Laparoscopic Heller Myotomy for Achalasia Cardia—Initial Experience in a Teaching Institute

Laparoscopic Heller cardiomyotomy and Dor fundoplication is the surgical procedure of choice for esophageal achalasia. The aim of our study was to investigate the clinical outcome and safety of laparoscopic Heller–Dor procedure performed by using Hook electrocautery and as a teaching module for advanced laparoscopic surgery. Between January 2005 and December 2010, 25 consecutive patients with achalasia underwent laparoscopic Heller–Dor operation by a single surgeon. All the patients received upper gastrointestinal series (barium swallow), esophagogastroscopy, and esophageal manometry to exclude esophageal carcinoma and to confirm the diagnosis. All the patients were operated by laparoscopic modified Heller myotomy with Dor fundoplication by using hook electrocautery. Among 25 operated patients, 14 were male and 11 were female with a median age of 43 years (range 18–72 years). The mean operative time was 93.3 min (range 50–50 min), the mean operative blood loss was 90 ml (range 40–200 ml), the median time to oral feeding was 2 days (2–4 days), and the median hospital stay was 4 days (4–7 days). There was no conversion to open surgery. Intraoperative mucosal perforation was encountered in three patients and was repaired in all of them by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication and had excellent clinical response (96 %) during follow-up. Laparoscopic Heller–Dor operation using hook electrocautery is safe, inexpensive, and effective treatment for achalasia which is useful for teaching and training surgical residents in advanced laparoscopic surgery.     

Measuring aortic valve coaptation surface area using three-dimensional transesophageal echocardiography

Background

As aortic valve (AV) repairs become more sophisticated, surgeons need increasingly detailed information about the structure and function of this valve. Unlike two-dimensional transesophageal echocardiography (2D-TEE), using three-dimensional (3D)-TEE makes it possible to image the entire AV. We hypothesized that measuring coaptation surface area (CoapSA) would be feasible and reproducible, and CoapSA would decrease in patients with aortic insufficiency.

Methods

We developed a new technique to calculate the AV-CoapSA using 3D-TEE. We measured the coaptation surfaces between the right coronary cusp/left coronary cusp, right coronary cusp/non-coronary cusp, and left coronary cusp/non-coronary cusp in ten normal AVs and ten AVs with moderate-severe aortic insufficiency (AI). Since computer models have previously shown that CoapSA is trapezoidal, we used the formula: trapezoid area = length × (medial coaptation height + lateral coaptation height)/2. The total CoapSA was calculated by adding all three areas. To adjust for valve size, we indexed the value to the diameter of the ventricular aortic junction (VAJ). Measurements were performed by two observers.

Results

The intra-observer correlation was 0.84 for one observer (P < 0.0001) and 0.93 for the other (P < 0.0001). The inter-observer correlation was 0.87 (P < 0.0001). In normal valves, the CoapSA [mean total (standard deviation)] was significantly greater than in the insufficient valves [1.61 (0.31) cm² vs 1.03 (0.22) cm², respectively; P < 0.001]. After indexing for the VAJ diameter, the total CoapSA remained significantly greater in normal valves than in insufficient valves.

Conclusion

In this proof of concept study, we present a new and innovative technique to measure AV-CoapSA using 3D-TEE. It is reproducible and shows decreased CoapSA in patients with AI. Coaptation surface area may provide insight into mechanisms of AI and may have predictive value following AV repair.     

Coronary bypass graft patency cannot be determined by multidetector spiral computed tomography

Objectives. Angiography by selective catheterization is the reference standard for coronary bypass graft patency assessment but carries a risk of serious complications. We have investigated whether 16-slice multidetector spiral computed tomography (MDCT) can substitute for selective angiography. Design. Two to three years after coronary artery bypass grafting, 45 patients with a total of 156 bypasses (100 single and 28 sequential grafts) were examined with both MDCT and conventional selective angiography on the same day. The bypasses were classified as patent, stenotic or occluded. Results. The likelihood ratio for MDCT-detected occlusion was 40, reflecting a fairly high combined sensitivity and specificity. However, 24% of the distal anastomoses could not be evaluated by MDCT, mainly because of respiratory movements, artifacts due to metal clips, and small vessel dimensions. Moreover, seven out of 117 bypasses (6%) deemed evaluable by MDCT were wrongly classified by this method. Conclusions. At present, 16-slice MDCT cannot replace selective angiography for assessment of coronary bypass graft patency since 24% of bypasses could not be evaluated by this method, and an error rate of 6% is unacceptable.     

Reliability and validity of the Arabic Screen for Child Anxiety Related Emotional Disorders (SCARED) in a clinical sample

This study aimed at investigating the reliability and validity of the Arabic Screen for Child Anxiety Related Emotional Disorders (SCARED) as a first child and adolescent anxiety screening tool in the Arab World. The English parent (SCARED-P) and child (SCARED-C) versions were translated into Arabic and administered along with the Arabic Strengths and Difficulties Questionnaire (SDQ) to 77 parents and 67 children attending a Psychiatry clinic. DSM-IV-TR diagnoses were made by a psychiatrist without knowledge of the scale scores. Internal consistency was confirmed by Cronbach's α=0.92 for SCARED-P and 0.91 for SCARED-C. Their subscales had internal consistencies between 0.65 and 0.89. Parent–child agreement was r=0.67, p<0.001. SCARED-P demonstrated good discriminant validity between participants with anxiety disorders and those with other psychiatric disorders (t(72)=3.13, p=0.003). For SCARED-C, this difference was significant when participants with depressive disorders were excluded (t(43)=2.58, p=0.01). Convergent validity was evident through a significant correlation between SCARED-P and the parent SDQ emotional subscale (r=0.70, p<0.001), and SCARED-C and the child SDQ emotional subscale (r=0.70, p<0.001). Divergent validity with the SDQ hyperactivity subscale was observed as no significant correlation was found. Overall, the Arabic SCARED demonstrated satisfactory psychometric properties in a clinical sample in Lebanon.     

Indian salutation test in acute dorsal carpometacarpal joint dislocation of the ulnar four fingers

Complete dislocation of the ulnar 4 carpometacarpal joints of the hand (excluding the thumb) is an uncommon injury. Anatomic reduction of the carpometacarpal joint (CMCJ) is essential to maintain function of the hand, and this can often be accomplished by prompt closed reduction and percutaneous Kirschner-wire fixation. The diagnosis is sometimes delayed or missed in the emergency department (ED), and a true lateral radiograph is mandatory in suspected cases. We present a case of dorsal unilateral dislocation of the ulnar 4 CMCJs without associated fracture. The injury was difficult to diagnose because of gross swelling of the hand. We describe a simple clinical test (Indian salutation test) that we found to be very helpful in raising the index of suspicion and hence increasing the likelihood of avoiding any clinical and medicolegal difficulties in such cases. A true lateral radiograph of the wrist confirmed the diagnosis, and prompt closed reduction and percutaneous Kirschner-wire fixation resulted in a good outcome in the case described here.