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Biomedical subjects

Peter G Devitt

Publications and source records attributed to Peter G Devitt.

12 recordsLinked to original sources
PubMed2006

Laparoscopic anterior 180 degrees partial fundoplication: five-year results and beyond.

HYPOTHESIS: Laparoscopic anterior 180 degrees partial fundoplication provides good long-term relief for symptoms of gastroesophageal reflux disease and is associated with few adverse effects. DESIGN: Prospectively evaluated case series. SETTING: University teaching hospital. PATIENTS: The late clinical outcome was determined for all patients who had undergone a laparoscopic anterior 180 degrees partial fundoplication by us between August 1, 1993, and November 30, 1999. INTERVENTIONS: Long-term (>/=5 years') follow-up after laparoscopic anterior 180 degrees partial fundoplication was obtained using a structured questionnaire. MAIN OUTCOME MEASURES: Overall satisfaction and the symptoms of heartburn and dysphagia were assessed using analog scales, and the presence or absence of other adverse outcomes was also determined. RESULTS: One hundred seventeen procedures were performed. The outcome at 5 to 11 years' (mean, 6.4 years') follow-up was determined for 113 patients (97%). Twelve patients (11%) died of unrelated causes during follow-up, and 1 patient underwent esophagectomy. Further surgery was undertaken in 12 patients (11%): 8 for recurrent reflux, 3 for a symptomatic hiatal hernia, and 1 for dysphagia. For 100 patients with clinical outcome data at late follow-up, gastroesophageal reflux symptoms were significantly improved following surgery and were well controlled in 80 patients. The incidence and severity of dysphagia were reduced after surgery. Normal belching was preserved in 91 patients, and almost all patients were able to eat normally. The overall outcome of surgery was rated as satisfactory, with 95 patients reporting that they considered their original decision to undergo surgery correct. CONCLUSIONS: Laparoscopic anterior 180 degrees partial fundoplication is an effective procedure for the surgical treatment of gastroesophageal reflux and is associated with a high rate of patient satisfaction at late follow-up. Compared with Nissen fundoplication, however, it is likely to be associated with a higher risk of recurrent reflux, although this is balanced by a lower rate of adverse effects.

Female↗
PubMed2006

Quality of life following laparoscopic anterior 90 degrees versus Nissen fundoplication: results from a multicenter randomized trial.

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.

Australia↗
PubMed2006

Single center prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees fundoplication.

Although Nissen fundoplication is a very effective treatment for gastroesophageal reflux, it is associated with a small incidence of troublesome postoperative side effects. To prevent this, progressive modification of surgical techniques has led to the development of an anterior 90 degrees fundoplication. We undertook a prospective randomized trial to compare this procedure with Nissen fundoplication to determine whether it would achieve a better clinical outcome. Patients presenting to a single center for primary laparoscopic antireflux surgery were randomized to undergo either an anterior 90 degrees fundoplication (n = 40) or a Nissen fundoplication without division of the short gastric vessels (n = 39). Clinical questionnaires were used to assess outcome at 1 month, 3-6 months, and 12 months. Both patients and the clinical interviewer were masked as to which procedure was performed. Follow-up with endoscopy, esophageal manometry, and pH monitoring was also undertaken. Operating time was similar for the two procedures (60 minutes for anterior vs. 55 minutes for Nissen fundoplication). Early postoperative complications were more common after Nissen fundoplication (18% vs. 5%). Two patients underwent laparoscopic reoperation for recurrent reflux after anterior 90 degrees fundoplication, and four underwent laparoscopic reoperation after Nissen fundoplication (dysphagia, 3 patients; acute hiatus hernia, 1 patient). One year after surgery, dysphagia and other wind-related side effects were less common after anterior 90 degrees fundoplication. Control of reflux symptoms and satisfaction with the overall outcome was similar for the two procedures. Anterior 90 degrees fundoplication is followed by fewer side effects than Nissen fundoplication. This advantage is offset by a greater likelihood of reflux recurrence. However, this does not diminish patient satisfaction.

Adult↗
PubMed2006

Laparoscopic cardiomyotomy for achalasia: long-term outcomes.

BACKGROUND: Although the laparoscopic approach to oesophageal myotomy for achalasia is associated with reduced early postoperative morbidity compared with the open approach, most published reports describe relatively short-term follow up. For this reason, in a prospective cohort study, we determined the longer-term outcome for patients with uncomplicated achalasia who underwent a laparoscopic myotomy. In addition, we sought to identify preoperative factors predicting a good postoperative outcome. METHODS: The outcome for 167 patients who underwent a laparoscopic cardiomyotomy and anterior partial fundoplication at one of two teaching hospitals was determined. All patients underwent preoperative assessment with a contrast swallow radiology, gastroscopy and oesophageal manometry. Patients also underwent objective symptom evaluation before and after surgery using various outcome scales to determine dysphagia, reflux symptoms, side-effects and overall satisfaction with the clinical outcomes. Patients were followed prospectively at yearly time points and data were managed on a computerized database. Postoperative objective investigations were undertaken if clinically indicated. RESULTS: Median operating time was 78 min (range, 30-210 min). Most patients left the hospital within 72 h of surgery. Surgery was associated with a 5% complication rate and a 4% rate of conversion to open surgery. Five per cent of patients required a subsequent intervention during follow up. Over longer-term follow up (5 years or longer), 77% of patients had either no or minimal symptoms. At 1, 3 and 5 years, 96, 93 and 97% of patients indicated that they thought that they had made the correct decision to undergo surgery, although men consistently fared worse on their reported dysphagia outcome across a range of measures. CONCLUSION: Laparoscopic myotomy with anterior partial fundoplication achieves a good outcome for patients undergoing treatment of achalasia. Male patients do not perceive their outcome to be optimal in comparison with females but in the long term, they do not regret proceeding.

Adolescent↗
PubMed2005

Assessment of an electronic voting system within the tutorial setting: a randomised controlled trial [ISRCTN54535861].

BACKGROUND: Electronic voting systems have been used in various educational settings with little measurement of the educational impact on students. The goal of this study was to measure the effects of the inclusion of an electronic voting system within a small group tutorial. METHOD: A prospective randomised controlled trial was run at the Royal Adelaide Hospital, a teaching hospital in Adelaide, Australia. 102 students in their first clinical year of medical school participated in the study where an electronic voting system was introduced as a teaching aid into a standard tutorial. Long-term retention of knowledge and understanding of the topics discussed in the tutorials was measured and student response to the introduction of the electronic voting system was assessed. RESULTS: Students using the electronic voting system had improved long-term retention of understanding of material taught in the tutorial. Students had a positive response to the use of this teaching aid. CONCLUSION: Electronic voting systems can provide a stimulating learning environment for students and in a small group tutorial may improve educational outcomes.

Adult↗
PubMed2005

Outcome of oesophagectomy for adenocarcinoma of the oesophagus and oesophagogastric junction.

BACKGROUND: Oesophageal adenocarcinoma is becoming an increasingly important problem in the Western world. Its incidence is increasing and its prognosis is poor. Because most reports of outcomes following oesophagectomy include patients with squamous cell carcinoma, the outcome following oesophagectomy for adenocarcinoma was evaluated at Flinders Medical Centre, Royal Adelaide Hospital and associated private hospitals. METHODS: The study group consisted of 121 patients with oesophageal adenocarcinoma or adenocarcinoma of the oesophagogastric junction who underwent an attempted oesophagectomy between 1985 and 2003. Thirty-two of these patients underwent surgery before 1999 at the Royal Adelaide Hospital. These patients were reviewed retrospectively. In 1999 the recording of details of all patients undergoing oesophagectomy was commenced on a prospectively maintained database. From 1999 to 2003, 89 patients underwent oesophagectomy at either the Royal Adelaide Hospital, Flinders Medical Centre or associated private hospitals. Overall, there were 101 male and 20 female patients, with a median age at surgery of 63 years (range 36-80). Survival data were available for all patients. The present study analysed factors affecting survival in these patients. RESULTS: Tumours were located entirely within the oesophagus in 83 patients, and involved the gastro-oesophageal junction in 38. Eighty-nine underwent an Ivor Lewis oesophagectomy; 20, a cervico-thoraco-abdominal oesophagectomy; nine, a cervico-abdominal oesophagectomy (with either transhiatal or blunt oesophageal dissection); and four procedures were abandoned. Sixty-four per cent of patients had evidence of Barrett's oesophagus in the resection specimen. The overall resection rate was 97%. Significant postoperative morbidity occurred in 36%, and the in-hospital mortality rate was 5% (30-day mortality 3%). The overall 1-year survival rate was 80%, and the 5-year survival rate (including surgical deaths) was 20%. Poorer survival was associated with advanced T stage, and lymph node metastasis. The outcome following resection of tumours confined to the oesophagus was similar to that for tumours involving the gastro-oesophageal junction. Since 2000, the number of oesophagectomies performed in men for adenocarcinoma has doubled, whereas the number performed in women and for squamous cell carcinoma has remained constant. CONCLUSIONS: Oesophagectomy can be performed for patients with adenocarcinoma with an acceptable perioperative mortality rate. However, the longer term outlook following oesophagectomy for most patients with adenocarcinoma remains poor. Nevertheless, early stage tumours are associated with much better survival. For this reason, efforts to diagnose this disease at an early stage are likely to offer the best chance for improving outcomes.

Adenocarcinoma↗
PubMed2004

Multicenter, prospective, double-blind, randomized trial of laparoscopic nissen vs anterior 90 degrees partial fundoplication.

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.

Adult↗
PubMed2004

Prospective randomized controlled trial of argon plasma coagulation ablation vs. endoscopic surveillance of patients with Barrett's esophagus after antireflux surgery.

BACKGROUND: Argon plasma coagulation is one of several techniques used to ablate Barrett's esophagus. This study assessed the efficacy and safety of argon plasma coagulation in the ablation of Barrett's esophagus in patients who have undergone antireflux surgery. METHODS: A total of 40 patients with Barrett's esophagus who had undergone a fundoplication were entered into a prospective, randomized, unblinded study comparing argon plasma coagulation with endoscopic surveillance. Treatment was repeated until either no Barrett's epithelium remained or a maximum of 6 treatment sessions. RESULTS: One month after the final treatment, complete ablation was achieved in 12 patients. In the remaining 8, a reduction of over 95% was observed. One patient died at 9 months of an unrelated cause. At 1 year, one patient with residual Barrett's epithelium regressed completely, while relapse of Barrett's esophagus was seen in another because of fundoplication failure. Buried glands were observed in 35% patients at 1 month, but only 5% at 1 year. Dysplasia was never seen. In the surveillance group, partial regression was observed in 11 patients, and, in 3 with short-segment Barrett's esophagus, regression was complete. The length of Barrett's esophagus increased in two patients. Two had low-grade dysplasia initially, but this was not evident at 1 year. Overall, complete ablation was achieved in 12 of 19 (63%) patients in the ablation group and 3 of 20 (15%) in the surveillance group (p<0.01). CONCLUSIONS: Argon plasma coagulation of Barrett's esophagus is safe and effective. The effects are durable, and buried glands may resolve with time. Long-term follow-up is required to assess the impact of argon plasma coagulation on cancer risk.

Adult↗
PubMed2004

Endoscopic stapling for pharyngeal pouch: does it make the cut?

BACKGROUND: Endoscopic stapling to treat pharyngeal pouch is a relatively new technique with the potential to reduce the morbidity associated with the open approach for pharyngeal pouch. Despite enthusiasm for the endoscopic approach there have been no series reported in Australia, and descriptions of outcomes and benefits are currently anecdotal. The aim of the present study was to determine the outcome associated with endoscopic stapling of pharyngeal pouch in an Australian setting. METHODS: All patients admitted for endoscopic stapling for a pharyngeal pouch between 1998 and 2002 by surgeons from the Adelaide and Flinders Universities were identified, and their medical records were reviewed for clinical and operative details. All patients were interviewed by telephone using a structured questionnaire to determine symptom resolution and patient satisfaction. The Likert scale was used to assess the impact of preoperative and postoperative symptoms upon quality of life. RESULTS: A total of 31 patients were identified. The mean age of the group was 75 years (range: 35-91 years) and half the patients had an American Society of Anesthesiologists physical status score of 3 or greater. In four patients the procedure was abandoned; (for three because of inability to pass the diverticuloscope and for one because the pouch was too small). Standard open surgery was undertaken in these patients. Of the 27 procedures completed endoscopically, interview follow up was obtained in 23, at a mean follow up of 17 months (range: 2-68 months). Outcome was very good or excellent in 21 (91%), with significant symptom resolution, reduction in Likert scores and high patient satisfaction. Three patients had previously had pouch surgery and endoscopic stapling was straightforward in these patients. Recurrence of a symptomatic pouch occurred in three patients. There was no significant morbidity related to the procedure. CONCLUSIONS: The early experience of endoscopic stapling for pharyngeal pouch in Adelaide is encouraging. The procedure achieves excellent control of symptoms and can be undertaken with minimal morbidity. Recurrence may be a problem, although repeat endoscopic stapling can be undertaken without difficulty.

Adult↗
PubMed2002

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↗