Ann Kjellin

Gastroesophageal Reflux in Obese Patients Is Not Reduced by Weight Reduction

BACKGROUND The present study tested the hypothesis that weight reduction improves the subjective and objective manifestations of gastroesophageal reflux. METHODS Twenty obese patients with gastroesophageal reflux as shown by 24-h pH measurement and with symptoms requiring daily medication were studied. The patients were randomized into a group (A) treated with very low-caloric diet (VLCD) and a control group (B). Objective measurements were repeated after 6 months. Group B was then treated with VLCD and reexamined. RESULTS Patients in group A lost 10.8 +/- 1.4 kg whereas group B gained 0.6 +/- 0.7 kg (P < 0.001). There was no reduction in reflux according to pH measurement. Furthermore, there were no significant changes in reflux symptoms. After VLCD treatment, group B lost 9.7 +/- 1.6 kg, but reflux indicators remained unchanged. All patients except one in group B remained dependent on daily anti-reflux medication. CONCLUSION Weight reduction does not improve the subjective or objective manifestations of reflux.

Pneumatic dilatation or laparoscopic cardiomyotomy in the management of newly diagnosed idiopathic achalasia. Results of a randomized controlled trial.

BackgroundThe most effective therapeutic strategy in newly diagnosed achalasia is yet to be established. Therefore we designed a study in which pneumatic dilatation was compared to laparoscopic cardiomyotomy to which was added a partial posterior fundoplication.Patients and ResultsA series of 51 patients (24 males, mean age 44 years) were randomly allocated to the therapeutic modalities (dilatation = 26, surgery = 25). All patients were followed for at least 12 months, and during that period the pneumatic dilatations strategy had significantly more treatment failures (P = 0.04). Only minor differences emerged between the study groups when symptoms, dysphagia scorings, and quality-of-life assessments were evaluated 12 months after initiation of therapy.ConclusionsLaparoscopic myotomy was found to be superior to an endoscopic balloon dilatation strategy in the treatment of achalasia when studied during the first 12 months after treatment.

Visuospatial skills and computer game experience influence the performance of virtual endoscopy

Advanced medical simulators have been introduced to facilitate surgical and endoscopic training and thereby improve patient safety. Residents trained in the Procedicus Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) laparoscopic simulator perform laparoscopic cholecystectomy safer and faster than a control group. Little has been reported regarding whether factors like gender, computer experience, and visuospatial tests can predict the performance with a medical simulator. Our aim was to investigate whether such factors influence the performance of simulated gastroscopy. Seventeen medical students were asked about computer gaming experiences. Before virtual endoscopy, they performed the visuospatial test PicCOr, which discriminates the ability of the tested person to create a three-dimensional image from a two-dimensional presentation. Each student performed one gastroscopy (level 1, case 1) in the GI Mentor II, Simbionix, and several variables related to performance were registered. Percentage of time spent with a clear view in the endoscope correlated well with the performance on the PicSOr test (r = 0.56, P < 0.001). Efficiency of screening also correlated with PicSOr (r = 0.23, P < 0.05). In students with computer gaming experience, the efficiency of screening increased (33.6% +- 3.1% versus 22.6% +- 2.8%, P < 0.05) and the duration of the examination decreased by 1.5 minutes (P < 0.05). A similar trend was seen in men compared with women. The visuospatial test PicSOr predicts the results with the endoscopic simulator GI Mentor II. Two-dimensional image experience, as in computer games, also seems to affect the outcome.

High-level visual-spatial ability for novices correlates with performance in a visual-spatial complex surgical simulator task

BackgroundThis study addresses how high-level visual-spatial ability of surgical novices is related to performance of two simulator tasks with (KSA) and without (MIST) anatomic graphics and haptic feedback, differing in visual-spatial complexity.MethodsVisual-spatial test scores assessed by Mental Rotation Test (MRT) and BasIQ and performance scores for Instrument Navigation (IN) in Key Surgical Activities (Procedicus KSA) and Manipulate and Diathermy (MD) in Minimally Invasive Surgical Trainer (Procedicus MIST) were correlated for 54 Swedish surgical novices.ResultsSignificant Pearson’s r correlations were obtained between visual-spatial scores measured by MRT-C and total score from the last trial for IN (r = 0.278, p < 0.05). Visual-spatial scores (measured by BasIQ) also correlated with total score from the first trial (r = 0.443, p < 0.05) and from the last trial (r = 0.489, p < 0.05).ConclusionHigh-level visual-spatial ability is important for surgical novices to possess in the early training phase of a visual-spatial complex task in KSA.

Training in tasks with different visual-spatial components does not improve virtual arthroscopy performance

Background: We earlier showed that training in the Procedicus KSA Simulator improves the performance of tasks done later in the same simulator. However, it is still unclear how performance in a specific visual-spatial simulator context may change after training in other simulators with different visual-spatial components. In particular, the aim of this study was to test whether performance in the Procedicus Virtual Arthroscopy (VA) Knee Simulator would remain unchanged after a training session in three other simulators with different visual-spatial components. Methods: Twenty-eight medical students participated in a quasi-transfer study. They were randomly allocated to an experimental group (n = 14) and a control group (n = 14). Results: Performance in the Procedicus VA Knee Simulator did not improve after training in other simulators with different visual-spatial components (t-test p = NS). No significant correlation was found between the Procedicus VA Knee and the Minimally Invasive Surgical Trainer (MIST) simulators. Conclusion: One hour of training in different visual-spatial contexts was not enough to improve the performance in virtual arthroscopy tasks. It cannot be excluded, however, that experienced trainees could improve their performance, because perceived similarity between different situations is influenced by many psychological factors, such as the knowledge or expertise of the person performing the transfer task.

Laparoscopic myotomy without fundoplication in patients with achalasia

OBJECTIVE Analysis of outcome after laparoscopic myotomy for achalasia. DESIGN Prospective audit. SETTING Teaching hospital, Sweden. SUBJECTS All patients with achalasia who had a laparoscopic myotomy without a simultaneous fundoplication. INTERVENTIONS Questionnaire, pH-measurements, radiography and manometry. MAIN OUTCOME MEASURES Operative and postoperative complications and reoperations. RESULTS Twenty-one patients were scheduled for laparoscopic myotomy. Three were converted to open operations, and four were reoperated on transabdominally for persistent or recurrent symptoms. All patients were satisfied afterwards. Follow-up in 14 patients, after a median of 22 months (range, 6-40), included manometry, questionnaire, and 24-hour pH measurements, and showed significant reduction in the lower oesophageal sphincter pressure together with relief of symptoms. Three patients had reflux symptoms and abnormal pH readings. An additional five patients had abnormal pH measurements but no symptoms of reflux. CONCLUSIONS Heller myotomy can safely be done laparoscopically. Whether a simultaneous antireflux procedure is needed remains to be seen.

Health economic evaluation of therapeutic strategies in patients with idiopathic achalasia: results of a randomized trial comparing pneumatic dilatation with laparoscopic cardiomyotomy

BackgroundWe have prospectively collected information concerning the costs incurred during the management of patients allocated to either forceful dilatation or to an immediate laparoscopic operation because of newly diagnosed achalasia.MethodsFifty-one patients with newly diagnosed achalasia were randomized to either pneumatic dilatation to a diameter of 30–40 mm or to a laparoscopic myotomy to which was added a posterior partial fundoplication. Follow-ups were scheduled at 1, 3, 6, and 12 months after inclusion. At each follow-up visit a study nurse interviewed the patients regarding symptoms and their quality of life (QoL) and a health economic questionnaire was completed. In the latter questionnaire, patients were asked to report the presence and character of contacts with the healthcare system since the last visit.ResultsIn the dilatation group six patients (23%), including the patient who was operated on because of perforation, were classified as failures during the first 12 months of follow-up compared to one (4%) in the myotomy group (p = 0.047). Five of those classified as failures in the dilatation group subsequently had a surgical myotomy and the sixth patient was treated with repeated dilatations. The patient classified as failure in the myotomy group was treated with endoscopic dilatation. The initial treatment cost and the total costs were significantly higher for laparoscopic myotomy compared to a pneumatic dilatation-based strategy (p = 0.0002 and p = 0.0019, respectively) When the total costs were subdivided into the different resources used, we found that the single largest cost item for pneumatic dilatation was that for hospital stay and that for laparoscopic myotomy was the actual operative treatment (operating room time) The cost-effectiveness analysis, relating to the actual treatment failures, revealed that the cost to avoid one treatment failure (incremental cost-effectiveness ratio) amounted to €9239.ConclusionThe current prospective, controlled clinical trial shows that despite a higher level of clinical efficacy of laparoscopic myotomy to prevent treatment failure in newly diagnosed achalasia, the cost effectiveness of pneumatic dilatation is superior, at least when a reasonable time horizon is applied.

Visuospatial abilities correlate with performance of senior endoscopy specialist in simulated colonoscopy

Visuospatial abilities have been demonstrated to predict the performance of medical students in simulated endoscopy. However, little has been reported whether differences in visuospatial abilities influence the performance of senior endoscopists or whether their vast endoscopy experience reduces the importance of these abilities. Eleven senior endoscopists were included in our study. Before the simulated endoscopies in GI Mentor II (gastroscopy: case 3, module 1 and colonoscopy: case 3, module 1), the endoscopists performed three visuospatial tests: (1) pictorial surface orientation (PicSOr), (2) card rotation, and (3) cube comparison tests that monitor the ability of the tested person to re-create a three-dimensional image from a two-dimensional presentation as well as mentally manipulate that re-created image. The results of the visuospatial tests were correlated to the performance parameters of the virtual-reality endoscopy simulator. The percent of time spent with clear view in the simulated colonoscopy correlated well with the performance in the visuospatial PicSOr (r= -0.75, P = 0.01), card rotation (r = 0.75, P = 0.01), and cube comparison (r = 0.79, P = 0.004) tests. The endoscopists who performed better in the visuospatial tests also were better at maintaining visualization of the colon lumen. Those who performed better in the PicSOr test formed fewer loops during colonoscopy (r = 0.60, P = 0.05). In the technically less demanding simulated gastroscopy, there were no such correlations. The visuospatial tests performed better in endoscopists not playing computer games. Good visuospatial ability correlates significantly with the performance of experienced endoscopists in a technically demanding simulated colonoscopy, but not in the less demanding simulated gastroscopy.

Objective assessment of visuospatial and psychomotor ability and flow of residents and senior endoscopists in simulated gastroscopy

BackgroundAdvanced medical simulators have predominantly been used to shorten the learning curve of endoscopy for medical students and young residents. Rarely have the effects of visuospatial ability and attitudes of intermediately experienced and experienced specialists been studied with regard to simulator training. The aim of this study was to assess the effects of visuospatial ability and attitude on performance in simulator training.MethodsEighteen surgical residents were included in the study. Prior to the simulated gastroscopy task, they performed a visuospatial test (the card rotation test). After the simulated gastroscopy task, they completed a questionnaire regarding flow experiences. Their results were compared with those of 11 expert endoscopists who performed the same tests.ResultsTotal gastroscopy time was significantly shorter for the expert endoscopists compared to residents (2 min 11 sec, p = 0.003). There was also a trend of more mucosa inspected (p = 0.088) and higher efficiency of screening (p = 0.069) by the experts. The residents made fewer errors in the card rotation test than the expert endoscopists (2.5 ± 0.8 vs 5.5 ± 1.2, respectively; p = 0.034), and their visuospatial card rotation test results correlated better with their performance in the simulated gastroscopy.ConclusionsA virtual gastroscopy task presents more of an emotional as well as a psychomotoric challenge to intermediately experienced endoscopists than to senior experts. Our study demonstrates that these differences can be objectively assessed by the use of visuospatial ability tests, flowsheets, and an endoscopic simulator.

Toupet versus Dor as a procedure to prevent reflux after cardiomyotomy for achalasia: Results of a randomised clinical trial

BACKGROUND The optimal anti-reflux procedure after Heller cardiomyotomy for oesophageal achalasia remains unclear. The most commonly used procedure is the anterior partial fundoplication according to Dor, although during recent years the posterior counterpart (Toupet) has become popular. METHODS Patients with newly diagnosed achalasia and referred for cardiomyotomy were randomised to receive either an anterior or partial posterior fundoplication following a classical cardiomyotomy. The effect of surgery was assessed during the first postoperative year by Eckardt scores, EORTC QLQ-OES18 scores and HRQL questionnaires. Timed barium oesophagogram (TBO) and ambulatory 24-h pH monitoring were performed to determine oesophageal emptying and the degree of reflux control, respectively. RESULTS Forty-two patients were randomised into Dor (n = 20) and Toupet (n = 22) groups. Eckardt scores improved dramatically with both procedures, but the EORTC QLQ-OES18 (functional scales) scores revealed significantly better relative improvements in the Toupet group compared to the Dor repair (P = 0.044). Corresponding advantages in favour of Toupet were observed postoperatively in the percentage of oesophageal emptying at TBO (P = 0.011 in height and P = 0.018 in area), an effect not observed in the Dor group. There were no other significant differences recorded between the study groups concerning HRQL evaluations and objective assessment of gastro-oesophageal acid reflux. CONCLUSIONS A partial posterior fundoplication after cardiomyotomy seems to achieve more improvement in oesophageal emptying and EORTC QLQ-OES18 functional scale scores than the anterior fundoplication. Otherwise no differences between the two anti-reflux repairs were noted. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT01933373.