Publications (98) View all
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Article: Outcomes for Trainees vs Experienced Surgeons Undertaking Laparoscopic Antireflux Surgery - Is Equipoise Achieved?
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ABSTRACT: BACKGROUND: There is a learning curve associated with laparoscopic antireflux surgery which has an impact on patient outcomes. It is unclear, however, whether this can be eliminated by supervision of early cases by experienced surgeons. The aim of this study was to evaluate the impact of training under supervision on outcomes for laparoscopic fundoplication. METHOD: Patients undergoing primary laparoscopic antireflux surgery from 1995 to 2009 were identified from a prospective database. Patients were classified according to whether they were operated on by an experienced consultant or supervised trainee, and sub-categorised according to the presence of a very large hiatus hernia. A standardised questionnaire was used to assess outcomes for heartburn, dysphagia and satisfaction at 1 and 5 years follow-up. Outcomes for the study groups were compared. RESULTS: One thousand seven hundred and ten patients underwent surgery; 1,112 were operated on by consultants and 598 by trainees. The peri-operative complication rate was not different between the groups, although in patients operated on by trainees, there were increased rates of endoscopic dilatation (9 vs. 5 % p = 0.014) and re-operation (9 vs. 6 %, p = 0.031), and a lower satisfaction rate (76 vs. 82 %, p = 0.044) within 5 years of surgery. All other outcomes were similar for trainees vs. consultants. CONCLUSION: The learning curve for laparoscopic fundoplication had a small, but statistically significant, impact on patient outcomes, with slightly lesser outcomes when surgery was undertaken by trainees, even when supervised by experienced surgeons. Although the differences were not large, they raise questions about equipoise and highlight ethical dilemmas with teaching new generations of surgeons.Journal of Gastrointestinal Surgery 05/2013; · 2.83 Impact Factor -
Article: Laparoscopic Anterior 180-Degree Versus Nissen Fundoplication for Gastroesophageal Reflux Disease: Systematic Review and Meta-Analysis of Randomized Clinical Trials.
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ABSTRACT: OBJECTIVE:: To compare short- and long-term outcome after 180-degree laparoscopic anterior fundoplication (180-degree LAF) with laparoscopic Nissen fundoplication (LNF). SUMMARY OF BACKGROUND DATA:: LNF is currently the most frequently performed surgical therapy for gastroesophageal reflux disease. Alternatively, 180-degree LAF has been alleged to reduce troublesome dysphagia and gas-related symptoms, with similar reflux control. METHODS:: MEDLINE, EMBASE, Cochrane Library, and web of Knowledge CPCI-S were searched for randomized clinical trials comparing primary 180-degree LAF with LNF. The methodological quality was evaluated to assess bias risk. Primary outcomes were esophageal acid exposure, esophagitis, heartburn score, dilatation for dysphagia, modified Dakkak dysphagia score (0-45), and reoperation rate. Meta-analysis was conducted at 1 and 5 years. RESULTS:: Five distinct randomized clinical trials comparing 180-degree LAF (n = 227) with LNF (n = 231) were identified. At 1 year, the Dakkak dysphagia score [2.8 vs 4.8; weighted mean difference: -2.25; 95% confidence interval (CI): -2.66 to -1.83; P < 0.001], gas bloating [11% vs 18%; relative risk (RR) 0.59; 95% CI: 0.36-0.97; P = 0.04], flatulence (14% vs 25%; RR: 0.57; 95% CI: 0.35-0.91; P = 0.02), inability to belch (19% vs 31%; RR: 0.63; 95% CI: 0.40-0.99; P = 0.05), and inability to relieve bloating (34% vs 44%; RR: 0.74; 95% CI: 0.55-0.99; P = 0.04) were lower after 180-degree LAF. Esophageal acid exposure (standardized mean difference: 0.19; 95% CI: -0.07 to 0.46; P = 0.15), esophagitis (19% vs 13%; RR: 1.42; 95% CI: 0.69-2.91; P = 0.34), heartburn score (standardized mean difference: 1.27; 95% CI:-0.36 to 2.90; P = 0.13), dilatation rate (1.4% vs 2.8%; RR: 0.60; 95% CI: 0.19-1.91; P = 0.39), reoperation rate (5.7% vs 2.8%; RR: 2.08; 95% CI: 0.80-5.41; P = 0.13), perioperative outcome, regurgitation, proton pump inhibitor (PPI) use, lower esophageal sphincter pressure, and patient satisfaction were similar after 180-degree LAF and LNF. At 5 years, the Dakkak dysphagia score, flatulence, inability to belch, and inability to relieve bloating remained lower after 180-degree LAF. The 5-year heartburn score, dilatation rate, reoperation rate, PPI use, and patient satisfaction were similar. CONCLUSIONS:: At 1 and 5 years, dysphagia and gas-related symptoms are lower after 180-degree LAF than after LNF, and esophageal acid exposure and esophagitis are similar, with no differences in heartburn scores, patient satisfaction, dilatations, and reoperation rate. These results lend level 1a support for the use of 180-degree LAF for the surgical treatment of gastroesophageal reflux disease.Annals of surgery 03/2013; · 7.90 Impact Factor -
Article: Can miRNA profiling allow us to determine which patients with esophageal cancer will respond to chemoradiotherapy?
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ABSTRACT: Evaluation of: Ko MA, Zehong G, Virtanen C et al. miRNA expression profiling of esophageal cancer before and after induction chemoradiotherapy. Ann. Thorac. Surg. 94(4), 1094-1103 (2012). Most patients undergoing surgery for esophageal cancer are treated before surgery with chemotherapy and radiotherapy. However, some tumors respond poorly to these treatments. The article under evaluation profiled miRNA levels in esophageal cancers from patients who did respond to chemoradiotherapy versus those who did not. A large number of miRNAs were differentially expressed between responders versus nonresponders, and patients with either decreased miR-135b or increased miR-145 expression in cancer tissue had improved disease-free survival. Although this study has several limitations, including a mixed cohort of patients with adenocarcinoma and squamous cell carcinoma, and the absence of a validation set of patients, the results do suggest that a miRNA profiling approach may be able to circumvent one of the primary challenges for biomarker development, molecular heterogeneity.Expert Review of Anti-infective Therapy 03/2013; 13(3):271-3. · 2.65 Impact Factor -
Article: Surgical management of peptic ulcer bleeding by Australian and New Zealand upper gastrointestinal surgeons.
ANZ Journal of Surgery 03/2013; 83(3):104-8. · 1.25 Impact Factor -
Article: Impact of gastroesophageal reflux on microRNA expression, location and function.
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ABSTRACT: BACKGROUND: Ulceration of the esophageal squamous mucosa (ulcerative esophagitis) is a pathological manifestation of gastroesophageal reflux disease, and is a major risk factor for the development of Barrett's esophagus. Barrett's esophagus is characterised by replacement of reflux-damaged esophageal squamous epithelium with a columnar intestinal-like epithelium. We previously reported discovery of microRNAs that are differentially expressed between esophageal squamous mucosa and Barrett's esophagus mucosa. Now, to better understand early steps in the initiation of Barrett's esophagus, we assessed the expression, location and function of these microRNAs in esophageal squamous mucosa from individuals with ulcerative esophagitis. METHODS: Quantitative real-time PCR was used to compare miR-21, 143, 145, 194, 203, 205 and 215 expression levels in esophageal mucosa from individuals without pathological gastroesophageal reflux to individuals with ulcerative esophagitis. Correlations between microRNA expression and messenger RNA differentiation markers BMP-4, CK8 and CK14 were analyzed. The cellular localization of microRNAs within the esophageal mucosa was determined using in-situ hybridisation. microRNA involvement in proliferation and apoptosis was assessed following transfection of a human squamous esophageal mucosal cell line (Het-1A). RESULTS: miR-143, miR-145 and miR-205 levels were significantly higher in gastroesophageal reflux compared with controls. Elevated miR-143 expression correlated with BMP-4 and CK8 expression, and elevated miR-205 expression correlated negatively with CK14 expression. Endogenous miR-143, miR-145 and miR-205 expression was localized to the basal layer of the esophageal epithelium. Transfection of miR-143, 145 and 205 mimics into Het-1A cells resulted in increased apoptosis and decreased proliferation. CONCLUSIONS: Elevated miR-143, miR-145 and miR-205 expression was observed in esophageal squamous mucosa of individuals with ulcerative esophagitis. These miRNAs localized to the basal layer of the esophageal epithelium. They reduced proliferation and increased apoptosis, and may play roles in regulating epithelial restoration in response to injury caused by gastroesophageal reflux.BMC Gastroenterology 01/2013; 13(1):4. · 2.42 Impact Factor
