Ten-year follow-up of laparoscopic Heller myotomy for achalasia shows durability

Objective Reports of long-term outcomes for laparoscopic Heller myotomy (LHM) are scarce. In this work, outcomes of LHM for achalasia in patients who underwent surgery more than 10 years prior were investigated. Methods A cohort of patients treated with LHM and partial fundoplication for achalasia between 1993 and 1996 was followed for long-term outcomes, which were compared to baseline data at presentation. Results Thirty-two consecutive patients were identified, and follow-up information was obtained for 20 patients (62.5%). Mean follow-up was 11.2 years (range 10.3 to 12.3 years). Three patients (9.4%) were deceased (mean of 40 months postoperation). Of the 17 living patients, dysphagia was rated as severe in one (5.9%), mild to moderate in eight (47.1%), and absent in eight (47.1%). This was a significant improvement from preoperative scores in which dysphagia was rated as severe in 42.9%, mild to moderate in 57.1%, and absent in 0% (p < 0.05). In addition, 10-year dysphagia scores were unchanged from those at short-term follow-up (mean 27 months, p = 0.84). Other symptoms of heartburn, chest pain, voice symptoms, cough, and asthma were reported in fewer than 30% of patients at 10 years. Esophageal dilation following surgery was required in three patients, and two patients required repeat operations (esophagectomy in one patient, hiatal hernia in one patient). Satisfaction with the operation was reported by 16 patients (94.1%) at 10 years. Conclusions Most patients who underwent LHM with partial fundoplication reported satisfaction 10 years after the operation. A small number of patients required additional intervention. Dysphagia scores at 10 years were not different from those collected at short-term follow-up. Our data suggest that the efficacy of LHM is sustained at 10-year follow-up.     

One-year follow-up after laparoscopic Heller-Dor operation for esophageal achalasia

Background: The Heller-Dor operation has recently been proposed for the treatment of esophageal achalasia even via a laparoscopic approach. Methods: To measure the medium-term effectiveness of this new minimally invasive technique, an evaluation of pre- and postoperative symptoms, esophagogram, endoscopic findings, esophageal manometry, and pH monitoring was prospectively designed in 43 patients with primary esophageal achalasia. The mean clinical follow-up for all the patients is 12 months (range 3–43), while the mean radiological follow-up is 11 months (range 1–23). Endoscopic data 1 year after surgery are currently available for 27 patients (63%), whereas a 12-month (range 1–26) functional follow-up (including manometric and pH-monitoring studies of the esophagus) is currently available for 35 patients (81.4%). Results: No dysphagia was reported in 38 cases (88.4%); two (4.6%) complained of occasional swallowing discomfort which regressed spontaneously; two (4.6%) had persistent dysphagia which regressed with pneumatic dilatation. One patient (2.8%) reported mild occasional dysphagia after a 1-year asymptomatic period. Preoperatively, esophagograms showed an average maximum diameter of 40.6 ± 9.1 mm which decreased to 24.1 ± 6.0 mm after operation. Mean lower esophageal sphincter (LES) resting and residual pressures decreased significantly from 28.6 ± 10.7 mmHg to 8.8 ± 4.1 mmHg and from 17.0 ± 9.7 mmHg to 4.7 ± 4.0 mmHg, respectively (p < 0.0001). These effects on esophageal diameter and LES function seem to persist over time. The complete absence of any peristaltic contractions recorded preoperatively in all cases remained unchanged after surgery in all but four patients. However, this rare recovery of peristalsis proved to be transient, and patients revealed a manometric impairment of their esophageal body function, but without complaining of dysphagia. Twenty-four-hour pH monitoring showed abnormal gastroesophageal reflux episodes in two (5.7%) of the 35 patients who were monitored: one was asymptomatic; the other had heartburn and endoscopically demonstrated grade II esophagitis. Conclusions: Laparoscopic Heller-Dor operation achieves excellent medium-term results which, together with the already-demonstrated advantages of a minimal surgical trauma and rapid convalescence, validate the use of such a minimally invasive approach to treat patients with primary achalasia of the esophagus. Received: 19 March 1996/Accepted: 15 May 1996     

Results of the laparoscopic Heller-Dor procedure for pediatric esophageal achalasia

Background: Esophageal achalasia is not a frequent disorder in children and different treatments have been proposed during past decades. This study reviews the results of the laparoscopic Heller-Dor procedure performed in pediatric patients in two different surgical units. Methods: We included the patients aged <14 years with a minimum follow-up of 6 months operated on in the period 1994–2001. A single longitudinal anterior esophageal myotomy (Heller) and a 180° anterior gastropexy (Dor) were laparoscopically performed. The patients were checked to detect intra- or postoperative complications and recurrence. Results: Twenty children were operated on. Mean follow-up was 45 months (range 6–102). Postoperative clinical score was Visick 1 in 15 cases and Visick 2 in five. Conclusions: As complication and recurrence rates are very low we consider modified Heller myotomy and Dor gastropexy through a laparoscopic approach our first choice to treat esophageal achalasia in the pediatric population.     

Laparoscopic extended cardiomyotomy in children: an effective procedure for the treatment of esophageal achalasia

Purpose

Achalasia of the esophagus is characterized by aperistalsis and incomplete relaxation of the lower esophageal sphincter in response to swallowing. The objective of the present study is to present the experience of a modified Heller myotomy via a laparoscopic approach for the treatment of children who had this condition.

Methods

A retrospective review of medical records of all patients who underwent this procedure from 2000 to 2009 was performed. The procedure consisted of an extended esophagomyotomy beginning on the lower part of the lower esophageal sphincter and continuing 5 to 6 cm above on the lower third of the esophagus, and then extended 3 to 4 cm below to the stomach, associated with an anterior 180-degree hemi-fundoplication according to Dor's technique.

Results

Fifteen patients were included in the study. There were 8 female and 7 male patients. Mean operating time was 190 minutes with no intraoperative complications and 1 conversion to open surgery because of difficulty in dissecting an inflamed distal esophagus. In a mean follow-up period of 32.3 months, 2 patients had recurrence of mild dysphagia that disappeared spontaneously, and 1 required a single botulinum toxin injection with complete resolution of symptoms.

Conclusion

We conclude that the laparoscopic extended Heller myotomy with Dor fundoplication is a safe and effective method for the treatment for achalasia in the pediatric population even in advanced cases.     

Clinical utility of routine barium esophagram after laparoscopic anterior esophageal myotomy for achalasia

Background  This study aimed to evaluate the clinical utility of routine barium esophagram after laparoscopic anterior esophageal myotomy for achalasia. Methods  The records of 260 consecutive patients who underwent laparoscopic anterior esophageal myotomy for achalasia from May 1996 to August 2007 were reviewed from a prospective institutional review board–approved database. Data are given as mean ± standard deviation. Statistical significance (p < 0.05) was determined using a two-tailed t-test and Fisher’s exact test. Results  Routine protocol barium esophagrams performed for 236 patients a mean of 1 ± 0.3 days postoperatively were interpreted for 145 (61.4%) of the patients as normal flow of contrast after esophageal myotomy. There were no false-negative studies in this group, and diet was initiated without incident at a mean of 1 ± 0.2 days. The time to the goal diet was 1.3 ± 0.7 postoperative days, and the mean postoperative time to discharge was 1.5 ± 1 days. Of the 236 patients, 91 (38.6%) had an abnormal barium esophagram (contrast retention or pooling, delayed emptying). For this group, initiation of a diet was delayed for only six (6.6%) patients. Two barium esophagrams (0.9%) interpreted as an esophageal leak were determined to be false-positives after the one patient underwent negative exploratory laparoscopy and the other was observed clinically. In this group, diet was initiated at a mean of 1.1 ± 0.3 days. The time to the goal diet was 1.4 ± 0.7 days, and the mean postoperative time to discharge was 1.8 ± 1.9 days. The mean times to diet initiation, goal diet, and discharge were not significantly different (p ≥ 0.14) between the normal and the abnormal barium esophagram groups. The sensitivity and specificity of an abnormal routine barium esophagram after laparoscopic esophageal myotomy were, respectively, 100% and 62.0%, and the positive and negative predictive values were 2.2% and 100%. Conclusions  Because of its poor positive predictive value, routine barium esophagram after laparoscopic anterior esophageal myotomy should be used selectively in the immediate postoperative period after an uncomplicated procedure.     

Botulinum toxin injection versus laparoscopic myotomy for the treatment of esophageal achalasia: Economic analysis of a randomized trial

Background: The treatment of esophageal achalasia is still controversial: current therapies are palliative and aim to relieve dysphagia by disrupting or relaxing the lower esophageal sphincter muscle fibers with botulinum toxin. The aim of this study was to compare the clinical and economic results of two such treatments: laparoscopic myotomy and botulinum toxin injection. Methods: A total of 37 patients with esophageal achalasia were randomly assigned to receive laparoscopic myotomy (20) or two Botox injections 1 month apart (17). All patients were treated at the same hospital and were part of a larger multicenter study. Symptom score, lower esophageal sphincter pressure, and esophageal diameter at barium swallow were compared. The economic analysis was performed considering only the direct costs (cost per treatment and cost effectiveness, i.e., cost per patient healed). Results: Mortality and morbidity were nil in both groups. The actuarial probability of being asymptomatic at 2 years was 90% for surgery and 34% for Botox (p < 0.05). The initial cost was lower for Botox (€1,245) than for surgery (€3,555), but when cost effectiveness at 2 years was considered, this difference nearly disappeared: Botox €3,364, surgery €3,950. Conclusion: Botox is still the least costly treatment, but the minimal difference in the longer term does not justify its use, given that surgery is a risk-free, definitive treatment.     

Redo laparoscopic surgery for achalasia

Background: Operative treatment of achalasia can fail in 10% to 15% of patients. No information is available on the outcome of laparoscopic reoperation for achalasia. Methods: Data from patients undergoing redo surgery for achalasia were prospectively collected. The data were analyzed, and a questionnaire was sent to all the patients. Results: Eight patients underwent redo procedures at our institution between 1994 and 1998. The reasons for failure of the initial operations were incomplete myotomy (n = 5), incorrect diagnosis (n = 2), and new onset of reflux symptoms (n = 1). All the redo procedures were performed laparoscopically. All the patients except one had excellent or good results. The average symptom severity score for dysphagia, regurgitation, chest pain, cough, and heartburn all improved after redo procedures. The average quality of life score improved from poor to good. Conclusions:Laparoscopic reoperation for achalasia is safe and feasible. It results in symptom improvement for most patients. Surgeon experience and recognition of the cause for failure of the original operation are most important in predicting the outcome.     

Single-port laparoscopic Heller myotomy and Dor fundoplication: initial experience with a new approach for the treatment of pediatric achalasia

Purpose

The aim of this report was to evaluate the safety and feasibility of single-port laparoscopic Heller myotomy and Dor fundoplication (SPLHD) as treatment of pediatric esophageal achalasia.

Methods

A 9-year-old boy with a significant history of achalasia underwent SPLHD. The single-port was inserted using an umbilical incision. The falciform ligament and left liver lobe were raised using an elevating suture, providing good visualization of the operative field at the cardia. The Heller myotomy was planned to be 4 cm long, extending 1 cm onto the gastric wall.

Results

The SPLHD was successfully accomplished without the need for any skin incisions or additional ports. Oral intake was resumed on the first postoperative day, and the length of hospital stay was 8 days. The patient had complete resolution of dysphagia and regurgitation. No complications were noted, and the patient had an excellent cosmetic result.

Conclusions

The SPLHD is a safe and feasible procedure for symptomatic pediatric achalasia when performed by a surgeon experienced in laparoscopic and esophageal surgery.     

Long-term outcome of laparoscopic Heller-Dor surgery for esophageal achalasia: Possible detrimental role of previous endoscopic treatment

Laparoscopic Heller myotomy has recently emerged as the treatment of choice for esophageal achalasia. Previous unsuccessful treatments (pneumatic dilations or botulinum toxin [BT] injections) can make surgery more difficult, causing a higher risk of mucosal perforation and jeopardizing the outcome. The study goal was to evaluate the effects of prior endoscopic treatments on laparoscopic Heller myotomy. Between January 1992 and February 2005, 248 patients (130 males and 118 females; median age, 43 years) underwent a laparoscopic Heller-Dor operation for achalasia: 203 underwent primary surgery (group A), 19 had been previously treated with pneumatic dilations (group B), and 26 had BT injections (alone [22] or with dilations [4] (group C). Median duration of the operation and rate of intraoperative mucosal lesions were not different in the three groups. Median follow-up was 41 months. The 5-year actuarial of control of dysphagia was similar in groups A (86%) and B (94%), whereas only 75% of group C patients were symptom free at 5 years (P 5 =.02). On logistic regression analysis, prior treatment with two BT injections or BT combined with dilation was associated with poor outcome of surgery. Further, dilations for surgical failure patients were effective in 80% of group A but in only 33% of group B or C patients. Heller-Dor surgery is safe and effective as a primary or a second-line treatment (after pneumatic dilations or BT injections) for achalasia. However, long-term results seem less satisfactory in patients previously treated with BT. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).     

Midterm follow-up evaluation after a novel approach to anterior fundoplication for achalasia

Background This study aimed to compare the outcomes for Heller myotomy alone and combined with different partial fundoplications. Methods The authors retrospectively reviewed their experience with 69 laparoscopic myotomies and 14 Heller myotomies, 80% of which were performed with partial fundoplication including 20 Toupet, 18 Dor, and 17 modified Dor procedures, in which the fundoplication is sutured to both sides of the crura and not the myotomy. Results The mean age of the study patients was 69 years (range, 15–80 years). Four mucosal perforations were repaired intraoperatively. There was one small bowel fistula in an area of open hernia repair distant from the myotomy. One patient with severe chronic obstructive pulmonary disease died of pneumonia. Phone follow-up evaluation was achieved in 68% of the cases at a mean of 37 months (range, 2–97 months). The results for no dysphagia and for heartburn requiring proton pump inhibitors, respectively, were as follows: Heller myotomy (85.7%, 28.5%), Toupet (66.6%, 33.3%), Dor (83.3%, 20%), and modified Dor (84.6%, 15.3%). Two patients with reflux strictures required annual dilation (Toupet, Dor). Two patients required revisions: one redo Heller myotomy (Dor) and one esophageal replacement (Toupet). Conclusion Heller myotomy provides excellent dysphagia relief with or without fundoplication. Heartburn is a significant problem for a minority of patients. In the authors’ hands, Toupet had the worst results and modified Dor was most protective for heartburn. Presented at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) 13–16 April 2005 in Hollywood, Florida     

Long-term results of laparoscopic Heller myotomy with partial fundoplication for the treatment of achalasia

BACKGROUND: Treatment options for achalasia include medications, endoscopic balloon dilation, injection of botulinum toxin, or surgery. METHODS: The clinical course of 75 consecutive patients who underwent minimally invasive Heller myotomy and partial fundoplication for achalasia between 1991 and 2001 was reviewed by means of a questionnaire. RESULTS: Mean follow-up was 5.3 (range .8 to 10.9) years. Sixty-four percent of questionnaires were returned. Thirty-seven patients (84%) felt much better and 6 (14%) slightly better; 1 (2%) rated the result as unchanged. Twenty-six patients (59%) experienced weight gain. Seven patients (16%) had persistent swallowing problems and 5 (11%) reported frequent reflux. Twenty-five percent underwent additional therapy, including dilation (n = 8, 18%), repeat surgery (n = 2, 5%), and botulinum toxin injection (n = 2, 5%). Eighteen patients (41%) were using a proton pump inhibitor or H2 blocker, three were on a calcium channel blocker (7%), and 1 was using nitroglycerine (2%). CONCLUSION: Laparoscopic Heller myotomy can achieve short- and long-term results comparable to open surgery and should be considered the treatment of choice for patients suffering from achalasia. Despite the frequent need for further therapy, patient satisfaction is good.     

Long-term results after Heller–Dor operation for oesophageal achalasia

Objective: In the literature, reports on the definitive rate of cure of the surgical treatment of oesophageal achalasia are not numerous. The aim of this study is to assess the clinical–instrumental-based patient's outcome related to long-term follow-up. Methods: One hundred and seventy-four patients (80 men, median age 57 years, range 7–83) consecutively submitted to first instance transabdominal Heller–Dor in the period 1978–2002 were considered. Follow-up consisted of clinical interview, endoscopy, barium-swallow and oesophageal manometry if required. Twenty-six cases (15%) were sigmoid achalasias. Results: One patient died post-operatively (severe haemorrhage in a patient previously operated upon for a cardiovascular malformation and suffering for portal hypertension), 173 were followed-up (mean 109 months, range 12–288, median 93 months) of whom 68 for more than 15 years. On the whole 151 patients (87.3%) had satisfactory and 22 (12.7%) had poor long-term results. Seven out of 173 patients (4%), 6 of whom were pre-operatively classified as sigmoid achalasia, subsequently underwent oesophagectomy, 3 for epidermoid cancer, 1 for Barrett's adenocarcinoma, 2 for stasis oesophagitis and recurrent sepsis, 1 for severe dysphagia. Fifteen patients (8.7%) had an insufficient result due to reflux oesophagitis which appeared in 2 (one erosion) after 184 and 252 months. All 22 patients, whether surgically or medically retreated, achieved satisfactory control of dysphagia and reflux symptoms. Conclusions: In the long term, insufficient results strictly related to Heller–Dor failure, always due to reflux oesophagitis, were recorded in 15/173 patients (8.7%) although it is questionable whether reflux oesophagitis appearing after more than 15 years is due to the Dor incompetence or to ageing. In sigmoid achalasia, oesophagectomy rather than myotomy should be taken into consideration in the first instance. In the long-term, surgery is the best definitive treatment for oesophageal achalasia.     

腹腔镜Heller肌切开联合胃底折叠术在贲门失弛缓症治疗中的应用

目的:探讨腹腔镜Heller肌切开联合胃底折叠术(laparoscopic Heller myotomy with a Toupet fundoplication,LHT)治疗贲门失弛缓症的临床价值。方法:回顾分析2000年4月至2008年4月我院为48例贲门失弛缓症患者行LHT的临床资料。结果:手术均获成功,无中转开腹。手术时间65~150min,平均86min,术中出血5~50ml。术后平均住院5.2d。随访1~24个月,术前吞咽困难症状均缓解。结论:LHT具有定位准确、安全、可靠、创伤小、痛苦轻、疗效好等优点,同时可提高手术质量,减少并发症。LHT治疗贲门失弛缓症值得临床推广。     

10-year weight loss outcomes after Roux-en-Y gastric bypass and attendance at follow-up visits: a single-center study

BackgroundLong-term durability of weight loss is a prerequisite for a greater acceptance of bariatric surgery.ObjectivesTo examine long-term weight trajectory in patients undergoing Roux-en-Y gastric bypass (RYGB) and determine factors predicting long-term follow-up and weight outcomes.SettingUniversity hospital.MethodsA retrospective cohort of adults who underwent RYGB during 1997–2010 were identified and followed until 2017. Predictors for attendance at periodic follow-up visits, reduction in body mass index (BMI), and percent excess BMI lost were determined using multivariable logistic regression and linear mixed-effects models. The latter was used to predict long-term weight outcomes for a typical patient.ResultsThe study included 1104 patients with a mean age of 45.5 (standard deviation [SD] 9.9) years and a preoperative BMI of 54.7 (SD 10.9) kg/m². Follow-up data were available for 92.8% of the patients after 1 year, 50.0% after 5 years, and 35.2% after 10 years post-surgery. Black patients, compared with White patients, were less likely to attend follow-up visits. Attendance at follow-up visits at least every other year was not associated with larger weight loss, but higher preoperative BMI, being White (versus Black), and female sex were. Predicted BMI reduction for a typical patient, a 45-year-old White female with a preoperative BMI of 54.7 kg/m² and private health insurance, undergoing laparoscopic RYGB in 2004, was 18.3 (standard error [SE] .36) kg/m² at year 5 and 17.6 (SE .49) kg/m² at year 10.ConclusionRYGB results in clinically significant and durable weight loss. Attendance at periodic follow-up visits does not appear to be associated with long-term weight loss outcomes. Future work should focus on strategies to remove barriers to post-operative care.     

Colonic interposition for esophageal replacement in children remains a good choice: 33-year median follow-up of 65 patients

Introduction

Gastric pull-up has become the predominant technique for esophageal replacement because of allegedly deficient results of colon grafts. This retrospective study examines the long-term results in a large series of colonic interpositions.

Patients and Method

One hundred six children (median, 2.9 years; range, 0.32-15 years) had their esophagus replaced between 1965 and 2008, of which 96 had colon grafts. Those survivors who were 18 years and older were contacted and, if willing, interviewed, examined, and had their functional ability rated using the Karnofsky index.

Results

Ninety-six children had undergone a colon graft, and of these, 9 (9.3%) died. There were 65 long-term survivors whose indications for surgery included caustic injury (n = 32), failed tracheoesophageal fistula repair (n = 16), pure esophageal atresia (n = 14), and others (n = 3). The graft was either retrosternal (n = 49) or mediastinal (n = 16 patients). Twelve patients were unavailable for long-term assessment. After a median follow-up of 33.3 (11-41) years, 23 (43%) of 53 individuals experienced mild symptoms of reflux; scoliosis, 12 (22%) of 53, and/or other complications, 15 (27%) of 53 required further surgery.Thirty-two patients (60%) with Karnofsky indexes of 80% or higher felt healthy, 19 (36%) had mild life-style limitations (index, 40%-80%), and 2 had indexes less than 40%. Most patients live normal lives.

Conclusions

Colon conduits restored gastrointestinal continuity with limited mortality and considerable morbidity but good functional outcome and health perception in the long-term. Our study suggests that colon grafts are no worse than gastric pull-ups in the long-term.     

The condylar plate for treatment of distal femoral fractures: A long-term follow-up study

The aim of this retrospective study was to present the long-term functional and radiological outcomes of indirect reduction techniques and fixation with a condylar plate for treatment of distal femoral supracondylar or intracondylar femoral fractures. The series included 24 men and 17 women, mean age 51 years, between March 1994 and April 1999. All fractures were AO type 33, and eight were open fractures. Primary iliac bone graft was used in five cases. In one case of severe osteoporosis, screw fixation was augmented with cement. There were three delayed unions, one non-union and two infections; four participants required reoperation with bone grafts. Two (5%) participants developed a second varus deformity and three a second valgus deformity; correction osteotomy with bone grafts was necessary in these cases.After a mean follow-up of 9.5 years, the mean Neer score was 82 points and indicated that function was excellent in 16, satisfactory in 9, unsatisfactory in 4 and poor in 2 cases. The mean Neer score in cases of isolated fracture was 89 points and in cases with additional injuries was 72 points. Thus the long-term results of indirect reduction techniques of distal femoral fractures treated with the condylar plate were good to excellent in 82% of cases.     

Tension-free vaginal tape for the treatment of urodynamic stress incontinence: efficacy and adverse effects at 10-year follow-up

Background

One of the most effective and popular current procedures for the surgical treatment of stress urinary incontinence (SUI) is tension-free midurethral slings.

Objective

To evaluate the outcomes of women with retropubic tension-free vaginal tape (TVT) for urodynamic stress incontinence (USI) after 10-yr follow-up.

Design, setting, and participants

This was a prospective observational study. Consecutive women with proven USI were treated with TVT. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded.

Intervention

Standard retropubic TVT.

Measurements

Patients underwent preoperative clinical and urodynamic evaluations. During follow-up examinations, women were assessed for subjective satisfaction and objective cure rates. Multivariable analyses were performed to investigate outcomes.

Results and limitations

A total of 63 women were included. After 10 yr, 5 patients (8%) were lost or no longer evaluable. The 10-yr subjective, objective, and urodynamic cure rates were 89.7%, 93.1%, and 91.4%, respectively. These rates were stable across the whole study period (p > 0.99). De novo overactive bladder was reported by 30.1% and 18.9% of patients at 3-mo and 10-yr follow-up, respectively (p for trend = 0.19). A total of 84.2% of women with detrusor overactivity received antimuscarinic drugs, but 43.8% were nonresponders 12 wk later. At multivariable analysis, maximum detrusor pressure during the filling phase >9 cm H₂O (hazard ratio [HR]: 16.2; p = 0.01) and maximum detrusor pressure during the voiding phase ≤29 cm H₂O (HR: 8.0; p = 0.01) were independent predictors for the recurrence of SUI, as well as obesity was for the recurrence of objective SUI (HR: 17.1; p = 0.01) and of USI (HR: 8.9; p = 0.02), respectively. Intraoperatively, bladder perforation occurred in two cases; no severe bleeding or other complications occurred.

Conclusions

The 10-yr results of this study seem to demonstrate that TVT is a highly effective option for the treatment of female SUI, recording a very high cure rate with low complications after a 10-yr follow-up.     

经改良的Jaslow技术治疗峡部裂型滑脱4年随访结果分析

目的:采用经改良的Jaslow技术治疗峡部裂型腰椎滑脱症,评价其远期疗效.方法:自2000年4月至2002年1月,75例峡部裂型滑脱患者(MeyerdingⅠ度24例,Ⅱ度35例,Ⅲ度16例),其中男35例,女40例,年龄23～71岁,平均40岁,临床症状主要为间歇性跛行、下腰痛和放射痛.采用改良的Jaslow技术辅助症状侧单枚椎间融合器进行手术.通过测量手术前后的滑脱率、腰椎前凸角、椎间隙高度比、植骨融合率观察影像学情况,通过视觉模拟量表(VAS)、Oswestry残疾指数(ODI)和侯树勋标准评价疼痛程度及社会和生活功能情况.结果:75例均获随访,时间48～62个月,平均50.2个月.滑脱率从术前35.6%降至术后9.7%(矫正72.8%),腰椎前凸角由术前(53.6±15.7)°减少至末VAS、ODI分别由术前(6.2±2.5)分、(47.8±10.3)%减轻至末次随访的(2.5±1.9)分、(10.3±3.0)%.经过比较,除腰椎前凸角外其他项目均有统计学意义.根据侯树勋评价标准:优53例,良12例,可8例,差2例,优良率86.7%.并发症:内固定失败2例,一过性神经功能障碍3例,假关节形成3例.结论:经改良的Jaslow技术适合治疗MeyerdingⅠ-Ⅲ度的峡部裂型滑脱,长期随访结果表明该技术减压充分、固定可靠、临床效果满意.     

Risk factors for umbilical trocar site incisional hernia in laparoscopic cholecystectomy: a prospective 3-year follow-up study

BackgroundTrocar site incisional hernia (TSIH) is a common complication after laparoscopic cholecystectomy. The aim of this study was to evaluate the prevalence of TSIH and analyze the influence of several risk factors for this complication in a prospective series.MethodsFrom 2007 to 2008, a prospective observational study with 3 years of follow-up was performed including all consecutive patients with cholelithiasis who underwent elective laparoscopic cholecystectomy. A multivariate analysis was performed to identify risk factors for TSIH.ResultsOverall, 241 patients were included. During a median follow-up period of 46.8 months, 57 patients (25.9%) were diagnosed with umbilical TSIH by physical exam or ultrasound. The multivariate analysis revealed that incision enlargement (odds ratio [OR], 14.17; 95% confidence interval [CI], 3.61 to 55.51; P < .001), wound infection (OR, 5.62; 95% CI, 2.35 to 13.42; P < .001), diabetes mellitus (OR, 2.79; 95% CI, 1.05 to 7.37; P = .0038), and obesity (OR, 2.71; 95% CI, 1.28 to 5.75; P = .009) contributed to the risk for developing a TSIH.ConclusionsUmbilical TSIH is highly prevalent. This study identified several factors that could be useful to introduce preventive measures in high-risk patients.