Background In 2006, we reported results of a randomized trial of laparoscopic paraesophageal hernia repair (LPEHR), comparing primary diaphragm repair (PR) with primary repair buttressed with a ...biologic prosthesis (small intestinal submucosa SIS). The primary endpoint, radiologic hiatal hernia (HH) recurrence, was higher with PR (24%) than with SIS buttressed repair (9%) after 6 months. The second phase of this trial was designed to determine the long-term durability of biologic mesh-buttressed repair. Methods We systematically searched for the 108 patients in phase I of this study to assess current clinical symptoms, quality of life (QOL) and determine ongoing durability of the repair by obtaining a follow-up upper gastrointestinal series (UGI) read by 2 radiologists blinded to treatment received. HH recurrence was defined as the greatest measured vertical height of stomach being at least 2 cm above the diaphragm. Results At median follow-up of 58 months (range 42 to 78 mo), 10 patients had died, 26 patients were not found, 72 completed clinical follow-up (PR, n = 39; SIS, n = 33), and 60 repeated a UGI (PR, n = 34; SIS, n = 26). There were 20 patients (59%) with recurrent HH in the PR group and 14 patients (54%) with recurrent HH in the SIS group (p = 0.7). There was no statistically significant difference in relevant symptoms or QOL between patients undergoing PR and SIS buttressed repair. There were no strictures, erosions, dysphagia, or other complications related to the use of SIS mesh. Conclusions LPEHR results in long and durable relief of symptoms and improvement in QOL with PR or SIS. There does not appear to be a higher rate of complications or side effects with biologic mesh, but its benefit in reducing HH recurrence diminishes at long-term follow-up (more than 5 years postoperatively) or earlier.
Abstract Objective Randomized trials show that pneumatic dilatation ≥30mm (PD) and laparoscopic myotomy (LM) provide equivalent symptom relief and disease-related quality of life for patients with ...achalasia. However, there remain questions about the safety, burden, and costs of treatment options. Methods We performed a retrospective cohort study of achalasia patients initially treated with PD or LM (2009-2014) using the Truven Health MarketScan® Research Databases. All patients had one year of follow-up after initial treatment. We compared safety, healthcare utilization, and total and out-of-pocket costs using generalized linear models. Results Among 1,061 patients, 82% were treated with LM. LM patients were younger (median age 49 vs. 52 years, p<0.01) but were similar in terms of sex (p=0.80) and prevalence of comorbid conditions (p=0.11). There were no significant differences in the one-year cumulative risk of esophageal perforation (LM 0.8% vs. PD 1.6%, p=0.32) or 30-day mortality (LM 0.3% vs. PD 0.5%, p=0.71). LM was associated with an 82% lower rate of re-intervention (p<0.01), 29% lower rate of subsequent diagnostic testing (p<0.01), and 53% lower rate of re-admission (p<0.01). Total and out-of-pocket costs were not significantly different (p>0.05). Conclusions In the United States, LM appears to be the preferred treatment for achalasia. Both LM and PD appear to be safe interventions. Along a short time-horizon, the costs of LM and PD were not different. Mirroring findings from randomized trials, LM is associated with fewer re-interventions, less diagnostic testing, and fewer hospitalizations.
The Consortium of American College of Surgeons-Accredited Education Institutes was created to explore new opportunities in simulation-based surgical education and training beyond the scope of ...individual accredited institutes. During the Third Annual Meeting of the Consortium of American College of Surgeons-Accredited Education Institutes Consortium, 4 work groups addressed the validation and transfer of surgical skills, the use of nonsurgeons as faculty, the use of simulation to screen and select surgery residents, and long-term follow-up of learners. The key elements from the deliberations and conclusions are summarized in this manuscript.
Background Esophagectomy has been recommended for patients when recurrent dysphagia develops after Heller myotomy for achalasia. My colleagues and I prefer to correct the specific anatomic problem ...with redo myotomy and preserve the esophagus. We examined the results of this approach. Study Design We analyzed the course of 43 patients undergoing redo Heller myotomy for achalasia between 1994 and 2011 with at least 1-year of follow-up. In 2012, a phone interview and a symptoms questionnaire were completed by 24 patients. Results Forty-three patients underwent redo Heller myotomy. All patients had dysphagia, 80% had had multiple dilations. Manometry confirmed the diagnosis, lower esophageal sphincter pressure averaged 17 mmHg; 24-hour pH monitoring was not useful because of fermentation; patients were divided into 4 groups according to findings on upper gastrointestinal series. Three patients underwent take down of previous fundoplication only, the remainder 40 had that and a redo myotomy with 3-cm gastric extension. Two mucosal perforations were repaired with primary closure and Dor fundoplication. At a median follow-up of 63 months, 19 of 24 patients reported improvement in dysphagia, with median overall satisfaction rating of 7 (range 3 to 10); 4 patients required esophagectomy for persistent dysphagia. Conclusions The majority of failures after Heller myotomy present with dysphagia associated with esophageal narrowing. Upper gastrointestinal series is most useful to plan therapy and predicts outcomes. With few exceptions, patients improve substantially with redo myotomy, which can be accomplished laparoscopically with relatively low risk. These findings challenge the previously held concept that all myotomy failures need to be treated by an esophagectomy.
Background Interprofessional education (IPE) in health care describes a process for training that places health care learners from different professional disciplines into an environment or situation ...in which shared or linked educational goals are pursued. IPE represents a new way of thinking about education as a value proposition directed at high-quality interprofessional patient care and as such is an innovative strategy endorsed in statements by the Institute of Medicine and the World Health Organization. The requirements of the American College of Surgeons−accredited Education Institutes (ACS-AEIs) for Comprehensive (Level I) accreditation state that education and training activities at the accredited institutes (simulation centers) must be multidisciplinary in nature. Until recently, concepts of shared interprofessional educational goals and facilitation of interdisciplinary colearning have not been addressed explicitly by the Consortium of ACS-AEIs. Methods In March 2012, the ACS Education Division convened a forum on IPE at the Annual Meeting of the Consortium of ACS-accredited Education Institutes in Chicago, IL. Five different ACS-AEI perspectives on IPE and training were presented, covering (1) simulation-based crisis resource management training for operating room teams, (2) the use of multidisciplinary simulation at an academic medical center-based simulation facility, (3) the development of a collaborative IPE curriculum between nursing and medical schools at a major university, (4) the development of a simulation-based interprofessional obstetrics educational program at a university medical center, and (5) the development of an interprofessional macrosystem simulation program in conjunction with opening a new hospital facility. We describe these experiences and present them as best practices in simulation-based IPE in surgery. Conclusion These IPE experiences in the ACS-AEIs reflect varied and robust approaches to integrated interdisciplinary teaching and learning. Demands and directives to increase these types of educational activities in the near future will have to be met with a wider range of offerings and greater specific knowledge and expertise within the ACS-AEI Consortium.
Lack of structured mentoring programs in modern academic surgery Kibbe, Melina R., MD, FACS, FAHA; Pellegrini, Carlos A., MD, FACS; Townsend, Courtney M., MD, FACS ...
Journal of the American College of Surgeons,
October 2015, Letnik:
221, Številka:
4
Journal Article
Background From 10% to 25% of patients undergoing antireflux procedures eventually redevelop symptoms as a result of anatomic failure of the hiatal repair or fundoplication. High-resolution manometry ...(HRM) allows for reliable evaluation of the lower esophageal sphincter (LES) in detail, including subtle evidence of a hiatus hernia. The aim of this study was to characterize the dynamics and function of the LES postoperatively using HRM to determine which elements may contribute to recurrent symptoms after antireflux surgery. Study Design Twenty-three patients with recurrent symptoms and/or abnormal 24-hour pH monitoring after Nissen fundoplication (Unsuccessful group) and 11 asymptomatic post-Nissen patients tested as routine follow-up (Successful group) underwent HRM. Tracings were analyzed for percentage of peristalsis, LES pressure, length of the high-pressure zone (HPZ), LES residual pressure, and the presence of a dual HPZ (indicating a recurrent hiatus hernia). Results were compared between the 2 groups. Results Mean LES pressure tended to be greater in the Successful group compared with the Unsuccessful group (p = 0.068). There were no differences in length of the HPZ, residual pressures, and peristalsis. A dual HPZ was identified in 13 Unsuccessful group patients (56%), and 1 (9%) of the Successful group patients (p < 0.05). Abnormal DeMeester scores were observed in 79% of patients with a dual HPZ, compared with 35% of patients without a dual HPZ (p < 0.05). Conclusions The presence of a dual HPZ on HRM in patients after fundoplication appears to be a strong predictor of recurrent gastroesophageal reflux disease. In patients with recurrent symptoms after antireflux surgery, HRM also provides valuable information about peristalsis and LES characteristics that help guide appropriate management.
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