17 research outputs found
Laparoscopic Heller Myotomy Versus Endoscopic Balloon Dilatation for the Treatment of Achalasia A Network Meta-Analysis
Objective: Comparison of short-and long-term effects after laparoscopic Heller myotomy (LHM) and endoscopic balloon dilation (EBD) considering the need for retreatment. Background: Previously published studies have indicated that LHM is the most effective treatment for Achalasia. In contrast to that a recent randomized trial found EBD equivalent to LHM 2 years after initial treatment. Methods: A search in Medline, PubMed, and Cochrane Central Register of Controlled Trials was conducted for prospective studies on interventional achalasia therapy with predefined exclusion criteria. Data on success rates after the initial and repeated treatment were extracted. An adjusted network meta-analysis and meta-regression analysis was used, combined with a headto-head comparison, for follow-up at 12, 24, and 60 months. Results: Sixteen studies including results of 590 LHM and EBD patients were identified. Odds ratio (OR) was 2.20 at 12 months (95% confidence interval: 1.18-4.09; P = 0.01); 5.06 at 24 months (2.61-9.80; P < 0.00001) and 29.83 at 60 months (3.96-224.68; P = 0.001). LHM was also significantly superior for all time points when therapy included re-treatments , and 17.90 (2.17-147.98); P ≤ 0.01 for all comparisons) Complication rates were not significantly different. Meta-regression analysis showed that amount of dilations had a significant impact on treatment effects (P = 0.009). Every dilation (up to 3) improved treatment effect by 11.9% (2.8%-21.8%). Conclusions: In this network meta-analysis, LHM demonstrated superior short-and long-term efficacy and should be considered first-line treatment of esophageal achalasia. Keywords: achalasia, economic cost, endoscopy, esophagus, health, idiopathic achalasia, laparoscopic surgery, meta-analysis, motility disorders, network meta-analysis, review, surgery (Ann Surg 2013;258:943-952 A chalasia is a rare esophageal motility disorder caused by degeneration of the myenteric plexus, resulting in esophageal dysmotility and incomplete lower esophageal sphincter relaxation. The disease is likely caused by a virus-induced autoimmune response, but this is still debated. 1 The incidence in the Western world is 1/100 000. 2-4 Treatment can be pharmacological, endoscopic, or surgical. Pharmacological treatment is only marginally effective and is reserved for patients with mild symptoms or who refuse other treatments. 7-9 Several studies and a large meta-analysis have indicated that laparoscopic Heller myotomy (LHM) is the most effective treatment for achalasia. 3,4,10 However, a recent large prospective randomized controlled trial (RCT) comparing EBD and LHM has challenged this view. 11 This study found similar success rates for EBD and LHM 2 years after initial treatment. However, the number of EBD interventions per patient was notably higher than other studies. 3,11 The purpose of this meta-analysis is to determine which treatment is most effective at relieving symptoms and to further clarify the impact of retreatments for patients with achalasia. METHODS This meta-analysis was registered in the international register of systematic reviews (PROSPERO) (CRD42012002071). 12 Search Strategy and Trial Selection A prospective search of Medline, PubMed, and Cochrane Central Register of Controlled Trials was performed to identify relevant publications. The search keyword was "Esophageal Achalasia." Subsequently, the search was limited by the terms "Human," "Clinical Trial," and publication language "English." Publications from 1975 through October 2011 were considered for review To obtain indirect evidence by adjusted network meta-analysis, relative evidence is needed (LHM vs X; EBD vs X). Therefore, success rates were compared with those of either EBTI or open Heller myotomy (OHM). Direct evidence was achieved from head-to-hea
Endoscopy in Canada: Proceedings of the National Roundtable
This 2014 roundtable discussion, hosted by the Canadian Association of General Surgeons, brought together general surgeons and gastroenterologists with expertise in endoscopy from across Canada to discuss the state of endoscopy in Canada. The focus of the roundtable was the evaluation of the competence of general surgeons at endoscopy, reviewing quality assurance parameters for high-quality endoscopy, measuring and assessing surgical resident preparedness for endoscopy practice, evaluating credentialing programs for the endosuite and predicting the future of endoscopic services in Canada. The roundtable noted several important observations. There exist inadequacies in both resident training and the assessment of competency in endoscopy. From these observations, several collaborative recommendations were then stated. These included the need for a formal and standardized system of both accreditation and training endoscopists
Defining competencies for safe thyroidectomy: An international Delphi consensus
BACKGROUND: Current methods for teaching and assessing competencies that characterize expert intraoperative performance are inconsistent, subjective, and lack standardization. This mixed-methods study was designed to define and establish expert consensus on the most important competencies required to perform a thyroidectomy safely.
METHODS: Cognitive task analyses for thyroidectomy were performed with semistructured interviews of experts in thyroid surgery. Verbal data were transcribed verbatim, coded, and categorized according to themes that were synthesized into a list of items. Once qualitative data reached saturation, 26 experts were invited to complete 2-round online Delphi surveys to rank each item on a Likert scale of importance (1-7). Consensus was predefined as a Cronbach\u27s α ≥ 0.80.
RESULTS: Sixty items were synthesized from 5 interviews and categorized into 8 sections: preparation (n = 8), incision/exposure (n = 11), general considerations (n = 4), middle thyroid vein (n = 1), superior pole (n = 5), inferior pole (n = 5), posterolateral dissection (n = 19), and closure (n = 7). Eighteen (69%) experts from 3 countries participated in the Delphi survey. Consensus was achieved after 2 voting rounds (Cronbach\u27s α = 0.95). Greatest weighted sections included Superior Pole Dissection and Posterolateral Dissection.
CONCLUSION: Consensus was achieved on defining the most important competencies for safe thyroidectomy. This blueprint serves as the basis for instructional design and objective assessment tools to evaluate performance
A Randomized Study Comparing Hemostasis of Laparoscopic Clips Delivered via Flexible Endoscopy Versus Conventional Endoscopic Clips On Porcine Mesenteric Vessels
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Fundamentals of Endoscopic Surgery cognitive examination: development and validity evidence
Flexible endoscopy is an integral part of surgical care. Exposure to endoscopic procedures varies greatly in surgical training. The Society of American Gastrointestinal and Endoscopic Surgeons has developed the Fundamentals of Endoscopic Surgery (FES), which serves to teach and assess the fundamental knowledge and skills required to practice flexible endoscopy of the gastrointestinal tract. This report describes the validity evidence in the development of the FES cognitive examination.Core areas in the practice of gastrointestinal endoscopy were identified through facilitated expert focus groups to establish validity evidence for the test content. Test items then were developed based on the content areas. Prospective enrollment of participants at various levels of training and experience was used for beta testing. Two FES cognitive test versions then were developed based on beta testing data. The Angoff and contrasting group methods were used to determine the passing score. Validity evidence was established through correlation of experience level with examination score.A total of 220 test items were developed in accordance with the defined test blueprint and formulated into two versions of 120 questions each. The versions were administered randomly to 363 participants. The correlation between test scores and training level was high (r = 0.69), with similar results noted for contrasting groups based on endoscopic rotation and endoscopic procedural experience. Items then were selected for two test forms of 75 items each, and a passing score was established.The FES cognitive examination is the first test with validity evidence to assess the basic knowledge needed to perform flexible endoscopy. Combined with the hands-on skills examination, this assessment tool is a key component for FES certification
Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study
Pilot studies have indicated that peroral endoscopic myotomy (POEM) might be a safe and effective treatment for achalasia. We performed a prospective, international, multicenter study to determine the outcomes of 70 patients who underwent POEM at 5 centers in Europe and North America. Three months after POEM, 97% of patients were in symptom remission (95% confidence interval, 89%-99%); symptom scores were reduced from 7 to 1 (P < .001) and lower esophageal sphincter pressures were reduced from 28 to 9 mm Hg (P < .001). The percentage of patients in symptom remission at 6 and 12 months was 89% and 82%, respectively. POEM was found to be an effective treatment for achalasia after a mean follow-up period of 10 month
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Fundamentals of endoscopic surgery: creation and validation of the hands-on test
The Fundamentals of Endoscopic Surgery™ (FES) program consists of online materials and didactic and skills-based tests. All components were designed to measure the skills and knowledge required to perform safe flexible endoscopy. The purpose of this multicenter study was to evaluate the reliability and validity of the hands-on component of the FES examination, and to establish the pass score.Expert endoscopists identified the critical skill set required for flexible endoscopy. They were then modeled in a virtual reality simulator (GI Mentor™ II, Simbionix™ Ltd., Airport City, Israel) to create five tasks and metrics. Scores were designed to measure both speed and precision. Validity evidence was assessed by correlating performance with self-reported endoscopic experience (surgeons and gastroenterologists [GIs]). Internal consistency of each test task was assessed using Cronbach’s alpha. Test–retest reliability was determined by having the same participant perform the test a second time and comparing their scores. Passing scores were determined by a contrasting groups methodology and use of receiver operating characteristic curves.A total of 160 participants (17 % GIs) performed the simulator test. Scores on the five tasks showed good internal consistency reliability and all had significant correlations with endoscopic experience. Total FES scores correlated 0.73, with participants’ level of endoscopic experience providing evidence of their validity, and their internal consistency reliability (Cronbach’s alpha) was 0.82. Test–retest reliability was assessed in 11 participants, and the intraclass correlation was 0.85. The passing score was determined and is estimated to have a sensitivity (true positive rate) of 0.81 and a 1-specificity (false positive rate) of 0.21.The FES hands-on skills test examines the basic procedural components required to perform safe flexible endoscopy. It meets rigorous standards of reliability and validity required for high-stakes examinations, and, together with the knowledge component, may help contribute to the definition and determination of competence in endoscopy