National trends in utilization and outcomes of antireflux surgery

Position paper on laparoscopic antireflux operations in infants and children for gastroesophageal reflux disease. American Pediatric Surgery Association

The use of the laparoscopic approach to perform antireflux procedures has increased dramatically since its introduction in 1991. To date, no prospective randomized studies comparing open surgery to the minimal invasive approach in children have been reported. Many retrospective reviews and case series have demonstrated that laparoscopic antireflux procedures are safe and effective once the learning curve is achieved. This position paper is coauthored by the New Technology Committee of the American Pediatric Surgery Association. The goal is to discuss the ongoing controversies and summarize the available evidence to identify the risks and benefits of laparoscopic antireflux procedures.

Gastro-oesophageal reflux disease in Asia : birth of a 'new' disease?

Gastro-oesophageal reflux disease (GORD) is one of the most common gastrointestinal diseases in the Western world and imposes a heavy burden on society. Although its prevalence in Asia is much lower, there is evidence that this is rapidly rising in Asia. The reported population prevalence of GORD in Eastern Asia ranges from 2.5% to 6.7% for at least weekly symptoms of heartburn and/or acid regurgitation. In general, Asians tend to have a milder spectrum of the disease. Most Asian patients have non-erosive GORD; erosive oesophagitis is less commonly seen than in the Western population. Complicated GORD, such as oesophageal stricture and Barrett's oesophagus, is seldom encountered. The mechanisms of GORD may be different in the Chinese population compared with the Western population. Chest pain is the most predominant extra-oesophageal manifestation of GORD in China, whereas an association with asthma has been shown in Japanese patients. The prevalence of GORD appears to be increasing and possible factors for GORD in Asian populations include Helicobacterpylori infection, obesity and increasing dietary fat intake. The adoption of a Western lifestyle in many developing Asian countries may account for the increasing prevalence of GORD. Proton pump inhibitors remain the most effective medical treatment for GORD. GORD will undoubtedly be a great challenge to clinicians both in primary care and in gastroenterology practice in the Asia-Pacific region in the coming years.

Diffusion of surgical innovation among patients with kidney cancer

BACKGROUND

Despite their potential benefits to patients with kidney cancer, the adoption of partial nephrectomy and laparoscopy has been gradual and asymmetric. To clarify whether this trend reflects differences in kidney cancer patients or differences in surgeon practice styles, the authors compared the magnitude of surgeon-attributable variance in the use of partial nephrectomy and laparoscopic radical nephrectomy with that attributable to patient and tumor characteristics.

METHODS

By using linked Surveillance, Epidemiology, and End Results-Medicare data, the authors identified a cohort of 5483 Medicare beneficiaries who underwent surgery for kidney cancer between 1997 and 2002. Two primary outcomes were defined: 1) the use of partial nephrectomy and (2) the use of laparoscopy among patients undergoing radical nephrectomy. By using multilevel models, surgeon- and patient-level contributions to observed variations in the use of partial nephrectomy and laparoscopic radical nephrectomy were estimated.

RESULTS

Of the 5483 cases identified, 611 (11.1%) underwent partial nephrectomy (43 performed laparoscopically), and 4872 (88.9%) underwent radical nephrectomy (515 performed laparoscopically). After adjusting for patient demographics, comorbidity, tumor size, and surgeon volume, the surgeon-attributable variance was 18.1% for partial nephrectomy and 37.4% for laparoscopy. For both outcomes, the percentage of total variance attributable to surgeon factors was consistently higher than that attributable to patient characteristics.

CONCLUSIONS

For many patients with kidney cancer, the surgery provided depends more on their surgeon's practice style than on the characteristics of the patient and his or her disease. Consequently, dismantling barriers to surgeon adoption of partial nephrectomy and laparoscopy is an important step toward improving the quality of care for patients with early-stage kidney cancer.

Review article: endoscopic antireflux procedures - an unfulfilled promise?

BACKGROUND

Most published reviews concerning the endoscopic treatment of gastro-oesophageal reflux disease date back to 2005.

AIM

To provide an updated review that includes all papers published up to 2007.

METHODS

A Medline search from January 2005 to June 2007 was performed regarding endoscopic procedures aiming at treating gastro-oesophageal reflux disease. In addition, we retrieved the abstracts presented at Digestive Disease Week during the last 3 years. We included in the review both 'mechanistic' studies - that is, papers exploring the potential mechanism of action of the procedure/device - and studies trying to assess its clinical efficacy.

RESULTS

During the last 3 years, the number of published papers has declined, and some devices are not available any more. The alleged mechanism(s) of action of the various devices or procedures is (are) still not completely elucidated; however, some concerns have arisen as far as durability and potential detrimental effects. Moreover, all the aspects of endoscopic therapy, except for its safety, are either insufficiently explored or not investigated at all, or assessed only in particularly selected patient subgroups.

CONCLUSIONS

None of the proposed antireflux therapies has fulfilled the criteria of efficacy, safety, cost, durability and, possibly, of reversibility. There is at present no definite indication for endoscopic therapy of gastro-oesophageal reflux disease. We suggest a list of recommendations to be followed when a new endoscopic therapeutic procedure is to be assessed for use in clinical practice.

Evaluation of endoscopic full-thickness plication on anti-reflux valve competency

BACKGROUND

We sought to investigate the efficacy of endoscopically created, full-thickness plications on the competency of the anti-reflux barrier when placed at different positions on the stomach adjacent to the gastroesophageal junction.

METHODS

Explanted human cadaver stomachs and esophagi were used. An endoscopic plication system (Plicator, NDO Surgical, Mansfield, Massachusetts) was then fitted over a pediatric gastroscope and passed through the esophagus into the stomach. A full-thickness plication implant was then deployed at 1 of 3 positions (fundus, anterior, and between the anterior and the lesser curvature) on the explanted stomach within 1 cm of the gastroesophageal junction. Intragastric pressure was measured before and after plication at the time of visible reflux from the esophagus (reflux threshold) using a water-perfused manometer.

RESULTS

Five explanted stomachs were used. The mean reflux threshold before plication (baseline) was 1.7 mm Hg. A single plication at each position resulted universally in a significantly increased reflux threshold over the baseline value (p < 0.006). The greatest reflux threshold was observed when plication was performed on the anterior wall of the stomach, although this reflux pressure did not achieve statistical significance over the other 2 positions. A second plication performed adjacent to the initial plication at the fundus (n = 2) and anterior (n = 2) positions did increase reflux threshold; however, this increase also failed to achieve statistical significance.

CONCLUSIONS

These results suggest that an endoscopic, full-thickness plication system can inhibit gastroesophageal reflux effectively in an explanted stomach model. Although anterior plication resulted in the greatest intragastric pressure at reflux, it was not significantly different from intragastric pressure recorded at the other plication positions. A second plication adjacent to the first showed incremental effect, but larger studies are warranted to understand its clinical significance.

Laparoscopic antireflux surgery: key to success in the community setting

Studies from large volume centers of excellence have proven the efficacy of laparoscopic antireflux surgery. However, the majority of these operations are performed in community hospitals, where the results are more variable. Major issues potentially affecting laparoscopic antireflux surgery in community hospitals include a) the individual skills and experience of the surgeons, b) the volume of operations per surgeon and hospital, and c) the sophistication of the esophageal motility labs evaluating these patients prior to surgery. Another evolving issue is the increasing number of fundoplication failures and where best to evaluate and treat these patients.

Nationwide trends in laparoscopic colectomy from 2000 to 2004

BACKGROUND

Over the past 5 years, several studies have demonstrated that laparoscopic colon resection is an acceptable and perhaps preferable alternative to open resection for both benign diseases and cancer. The extent to which laparoscopic colon resections are used nationally is not known.

METHODS

The Nationwide Inpatient Sample was used to identify laparoscopic and open elective colon resections performed in the United States each year from 2000 through 2004. The trends in adoption of the laparoscopic technique for each type of colon resection and for the most common diagnoses were identified, and differences in patient and provider characteristics were examined.

RESULTS

From 2000 to 2004, the proportion of colon resections performed laparoscopically increased from 3% to 6.5%. The proportion performed for cancer increased from 1.4% to 4.3%, and for benign disease from 4.6% to 8.2%. Patients treated laparoscopically tended to be younger (median age, 61 years vs 66 years; p < 0.001) and to have fewer comorbidities (Charlson score of zero for 58.1% vs 37%; p < 0.001). Laparoscopic colon resections were more widely adopted in teaching versus nonteaching hospitals (5.1% vs 3.7%; p < 0.001) and in urban versus rural hospitals (4.7% vs 2.2%; p < 0.001).

CONCLUSION

Although the proportion of colon resections performed laparoscopically increased in the first half of this decade, it has remained very low. This trend is similar across procedure types and diagnoses. It remains to be seen whether greater patient demand and more recent trials will result in wider adoption of the laparoscopic approach.

Differential adoption of laparoscopy by treatment indication

PURPOSE

The diffusion of laparoscopic renal surgery has been gradual. While surgery for benign and malignant kidney disease is usually within the urological domain, donor nephrectomy is multidisciplinary. Therefore, we compared the use of laparoscopy by procedure indication (kidney donor, and benign and malignant kidney disease) to examine potential specialty specific associations with the slow uptake of this technology.

MATERIALS AND METHODS

Data on 53,461 patients undergoing nephrectomy for all indications between 1998 and 2003 were abstracted from the Nationwide Inpatient Sample using International Classification of Diseases, 9th Revision, Clinical Modification procedure and diagnostic codes. Generalized estimating equations were fitted to measure the association between laparoscopy use and the procedure indication (kidney donor, benign kidney disease and kidney cancer).

RESULTS

The use of laparoscopy varied by treatment indication. In 2003, 33% of kidney donors underwent a laparoscopic approach compared to 22% and 16% of patients with benign and malignant kidney disease, respectively (p <0.0001). After adjusting for patient and hospital differences patients with benign (adjusted OR 0.71, 95% CI 0.58-0.94) and malignant (adjusted OR 0.51, 95% CI 0.35-0.74) kidney disease were significantly less likely to undergo laparoscopic nephrectomy than kidney donors.

CONCLUSIONS

These data highlight that the use of laparoscopic renal surgery varies by procedure indication with slower adoption of laparoscopy for malignant or benign indications than for donor nephrectomy. This variation was not readily explained by differences in measurable patient and hospital factors. Further characterization of provider and nonclinical characteristics may provide additional insight into differences in the adoption of this technology, which appears to be a specialty specific phenomenon.

Minimally-invasive pediatric surgery in 2004: a survey including 50 German institutions

BACKGROUND

A survey on the practice of laparoscopic and thoracoscopic surgery in pediatric surgical departments in Germany is presented.

MATERIALS AND METHODS

A questionnaire was sent to all 71 pediatric surgical departments in Germany (population 82 million). Fifty institutions (70%) took part in the survey that mainly included data for the year 2004: spectrum of minimally invasive operations, quantity of procedures, conversions, major complications, number of performing surgeons and residents.

RESULTS

Laparoscopic techniques were used in 48 departments (96%) and thoracoscopic techniques in 37 (74%). The annual frequency of laparoscopies was less than 100 in 30 departments (62%) and more than 100 in 15 (31%). The number of thoracoscopies was less than 50 in 35 departments (73%) and more than 50 in 2 (4%). Appendectomy was offered in 45 (90%), varicocelectomy in 32 (64%), and Fowler-Stephens operation in 33 (66%). Twenty-one departments (42%) covered more advanced procedures such as laparoscopically assisted pull-through for Hirschsprung disease. Most demanding procedures such as laparoscopic choledochal cyst resection, duodeno-duodenostomy, heminephrectomy, or pyeloplasty were offered by 10 departments (20%). Minimally invasive surgery was performed by 1 surgeon (12%) in 6 institutions and by more than 5 surgeons (14%) in 7 institutions.

CONCLUSION

Minimally invasive techniques are increasingly accepted in most German pediatric surgical institutions for a wide range of indications. However, the number of departments offering major minimally invasive procedures remains limited.

Ten-Year Follow up after Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux Disease

Laparoscopic Nissen fundoplication was first undertaken in the early 1990s. Appreciable numbers of patients with 10-year follow up are only now available. This study assesses long-term outcome and durability of outcome after laparoscopic Nissen fundoplication for treatment of gastro-esophageal reflux disease. Since 1991, 829 patients have undergone laparoscopic fundoplications and are prospectively followed. Two hundred thirty-nine patients, 44 per cent male, with a median age of 53 years (± 15 standard deviation) underwent laparoscopic Nissen fundoplications at least 10 years ago; 28 (12%) patients were “redo” fundoplications. Before and after fundoplication, among many symptoms, patients scored the frequency and severity of dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Symptom scores before versus after fundoplication were compared using a Wilcoxon matched-pairs test. Data are reported as median, mean ± standard deviation, when appropriate. After fundoplication, length of stay was 2 days, 3 days ± 4.8. Intra-operative inadvertent events were uncommon and without sequela: 1 esophagotomy, 1 gastrotomy, 3 cardiac dysrhythmias, and 3 CO2 pneumothoraces. Complications after fundoplication included: 1 postpneumonic empyema, 3 urinary retentions, 2 superficial wound infections, 1 urinary tract infection, 1 ileus, and 1 intraabdominal abscess. There were two perioperative deaths; 88 per cent of the patients are still alive. After laparoscopic Nissen fundoplication, frequency and severity scores dramatically improved for all symptoms queried (P < 0.001), especially for heartburn frequency (8, 8 ± 3.2 versus 2, 3 ± 2.8, P < 0.001) and severity (10, 8 ± 2.9 versus 1, 2 ± 2.5, P < 0.001). Eighty per cent of patients rate their symptoms as almost completely resolved or greatly improved, and 85 per cent note they would again have the laparoscopic fundoplication as a result of analysis of our initial experience, thereby promoting superior outcomes in the future. Nonetheless, follow up at 10 years and beyond of our initial experience documents that laparoscopic fundoplication durably provides high patient satisfaction resulting from long-term amelioration of the frequency and severity of symptoms of gastroesophageal reflux disease. These results promote further application of laparoscopic Nissen fundoplication.

Robotic foregut surgery

BACKGROUND

Computer-assisted surgical systems, or surgical robots as they are more commonly called, are complex new devices which may be used to perform minimally invasive surgical procedures. There are certain technical limitations to a traditional laparoscopic approach that these devices can help a surgeon to overcome. Several surgical teams have applied these new devices to surgical procedures of the upper gastrointestinal tract and foregut.

METHODS

A retrospective review of the currently published literature on robotic foregut surgery.

RESULTS

Robotic foregut surgery appears to be feasible and safe. These procedures may be associated with increased operative time and cost when compared to their traditional laparoscopic counterparts. Procedures that require complex manoeuvres, delicate dissection, or a magnified high-definition image may be best suited to a computer-assisted approach.

CONCLUSIONS

Robotic foregut surgery is an exciting new field with tremendous potential for growth and dissemination.

The durability of laparoscopic Nissen fundoplication: 11-year outcomes

Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireflux procedure since its introduction in 1991. There are few studies with greater than 5-year outcomes. Herein we report a series of 312 consecutive patients who underwent primary LNF before 1996. Follow-up of more than 6 years was available in 166 patients, and the mean follow-up was 11 years (median 11.1 years, range 6.1-13.3 years). Prospective data collection included preoperative and current symptom scores (scale 0 = none to 3 = severe), as well as the level of patient satisfaction and use of antireflux medications. Total symptom score for each patient was summed from seven symptoms for a maximum value of 21. Heartburn and regurgitation were the most improved symptoms; however, all symptoms were significantly improved (P < 0.01). The total symptom score at follow-up was 2.6 down from 7.5 at baseline, with a mean difference of -4.9 (range -12 to 3). The percentage of patients stating they would have the procedure again was 93.3%, and 70% were off daily antireflux medications. Outcomes at a mean of 11 years after LNF are excellent, and the majority of patients had their symptoms resolved or significantly improved and are satisfied with their results.

Late gastric perforations after laparoscopic fundoplication

BACKGROUND

Late complications are rarely encountered after laparoscopic Nissen fundoplication. These complications include acute gastric herniation through the esophageal hiatus, port-site herniation, recurrent reflux, and anatomic failure of the fundoplication. Only three cases of late gastric perforation after laparoscopic Nissen fundoplication have been reported, all associated with intrathoracic wrap herniation.

METHODS

We retrospectively reviewed all cases of gastric perforation after laparoscopic antireflux procedures performed between July 1991 and March 2002 by a single surgeon.

RESULTS

In this series of 1,600 laparoscopic antireflux procedures, we found six delayed gastric fundal perforations occurring in three patients at 1, 41, 48, 51, 68, and 72 months after surgery. All the perforations were on the anterior wall of the fundus of the stomach and were distant from the stitches of the fundoplication. None of the perforations was associated with severe peritoneal contamination.

CONCLUSIONS

This series of late gastric fundal perforations in 0.2% of our patients after laparoscopic fundoplication may have been caused by medications, gastric stasis, ischemia, or a foreign body such as a stitch or Teflon pledget.

Endoscopic ultrasound for the evaluation of Nissen fundoplication integrity: a blinded comparison with conventional testing

BACKGROUND

For patients whose symptoms develop after Nissen fundoplication, the precise mechanism of anatomic failure can be difficult to determine. The authors have previously reported the endosonographic hallmarks defining an intact Nissen fundoplication in swine and the known causes of failure. The current clinical trial tested the hypothesis that a defined set of endosonographic criteria can be applied to determine fundoplication integrity in humans.

METHODS

The study enrolled seven symptomatic and nine asymptomatic subjects at a mean of 6 years (range, 1-30 years) after Nissen fundoplication. A validated gastroesophageal reflux disease (GERD)-specific questionnaire and medication history were completed. Before endoscopic ultrasound (EUS), all the patients underwent complete conventional testing (upper endoscopy, esophagram, manometry, 24-h pH). A diagnosis was rendered on the basis of combined test results. Then EUS was performed by an observer blinded to symptoms, medication use, and conventional testing diagnoses. Because EUS and esophagogastroduodenoscopy (EGD) are uniformly performed in combination, the EUS diagnosis was rendered on the basis of previously established criteria combined with the EGD interpretation. The diagnoses then were compared to examine the contribution of EUS in this setting.

RESULTS

The technique and defined criteria were easily applied to all subjects. All symptomatic patients had heartburn and were taking proton pump inhibitors (PPI). No asymptomatic patients were taking PPI. All diagnoses established with combined conventional testing were detected on EUS with upper endoscopy. Additionally, EUS resolved the etiology of a low lower esophageal sphincter pressure in two symptomatic patients and detected the additional diagnoses of slippage in two subjects. Among asymptomatic subjects, EUS identified additional diagnoses in two subjects considered to be normal by conventional testing methods.

CONCLUSION

According to the findings, EUS is a feasible method for evaluating post-Nissen fundoplication hiatal anatomic relationships. The combination of EUS and EGD allows the mechanism of failure to be detected in patients presenting with postoperative symptoms after Nissen fundoplication.

Radiofrequency energy delivery to the lower esophageal sphincter (Stretta procedure) in patients with recurrent reflux after antireflux surgery: can surgery be avoided?

BACKGROUND

Recurrent reflux following antireflux surgery (ARS) can be difficult to manage, especially in patients who also fail medical management. In these patients, redo ARS remains the only treatment option. Endoscopic radiofrequency energy delivery to the lower esophageal sphincter (the Stretta procedure; Stretta, Curon, Sunnyvale, CA) has been shown to significantly decreased symptom scores and improve quality of life in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the use of the Stretta procedure in treating patients with recurrent reflux after fundoplication.

METHODS

Between March 2002 and December 2003, eight patients with recurrent reflux following ARS underwent the Stretta procedure. All patients were asked to complete an institutional symptom survey pre-Stretta and at 1, 6, and 12 months after the procedure. Patients rated 7 reflux-related symptoms (heartburn, dysphagia, regurgitation, cough, voice changes/hoarseness, asthma, chest pain) on a 0 (none) to 3 (severe) scale. Data were analyzed using a Wilcoxon matched pairs signed rank test where appropriate.

RESULTS

Complete data were obtained for seven of the eight patients, with a median follow-up of 253 days (range, 67-378 days). One patient was lost to follow-up and not included in our analysis. Symptom scores decreased significantly, with six patients noting both improved typical and atypical symptoms. Overall, six patients (85%) were satisfied with their results.

CONCLUSIONS

Based on this small series, the Stretta procedure significantly reduces subjective symptoms of GERD. The Stretta procedure may serve an important role as an additional management strategy to help manage recurrent GERD after ARS.

Accuracy of administrative health data for the diagnosis of upper gastrointestinal diseases

BACKGROUND

The use of administrative health data is increasingly common for the study of various medical and surgical diseases. The validity of diagnosis codes for the study of benign upper gastrointestinal disorders has not been well studied.

METHODS

The authors abstracted the charts for 590 adult patients who underwent upper gastrointestinal endoscopy between January 1, 2000 and June 30, 2001 in Toronto, Ontario, Canada. Clinical diagnoses from medical records were compared with International Classification of Diseases Version 9 (ICD-9) codes in electronic hospital discharge abstracts. The primary analysis aimed to determine the sensitivity, specificity, and positive predictive value (PPV) of a most responsible "esophagitis" diagnosis code for the prediction of esophagitis. Secondary analyses determined the performance characteristics of the diagnostic codes for esophageal ulcer, esophageal stricture, gastroesophageal reflux disease (GERD), gastritis, gastric ulcer, and duodenal ulcer.

RESULTS

The authors linked 500 patient records to electronic discharge abstracts. When listed as the most responsible diagnosis for admission, the ICD-9 codes for esophagitis showed a sensitivity of 46.79%, a specificity of 98.83%, and a PPV of 94.81%. When listed as a secondary diagnosis, the ICD-9 codes showed a sensitivity of 70.51%, a specificity of 97.67%, and a PPV of 93.22%. The diagnostic properties of ICD-9 codes for GERD (most responsible, secondary) were as follows: sensitivity (56.10%, 78.66%), specificity (98.51%, 96.73%), and PPV (94.84%, 92.14%).

CONCLUSIONS

The ICD-9 diagnosis codes for benign upper gastrointestinal diseases are highly specific and associated with strong PPVs, but have poor sensitivity.

Gastroesophageal reflux disease as a cause of death is increasing: analysis of fatal cases after medical and surgical treatment

OBJECTIVES

The population impact of modern treatment on complicated gastroesophageal reflux disease (GERD) is not well understood. Our aim was to determine the current mortality from GERD in Finland and compare this with the use of health resources.

METHODS

In this population-based retrospective study, Finland's administrative databases provided figures on the nationwide use of antireflux medication, rate of antireflux surgery, and mortality from GERD. Any deceased person included had classic symptoms as well as objective findings of GERD.

RESULTS

After analysis of the medical records of 306 patients, 213 were included. Annual mortality from GERD increased (P < 0.001) from 0.18/100,000 in 1987 to 0.46/100,000 in 2000. During that time, use of H2-blockers and proton pump inhibitors and the annual rate of antireflux surgery increased significantly (P < 0.001). Mortality from antireflux surgery, including fundoplication and gastric and esophageal resection, remained around 1.9/1,000 operations. Of the 213 patients whose cause of death was considered to be GERD, 180 (85%) had received medical treatment, including 4 patients whose death was related to either diagnostic or therapeutic endoscopy. Early complications of antireflux surgery caused 24 (11%) deaths; 9 (4%) were late failures of antireflux surgery. Causes of death in the medical group were hemorrhagic esophagitis (82, 47%), aspiration pneumonia (41, 23%), ulcer perforation (25, 14%), rupture with esophagitis (15, 9%), and stricture (13, 7%).

CONCLUSIONS

Regardless of the increased use of health resources, mortality from GERD, especially with medical treatment, rose. Surgery for GERD was also associated with early mortality and usually could not prevent the fatal outcome.

National trends in the use of antireflux procedures for children

OBJECTIVE

The purpose of this study was to analyze recent nationwide trends in the use of and outcomes after antireflux surgery for children.

METHODS

We conducted a retrospective cohort study of children (age: <18 years) undergoing antireflux surgery by using data from 1996 to 2003 from the Nationwide Inpatient Sample. Census data were used to calculate the population-based rates of procedures stratified according to age and presence of neurologic impairment. Multivariate analyses were performed to determine factors associated with length of stay and in-hospital death.

RESULTS

During the study period, 48,665 antireflux procedures were performed for children in the US. Although procedure rates were generally higher in 2003 than in 1996, no trends in rates were observed among different age groups and census regions during the study period. The highest population-based procedure rates were observed among infants (49-101 procedures per 100,000 population). There was a significant decrease in the percentages of children undergoing antireflux procedures who were neurologically impaired between 1996 and 2003 (53% vs 40%). Neurologically impaired children had longer lengths of stay and higher mortality rates than did neurologically normal children.

CONCLUSIONS

Although procedure rates have not changed, the use of antireflux surgery has evolved during the laparoscopic era, with a decreasing percentage of neurologically impaired children undergoing this procedure. Antireflux procedures were performed predominantly for infants, most of whom were neurologically normal. Neurologically impaired children remain a group at high risk for death after antireflux procedures.

The rise and fall of antireflux surgery in the United States

BACKGROUND

National rates of laparoscopic antireflux surgery grew steadily in the 1990s. Since then, a highly visible randomized trial has questioned the long-term effectiveness of antireflux surgery, several new endoscopic therapies have been developed, and proton pump inhibitors have become available over the counter. Whether these recent developments have had an impact on the use of antireflux surgery remains unknown.

METHODS

Using data from the Nationwide Inpatient Sample, this study identified all patients older than 18 years who underwent antireflux surgery between 1994 and 2003. Sampling weights were used to estimate the total number of procedures performed in the United States each year. Population-based rates were determined using denominators from U.S. census data.

RESULTS

Confirming the results of earlier studies, this study found that the annual number of antireflux procedures grew rapidly during the 1990s, peaking at 31,695 (15.7 cases per 100,000 adults) in 1999. After 1999, surgical rates declined steadily, falling approximately 30% by 2003 to 23,998 (11 cases per 100,000; p < 0.0001). Use of antireflux procedures fell more precipitously among younger patients (39% for 30- to 49-year-olds vs 12.5% for those older than 60 years; p < 0.0001) and at teaching hospitals (36% vs 23% at nonteaching hospitals; p < 0.0001). The proportion of cases managed laparoscopically remained stable after 1999.

CONCLUSIONS

The use of antireflux surgery in the United States has declined substantially. Although other factors may be involved, this trend may reflect new questions about the long-term effectiveness of surgery and suggests the need for prospective randomized clinical trials assessing current therapies.

Laparoscopy for Renal Cell Carcinoma: Diffusion Versus Regionalization?

PURPOSE

Recognizing the emergence of laparoscopy as a standard of care for surgical treatment in many patients with organ confined renal cell carcinoma, we explored the diffusion of this technology by examining temporal trends in the nationwide use of laparoscopic total and partial nephrectomy in patients with renal cell carcinoma.

MATERIALS AND METHODS

Data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample were abstracted for 1991 through 2003. International Classification of Diseases-Ninth Revision, Clinical Modification 9 codes were used to identify patients undergoing open and laparoscopic total and partial nephrectomy for renal cell carcinoma. Using hospital sampling weights we calculated annual incidence rates for open and laparoscopic nephrectomy, thereby estimating the diffusion of laparoscopy. Bivariate and multivariate analyses were used to identify patient and hospital characteristics associated with the more frequent use of laparoscopic techniques.

RESULTS

Data on 63,812 patients were abstracted from the Nationwide Inpatient Sample, yielding a weighted national estimate of 323,979 who underwent laparoscopic (4.9%) or open (95.1%) nephrectomy (total or partial) for renal cell carcinoma between 1991 and 2003. Although it is still infrequent, the use of laparoscopy has increased steadily since 1998 with a utilization peak in 2003 of 1.7 laparoscopic nephrectomies per 100,000 American population, representing 16% of all total and partial nephrectomies for renal cell carcinoma in 2003. Treatment year, overall hospital nephrectomy volume and teaching hospital status were the most robust determinants of increased laparoscopic use (each p <0.001).

CONCLUSIONS

Although its use has increased progressively in the last decade, the dissemination of laparoscopy for renal cell carcinoma has been generally slow and limited in scope. The next step in this body of work is to identify specific technical, educational and policy interventions that will influence the diffusion of this alternative standard of care.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease refers to reflux of gastric contents into the oesophagus leading to oesophagitis, reflux symptoms sufficient to impair quality of life, or long-term complications. Transient relaxation of the lower oesophageal sphincter is believed to be the primary mechanism of the disease although the underlying cause remains uncertain. Obesity and smoking are weakly associated with the disease and genetic factors might be important. A negative association with Helicobacter pylori exists, but eradication of H pylori does not seem to cause reflux disease. Diagnosis is imprecise as there is no gold standard. Reflux symptoms are helpful in diagnosis but they lack sensitivity. Ambulatory oesophageal pH monitoring also seems to be insensitive despite high specificity. Empirical acid suppression with a proton-pump inhibitor (PPI) has reasonable sensitivity but poor specificity. Some evidence suggests that once patients develop the disease, severity is determined early and patients seem to continue with that phenotype long term. Unfortunately, most patients do not respond to life-style advice and require further therapy. H2 receptor antagonists and PPIs are better than placebo in oesophagitis, with a number needed to treat of five and two, respectively. In non-erosive reflux disease, acid suppression is better than placebo but the response rate is lower. Most patients need long-term treatment because the disease usually relapses. The role of endoscopic therapy is uncertain. Anti-reflux surgery is probably as effective as PPI therapy although there is a low operative mortality and morbidity.

NIS vs SAGES: a comparison of national and voluntary databases

BACKGROUND

Surgical outcomes are increasingly examined in an effort to improve quality and reduce medical error. The Nationwide Inpatient Sample (NIS) is a retrospective, claims-derived and population-based database and the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Outcomes Project is a prospective, voluntary and specialty surgeon database. We hypothesized that these two sources of outcome data would differ in regard to a single, commonly performed procedure.

METHODS

Both the NIS, a national sample of all nonfederal hospital discharges, and the gastroesophageal reflux disease log of the SAGES Outcomes Project were queried for all fundoplications performed between 1999 and 2001 using either ICD-9 procedure code 44.66 or CPT codes 43280 or 43324. Patients with an emergency admission, age <17 years, and/or diagnoses for either esophageal cancer or achalasia were excluded. Both demographic and outcome variables were compared by either t-test or chi-square analysis, with a p value of <0.05 as significant.

RESULTS

Both data sets were comparable for age and gender; however, the SAGES group had a higher rate of teaching hospital affiliation (71 vs 48%, p < 0.001). SAGES fundoplications had a consistently higher rate of comorbidities, including Barrett's esophagus (2.3 vs 1.1%, p = 0.005). The NIS fundoplications had a clear trend toward more associated procedures, including cholecystectomy (7.2 vs 2%, p < 0.001). Complication rates for the NIS data set were higher, including pulmonary complications (1.7 vs 0.5%, p = 0.03). No statistically significant differences existed between the two data sets for either length of stay or mortality.

CONCLUSIONS

The two databases indicate that fundoplication is an operation with low morbidity and mortality. The SAGES Outcomes Project demonstrated that participating surgeons had a higher affiliation with teaching hospitals, higher reporting of comorbidity, and lower associated procedures than the NIS. Despite having more comorbidity and technical difficulty, patients from the SAGES Outcomes Project had equivalent or lower complication rates.

Laparoscopic skills laboratories: current assessment and a call for resident training standards

BACKGROUND

Numerous protocols for laparoscopic skills training using simulator-based laboratories have proven effective. However, little is known about the availability and uniformity of such facilities. The purpose of this study was to evaluate the prevalence, utilization, and costs of skills laboratories currently in use.

METHODS

A survey was mailed to 253 general surgery program directors to determine the perceived value, prevalence, equipment, types of training, supervision, and costs of the labs.

RESULTS

One hundred sixty-two (64%) programs completed the survey. Eighty-eight percent of responders consider skills labs effective in improving operating room performance; however, only 55% have skills labs. Of 89 programs with skills labs, 99% have videotrainer equipment (mean 3.8 trainers per lab, range 1 to 15); 46% have virtual reality trainer equipment (mean 1.7 trainers per lab, range 1 to 7). Eighty-two percent of programs teach basic skills using a variety of tasks (Rosser/Southwestern stations, MIST-VR, MISTELS, department-created); 96% teach suturing (intracorporeal, extracorporeal, suture devices). On average, residents train 0.8 hours per week (range 0 to 6). Training is mandatory in 55% and supervised in 73% of the programs. The mean development cost was 133,000 dollars (range 300 dollars to 1,000,000 dollars).

CONCLUSIONS

While a large majority of program directors consider skills labs important, 45% of programs have no such facilities. Moreover, significant variability of equipment and training practices exist in currently available labs. Strategies are needed for more widespread implementation of skills labs, and standards should be developed to facilitate uniform adoption of validated curricula that reliably maximize training efficiency and educational benefit.

Complications and antireflux medication use after antireflux surgery

BACKGROUND & AIMS

Although antireflux surgery is increasingly common, few studies have assessed the associated complications and health care use after surgery. The aim of this study was to estimate postoperative complications and continued use of antireflux medications and to identify predictors of complications.

METHODS

Through a review of the Department of Veterans Affairs administrative databases, all patients undergoing antireflux surgery from October 1, 1990, through January 29, 2001, were identified. Of 3367 patients identified, 222 were excluded as a result of a diagnosis of esophageal cancer, achalasia, or because there was no diagnosis related to gastroesophageal reflux disease. Medication use was determined for 2406 patients who had a minimum of 1 year of follow-up, including 1 or more outpatient visits at least 6 months after surgery and during the time when national pharmacy records were available.

RESULTS

Dysphagia was recorded in 19.4%, dilation was performed in 6.4%, and a repeat antireflux surgery was performed in 2.3%. The surgical mortality rate was .8%. Prescriptions were dispensed repeatedly for H2 receptor antagonists in 23.8%, proton pump inhibitors in 34.3%, and promotility agents in 9.2% of patients. Overall, 49.8% of patients received at least 3 prescriptions for one of these medications.

CONCLUSIONS

A moderate proportion of patients undergoing antireflux surgeries experienced complications and approximately 50% of patients received multiple prescriptions for antireflux medications at a median of 5 years of follow-up evaluation. Therefore, before surgery is performed, patients considering surgery should be counseled fully about the risk for complications and the likelihood of continued antireflux medication use.

Wireless esophageal pH monitoring: new technique means new questions

INTRODUCTION

The introduction of wireless pH monitoring has been touted as a significant advance in the diagnosis of gastroesophageal reflux and associated disorders. We prospectively enrolled patients in a research registry to assess the feasibility and safety in clinical use.

METHODS

All patients undergoing endoscopy with wireless pH studies (Medtronic Bravo pH system) for a 12-month period starting in April 2004 were prospectively enrolled. Probes were placed 6 cm above the endoscopically localized squamocolumnar junction. Successful completion was defined as at least 24 hours of pH recording. Safety data were obtained by review of patient diaries. All results are given as median with 25% to 75% confidence interval (CI).

RESULTS

A total of 217 studies with endoscopy and capsule placement were performed (65% women; median age, 51 years; range, 42-58 years) and included in the study; 1 patient refused participation in the registry and 5 studies were performed without preceding endoscopy and were excluded from this analysis. The pH study was successfully completed in 95.1%; early capsule detachment (1 hours; CI, 0-5 hours) or receiver malfunction occurred in 7 and 2 cases, respectively. There were no immediate adverse effects; 18 patients (9%) complained about significant chest discomfort, associated with odyno- or dysphagia, requiring removal of the capsule in 3 patients (1.5%). Of the completed studies, 56% were abnormal with 32.2% being abnormal on both days, whereas 16.1% and 6.9% only showed increased acid exposure on day 1 or 2, respectively. The higher likelihood of abnormal results for day 1 was associated with a significantly increased esophageal acid exposure during the first 6 hours after capsule insertion on day 1 (total time with pH < 4: 6.9%; CI, 3.2%-16.5%) compared with the corresponding time on day 2 (5.0%; CI, 0.9%-10.8%; P < 0.01), without differences esophageal acidification during the remaining time or differences in recorded activity.

CONCLUSIONS

Using a large registry of patients with suspected gastroesophageal reflux symptoms, our data show that wireless pH studies can be safely completed in more than 90% of patients. Whereas variability during prolonged recordings should be expected, the significantly higher likelihood of abnormal findings during the initial period of pH monitoring suggests a systematic influence of endoscopy and associated premedication, typically performed prior to capsule insertion, which needs to be considered when pH data are analyzed.

EUS characteristics of Nissen fundoplication: normal appearance and mechanisms of failure

BACKGROUND

In patients who develop symptoms after Nissen fundoplication, the precise mechanism of failure can be difficult to determine. Current testing modalities do not demonstrate sufficient anatomic detail to definitively determine the mechanism. This observational study establishes that EUS can determine fundoplication integrity and hiatal anatomic relationships after Nissen fundoplication.

METHODS

EUS was performed on the native esophagogastric junction and after Nissen fundoplication in two swine. The EUS characteristics of a properly performed fundoplication were determined. Subsequently, complications of Nissen fundoplication were created, and EUS was performed on each. The EUS criteria of each mechanism of failure were defined.

RESULTS

EUS provided sufficient axial resolution to distinguish the esophagus, the fundoplication, and the surrounding hiatal structures within a single image. US of the native esophagogastric junction discerned the length of intra-abdominal esophagus, esophagogastric junction, crura, and anterior hiatus, and, thus, the point of entry into the abdominal cavity. EUS of Nissen fundoplication revealed a 5-layered pattern in a 360 degree configuration. These layers represent the following: (1) the esophageal wall, (2) the space between the esophagus and the fundoplication, (3) the inner gastric wall of the fundoplication, (4) the gastric lumen, and (5) the outer gastric wall of the fundoplication. A slipped repair was identified by the presence of an echogenic gastric serosa within the fundoplication. A tight fundoplication results in attenuation of the gastric walls, thickening of the esophageal wall, and loss of the 5-layer pattern secondary to obliteration of the potential spaces of the gastric lumen. Dehiscence of the fundoplication was evidenced by a less than 360 degree 5-layer pattern.

CONCLUSIONS

EUS of hiatal anatomic relationships is feasible and provides detailed information regarding the integrity and the position of a Nissen fundoplication. EUS may enable a precise determination of the anatomic causes of failure after antireflux surgery.

Bladder exstrophy in the newborn: A snapshot of contemporary practice patterns

OBJECTIVES

To use a large nationwide database to investigate and describe practice patterns in the contemporary management of bladder exstrophy.

METHODS

The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (1988 to 2000) was queried to identify infants with bladder exstrophy hospitalized during the first week after birth. Admission and disposition patterns, resource utilization and length of stay, surgical repair trends, and factors associated with in-hospital death were analyzed.

RESULTS

We identified 426 hospital admissions of newborns with exstrophy. Most patients (75%) were transferred in from, or out to, other facilities; this was a fundamental feature of early exstrophy care. Racial differences were evident, with Hispanics less likely to be transferred (19% versus 60%, P = 0.001). Among newborns who were not transferred, many (46%) were discharged without bladder surgery. Surgical repair was usually done in a hospital other than the birth hospital; the mean hospital charges for surgery were 75,742 dollars. Of the 5 patients who died after repair, all had undergone surgery at "low-volume" hospitals. The length of stay did not change significantly during the study period, helping to keep resource utilization high in this population.

CONCLUSIONS

The results of this study provide a "snapshot" of bladder exstrophy practice patterns during the newborn period between 1988 and 2000. Additional research should investigate whether newborns with exstrophy are receiving optimal care, including appropriate timing of surgery, equitable transfers to tertiary centers, and reconstruction at centers with adequate volume and experience.

Decision Making in Medicine and Health Care

Decision making is central to health policy and medical practice. Because health outcomes are probabilistic, most decisions are made under conditions of uncertainty. This review considers two classes of decisions in health care: decisions made by providers on behalf of patients, and shared decisions between patients and providers. Considerable evidence suggests wide regional variation exists in services received by patients. Evidence-based guidelines that incorporate quality of life and patient preferences may help address this problem. Systematic cost-effectiveness analysis can be used to improve resource allocation decisions. Shared medical decision making seeks to engage patients and providers in a collaborative process to choose clinical options that reflect patient preferences. Although some evidence indicates patients want an active role in making decisions, other evidence suggests that some patients prefer a passive role. Decision aids hold promise for improving individual decisions, but there are still few systematic evaluations of these aids. Several directions for future research are offered.

Failed fundoplications

BACKGROUND

Five percent of patients who undergo fundoplication will require reoperation. The cause of this high failure rate and the best management for these patients remains poorly understood. The aim of this study was to identify patterns and causes of failure of primary antireflux procedures.

METHODS

Retrospective review of the medical records of patients who underwent revisional antireflux surgery at 2 tertiary referral centers.

RESULTS

Between 1998 and 2003, 39 patients underwent laparoscopic revisional antireflux surgery. The time between primary and revisional surgery was 5.9 +/- 0.4 years. Primary operations included 26 laparoscopic and 13 open fundoplications. All of the 39 revisional operations were attempted laparoscopically, and there was 1 open conversion. Revisional procedures included 31 Nissen and 8 partial fundoplications. The duration of surgery was 138 +/- 10 minutes. Length of hospital stay was 2.1 +/- 0.3 days. At a mean follow-up of 6 months, reflux resolved in 94% of patients. Morbidity occurred in 23% of patients. Four types of failure were identified: type 1 = herniation of the gastroesophageal junction through the hiatus with or without the wrap (n = 21); type 2 = paraesophageal hernia (n = 9); type 3 = malformation of the wrap (n = 2). Six patients had primary wrap failure, and 1 had esophageal dysmotility.

CONCLUSIONS

Laparoscopic revisional antireflux surgery is effective treatment for patients with failed primary fundoplications. Successful revisional surgery depends on identification and correction of the reason for primary fundoplication failure.

Robotic Laparoscopic Fundoplication

Gastroesophageal reflux disease is a very common disorder, and both medical and surgical treatments have shown outstanding results. Whereas proton pump inhibitors are the mainstay of treatment, laparoscopic fundoplication has become a very attractive alternative due to its efficacy and low morbidity. There are defined patient categories that may benefit more from laparoscopy than medical therapy, but a conclusive comparison between the two is lacking. Robotic laparoscopic fundoplication can be performed safely without increased morbidity. Potential advantages include enhanced precision, improved dexterity, and remote telesurgical applications. Disadvantages include increased cost and prolonged operative times. Further studies and more long-term outcome data are needed to fully evaluate the procedure. Robotic surgery is currently in its infancy and not cost effective but has a very promising future. With further development of automatization and miniaturization features, robotic surgery may prove more efficient than conventional laparoscopy.