[Show abstract][Hide abstract] ABSTRACT: Objectives:
Return to sports (RTS) is a primary goal for ACL reconstruction. Recent studies indicate that return to prior level of sports participation is poor with only 45% of patients having returned to sport.1 The purpose of this study was to evaluate return to pre-injury level of sports participation after ACL reconstruction using a strict comprehensive definition for RTS.
Participants who were 1 to 5 years after ACL reconstruction completed a survey to determine their pre-and post-surgery sports activity levels. Comprehensive return to pre-injury level of sports (comprehensive RTS) was operationally defined as returning to the same type and frequency of sports and same Marx Activity Score (MAS) as before injury. Patients also answered a global question on whether they had returned to their pre-injury level of sports (global RTS). The International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) was used to compare symptoms and function between patients who did and did not meet comprehensive RTS criteria.
One hundred sixty eight participants (mean age, 28.8±10.9 years) completed the survey. Using comprehensive RTS criteria, 69 (41.1%) participants returned to their pre-injury level of sports. Based on the global RTS, 79 (47%) reported they had returned to their pre-injury level of sports. Fifty nine (74.7%) of the 79 individuals that reported global RTS met the comprehensive RTS criteria. Patients who met the comprehensive RTS criteria had fewer symptoms and better function based on the IKDC-SKF than those who did not (87.5±10.6 vs. 80.1±13.7, p<0.001). Of the 93 patients who did not meet comprehensive RTS criteria, 46 (49.5%) did not return because of fear of re-injury, 32 (34.4%) due to ongoing problems with their knee, 31 (31.3%) lacked confidence in the knee, 20 (21.5%) work or family obligations, and 6 (6.5%) were no longer eligible for participation in competitive sports.
RTS is more common if based on a global RTS question than if measured by strict comprehensive criteria that combine return to the same type and frequency of sports and MAS. Patients who do not meet comprehensive RTS criteria demonstrate poorer function than those that do. A global rating of RTS may overestimate the true RTS rate by 25%. Fear of re-injury, ongoing knee problems, and lack of confidence play a greater role in preventing RTS than lifestyle changes. These issues need to be addressed to improve RTS after ACL reconstruction
[Show abstract][Hide abstract] ABSTRACT: Preservation of esophageal and gastric function is a hallmark principle in ensuring optimal surgical outcomes after gastric fundoplication. In this study, we evaluated the impact of fundoplication on esophageal transit and gastric emptying using scintigraphy studies and related these functional findings to symptomatic outcomes.
A total of 106 consecutive patients (37 women, 69 men) with both preoperative and 6-month postoperative nuclear scintigraphy studies undergoing partial (Toupet) fundoplication at a single institution were analyzed. Primary variables included alterations in esophageal transit and gastric emptying times after fundoplication (1 = rapid; 2 = normal; 3 = mild delay; 4 = severe delay). Symptomatic variables included heartburn, regurgitation, dysphagia, pulmonary symptoms, and bloating.
Mean age was 57.2 years. Symptomatic improvement was achieved in 91.5% of patients. Significant reduction of all symptoms (heartburn, regurgitation, pulmonary symptoms, and dysphagia) was noted after fundoplication, except gas bloating (4.7 vs. 20.8%). There were no significant differences in preoperative and postoperative esophageal transit (2.53 vs. 2.52) and gastric emptying (2.13 vs. 2.06) scores after fundoplication. Interestingly, 17% of esophageal transit times and 18% of gastric emptying times improved after fundoplication. However, worsening scores were seen in 16 and 12%, respectively. There was no significant postoperative dysphagia, even in patients with impaired transit times.
Nuclear scintigraphic assessment of esophageal transit and gastric emptying are valuable, user-friendly tools to identify and avoid functional motility problems in the setting of fundoplication. These studies seem to be a reasonable alternative to manometry in assessing esophageal function before surgery in this setting. Postoperative symptoms may be related to objective changes in esophageal transit or gastric emptying. The causes may be iatrogenic in nature or related to vagal denervation with associated changes in esophagogastric compliance. Awareness of these physiologic changes may prompt further technical precautions at the time of surgery to avoid vagal injury and also may facilitate postoperative medical management.
No preview · Article · Dec 2010 · Surgical Endoscopy
[Show abstract][Hide abstract] ABSTRACT: The development of anastomotic leaks and/or strictures can be associated with considerable morbidity and impairment of quality of life. In the current study, we evaluated the outcomes of patients who developed anastomotic complications after esophagectomy to elucidate the impact of these events on morbidity, mortality, and subsequent need for dilation.
We analyzed retrospectively the clinical course of 235 patients who underwent transhiatal esophagectomy for cancer from 2001 to 2009. Patients with confirmed anastomotic leaks were identified and classified with the following scale: class 1: Radiographic leak only, no intervention; class 2: leak requiring opening of the wound, cervical and/or percutaneous drainage; class 3: disruption of anastomosis (10-50% circumference) with perianastomotic abscess requiring video-assisted thoracoscopic surgery or thoracotomy; and class 4: gastric tip necrosis with anastomotic separation (>50% circumference).
Anastomotic leaks were encountered in 30 patients (13%). Anastomotic leaks were associated with greater morbidity (70% vs 47%; P = .02) and stricture formation (57% vs 19%; P = .0001). Mortality was not different. Increasing leak class was associated with an increased need for postoperative anastomotic dilations (P = .016).
Anastomotic integrity after esophagectomy has a substantial impact on perioperative course and long-term swallowing. A more formal radiographic and endoscopic leak classification system seems justified.