%), and overall morbidity (17% versus 13%). CONCLUSIONS: These data suggest that the majority of secondary BD stones can be diagnosed at the time of cholecystectomy and cleared trans-cystically, with those failing having either choledochotomy or postoperative ERCP. However, because of the small trial size, a significant chance exists that small differences in outcome may exist. We would avoid choledochotomy in ducts less than 7 mm measured at the time of operative cholangiogram and severely inflamed friable tissues leading to a difficult dissection. We would advocate choledochotomy as a good choice for patients after Billroth 11 gastrectomy, failed ERCP access, or where long delays would occur for patient transfer to other locations for the ERCP.
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Colangiopancreatografia Retrógrada Endoscópica , Conducto Colédoco/cirugía , Cálculos Biliares/terapia , Adolescente , Adulto , Anciano , Colangiografía , Colecistectomía Laparoscópica , Femenino , Humanos , Laparoscopía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
HYPOTHESIS: Laparoscopic anterior 90 degrees partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication. DESIGN: A multicenter, prospective, double-blind, randomized controlled trial. SETTING: Nine university teaching hospitals in 6 major cities in Australia and New Zealand. PARTICIPANTS: One hundred twelve patients with proven gastroesophageal reflux disease presenting for laparoscopic fundoplication were randomized to undergo either a Nissen (52 patients) or an anterior 90 degrees partial procedure (60 patients). Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded from this study. INTERVENTIONS: Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, and overall satisfaction 1, 3, and 6 months after surgery using multiple clinical grading systems. Objective measurement of esophageal manometric parameters, esophageal acid exposure, and endoscopic assessment. RESULTS: Postoperative dysphagia, and wind-related adverse effects were less common after a laparoscopic anterior 90 degrees partial fundoplication. Relief of heartburn was better following laparoscopic Nissen fundoplication. Overall satisfaction was better after anterior 90 degrees partial fundoplication. Lower esophageal sphincter pressure, acid exposure, and endoscopy findings were similar for both procedures. CONCLUSIONS: At the 6-month follow-up, laparoscopic anterior 90 degrees culine partial fundoplication is followed by fewer adverse effects than laparoscopic Nissen fundoplication with full fundal mobilization, and it achieves a higher rate of satisfaction with the overall outcome. However, this is offset to some extent by a greater likelihood of recurrent gastroesophageal reflux symptoms.