Exploration of the common bile duct in the era of laparoscopic cholecystectomy.
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Cholecystectomy, Laparoscopic↗
Biomedical subjects
David I Watson
Publications and source records attributed to David I Watson.
Preoperative prediction of long-term outcome following laparoscopic fundoplication.
BACKGROUND: Although long-term outcomes following laparoscopic fundoplication for gastro-oesophageal disease have now been reported as very satisfactory, a small, but important, minority of patients are unhappy with the outcome, often due to recurrent reflux symptoms or new-onset dysphagia. In this study, we sought to establish whether various parameters that can be determined before surgery, can predict the long-term outcome of surgery. METHODS: Data collected prospectively were evaluated to determine factors that were associated with outcome at 5 years following laparoscopic fundoplication. Inclusion criteria were complete preoperative assessment data and 5-year follow-up data. Data examined included information on preoperative age, sex, weight, home address, health insurance status, duration of reflux symptoms, previous surgery, operating surgeon, endoscopy and 24-h pH monitoring. In addition, lower oesophageal sphincter resting and residual relaxation pressures were evaluated before and after surgery. The postoperative symptoms of heartburn and dysphagia, as well as overall satisfaction 5 years following surgery was determined using a 0-10 visual analogue scale. The association of the pre- and perioperative factors and outcome at 5 years was determined by univariate and linear regression analysis. RESULTS: Two hundred and sixty-two patients from an overall experience of over 1000 laparoscopic anti-reflux procedures met the entry criteria. There was no association between patient address, age, weight, duration of symptoms, the presence of endoscopically proven oesophagitis, operating surgeon, the necessity for conversion to an open procedure, change in lower oesophageal sphincter residual relaxation pressure and the outcome parameters. Using univariate analysis, a higher heartburn score was associated with previous abdominal surgery, female sex, no private health insurance, and a normal preoperative 24-h pH study. A higher dysphagia score was associated with a normal preoperative pH study, a postoperative increase in lower oesophageal sphincter resting pressure of more than 6 mmHg, and previous abdominal surgery. Overall satisfaction with the outcome at 5 years was higher among male patients, private patients, patients who had a hiatus hernia, and patients who had an abnormal preoperative pH study. Linear regression analysis confirmed that private insurance, male sex, and the absence of previous abdominal surgery, were the strongest predictors of an improved heartburn score, whereas male sex and private health insurance were the strongest predictors of greater satisfaction with the overall outcome. CONCLUSIONS: There are parameters that can be assessed before or during laparoscopic Nissen fundoplication that correlate with late outcome parameters. In particular, male patients and those from higher socioeconomic groups appear to have a better long-term outcome.
Adult↗
Division of short gastric vessels at laparoscopic nissen fundoplication: a prospective double-blind randomized trial with 5-year follow-up.
OBJECTIVE: To determine whether division of the short gastric vessels at laparoscopic fundoplication confers long-term clinical benefit to patients. SUMMARY BACKGROUND DATA: Dividing the short gastric vessels during surgery for gastroesophageal reflux is controversial. This prospective randomized study was designed to determine whether there is a benefit in terms of patient outcome at a minimum of 5 years after primary surgery. METHODS: Between May 1994 and October 1995, 102 patients undergoing a laparoscopic Nissen fundoplication were randomized to have their short gastric vessels either divided or left intact. By September 2000, 99 (50 no division, 49 division) patients were available for follow-up, and they all underwent a detailed telephone interview by an independent and masked investigator. RESULTS: There were no significant differences between the groups at 5 years of follow-up in terms of the incidence of epigastric pain, regurgitation, odynophagia, early satiety, inability to belch, anorexia, nausea, vomiting, nocturnal coughing, and nocturnal wheezing. There was also no difference between the groups in the incidence of heartburn when determined by either yes/no questioning or a 0-to-10 visual analog scale. There was no difference between the groups in terms of the incidence and severity of dysphagia determined by yes/no questioning, 0-to-10 visual analog scales, or a composite dysphagia score. There was a significantly increased incidence of flatus production and epigastric bloating and a decreased incidence of ability to relieve bloating in patients who underwent division of the short gastric vessels. CONCLUSIONS: Division of the short gastric vessels during laparoscopic Nissen fundoplication does not improve any measured clinical outcome at 5 years of follow-up and is associated with an increased incidence of "wind-related" problems.
Double-Blind Method↗
Suturing efficiency during hiatal repair for laparoscopic fundoplication.
BACKGROUND: An increasingly important part of general surgical training is the development of skills in advanced laparoscopic surgery. However, this aspect of laparoscopy is not always well taught, and there is scope for improving both training and the assessment of performance. Recently, the improved affordability and accessibility of digital video technology and supporting computer systems has enabled critical analysis of operative techniques in laparoscopic surgery to be carried out inexpensively. The aim of the present project was to develop a method for the objective analysis of a laparoscopic suturing task in the real clinical environment, so that surgeon-in-training performance could be objectively evaluated. METHODS: Eight videos of laparoscopic fundoplication procedures were used and the process of posterior hiatal repair was specifically analysed. The procedures were carried out by three operators, each with a different level of advanced laparoscopic experience. Two blinded assessors independently analysed the videos in 5-s intervals at two separate sittings. Analysis concentrated on the types of movements as well as their efficiency in progressing the task. RESULTS: The total time taken for the posterior hiatal repair varied between 165 and 350 s (mean 240), and the mean number of actions was 42 (range 25-55). The mean percentage of efficiency (actions deemed 'very efficient' and 'efficient'vs actions deemed fair or inefficient) was 44% overall. More experienced surgeons took less time to complete the hiatal repair and had a higher percentage of efficiency of actions than inexperienced surgeons. Inefficient or unnecessary movements could be identified; these were less common for the more experienced surgeons. CONCLUSION: Video deconstruction enabled critical analysis of hiatal suturing in advanced laparoscopic surgery, highlighting inefficient actions. This offers a method for objectively assessing technique using readily available equipment. The method could be used to provide constructive feedback to surgical trainees.
Clinical Competence↗