Current standard values of health utility scores for evaluating cost-effectiveness in liver disease: A meta-analysis

BACKGROUND

Health utility assessments have been developed for various conditions, including chronic liver disease. Health utility scores are required for socio-economic evaluations, which can aid the distribution of national budgets. However, the standard health utility assessment scores for specific health conditions are largely unknown.

AIM

To summarize the health utility scores, including the EuroQOL 5-dimensions 5-levels (EQ-5D-5L), EuroQol-visual analogue scale, short from-36 (SF-36), RAND-36, and Health Utilities Index (HUI)-Mark2/Mark3 scores, for the normal population and chronic liver disease patients.

METHODS

A systematic literature search of PubMed and MEDLINE, including the Cochrane Library, was performed. Meta-analysis was performed using the RevMan software. Multiple means and standard deviations were combined using the StatsToDo online web program.

RESULTS

The EQ-5D-5L and SF-36 can be used for health utility evaluations during antiviral therapy for hepatitis C. HUI-Mark2/Mark3 indicated that the health utility scores of hepatitis B patients are roughly 30% better than those of hepatitis C patients.

CONCLUSION

The EQ-5D-5L is the most popular questionnaire for health utility assessments. Health assessments that allow free registration would be useful for evaluating health utility in patients with liver disease.

Maturation of robotic liver resection during the last decade: A systematic review and meta-analysis

BACKGROUND

Minimally invasive hepatectomy techniques have developed rapidly since 2000. Pure laparoscopic liver resection (LLR) has become the primary approach for managing liver tumors and procuring donor organs for liver transplantation. Robotic liver resection (RLR) has emerged during the last decade. The technical status of RLR seems to be improving.

AIM

To conduct a systematic review and meta-analysis comparing the short-term clinical outcomes of LLR and RLR over two 5-year periods.

METHODS

A systematic literature search was performed using PubMed and Medline, including the Cochrane Library. The following inclusion criteria were set for the meta-analysis: (1) Studies comparing LLR vs RLR; and (2) Studies that described clinical outcomes, such as the operative time, intraoperative bleeding, intraoperative conversion rate, and postoperative complications.

RESULTS

A total of 25 articles were included in this meta-analysis after 40 articles had been subjected to full-text evaluations. The studies were divided into early (n = 14) and recent (n = 11) groups. In the recent group, the operative time did not differ significantly between LLR and RLR (P = 0.70), whereas in the early group the operative time of LLR was significantly shorter than that of RLR (P < 0.001).

CONCLUSION

The initial disadvantages of RLR, such as its long operation time, have been overcome during the last 5 years. The other clinical outcomes of RLR are comparable to those of LLR. The cost and quality-of-life outcomes of RLR should be evaluated in future studies to promote its routine clinical use.

Health-related quality of life in patients that have undergone liver resection: A systematic review and meta-analysis

BACKGROUND

Mortality after hepatectomy has decreased, and the quality of various surgical approaches to hepatectomy have been evaluated. Various assessments of quality of life (QOL) after hepatectomy have been developed and investigated in different clinical settings.

AIM

To conduct a systematic review and meta-analysis to examine two clinical topics: Laparoscopic hepatectomy vs open hepatectomy, and preoperative QOL status vs postoperative QOL status.

METHODS

A systematic literature search was performed using PubMed and MEDLINE, including the Cochrane Library Central. The following inclusion criteria were set for inclusion in this meta-analysis: (1) Studies comparing preoperative QOL and postoperative QOL; and (2) Studies comparing QOL between laparoscopic hepatectomy and open hepatectomy.

RESULTS

A total of 8 articles were included in this meta-analysis. QOL was better after laparoscopic hepatectomy than after open hepatectomy.

CONCLUSION

The outcomes of evaluations of QOL after hepatectomy can depend on the type of questionnaire used, the timing of the assessment, and the etiology of the hepatic disease.

The Unique Mental Impacts of Breast-Conserving Surgery and Mastectomy According to a Multi-Centered Cross Sectional Survey Conducted in Japan

Background: Improving health-related quality of life (HRQOL) has become a fundamental goal of breast cancer management. This study aimed to examine the differences between the QOL outcomes of breast-conserving surgery (BCS) and mastectomy. We also established structural equation models for BCS and mastectomy to elucidate their unique effects on QOL.Methods: Between July 2019 and November 2019, 254 patients, who were scheduled to visit one of four clinics, were recruited for this study. We evaluated HRQOL using various questionnaires, such as the BREAST-Q, EQ-5D-5L, and Hospital Anxiety and Depression Scale (HADS). The relationships among the examined clinical indicators were evaluated using structural equation modeling (SEM). Results: The QOL scores of the BCS group were better than those of the mastectomy group (0.85±0.129 vs. 0.81±0.12, P=0.020). Also, anxiety (2.94±2.95 vs. 3.81±3.08, P=0.025) and depression (2.55±2.77 vs. 3.74±3.19, P=0.002) were less severe in the BCS group than in the mastectomy group. Furthermore, the relationships among QOL status and mental health status were more complex in the BCS group than in the mastectomy group (Chi-square minimization p-value: 0.231 vs. 0.469, respectively). Also, depression directly affected QOL in the mastectomy group (R=-0.47), but not in the BCS group.Conclusions: There were differences in QOL and mental health between the BCS and mastectomy groups. SEM is useful for identifying such differences, which can be used to develop strategies for improving QOL.

Altered fecal short chain fatty acid composition in children with a history of Hirschsprung-associated enterocolitis

PURPOSE

Children with Hirschsprung disease (HD) who have a history of enterocolitis (HAEC) have a shift in colonic microbiota, many of which are necessary for short chain fatty acid (SCFA) production. As SCFAs play a critical role in colonic mucosal preservation, we hypothesized that fecal SCFA composition is altered in children with HAEC.

METHODS

A multicenter study enrolled 18 HD children, abstracting for history of feeding, antibiotic/probiotic use, and enterocolitis symptoms. HAEC status was determined per Pastor et al. criteria (12). Fresh feces were collected for microbial community analysis via 16S sequencing as well as SCFA analysis by gas chromatography-mass spectrometry.

RESULTS

Nine patients had a history of HAEC, and nine had never had HAEC. Fecal samples from HAEC children showed a 4-fold decline in total SCFA concentration vs. non-HAEC HD patients. We then compared the relative composition of individual SCFAs and found reduced acetate and increased butyrate in HAEC children. Finally, we measured relative abundance of SCFA-producing fecal microbiota. Interestingly, 10 of 12 butyrate-producing genera as well as 3 of 4 acetate-producing genera demonstrated multi-fold expansion.

CONCLUSION

Children with HAEC history have reduced fecal SCFAs and altered SCFA profile. These findings suggest a complex interplay between the colonic metabolome and changes in microbiota, which may influence the pathogenesis of HAEC.

Characterization of Bacterial and Fungal Microbiome in Children with Hirschsprung Disease with and without a History of Enterocolitis: A Multicenter Study

Development of potentially life-threatening enterocolitis is the most frequent complication in children with Hirschsprung disease (HSCR), even after definitive corrective surgery. Intestinal microbiota likely contribute to the etiology of enterocolitis, so the aim of this study was to compare the fecal bacterial and fungal communities of children who developed Hirschsprung-associated enterocolitis (HAEC) with HSCR patients who had never had enterocolitis. Eighteen Hirschsprung patients who had completed definitive surgery were enrolled: 9 had a history of HAEC and 9 did not. Fecal DNA was isolated and 16S and ITS-1 regions sequenced using Next Generation Sequencing and data analysis for species identification. The HAEC group bacterial composition showed a modest reduction in Firmicutes and Verrucomicrobia with increased Bacteroidetes and Proteobacteria compared with the HSCR group. In contrast, the fecal fungi composition of the HAEC group showed marked reduction in diversity with increased Candida sp., and reduced Malassezia and Saccharomyces sp. compared with the HSCR group. The most striking finding within the HAEC group is that the Candida genus segregated into “high burden” patients with 97.8% C. albicans and 2.2% C. tropicalis compared with “low burden” patients 26.8% C. albicans and 73% C. tropicalis. Interestingly even the low burden HAEC group had altered Candida community structure with just two species compared to more diverse Candida populations in the HSCR patients. This is the first study to identify Candida sp. as potentially playing a role in HAEC either as expanded commensal species as a consequence of enterocolitis (or treatment), or possibly as pathobioants contributing to the pathogenesis of HAEC. These findings suggest a dysbiosis in the gut microbial ecosystem of HAEC patients, such that there may be dominance of fungi and bacteria predisposing patients to development of HAEC.

Propensity score analysis demonstrated the prognostic advantage of anatomical liver resection in hepatocellular carcinoma

AIM: To compare the prognoses of hepatocellular carcinoma (HCC) patients that underwent anatomic liver resection (AR) or non-anatomic liver resection (NAR) using propensity score-matched populations.

METHODS: Between January 2002 and December 2010, 268 consecutive HCC patients, including 110 and 158 patients that underwent AR and NAR, respectively, were retrospectively enrolled in this study. Forty-four patients from each group were selected and matched using logistic multivariate analysis followed by propensity score analysis.

RESULTS: In the whole analysis set, the histological background of the liver, liver function, and tumor marker levels differed significantly among the groups. Although the overall survival (OS) and recurrence-free survival rates of the two groups did not differ significantly in the whole analysis set, the OS of the AR group was significantly longer than that of the NAR group after propensity matching (76.2 ± 6.3 mo vs 58.9 ± 6.3 mo; P = 0.0039). Although AR (HR = 0.456, P = 0.039) was found to be a prognostic factor in the univariate analysis, only vascular invasion (HR = 0.228, P = 0.002) and the hepatocyte growth factor level (HR = 52.366, P = 0.035) were subsequently found to be independent prognostic factors.

CONCLUSION: AR conveys a survival advantage over NAR in specific subpopulations of HCC patients with tumors of less than 5 cm in diameter, single tumor, and good liver function.

Prognosis and predictors of surgical complications in hepatocellular carcinoma patients with or without cirrhosis after hepatectomy

BACKGROUND

Although poor liver function is associated with a high morbidity rate and poor prognosis in hepatocellular carcinoma (HCC) patients, the exact effects of liver pathology on the surgical outcomes of HCC patients are poorly understood. The purpose of this study was to assess how the liver pathology of HCC patients affects their prognosis and complications rate after liver resection.

METHODS

Between January 2006 and November 2010, 149 consecutive hepatocellular carcinoma patients, including 79 noncirrhosis patients and 70 cirrhosis patients, were enrolled in this study.

RESULTS

Among the noncirrhotic patients, operative time, fresh frozen plasma (FFP) transfusion requirement, tumor size, and serum retinol binding protein (RBP) levels were significantly higher in the complications group than in the complications-free groups. On the other hand, in the cirrhotic patients the prothrombin time (PT) and indocyanine green retention value at 15 min (ICGR15) of the complications group were significantly lower and higher, respectively, than those of the complications-free group. In the noncirrhotic patients, recurrence-free survival and overall survival did not differ between the complications and complications-free groups. On the other hand, in the cirrhotic patients, the recurrence-free survival and overall survival of the complications-free group were significantly longer than those of the complications group.

CONCLUSIONS

In the noncirrhotic patients, surgical complications had no prognostic effect, whereas they had a significant survival impact in the cirrhotic patients. The surgical strategy for HCC should be based on the patient's pathological background.

Preoperative liver function assessments to estimate the prognosis and safety of liver resections

Liver function assessment is important to ensure safe surgical procedures in patients with hepatocellular disease. Because the liver influences a wide variety of functions, including protein synthesis and metabolic, immune and storage functions, no single parameter is sufficient to adequately address all of these functions. We reviewed the relevant literature concerning the scoring systems, functional tests, plasma parameters and imaging modalities currently used to evaluate the liver function in an attempt to determine which parameters provide the most comprehensive and useful results. While the Child-Pugh scoring system is the gold standard for liver disease assessment, the liver damage grading system recommended by the Liver Cancer Study Group of Japan is also useful. Various models for end-stage liver disease scoring are used for organ allocation. While the indocyanine green clearance test is widely accepted throughout the world, other assessments have not been used routinely for clinical evaluations. The levels of plasma proteins, including albumin, prealbumin, retinol binding protein, apolipoprotein, coagulation factors and antithrombin III, represent the liver productivity. Liver fibrotic markers also correlate with liver function. Imaging modalities such as (99m)Tc-galactosyl serum albumin scintigraphy, (99m)Tc-mebrofenin hepatobiliary scintigraphy and transient elastography are also available, but future studies are needed to validate their clinical efficacy.

Dirofilaria causing eye infection in a patient from Malaysia

Human dirofilariasis caused by Dirofilaria immitis and Dirofilaria repens have been reported in Malaysia. This is the fourth reported case of dirofilariasis caused by D. repens. The patient was a Chinese male from Kuching Sarawak, Malaysia who presented with a one day history of redness and itchiness over the temporal aspect of his left eye. A worm was seen and later removed from beneath the conjunctiva under local anesthesia and based on the morphological characteristics, it was identified as an immature Dirofilaria repens.

Octreotide in the treatment of lymphorrhea after axillary node dissection: a prospective randomized controlled trial

BACKGROUND

Axillary lymph node dissection for staging and local control of nodal disease is an integral part of breast cancer therapy. Lymphorrea is a serious and disabling complication of axillary lymphadenectomy, but no effective therapy is currently available. Octreotide is a hormone with general antisecretory effects that has been used to control lymphorrhea in thoracic duct injury and after radical neck dissection. The aim of the study we describe in this article was to determine whether octreotide has a role in the treatment of post axillary lymphadenectomy lymphorrhea.

STUDY DESIGN

This is a prospective randomized controlled trial. Two hundred sixty-one consecutive patients with various stages of breast cancer who underwent axillary lymph node dissection were randomized and followed for 7 years. The treatment group received 0.1 mg octreotide subcutaneously three times a day for 5 days, starting on the first postoperative day, while the control group received no treatment. Of the 261 patients undergoing axillary node dissection, 136 were assigned to the control group and 125 composed the treatment group. The control group and the treatment group were evaluated for amount and duration of lymphorrhea as well as inflammatory and infectious complications.

RESULTS

In the control group, the mean quantity (+/- standard deviation) of lymphorrhea was 94.6 +/- 19 cc per day and the average duration was 16.7 +/- 3.0 days. In comparison, the mean quantity of lymphorrhea in the treatment group was 65.4 +/- 21.1 cc (p < 0.0001) per day and the average duration was 7.1 +/- 2.9 days (p < 0.0001). We did not find an important difference in the number of infectious complication or hematomas formation between the study groups.

CONCLUSIONS

Octreotide can be used successfully for the treatment of post-axillary dissection lymphorrea, and potentially, in the prevention of post-axillary lymph node dissection lymphosarcoma, since the amount and duration of lymphorrhea in this setting are known to be important risk factors for its development. Potentially, octreotide might be used in similar situations where lymphorrhea is detrimental, such as peripheral vascular surgery and regional lymph node dissection for melanoma.

Outcome of elderly patients with appendicitis: effect of computed tomography and laparoscopy

HYPOTHESIS

Elderly patients who have appendicitis have a greater morbidity and mortality rate when compared with younger patients. We hypothesized that recent changes in the diagnosis and management of appendicitis in elderly patients might affect the outcome.

DESIGN

Retrospective review.

SETTING

Large metropolitan teaching hospital.

PATIENTS

All patients aged 70 years and older who underwent appendectomy for appendicitis between January 1, 1991, and December 31, 2000, were divided into groups 1 (those treated from January 1, 1991, through December 31, 1995) and 2 (those treated from January 1, 1996, through December 31, 2000).

MAIN OUTCOME MEASURES

Age, sex, preoperative evaluation, operative duration and findings, postoperative course, duration of hospital stay, and mortality rate. Continuous and categorical variables were analyzed using t and chi(2) tests, respectively.

RESULTS

Ninety-five patients met inclusionary criteria. The mean age (78 years), sex, preoperative suggestion of appendicitis (group 1, 39 [83%] of 47 patients; group 2, 45 [94%] of 48 patients), and duration of the preoperative hospitalization over 24 hours (group 1, 11 patients [23%]; group 2, 9 patients [19%]) were similar in both groups. There was an increasing use of diagnostic computed tomography (group 1, 13 patients [28%]; group 2, 32 patients [67%]; P<.001) and laparoscopy (group 1, 14 patients [30%]; group 2, 23 patients [48%]; P =.02) between the 2 study periods associated with no significant difference in the duration of hospitalization, frequency of appendiceal perforation or abscess, occurrence of complications, or mortality. The length of operating time increased in the second period (ie, January 1, 1996, through December 31, 2000).

CONCLUSIONS

Appendicitis in elderly patients continues to be a challenging surgical problem. While computed tomography may represent a useful diagnostic tool and laparoscopic appendectomy may be appropriate therapy for selected patients, neither has affected outcome when measured for morbidity and mortality rates. Overall results might improve with earlier consideration of the diagnosis in elderly patients with abdominal pain, followed by prompt surgical consultation and operation.

The impact of changing neonatal respiratory management on extracorporeal membrane oxygenation utilization

BACKGROUND

The introduction of inhaled nitric oxide (INO) and high-frequency oscillatory ventilation (HFV) has had a profound effect on the use of extracorporeal membrane oxygenation (ECMO) for respiratory failure in neonates without congenital diaphragmatic hernia (CDH). The purpose of this study was to evaluate the changes in the demographics and outcome of non-CDH neonates who underwent ECMO for hypoxemic respiratory failure.

METHODS

All neonates (non-CDH and noncardiac) who underwent ECMO between January 1, 1989 and January 1, 2001 were reviewed. Patients were separated into 3, 4-year periods for comparison (period A, 1989 through 1992; B, 1993 through 1996; C, 1997 through 2000). Data were examined by analysis of variance and contingency table analysis.

RESULTS

There was a progressive decline in the total number of neonates requiring ECMO over time (period A, 172; B, 114; C, 56; P <.01). The utilization of pre-ECMO alternate respiratory therapies such as INO (period A, 0%; B, 23%; C, 98%; P <.01) and HFV (period A, 9%; B, 61%; C, 89%; P <.01) have increased significantly associated with an increase in the age of ECMO initiation (Period A, 40.5 hours; B, 58.3 hours; C, 68.5 hours; P <.01). The length of ECMO run also has increased (period A, 154.7 hours; B, 193.0 hours; C, 174.5 hours; P <.01), but the overall mortality rate has remained unchanged.

CONCLUSIONS

With the increasing use of INO and HFO, the absolute number of non-CDH, noncardiac neonates with hypoxemic respiratory failure requiring ECMO has decreased. Initiation of ECMO has become progressively later likely because of the use of these rescue therapies, but the overall mortality rate remains unchanged despite this delay.

Immediate early genes and p21 regulation in liver of rats with acute hepatic failure

It has been observed that liver regeneration in acute hepatic failure (AHF) is suppressed [Eguchi et al. Hepatology 1996;24(6):1452-9]. The molecular mechanism regulating this inhibition is not known. We previously reported that in AHF rats, hepatocyte proliferation was significantly impaired with elevation in serum IL-6, TGF-beta1, and HGF [Kamohara et al. Biochem Biophys Res Commun 2000;273(1):129-35]. Following either 70% partial hepatectomy (PH) or liver injury, quiescent mature hepatocytes are "primed" to re-enter the cell cycle. The process of "priming" appears to be triggered by extracellular cytokines (IL-6 and TNF-alpha) and is characterized by expression of immediate early genes. Under the stimulation of growth factors such as HGF, "primed" hepatocytes exit the G1 phase of the cell cycle. G1-associated cyclins and their inhibitors play a pivotal role in G1/S cell cycle transition. Here, we demonstrate that immediate early gene (i.e. c-myc, c-fos) expression and AP-1 activity are preserved in AHF rat livers despite absence of hepatocyte proliferation. In contrast, p21 mRNA and protein are both over-expressed in AHF livers compared to livers from rats undergoing PH; this elevation leads to inhibition in Cdk2 activity, resulting in G1 cell cycle arrest and inhibition of regeneration.

Laparoscopic antireflux surgery and its effect on cough in patients with gastroesophageal reflux disease

In addition to heartburn and regurgitation, cough is a frequent nonspecific complaint of patients with gastroesophageal reflux disease. The incidence of alternative etiologies for patients with chronic cough who are undergoing antireflux surgery is not known. To determine this, and the response of chronic cough to fundoplication, we performed a retrospective review of 129 patients with proven gastroesophageal reflux referred for surgical therapy. Chronic cough was present in 37 (29%) preoperatively. No differences were found in age, sex, or preoperative manometric findings between those with and without chronic cough. Patients with cough had a higher number of lower esophageal reflux events on preoperative 24-hour pH testing, and were more likely to have persistent dysphagia after surgery. Fifty-nine percent of patients with cough had an alternative etiology for cough, compared to 36% of those without cough. Of the common alternative etiologies, only a history of postnasal drip occurred more frequently in those with cough. Complete resolution of cough occurred in 24 patients (64%), with another 10 (27%) reporting significant improvement. The average cough score improved significantly regardless of which coexisting etiology the patients may have had. Additionally, heartburn and regurgitation were improved in 94% of all patients.

Mesh crural repair of large paraesophageal hiatal hernias

Surgical repair is indicated in patients with paraesophageal hernias but is associated with a high recurrence rate. Our objective was to assess the safety and efficacy of mesh reinforcement of the crural closure in laparoscopic paraesophageal hernia repair. We conducted a 7-year retrospective review of all patients undergoing laparoscopic paraesophageal hernia repair with or without use of mesh. The main outcome measures were use of mesh, reason for use, age, sex, preoperative symptoms, length of operation, length of hospital stay, postoperative complications, and long-term follow-up conducted by physician interview. Twelve patients were repaired with mesh (Group A) and 12 without (Group B). Age, sex, operating time, length of hospital stay, and postoperative complications were similar in both groups. In Group A two patients required an interposition graft and ten required mesh reinforcement of the crural closure. One Group A patient developed an early recurrence requiring a reoperation, and one Group B patient developed a gastric leak where the fundus was sutured to the crura. The remainder of the patients experienced resolution of their symptoms at 2 weeks follow-up. Long-term follow-up (average 37 months) showed one Group B patient with a recurrence of reflux symptoms, but an upper gastrointestinal study showed no recurrence of hernia. All others remained asymptomatic. We conclude that the use of mesh in laparoscopic repair of large paraesophageal hernias appears safe and may reduce recurrence.

Safety of laparoscopic splenectomy in elderly patients with idiopathic thrombocytopenic purpura

Laparoscopic splenectomy (LS) for immune thrombocytopenic purpura (ITP) is very successful. However, the safety of LS in older patients who have less cardiac and pulmonary reserve has not been studied. Our objective was to compare results of LS in elderly and younger patients with ITP. LS performed for ITP between 1992 and 1999 were studied. Perioperative data were collected concurrently. Follow-up was obtained by chart review and phone interview. Groups were arbitrarily divided: Group A, age > or =70; group B, age <70. Main outcome measures were platelet response, duration of operation, hospitalization, blood loss, and complications were compared using t test and Chi-square analyses. Group A had more comorbid conditions (80% vs 28%, P = 0.04). Operative time (80 vs 119 minutes, P = 0.23), estimated blood loss (156 vs 189 cm3, P = 0.62), and hospitalization (3.6 vs 2.8 days, P = 0.23) were similar for both groups. Although group B had significantly more patients with an early platelet response (70% vs 97%, P = 0.02), there was no difference in platelet response at long-term follow-up (70% vs 84%, P = 0.22). Long-term follow-up was completed on 87 per cent of patients at an average of 43 months postoperatively. We conclude that LS is safe and effective in elderly patients with ITP.

Safety of Laparoscopic Splenectomy in Elderly Patients with Idiopathic Thrombocytopenic Purpura

Laparoscopic splenectomy (LS) for immune thrombocytopenic purpura (ITP) is very successful. However, the safety of LS in older patients who have less cardiac and pulmonary reserve has not been studied. Our objective was to compare results of LS in elderly and younger patients with ITP. LS performed for ITP between 1992 and 1999 were studied. Perioperative data were collected concurrently. Follow-up was obtained by chart review and phone interview. Groups were arbitrarily divided: Group A, age ≥70; group B, age <70. Main outcome measures were platelet response, duration of operation, hospitalization, blood loss, and complications were compared using t test and Chi-square analyses. Group A had more comorbid conditions (80% vs 28%, P = 0.04). Operative time (80 vs 119 minutes, P = 0.23), estimated blood loss (156 vs 189 cm3, P = 0.62), and hospitalization (3.6 vs 2.8 days, P = 0.23) were similar for both groups. Although group B had significantly more patients with an early platelet response (70% vs 97%, P = 0.02), there was no difference in platelet response at long-term follow-up (70% vs 84%, P = 0.22). Long-term follow-up was completed on 87 per cent of patients at an average of 43 months postoperatively. We conclude that LS is safe and effective in elderly patients with ITP.

Gastroesophageal disease and nausea: does fundoplication help or hurt?

HYPOTHESIS

Nausea associated with gastroesophageal reflux disease is cured by laparoscopic Nissen fundoplication (LNF).

DESIGN

Prospective cohort study of unselected patients who underwent LNF from January 1, 1995, through March 31, 1999. Patients were followed up by a physician for 6 to 36 months.

SETTING

A large community teaching hospital.

PATIENTS

One hundred consecutive patients with gastroesophageal reflux disease who underwent LNF; all patients were followed up. Patients were grouped according to the presence (group A, n = 33) or absence (group B, n = 67) of preoperative nausea. Interventions were LNF, esophageal manometry, 24-hour pH monitoring, and nuclear gastric emptying studies.

MAIN OUTCOME MEASURES

Resolution of symptoms after LNF.

RESULTS

Nausea was the most common atypical symptom of gastroesophageal reflux disease, occurring in 33 patients (33%). There were no differences in esophageal manometry or 24-hour pH results between groups. There was a female preponderance in group A (55% vs 33%; P = .003). Patients in group A had a higher prevalence of preoperative dysphagia (P = .02). Patients with persistent postoperative nausea had a higher prevalence of cough (P = .003) and dysphagia (P = .009). The LNF was more effective in reducing heartburn (95% reduction) and regurgitation (95% reduction) than cough and dysphagia (60% reduction). There was a 79% reduction in the number of patients with nausea (33 to 7; P<.001).

CONCLUSION

Laparoscopic Nissen fundoplication is effective in eliminating nausea associated with gastroesophageal reflux disease and is not contraindicated in these patients.

Iatrogenic gallbladder perforation during laparoscopic cholecystectomy: etiology and sequelae

Iatrogenic perforation of the gallbladder (PGB) during laparoscopic cholecystectomy (LC) leads to spillage of bile and gallstones into the peritoneal cavity, which can result in serious postoperative infection. The objective of this study is to prospectively evaluate with long-term follow-up the risk factors, mechanisms, and complications associated with PGB in patients undergoing LC. Data from 1412 patients undergoing LC were collected prospectively between 1989 and 1995. Patients with and without iatrogenic gallbladder perforation were compared. Long-term follow-up was obtained using mailed questionnaires and telephone interviews, when needed. Of the 1412 patients, 512 (36%) sustained a PGB. Male sex, weight, gallbladder inflammation, thickening of the gallbladder, presence of adhesions, and a difficult hilar dissection were all associated with an increased incidence of PGB. The most common mechanisms of PGB were laceration due to grasper traction (55%) and electrocautery dissection (40%). Both the operating time and length of hospital stay were significantly longer in the PGB group. No difference was observed in the rate of wound infections between PGB and non-PGB patients (1.6% versus 1.8%). Only one patient (with an inflamed and perforated gallbladder) developed an early postoperative intra-abdominal abscess. Long-term follow-up averaging 48 months was achieved with a response rate of 44 per cent. No late intra-abdominal abscesses or complications attributable to retained gallstones were discovered.

Iatrogenic Gallbladder Perforation during Laparoscopic Cholecystectomy: Etiology and Sequelae

Iatrogenic perforation of the gallbladder (PGB) during laparoscopic cholecystectomy (LC) leads to spillage of bile and gallstones into the peritoneal cavity, which can result in serious postoperative infection. The objective of this study is to prospectively evaluate with long-term follow-up the risk factors, mechanisms, and complications associated with PGB in patients undergoing LC. Data from 1412 patients undergoing LC were collected prospectively between 1989 and 1995. Patients with and without iatrogenic gallbladder perforation were compared. Long-term follow-up was obtained using mailed questionnaires and telephone interviews, when needed. Of the 1412 patients, 512 (36%) sustained a PGB. Male sex, weight, gallbladder inflammation, thickening of the gallbladder, presence of adhesions, and a difficult hilar dissection were all associated with an increased incidence of PGB. The most common mechanisms of PGB were laceration due to grasper traction (55%) and electrocautery dissection (40%). Both the operating time and length of hospital stay were significantly longer in the PGB group. No difference was observed in the rate of wound infections between PGB and non-PGB patients (1.6% versus 1.8%). Only one patient (with an inflamed and perforated gallbladder) developed an early postoperative intra-abdominal abscess. Long-term follow-up averaging 48 months was achieved with a response rate of 44 per cent. No late intra-abdominal abscesses or complications attributable to retained gallstones were discovered.