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At least 217 records · Page 12Linked to original sources
PubMed2004

Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials.

BACKGROUND: For the scientific evaluation of the endoscopic and open mesh techniques for the repair of inguinal hernia, meta-analyses of randomized controlled trials (RCT) are necessary. The Lichtenstein repair is one of the most common open mesh techniques and therefore of special interest. METHODS: After an extensive search of the literature and a quality assessment, a total of 34 RCT comparing endoscopic procedures both transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP)--with various open mesh repairs were deemed to be suitable for a formal meta-analysis of the relevant parameters. These studies included data for 7,223 patients. Trials that used the Lichtenstein repair for the control group (23 of 34 trials) were analyzed-separately. RESULTS: Significant advantages for the endoscopic procedures compared with the Lichtenstein repair include a lower incidence of wound infection (Peto odds ratio, 0.39; 95% confidence interval, 0.26, 0.61), a reduction in hematoma formation (0.69 [0.54, 0.90]) and nerve injury (0.46 [0.35, 0.61]), an earlier return to normal activities or work (-1.35[-1.72, -0.97]), and fewer incidences of chronic pain syndrome (0.56[0.44, 0.70]). No difference was found in total morbidity or in the incidence of intestinal lesions, urinary bladder lesions, major vascular lesions, urinary retention and testicular problems. Significant advantages for the Lichtenstein repair include in a shorter operating time (5.45[1.18, 9.73]), a lower incidence of seroma formation (1.42[1.13, 1.79]), and fewer hernia recurrences (2.00[1.46, 2.74]). Similar results are seen when endoscopic procedures are compared with other open mesh repairs. However, in this comparison, total morbidity was lower with the endoscopic operations (0.73[0.61, 0.89]). The incidence of seroma formation, chronic pain syndromes, and hernia recurrence was not significantly different. CONCLUSION: Endoscopic repairs do have advantages interms of local complications and pain-associated parameters. For more detailed evaluation further well-structured trials with improved standardization of hernia type, operative technique, and surgeons' experience are necessary.

Digestive System Surgical Procedures↗
PubMed2005

Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males: a randomized trial.

BACKGROUND: Endoscopic totally extraperitoneal inguinal hernioplasty (TEP) is an accepted technique for the repair of recurrent and bilateral inguinal hernia, but its role in the management of unilateral primary inguinal hernia remains controversial. The current randomized trial was undertaken to compare the postoperative and 1-year outcomes of day-case TEP and open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males. METHODS: From January 2002 to January 2004, a total of 200 male patients were randomized to undergo either day-case unilateral TEP or open Lichtenstein hernioplasty under general anesthesia. The primary outcome measures included postoperative pain score, time until return to work, incidence of chronic groin pain, and recurrence rate 1 year after the operation. RESULTS: All TEP procedures were successfully performed without conversion. The mean operation time for TEP (50 +/- 13.2 min) was significantly shorter than for open Lichtenstein hernioplasty (58 +/- 17.6 min) (p < 0.001). The pain score at rest was significantly lower in the TEP group than in the open group on postoperative days 0, 1, 4, 5, and 6. On the average, the patients returned to work 8.6 days after TEP and 14 days after Lichtenstein hernioplasty (p = 0.006). Postoperative recovery and morbidity rates were otherwise comparable between the two groups. The incidence of chronic groin pain 1 year after TEP (9.9%) was significantly lower than after open surgery (21.7%) (p = 0.032). None of the patients in either group showed recurrence at the last follow-up assessment. CONCLUSIONS: Day-case TEP was superior to open Lichtenstein hernioplasty for the repair of unilateral primary inguinal hernia in males. The benefits of day-case TEP included less postoperative pain, a faster return to work, and a lower incidence of chronic groin pain.

Adult↗
PubMed2004

Still any role for transduodenal local excision in tumors of the papilla of Vater?

Tumors of the papilla and ampulla of Vater are rare neoplasms which are usually detected at an early stage due to their symptoms. The accurate preoperative histological diagnosis and staging of ampullary tumors is often difficult and inconclusive, leading to controversy over the adequate treatment of these lesions. Three procedures are currently being used to treat such tumors. Pancreatoduodenectomy (PD) is a procedure with low morbidity and mortality at experienced centers, and is considered the treatment of choice for invasive carcinoma and large benign ampullary lesions with suspicion of malignancy. Transduodenal local excision (TDE) of ampullary tumors is a relatively simple procedure with operative morbidity and mortality rates comparable to PD. TDE is challenged at endoscopic centers by endoscopic snare excision (ESE). Due to technical advances, the safety and outcomes of ESE for ampullary tumors have improved in recent years. ESE and TDE represent adequate methods for treatment of benign tumors and also for small malignant tumors detected at an early stage if the diagnosis and stage have been accurately established preoperatively. Due to the safety of PD and the technical advances of ESE, TDE is reserved for selected patients. Randomized controlled studies are needed to establish the correct indications for PD, TDE, and ESE.

Adenocarcinoma↗
PubMed2002

The case for laparoscopic common bile duct exploration.

The modern surgeon's approach to choledocholithiasis depends his or her view of cholangiography. During the early 1990 there was a swing away from cholangiography, which had previously been common practice. This was because of perceptions of difficulty with the technique, the time it took, and perhaps an implied increase in costs because of the time factor. There was no evidence on which to base this decision. This led to a marked upswing in the use of endoscopic retrograde cholangiopancreatography (ERCP). There were a large number of ERCPs with normal results performed prior to laparoscopic cholecystectomy. This paper states the case for intraoperative cholangiography and common bile duct clearance at the time of cholecystectomy. It is hoped that this technique will be adopted so patients can undergo a single procedure to remove their gallstones and common bile duct stones if they exist and to decrease the incidence of normal preoperative ERCPs and the need for a second procedure postoperatively to clear stones if they are found.

Cholangiography↗
PubMedDate not supplied

Iatrogenic intestinal injury concomitant to iatrogenic bile duct injury: the second component.

OBJECTIVE: Bile duct injuries have a frequency of 0.1% to 0.3% even in the most experienced centers. Complex biliary lesions usually require a bilioenteric anastomosis, achieving good long-term results in 80% to 90% of the cases. Besides injuries to the abdominal contents during laparoscopy (by trocars or electrocautery), intestinal complications associated with reconstruction attempts can be observed. We analyzed the concomitant intestinal complications in 251 patients with iatrogenic biliary injuries reconstructed over this 12-year period. METHODS: A retrospective review of patients with biliary tract reconstruction after iatrogenic injury in a tertiary academic health-care center was done. All patients with concomitant intestinal injury were included; type of operation and postoperative outcome were analyzed. RESULTS: Among 251 patients, 35 cases had a concomitant intestinal injury. The most common site of fistulization was the duodenum (18 cases, 50%); 9 cases were associated with long-term subhepatic drains (more than three weeks), and the other 9 cases were associated with a dehiscent hepatoduodenostomy. Faulty Roux-en-Y reconstruction was observed in 5 cases. In 5 cases, fistulization of the jejunum and ileum, secondary to drain placement, was documented, as well as 3 cases with colonic injuries. Two patients had a dehisced Roux-en-Y anastomosis. One had a bilioenteric omega type ileal anastomosis, and 1 had a hepatoileal anastomosis without omega reconstruction. Primary repair of the duodenum with resection of the affected intestinal or colonic segment was done at the same time of biliary repair without related morbidity. CONCLUSIONS: Concomitant gastrointestinal injures were found with an incidence of 15% in our series. The most common site of fistulization is the duodenum. In half of the patients, it was secondary to a dehiscent hepatoduodenostomy, whereas in the other, it was caused by long-term subhepatic drains. Besides faulty Roux-en-Y reconstruction, fistulization was related with long-term drains. Primary repair and resection of the affected segment of jejunum, ileum, and colon can be done during the same operative stage of biliary reconstruction, without significant correlated mortality.

Academic Medical Centers↗
PubMed2001

[Surgical treatment of gastroesophageal reflux disease in adults].

Pathological gastroesophageal reflux is common. The aim of this review was to compare the results of different surgical techniques. Papers were selected on Medline from 1990 to April 2001. A critical analysis was performed, concerning definitions of included patients, surgical techniques, and criteria of evaluation. For comparison, the results of 23 randomized studies were mainly selected. Their heterogeneity has not allowed a meta-analysis. A few techniques had poorer results than others: simple closure of His angle, Hill operation, Belsey Mark IV technique, and Angelchik prosthesis. In most studies, results of partial fundoplication on reflux were as good as those of total Nissen fundoplication and fewer patients had postoperative dysphagia. In a double blind trial, immediate advantages of laparoscopic approach were less important than those observed in non comparative studies. Another trial was interrupted after inclusion of 103 patients because of the higher rate of side-effects in the laparoscopic group. These results may help the surgeon in the choice of a technique. Patients have to be informed of potential adverse effects of the different techniques chosen by their surgeon.

Adult↗
PubMed2005

Endoscopic stenting versus surgical bypass in advanced malignant distal bile duct obstruction: cost-effectiveness analysis.

OBJECTIVE: Palliative treatment of obstructive jaundice from advanced tumour of the distal bile duct is controversial. The aim of this study was to compare the clinical outcomes and costs between endoscopic stent insertion and surgery. METHODS: The clinical data for 116 patients treated with either endoscopic plastic stenting (65 patients) or surgical bypass (51 patients) were reviewed and analysed. RESULTS: No significant difference was found between the two groups in terms of the length of hospital stay, survival time, cost, effectiveness, and early complications. However, late complications were significantly more common in the stenting group (p = 0.007). Jaundice recurred in 15 stented patients at a median time of 3 months due to stent blockage, and one surgical patient had recurrent jaundice from anastomosis stricture. Late gastric outlet obstruction occurred in one of 36 surgical patients who did not undergo prophylactic gastroenterostomy and one of 65 stented patients developed this complication. CONCLUSION: Both techniques are equally effective in biliary drainage, but stenting has a higher rate of recurrent jaundice. We recommend surgery for patients with low surgical risks and endoscopic stent in those with a short life expectancy or those unfit for surgery.

Adult↗
PubMed2002

Chronic pancreatitis: Asia-Pacific consensus report.

Current knowledge about chronic pancreatitis (CP) is limited and there is a particular dearth of information about the entity known as tropical pancreatitis. A consensus working party was convened by the Trustees of the Journal of Gastroenterology and Hepatology Foundation to conduct a systematic investigation into available evidence about the epidemiology, etiopathogenesis, diagnosis and management of CP. A literature search and formal survey of international experts in the field were used to assemble reliable evidence about these issues. The present review summarizes the results of the working party's findings and presents a series of practice guidelines to improve diagnosis, investigation and treatment of patients with CP, particularly those in the Asia-Pacific region. Areas for further research have also been identified.

Asia↗
PubMed2000

What is heartburn worth? A cost-utility analysis of management strategies.

OBJECTIVE: To determine the best treatment strategy for the management of patients presenting with symptoms consistent with uncomplicated heartburn. METHODS: We performed a cost-utility analysis of 4 alternatives: empirical proton pump inhibitor, empirical histamine2-receptor antagonist, and diagnostic strategies consisting of either esophagogastroduodenoscopy (EGD) or an upper gastrointestinal series before treatment. The time horizon of the model was 1 year. The base case analysis assumed a cohort of otherwise healthy 45-year-old individuals in a primary care practice. MAIN RESULTS: Empirical treatment with a proton pump inhibitor was projected to provide the greatest quality-adjusted survival for the cohort. Empirical treatment with a histamine2 receptor antagonist was projected to be the least costly of the alternatives. The marginal cost-effectiveness of using a proton pump inhibitor over a histamine2-receptor antagonist was approximately $10,400 per quality-adjusted life year (QALY) gained in the base case analysis and was less than $50,000 per QALY as long as the utility for heartburn was less than 0.95. Both diagnostic strategies were dominated by proton pump inhibitor alternative. CONCLUSIONS: Empirical treatment seems to be the optimal initial management strategy for patients with heartburn, but the choice between a proton pump inhibitor or histamine2-receptor antagonist depends on the impact of heartburn on quality of life.

Anti-Ulcer Agents↗
PubMed2003

Unsedated transnasal EGD in daily practice: results with 1100 consecutive patients.

BACKGROUND: EGD can be performed transnasally in adults by using small-diameter endoscopes. A large prospective study was conducted to evaluate the feasibility and tolerance of diagnostic transnasal EGD in daily practice. METHODS: Unsedated transnasal EGD was attempted in 1100 consecutive patients, in 3 different institutions, by using a 5.9-mm or a 5.3-mm diameter endoscope. The operator determined whether the procedure was successful or unsuccessful, the reason for failures, and any side effects. The influence of gender, age, endoscope diameter, and type of topical anesthesia on the success or failure of the procedure was evaluated. Patients who previously had undergone peroral EGD were queried as to which procedure they preferred. RESULTS: Transnasal EGD was feasible in 93.9% of the patients. The causes of failure were as follows: unsuccessful transnasal insertion (62.7%), patient refusal (19.4%), and nasal pain (17.9%). Female gender, young age (< or =35 years), and larger-endoscope diameter were significant predictive factors for procedure failure. Side effects included the following: epistaxis (2.3%), nasal pain (1.6%), and vaso-vagal reaction (0.3%). A majority (91%) of the patients who previously had undergone unsedated peroral EGD with a standard 9.8-mm diameter endoscope preferred transnasal EGD with a small-diameter endoscope. CONCLUSIONS: Transnasal EGD is feasible in daily endoscopic practice and is preferred by patients. Side effects are rare.

Adolescent↗
PubMed2005

Obstructive fibrostenotic Crohn's disease.

Crohn's disease is often complicated by gastrointestinal strictures. Postoperative recurrence at the anastomotic site is common and repeated surgical interventions may be necessary. Medical treatment may relieve active inflammation (see chapter on active luminal disease) but fibrous strictures will not respond to this. Mechanical treatment methods consist of endoscopic balloon dilation, stricturoplasty or surgical resection. Fibrostenotic Crohn's disease does not respond to medical therapy and requires endoscopic or surgical treatment.

Catheterization↗