Esophageal ileus following laparoscopic fundoplication

Early postoperative dysphagia occurs in most patients following laparoscopic fundoplication. Whether dysphagia is associated with a change in esophageal motor function and/or a change in gastroesophageal junction characteristics is unknown. Esophageal motility in the early postoperative period has not been evaluated previously. Esophageal motility was studied on the first postoperative day in 10 patients who underwent laparoscopic Nissen fundoplication and 10 patients who underwent laparoscopic cholecystectomy (control group), using standard perfusion manometry. Primary peristalsis on water swallows following fundoplication elicted a median response of 5% successful peristalsis compared with median response of 100% successful peristalsis following cholecystectomy (P = 0.05). The fundoplication was associated with failure of primary esophageal peristalsis in 7/10 patients, compared to 2/10 patients who underwent cholecystectomy (P = 0.068 Fisher's exact test). Three months after fundoplication, in nine patients studied, primary peristalsis was similar to peristalsis observed preoperatively in seven patients and two patients still had an aperistaltic esophagus. In this study, esophageal manometry 1 day after surgery demonstrated grossly disturbed esophageal motility in most patents following laparoscopic fundoplication, compared to normal motility following laparoscopic cholecystectomy. Peristalsis improved at 3 months or more following surgery. This suggests that an 'esophageal ileus' occurs during the early period after laparoscopic fundoplication.     

Management of achalasia with transabdominal esophagocardiomyotomy and partial posterior fundoplication

In this article we present our experience in the management of achalasia. From May 1988 through August 2005, 71 patients with achalasia underwent transabdominal esophagocardiomyotomy and partial posterior fundoplication. Barium swallow, manometry, and 24-h pH studies were performed in all patients preoperatively. Manometry and 24-h pH monitoring were only carried out in 58 patients at the third post-operative week and in 43 patients during follow-up, even though 52 patients were included in the follow-up. There were no operative deaths or complications. All the 71 patients were able to eat semifluid or solid food without dysphagia and heartburn at discharge. Esophageal barium studies showed that the maximum esophageal diameter decreased 2.2 cm and the minimum gastroesophageal junction diameter increased 8.4 mm after operation. Manometry examination in 58 patients revealed that the lower esophageal sphincter resting pressure decreased 15.0 mmHg in the wake of the procedure. Twenty-four hour pH monitoring demonstrated that reflux events were within the normal post-operative range. Fifty-five of the 58 patients had normal DeMeester scores. Among the patients with a mean 90-month follow-up, 49 patients had normal intake of food without reflux, the remaining three had mild dysphagia without requiring treatment. All the patients resumed their preoperative work and social activities. The manometry and 24-h pH studies in the 43 patients showed there were no significant changes between the third post-operative week and during follow-up. Transabdominal esophagocardiomyotomy and posterior partial fundoplication are able to relieve the functional outflow obstruction of the lower esophageal sphincter, obviate the rehealing of the myotomy edge and prevent gastroesophageal reflux in patients who have undergone myotomy alone.     

Long-term effects of myotomy and partial fundoplication for esophageal achalasia.

Controversy persists in the surgical approach to treat esophageal achalasia. This investigation reports the long-term effects of esophageal myotomy and partial fundoplication in treating this disorder. From 1984 to 1998, 32 patients with achalasia underwent myotomy and partial fundoplication (Belsey Mark IV) using a left thoracotomy. The median follow up is 7.2 years. Assessments include clinical evaluation, esophagogram, radionuclide transit, manometry, 24-h pH, and endoscopy. There is no complication and no mortality. Preoperative assessment was compared with that in 0-3, 3-7, and 7-16 postoperative years. Clinically, the prevalence of dysphagia was decreased from 100% to 6%, 12%, and 13%, respectively (P < 0.001). Heartburn remains unchanged (P > 0.25). On radiology, the prevalence of barium stasis was decreased from 97% to 44%, 48%, and 47%, respectively (P=0.001), whereas a pseudo-diverticulum was observed in two-thirds of patients after operation (P=0.001). Percent radionuclide stasis at 2 min was measured as 70%, 17%, 20%, and 20%, respectively (P=0.001). Manometrically, lower esophageal sphincter (LES) gradient was decreased from 29 to 10, 9, and 9 mmHg, respectively (P=0.001). LES relaxation was improved from 41% preoperatively to 100% postoperatively at each postoperative period (P < 0.001). An abnormal acid exposure was observed in four patients after the operation. Endoscopy documented mucosal damage in three patients (P > 0.25). In conclusion, on long-term follow up, myotomy and partial fundoplication for achalasia relieve obstructive symptoms and improve esophageal emptying, and reduce LES gradient and improve LES relaxation. Acid reflux is recorded in 13% of patients and esophageal mucosal damage is identified in 11% of the patient population. A longer myotomy not covered by the fundoplication results in pseudodiverticulum formation and increased esophageal retention.     

The effect of laparoscopic partial fundoplication on dysphagia, esophageal and lower esophageal sphincter motility

It has been suggested that dysphagia is less common after partial versus complete fundoplication. The mechanisms contributing to postoperative dysphagia remain unclear. The objective of the present prospective study was to investigate esophageal motility and the prevalence of dysphagia in patients who have undergone laparoscopic partial fundoplication. Symptoms, lower esophageal sphincter (LES) characteristics and esophageal body motility were evaluated prospectively in 62 patients before and after laparoscopic partial fundoplication: 33 women and 29 men with a mean age of 44 +/- 1.5 years (range, 21-71). The patients filled in symptom questionnaires and underwent stationary and ambulatory manometry and 24-h pH-metry before and after operation. A small but significant increase in LES pressure from 14.8 +/- 0.9 to 17.8 +/- 0.8 mmHg was seen after laparoscopic partial fundoplication. Further, LES characteristics and esophageal body motility were not different post- versus preoperation. Three months after surgery, dysphagia was present in eight patients. No differences in LES characteristics or body motility were present between patients with and without dysphagia. Six months after the operation dysphagia was present in only three patients (3.2% mild and 1.6% severe dysphagia). Adequate reflux control was obtained in 85% of the patients. Laparoscopic partial fundoplication offers adequate reflux control without affecting esophageal body motility and with a very low incidence of postoperative dysphagia.     

Preoperative esophageal manometry does not predict postoperative dysphagia following anti-reflux surgery

This prospective study was undertaken to determine the value of manometric studies in predicting postoperative dysphagia in patients undergoing laparoscopic Toupet fundoplication. Two hundred and twenty-nine out of 401 patients (57%) had preoperative dysphagia, and 26 patients had late postoperative dysphagia (6.5%). Eight patients who had no preoperative dysphagia developed dysphagia following surgery. There were no significant differences in esophageal motility for patients without postoperative dysphagia (n = 375) compared with those with postoperative dysphagia (n = 26). Among patients with postoperative dysphagia as a new symptom (n = 8), six had normal preoperative distal esophageal pressures, and none had esophageal hypomotility. In those with both pre- and postoperative dysphagia 15 of 18 had normal esophageal motility and hypomotility was only found in one. The positive predictive values of distal esophageal hypomotility and other measures for postoperative dysphagia are poor. In conclusion, preoperative manometry does not predict postoperative dysphagia following laparoscopic Toupet partial fundoplication.     

Outcome of floppy Nissen fundoplication with intraoperative manometry to treat sliding hiatal hernia

SUMMARY.  The aim of this study was to evaluate the effectiveness of floppy Nissen fundoplication with intraoperative esophageal manometry. Between February 1992 and July 2004, there were 102 patients with sliding hiatal hernia undergoing transabdominal Nissen fundoplication. They were divided into three groups: 27 patients were in the Nissen group (CNF), 44 in the floppy Nissen group (FNF, including 5 with laparoscopic Nissen fundoplication), and 31 in the intraoperative-esophageal-manometry group (INF, 13 with laparoscopic Nissen fundoplication). There were no operation-related deaths. Operation-related complications occurred in five patients within 1 month after operation: In CNF, two patients suffered from dysphagia and one from regurgitation; in FNF, one patient had slight dysphagia and two had regurgitation; in INF, there was no one who complained about dysphagia or regurgitation, but pneumothorax occurred in one case. After more than 2 years of follow-up, two patients, in CNF, suffered from severe dysphagia, one recurred and two with abnormal 24 h pH monitoring. In FNF, one patient had dysphagia, one recurred and three had abnormal 24 h pH monitoring; in INF, two patients had acid reflux on 24 h pH monitoring. The postoperative lower esophageal sphincter pressure was in the normal range in 30 of 31 patients (96.5%). The normal rate of postoperative tests in CNF, FNF and INF were 81.5%, 86.4% and 93.5%, respectively. Both the Nissen fundoplication and the floppy Nissen fundoplication are effective approaches to treat patients with sliding hiatal hernia. Intraoperative manometry is useful in standardizing the tightness of the wrap in floppy Nissen fundoplication and may contribute to reducing or avoiding the occurence of postoperative complications.     

Laparoscopic Heller myotomy with Dor fundoplication for achalasia: long‐term outcomes and effect on chest pain

The aim of the present study was to evaluate the long‐term outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD) and its effect on chest pain. Between June 1995 and August 2009, a total of 35 patients with achalasia underwent an LHD. The symptom scores were calculated by combining the frequency and the severity. Pre‐ and postoperative evaluations included symptom score, radiology, manometry, and 24‐hour pH manometry. Median total symptom score was significantly lower than the preoperative score (19 vs 4, P < 0.001) at a median follow‐up of 94 months. Among the 35 patients, 18 (51%) had chest pain. The frequency of chest pain was similar for the pre‐ and postoperative scores, but the severity tended to be less. Median esophageal diameter (5.4 cm vs 3.5 cm, P < 0.001) and lower esophageal sphincter pressure (41 mmHg vs 8.9 mmHg, P < 0.001) were significantly reduced after surgery. Median age, duration of symptoms, esophageal diameter, and lower esophageal sphincter pressure were similar between patients with and without chest pain prior to surgery. No significant differences were observed between the two groups in terms of amplitude, duration, and frequency of contractions from the findings of postoperative 24‐hour esophageal manometry. Chest pain resolved in three patients (17%) and improved in seven patients (39%) after surgery. LHD can durably relieve achalasic symptoms of both dysphagia and regurgitation, and it can be considered the surgical procedure of choice. However, achalasic chest pain does not always seem to be related with patient characteristics and manometric findings.     

High‐resolution manometry findings in symptomatic post‐Nissen fundoplication patients with normal endoscopic configuration

The aim of this study was to investigate high‐resolution manometry (HRM) findings in symptomatic post‐fundoplication patients with normal endoscopic configuration. A retrospective review of a prospectively maintained database was conducted to identify patients who underwent evaluation with HRM and endoscopy for symptom evaluation after previous fundoplication. Study period extends from September 2008 to December 2012. Only patients with complete 360° fundoplication (Nissen) were included, and patients with partial fundoplication were excluded. Patients with endoscopic abnormality or patients who underwent Collis procedure were also excluded. Additionally, contrast study and 24‐hour pH study if done were reviewed. Symptoms were graded using a standard questionnaire with symptoms graded on a scale of 0–3. Symptom grade 2 or 3 was considered a significant symptom. One hundred seventy‐nine symptomatic patients with previous Nissen fundoplication underwent HRM and endoscopy during the study period. Of these, 136 patients were excluded (51 had recurrent hiatal hernia, 2 had disrupted fundoplication, 68 had slipped fundoplication, 10 had twisted fundoplication, 2 had esophageal stricture, and 3 had Collis procedure). Remaining forty‐three patients met inclusion criteria (mean age of 56.0 ± 14.8, 32 females).The most common symptom was dysphagia (67%). Patients with dysphagia had a significantly longer length of distal esophageal high pressure zone (HPZ) and a higher integrated relaxation pressure (IRP) than patients without dysphagia (P = 0.020, 0.049). Especially, patients who had shorter HPZ (≤2 cm) were less likely to have significant dysphagia. Twenty‐three patients (53%) had heartburn. There was no significant difference in HRM findings between patients with and without heartburn. Only 4 of 28 patients with concomitant pH study showed abnormal DeMeester score (>14.7), and there was no correlation between results of pH study and lower esophageal sphincter pressure/length and IRP. Longer HPZ complex length and higher IRP as measured with HRM is associated with post‐Nissen fundoplication dysphagia in patients with normal endoscopic configuration. No HRM parameters are associated with reported heartburn or a positive pH score.     

Achalasie – welche Heilungsmethode soll für ?ltere Patienten gew?hlt werden?

Background Achalasia is an uncommon illness affecting 1 per 100,000 patients a year. It encompasses a rare, primary motor disorder of the distal esophagus. Methods Over the period 1998-2006, 115 patients underwent various treatments for achalasia; the subgroup of seniors consisted of 26 patients. Six patients of these (age 69.7 y) underwent a modified Heller cardiomyotomy due to failure of previous endoscopic interventions. Standard esophageal manometry and 24 hour pH metry were performed pre- and postoperatively. Results Six senior patients with achalasia underwent a laparoscopic Heller myotomy. Average preoperative tonus of the LES was 55 mmHg, postoperative tonus of the LES decreased to 11 mmHg. We performed Toupet partial fundoplication in all patients; no microperforation of the esophagus was found in the preoperative esophagoscopy. We recorded minimal pathological gastroesophageal reflux in pH metry – the average preoperative DeMeester score was 8, postoperatively 10.5. Prolonged dysphagia was not present in any patient – preoperative GIQLI score was 94, postoperative score was 106. There was no mortality or morbidity in the group of the operated patients. Conclusion Our operational results and postoperative follow-up show that laparoscopic Heller myotomy with Toupet partial fundoplication is a safe and effective treatment and can be recommended as the method of first choice for senior patients with no contraindication for laparoscopic operation.     

Surgical treatment of the non-complicated gastroesophageal reflux: fundoplication without division of the short gastric vessels

BACKGROUND: There is today a significant greater number of laparoscopic antireflux procedures for the surgical treatment of gastroesophageal reflux disease and there are yet controversies about the necessity of division of the short gastric vessels and full mobilization of the gastric fundus to perform an adequate fundoplication. AIM: To verify the results of the surgical treatment of non-complicated gastroesophageal reflux disease performing Rossetti modification of the Nissen fundoplication. Patients and Methods - Fourteen patients were operated consecutively and prospectively (mean age 44.07 years); all had erosive esophagitis without Barrett's endoscopic signals (grade 3, Savary-Miller) and they were submitted to the Rossetti modification of the Nissen fundoplication. Endoscopy, esophageal manometry and pHmetry were performed before the procedure and around 18 months postoperatively. RESULTS: There was no morbidity, transient dysphagia average was 18.42 days; there was no register of dehiscence or displacement of the fundoplication and only one patient revealed a light esophagitis at postoperative endoscopy; the others presented a normal endoscopic view of the distal esophagus. All noticed a marked improvement of preoperative symptoms. Lower esophageal sphincter pressure changed from 5.82 mm Hg (preoperative mean) to 12 mm Hg (postoperative mean); lower esophageal sphincter relaxing pressure, from 0.38 mm Hg to 5.24 mm Hg and DeMeester score, from 16.75 to 0.8. CONCLUSION: Rossetti procedure (fundoplication without division of the short gastric vessels) is an effective surgical method to treat gastroesophageal reflux disease.     

Dysphagia and esophageal motor dysfunction in gastroesophageal reflux are corrected by fundoplication

Abnormalities in esophageal peristaltic function and acid clearance appear to be responsible for prolonged esophageal acid exposure, a major determinant of the reflux esophagitis and esophageal stricture. We evaluated esophageal motility by manometry in 50 healthy controls and in 35 symptomatic reflux patients before, within 6 months, and 1 year after Nissen fundoplication. Preoperative motility was analyzed in relation to the presence or absence of both nonobstructive dysphagia and erosive esophagitis. We found that (a) preoperative dysphagia was related more to peristaltic dysfunction than to esophagitis; (b) peristaltic wave amplitude and duration were significantly lower than control values in patients with reflux, without correlation to degree of esophagitis or lower esophageal sphincter hypotension; (c) dysphagia ceased in most patients after antireflux surgery at the same time that normal motility was restored independently of lower esophageal sphincter pressure increments. These results suggest that motility disturbances are an important cause of dysphagia in reflux disease, and that reflux is the cause of, rather than the consequence of, peristaltic dysfunction.     

Persistent dysphagia after laparoscopic fundoplication for gastro-esophageal reflux disease

SUMMARY.  Persistent postoperative dysphagia is a potentially severe complication of fundoplication for gastroesophageal reflux disease (GERD). The aim of this retrospective study was to analyze our experience of laparoscopic fundoplication for GERD in 276 consecutive patients, to determine the frequency of postoperative dysphagia and assess treatments and outcomes. There was no relation between preoperative dysphagia, present in 24 patients (8.7%), and postoperative DeMeester grade 2 or 3 dysphagia, present in 25 patients (9.1%). Ten (3.6%) patients had clinically significant postoperative dysphagia, eight (2.9%) underwent esophageal dilation, with symptom improvement in five. Four (1.4%) of our patients (two with failed dilation) and 11 patients receiving antireflux surgery elsewhere, underwent re-operation for persistent dysphagia 12 months (median) after the first operation. DeMeester grade 0 or 1 dysphagia was obtained in 10/13 evaluable patients. Our experience is fully consistent with that of the recent literature. Redo surgery is necessary in only a small fraction of operated patients with GERD with good probability of resolving the dysphagia. Best outcomes are obtained when an anatomical cause of the dysphagia is documented preoperatively.     

Gastric volvulus after laparoscopic fundoplication: a rare complication after Heller-Dor operation for achalasia

A laparoscopic Heller-Dor operation is a safe and effective procedure for esophageal achalasia. We experienced postoperative gastric volvulus after performing a laparoscopic Heller-Dor operation. This was successfully treated with laparoscopic-assisted gastropexy. A 56-year-old Japanese woman had complained of dysphagia for 3 years. She was diagnosed as having achalasia and then underwent a laparoscopic Heller-Dor operation. She complained of nausea and abdominal fullness on postoperative day 5 and gastrography revealed organoaxial gastric volvulus. We performed a reoperation using a laparoscopic-assisted approach. Because of preexisting gastric ptosis, the stomach was unusually movable. In addition, a rotational torque due to the fundoplication might have caused the volvulus. We performed an anterior gastropexy. The patient’s dysphagia disappeared after the second surgery, and recurrent volvulus has not been observed for 13 months. In cases with an unusually movable stomach, the addition of gastropexy may be effective in preventing postoperative gastric volvulus, which is rare but may possibly occur after laparoscopic fundoplication.     

Outcome of laparoscopic Nissen fundoplication in patients with disordered preoperative peristalsis.

BACKGROUND: A 360 degrees or Nissen fundoplication remains controversial in patients with disordered peristalsis, some surgeons preferring a partial wrap to minimise postoperative dysphagia. AIM: To evaluate symptoms and manometric outcome in patients with disordered peristalsis after Nissen fundoplication. PATIENTS: In an initial series of 345 patients studied prospectively, 31 patients who had undergone a Nissen fundoplication had disordered peristalsis. Using preoperative manometry, patients were classified as: equivocal primary peristalsis (eight patients); abnormal primary peristalsis (four patients); abnormal maximal contraction pressure (13 patients); abnormal primary peristalsis and maximal contraction pressure (six patients). METHODS: Postoperatively, patients underwent a barium meal, oesophageal manometry and standardised clinical review by a blinded scientific officer. RESULTS: Twenty eight (90%) patients had satisfaction scores of at least 8 out of a maximum of 10 and all would undergo surgery again. Whereas 15 (48%) patients had dysphagia scores greater than 4/10 preoperatively, only two (6%) had these scores at one year. Improved peristalsis was seen in 78% of postoperative manometric studies, and mean preoperative lower oesophageal sphincter pressure increased from 6.6 (range 0-21) mm Hg to 19 (4-50) mm Hg. CONCLUSIONS: These results are similar to the overall group of 345 patients and suggest that disordered peristalsis, and possibly even absent peristalsis, is not a contraindication to Nissen fundoplication as performed in these patients.     

Heller''s esophagomyotomy with or without a 360° floppy Nissen fundoplication for achalasia. Long-term results from a prospective randomized study

Heller's esophagomyotomy relieves dysphagia but does not restore esophageal peristalsis. The myotomy may induce reflux and the addition of a 360 degrees fundoplication may be hazardous with regard to the remaining aperistaltic esophagus. The aim of this prospectively randomized clinical trial was to compare the outcome for patients with uncomplicated achalasia who underwent an anterior Heller's esophagomyotomy (H group) with or without an additional floppy Nissen fundoplication (H + N group). Between 1984 and 1995, 20 patients were prospectively randomized to one or other of the performed operations, 10 patients per group. Esophagitis including Barrett's esophagus (n = 2) was seen under medical treatment, in 6 of 9 in the H group but none in the H + N group. No patient in the H + N group required postoperative continuous acid-reducing drugs. Twenty-four-hour esophageal pH-studies in median 3.4 years after surgery showed pathological reflux expressed as a percentage of time below pH 4 of 13.1% in the H group compared to 0.15% (P < 0.001) in H + N group. One patient with recurrent dysphagia in the H + N group later had an esophagectomy. The remaining patients reported significant improvement of dysphagia without symptoms of reflux at 8.0 years follow-up. Heller's esophagomyotomy eliminates dysphagia, but can induce advanced reflux that requires medical treatment. The addition of a 360 degrees fundoplication eliminates reflux without adding dysphagia in the majority of patients and can be recommended for most patients with uncomplicated achalasia.     

A case of long myotomy and fundoplication for diffuse esophageal spasm

We report a case of diffuse esophageal spasm (DES) successfully treated by esophageal long myotomy and Dor’s fundoplication. The patient was a 52-year-old man with a history of hepatitis C and severe chronic heart failure due to hypertensive cardiomyopathy. He had also undergone hemodialysis for chronic renal failure for 10 years. He had complained of dysphagia for 10 years. Diffuse esophageal spasm was diagnosed by fluoroscopy and esophageal manometry. We performed esophageal long myotomy through the opened hiatus and Dor’s fundoplication. The upper extent of the myotomy was confirmed by intraoperative endoscopic ultrasonography used to detect muscle thickening and low compliance of the esophageal wall. The procedure and postoperative recovery were uneventful, and the patient’s symptoms were relieved. This approach appears to be a potentially useful means of treating severe symptoms of DES resistant to conservative therapy, with ultrasound endoscopy being a helpful means of confirming the extent of esophageal myotomy.     

Preoperative esophageal body motility does not influence the outcome of laparoscopic Nissen fundoplication for gastroesophageal reflux disease.

We evaluated a policy of performing laparoscopic antireflux surgery without tailoring the procedure to the results of preoperative esophageal motility tests. A total of 117 patients (82 with normal esophageal motility; 35 with ineffective motility, IEM) underwent laparoscopic Nissen fundoplication for symptomatic gastroesophageal reflux. There were no significant differences in preoperative symptom length, dysphagia, DeMeester symptom scores, acid exposure times or lower esophageal sphincter pressures between the two groups. Both groups showed postoperative improvements in DeMeester symptom scores, dysphagia and acid exposure, with no differences between groups. At 1 year after surgery, 95% of the normal motility group and 91% of the IEM group had a good/excellent outcome from surgery. None of the IEM group required postoperative dilatation or reoperation. Patients with IEM fare equally well from laparoscopic Nissen fundoplication as those with normal esophageal motility. There is no merit in tailoring antireflux surgery to the results of preoperative motility tests.     

Does combined multichannel intraluminal esophageal impedance and manometry predict postoperative dysphagia after laparoscopic Nissen fundoplication?

Laparoscopic Nissen fundoplication (LNF) is an effective treatment for gastroesophageal reflux disease; however, some patients develop dysphagia postoperatively. Manometry is used to evaluate disorders of peristalsis, but has not been proven useful to identify which patients may be at risk for postoperative dysphagia. Multichannel intraluminal impedance (MII) evaluates the effective clearance of a swallowed bolus through the esophagus. We hypothesized that MII combined with manometry may detect those patients most at risk of developing dysphagia after LNF. Between March 2003 and January 2007, 74 patients who agreed to participate in this study were prospectively enrolled. All patients completed a preoperative symptom questionnaire, MII/manometry, and 24‐h pH monitoring. All patients underwent LNF. Symptom questionnaires were administered postoperatively at a median of 18 months (range: 6–46 months), and we defined dysphagia (both preoperatively and postoperatively) as occurring more than once a month with a severity ≥4 (0–10 Symptom Severity Index). Thirty‐two patients (43%) reported preoperative dysphagia, but there was no significant difference in pH monitoring, lower esophageal sphincter pressure/relaxation, peristalsis, liquid or viscous bolus transit (MII), or bolus transit time (MII) between patients with and without preoperative dysphagia. In those patients reporting preoperative dysphagia, the severity of dysphagia improved significantly from 6.8 ± 2 to 2.6 ± 3.4 (P < 0.001) after LNF. Thirteen (17%) patients reported dysphagia postoperatively, 10 of whom (75%) reported some degree of preoperative dysphagia. The presence of postoperative dysphagia was significantly more common in patients with preoperative dysphagia (P= 0.01). Patients with postoperative dysphagia had similar lower esophageal sphincter pressure and relaxation, peristalsis, and esophageal clearance to those without dysphagia. Neither MII nor manometry predicts dysphagia in patients with gastroesophageal reflux disease or its occurrence after LNF. The presence of dysphagia preoperatively is the only predictor of dysphagia after LNF.     

Differential diagnosis of esophageal motor disorders based in characteristics of dysphagia

BACKGROUND: Dysphagia is one of principal symptoms of esophageal disorders and its characterization is important for diagnosis and management of patients. Anamnesis is useful for differentiating organic and functional dysphagia, but data are lacking about dysphagia characterization among different motor disorders. OBJECTIVES: To evaluate if it is possible the distinction among esophageal motor disorders according to their manometric diagnosis, based on dysphagia characteristics. PATIENTS AND METHODS: Dysphagia characteristics (relation with bolus, frequency and localization) of 133 patients submitted to esophageal manometry were reviewed and analysed. All patients had barium swallow studies and/or endoscopy in order to exclude organic lesions. RESULTS: Esophageal manometry was abnormal in 85% of the patients. Characteristics of dysphagia were compared among groups of patients with achalasia, esophageal spastic disorders, non-specific esophageal motor disorders and with normal test. The precise distinction among groups based solely on characteristics of dysphagia was not possible, however some aspects could point to one or another group. In achalasia patients, dysphagia for both solid food and liquids, constant and felt in substernal area, was more frequent in relation to every other group. Intermittent dysphagia was more frequent in patients with spastic disorders. Characteristics of dysphagia in patients with non-specific esophageal motor disorders were similar to those observed in the group with normal test, frequently referred in the neck. CONCLUSION: Characteristics of dysphagia were ancillary to presume the diagnosis of these motor disturbances, however esophageal manometry is necessary for the correct diagnosis in patients with functional dysphagia.     

腹腔镜下贲门肌层切开术及Dor胃底折叠术治疗贲门失弛缓症临床分析

目的探讨腹腔镜下食管下括约肌切开及Dor胃底折叠术治疗贲门失弛缓症的可行性和临床疗效。 方法回顾性分析2010年1月至2015年7月,新疆维吾尔自治区人民医院收治的14例贲门失弛缓症患者的临床资料。 结果14例患者均顺利在胃镜定位下行腹腔镜下食管下括约肌切开及胃底折叠术,无中转开腹,手术时间65～125 min,术中出血量5～25 ml,未发生消化道漏,术后平均住院5～7 d。 结论腹腔镜下食管下括约肌切开及胃底折叠术治疗贲门失弛缓症创伤小,术后恢复快,疗效客观,是安全可行的手术方式。