Biomedical subjects

A Torquati

Publications and source records attributed to A Torquati.

13 recordsLinked to original sources

PubMed2006

Long-term evaluation of patient satisfaction and reflux symptoms after laparoscopic fundoplication with Collis gastroplasty.

BACKGROUND: Esophageal shortening is a complication of advanced gastroesophageal reflux disease (GERD). For patients with short esophagus, Collis gastroplasty combined with fundoplication provides excellent symptomatic relief from GERD disease. The literature lacks studies comparing satisfaction and reflux symptoms between patients who underwent Nissen fundoplication with Collis gastroplasty and those who had primary fundoplication alone. This study aimed to assess long-term satisfaction and GERD-related quality of life after laparoscopic Collis-Nissen fundoplication, and to compare them with those for Nissen fundoplication alone. METHODS: A nested case-control study was conducted. In this study, 14 cases of laparoscopic Collis-Nissen fundoplications were matched for age, gender, and length of the follow-up period to a cohort of 120 control subjects who underwent laparoscopic Nissen fundoplication. All the patients were mailed a follow-up survey which included a Short Form-12 (SF-12) health status (quality-of-life) questionnaire (a validated quality-of-life instrument), a Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire (a GERD-specific quality-of-life instrument), and queries regarding long-term satisfaction and medication use. RESULTS: Both groups showed a significant postoperative increase in QOLRAD mean scores (p = 0.01). However, the difference in the delta (postoperative-preoperative) score between the two groups was not significant (Fig. 1). There were no differences in mental (MCS) or physical (PCS) SF-12 scores between the two groups. The rate of satisfaction with the surgery was similar in the Nissen-Collis fundoplication (87.5%) and Nissen fundoplication (87%) groups. CONCLUSIONS: Collis gastroplasty combined with Nissen fundoplication is an effective procedure for patients with a shortened esophagus diagnosed intraoperatively during antireflux surgery. Patient satisfaction, postoperative quality of life, and QOLRAD score improvement after this procedure are comparable with those observed in patients treated with Nissen fundoplication alone.

Adult↗

PubMed2006

Predictors of success after laparoscopic gastric bypass: a multivariate analysis of socioeconomic factors.

BACKGROUND: Laparoscopic gastric bypass (LGB) has proven efficacy in causing significant and durable weight loss. However, the degree of postoperative weight loss and metabolic improvement varies greatly among individuals. Our study is aimed to identify independent predictors of successful weight loss after LGB. METHODS: Socioeconomic demographics were prospectively collected on patients undergoing LGB. Primary endpoint was percent of excess weight loss (EWL) at 1-year follow-up. Insufficient weight loss was defined as EWL or=52.8%. According to this definition, 147 patients (81.7%) achieved successful weight loss 1 year after LGB. On univariate analysis, preoperative BMI had a significant effect on EWL, with patients with BMI <50 achieving a higher percentage of EWL (91.7% vs 61.6%; p = 0.001). Marriage status was also a significant predictor of successful outcome, with single patients achieving a higher percentage of EWL than married patients (89.8% vs 77.7%; p = 0.04). Race had a noticeable but not statistically significant effect, with Caucasian patients achieving a higher percentage of EWL than African Americans (82.9% vs 60%; p = 0.06). Marital status remained an independent predictor of success in the multivariate logistic regression model after adjusting for covariates. Married patients were at more than two times the risk of failure compared to those who were unmarried (OR 2.6; 95% CI: 1.1-6.5, p = 0.04). CONCLUSIONS: Weight loss achieved at 1 year after LGB is suboptimal in superobese patients. Single patients with BMI < 50 had the best chance of achieving greater weight loss.

Adult↗

PubMed2006

Heller myotomy vs Heller myotomy plus Dor fundoplication: cost-utility analysis of a randomized trial.

BACKGROUND: The addition of a Dor antireflux procedure reduces the risk of pathologic gastroesophageal reflux (GER) by ninefold following laparoscopic Heller myotomy for achalasia. It is not clear, however, how these benefits compare with the increased cost of the fundoplication. The objective of this study was to estimate the cost-effectiveness of Heller myotomy plus Dor fundoplication compared with Heller alone in patients with achalasia. METHODS: We conducted a cost-utility analysis using the Markov simulation model to examine the two treatment alternatives. The model estimated the total expected costs of each strategy over a 10-year time horizon. Data for the model were derived from our randomized clinical trial. The strategies were compared using the method of incremental cost-effectiveness analysis. RESULTS: The incidence of pathologic GER was 47.6% (10 of 21 patients) in the Heller group and 9.1% (2 of 22 patients) in the Heller plus Dor group using an intention-to-treat analysis (p = 0.005). Heller plus Dor was associated with a significant reduction in the risk of GERD (relative risk 0.11; 95% confidence interval 0.02-0.59; p = 0.01). The cost of surgery was significantly higher for Heller plus Dor than for Heller alone (mean difference $942; p = 0.04), secondary to a longer operating room time (mean difference 40 min; p = 0.01). At a time horizon of 10 years, when proton pump inhibitor (PPI) therapy costs are considered, the cost-utility analysis demonstrates that Heller plus Dor surgery is associated with a total cost of $6,861 per patient and a quality-adjusted life expectancy of 9.9 years, whereas Heller-alone surgery is associated with a cost of $9,541 per patient and a quality-adjusted life expectancy of 9.5 years. CONCLUSIONS: In achalasia patients, Heller myotomy plus Dor fundoplication is preferred to Heller alone because it is both more effective in preventing postoperative GERD and more cost-effective at a time horizon of 10 years.

Cost-Benefit Analysis↗

PubMed2005

Endoscopic evaluation of the gastrojejunostomy in laparoscopic gastric bypass. A series of 340 patients without postoperative leak.

BACKGROUND: A significant and potentially deadly complication of the Roux-en-Y gastric bypass is leakage from the gastrojejunostomy (GJ). The aim of our study was to evaluate the efficacy of intraoperative endoscopy in preventing postoperative anastomotic leakage. METHODS: The study enrolled 340 consecutive patients undergoing laparoscopic gastric bypass procedures performed from January 2001 to July 2004. In all cases, an endoscopist performed video gastroscopy to evaluate the integrity of the GJ using air insufflation of the pouch after distal clamping of the Roux limb. Intraoperative leaks were repaired and the anastomosis was retested. Demographic, operative, and endoscopic data were collected and analyzed. Logistic regression was used in both univariate and multivariate modeling to identify independent preoperative variables associated with the presence of intraoperative leak. Model parameters were estimated by the maximum likelihood method. From these estimates, odds ratios (ORs) with 95% confidence intervals (CIs) were computed. RESULTS: There were no postoperative anastomotic leaks or mortalities in our series. Overall, endoscopic evaluation of the GJ resulted in the detection of 56 intraoperative leaks (16.4%). There was a significant difference in the incidence of intraoperative leakage for patients older than 40 years (21%) vs those younger than 40 years (10.5%; p = 0.01). In the initial 91 cases, the GJ was performed by the end-to-end anastomosis (EEA) technique; the subsequent 249 were performed with a combination of linear stapling and handsewn technique. There was a trend toward more leakage in the GIA group (18%) versus EEA (12%); however, the difference was not significant (p = 0.188). Age remained an independent risk factor for leak detected intraoperatively in the multivariate logistic regression model after adjusting for covariates. Age >40 years increased the risk of intraoperative leakage by 2.3 times (OR, 2.3; 95% CI, 1.2-4.6; p = 0.01). The rate of postoperative anastomotic stricture was the same among patients detected with an intraoperative leak (5.4%) and those without (5.6%; p = 0.934). CONCLUSIONS: Endoscopic evaluation of the GJ is a sensitive and reliable technique for demonstrating anastomotic integrity and preventing postoperative morbidity after gastric bypass. Age >40 years was identified as an independent risk factor for intraoperative leak in this series.

Adult↗

PubMed2004

Three year's experience with the Stretta procedure: did it really make a difference?

BACKGROUND: Endoscopic treatment is merging as a new option for GERD treatment. Many modalities have been used with modest short-term success, but no long-term follow-ups have been published. We present our 3-yr experience at Vanderbilt University using endoscopic radiofrequency energy (Stretta procedure) for GERD treatment. METHODS: Patients with follow-up >6 months were prospectively studied under IRB protocol. All were mailed SF-12 health status questionnaire and GERD specific quality-of-life (QOLRAD) questionnaires, queries about satisfaction with Stretta, and medication use. All were invited for 24-hour pH study. RESULTS: Eighty-six Stretta procedures were performed between 8/2000 and 7/2003 on 85 patients; all were outpatients, 89% under conscious sedation. Seventy-seven patients qualified for the study; 61 completed the survey, 24 returned for pH study. Follow-up was 26.2 +/- 7.5 months (6-36). All were on daily PPIs, with proven GERD by pH study or endoscopy. Mean preoperative acid exposure time was 7.8+/-2.6%, mean DeMeester score was 40.2+/-17.6. Postoperative mean acid exposure time was 5.1+/-3.3 (p=0.001), DeMeester score was 29.5+/-20.5 (p=0.041). Normal postoperative acid exposure time (pH<4 in <4.2%) was achieved in 42% of patients tested. Patients were then divided according to medication use at the end of f/u in 2 groups: Responders (off or >50% decrease in PPI dose), and nonresponders (on >50% of original PPI dose, or had fundoplication). Response rate was 60% (39 patients), 8 nonresponders underwent fundoplication (12%). Satisfaction rate was 73%. Statistically significant difference was found between the 2 groups in all measurements; SF-12 physical and mental score for responders were 45.5+/-10.2, and 52.6+/-7.8; and for nonresponders were 37.8+/-11.2 and 40.9+/-11.3 (p=0.012, p=0.0001), respectively. Statistically significant difference was also found between responders and nonresponders in postoperative acid exposure (4.5+/-3.34 vs 7.2+/-2.3, p=0.034), and DeMeester score (26.3+/-20.4 vs 39.7+/-20.2, p=0.05). Paired T test was used to compare pre- and postoperative acid exposure in each group; statistically significant difference was found only among responders: total reflux time was 7.50+/-2.3 preop and 4.5+/-3.34 postop (p=0.0001), whereas for nonresponders it was 8.6+/-3.7 and 7.2+/-2.3 (p=0.8), DeMeester scores pre- and postop among responders were 40.0+/-19.7 and 26.3+/-20.4, respectively (p=0.016), whereas for nonresponders it was 40.5+/-14.3 and 39.7+/-20.2 (p=0.79). CONCLUSIONS: Stretta is a safe modestly effective, totally endoscopic treatment for GERD. Symptomatic improvement when achieved is often associated with correlating improvement in distal acid exposure. This exposure normalizes in nearly half the treated patients.

Adult↗

PubMed2004

Long-term follow-up study of the Stretta procedure for the treatment of gastroesophageal reflux disease.

BACKGROUND: The endoscopic delivery of temperature-controlled radiofrequency energy to the gastroesophageal junction (Stretta procedure) recently has been shown effective for patients with gastroesophageal reflux disease (GERD). However, its effectiveness has been assessed mainly over short periods (6-12 months). This study aimed to evaluate long-term results of the Stretta procedure. METHODS: All patients undergoing the Stretta procedure since August 2000 were prospectively evaluated under an institutional review board-approved protocol. All patients with a follow-up period longer than 18 months were recruited for a 24-h pH study and mailed a follow-up survey, which included the following: Short Form 12 (SF-12) health status questionnaire, GERD-specific quality-of-life questionnaire (QOLRAD), and queries regarding long-term satisfaction and medication use. RESULTS: The Stretta procedure was performed on 82 patients, and 41 patients with a follow-up period longer than 18 months qualified for the study. Follow-up surveys were completed by 36 patients (88%) during a mean follow-up period of 27.1 +/- 3.7 months. Of these 36 patients, 30 (83%) were highly satisfied with the procedure and would have it performed again. More than half of the Fifty Stretta patients (56%) had completely discontinued their use of proton pump inhibitors (PPIs), and an additional 31% had reduced their dose significantly. The mean PPI equivalent doses were 37.8 +/- 22.2 mg/day before the Stretta procedure and 11.6 +/- 14.6 mg/day at 27-month follow-up assessment (p = 0.001). According to the patient outcomes for daily PPI use (yes/no), the patients were divided into two groups: responders (n = 20) and nonresponders (n = 16). The responder group scored higher in QOLRAD score (p = 0.0001), SF-12 physical score (p = 0.038), and SF-12 mental score (p = 0.003). In the 24-hour pH study, the responder group demonstrated a significant decrease in distal esophageal acid exposure time (6.4% +/- 1.5% to 3.1% +/- 1.4%; p = 0.0001). CONCLUSION: The Stretta procedure results in a statistical significant long-term decrease in GERD symptoms and PPI use. The treatment effect is durable beyond 2 years, and 56% of patients had discontinued their user of all antisecretory drugs.

Catheter Ablation↗

PubMed2004

Endoscopic treatment modalities for gastroesophageal reflux disease.

A debate has been going for decades between surgeons and gastroenterologists about the treatment of choice for gastroesophageal reflux disease (GERD). The lower esophageal sphincter (LES) has been historically far from the reach of gastroenterologists, who adopted the symptomatic treatment as their approach to reflux disease through reduction of gastric acid. As for surgeons, reaching the LES was only possible by invading the thoracic or abdominal cavity. Although their approach was later refined to become "minimally" invasive, it was still deemed too invasive by others to allow it to be the "gold standard." Simple logic should lead one to think about the "natural route" as the easiest way to reach the LES. This concept has opened the door for the new era of GERD treatment through "endoscopic modality." Seven different techniques are currently being used to treat patients with GERD. We review the mechanism of action, potential side effects, efficacy, durability, and results from the most recent or largest experience of each. This review shows that endoscopic treatment has definitely earned its place as a viable option for GERD treatment in selected patients. With the available data from clinical trials, it is not possible to determine the best modality available, and the endoscopic treatment of choice is to be determined with further studies.

Catheter Ablation↗

PubMed2004

Laparoscopic fundoplication: 5-year follow-up.

There are few published reports on outcomes of 5 or more years following laparoscopic fundoplication. Gastroesophageal reflux disease (GERD) specific quality of life questionnaires (QOLRAD), short form health surveys (SF12), and queries regarding current medication use and long-term satisfaction were mailed to all patients who underwent laparoscopic fundoplication at our institution. Results are reported as mean +/- SEM. Seventy-six patients underwent laparoscopic fundoplication (63 Nissen, 13 Toupet) between November 1992 and December 1997. Fifty-two patients completed questionnaires (68%). Mean follow-up was 5.1 +/- 0.2 years (range, 4-9 years). Mean QOLRAD scores were 5.8 +/- 0.2, (scale 0-7, a higher score reflecting improved QOL), which is comparable to the general population (6.0 mean). SF-12 mental and physical scores were 46.6 +/- 1.7 and 34.2 +/- 1.6, respectively, versus 50.7 and 51.2 for the general population. Forty-seven patients (92%) would have the procedure again. Eleven (21%) remained on antisecretory medications (15% proton pump inhibitor and 6% H2 receptor antagonists). None of the 11 patients underwent 24-hour pH testing to document persistent acid exposure. Furthermore, postoperative symptoms of heartburn, dysphagia, and abdominal bloating were rated as none to mild in the majority of patients. Laparoscopic fundoplication is an effective long-term treatment for GERD, resulting in high patient satisfaction, improved quality of life, and elimination of antisecretory medicines in the majority of patients.

Adolescent↗

PubMed1993

Multivariate analysis for predicting the presence of bacteria in bile in patients with acute cholecystitis.

OBJECTIVE: to find out whether the presence of bacteria in bile could be predicted accurately from preoperative data in patients with acute cholecystitis. DESIGN: Prospective open study. SETTING: University hospital. SUBJECTS: 42 patients undergoing cholecystectomy for acute gallstone cholecystitis. MAIN OUTCOME MEASURES: Correlations between 24 preoperative clinical and laboratory variables, and the incidence of pathogenic organism in bile. RESULTS: 4 of the 24 variables tested were of predictive significance. These were external body temperature on admission, percentage of neutrophils, preoperative white blood cell count, and total serum concentration of bilirubin. When these predictive variables were evaluated in the discriminant analysis equation they had a sensitivity of 92% and a specificity of 100% in predicting positive bile culture. CONCLUSION: Multivariate discriminant analysis permits accurate preoperative prediction of bile cultures growing pathogens in patient undergoing cholecystectomy for acute cholecystitis.

Acute Disease↗

PubMed1992

Wound infection after cholecystectomy. Correlation between bacteria in bile and wound infection after operation on the gallbladder for acute and chronic gallstone disease.

OBJECTIVE: To see if there was a difference in the wound infection rates after operation for acute and chronic cholecystitis, and to see if the presence of bacteria in the bile had any influence on those rates. DESIGN: Prospective open study. SETTING: University hospital. SUBJECTS: 213 Patients undergoing cholecystectomy for acute or chronic gallstone disease. MAIN OUTCOME MEASURES: Incidence of postoperative wound infection, and of bile cultures growing pathogenic organism. RESULTS: There was no difference in wound infection rates between patients operated on for acute and those operated on for chronic cholecystitis. The presence of bacteria in the bile did not seem to influence the wound infection rate in either group. CONCLUSIONS: Early cholecystectomy and appropriate antibiotic prophylaxis result in an acceptably low wound infection rate, and the growth of bacteria from bile is not predictive of the development of wound infection.

Acute Disease↗

PubMedDate not supplied

[Computers in surgery].

The introduction of computers in medicine, particularly for what surgery is concerned, has many implications related to its optimal utilization. Possible applications as well as advantages and limits of such recording system in a surgical ward are examined. Emphasis is placed on the clinical data management model and the ways the different structures of the system are related. The computer processing of these data provides valid material for either clinical and surgical research or statistical studies.

Computers↗

PubMedDate not supplied

Major acute inflammatory complications of diverticular disease of the colon: planning of surgical management.

BACKGROUND/AIMS: The aim of this study was to determine the most appropriate surgical strategy in the management of patients with major inflammatory complications of colonic diverticular disease. MATERIALS AND METHODS: Out of 259 patients affected by complicated diverticular disease of the colon, 43 consecutive patients (16.6%) who underwent urgent or emergency surgical intervention for diverticular perforation during a 20-year period (1975-1994) were retrospectively analyzed. According to the changes in the surgical approach over the time, the series was divided into two groups: 1975-1985 group A (n = 23), 1986-1994 group B (n = 20). The clinical diagnosis was confirmed by operative and pathologic findings. RESULTS: Out of 43 patients, 11 underwent derivative procedure and 32 resection. There were no significant differences among the two groups of patients according to sex ratio and mean age. The overall percentage of patients in group B who underwent resective procedure (100%) was significantly greater in comparison with that in group A (52%) (p < 0.001). Colostomy and drainage was employed only during the first period (30%)(vs group B, p < 0.05) and the proportion of patients who underwent primary resection and anastomosis was significantly higher during the second period (45%) (vs group A, p < 0.05). CONCLUSIONS: It must be stressed that resection of the diseased segment at initial operation appears mandatory; one-stage procedure is indicated when infection is confined to the mesentery, while resection and anastomosis with covering colostomy (two-stage procedure) is preferable whenever peritoneal contamination has occurred. Hartmann's operation remains the procedure of choice in the patients presenting known impaired immunity or fecal contamination.

Abdominal Abscess↗

PubMedDate not supplied

Acute pseudo-obstruction of the colon (Ogilvie's syndrome): advances in management.

The management of the patients with acute pseudo-obstruction of the colon (APOC) still represents a matter of debate. To better evaluate and compare the effectiveness of various therapeutic approaches in the management of APOC 29 patients were considered. These were included according to three consecutive periods in: group A (1977-1982) concerning patients who underwent medical treatment alone (n = 8) or endoscopic (n = 4) and surgical (n = 1) decompression; group B (1983-1990) in which the management was based on simple endoscopic decompression (n = 10); group C (1991-1995) including patients in whom placement, under fluoroscopic control, of a tube in the cecum following endoscopic decompression was provided (n = 6). Mean time required for resolution of colonic distension was 2.3 (+/- 0.50 SD) days in patients who underwent endoscopic decompression and tube placement, as compared to 4.5 (+/- 2.47 SD) days in the group of patients treated either with conservative measures or simple endoscopic decompression (p = 0.04). No recurrence occurred after colonoscopic decompression and tube placement while colonic distension recurred in 4 of 14 patients managed by simple endoscopic decompression (0% vs. 28.6%, n.s.). Our experience showed that endoscopic decompression is an effective method, moreover if associated with the placement of an indwelling tube into the right colon. This method, for its easiness and safeness, besides its effectiveness in preventing the recurrence of colonic distension, may be surely considered an advance in the management of acute pseudo-obstruction of the colon.

Aged↗