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1.
R. Rosati U. Fumagalli S. Bona L. Bonavina M. Pagani A. Peracchia 《Surgical endoscopy》1998,12(3):270-273
Background: Extramucosal myotomy of the lower esophagus and cardia, combined with anterior fundoplication, is, in our opinion, the procedure
of choice to treat stage I–III esophageal achalasia.
Methods: After a successful experience with open surgery in over 280 patients, from January 1992 through February 1997, 61 patients
underwent laparoscopic Heller-Dor for stage I–III achalasia. Conversion to laparotomy was done in three cases. All procedures
were performed under intraoperative endoscopic control. Intraoperative complications were seven mucosal tears, which were
sutured laparoscopically in five cases. The sole postoperative complication was bleeding from an acute gastric ulcer (conservative
treatment).
Results: Follow-up consisted of clinical and radiographic study 1 month after surgery, and endoscopy and manometry within 1 year.
After a mean follow-up (F.U.) of 21 months (1–62), clinical results range from excellent to good in 98.2%. One patient (1.7%)
complaining of recurrent dysphagia improved after endoscopic dilation. Esophageal diameter reduced from 52 to 27 mm. LES pressure
reduced from 30.3 ± 12.4 to 10.7 ± 3.5 mmHg (basal) and from 14.8 ± 9.3 to 2.9 ± 2.1 mmHg (residual).
Conclusions: Laparoscopic Heller-Dor operation is feasible, safe, and effective. Special care should be taken in patients with previous
endoscopic dilations.
Received: 3 April 1997/Accepted: 28 July 1997 相似文献
2.
W. O. Richards R. H. Clements P. C. Wang C. D. Lind H. Mertz J. K. Ladipo M. D. Holzman K. W. Sharp 《Surgical endoscopy》1999,13(10):1010-1014
Background: There is still some controversy over the need for antireflux procedures with Heller myotomy in the treatment of achalasia.
This study was undertaken in an effort to clarify this question.
Methods: To determine whether Heller myotomy alone would cause significant gastroesophageal reflux (GER), we studied 16 patients who
had undergone laparoscopic Heller myotomy without concomitant antireflux procedures. Patients were asked to return for esophageal
manometry and 24-h pH studies after giving informed consent for the Institutional Review Board (IRB)-approved study at a median
follow-up time of 8.3 months (range, 3–51). Results are expressed as the mean ± SEM.
Results: Fourteen of the 16 patients reported good to excellent relief of dysphagia after myotomy. They were subsequently studied
with a 24-h pH probe and esophageal manometry. These 14 patients had a significant fall in lower esophageal sphincter (LES)
pressure from 41.4 ± 4.2 mmHg to 14.2 ± 1.3 mmHg, after the myotomy (p < 0.01, Student's t-test). The two patients who reported more dysphagia postoperatively had LES pressures of 20 and 25 mmHg, respectively. Two
of 14 patients had DeMeester scores of >22 (scores = 61.8, 29.4), while only one patient had a pathologic total time of reflux
(percent time of reflux, 8%). The mean percent time of reflux in the other 13 patients was 1.9 ± 0.6% (range, 0.1–4%), and
the mean DeMeester score was 11.7 ± 4.6 (range, 0.48–19.7).
Conclusions: Laparoscopic Heller myotomy is effective for the relief of dysphagia in achalasia if the myotomy lowers the LES pressure
to <17 mmHg. If performed without dissection of the entire esophagus, the laparoscopic Heller myotomy does not create significant
GER in the postoperative period. Clearance of acid refluxate from the aperistaltic esophagus is an important component of
the pathologic gastroesophageal reflux disease (GERD) seen after Heller myotomy for achalasia. Furthermore, GERD symptoms
do not correlate with objective measurement of GE reflux in patients with achalasia. Objective measurement of GERD with 24
h pH probes may be indicated to identify those patients with pathologic acid reflux who need additional medical treatment.
Received: 12 May 1998/Accepted: 15 December 1998 相似文献
3.
Background: We report our initial experience using operative esophageal manometry as an adjunct to endoscopy to determine the completeness
of esophagogastric high-pressure zone (HPZ) obliteration during laparoscopic Heller myotomy.
Methods: Between July 1997 and October 1998, we performed laparoscopic Heller myotomies in 20 patients (eight male, 12 female; median
age, 41 years). Mean duration of symptoms was 3.2 ± 2.6 years (r= 0.5–11), and 45% of the patients had received prior dilation or toxin injection. A 16-channel esophageal manometry catheter
was placed prior to anesthesia, with sites crossing the lower esophageal sphincter (LES). An endoscope was passed intraoperatively
to localize the squamocolumnar junction, and the myotomy was performed. While the translucency was imaged in the area of the
incision, we determined the adequacy of myotomy by visual assessment of LES and gastric cardia opening in response to endoscopic
air insufflation. Manometry was then performed to detect any potential residual high pressure at the myotomized esophagogastric
junction (EGJ). If it was found, the locus of persistent pressure was identified by probing along the myotomy, and residual
muscle fibers were cut to yield a minimum pressure at the EGJ.
Results: A persistent HPZ was identified after the initial myotomy in 10 of 20 patients (50%). A Dor fundoplasty completed the operation.
The mean operating time was 2.6 ± 0.5 h (median, 2.5; r= 2–3.5 h), and the mean hospital stay was 1.6 ± 1 days (median, 1, r= 1–5 days). The mean LES pressure was 2 ± 3 mmHg immediately postmyotomy (p < 0.001 compared with preoperative value). Of 20 patients, only two have reported recurrence of dysphagia (10%). One had
a recurrent HPZ on manometry, and one developed esophagitis, which resolved with omeprazole.
Conclusions: Our initial experience suggests that operative esophageal manometry is a useful adjunct to upper endoscopy during laparoscopic
Heller myotomy, quantitatively assuring obliteration of the nonrelaxing LES and HPZ.
Received: 1 March 1999/Accepted: 30 June 1999 相似文献
4.
Background: It has been suggested that antireflux surgery may cause an improvement in esophageal motor function (EMF) and lead to reduced
postoperative dysphagia.
Methods: We evaluated the changes in dysphagia symptom scores and esophageal and lower esophageal sphincter (LES) pressures in patients
before (n= 381), at 6 months (n= 260), and at 24 months (n= 97) after laparoscopic fundoplication.
Results: There was a significant increase in LES basal and nadir pressure following surgery in all patients and an improvement in
EMF only in patients with poor preoperative esophageal motor function. A total of 76% of the patients reported no dysphagia
or an improved dysphagia score 6 and 24 months after surgery. This improvement was more marked in patients with poor EMF.
An improvement in EMF did not correlate with the improvement in dysphagia score reported by other patients. Patients with
increased dysphagia scores 2 years after surgery had significantly higher LES basal and nadir pressures as compared to other
patients.
Conclusions: Laparoscopic Nissen fundoplication is associated with an overall reduction in dysphagia scores and leads to an improvement
in esophageal motor function in patients with poor preoperative esophageal motility. Tightness and inadequate relaxation of
the wrap during swallowing may be a determinant of long-term dysphagia.
Received: 5 May 1997/Accepted: 19 August 1997 相似文献
5.
Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated 总被引:4,自引:1,他引:3
M. G. Patti C. V. Feo U. Diener A. Tamburini M. Arcerito B. Safadi L. W. Way 《Surgical endoscopy》1999,13(9):843-847
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.
Received: 1 March 1999/Accepted: 21 June 1999 相似文献
6.
Melman L Quinlan J Robertson B Brunt LM Halpin VJ Eagon JC Frisella MM Matthews BD 《Surgical endoscopy》2009,23(6):1337-1341
Purpose The purpose of this study is to characterize the esophageal motor and lower esophageal sphincter (LES) abnormalities associated
with epiphrenic esophageal diverticula and analyze outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial
fundoplication.
Methods The endoscopic, radiographic, manometric, and perioperative records for patients undergoing laparoscopic esophageal diverticulectomy,
anterior esophageal myotomy, and partial fundoplication from 8/99 until 9/06 were reviewed from an Institutional Review Board
(IRB)-approved outcomes database. Data are given as mean ± standard deviation (SD).
Results An esophageal body motor disorder and/or LES abnormalities were present in 11 patients with epiphrenic diverticula; three
patients were characterized as achalasia, one had vigorous achalasia, two had diffuse esophageal spasm, and five had a nonspecific
motor disorder. Presenting symptoms included dysphagia (13/13), regurgitation (7/13), and chest pain (4/13). Three patients
had previous Botox injections and three patients had esophageal dilatations. Laparoscopic epiphrenic diverticulectomy with
an anterior esophageal myotomy was completed in 13 patients (M:F; 3:10) with a mean age of 67.6 ± 4.2 years, body mass index
(BMI) of 28.1 ± 1.9 kg/m2 and American Society of Anesthesiologists (ASA) 2.2 ± 0.1. Partial fundoplication was performed in 12/13 patients (Dor, n = 2; Toupet, n = 10). Four patients had a type I and one patient had a type III hiatal hernia requiring repair. Mean operative time was
210 ± 15.1 min and mean length of stay (LOS) was 2.8 ± 0.4 days. Two grade II or higher complications occurred, including
one patient who was readmitted on postoperative day 4 with a leak requiring a thoracotomy. After a mean follow-up of 13.6 ± 3.0 months
(range 3–36 months), two patients complained of mild solid food dysphagia and one patient required proton pump inhibitor (PPI)
for gastroesophageal reflux disease (GERD) symptoms.
Conclusion The majority of patients with epiphrenic esophageal diverticula have esophageal body motor disorders and/or LES abnormalities.
Laparoscopic esophageal diverticulectomy and anterior esophageal myotomy with partial fundoplication is an appropriate alternative
with acceptable short-term outcomes in symptomatic patients. 相似文献
7.
Laparoscopic esophagomyotomy with posterior partial fundoplication for primary esophageal motility disorders 总被引:2,自引:0,他引:2
Background: The outcomes of a laparoscopic esophagomyotomy with posterior partial fundoplication were compared between groups of patients
with primary motility disorders.
Methods: In this study, 47 patients (26 women and 21 men, ages 24 to 77 years; mean, 47 years) with significant dysphagia or chest
pain who failed conservative treatment underwent a laparoscopic esophagomyotomy and posterior partial fundoplication. Preoperative
evaluation revealed four groups of primary motility disorders: achalasia (n= 12), nutcracker esophagus (n= 12), hypertensive lower esophageal sphincter (LES) (n= 16), and diffuse esophageal spasm (n= 7). Statistical analysis was performed by Cramer's V test.
Results: Average follow-up period was 30.3 months. There was no mortality or early morbidity. Late morbidity included dysphagia or
chest pain over 6 weeks in 10 patients (21%), recurrent gastroesophageal reflux disease (GERD) in 3 patients (6%), and recurrent
motility disorder in 2 patients (4%). Overall, 94% of the patients ultimately had complete resolution of dysphagia or chest
pain. There was no significant difference in outcomes between groups.
Conclusion: Early results suggest that laparoscopic esophagomyotomy with posterior partial fundoplication provides safe and effective
relief from dysphagia and chest pain in patients with each of the primary motility disorders.
Received: 18 February 1999/Accepted: 16 December 1999/Online publication: 13 June 2000 相似文献
8.
Endoscopic photodynamic therapy for obstructing esophageal cancer: 77 cases over a 2-year period 总被引:14,自引:0,他引:14
Luketich JD Christie NA Buenaventura PO Weigel TL Keenan RJ Nguyen NT 《Surgical endoscopy》2000,14(7):653-657
rid="id="<e5>Correspondence to:</e5> J. D. Luketich, 200 Lothrop Street, C-800, Presbyterian Hospital, Pittsburgh, PA 15213,
USA
Background: Photodynamic therapy (PDT) is an alternative treatment option for the palliation of obstructive esophageal cancer. We report
our experience with PDT for patients presenting with inoperable, obstructing, or bleeding esophageal cancer.
Methods: Seventy-seven patients with inoperable, obstructing esophageal cancer were treated with PDT from November 1996 to July 1998.
Photofrin (1.5–2.0 mg/kg) was administered, followed by endoscopic light treatment (630 nm red dye laser) at 48 h. Dysphagia
score (1 for no dysphagia to 5 for complete obstruction), dysphagia-free interval, and patient survival were assessed.
Results: Seventy-seven patients underwent 125 PDT courses. The mean dysphagia score at 4 weeks after PDT in 90.8% of the patients
improved from 3.2 ± 0.7 to 1.9 ± 0.8 (p < 0.05). PDT adequately controlled bleeding in all six patients who had bleeding. The most common complications after the
125 PDT courses were esophageal stricture (4.8%), Candida esophagitis (3.2%), symptomatic pleural effusion (3.2%), and sunburn (10.0%). Twenty-nine patients (38%) required more than
one PDT course, and seven patients required placement of an expandable metal stent for recurrent dysphagia. The mean dysphagia-free
interval was 80.3 ± 58.2 days. The median survival was 5.9 months.
Conclusions: Photodynamic therapy is a safe and effective treatment for the palliation of obstructing and bleeding esophagus cancer.
Received: 8 May 1999/Accepted: 24 September 1999/Online publication: 15 May 2000 相似文献
9.
Laparoscopic Heller myotomy relieves dysphagia in patients with achalasia and low LES pressure following pneumatic dilatation 总被引:3,自引:0,他引:3
Diener U Patti MG Molena D Tamburini A Fisichella PM Whang K Way LW 《Surgical endoscopy》2001,15(7):687-690
Background: Although pneumatic dilatation is said to relieve dysphagia in achalasia if it decreases lower esophageal sphincter
(LES) pressure to <10 mmHg, dysphagia persists in some cases. Performing a Heller myotomy in this setting has been challenged
on the assumption that everything possible has already been done to eliminate the barrier posed by the malfunctioning sphincter.
Therefore, we set out to assess the results of laparoscopic Heller myotomy and Dor fundoplication in achalasia in relation
to LES pressure. Methods: Fifty-seven patients with achalasia were divided into the following three groups, based on the LES
pressure and previous treatment: group A, previous balloon dilatation and LES pressure ?10 mmHg (n = 9); group B, previous
balloon dilatation and LES pressure >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.
apd: 11 May 2001 相似文献
10.
Background: Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia
and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always
as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success
and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF).
Methods: A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively
in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry;
24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical
follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated
further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption
on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision.
Results: At a mean follow-up of 30 months (range, 3–51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux.
Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis
(13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either
complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis
and a normal LES was reflected in a 96% 3-year success rate.
Conclusion: Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy.
Received: 29 June 1998/Accepted: 2 July 1999 相似文献
11.
Koppman JS Poggi L Szomstein S Ukleja A Botoman A Rosenthal R 《Surgical endoscopy》2007,21(5):761-764
Background Most studies investigating esophageal motility among the morbidly obese have focused on the relationship between lower esophageal
sphincter (LES) pressure and gastroesophageal reflux disease (GERD). Very few studies in the literature have examined motility
disorders among the morbidly obese population in general outside the context of GERD. This study aimed to determine the prevalence
of esophageal motility disorders in obese patients selected for bariatric surgery.
Methods A total of 116 obese patients (81 women and 35 men) selected for laparoscopic gastric banding underwent manometric evaluation
of their esophagus from January to March 2003. Tracings were retrospectively reviewed for the end points of LES resting pressure,
LES relaxation, and esophageal peristalsis.
Results The study patients had a body mass index (BMI) of 42.9 kg/m2, and a mean age of 48.6 years. The following abnormal manometric findings were demonstrated in 41% of the patients: nonspecific
esophageal motility disorders (23%), nutcracker esophagus (peristaltic amplitude >180 mmHg) (11%), isolated hypertensive LES
pressure (>35 mmHg) (3%), isolated hypotensive LES pressure (<12 mmHg) (3%), diffuse esophageal spasm (1%), and achalasia
(1%). Only one patient with abnormal esophageal motility reported noncardiac chest pain.
Conclusions Despite a high prevalence of esophageal dysmotility in our morbidly obese study population, there was a conspicuous absence
of symptoms. Although the patients in this study were not directly questioned with regard to esophageal symptoms, several
studies in the literature support our conclusion.
Podium presentation at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), 26–29 April
2006, Dallas, TX, USA 相似文献
12.
Background: Persistent postoperative dysphagia occurs in up to 24% of patients who undergo a laparoscopic Nissen fundoplication for reflux
disease [7]. We hypothesized that patient history, pH testing, and esophageal manometry could be used to preoperatively identify
patients at risk for this complication.
Methods: Of 156 laparoscopic Nissen fundoplications performed over a 27-month period, we identified 19 patients (12%) who suffered
from postoperative dysphagia longer than 3 months. The presenting complaint of preoperative swallowing difficulty was noted
as was the presence of a known esophageal stricture. Preoperative pH testing and esophageal manometry were performed for all
subjects. We compared the following parameters to an age and gender-matched control group: history of esophageal stricture,
presence of preoperative dysphagia, DeMeester reflux score, upper esophageal sphincter pressure and relaxation, esophageal
body motility, location of respiratory inversion point, and lower esophageal sphincter length, resting pressure, and relaxation.
Data were compared via t-test and Fisher's exact test.
Results: Patients who presented before surgery with complaints of difficulty swallowing were more likely to suffer from postoperative
dysphagia (p= 0.029). Incidence of stricture, DeMeester score, and manometric measurements did not differ between the dysphagia and control
groups (p > 0.05 for all parameters).
Conclusions: Although preoperative studies are not helpful in identifying patients at risk for persistent dysphagia after laparoscopic
Nissen fundoplication, patients presenting with the preoperative complaint of difficulty swallowing are at increased risk
for this complication.
Received: 1 April 1999/Accepted: 22 July 1999 相似文献
13.
Background: This study was designed to determine the feasibility and outcome of laparoscopic cardiomyotomy in patients with achalasia
who have persistent or recurrent dysphagia following balloon dilatation.
Methods: Ten patients who had undergone a minimum of two (range, two to seven) previous balloon dilatations underwent a single anterior
cardiomyotomy extending from the gastroesophageal junction onto the esophagus proximally for 6 cm. Four patients had a Toupet
fundoplication. Patients were analyzed using pre- and postoperative DeMeester symptom scores for dysphagia, regurgitation,
and heartburn (0 = none–3 = maximal) and esophageal manometry.
Results: Mean operating time was 90 min. Periesophagitis was noted in some patients but was rarely troublesome. Submucosal fibrosis
was present in all patients and made dissection more difficult particularly around the cardioesophageal junction. As a result,
three patients had mucosal perforations that required repair by laparoscopic suturing. There were no subsequent postoperative
complications. Median (IQR) postoperative stay was 3 (2–4) days. At 3-month reassessment, there was a reduction in the median
dysphagia score from 3 to 0, and also in the regurgitation score from 3 to 0. At last follow-up (median, 22 months), one patient
had developed recurrent dysphagia (grade 2), which improved with dilatation. Overall success of the laparoscopic procedure
was therefore 90%. Only one patient developed new symptoms of reflux (mild, grade 1) after surgery.
Conclusions: Laparoscopic cardiomyotomy provides good control of the symptoms of dysphagia and regurgitation without the morbidity of
a laparotomy or thoracotomy incision. Although technically more difficult, the technique can be extended to those who have
had previous balloon dilatation with complication and success rates similar to published results in patients who have not
undergone previous dilatation.
Received: 7 January 1998/Accepted: 22 June 1998 相似文献
14.
Background Anterior fundoplication (AF) following laparoscopic Heller myotomy (LHM) for achalasia may prevent esophageal leaks and gastroesophageal
reflux but cause dysphagia. Our study attempts to determine the effect of AF on esophageal leaks, nuclear medicine esophageal
clearance (EC), symptom frequency (SF), and Van Trappen symptom scores (SS) for dysphagia, regurgitation, and heartburn.
Methods Between 1995 and 2004, pre- and postoperative (2–12 months) EC, SF, and SS scores were compared in 95 patients undergoing
LHM for achalasia with AF (n = 71) and without (n = 24) AF.
Results There were no leaks or deaths. Laparoscopic Heller myotomy decreased the frequency of postoperative dysphagia, regurgitation,
and heartburn with AF (96% preoperation versus 6% postoperation, 94% versus 3%, 58% versus 6%) (p = 0.001) and without AF (100% versus 0%, 83% versus 0%, 50% versus 4%) (p = 0.001). Laparoscopic Heller myotomy improved all SS in both groups. There was no difference between postoperative dysphagia
(1.38 ± 0.64 versus 1.17 ± 38) p = 0.06, regurgitation (1.17 ± 51 versus 1.04 ± 0.20) p = 0.08, and heartburn (1.29 ± 62 versus 1.53 ± 0.80) p = 0.185 scores between the AF and no-AF group, respectively. There is a trend toward improvement in dysphagia and regurgitation
in the no-AF group. Laparoscopic Heller myotomy improved EC in the supine and upright positions in both groups of patients
(p = 0.001). There was an improved mean change in EC (10 min upright) in the no-AF group versus the AF group (50.7% ± 30.8 versus
29.7% ± 30.2) p = 0.004.
Conclusions Laparoscopic Heller myotomy improves esophageal transit and the frequency and severity of dysphagia, heartburn, and regurgitation
in a safe manner. Patients without AF show a statistically better upright EC with a trend toward improved dysphagia and regurgitation. 相似文献
15.
Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia 总被引:1,自引:0,他引:1
Background The standard Heller myotomy (SM) for achalasia extends 1 to 2 cm on to the stomach. The authors perform an extended myotomy
(EM) (>3 cm) with the goal of reducing postoperative dysphagia. This study examines the long-term efficacy and durability
of EM compared with SM.
Methods Patients with achalasia who underwent a laparoscopic Heller myotomy were identified from a prospective database that includes
symptom evaluation and results of esophageal functional studies. From September 1994 to August 1998, the authors performed
SM with Dor fundoplication, and from September 1998 through 2003, they performed EM with Toupet fundoplication. In 2001, they
performed a telephone survey of all available patients. This was repeated in 2005 for the EM group. The survey included scales
of symptom frequency (0 [never], 1 [once per month], 2 [once per week], 3 [once per day], 4 [more than once per day]) and
severity (0 [no symptoms] to 10 [symptoms equal to preoperative state]) as well as the need to undergo postoperative intervention
for dysphagia.
Results For this study, 52 patients underwent SM with Dor fundoplication (median follow-up period, 46 ± 24 months), and 63 patients
underwent EM with Toupet fundoplication (median follow-up period, 45 ± 17 months. Postoperative dysphagia severity was significantly
better in the EM group (4.8 ± 2.3 vs 3.1 ± 2.6; p < 0.005). There was no significant difference in postoperative heartburn frequency, esophageal acid exposure, or lower esophageal
sphincter pressure. In the SM group, 9 patients (17%) required reintervention for dysphagia: 14 endoscopic interventions for
5 patients (10%) and reoperation for 4 patients. Three patients (5%) in the EM group required reintervention for dysphagia:
one endoscopic intervention each and no reoperations (p < 0.05). A total of 30 patients in the EM group were contacted in both 2001 (median follow-up period, 19 ± 11 months) and
2005 (median follow-up period, 63 ± 10 months). There was no significant change over time in dysphagia severity (2.6 ± 1.9
vs 3.7 ± 2.0; p = 0.19).
Conclusions For the treatment of achalasia, EM with Toupet fundoplication provides excellent durable dysphagia relief that is superior
to SM with Dor fundoplication. 相似文献
16.
Silvana Perretta M.D. Piero M. Fisichella M.D. Carlos Galvani M.D. Maria V. Gorodner M.D. Lawrence W. Way M.D. Marco G. Patti M.D. F.A.C.S. 《Journal of gastrointestinal surgery》2003,7(5):595-598
Some patients with achalasia complain of chest pain in addition to dysphagia and regurgitation. Chest pain is said to be most
common in young patients who have been symptomatic for a short time, and who often have vigorous achalasia (distal esophageal
amplitude ≥37 mm Hg). Although pneumatic dilatation is reported to improve chest pain in 20% of patients, the effect of laparoscopic
Heller myotomy on chest pain is unknown. The aim of this study was to determine the following in achalasia: (1) the prevalence
of chest pain; (2) the clinical and manometric profiles of patients with chest pain; and (3) the effect of laparoscopic Heller
myotomy. Between 1990 and 2001, a total of 211 patients with achalasia were studied (upper gastrointestinal series, esophagoduodenoscopy,
and manometry). A total of 117 patients (55%) had chest pain in addition to dysphagia and regurgitation; 63 (54%) of these
117 patients underwent laparoscopic Heller myotomy and Dor fundoplication. Median follow up was 24 months. Age (49 ± 16 years
vs. 51 ± 14 years [mean ± SD]), duration of symptoms (71 ± 91 months vs. 67 ± 92 months [mean ± SD]), and presence of vigorous
achalasia (50% vs. 47%) were similar in those with and without chest pain. Ten (16%) of the 63 patients with chest pain who
underwent Heller myotomy had vigorous achalasia. Postoperatively chest pain resolved in 84% and improved in 11 % of patients.
There was no difference in clinical outcome between patients with and without vigorous achalasia. These data demonstrate the
following: (1) chest pain was present in 55% of patients with esophageal achalasia; (2) chest pain was not related to age,
duration of symptoms, or manometric findings; and (3) laparoscopic Heller myotomy improved chest pain in 95% of patients,
regardless of the manometric findings. Thus laparoscopic Heller myotomy was highly effective in treating achalasia with chest
pain.
Considered for the 2002 Grassi Prize, International Society of Digestive Surgery, Hong Kong, China, December 11, 2002. 相似文献
17.
18.
Renato Salvador Mario Costantini Giovanni Zaninotto Tiziana Morbin Christian Rizzetto Lisa Zanatta Martina Ceolin Elena Finotti Loredana Nicoletti Gianfranco Da Dalt Francesco Cavallin Ermanno Ancona 《Journal of gastrointestinal surgery》2010,14(11):1635-1645
Background
A new manometric classification of esophageal achalasia has recently been proposed that also suggests a correlation with the final outcome of treatment. The aim of this study was to investigate this hypothesis in a large group of achalasia patients undergoing laparoscopic Heller–Dor myotomy.Methods
We evaluated 246 consecutive achalasia patients who underwent surgery as their first treatment from 2001 to 2009. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored and barium swallow X-ray, endoscopy, and esophageal manometry were performed before and again at 6 months after surgery. Patients were divided into three groups: (I) no distal esophageal pressurization (contraction wave amplitude <30 mmHg); (II) rapidly propagating compartmentalized pressurization (panesophageal pressurization >30 mmHg); and (III) rapidly propagating pressurization attributable to spastic contractions. Treatment failure was defined as a postoperative symptom score greater than the 10th percentile of the preoperative score (i.e., >7).Results
Type III achalasia coincided with a longer overall lower esophageal sphincter (LES) length, a lower symptom score, and a smaller esophageal diameter. Treatment failure rates differed significantly in the three groups: I?=?14.6% (14/96), II?=?4.7% (6/127), and III?=?30.4% (7/23; p?=?0.0007). At univariate analysis, the manometric pattern, a low LES resting pressure, and a high chest pain score were the only factors predicting treatment failure. At multivariate analysis, the manometric pattern and a LES resting pressure <30 mmHg predicted a negative outcome.Conclusion
This is the first study by a surgical group to assess the outcome of surgery in 3 manometric achalasia subtypes: patients with panesophageal pressurization have the best outcome after laparoscopic Heller–Dor myotomy. 相似文献19.
Patti MG Perretta S Fisichella PM D'Avanzo A Galvani C Gorodner V Way LW 《Surgical endoscopy》2003,17(3):386-389
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, ?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. 相似文献
20.
Gamagaris Z Patterson C Schaye V Francois F Traube M Fielding CJ Fielding GA Youn AH Weinshel EH 《Obesity surgery》2008,18(10):1268-1272
Background The laparoscopic adjustable gastric band (LAGB) has been widely used to treat morbid obesity. There is conflicting data on
its long-term effect on esophageal function. Our aim was to assess the long-term impact of the LAGB on esophageal motility
and pH-metry in patients who had LAGB who had normal and abnormal esophageal function at baseline.
Methods Consecutive patients referred for bariatric surgery were prospectively enrolled. A detailed medical history was obtained,
and esophageal manometric and 24-h pH evaluations were performed in standard fashion preoperatively and 6 and 12 months postoperatively;
patients served as their own controls.
Results Twenty-two patients completed manometric evaluation. Ten patients had normal manometric parameters at baseline; at 6 months,
mean lower esophageal sphincter (LES) residual pressure increased significantly from baseline (3.9 ± 2 vs. 8.9 ± 4 mmHg, p = 0.014). At 12 months, the mean peristaltic wave duration increased from 3.6 ± 1 at baseline to 6.8 ± 2 s, p = 0.025 and wave amplitude decreased during the same period (98.7 ± 22 vs. 52.3 ± 24, p = 0.013). LES pressure and percent peristalsis did not differ significantly pre- and post-LAGB. Twelve patients had one or
more abnormal manometric findings at baseline; at 12 months, LES pressure in these 12 patients decreased significantly (31.1 ± 10
vs 23.6 ± 7, p = 0.011) and wave amplitude was significantly reduced (125.9 ± 117 vs 103 ± 107, p = 0.039). LES residual pressure did not change significantly pre- and post-LAGB. Twenty-two individuals were evaluated for
impact of Lap-Band on esophageal acid exposure. Sixteen of these patients had normal esophageal pH-metry values at baseline
and had no significant changes in 12 months in any pH-metry measurement. Six patients had abnormal pH-metry values at baseline.
Among these patients, time with pH < 4.0 and Johnson/DeMeester score did not change significantly during follow-up. There
was a significant decrease in the number of reflux episodes from baseline to 6 months (159 ± 48 vs. 81 ± 61, p = 0.016).
Conclusions Abnormal manometric findings are frequently encountered post-LAGB. Increases in LES residual pressure and peristaltic wave
duration were the most significant changes. LAGB is not associated with an increase in total esophageal acidification time.
Further evaluation of the clinical significance of manometric abnormalities is warranted. 相似文献