Laparoscopic antireflux surgery for the elderly: A surgical and quality-of-life study

Purpose Laparoscopic antireflux surgery (LARS) has long been introduced as an alternative method for the treatment of gastroesophageal reflux disease (GERD) in young adults. However, the safety of this procedure and the associated improvement in the quality of life for the elderly are rarely discussed. This study compared the results between young and elderly patients who underwent laparoscopic fundoplication for the treatment of GERD. Methods From January 1999 to January 2006, there were 231 adult patients who underwent LARS for GERD at a single institute. Among all patients, 33 patients were older than 70 years old (14.3%, 73.0 ± 1.9, range 70–76), 198 patients were younger than 70 years old (85.7%, 46.6 ± 11.5, range 20–69). The clinical characteristics, operation time, postoperative hospital stay, surgical complications, and quality of life were retrospectively analyzed. Results The mean operation time had no significant difference between the younger group and the elderly group. The mean postoperative hospital stay in the elderly group was slightly longer than the younger group (4.1 ± 2.5 days vs 3.4 ± 1.3 days, P = 0.19). There were no mortalities and no major complications found in each group. No patients required conversion to an open procedure. Four patients had minor complications (three in the elderly group, rate: 9.0%; one in the younger group, rate: 0.5%, P < 0.05). There were two patients in the nonelderly group who had recurrence. A comparison of the preoperative and postoperative Gastro-Intestinal Quality of Life Index (GIQLI) scores showed significant improvements (99.3 ± 19.2 points, and 110.2 ± 20.6 points, respectively, P < 0.05) with no significant difference between the two groups. Conclusion Laparoscopic antireflux surgery thus appears to provide an equivalent degree of safety and symptomatic relief for elderly patients with GERD as that observed in young patients.     

The effect of chronic pain syndromes and psychoemotional disorders on symptomatic and quality-of-life outcomes of antireflux surgery

Psychoemotional disorders (PED) and chronic pain syndromes (CPS) are common problems. Many patients with these disorders also suffer from gastroesophageal reflux disease (GERD). It is unclear how PED/CPS affect outcomes of antireflux surgery; therefore, the purpose of this study was to determine if PED/CPS adversely affects the results of surgical therapy for GERD. All patients referred for surgical therapy for GERD completed both the GERD-HRQL symptom severity instrument and the SF-36 generic quality-of-life instrument prior to surgery. To be candidates for surgery, patients must have symptomatic GERD and objective evidence of pathologic reflux by upper endoscopy, esophageal manometry and 24-hour pH monitoring. Patients underwent either laparoscopic or open Nissen or Toupet fundopli-cation. Six to 24 months postoperatively, patients were evaluated for satisfaction and quality-of-life. Ninety-three percent of control patients compared to 25% of PED/CPS patients were satisfied with surgery (P < 0.001). Dissatisfaction in PED/CPS patients was generally due to persistent or new somatic complaints. Median total GERD-HRQL scores improved for both groups, although postoperative scores were worse in the PED/CPS group. PED/CPS patients had significantly worse SF-36 scores both preop-eratively and postoperatively compared to control patients. SF-36 scores improved in four of eight domains in control patients and none in the PED/CPS patients. In conclusion, PED/CPS patients are generally dissatisfied with antireflux surgery. Although some patients do benefit from surgery, careful patient selection is required. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

Can patient satisfaction with decisions predict compliance with surgery?

BACKGROUND: Patient satisfaction with treatment decisions is a discrete and measurable component of the satisfaction paradigm, distinct from satisfaction with health care services. OBJECTIVE: The study goal was to determine if the Satisfaction With Decision (SWD) scale, a valid and reliable 6-item survey, can predict patient compliance with surgery proposed by their otolaryngologist. DESIGN: Prospective study using the SWD scale plus measures of office visit satisfaction, provider satisfaction, and disease-specific quality of life. SETTING: Metropolitan, private nonprofit hospital. PATIENTS: The study population consisted of 151 patients scheduled for surgery, with a median age of 5.8 years and an age range of 0.6 to 65.3 years. INTERVENTIONS: At the time surgery was scheduled, the decision-maker completed a 12-item questionnaire about satisfaction and quality of life that included the SWD scale. Noncompliant patients were contacted, and the specific reason for cancellation was ascertained. RESULTS: The strongest predictor of surgical cancellation was the SWD survey score, with a median value of 4.8 for patients completing surgery compared with 3.8 for those who cancelled (P < 0.001). Patients with scores <4.0 had a 57% cancellation rate, whereas those with scores > or =4.0 had a 98% completion rate. Patients were also more likely to cancel if it was their first visit with the surgeon (P = 0.004) or if they were responsible for their own decisions (P = 0.007). Cancellations were not associated with office visit satisfaction, patient quality of life, or demographic characteristics of the decision-maker. CONCLUSIONS: Patients who are satisfied with their initial decision to undergo surgery are most likely to comply with planned therapy. Conversely, patients who score <4.0 on the SWD scale may benefit from additional preoperative counseling to increase the likelihood of compliance.     

Symptomatic outcomes after laparoscopic antireflux surgery

Purpose: This study was designed to evaluate symptomatic outcomes following laparoscopic antireflux surgery.Methods: Patients referred for antireflux surgery completed a self-administered 19-question gastrointestinal (GI) survey. The survey evaluates 4 GI symptom complexes: gastroesophageal reflux disease (GERD), abdominal pain, dysphagia and irritable bowel. The GERD symptoms are broken down into GI and respiratory symptoms. Questions are scored on a Likert scale with 0 = no symptoms and 100 = severe symptoms. All patients who had an antireflux procedure and completed pre- and postoperative surveys were included in the study.Results: The 40 patients studied included 21 men and 19 women of mean age 47 ± 15 years. Analysis of pre- and postoperative scores using the paired Student’s t-test was as follows (values expressed as mean ± SEM):      

6.

Using self-assessed health to predict patient outcomes after total knee replacement     

Long MJ  McQueen DA  Bangalore VG  Schurman JR 《Clinical orthopaedics and related research》2005,(434):189-192

Self-assessed health status has been shown to be a powerful predictor of mortality, service use, and total cost of medical care treatment. We investigated the potential for self-assessed health to further serve as a predictor of improvement in health status after a clinical intervention. Using the five-category measure of self-assessed health (excellent, very good, good, fair, or poor), we examined patients' improvements in health status after total knee arthroplasty in each of the WOMAC-defined categories for health status in patients. The results indicate that the greater patients rated their preoperative health, the greater their postoperative improvement. The results suggest that a simple process of asking patients to rate their own health in a presurgery clinic could be a powerful tool in predicting patient outcome. This also suggests that by stratifying preoperative self-assessed health, potential improvements in health status will be more fully captured.     

7.

Quality of life and patient satisfaction after laparoscopic antireflux surgery using the QOLARS questionnaire     

Zéman Z  Tihanyi T 《Surgical endoscopy》2007,21(8):1418-1422

Background Currently, evaluation of patient satisfaction and quality-of-life data to estimate the outcome of laparoscopic antireflux surgery is an important issue. This study aimed first to report the midterm results for the surgical management of gastroesophageal reflux disease (GERD) by laparoscopic fundoplication and to evaluate surgical outcome, including quality of life and patient satisfaction. The second aim was to determine whether preoperative quality-of-life measurement can predict which patients will be satisfied with antireflux surgery. Methods The current prospective study evaluated the outcome of the quality-of-life data for 41 patients (13 men and 28 women) who underwent laparoscopic fundoplication in the author’s department of surgery between 1 January 2002 and 31 May 2003. The mean age of the patients was 41 years. Quality of life was measured by using a new quality-of-life instrument (QOLARS) developed and validated by the author’s study group. The patients completed the QOLARS questionnaire before surgery, then 6 weeks, 1 year, and 3 years after surgery. Results Before surgery, all the patients had a poor quality of life. The general quality-of-life and heartburn scores improved significantly within 6 weeks after surgery and showed further improvement by the end of the first postoperative year, then remained stable 3 years after surgery. The patients who became completely free of reflux-related symptoms were divided into two groups according to their satisfaction with the operative result. The patients dissatisfied with surgery had significantly worse median preoparative scores in four domians (physical functioning, emotional functioning, sleep disturbance, constipation) than the patients satisfied with the procedure. Conclusions The findings show that QOLARS is a sensitive tool for assessing surgical outcome after laparoscopic antireflux surgery. The quality-of-life response closely follows the clinical outcome of surgical treatment, reflecting its side effects as well. This study suggests that a generic quality-of-life scale can preoperatively identify patients with GERD who are likely to be dissatisfied with antireflux surgery.     

8.

Using quality-of-life measurements in clinical practice   总被引：3，自引：0，他引：3  

Velanovich V 《Surgery》2007,141(2):127-133

     

9.

Psychometric documentation of a quality-of-life questionnaire for patients undergoing antireflux surgery (QOLARS)     

Zéman Z  Rózsa S  Tihanyi T  Tarkó E 《Surgical endoscopy》2005,19(2):257-261

Background The purpose of our study was to develop a quality-of-life (QoL) questionnaire for patients with gastroesophageal reflux disease (GERD) who have undergone laparoscopic fundoplication. This questionnaire was developed to be more comprehensive than existing measures.Methods Between 1994 and 2002, 252 patients underwent laparoscopic fundoplication for GERD in the 1^st Department of Surgery, Semmelweis University. We undertook a retrospective analysis: each of 252 operated patients was given a questionnaire and was requested to complete it and return it in an enclosed envelope. A total of 116 patients returned completed questionnaires. The patients included 55 men and 61 women, with a mean age of 46 years (range 14–77). These patients were used in the psychometric evaluation. The questionnaire consisted of 50 questions (including the Visick score, EORTC-QLQ-C30, and a modified GERD-HRQL).Results Internal consistency reliability was high (alpha value overall, 0.95, range, 0.74–0.96). Using convergent and divergent validity, construct validity was evaluated by examining Pearson correlation coefficients between items and scales. Construct validity was demonstrated based on observed correlations. Known groups validity was upheld because patients who experienced more symptoms and patients who has higher Visick scores reported worse QoL than those with less symptoms or lower Visick scores.Conclusions Our questionnaire is a short and user-friendly instrument with excellent psychometric properties. It has been found to be valid and reliable.     

10.

Intraoperative graft flow measurements during coronary artery bypass surgery predict in-hospital outcomes     

Herman C  Sullivan JA  Buth K  Legare JF 《Interactive Cardiovascular and Thoracic Surgery》2008,7(4):582-585

Transit-time flowmetry enables immediate intraoperative assessment of blood flow parameters in coronary artery bypass grafts (CABG). The present study assesses the predictive value of measured graft flows on early and medium-term outcomes. All cardiac surgery patients with measured graft flows were included. The last intraoperative flow measurements recorded using the Medtronic Butterfly Flowmetry system were used for analysis. Patients were separated into two groups: patients with normal flow in all grafts or patients with abnormal flow > or =1 graft. Any pulsatility index (pulsatility index=min-max flow/mean flow) < or =5 was determined to be normal flow. The study population included 985 patients. Nineteen percent of patients had abnormal flow in > or =1 graft. Overall in-hospital mortality was 4.7% and not significant between the two groups. After adjusting for covariates, the in-hospital composite outcome for adverse cardiac events was more prevalent in the abnormal flow group (31% vs. 17%; P<0.0001) with an odds ratio of 1.7 (CI 1.1-2.7). Survivors to discharge had a mean follow-up of 1.8 years. However, abnormal flow was not an independent predictor of the medium-term mortality and readmission to hospital for cardiac reason following discharge. Our findings suggest that abnormal flows measured intraoperatively are independently associated with short-term in-hospital adverse outcome.     

11.

Evaluation of patient-reported quality-of-life outcomes after renal surgery     

Kim SB  Williams SB  Cheng SC  Sanda MG  Wagner AA 《Urology》2012,79(6):1268-1273

     

12.

Early outcomes of antireflux surgery for United States lung transplant recipients     

Arman Kilic  Ashish S. Shah  Christian A. Merlo  Christine G. Gourin  Anne O. Lidor 《Surgical endoscopy》2013,27(5):1754-1760

Background

This study aimed to evaluate early outcomes after antireflux surgery for lung transplant (LTx) recipients in the United States.

Methods

Adult patients undergoing elective antireflux surgery between 2003 and 2008 were identified in the Nationwide Inpatient Sample. A propensity-matched analysis compared early outcomes between prior LTx recipients and well-matched control subjects consisting of non-LTx patients undergoing elective antireflux surgery during the same era. The primary outcome was inpatient mortality, and the secondary outcomes were hospital length of stay (LOS), perioperative complications, and hospital costs.

Results

During the study period, 401 LTx recipients underwent elective antireflux surgery. These patients were well matched with 401 control patients in terms of age, sex, individual and overall comorbidity burden, hospital teaching status, hospital location, hospital antireflux volume, and open versus laparoscopic approach. The overall operative mortality rate was 1.4 %, with no difference between the groups. The overall and individual morbidity rates also were similar. The LOS and hospital costs were significantly greater in the LTx group. Multivariable logistic regression analysis confirmed that prior LTx did not confer an increased risk of inpatient mortality after antireflux surgery.

Conclusions

To date, this is the largest study to examine outcomes of antireflux surgery for LTx recipients. Operative mortality and morbidity appear to be comparable with those of the general population, although resource utilization is greater. Based on these data, trials to evaluate the role of antireflux surgery in preserving allograft function after LTx should not be hindered by a perceived notion of prohibitive operative risk in this patient population.     

13.

Preparing the patient for surgery to improve outcomes     

《Best Practice & Research: Clinical Anaesthesiology》2016,30(2):145-157

     

14.

National trends in utilization and outcomes of antireflux surgery   总被引：3，自引：3，他引：0  

Finlayson SR  Laycock WS  Birkmeyer JD 《Surgical endoscopy》2003,17(6):864-867

BACKGROUND: Studies examining the outcomes of surgery for gastroesophageal reflux disease (GERD) have consisted primarily of case series. We sought to assess trends in both utilization and outcomes of antireflux surgery from a national perspective. METHODS: Using ICD-9 codes, we identified all antireflux procedures (N = 24,208) performed on adults from 1990 to 1997 in hospitals participating in the Nationwide Inpatient Sample, the largest all-payer inpatient care database in the United States. Using sampling weights and U.S. Census data, we then calculated the national population-based rate of antireflux surgery for each year and examined secular trends in utilization, in-hospital mortality, splenectomy (a technical complication), and length of hospital stay. Using a coding algorithm, we also assessed trends in the proportion of procedures performed via the laparoscopic, open abdominal, and thoracic approaches. RESULTS: From 1990 to 1997, the population-based annual rate of antireflux surgery increased from 4.4 to 12.0 per 100,000 adults. A substantial increase in utilization was observed from 1993 to 1995, but annual rates before and after this period were relatively stable. Between 1990 and 1997, in-hospital surgical mortality decreased from 1.2% to 0.5% (p = 0.002), splenectomy rates decreased from 3.9% to 1.5% (p <0.001), and median length of stay decreased from 7 to 2 days (p <0.01). The proportion of antireflux procedures performed laparoscopically increased from 0.5% to 64% (p <0.001), and the proportion of procedures performed using a thoracic approach decreased from 12% to 1% (p <0.001). CONCLUSIONS: With the dissemination of the laparoscopic approach, the population-based rate of antireflux surgery has more than doubled. At the same time, operative mortality and splenectomy risks have diminished.     

15.

Developing tools to predict outcomes following cardiovascular surgery     

Boult M  Fitzpatrick K  Barnes M  Maddern G  Fitridge R 《ANZ journal of surgery》2011,81(11):768-773

Background: Surgical decision‐making tools may help surgeons achieve better outcomes by providing more personally relevant information to patients. This paper describes approaches to developing statistical tools capable of estimating the probability of morbidity and mortality after cardiovascular surgery. Our aim is to inform surgeons about the important stages that contribute to the development of decision tools. Methods: The key elements described include study design (data quality, cohort size, etc.) and statistical methodology for developing and testing decision tools. Mention is made of the delivery of decision tools, simplicity of use, ease of interpretation of results and accessibility. Information specific to cardiac and vascular surgery is included. Results: Development of useful and effective decision tools is dependent on robust and reliable data, unambiguous outcome requirements and considerable statistical expertise. Decision tools must also be extensively tested for validity and reliability, both internally and with external data. Conclusion: Understanding the development and assumptions that underlie surgical decision tool development will help cardiovascular surgeons appreciate the value of applying such techniques at a clinical level.     

16.

Long-term follow-up after laparoscopic refundoplication for failed antireflux surgery: Quality of life, symptomatic outcome, and patient satisfaction   总被引：4，自引：0，他引：4  

Frank A. Granderath M.D.  Thomas Kamolz Ph.D.  Ursula M. Schweiger M.D.  Rudolph Pointner M.D. 《Journal of gastrointestinal surgery》2002,6(6):812-818

Quality of life and patient satisfaction have been shown to be important factors in evaluating outcome of laparoscopic antireflux surgery (LARS). The aim of this study was to evaluate data pertaining to quality of life, patient satisfaction, and changes in symptoms in patients who underwent laparoscopic redo surgery after primary failed open or laparoscopic antireflux surgery 3 to 5 years postoperatively. Between March 1995 and June 1998, a total of 27 patients whose mean age was 57 years (range 35 to 78 years) Underwent laparoscopic refundoplication for primary failed open or laparoscopic antireflux surgery. Quality of life was evaluated by means of the Gastrointestinal Quality of Life Index (GIQLI). Additionally, patient satisfaction and symptomatic outcome were evaluted using a standardized questionnaire. Three to 5 years after laparoscopic refundoplication, patients rated their quality of life (GIQLI) in an overall score of 113.4 points. Twenty-five patients (92.6%) rated their satisfaction with the redo procedure as very good and would undergo surgery again, if necessary. These patients were no longer taking any antireflux medication at follow-up. Two patients (7.4%) reported rare episodes of heartburn, which were managed successfully with proton pump inhibitors on demand, and four patients (14.8%) reported some episodes of regurgitation but with no decrease in quality of life. Seven patients (25.9%) suffer from mild-to-moderate dysphagia 5 years postoperatively, and 12 patients (44.4%) report having occasional chest pain but no other symptoms of gastroesophageal reflux disease. Nine of these patients suffer from concomitant cardiopulmonary disease. Laparoscopic refundoplication after primary failed antireflux surgery results in a high degree of patient satisfaction and significant improvement in quality of life with a good symptomatic outcome for a follow-up period of 3 to 5 years after surgery. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

17.

Revisional surgery for failed antireflux surgery     

Chukwumah CV  Ponsky JL 《Surgical laparoscopy, endoscopy & percutaneous techniques》2010,20(5):326-331

The outcome and morbidity of revisional surgery after antireflux surgery has been suggested to be suboptimal compared with primary repair. Therefore, an individualized therapeutic approach based on exact analysis of the reasons for failure of the initial procedure is essential for successful management of these patients. This study attempts to summarize the management of this challenging patient population with a focus on the clinical presentation, causes of failure, evaluation, and variety and choice of revisional techniques.     

18.

Symptomatic outcomes of laparoscopic antireflux surgery in patients eligible for endoluminal therapies     

Desai KM  Klingensmith ME  Winslow ER  Frisella P  Soper NJ 《Surgical endoscopy》2002,16(12):1669-1673

Background: This study compared clinical outcomes after laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) who would be eligible for endoluminal therapies (ET) with those in patients who would be excluded from ET. Methods: From 1995 to the present, 459 patients who underwent LARS were analyzed prospectively. Of these, 117 patients (25%) without preoperative dysphagia, stricture, esophagitis worse than grade 2 or hiatal hernia larger than 2 cm were considered potential candidates for ET (group 1). By these criteria, 342 patients (75%) were not eligible for ET (group 2). Medication use and GERD symptoms were evaluated and compared between the two groups. Results: Perioperative outcomes including duration of operation, morbidity, length of hospital stay and return to work were similar in the two groups. Although LARS significantly reduced medication use and GERD symptoms in both groups during a mean follow-up period longer than 2 years, there were no outcome differences between groups 1 and 2. The reported improvement in esophageal symptoms and overall satisfaction was 90% or more in both groups. Conclusions: The findings show that LARS is an effective treatment option in patients with GERD whether they are candidates for ET or not. In patients with uncomplicated GERD who currently meet inclusion criteria for ET, LARS provides excellent symptom relief and marked reduction in medication use during a mean follow-up period longer than 2 years.     

19.

A broad assessment of clinical outcomes after laparoscopic antireflux surgery     

Oelschlager BK  Ma KC  Soares RV  Montenovo MI  Munoz Oca JE  Pellegrini CA 《Annals of surgery》2012,256(1):87-94

     

20.

Laparoscopic antireflux surgery: long-term outcomes and quality of life     

Rosenthal R  Peterli R  Guenin MO  von Flüe M  Ackermann C 《Journal of laparoendoscopic & advanced surgical techniques. Part A》2006,16(6):557-561

BACKGROUND: To evaluate the outcome of antireflux surgery, we assessed disease-specific symptoms and quality of life of all patients treated by laparoscopic fundoplication at our center between 1992 and 2002. MATERIALS AND METHODS: Preoperative symptoms and details of surgery were evaluated for 186 laparoscopic fundoplications. Disease-specific symptoms and quality of life were assessed using a questionnaire. Of 186 patients, 143 returned the questionnaire. RESULTS: The most common preoperative symptoms under medical antireflux therapy were regurgitation (54%) and heartburn (30%). Indications for surgery were refractory symptoms (88%) and the patient denying long-term medication (42%). The surgical approaches were Nissen fundoplication (98%) or Toupet fundoplication (2%, for heavy esophageal motility disorder). The conversion rate was 10%. There were no deaths, and 6 patients (3%) had to be reoperated. The questionnaire revealed that in 82% of the patients who responded, the preoperative reflux symptoms were gone, and 94% were satisfied with the result and would undergo surgery again. The average gastrointestinal quality of life index was 115 points (healthy volunteers in the literature, 120.8 points). CONCLUSION: Laparoscopic fundoplication is a safe antireflux therapy resulting in high levels of patient satisfaction and near-normal quality of life in the long term.     

Using self-assessed health to predict patient outcomes after total knee replacement

Self-assessed health status has been shown to be a powerful predictor of mortality, service use, and total cost of medical care treatment. We investigated the potential for self-assessed health to further serve as a predictor of improvement in health status after a clinical intervention. Using the five-category measure of self-assessed health (excellent, very good, good, fair, or poor), we examined patients' improvements in health status after total knee arthroplasty in each of the WOMAC-defined categories for health status in patients. The results indicate that the greater patients rated their preoperative health, the greater their postoperative improvement. The results suggest that a simple process of asking patients to rate their own health in a presurgery clinic could be a powerful tool in predicting patient outcome. This also suggests that by stratifying preoperative self-assessed health, potential improvements in health status will be more fully captured.     

Quality of life and patient satisfaction after laparoscopic antireflux surgery using the QOLARS questionnaire

Background Currently, evaluation of patient satisfaction and quality-of-life data to estimate the outcome of laparoscopic antireflux surgery is an important issue. This study aimed first to report the midterm results for the surgical management of gastroesophageal reflux disease (GERD) by laparoscopic fundoplication and to evaluate surgical outcome, including quality of life and patient satisfaction. The second aim was to determine whether preoperative quality-of-life measurement can predict which patients will be satisfied with antireflux surgery. Methods The current prospective study evaluated the outcome of the quality-of-life data for 41 patients (13 men and 28 women) who underwent laparoscopic fundoplication in the author’s department of surgery between 1 January 2002 and 31 May 2003. The mean age of the patients was 41 years. Quality of life was measured by using a new quality-of-life instrument (QOLARS) developed and validated by the author’s study group. The patients completed the QOLARS questionnaire before surgery, then 6 weeks, 1 year, and 3 years after surgery. Results Before surgery, all the patients had a poor quality of life. The general quality-of-life and heartburn scores improved significantly within 6 weeks after surgery and showed further improvement by the end of the first postoperative year, then remained stable 3 years after surgery. The patients who became completely free of reflux-related symptoms were divided into two groups according to their satisfaction with the operative result. The patients dissatisfied with surgery had significantly worse median preoparative scores in four domians (physical functioning, emotional functioning, sleep disturbance, constipation) than the patients satisfied with the procedure. Conclusions The findings show that QOLARS is a sensitive tool for assessing surgical outcome after laparoscopic antireflux surgery. The quality-of-life response closely follows the clinical outcome of surgical treatment, reflecting its side effects as well. This study suggests that a generic quality-of-life scale can preoperatively identify patients with GERD who are likely to be dissatisfied with antireflux surgery.     

Psychometric documentation of a quality-of-life questionnaire for patients undergoing antireflux surgery (QOLARS)

Background The purpose of our study was to develop a quality-of-life (QoL) questionnaire for patients with gastroesophageal reflux disease (GERD) who have undergone laparoscopic fundoplication. This questionnaire was developed to be more comprehensive than existing measures.Methods Between 1994 and 2002, 252 patients underwent laparoscopic fundoplication for GERD in the 1^st Department of Surgery, Semmelweis University. We undertook a retrospective analysis: each of 252 operated patients was given a questionnaire and was requested to complete it and return it in an enclosed envelope. A total of 116 patients returned completed questionnaires. The patients included 55 men and 61 women, with a mean age of 46 years (range 14–77). These patients were used in the psychometric evaluation. The questionnaire consisted of 50 questions (including the Visick score, EORTC-QLQ-C30, and a modified GERD-HRQL).Results Internal consistency reliability was high (alpha value overall, 0.95, range, 0.74–0.96). Using convergent and divergent validity, construct validity was evaluated by examining Pearson correlation coefficients between items and scales. Construct validity was demonstrated based on observed correlations. Known groups validity was upheld because patients who experienced more symptoms and patients who has higher Visick scores reported worse QoL than those with less symptoms or lower Visick scores.Conclusions Our questionnaire is a short and user-friendly instrument with excellent psychometric properties. It has been found to be valid and reliable.     

Intraoperative graft flow measurements during coronary artery bypass surgery predict in-hospital outcomes

Transit-time flowmetry enables immediate intraoperative assessment of blood flow parameters in coronary artery bypass grafts (CABG). The present study assesses the predictive value of measured graft flows on early and medium-term outcomes. All cardiac surgery patients with measured graft flows were included. The last intraoperative flow measurements recorded using the Medtronic Butterfly Flowmetry system were used for analysis. Patients were separated into two groups: patients with normal flow in all grafts or patients with abnormal flow > or =1 graft. Any pulsatility index (pulsatility index=min-max flow/mean flow) < or =5 was determined to be normal flow. The study population included 985 patients. Nineteen percent of patients had abnormal flow in > or =1 graft. Overall in-hospital mortality was 4.7% and not significant between the two groups. After adjusting for covariates, the in-hospital composite outcome for adverse cardiac events was more prevalent in the abnormal flow group (31% vs. 17%; P<0.0001) with an odds ratio of 1.7 (CI 1.1-2.7). Survivors to discharge had a mean follow-up of 1.8 years. However, abnormal flow was not an independent predictor of the medium-term mortality and readmission to hospital for cardiac reason following discharge. Our findings suggest that abnormal flows measured intraoperatively are independently associated with short-term in-hospital adverse outcome.     

Early outcomes of antireflux surgery for United States lung transplant recipients

Background

This study aimed to evaluate early outcomes after antireflux surgery for lung transplant (LTx) recipients in the United States.

Methods

Adult patients undergoing elective antireflux surgery between 2003 and 2008 were identified in the Nationwide Inpatient Sample. A propensity-matched analysis compared early outcomes between prior LTx recipients and well-matched control subjects consisting of non-LTx patients undergoing elective antireflux surgery during the same era. The primary outcome was inpatient mortality, and the secondary outcomes were hospital length of stay (LOS), perioperative complications, and hospital costs.

Results

During the study period, 401 LTx recipients underwent elective antireflux surgery. These patients were well matched with 401 control patients in terms of age, sex, individual and overall comorbidity burden, hospital teaching status, hospital location, hospital antireflux volume, and open versus laparoscopic approach. The overall operative mortality rate was 1.4 %, with no difference between the groups. The overall and individual morbidity rates also were similar. The LOS and hospital costs were significantly greater in the LTx group. Multivariable logistic regression analysis confirmed that prior LTx did not confer an increased risk of inpatient mortality after antireflux surgery.

Conclusions

To date, this is the largest study to examine outcomes of antireflux surgery for LTx recipients. Operative mortality and morbidity appear to be comparable with those of the general population, although resource utilization is greater. Based on these data, trials to evaluate the role of antireflux surgery in preserving allograft function after LTx should not be hindered by a perceived notion of prohibitive operative risk in this patient population.     

National trends in utilization and outcomes of antireflux surgery

BACKGROUND: Studies examining the outcomes of surgery for gastroesophageal reflux disease (GERD) have consisted primarily of case series. We sought to assess trends in both utilization and outcomes of antireflux surgery from a national perspective. METHODS: Using ICD-9 codes, we identified all antireflux procedures (N = 24,208) performed on adults from 1990 to 1997 in hospitals participating in the Nationwide Inpatient Sample, the largest all-payer inpatient care database in the United States. Using sampling weights and U.S. Census data, we then calculated the national population-based rate of antireflux surgery for each year and examined secular trends in utilization, in-hospital mortality, splenectomy (a technical complication), and length of hospital stay. Using a coding algorithm, we also assessed trends in the proportion of procedures performed via the laparoscopic, open abdominal, and thoracic approaches. RESULTS: From 1990 to 1997, the population-based annual rate of antireflux surgery increased from 4.4 to 12.0 per 100,000 adults. A substantial increase in utilization was observed from 1993 to 1995, but annual rates before and after this period were relatively stable. Between 1990 and 1997, in-hospital surgical mortality decreased from 1.2% to 0.5% (p = 0.002), splenectomy rates decreased from 3.9% to 1.5% (p <0.001), and median length of stay decreased from 7 to 2 days (p <0.01). The proportion of antireflux procedures performed laparoscopically increased from 0.5% to 64% (p <0.001), and the proportion of procedures performed using a thoracic approach decreased from 12% to 1% (p <0.001). CONCLUSIONS: With the dissemination of the laparoscopic approach, the population-based rate of antireflux surgery has more than doubled. At the same time, operative mortality and splenectomy risks have diminished.     

Developing tools to predict outcomes following cardiovascular surgery

Background: Surgical decision‐making tools may help surgeons achieve better outcomes by providing more personally relevant information to patients. This paper describes approaches to developing statistical tools capable of estimating the probability of morbidity and mortality after cardiovascular surgery. Our aim is to inform surgeons about the important stages that contribute to the development of decision tools. Methods: The key elements described include study design (data quality, cohort size, etc.) and statistical methodology for developing and testing decision tools. Mention is made of the delivery of decision tools, simplicity of use, ease of interpretation of results and accessibility. Information specific to cardiac and vascular surgery is included. Results: Development of useful and effective decision tools is dependent on robust and reliable data, unambiguous outcome requirements and considerable statistical expertise. Decision tools must also be extensively tested for validity and reliability, both internally and with external data. Conclusion: Understanding the development and assumptions that underlie surgical decision tool development will help cardiovascular surgeons appreciate the value of applying such techniques at a clinical level.     

Long-term follow-up after laparoscopic refundoplication for failed antireflux surgery: Quality of life, symptomatic outcome, and patient satisfaction

Quality of life and patient satisfaction have been shown to be important factors in evaluating outcome of laparoscopic antireflux surgery (LARS). The aim of this study was to evaluate data pertaining to quality of life, patient satisfaction, and changes in symptoms in patients who underwent laparoscopic redo surgery after primary failed open or laparoscopic antireflux surgery 3 to 5 years postoperatively. Between March 1995 and June 1998, a total of 27 patients whose mean age was 57 years (range 35 to 78 years) Underwent laparoscopic refundoplication for primary failed open or laparoscopic antireflux surgery. Quality of life was evaluated by means of the Gastrointestinal Quality of Life Index (GIQLI). Additionally, patient satisfaction and symptomatic outcome were evaluted using a standardized questionnaire. Three to 5 years after laparoscopic refundoplication, patients rated their quality of life (GIQLI) in an overall score of 113.4 points. Twenty-five patients (92.6%) rated their satisfaction with the redo procedure as very good and would undergo surgery again, if necessary. These patients were no longer taking any antireflux medication at follow-up. Two patients (7.4%) reported rare episodes of heartburn, which were managed successfully with proton pump inhibitors on demand, and four patients (14.8%) reported some episodes of regurgitation but with no decrease in quality of life. Seven patients (25.9%) suffer from mild-to-moderate dysphagia 5 years postoperatively, and 12 patients (44.4%) report having occasional chest pain but no other symptoms of gastroesophageal reflux disease. Nine of these patients suffer from concomitant cardiopulmonary disease. Laparoscopic refundoplication after primary failed antireflux surgery results in a high degree of patient satisfaction and significant improvement in quality of life with a good symptomatic outcome for a follow-up period of 3 to 5 years after surgery. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

Revisional surgery for failed antireflux surgery

The outcome and morbidity of revisional surgery after antireflux surgery has been suggested to be suboptimal compared with primary repair. Therefore, an individualized therapeutic approach based on exact analysis of the reasons for failure of the initial procedure is essential for successful management of these patients. This study attempts to summarize the management of this challenging patient population with a focus on the clinical presentation, causes of failure, evaluation, and variety and choice of revisional techniques.     

Symptomatic outcomes of laparoscopic antireflux surgery in patients eligible for endoluminal therapies

Background: This study compared clinical outcomes after laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) who would be eligible for endoluminal therapies (ET) with those in patients who would be excluded from ET. Methods: From 1995 to the present, 459 patients who underwent LARS were analyzed prospectively. Of these, 117 patients (25%) without preoperative dysphagia, stricture, esophagitis worse than grade 2 or hiatal hernia larger than 2 cm were considered potential candidates for ET (group 1). By these criteria, 342 patients (75%) were not eligible for ET (group 2). Medication use and GERD symptoms were evaluated and compared between the two groups. Results: Perioperative outcomes including duration of operation, morbidity, length of hospital stay and return to work were similar in the two groups. Although LARS significantly reduced medication use and GERD symptoms in both groups during a mean follow-up period longer than 2 years, there were no outcome differences between groups 1 and 2. The reported improvement in esophageal symptoms and overall satisfaction was 90% or more in both groups. Conclusions: The findings show that LARS is an effective treatment option in patients with GERD whether they are candidates for ET or not. In patients with uncomplicated GERD who currently meet inclusion criteria for ET, LARS provides excellent symptom relief and marked reduction in medication use during a mean follow-up period longer than 2 years.     

Laparoscopic antireflux surgery: long-term outcomes and quality of life

BACKGROUND: To evaluate the outcome of antireflux surgery, we assessed disease-specific symptoms and quality of life of all patients treated by laparoscopic fundoplication at our center between 1992 and 2002. MATERIALS AND METHODS: Preoperative symptoms and details of surgery were evaluated for 186 laparoscopic fundoplications. Disease-specific symptoms and quality of life were assessed using a questionnaire. Of 186 patients, 143 returned the questionnaire. RESULTS: The most common preoperative symptoms under medical antireflux therapy were regurgitation (54%) and heartburn (30%). Indications for surgery were refractory symptoms (88%) and the patient denying long-term medication (42%). The surgical approaches were Nissen fundoplication (98%) or Toupet fundoplication (2%, for heavy esophageal motility disorder). The conversion rate was 10%. There were no deaths, and 6 patients (3%) had to be reoperated. The questionnaire revealed that in 82% of the patients who responded, the preoperative reflux symptoms were gone, and 94% were satisfied with the result and would undergo surgery again. The average gastrointestinal quality of life index was 115 points (healthy volunteers in the literature, 120.8 points). CONCLUSION: Laparoscopic fundoplication is a safe antireflux therapy resulting in high levels of patient satisfaction and near-normal quality of life in the long term.