Biomedical subjects

L W Way

Publications and source records attributed to L W Way.

At least 19 recordsLinked to original sources

PubMed2002

Laparoscopic antireflux surgery: preoperative lower esophageal sphincter pressure does not affect outcome.

BACKGROUND: Concern has been raised about operating on patients with gastroesophageal reflux disease (GERD) and normal lower esophageal sphincter (LES) pressure for the fear that a fundoplication may fail to control reflux and result in a high rate of postoperative dysphagia. We hypothesized that fundoplication is effective in patients with GERD irrespective of the preoperative LES pressure, and that in patients with normal LES pressure, a total fundoplication does not result in a high incidence of dysphagia. METHODS: We studied 280 unselected patients with GERD who underwent laparoscopic fundoplication. They were divided in three groups based on the preoperative LES pressure (normal, 14-24 mmHg): group A (LES pressure, 0-6 mmHg; 61 patients; 22%); group B (LES pressure, 7-13 mmHg; 178 patients; 64%); group C (LES pressure, >or=14 mmHg; 41 patients; 14%). De novo dysphagia was defined as new onset of postoperative dysphagia lasting more than 10 weeks. The average follow-up period was 17 +/- 22 months. RESULTS: There was no difference in resolution of symptoms among the three groups. Heartburn and regurgitation resolved or improved respectively in 96% of group A, 90% of group B, and 91% of group C patients. In addition, there was no difference in the incidence of de novo dysphagia, which occurred in 8% of group A, 7% of group B, and 2% of group C. CONCLUSIONS: We conclude that fundoplication controlled GERD irrespective of preoperative LES pressure, and that a normal LES pressure before surgery was not associated with a higher rate of postoperative dysphagia.

Analysis of Variance↗

PubMed2002

Gastroesophageal reflux disease (GERD) and chest pain. Results of laparoscopic antireflux surgery.

BACKGROUND: Laparoscopic fundoplication cures heartburn and regurgitation in patients with gastroesophageal reflux disease (GERD) but its effect on the chest pain that is also experienced by some patients is less clear. Confusion stems from the fact that it is difficult to determine preoperatively whether the chest pain is actually caused by the reflux. Therefore, we designed a study in patients with GERD and chest pain that would assess the value of pH monitoring in establishing a correlation between the symptom and the disease, the predictive value of pH monitoring on the results of surgical treatment, and the outcome of laparoscopic fundoplication on chest pain in patients with GERD. METHODS: Of 487 patients who underwent laparoscopic fundoplication for GERD at our institution between October 1992 and July 2000, 165 (34%) complained of chest pain in addition to heartburn and regurgitation. Their symptoms had been present for an average of 118 months. The pH monitoring tracings were analyzed for a correlation between episodes of reflux and chest pain. The mean length of follow-up was 13 months. RESULTS: Among the 165 patients with chest pain, the relationship between pain and reflux during pH monitoring was as follows: 39 patients (group A) experienced no chest pain during the study; in 28 patients (group B), chest pain correlated with reflux in <40% of instances; in 98 patients (group C), chest pain correlated with reflux in ?40% of instances. Chest pain improved postoperatively in 65% of group A patients, 79% of group B patients, and 96% of group C patients (group C vs A and B: p <0.05). Heartburn and regurgitation resolved or improved in 97% and 95% of patients, respectively. CONCLUSIONS: These data show that pH monitoring helped to identify a relationship between chest pain and reflux; and when the two coincided, the chest pain was relieved by antireflux surgery.

Adolescent↗

PubMed2001

Laparoscopic Heller myotomy relieves dysphagia in patients with achalasia and low LES pressure following pneumatic dilatation.

BACKGROUND: Although pneumatic dilatation is said to relieve dysphagia in achalasia if it decreases lower esophageal sphincter (LES) pressure to 10 mmHg (n = 23); group C, no previous balloon dilatation and LES pressure >10 mmHg (n = 25). All patients underwent a laparoscopic Heller myotomy and Dor fundoplication. The severity of dysphagia was gauged on a scale of 0-4. RESULTS: In group A, LES pressure was 7 +/- 2 mmHg preoperatively and 8 +/- 3 mmHg postoperatively; the dysphagia score was 3.3 +/- 0.7 preoperatively and 0.9 +/- 1.1 postoperatively. Eighty-nine percent of patients had excellent or good results. In group B, LES pressure was 23 +/- 8 mmHg preoperatively and 10 +/- 1 mmHg postoperatively; the dysphagia score was 3.3 +/- 0.7 preoperatively and 0.3 +/- 0.5 postoperatively. All patients had excellent or good results. In group C, LES pressure was 23 +/- 11 mmHg preoperatively and 14 +/- 12 mmHg postoperatively; the dysphagia score was 3.6 +/- 0.6 preoperatively and 0.2 +/- 0.5 postoperatively. All patients had excellent or good results. CONCLUSIONS: These results show that (a) a LES pressure of <10 mmHg after pneumatic dilatation does not guarantee relief of dysphagia, and (b) laparoscopic Heller myotomy relieves dysphagia in most patients with a postdilatation LES pressure <10 mmHg. Thus, a laparoscopic Heller myotomy is indicated if dilatation does not relieve dysphagia, even if LES pressure has been decreased to <10 mmHg. Esophagectomy should be reserved for the occasional failure of this simpler operation.

Adolescent↗

PubMed2001

Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures.

BACKGROUND: In the treatment of achalasia, surgery has been traditionally reserved for patients with residual dysphagia after pneumatic dilatation. The results of laparoscopic Heller myotomy have proven to be so good, however, that most experts now consider surgery the primary treatment. HYPOTHESIS: The outcome of laparoscopic myotomy and fundoplication for achalasia is dictated by technical factors. SETTING: University hospital tertiary care center. DESIGN: Retrospective study. PATIENTS AND METHODS: One hundred two patients with esophageal achalasia underwent laparoscopic Heller myotomy and Dor fundoplication. Fifty-seven patients had been previously treated by pneumatic dilatation or botulinum toxin. The design of the operation involved a 7-cm myotomy, which extended 1.5 cm onto the gastric wall, and a Dor fundoplication. Esophagrams, esophageal manometric findings, and video records of the procedure were analyzed to determine the technical factors that contributed to the clinical success or failure of the operation. MAIN OUTCOME MEASURE: Swallowing status. RESULTS: In 91 (89%) of the 102 patients, good or excellent results were obtained after the first operation. A second operation was performed in 5 patients to either lengthen the myotomy (3 patients) or take down the fundoplication (2 patients). Dysphagia resolved in 4 of these patients. The remaining 6 patients were treated by pneumatic dilatation, but dysphagia improved in only 1. At the conclusion of treatment, excellent or good results had been obtained in 96 (94%) of the 102 patients. CONCLUSIONS: These data show that a Heller myotomy was unsuccessful in patients with an esophageal stricture; a short myotomy and a constricting Dor fundoplication were the avoidable causes of residual dysphagia; a second operation, but not pneumatic dilatation, was able to correct most failures; and that the identified technical flaws were eliminated from the last half of the patients in the series.

Adolescent↗

PubMed2001

Three spectra of laparoscopic entry access injuries.

BACKGROUND: Procedure-based surveys oflaparoscopic entry access injuries show a reassuringly low incidence, varying from 5 per 10,000 to 3 per 1,000, and, consequently, can provide only limited specific injury data. The current study uses existing injury-based reporting systems to access a uniquely large number of entry injuries to define the nature and outcomes of such events. STUDY DESIGN: Claims arising from US and non-US entry access injuries, between 1980 and 1999, reported to the Physicians Insurers Association of America by their member and affiliate companies and entry-injury medical device reports to the US FDA, from 1995 through October 1997, were analyzed to determine operative procedures, physician specialties, entry devices, and techniques associated with specific injuries. Individual injuries were analyzed for their relative incidence and potential to cause disability and death. RESULTS: Five hundred ninety-four structures or organs were injured in 506 patients, resulting in 65 deaths (13%). General surgical procedures made up at least 67% of combined medical device reports and US Physicians Insurers Association of America cases, and gynecologic procedures accounted for 63% of non-US claims. Bowel and retroperitoneal vascular injuries comprised 76% of all injuries incurred in the process of establishing a primary port. Nearly 50% of both small and large bowel injuries were unrecognized for 24 hours or longer. Delayed recognition, along with age greater than 59 years and major visceral vascular injuries, were each independent significant predictors of death. CONCLUSIONS: No entry technique or device is absolutely safe. Avoidance of entry injuries depends on patient-specific anatomic orientation and control of entry axial force. Certain entry devices can be facilitating in controlling axial force. Overall, this large aggregate of entry access injuries shows them to be more serious and, along with other data, implies that they might be more common than reported in procedure-based studies.

Adolescent↗

PubMed2001

Trocar injuries in laparoscopic surgery.

BACKGROUND: Disposable trocars with safety shields are widely used for laparoscopic access. The aim of this study was to analyze risk factors associated with injuries resulting from their use as reported to the Food and Drug Administration. STUDY DESIGN: Manufacturers are required to report medical device-related incidents to the Food and Drug Administration. We analyzed the 629 trocar injuries reported from 1993 through 1996. RESULTS: There were three types of injury: 408 injuries of major blood vessels, 182 other visceral injuries (mainly bowel injuries), and 30 abdominal wall hematomas. Of the 32 deaths, 26 (81%) resulted from vascular injuries and 6 (19%) resulted from bowel injuries. Eighty-seven percent of deaths from vascular injuries involved the use of disposable trocars with safety shields and 9% involved disposable trocars with a direct-viewing feature. The aorta (23%) and inferior vena cava (15%) were the vessels most commonly traumatized in the fatal vascular injuries. Ninety-one percent of bowel injuries involved trocars with safety shields and 7% involved direct-view trocars. The diagnosis of an enterotomy was delayed in 10% of cases, and the mortality rate in this group was 21%. In 41 cases (10%) the surgeon initially thought the trocar had malfunctioned, but in only 1 instance was malfunction subsequently found when the device was examined. The likelihood of injury was not related to any specific procedure or manufacturer. CONCLUSIONS: These data show that safety shields and direct-view trocars cannot prevent serious injuries. Retroperitoneal vascular injuries should be largely avoidable by following safe techniques. Bowel injuries often went unrecognized, in which case they were highly lethal. Device malfunction was rarely a cause of trocar injuries.

Abdominal Muscles↗

PubMed2001

Survey of laparoscopic entry injuries provoking litigation.

STUDY OBJECTIVE: To examine injuries sustained during laparoscopic entry procedures that provoked malpractice claims in order to discern relative vulnerability of specific organs and differences in injury patterns, mortality, and financial awards, and specific entry devices involved in domestic claims versus those in other countries. DESIGN: Survey (Canadian Task Force classification II-2). SETTING: Insurance company records. INTERVENTIONS: Abstracts of malpractice allegations in 135 domestic cases insured by United States member companies of the Physician Insurers Association of America and 111 cases by its non-United States affiliates were examined. MEASUREMENTS AND MAIN RESULTS: Most cases in the United States involved biliary-gastrointestinal surgery rather than gynecologic procedures; this was reversed for the non-United States database. Major vessel injury was proportionally more common in the domestic group. Small bowel led the group of structures injured. Most injuries involved trocars of various types (185), including blunt types (16); and needle injuries were noted in 39 cases. Injuries were recognized more immediately in the United States, and mortality was related to delay in diagnosis of bowel penetration. Indemnity payments were greater for serious nonfatal injuries versus deaths in the United States, but the opposite was true in other countries. CONCLUSION: Probably no needle-trocar system can guarantee avoidance of injury during laparoscopic entry, especially when the trajectory of insertion puts great vessels at risk. Bowel injuries occur during open as well as closed techniques of insertion, and with optical trocar systems as well. Vascular injury is usually obvious, but delayed recognition of loss of bowel integrity is related to increased mortality, especially in patients over 60 years of age.

Abdominal Injuries↗

PubMed2001

Role of esophageal function tests in diagnosis of gastroesophageal reflux disease.

Clinicians typically make the diagnosis of gastroesophageal reflux disease (GERD) from the clinical findings and then prescribe acid-suppressing drugs. Endoscopy is usually done for persistent or severe symptoms. Esophageal function tests (EFTs: esophageal manometry and 24-hr pH monitoring) are generally reserved for patients who have the most severe disease, including those being considered for surgery. We hypothesized that EFTs are more accurate than symptoms and endoscopy in the diagnosis of GERD. This was a retrospective study undertaken in a university tertiary care center. Between October 1989 and November 1998, 822 patients with a clinical diagnosis of GERD (based on symptoms and endoscopic findings) were referred for EFTs. The patients were divided into two groups depending on whether the 24-hr pH monitoring score showed GERD (group A, GERD-; group B, GERD+). The groups were compared with respect to the incidence and severity of symptoms, presence of a hiatal hernia on barium x-rays, presence and severity of esophagitis on endoscopy, and esophageal motility. In all, 247 patients (30%) had normal reflux scores (group A, GERD-), and 575 patients (70%) had abnormal scores (Group B, GERD+). Eighty percent of group A and 88% of group B had been treated with acid-suppressing medications. The incidence of heartburn and regurgitation was similar in the two groups. Grade I-II esophagitis was diagnosed by endoscopy in 25% of group A and 35% of group B, and grade III esophagitis in 4% of group A and 11% of group B. Esophageal manometry showed that group B more often had esophageal dysmotility, consisting of a hypotensive lower esophageal sphincter and abnormal esophageal peristalsis. These data show that: (1) symptoms were unreliable for diagnosing GERD; (2) endoscopic evidence of grade I-II esophagitis was diagnostically nonspecific, and grade III was much less certain than claimed in other reports; and (3) pH monitoring identified patients with GERD and stratified them according to the severity of the disease. We conclude that esophageal manometry and pH monitoring are important in diagnosing GERD accurately. More liberal use of these tests early in patient management would avoid much improper and costly medical therapy and would help single out for special attention the patients with GERD who have the most severe disease.

Adolescent↗

PubMed2001

Laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children.

BACKGROUND/PURPOSE: In the past, surgical treatment in achalasia usually has been reserved for patients whose dysphagia does not respond to pneumatic dilatation. The success of minimally invasive myotomy, however, has resulted in a shift in practice in adult patients, whereby laparoscopic surgery is becoming preferred as primary treatment by most gastroenterologists and surgeons. The aim of this study was to assess the efficacy of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children. METHODS: Thirteen patients with esophageal achalasia (median age, 15 years; 6 boys and 7 girls; median duration of symptoms, 24 months) underwent laparoscopic Heller myotomy and Dor fundoplication between 1996 and 1999. Two patients had been treated previously by pneumatic dilatation, and 1 patient had received intrasphincteric Botulinum toxin injections. RESULTS: Median duration of the operation was 130 minutes. The patients were fed after an average of 33 hours, and they all left the hospital within 2 days. At a median follow-up of 19 months, there was no residual dysphagia in any patient. CONCLUSIONS: Laparoscopic Heller myotomy and Dor fundoplication were effective and safe for children with esophageal achalasia. Hospital stay and recovery time was short, and the functional results were excellent. These data support the notion that laparoscopic Heller myotomy should become the primary treatment of esophageal achalasia in children.

Adolescent↗

PubMed2000

Postcholecystectomy abdominal bile collections.

HYPOTHESIS: The clinical syndromes caused by bile collections in the abdomen span a wide spectrum and their natural history and risks are not fully appreciated. DESIGN: Analysis of 179 patients with bile fistulas after cholecystectomy, of which 154 patients had undrained bile collections. OBJECTIVE: To characterize the manifestations and natural history of abdominal bile collections. SETTING: A tertiary care teaching hospital. PATIENTS AND METHODS: The clinical findings in 179 patients with bile fistulas resulting from iatrogenic laparoscopic bile duct injuries and other miscellaneous operations between 1990 and 1999 were analyzed. The group of main interest consisted of 154 patients with undrained bile collections. Of these 154 patients, 21% had serious complications, including sepsis and multiorgan failure. The data were analyzed to identify the variables associated with this undesirable outcome. MAIN OUTCOME MEASURES: Symptoms, physical findings, course of illness, and laboratory and imaging findings. RESULTS: The clinical manifestations of intra-abdominal bile collections were initially discounted in 77% of patients, so the problem went unsuspected for a variable and often lengthy period. Abdominal pain and tenderness (bile peritonitis) gradually developed in 18% of patients with bile ascites. There were no differences in the initial clinical findings in this group compared with those who did not develop peritonitis. Nineteen percent of patients with undrained bile collections experienced serious morbidity. The initial clinical findings did not differ in these patients compared with those with a less complicated illness. Serious illness, however, was associated with the following: (1) a longer period of undrained bile (15.4 vs 9.2 days, P=.04) and (2) a higher incidence of infected bile (45% vs 7%, P=.001). CONCLUSIONS: (1) Prominent abdominal pain and tenderness developed in only 21% of patients with abdominal bile collections; (2) the symptoms caused by bile collections were often subtle and their significance was overlooked, which resulted in a delay in diagnosis; (3) the early clinical findings could not distinguish patients who did become critically ill from those who did not; and (4) seriously ill patients more often had delayed drainage and infected bile. Still, failure to drain a bile collection within just 5 days resulted in serious illness in a few patients. Surgeons must watch for the clinical manifestations of bile ascites after laparoscopic cholecystectomy. This diagnosis should be suspected whenever persistent bloating and anorexia last for more than a few days; failure to recover as smoothly as expected is the most common early symptom of bile ascites. If bile collections were promptly diagnosed and drained, the rate of serious illness resulting from this complication would decline.

Adolescent↗

PubMed2000

Laparoscopic pancreatic cystgastrostomy.

Internal drainage of acute pancreatic pseudocysts is indicated 6 weeks after the first documentation of pseudocyst. It is also indicated for symptomatic chronic pseudocysts 6 cm or more in diameter. When pseudocysts are located in close contact with the posterior wall of the stomach, they are best drained by pseudocyst-gastrostomy. This procedure can also be completed making use of intragastric surgical techniques. Under standard laparoscopic observation, three intragastric ports are placed through the abdominal and anterior gastric walls, establishing working channels for a telescope and hand instruments. After the presence of pseudocysts is confirmed, the posterior wall of the stomach and the cyst wall can be incised by electrocautery. After a sufficient drainage orifice is made and the cyst contents are thoroughly debrided, the intragastric ports are removed and defects in the gastric wall are closed with sutures placed via the standard laparoscopic approach. This approach is much less invasive than the conventional approach, which entails a large gastrotomy in the anterior wall of the stomach. This procedure should be the method of choice when interventional radiology or endoscopic intervention fails to effectively drain retrogastric pseudocysts.

Drainage↗

PubMed1999

Laparoscopic gastrostomy and jejunostomy: safety and cost with local vs general anesthesia.

BACKGROUND AND HYPOTHESIS: General anesthesia is used for laparoscopic enteral access because pneumoperitoneum requires relaxation of the abdominal muscles. We wanted to determine whether these procedures could be performed with similar results and cost under local anesthesia. DESIGN: Randomized controlled study with 30-day follow-up including a cost-benefit analysis. SETTING: University-affiliated hospitals. PATIENTS: Forty-eight patients (32 men, 16 women; mean age, 67 years) undergoing laparoscopic gastrostomies (n = 32) and jejunostomies (n = 16). INTERVENTION: Twenty-four patients underwent laparoscopic gastrostomy (n = 15) and jejunostomy (n = 9) under local anesthesia with intravenous conscious sedation and monitored anesthesia care. Twenty-four patients had general anesthesia. MAIN OUTCOME MEASURES: Conversion to general anesthesia, complications, and cost. RESULTS: Ten patients under local anesthesia had periods of deep sedation and 1 required conversion to general anesthesia. One patient under general anesthesia required conversion to open gastrostomy. No patients had intraoperative aspiration; however, 4 aspirated after the procedure. One patient died of myocardial infarction during the 30-day follow-up. We found no significant difference in the total mean cost and actual procedure time. The surgeon's fee accounted for 31% of the total cost. CONCLUSIONS: Some patients undergoing laparoscopic enteral access may require deep sedation and a rare patient may require general anesthesia. Clinical conditions and surgeon preference, therefore, should determine whether local anesthesia is suitable for laparoscopic gastrostomies and jejunostomies, and in what setting, since there is no difference in success rate or complications when compared with general anesthesia. Potential savings are possible from the operating room (26% of total cost) or anesthesiologist (12% of total cost) if these procedures are performed in an endoscopy suite without monitored anesthesia care.

Aged↗

PubMed1999

Percutaneous management of abscess and fistula following pancreaticoduodenectomy.

PURPOSE: To evaluate the efficacy of percutaneous drainage of fluid collections following pancreaticoduodenectomy (Whipple's procedure). METHODS: We performed a retrospective review of 19 patients referred to our service with fluid collections following pancreaticoduodenectomy. The presence of associated enteric or biliary fistulas, the route(s) of access for image-guided drainage, the incidence of positive bacterial cultures, and the duration and success of percutaneous management were recorded. RESULTS: Fistulous communication to the jejunum in the region of the pancreatico-jejunal anastomosis was demonstrable in all 19 patients by gentle contrast injection into drainage tubes. Three patients had concurrent biliary fistulas. In 18 of 19 patients, fluid samples yielded positive bacterial cultures. Successful percutaneous evacuation of fluid was achieved in 17 of 19 patients (89%). The mean duration of drainage was 31 days. CONCLUSION: Percutaneous drainage of abscess following pancreaticoduodenectomy is effective in virtually all patients despite the coexistence of enteric and biliary fistulas.

Abdominal Abscess↗

PubMed1999

Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated.

BACKGROUND: It has been said that a Heller myotomy cannot improve dysphagia in achalasia when the esophagus is markedly dilated or sigmoid shaped. Those who hold this belief recommend esophagectomy as the primary treatment in such cases. This study aimed to compare the results of laparoscopic Heller myotomy combined with Dor fundoplication in 66 patients with and without esophageal dilatation, all of whom had achalasia. METHODS: On the basis of the maximal diameter of the esophageal lumen and the shape of the esophagus, the patients were placed into four groups: group A (esophageal diameter <4.0 cm; 26 patients), group B (diameter 4.0-6.0 cm; 21 patients), group C1 (diameter >6.0 cm and straight esophageal axis; 12 patients), and group C2 (diameter >6.0 cm and sigmoid-shaped esophagus; 7 patients). All patients underwent a laparoscopic Heller myotomy and Dor fundoplication. RESULTS: The duration of the operation and the length of hospital stay were similar among the four groups. Excellent or good results were obtained in 88% of group A, 100% of group B, 83% of group C1, and 100% of group C2. No patient in this consecutive series ultimately required an esophagectomy. CONCLUSIONS: In patients with achalasia who have esophageal dilation, a laparoscopic Heller myotomy and Dor fundoplication (a) took no longer and was no more difficult, (b) was associated with no more postoperative complications, and (c) gave just as good relief of dysphagia. We conclude that esophageal dilation by itself should rarely serve as an indication for esophagectomy rather than myotomy as the initial surgical treatment.

Adolescent↗

PubMed1999

Effects of previous treatment on results of laparoscopic Heller myotomy for achalasia.

Until recently, pneumatic dilatation and intrasphincteric injection of botulinum toxin (Botox) have been used as initial treatments for achalasia, with myotomy reserved for patients with residual dysphagia. It is unknown, however, whether these nonsurgical treatments affect the performance of a subsequent myotomy. We compared the results of laparoscopic Heller myotomy and Dor fundoplication in 44 patients with achalasia who had been treated with medications (group A, 16 patients), pneumatic dilatation (group B, 18 patients), or botulinum toxin (group C, 10 patients). The last group was further subdivided according to whether there was (C2, 4 patients) or was not (C1, 6 patients) a response to the treatment. Results for groups A, B, C1, and C2, respectively, were: anatomic planes identified at surgery (% of patients)--100%, 89%, 100%, and 25%; esophageal perforation (% of patients)--0%, 5%, 0%, and 50%; hospital stay (hrs)--26+/-8, 38+/-25, 26+/-11, and 72+/-65; and excellent/good results (% of patients)--87%, 95%, 100%, and 50%. These results show that: (1) previous pneumatic dilatation did not affect the results of myotomy; (2) in patients who did not respond to botulinum toxin, the myotomy was technically straightforward and the outcome was excellent; (3) in patients who responded to botulinum toxin, the LES muscle had become fibrotic (perforation occurred more often in this setting, and dysphagia was less predictably improved); and (4) myotomy relieved dysphagia in 91% of patients who had not been treated with botulinum toxin. These data support a strategy of reserving botulinum toxin for patients who are not candidates for pneumatic dilatation or laparoscopic Heller myotomy.

Botulinum Toxins, Type A↗

PubMed1999

Minimally invasive surgery for achalasia: an 8-year experience with 168 patients.

BACKGROUND: Seven years ago, the authors reported on the feasibility and short-term results of minimally invasive surgical methods to treat esophageal achalasia. In this report, they describe the evolution of the surgical technique and the clinical results in a large group of patients with long follow-up. PATIENTS AND METHODS: Between January 1991 and October 1998, 168 patients (96 men, 72 women; mean age 45 years, median duration of symptoms 48 months), who fulfilled the clinical, radiographic, endoscopic, and manometric criteria for a diagnosis of achalasia, underwent esophagomyotomy by minimally invasive techniques. Forty-eight patients had marked esophageal dilatation (diameter >6.0 cm). Thirty-five patients had a left thoracoscopic myotomy, and 133 patients had a laparoscopic myotomy plus a partial fundoplication. Follow-up to October 1998 was complete in 145 patients (86%). RESULTS: Median hospital stay was 72 hours for the thoracoscopic group and 48 hours for the laparoscopic group. Eight patients required a second operation for recurrent or persistent dysphagia, and two patients required an esophagectomy. There were no deaths. Good or excellent relief of dysphagia was obtained in 90% of patients (85% after thoracoscopic and 93% after laparoscopic myotomy). Gastroesophageal reflux developed in 60% of tested patients after thoracoscopic myotomy and in 17% after laparoscopic myotomy plus fundoplication. Laparoscopic myotomy plus fundoplication corrected reflux present before surgery in five of seven patients. Patients with a dilated esophagus had excellent relief of dysphagia after laparoscopic myotomy; none required an esophagectomy. CONCLUSIONS: Minimally invasive techniques provided effective and long-lasting relief of dysphagia in patients with achalasia. The authors prefer the laparoscopic approach for three reasons: it more effectively relieved dysphagia, it was associated with a shorter hospital stay, and it was associated with less postoperative reflux. Laparoscopic Heller myotomy and partial fundoplication should be considered the primary treatment for esophageal achalasia.

Adolescent↗

PubMed1998

An analysis of operations for gastroesophageal reflux disease: identifying the important technical elements.

BACKGROUND: Better understanding of the pathogenesis of gastroesophageal reflux disease in recent years has not been accompanied by appreciable advances in the design of antireflux operations. In many cases, operations are still being performed just as they were described 30 years ago. It is important now to go beyond the eponymous procedures traditionally associated with antireflux operations and to identify the technical elements that contribute to effective and durable fundoplications. OBJECTIVES: To compare antireflux operations and identify the important technical elements. DESIGN AND SETTING: Retrospective study in a university-based tertiary care center. PATIENTS: Two hundred one patients had laparoscopic fundoplications for gastroesophageal reflux disease. The first 22 patients underwent Nissen-Rossetti procedures (360 degree wrap; no division of short gastric vessels). Subsequently, 82 patients had a total (360 degree Nissen wrap) fundoplication and 97 patients had a partial (240 degree Guarner wrap) fundoplication (both with the short gastric vessels divided), with the choice between them based on the quality of esophageal peristalsis. The 3 groups of patients were similar in age, duration of symptoms, incidence of hiatal hernia, and incidence of esophagitis. MAIN OUTCOME MEASURES: Resolution of heartburn, incidence of postoperative dysphagia, and stability of the reconstruction. RESULTS: The resolution of heartburn was achieved for 15 patients (68%) who had the Nissen-Rossetti procedure, 73 patients (89%) who had a 360 degrees Nissen wrap, and 88 patients (91%) who had a 240 degree Guarner wrap. Postoperative dysphagia occurred in 3 patients (14%) having the Nissen-Rossetti procedure, 5 patients (6%) having a 360 degree wrap, and 2 patients (2%) having a 240 degree wrap. Herniation or disruption of the wrap occurred postoperatively in 9 patients (4.5%). Review of the videotapes of these 9 operations showed that important technical elements had been omitted in 8. Seven patients required a second operation. CONCLUSION: Laparoscopic antireflux operations control symptoms without producing adverse effects if the following technical elements are included: the hernia is repaired and the hiatus reduced to a normal size, the short gastric vessels are divided, a total or partial wrap is used based on the quality of esophageal peristalsis, and the wrap is anchored in the abdomen.

Digestive System Surgical Procedures↗

PubMed1998

Results of laparoscopic antireflux surgery for dysphagia and gastroesophageal reflux disease.

BACKGROUND: Little attention has been paid to nonobstructive dysphagia (dysphagia in the absence of an esophageal stricture) in patients with gastroesophageal reflux disease (GERD). The objectives of this study were to assess (a) the incidence of nonobstructive dysphagia in patients with GERD; and (b) the effects of laparoscopic fundoplication on nonobstructive dysphagia. METHODS: Esophageal manometry and pH monitoring identified 666 patients with GERD. Two hundred and eight patients (31 %) without esophageal strictures complained of dysphagia in addition to heartburn and regurgitation. Forty-nine (24%) of these patients underwent laparoscopic fundoplication. Esophageal function tests were repeated postoperatively in 12 patients (25%). Main outcome measures were effects of laparoscopic fundoplication on symptoms and esophageal motor function. RESULTS: Dysphagia resolved postoperatively in 44 patients (90%), and improved in 2 patients (4%). Postoperative esophageal manometry showed a significant increase in the length and pressure of the lower esophageal sphincter, without changes in its ability to relax in response to swallowing. CONCLUSIONS: About one third of GERD patients without strictures experienced dysphagia; and dysphagia resolved in about 90% of such patients following a laparoscopic fundoplication.

Deglutition↗