51
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Iğci A, Müslümanoğlu M, Dolay K, Yamaner S, Asoğlu O, Avci C. Laparoscopic esophagomyotomy without an antireflux procedure for the treatment of achalasia. J Laparoendosc Adv Surg Tech A 1998; 8:409-16. [PMID: 9916594 DOI: 10.1089/lap.1998.8.409] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Various gastroenteric surgical procedures have been attempted laparoscopically. Laparoscopic esophagomyotomy (LE) with or without fundoplication, performed for achalasia, has gained popularity. In our clinic, LE (Heller's myotomy) was performed on six patients with achalasia. All patients underwent barium esophagography, endoscopy, and esophageal manometry for diagnosis. Extramucosal myotomy was started 6 cm above the cardioesophageal junction on the left anterolateral aspect of the esophagus and continued 1 cm below this area. Endoscopic control of the distal esophageal mucosa and the stomach was carried out under direct laparoscopic visualization following the completion of myotomy during the operation. LE was completed without complication in five patients. In one patient (16%), mucosal perforation occurred after myotomy during endoscopic control and was repaired with endostitches. There were no postoperative complications. The average hospital stay was 3 days. Three of the six patients agreed to 24-h pH monitoring, the results of which showed no evidence of reflux. All patients were completely symptom free in the postoperative period. The average preoperative lower esophageal sphincter pressure was 44 mm Hg, whereas in the early postoperative period and 6 months later, it was 11 mm Hg. There was no dysphagia or reflux esophagitis during the follow-up period (range 12 to 24 months). LE is associated with low morbidity and a high success rate, comparable with an open procedure, and can be done without an antireflux procedure.
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Affiliation(s)
- A Iğci
- Department of Surgery, Istanbul University, Istanbul Medical School, Turkey
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52
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Abstract
Although achalasia is not a common illness in the United States and Europe, there continues to be a need for surgical therapy for treatment. Laparoscopic Heller myotomy and partial fundoplication has, for the most part, replaced open surgery (abdominal or thoracic) as the surgical treatment of choice. In order to perform this procedure well, one must select patients carefully, evaluate them fully, and adhere to the technical principles required to achieve consistently good results.
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Affiliation(s)
- J G Hunter
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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53
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Koshy SS, Nostrant TT. Pathophysiology and endoscopic/balloon treatment of esophageal motility disorders. Surg Clin North Am 1997; 77:971-92. [PMID: 9347827 DOI: 10.1016/s0039-6109(05)70601-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Diagnostic and therapeutic dilemmas associated with esophageal dysmotility syndromes continue to confront physicians managing these patient populations. Although modern manometric systems have allowed us to better define normal parameters of esophageal motility, with the exception of primary achalasia, the clinical relevance of many aberrant motor patterns remains unclear. The novel use of botulinum toxin in idiopathic achalasia stems from increased understanding of the pathogenesis of the disease. Similarly, as our knowledge of the pathophysiology of other esophageal motor disorders grows, in conjunction with improved diagnostic capabilities, more effective management strategies may be used in the future.
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Affiliation(s)
- S S Koshy
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, USA
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54
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Abstract
BACKGROUND Achalasia can be effectively treated by either hydrostatic balloon dilatation or transthoracic modified Heller myotomy. The purpose of this study was to determine whether thoracoscopic methods could be used to achieve surgical results equal to the transthoracic approach with less pain. METHODS Twenty-one patients (10 men, 11 women; median age 42 years) had the diagnosis of achalasia confirmed by manometry, radiography, and endoscopy. All had dysphagia; five had weight loss. Median duration of symptoms was 12 months (range: 1 to 360 months). Eleven patients had undergone previous unsuccessful hydrostatic dilatation. Mean esophageal diameter was 5.5 +/- 2.2 cm. RESULTS All patients underwent attempted modified Heller myotomy through a left thoracoscopic approach. Three patients required conversion to thoracotomy. The myotomy was extended < 1 cm past the squamocolumnar junction. There was one intraoperative perforation and no postoperative complications. All patients were begun on a regular diet on the first postoperative morning. Median length of stay was 2 days, Median follow-up was 22 months (range: 1 to 52 months). Sixteen patients (80%) had excellent relief of their dysphagia. Two patients (10%) had good relief, and two patients had only a fair result, although even they claim to be much improved. CONCLUSIONS Thoracoscopic Heller myotomy reproduces the superior results of open esophagomyotomy with a reduced hospitalization and reduced incisional pain and disability.
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Affiliation(s)
- J W Maher
- University of Iowa College of Medicine, Department of Surgery, Iowa City, USA
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55
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Hunter JG, Trus TL, Branum GD, Waring JP. Laparoscopic Heller myotomy and fundoplication for achalasia. Ann Surg 1997; 225:655-64; discussion 664-5. [PMID: 9230806 PMCID: PMC1190864 DOI: 10.1097/00000658-199706000-00003] [Citation(s) in RCA: 203] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The goal of this study was to review the authors' results with laparoscopic cardiomyotomy and partial fundoplication for achalasia. SUMMARY BACKGROUND DATA Pneumatic dilatation and botulinum toxin (BOTOX) injection of the lower esophageal sphincter largely have replaced cardiomyotomy for treatment of achalasia. After a brief experience with a thoracoscopic approach, the authors elected to perform cardiomyotomy laparoscopically, in combination with a partial fundoplication (anterior or posterior). PATIENTS AND METHODS Forty patients were treated between July 1992 and November 1996. Thirty patients had previous therapy of achalasia, 21 with pneumatic dilation, 1 with BOTOX, 6 with balloon and BOTOX, and 2 with transthoracic cardiomyotomy. Three patients had previous laparoscopic fundoplication for gastroesophageal reflux. Symptom scores (0 = none to 4 = disabling) were obtained before surgery and after surgery. Barium swallows and esophagogastroduodenoscopy were performed in all patients. Esophageal motility study was performed in 36 patients. Laparoscopic Heller myotomy and fundoplication was performed through five upper abdominal trocars. A 7-cm myotomy extended 6 cm above the GE junction and 1 cm below the GE junction. A posterior fundoplication was performed in 32 patients, anterior fundoplication in 7 patients, and no fundoplication in 1 patient. Statistical inference was performed with a Wilcoxon signed rank test. RESULTS Mean operative duration was 199 +/- 36.2 minutes. Mean hospital stay was 2.75 days (range, 1-13 days). Dysphagia was alleviated in all but four patients (90%), and regurgitation in all but two patients (95%) (p < 0.001). Chest pain and heartburn improved significantly (p < 0.01) as well. Intraoperative complications included mucosal laceration in six patients and hypercarbia in one. Postoperative pneumonia developed in two patients, and one patient had moderate hemorrhage from an esophageal ulcer 2 weeks after surgery. CONCLUSIONS Laparoscopic cardiomyotomy and fundoplication appears to provide definitive treatment of achalasia with rapid rehabilitation and few complications.
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Affiliation(s)
- J G Hunter
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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56
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Abstract
BACKGROUND Minimally invasive surgery has assumed an ever-expanding role in gastrointestinal surgery since the introduction of laparoscopic cholecystectomy. This review describes some of the more common minimally invasive procedures of the esophagus and stomach, with particular attention to technique. DATA SOURCES A literature review of minimally invasive surgery of the esophagus and stomach was conducted. CONCLUSIONS Laparoscopic (and thoracoscopic) approaches for gastroesophageal reflux disease appear to have excellent operative and short-term follow-up results. Long-term follow-up data, however, remain unobtainable for several more years. Limited reports of esophageal cardiomyotomy, paraesophageal hernia repair, and gastric surgery for peptic ulcer disease performed through a minimally invasive approach are encouraging. Experience with resection of esophageal and gastric neoplasia is limited to a few specialized centers. Results should be scrutinized and compared with open operation before proclaiming the benefits of a minimally invasive approach.
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Affiliation(s)
- T L Trus
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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57
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Xynos E, Tzovaras G, Petrakis I, Chrysos E, Vassilakis JS. Laparoscopic Heller's cardiomyotomy and Dor's fundoplication for esophageal achalasia. JOURNAL OF LAPAROENDOSCOPIC SURGERY 1996; 6:253-8. [PMID: 8877745 DOI: 10.1089/lps.1996.6.253] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The study's aim was to assess the functional results of laparoscopically performed Heller's myotomy and Dor's fundoplication in our first few cases of esophageal achalasia. Four male patients (mean age: 61 years) with long-standing symptoms of achalasia (documented on esophagogram and esophageal manometry) and not responding to several sessions of pneumatic dilatation, had laparoscopic Heller's myotomy and Dor's fundoplication. Myotomy was facilitated by distending the esophagus. The mean duration of the operation was 99 min. The third patient developed a leak from the exposed esophageal mucosa on the 5th postoperative day while at home. The leak was attributed to late desloughing of a mucosal burn, and was sealed spontaneously 15 days later after drainage. The remaining three patients were discharged after resuming diet within the first 2 postoperative days. By 1 year postoperatively, dysphagia was abolished in all cases, and there were no gastroesophageal reflux symptoms. The esophagogram showed no reflux, which was also confirmed on ambulatory 24-h esophageal pH measurement. On manometry, lower esophageal sphincter (LES) pressure dropped significantly postoperatively (preop: 56 +/- 7 SD mm Hg, postop: 5 +/- 1 SD mm Hg, p < 0.001). In conclusion, laparoscopic Heller's myotomy with Dor's fundoplication for esophageal achalasia is a feasible procedure, offering clinical and laboratory results similar to the open approach, but with better patient tolerance.
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Affiliation(s)
- E Xynos
- Department of General Surgery, University Hospital of Heraklion, Medical School, University of Crete, Greece
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58
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Abstract
Cardiomyotomy for achalasia is one of the ideal procedures for the video endoscopic approach. Magnification of the operative field during laparoscopic surgery allows precise division of the muscle fibers with excellent results. The number of reports on cardiomyotomy performed with laparoscopic (and thoracoscopic) access is growing. They all show the same excellent results as for conventional (open) myotomy, with minimal morbidity, short hospital stay, and early return to routine activity.
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Affiliation(s)
- M Oddsdóttir
- Department of Surgery, University of Iceland Medical School, Reykjavik, Iceland
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59
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Delgado F, Bolufer J, Martinez-abad M, Martin J, Blanes F, Castro C, Moreno-osset E, Mora F, Benages A. Surg Laparosc Endosc Percutan Tech 1996; 6:83-90. [DOI: 10.1097/00019509-199604000-00001] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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60
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Avanoğlu A, Mutaf O. Surgical treatment of achalasia in children: is an added antireflux procedure necessary? Pediatr Surg Int 1996; 11:134-6. [PMID: 24057536 DOI: 10.1007/bf00183745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/1995] [Indexed: 11/28/2022]
Abstract
Between 1975 and 1994, nine patients with achalasia were treated surgically at the Department of Pediatric Surgery, Ege University Hospital. The mean age was 8.3 years; there were 4 boys and 5 girls; and dysphagia was the leading symptom. There was also significant growth retardation in most of the patients. A modified Heller's myotomy was performed in all cases via a transthoracic approach without an antireflux procedure. In one patient the myotomy resulted in significant gastroesophageal reflux, but this could be controlled medically. This patient also needed esophageal balloon dilatation twice after the operation. Symptoms were relieved dramatically in the rest of the patients after surgery. We conclude that an additional antireflux procedure need only be performed when the esophagomyotomy is done incorrectly (an unnecessarily long incision extended onto the stomach), but is otherwise unnecessary.
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Affiliation(s)
- A Avanoğlu
- Department of Pediatric Surgery, Thoracic Unit, Faculty of Medicine, Ege University, İzmir, Turkey
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61
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Robertson GS, Veitch PS, Wicks AC. Heartburn in patients with achalasia. Gut 1996; 38:475. [PMID: 8675109 PMCID: PMC1383088 DOI: 10.1136/gut.38.3.475-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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62
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Abstract
Gastroesophageal reflux (GER) is one of the most frequent symptomatic clinical disorders affecting the gastrointestinal tract of infants and children. During the past 2 decades, GER has been recognized more frequently because of an increased awareness of the condition and also because of the more sophisticated diagnostic techniques that have been developed for both identifying and quantifying the disorder. Gastroesophageal fundoplication is currently one of the three most common major operations performed on infants and children by pediatric surgeons in the United States. Normal gastroesophageal function is a complex mechanism that depends on effective esophageal motility, timely relaxation and contractility of the lower esophageal sphincter, the mean intraluminal pressure in the stomach, the effectiveness of contractility in emptying of the stomach, and the ease of gastric outflow. More than one of these factors are often abnormal in the same child with symptomatic GER. In addition, in patients with GER disease, and particularly in those patients with neurologic disorders, there appears to be a high prevalence of autonomic neuropathy in which esophagogastric transit and gastric emptying are frequently delayed, producing a somewhat complex foregut motility disorder. GER has a different course and prognosis depending on the age of onset. The incompetent lower esophageal sphincter mechanism present in most newborn infants combined with the increased intraabdominal pressure from crying or straining commonly becomes much less frequent as a cause of vomiting after the age of 4 months. Chalasia and rumination of infancy are self-limited and should be carefully separated from symptomatic GER, which requires treatment. The most frequent complications of recurrent GER in childhood are failure to thrive as a result of caloric deprivation and recurrent bronchitis or pneumonia caused by repeated pulmonary aspiration of gastric fluid. Children with GER disease commonly have more refluxing episodes when in the supine position, particularly during sleep. The reflux of acid into the mid or upper esophagus may stimulate vagal reflexes and produce reflex laryngospasm, bronchospasm, or both, which may accentuate the symptoms of asthma. Reflux may also be a cause of obstructive apnea in infants and possibly a cause of recurrent stridor, acute hypoxia, and even the sudden infant death syndrome. Premature infants with respiratory distress syndrome have a high incidence of GER. Esophagitis and severe dental carries are common manifestations of GER in childhood. Barrett's columnar mucosal changes in the lower esophagus are not infrequent in adolescent children with chronic GER, particularly when Heliobacter pylori is present in the gastric mucosa. Associated disorders include esophageal dysmotility, which has been recognized in approximately one third of children with severe GER. Symptomatic GER is estimated to occur in 30% to 80% of infants who have undergone repair of esophageal atresia malformations. Neurologically impaired children are at high risk for having symptomatic GER, particularly if nasogastric or gastrostomy feedings are necessary. Delayed gastric emptying (DGE) has been documented with increasing frequency in infants and children who have symptoms of GER, particularly those with neurologic disorders. DGE may also be a cause of gas bloat, gagging, and breakdown or slippage of a well-constructed gastroesophageal fundoplication. The most helpful test for diagnosing and quantifying GER in childhood is the 24-hour esophageal pH monitoring study. Miniaturized probes that are small enough to use easily in the newborn infant are available. This study is 100% accurate in diagnosing reflux when the esophageal pH is less than 4.0 for more than 5% of the total monitored time.
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63
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Benini L, Sembenini C, Castellani G, Bardelli E, Brentegani MT, Giorgetti P, Vantini I. Pathological esophageal acidification and pneumatic dilitation in achalasic patients. Too much or not enough? Dig Dis Sci 1996; 41:365-71. [PMID: 8601384 DOI: 10.1007/bf02093830] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Endoscopy, esophageal manometry and pH monitoring, gastric emptying test, and heartburn quantification on a visual analog scale were performed in 22 achalasic patients in order to clarify which events are associated with pathological esophageal acidification after successful LES dilatation. Five patients presented pathological acidification. Dilatation reduced LES tone from 38.3 +/- 4.2 to 14.6 +/- 1.1 mm Hg (mean +/- SEM); there was, however, no difference between nonrefluxers and refluxers (14.8 +/- 1.2 vs 13.8 +/- 2.5 mm Hg). The emptying time in achalasic patients was delayed compared to controls (315.9 +/- 20.9 min vs 209 +/- 10.4) due to prolonged lag-phase and reduced slope of the antral section-time curve, but, again, there was no difference between refluxers and nonrefluxers. The acid clearance was delayed in refluxers compared to nonrefluxers (15.9 +/- 4.5 vs 2.5 +/- 1.8 min, P<0.05). Two refluxers presented grade 1 esophagitis; one of them developed an esophageal ulcer. The heartburn score was the same in refluxers and nonrefluxers. Pathological acidification after pneumatic dilatation is associated with persistent problems in esophageal emptying rather than with excessive sphincter divulsion.
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Affiliation(s)
- L Benini
- Department of Gastroenterology, Rehabilitation Hospital of Valeggio sM, University of Verona, Italy
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64
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Bornman PC. Laparoscopic surgery. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1996; 220:66-70. [PMID: 8898439 DOI: 10.3109/00365529609094753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The introduction of video assisted laparoscopic surgery in 1987 signalled the beginning of a new era in surgery, and together with interventional endoscopy and radiology has broadened the scope of minimal access therapy and improved the multidisciplinary management of complex diseases in gastroenterology. The unprecedented enthusiasm for laparoscopic surgery and the overwhelming demands for the training of qualified surgeons to acquire the laparoscopic skills resulted in a compromise of traditional graduated teaching principles in surgery. A phase of consolidation has now been entered where academic centres are in the process of evaluating the application of minimal access surgery in a controlled fashion. This review will examine the current role of laparoscopic surgery in common gastrointestinal conditions.
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Affiliation(s)
- P C Bornman
- Dept. of Surgery, Medical School, Observatory, Cape Town, South Africa
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65
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Ancona E, Anselmino M, Zaninotto G, Costantini M, Rossi M, Bonavina L, Boccu C, Buin F, Peracchia A. Esophageal achalasia: laparoscopic versus conventional open Heller-Dor operation. Am J Surg 1995; 170:265-70. [PMID: 7661295 DOI: 10.1016/s0002-9610(05)80012-1] [Citation(s) in RCA: 109] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The laparoscopic treatment of esophageal achalasia has recently been introduced, and the occasional reports in the literature seem to indicate considerable advantages for patients in terms of surgical trauma, postoperative discomfort, and appearance. As yet, however, no studies have directly analyzed the benefits and shortcomings of the new surgical technique by comparison with the conventional open procedure. The objective of our study was to review recent experience with the laparoscopic Heller-Dor operation (LAP-HD) at the Department of Surgery of Padua University and compare it with the traditional open Heller-Dor procedure (OPEN-HD) to assess early effectiveness in patients with primary esophageal achalasia. PATIENTS AND METHODS The records of 17 patients who had LAP-HD and a matched group of 17 patients who had OPEN-HD were retrospectively reviewed. The duration of procedures, morbidity, several aspects of the postoperative course, and hospital costs were recorded and compared. Results of clinical follow-up and of manometric and pH-monitoring studies performed 6 months postoperatively were also evaluated in both patient groups. RESULTS LAP-HD took longer than OPEN-HD (mean 178 versus 125 minutes). There was no mortality or major morbidity in either group. Postoperative pain and ileus and need for IV nutrition lasted a shorter time for LAP-HD patients (P < 0.0001). Consequently, the median postoperative hospital stay and the median interval before returning to normal activity were also shorter (4 and 14 days for the LAP-HD group versus 10 and 30 days for the OPEN-HD group, P < 0.0001). During follow-up, dysphagia recurred in 1 patient of the LAP-HD group and gastroesophageal reflux was registered in 1 patient of the OPEN-HD group. Lower esophageal sphincter pressure decreased significantly after both procedures. CONCLUSIONS Laparoscopic management of achalasia leads to short-term results comparable to those of the well-established open technique. In view of the less severe surgical trauma and lower hospital cost, the laparoscopic approach is preferable, but long-term studies are needed.
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Affiliation(s)
- E Ancona
- Department of Surgery, University of Padua, Italy
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66
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Robertson GS, Lloyd DM, Wicks AC, de Caestecker J, Veitch PS. Laparoscopic Heller's cardiomyotomy without an antireflux procedure. Br J Surg 1995; 82:957-9. [PMID: 7648119 DOI: 10.1002/bjs.1800820733] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The treatment of achalasia by laparoscopic Heller's cardiomyotomy may combine the minimally invasive advantages of pneumatic dilatation with the success rate and low risk of perforation of conventional surgery. The requirement for an antireflux procedure remains a contentious issue, as in conventional surgery. Nine patients underwent laparoscopic cardiomyotomy; excellent symptomatic relief was obtained in eight at follow-up between 12 and 21 months after operation. Four of these patients agreed to 24-h pH monitoring and showed no evidence of acid reflux. One patient, however, developed recurrent symptoms associated with significant acidity on monitoring. Laparoscopic Heller's cardiomyotomy without an antireflux procedure produced effective symptomatic relief in this small group of patients.
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Affiliation(s)
- G S Robertson
- Department of Surgery, Leicester Royal Infirmary, UK
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67
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Abstract
Results of an ongoing clinical study treating achalasia patients with a transabdominal laparoscopic Heller myotomy and Toupet partial fundoplication are presented. Twelve patients underwent surgery between January 1992 and October 1993. All patients had barium esophagograms, preoperative endoscopy, esophageal manometry, 24-h pH studies, and extensive GI history preoperatively. Surgical complications included two perforations of the mucosa at the gastroesophageal junction repaired laparoscopically. There were no surgical mortalities and the average hospital stay was 39 h. Postoperatively all patients at follow-up had a repeat GI history, esophagogastroscopy, 24-h pH testing, and esophageal manometry. This follow-up showed good-to-excellent relief of dysphagia in all 12 patients with one patient complaining of heartburn documented to be from reflux postoperatively. Manometry showed a mean decrease in the lower esophageal sphincter pressure from 33.4 mmHg preoperatively to 19.3 mmHg postoperatively; 24-hour pH testing showed no significant reflux in the nine patients who had Heller myotomy plus a Toupet fundoplication. However, two of three patients who had Heller myotomy alone demonstrated abnormal 24-h pH testing. One of these patients was symptomatic and was found to have mild esophagitis by biopsy on postoperative endoscopy. These good results have persisted for mean follow-up of 16 months.
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Affiliation(s)
- L L Swanstrom
- Oregon Health Sciences University, Legacy Health System, Portland 97227, USA
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68
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Scott HJ, Rosin RD. Thoracoscopic Laser Heller's Myotomy. Med Chir Trans 1994. [DOI: 10.1177/014107689408701026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- H J Scott
- St Mary's Hospital, Praed St, London W2 1NY, UK
| | - R D Rosin
- St Mary's Hospital, Praed St, London W2 1NY, UK
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69
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Filipi CJ, Hinder RA. Thoracoscopic esophageal myotomy--a surgical technique for achalasia diffuse esophageal spasm and "nutcracker esophagus". Surg Endosc 1994; 8:921-5; discussion 925-6. [PMID: 7992167 DOI: 10.1007/bf00843474] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Thoracoscopic myotomy has been performed for diffuse esophageal spasm "nutcracker esophagus" and achalasia. Technical considerations for thoracoscopic long myotomy such as trocar placement, length of myotomy, extent of myotomy distal to the gastroesophageal junction, hiatal closure, fundoplication and degree of esophageal mobilization are discussed.
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Affiliation(s)
- C J Filipi
- Department of Surgery, Creighton University, Omaha, NE 68131
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70
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Dallemagne B. Endoscopic approaches to oesophageal disease. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1993; 7:795-822. [PMID: 8118074 DOI: 10.1016/0950-3528(93)90016-l] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- B Dallemagne
- Department of Surgery, Centre Hospitalier Saint Joseph-Esperance, Liège, Belgium
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71
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Abstract
This article presents the normal physiology of esophageal peristalsis. It discusses current approaches to the diagnosis and treatment of primary disorders of the esophagus, including achalasia, nutcracker esophagus, diffuse esophageal spasm, as well as the secondary disorder, scleroderma.
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72
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Picciocchi A, Cardillo G, D'Ugo D, Castrucci G, Mascellari L, Granone P. Surgical treatment of achalasia: a retrospective comparative study. Surg Today 1993; 23:855-9. [PMID: 8298228 DOI: 10.1007/bf00311361] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A retrospective study carried out on 74 patients among 101 consecutive cases of achalasia of the esophagus operated from 1967 to 1989 is reported. On 21 patients observed between 1967 and 1975, a standard transabdominal Heller cardiomyotomy was performed (group A). From 1976 to 1989, the treatment of choice was a Heller myotomy associated with a modified Dor's fundoplication. In 80 consecutive cases (group B) the extension of myotomy was regulated by intraoperative monitoring of lower esophageal sphincter pressure. A 5-year follow-up with questionnaires, physical examination, and barium swallows was carried out on 16 patients in group A and on 58 patients in group B. In 75.6% of the cases (56 patients) follow-up examinations included esophageal manometry and 24-hour esophageal pH monitoring. Recurrence of dysphagia was recognized in 3 cases in group A (18.7%) and in 2 cases in group B (3.4%) (P = 0.053); postoperative gastroesophageal reflux, measured as a percentage of total reflux time, showed a significantly lower mean value in group B than in group A (1.8% vs. 4.1%, P < 0.01). This study suggests that an anti-reflux procedure lowers postoperative gastroesophageal reflux after Heller myotomy. Due to the low incidence of postoperative reflux and the negligible recurrence of dysphagia, Heller myotomy associated with a modified Dor's fundoplication may represent the surgical treatment of choice for achalasia of the esophagus.
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Affiliation(s)
- A Picciocchi
- Department of Surgery, A. Gemelli Medical School, Catholic University of Rome, Italy
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73
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Abstract
To determine the clinical results in achalasia, particularly as regards postoperative gastro-oesophageal reflux, a 22-year personal experience with transthoracic short oesophagomyotomy without an antireflux procedure was analysed. A total of 185 such procedures were performed, of which 179 (97 per cent) were available for analysis. There was an overall improvement rate of 89 per cent over a mean postoperative interval of 9 years. Primary procedures were followed by a 93 per cent rate of improvement. Twenty patients, nine of whom had previously undergone one or more oesophageal operations, were considered as having a poor result. Marked gastro-oesophageal reflux accounted for a poor outcome in nine patients. Although the overall rate of postoperative improvement did not deteriorate significantly with time, the level of improvement did, the proportion of excellent results declining from 54 to 32 per cent (P = 0.02) at 10-20 years after operation. These findings substantiate the view that a short transthoracic oesophagomyotomy without an antireflux procedure provides excellent long-term relief of dysphagia for the patient with oesophageal achalasia and is accompanied by an extremely low risk of serious postoperative gastro-oesophageal reflux.
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Affiliation(s)
- F H Ellis
- Division of Cardiothoracic Surgery, New England Deaconess Hosital, Harvard Medical School, Boston, Massachusetts
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74
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Abstract
Surgical treatment is either the therapy of choice or a facultative procedure in various types of esophageal motility disorders. In achalasia, cardiomyotomy, frequently combined with fundoplasty, achieves good or excellent results in > 80% of cases, and is, therefore, advised in cases when pneumostatic dilatation fails. Diverticulectomy and myotomy of the upper or lower esophageal sphincter are proven procedures to treat cervical and epiphrenic diverticula, leading to good/excellent results or at least an improvement in more than 95%. If, exceptionally, parabronchial diverticula require therapy, they should be excised transthoracically. Cervical myotomy is indicated in cases of cervical achalasia, when sufficient pharyngeal propulsion is preserved. In systemic diseases like scleroderma reflux induced complications may require surgical intervention in medically intractable cases. In these rather few cases, subtotal gastrectomy with a Roux-en-Y anastomosis is advised. In patients suffering from diffuse esophageal spasm or symptomatic "nutcracker" esophagus, extended esophageal myotomy can relieve symptoms. If a clear diagnosis is provided, about 75% of patients will have an improvement of symptoms.
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Affiliation(s)
- H Feussner
- Chirurgische Klinik und Poliklinik, Technische Universität München, Germany
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75
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Gatzinsky P, Dernevik L, Björk S, Sandberg N. Technique for prevention of gastroesophageal reflux after transthoracic Heller’s operation. J Thorac Cardiovasc Surg 1993. [DOI: 10.1016/s0022-5223(19)34242-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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76
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Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology 1992; 103:1732-8. [PMID: 1451966 DOI: 10.1016/0016-5085(92)91428-7] [Citation(s) in RCA: 474] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This prospective study investigates whether the effect of pneumatic dilation in patients with achalasia can be predicted on the basis of patient characteristics, type of treatment, or results of postdilation investigations. Over a period of 10 years, 54 consecutive patients with newly diagnosed achalasia were treated with pneumatic dilation and underwent pretreatment and posttreatment manometric, radiographic, and scintigraphic investigations. They were followed up every 2 years until the fall of 1991. Among the factors evaluated in the initial examination, only young age adversely affected outcome (P < 0.05). With the exception of the diameter of the dilating balloon, the treatment characteristics had a low predictive value. Postdilation lower esophageal sphincter pressure was the single most valuable factor for predicting the long-term clinical response (P < 0.0005). However, patients with high sphincter pressures and poor treatment results benefited from repeated dilations by having progressively longer remissions. It is concluded that young patients are poor candidates for pneumatic dilation, that treatment should be aimed at near complete inflation of the dilating bag, and that postdilation sphincter pressure may guide further treatment.
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Affiliation(s)
- V F Eckardt
- Gastroenterologisches Institut Wiesbaden, Universität Mainz, Germany
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77
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Abstract
Laparoscopic procedures have begun to replace many conventional operations because of the avoidance of major surgery and the rapid recovery of the patient. The majority of these traditional operations will be performed laparoscopically in the future. For example, patients who suffer from achalasia will be able to undergo laparoscopic cardiomyotomy and patients with non-cardiac chest pain of esophageal origin will be able to undergo thoracoscopic myotomy. Likewise, a viable alternative to long-term medication with H2 blockers or omeprazole will be laparoscopic posterior vagotomy and anterior lesser curve seromyotomy. As methods are developed to deal with the extraction of large specimens, many ablative procedures will be undertaken by the laparoscopic route. Extraction techniques must not compromise the need for histopathological examination of the resected specimen in cancer resections. The ultimate spectrum of laparoscopic surgery will be determined by the progress in remote handling technology, overcoming the manipulative restrictions inherent in the current instrumentation. Research evaluating the efficacy of new methods will be essential.
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Affiliation(s)
- A Cuschieri
- Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Scotland
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78
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Abstract
The Dor-Gavriliu procedure was utilized in six children with achalasia of the cardia from 1983 to 1991. Four boys and two girls (mean age, 10.1 years; range, 3 months to 16 years) presented with symptoms of weight loss (83%), emesis (83%), dysphagia (67%), recurrent respiratory infections (67%), and nocturnal regurgitation (33%). The diagnosis of achalasia was established by barium swallow in all patients; esophageal manometry was used in four patients to confirm the diagnosis. Follow-up ranged from 10 months to 8 years (mean, 3.5 years). Four neurologically normal patients had excellent results with complete resolution of their preoperative symptoms. Two neurologically impaired children, both afflicted with Down's syndrome, had less than excellent results. One moderately impaired child had a good result (required three postoperative bougie dilations over 8 years without demonstration of gastroesophageal reflux); the second, more severely impaired child, had only a fair result (persistent failure to thrive with the development of grade II gastroesophageal reflux). The Dor-Gavriliu procedure uses a transabdominal, anterior esophageal myotomy with incorporation of an effective, nonobstructing, antireflux mechanism that should prevent myotomy reapposition.
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Affiliation(s)
- K B Allen
- Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St Luke's Medical Center, Chicago, IL
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79
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Pellegrini C, Wetter LA, Patti M, Leichter R, Mussan G, Mori T, Bernstein G, Way L. Thoracoscopic esophagomyotomy. Initial experience with a new approach for the treatment of achalasia. Ann Surg 1992; 216:291-6; discussion 296-9. [PMID: 1417178 PMCID: PMC1242610 DOI: 10.1097/00000658-199209000-00008] [Citation(s) in RCA: 242] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The authors treated 17 patients with achalasia by a thoracoscopic (15 patients) or laparoscopic (2 patients) Heller myotomy. All patients had dysphagia and an upper gastrointestinal series demonstrating a dilated esophagus with a bird-beak deformity at the cardia. Manometry showed a mean lower esophageal sphincter (LES) pressure of 32 +/- 4 mmHg, incomplete sphincter relaxation on swallowing, and no primary esophageal peristalsis. After operation, mean LES pressure was 10 +/- 2 mmHg. Fifteen patients were fed on the second postoperative day. The average hospital stay was 3 days, and there were no deaths or major complications. In three early patients, the myotomy was not carried far enough onto the stomach, and dysphagia persisted until a second myotomy was performed (laparoscopically in two patients). The authors found that having an endoscope in the esophagus during the operation facilitated exposure and was vital to determine the appropriate length of the myotomy. With regard to dysphagia, final results were excellent in 12 patients (70%), good in two patients (12%), fair in two patients (12%), and poor in one patient (6%). Heller myotomy can be safely and reliably performed with minimally invasive techniques. Dysphagia is relieved, postoperative pain is minimal, hospital stay is short, and the patient can return quickly to normal activity.
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Affiliation(s)
- C Pellegrini
- Department of Surgery, University of California, San Francisco 94143-0788
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80
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Stein HJ, DeMeester TR. Outpatient physiologic testing and surgical management of foregut motility disorders. Curr Probl Surg 1992; 29:413-555. [PMID: 1606845 DOI: 10.1016/0011-3840(92)90036-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- H J Stein
- Department of Surgery, University of Southern California Medical School, Los Angeles
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81
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Abstract
The current evaluation of and therapy for achalasia are reviewed. Esophageal manometry remains the best means for diagnosing achalasia. Initial therapy can include either pneumatic dilation or esophagomyotomy. Symptomatic improvement occurs in 71% of patients after pneumatic dilation, with a risk of perforation of 1.4%. Eight percent of these patients require subsequent esophagomyotomy. Surgical procedures for achalasia can be performed through either an abdominal or a thoracic incision. Nearly all authors favoring an abdominal approach add an antireflux operation to esophagomyotomy, whereas many authors advocating a transthoracic esophagomyotomy believe that an antireflux wrap is unnecessary. Overall results for the various surgical approaches used as initial therapy are excellent, with symptomatic improvement in 89% of patients, a mortality rate of less than 1%, and development of gastroesophageal acid reflux in less than 10%. Factors governing the choice of initial therapy are discussed.
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Affiliation(s)
- M K Ferguson
- Department of Surgery, University of Chicago Hospitals, Illinois 60637
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82
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Abstract
Fifty-three patients suffering from dysphagia because of suspected esophageal motor disorders were treated by pneumatic dilatation using the Rider-Moeller technique. Fifteen had achalasia demonstrated by manometric studies. Forty-nine of them had remarkable clinical improvement after the procedure. During the mean period of follow-up (average 5 years, range 1-11), 75% of the patients needed a new dilatation, with a delay of two years. The results of the dilatation were excellent or good in 80% of the cases. Early complications consisted in two esophageal perforations surgically treated. There was no mortality. We did not observe late complications of the procedure. We conclude that pneumatic dilatation should be the initial procedure in the treatment of dysphagia in suspected esophageal motor disorders.
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83
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Russell CO, Bright N, Schmidt G, Sloan J. Achalasia of the oesophagus: results of treatment. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1991; 61:43-8. [PMID: 1994884 DOI: 10.1111/j.1445-2197.1991.tb00125.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Achalasia of the oesophagus is an uncommon neuromuscular disorder characterized by symptoms of dysphagia and regurgitation of undigested food. The results of treatment of 43 patients with achalasia over 10 years are presented. Clinical data on presenting complaints and duration, and all subsequent treatments, were recorded. Patients were contacted to assess their current symptomatic status.
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Affiliation(s)
- C O Russell
- Monash University Department of Surgery, Monash Medical Centre, Melbourne, Victoria
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84
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85
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Abstract
Primary motor disorders of the oesophagus have distinct manometric patterns but require full oesophageal investigation to exclude a secondary cause. Myotomy and forceful dilatation give good results in achalasia, though myotomy is superior in the long term. Indications for surgery are rare in diffuse spasm and nutcracker oesophagus. Non-cardiac chest pain may be related to reflux, diffuse spasm or nutcracker oesophagus, but correlation between motor abnormalities and symptoms is poor and psychological disturbances are frequent.
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Affiliation(s)
- R C Stuart
- Department of Surgery, St James's Hospital, Dublin, Ireland
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86
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Cuschieri A. Partial fundoplication after abdominal Heller's myopathy. Br J Surg 1989; 76:527. [PMID: 2736374 DOI: 10.1002/bjs.1800760541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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87
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88
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