Intraoperative Manometry Research Articles

582. REPORT ON A 42 YEAR EXPERIENCE WITH THE LAPAROTOMIC/LAPAROSCOPIC HELLER-DOR OPERATION PERFORMED WITH INTRAOPERATIVE MANOMETRY FOR ESOPHAGEAL ACHALASIA

Abstract In 1979 our surgical group proposed the Heller-Dor operation (HD) to accomplish new concepts of surgical pathophysiology: to abolish the lower esophageal sphincter with the division of the U-and sling fibers of the lesser gastric curvature, to prevent GER with an effective but not too effective partial fundoplication which protects the myotomy surface. Aim is to report very long-term results of the treatment of esophageal achalasia with the Heller-Dor operation performed with intra operative manometry. In the period 1979-2021 HD was in first instance adopted in 202 patients (97 men; median age 45 years; IQR 31–59) in laparotomy (L-HD) and in 162 (79 men; age 48 years; IQR 35–63) in laparoscopy (V-HD). At intraoperative manometry, the complete abolition of the high-pressure zone was always obtained and the Dor length and pressure were trimmed according to reference values. Follow-up consisted of interview, endoscopy and barium swallow performed every 3 years. The overall outcome was graded from excellent to poor according to the severity of symptoms and esophagitis. Median follow-up was 14.8 years in HD, 7.5 years in V-HD (p<0.001). Esophageal diameter and residual barium column decreased substantially during the first 3 years after the operation, but not successively. In the L-HD group poor results were 22 (10.9%): due to esophagitis in 17 (8.4%) and to recurrent dysphagia in 5 (2.5%). In V-HD, 4 (2.5%) had esophagitis and 2 (1.2%) severe dysphagia. Outcome was satisfactory in 89% of L-HD and in 96% of V-HD (p<0.001). Postoperatively, according to the Kaplan Mayer curve, dysphagia, reflux symptoms and esophagitis occurred within 60-65 months after surgery. Timing of dysphagia relapse and post-myotomy reflux occurrence indicate that after five years, surgical results can be considered definitive. The 96% of satisfactory results we achieved with VL-HD, at a median follow-up time of 8 years, shows the potentiality of this surgical technique. In our experience, the learning process, not the follow-up length or the laparotomy/laparoscopy method is the cause of improved results of the laparoscopy HD.

576. ESOPHAGEAL ACHALASIA: VERY LONG FOLLOW-UP STUDY ON PATTERNS AND COMPLICATIONS OF POST MYOTOMY GERD

Abstract Since the adoption of the Heller myotomy, surgeons have modified the original technique to balance the cure of dysphagia and the consequent cardial incontinence. Surprisingly, today post POEM 30-50% erosive-ulcerative esophagitis rates are by some put inside normality. Our group had the opportunity to follow up methodically patients submitted to Heller myotomy since 1955. Aim is to provide information on long-term outcomes of Heller myotomy for esophageal achalasia with or without an antireflux fundoplication. In first instance 83 patients underwent a long abdominal myotomy (AM 1955-72), 30 patients a transthoracic myotomy according to Ellis (TM 1973-78), 364 patients the Heller-Dor operation with intraoperative manometry to calibrate myotomy, length and pressure of the Dor fundoplication (HD 1979-2021). Starting on 1973 these patients underwent a prospective follow-up program of timed lifelong clinical, radiological, endoscopic evaluations. Since 1973 an endoscopic-radiologic-clinical timed follow up has been established. GERD symptoms/esophagitis were evaluated. AM, TM and HD groups were followed up for a median period of 25, 27, 14 years respectively. GERD symptoms-esophagitis occurred in AM 29.5%-28.1%, TM 30%-30%, HD 6.6%-5.8%. Timing of esophagitis after HD revealed: early onset (6-24 months) in 8 (2.2%), late onset (25 months-14 years) in 13 (3.6%). PPIs controlled reflux symptoms (71%vs14%, p<0.0001) but not esophagitis (43%vs46%, p= 0.075). Among 50 patients with erosive/ulcerative reflux esophagitis, Barrett’s esophagus was diagnosed in 21 (42%) at a median period of 112 months since myotomy. In this group low-grade dysplasia occurred in 12 (24%) and high grade dysplasia/adenocarcinoma in 5 (10%). After surgical Heller myotomy not associated with an efficient antireflux procedure, GERD occurred in 30% which decreased to 6% after HD. A Heller-Dor operation is a competitive option for the cure of esophageal achalasia if this operation is performed according to the rules of surgical physiology learned by means of intraoperative manometry. The adoption of POEM in alternative to HD for the treatment of achalasia should be questioned.

Outcomes of Heller Myotomy for Esophageal Achalasia: Lessons From a 48-Year Prospective Experience With 4 Different Techniques.

To provide information on long-term outcomes of Heller myotomy for esophageal achalasia with or without an antireflux fundoplication. Since the adoption of the Heller myotomy, surgeons have modified the original technique in order to balance the cure of dysphagia and the consequent cardial incontinence. Totally, 470 patients underwent primary Heller myotomy between 1955 and 2020. A long abdominal myotomy (AM) was performed in 83 patients, the Ellis limited transthoracic myotomy (TM) in 30, the laparotomic Heller-Dor (L-HD) in 202, the videolaparoscopic Heller-Dor (VL-HD) in 155. The HD was performed under intraoperative manometric assessment. Starting on 1973 these patients underwent a prospective follow-up program of timed lifelong clinical, radiological, endoscopic evaluations. Median follow-up time was 23.06 years [interquantile range (IQR): 15.04-32.06] for AM, 29.22 years (IQR: 13.46-40.17) for TM, 14.85 years (IQR: 11.05-21.56) for L-HD and 7.51 years (IQR: 3.25-9.60) for VL-HD. In AM, relapse of dysphagia occurred in 25/71 (35.21%), in TM in 11/30 (36.66%), in LH-D in 10/201 (4.97%), in VL-HD in 3/155 (1.93%). Erosive-ulcerative esophagitis was diagnosed for AM in 28.16%, for TM in 30%, for L-HD in 8.45%, for VL-HD in 2.58%. Overall, the outcome was satisfactory in 52.11% for AM, 41.9% for TM, 89.05% for L-HD, 96.12% for VL-HD. The Dor fundoplication drastically reduces postmyotomy gastroesophageal reflux. The Heller-Dor operation is a competitive option for the cure of esophageal achalasia if this operation is performed according to the rules of surgical physiology learned by means of intraoperative manometry.

How a modified Nissen procedure works: a mechanistic study using intraoperative esophageal high-resolution manometry.

We aimed at demonstrating how a modified Nissen procedure works by analyzing intraoperatively the variations of the low esophageal sphincter pressure values using high resolution manometry. This study included 15 patients with documented gastroesophageal reflux disease who underwent a laparoscopic modified Nissen procedure. Data regarding the changes in the pressure values were recorded at each step of the procedures using high resolution manometry and after the progressive insufflation of air in the stomach. Categorical data were compared between the preoperative and postoperative periods using Fisher's test, and continuous data were compared using Mann-Whitney U non-parametric test. Preoperative versus postoperative variations in continuous data were assessed using Wilcoxon's non-parametric test for paired data. Intraoperative manometric data showed a rise of basal LES pressure until the creation of the wrap. An evident increase of pressure values was recorded after gastric air insufflation, as consequence of the increase of intragastric pressure. No intraoperative and postoperative complications were observed. All patients experienced a significant reduction in terms of intensity and frequency of gastroesophageal reflux symptoms and no patients complained of dysphagia. Intraoperative high resolution manometry was feasible in all patients and demonstrated that the modified Nissen procedure works by increasing the LES pressure in response to gastric distension, without impeding the progression of the bolus into the stomach.

Hill Repair—Why It Is Still Relevant and Should Be Taught

The Hill repair for gastroesophageal reflux disease, though effective, durable, and in some regards a superior repair, has unfortunately seen less widespread adoption in the laparoscopic era relative to Nissen and Toupet fundoplications. Some purported objections to the Hill repair include conceptual and technical barriers, need for intraoperative manometry, and lack of clear-cut advantages. However, it has proven to be remarkably durable at 20 years and beyond relative to other repairs, with a low side-effect profile; there are also unique applications of the Hill repair and Hill sutures which broaden one’s armamentarium for managing the spectrum of patients with reflux disease. Lastly, understanding its anatomic components strengthens the surgeon’s knowledge of the anatomy and function of the gastroesophageal junction and antireflux repairs.

Endoscopic treatment for persistent dysphagia after heller myotomy in a patient with spastic type of achalasia with the use of the intraoperative high-resolution manometry

A Peroral Endoscopic Myotomy was performed on the patient with the persistent dysphagia despite preceding Heller myotomy combined with partial fundoplication, relaparotomy, fundoplication wrap reconstruction, gastrostomy and left-sided thoracoscopy with the drainage of the thoracic abscess. The use of intraoperative High-Resolution Manometry during Endoscopic Peroral Myotomy helped to reveal the reasons for the failure of previous treatment and to address the dysphagia.

Intraoperative high-resolution esophageal manometry during peroral endoscopic myotomy

Peroral endoscopic myotomy is an accepted treatment of achalasia. Some of the treatment failures can be attributable to an insufficient length of the myotomy on the gastric side, because of a more technically challenging submucosal dissection. We assessed the feasibility and the impact of an intraoperative esophageal manometry during the peroral endoscopic myotomy procedure. A high-resolution manometry catheter was introduced through the nostril before the endoscope, and left in place during the peroral endoscopic myotomy procedure. The lower esophageal sphincter pressure was recorded throughout the peroral endoscopic myotomy. The myotomy was extended on the gastric side until the lower esophageal sphincter pressure dropped below 10 mmHg. We included 10 patients (mean age = 55 years old, 3 men) treated by peroral endoscopic myotomy for type I (3/10), type II (3/10), type III achalasia (3/10) or esophagogastric junction outflow obstruction (1/10). Manometric recording was possible in all patients. The median (IQR) lower esophageal sphincter resting pressure was 23 (17–37) mmHg before myotomy, 15 (13–19) mmHg at the end of the tunnel, and 7 (6–11) mmHg at the end of the myotomy. In 4 patients out of 10, the myotomy was extended on the base of the intraoperative manometry findings. High-resolution esophageal manometry is feasible during the peroral endoscopic myotomy procedure, and leads to increase the length of the gastric myotomy in 4 out of 10 patients. However, the cumbersome nature of intraoperative high-resolution manometry during peroral endoscopic myotomy and the high frequency of gastro-esophageal reflux disease after extended gastric myotomy suggest to limit this technique to selected patients refractory to a first myotomy.

Device profile of the EYEMATE-IO™ system for intraocular pressure monitoring: overview of its safety and efficacy

ABSTRACT Introduction Assessment of intraocular pressure (IOP) is a core diagnostic tool in management of glaucoma. All established ways to measure IOP use indirect approaches through ocular tissues, mainly the cornea or the sclera. Telemetric IOP measurement with an implantable device could eliminate bias caused by indirect techniques and could allow continuous monitoring. A favorable safety profile, high efficacy and good tolerability are key requirements. Areas covered The Eyemate-IO™ system (Implandata Ophthalmic Products GmbH, Hannover, Germany) is a novel CE-marked implantable medical device for direct measurement of IOP. It consists of an intraocular sensor ring and an external reading device. This review presents the mechanism of telemetric IOP measurement and summarizes the available clinical data. Twelve months follow-up data of two clinical trials provide support for the efficacy and safety of this device. Expert opinion The implantable Eyemate-IO™ in keratoprosthesis was well tolerated; recorded adverse events were known complications of standalone surgery. The system had a good agreement with other IOP measuring modalities, including intraoperative manometry. In glaucoma patients, the Eyemate-IO™ could be implanted safely and showed a favorable efficacy and safety profile in the first twelve months postoperatively. The potential to achieve IOP monitoring with the Eyemate-IO™ seems promising.

P68 DEFINITIVE RESULTS OF THE HELLER MYOTOMY ASSOCIATED WITH THE DOR FUNDOPLICATION PERFORMED WITH INTRAOPERATIVE MANOMETRY FOR THE PRIMARY SURGICAL TREATMENT OF ESOPHAGEAL ACHALASIA: ONE CENTER EXPERIENCE

Abstract Objective In 1978 the Heller-Dor operation was proposed to accomplish new concepts of surgical pathophysiology: to abolish the lower esophageal sphincter with the division of the U-and sling fibers of the lesser gastric curvature, to prevent GER with an effective but not too effective partial fundoplication which protects the myotomy surface. Proponents performed this operation under intraoperative manometric control. We report on results we achieved in the period 1978-2016. Methods The Heller-Dor was performed in 367 patients (laparotomy 1978-1993, 209, 96 men; median age, 45 years; IQR 31.8–59.4 years, laparoscopy 1994-2016,158, 78 men; median age, 48 years; IQR 35.5–63.7 years; age p=0.166; gender p=0.346). Intraoperative manometry was performed and interpreted according to standard criteria. Follow-up consisted of periodical interview, endoscopy, barium swallow, which reports were graded in semiquantitative scales of evaluation. Results Mortality occurred in 1/209 (heart failure), 1/158 (coagulation disorder). Median follow-up was 193 months (IQR 137.1–273.4 months) in the laparotomy group, 95 months (IQR 71.1–140 months) in the laparoscopy group. Myotomy achieved the complete abolition of the high pressure zone in 100% of the patients in both groups. In the laparotomy group poor results were assessed in 22 (10.5%), for esophagitis in 15 and recurrent dysphagia in 7 with sigmoid achalasia. In the laparoscopy group poor results occurred in 7 (4.3%), 5 for esophagitis and 2 for recurrent dysphagia in sigmoid achalasia. In the second period the fundoplication was always sutured to the diaphragm to avoid slipping, the number of sigmoid esophagus cases decreased significantly. In the laparotomy group, gastroesophageal reflux and esophagitis appeared after a median period of 74.8 months since myotomy, recurrent dysphagia was evident shortly after surgery. Conclusions In light of the timing of appearance of causes of poor results assed in the laparotomy group, we consider the 95.7% of satisfactory results achieved with the laparoscopic Heller-Dor after 95 months median follow up, the indicator of potential of cure of this operation.

Can intraoperative manometry influence the outcome of the surgical treatment of achalasia?

Introduction. Achalasia is defined as incomplete or even absent relaxation of the lower esophageal sphincter secondary to the chronic degeneration of unspecified etiology of the myenteric nerve plexus. Material and method. The retrospective study extended over 1 year. The collected variables were: age, sex, type of surgical intervention, intraoperative manometry results, and postoperative complications. Results. We identified 8 patients. The mean operative time was 100 minutes. The use of manometry determined an increase in time of 30 to 40 minutes. Manometry was successfully achieved in all cases, although in one case the sensor could not pass through the lower esophagus, so a prior pneumatic dilation was required. Manometry has proven useful during fundoplication as it offers a direct view of the pressure produced when knots set at 12 - 15 mmHg with a length of 4-5 cm were tightened. Of the 8 patients, 6 required an increase in the length of the resection of the esophagus after the results of the intraoperative manometry were reviewed. Conclusion. In our opinion, after reviewing our experience and the literature data, intraoperative manometry should become a standard procedure in the laparoscopic treatment of achalasia.

Intraoperative rectal ampullar manometry in spinal cord conus lipoma surgery in children

Objective . To assess a potential of using intraoperative rectal ampullar manometry to prevent bladder dysfunction in surgical treatment of the spinal cord conus lipoma. Material and Methods . The results of surgical treatment of 59 children with lipomas of the spinal cord conus were studied. The presence of urological symptoms (urinary retention or incontinence) was assessed before and after surgery. Intraoperative rectal ampullar manometry was performed in 22 cases with registration of signs of irritation (increased pressure in the rectal ampulla) and depression (decreased pressure in the rectal ampulla) of sacral parasympathetic centers which allowed controlling their proximity and tolerance to the performed manipulations. Results . Urological symptoms before surgery were detected in 25 (42 %) patients: urinary retention in 7 (28 %), and incontinence in 18 (72 %). Symptoms were significantly more often detected in children older than 3 years (p 3 mm Hg) have precluded from the total removal of lipoma in all 22 patients; subtotal or partial lipoma removal and release of the tethered spinal cord were achieved in all cases. None of the patients operated on using rectal ampullar manometry presented urinary retention after surgery, these disorders developed in 12 (32 %) children operated on without this procedure (p < 0.05). Conclusion . Paresis or paralysis of the bladder detrusor after removal of the spinal cord conus lipoma may result from direct damage to the parasympathetic sacral centers located at the borderline between the lipoma and the spinal cord. The method of intraoperative rectal ampullar manometry allows protecting the functions of the pelvic organs and determining the safe volume of lipoma resection.

Changing rules of free portal pressure and influencing factors after splenectomy combined with pericardial devascularization

Objective To summarize the changing rules of free portal pressure (FPP) after splenectomy combined with pericardial devascularization and investigate its influencing factors. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 55 patients with portal hypertension who were admitted to the People′s Hospital of Ningxia Hui Autonomous Region from January 2016 to September 2018 were collected. There were 39 males and 16 females, aged from 17 to 67 years, with a median age of 46 years. FPP was measured using CT portal vein angiography before splenectomy and intraoperative manometry after cantheterization to the right gastroepiploic veins. Observation indicators: (1) comparison between intraoperative and postoperative FPP; (2) dynamic changes of FPP at the seventh postoperative day; (3) comparison of FPP before and after Valsalva manoeuvre; (4) relationship of FPP with mean arterial pressure and heart rate. Measurement data with normal distribution were represented as Mean±SD. Repeated measurement data were analyzed using repeated ANOVA. Paired data were analyzed by the paired t test. The linear correlation analysis was done for relevance. Results (1) Comparison between intraoperative and postoperative FPP: 55 patients underwent open splenectomy combined with pericardial devascularization. The FPP before splenectomy, after splenectomy combined with pericardial devascularization intraoperatively, at the first and the seventh day postoperatively was (34±6)cmH2O (1 cmH2O=0.098 kPa), (28±6)cmH2O, (34±5)cmH2O and (30±5)cmH2O, respectively, showing a statistically significant difference (F=43.23, P<0.05). The FPP before splenectomy was statistically significant different from the FPP after splenectomy combined with pericardial devascularization intraoperatively, at the first and the seventh day postoperatively, respectively (P<0.05). The FPP after splenectomy combined with pericardial devascularization intraoperatively was statistically significant different from the FPP at the first and the seventh day postoperatively, respectively (P<0.05). There was a statistically significant difference between FPP at the first and the seventh day postoperatively (P<0.05). (2) Dynamic changes of FPP at the seventh postoperative day: the FPP was (30±5)cmH2O, (29±5)cmH2O, (29±5)cmH2O, (29±5)cmH2O, (28±5)cmH2O, (28±5)cmH2O, (28±5)cmH2O, (29±5)cmH2O, (29±5)cmH2O, (30±5)cmH2O, (30±5)cmH2O, (30±5)cmH2O, (31±5)cmH2O, (31±5)cmH2O, (31±5)cmH2O, (31±5)cmH2O, (31±5)cmH2O, (32±5)cmH2O, (31±5)cmH2O, (31±5)cmH2O, (31±5)cmH2O, (31±5)cmH2O, (30±5)cmH2O, (30±5)cmH2O from 00∶00 to 24∶00 at the seventh day postoperatively. Level of FPP was higher from 12∶00 to 21∶00 and lower from 01∶00 to 08∶00, with a peak value at 17∶00 and valley value from 04∶00 to 06∶00. (3) Comparison of FPP before and after Valsalva maneuvre: the FPP was (30±5)cmH2O and (32±5)cmH2O before and after Valsalva manoeuvre, respectively, showing a statistically significant difference (t=82.72, P<0.05). (4) Relationship of FPP with mean arterial pressure and heart rate. Linear correlation analysis showed positive correlations of FPP with mean arterial pressure and heart rate respectively, but the correlation was not significant (r=0.10, 0.16, P<0.05). Conclusions FPP can be reduced significantly after splenectomy combined with pericardial devascularization intraoperatively and it rises briefly again after operation. FPP has regularly circadian fluctuations and is significantly increased by Valsalva Manoeuvre. There is a positive correlation of FPP with mean arterial pressure and heart rate respectively, but the correlation is not significant. Key words: Portal hypertension; Splenectomy; Devascularization; Free portal pressure change; Influencing factors; Valsalva Manoeuvre

The Value of Intraoperative Endoscopy and Manometry in the Surgical Treatment of Achalasia.

This is a retrospective chart review of a cohort of patients diagnosed with achalasia at St Mary Clinical Hospital, Bucharest between 2013 and 2017. The objective of this study was the assessment of the immediate and long term efficacy of laparoscopic Heller myotomy associated with Dor anterior fundoplication, intraoperative endoscopy and intraoperative manometry, as well as the assessment of late post-operative complications. The diagnosis of achalasia was based on symptoms, barium esophagogram, upper endoscopy and esophageal manometry. The immediate efficacy was assessed by comparing Eckhart score, LES pressure and LES vector volume before and after surgery. Results: In total, 47 patients, had surgical treatment for achalasia between 2013 and 2017. For 7 patients who failed prior endoscopic or surgical, this was the second therapeutic intervention. 39 patients underwent laparoscopic surgery, 30 patients had associated intraoperative endoscopy and, 22 patients had associated intraoperative manometry. There was a significant improvement in mean Eckardt score (from 6,5 to 1,26, p 0,001), mean LES pressure (from 18,5 mmHg to 7 mmHg, p 0,001). Morbidity was 2,12 % and we have had 1 recurrence and 2 postoperative esophagitis. Conclusions: At present, laparoscopic Heller myotomy with an anterior Dor fundoplication, is a standard indication in achalasia, proving its efficiency and safety. Intraoperative use of endoscopy is recommended and intraoperative manometry may provide additional information on the effectiveness of myotomy. Surgical treatment of achalasia should be performed in specialized, experienced centers.

Perioperative Support of Portosystemic Shunting Interventions in Complicated Portal Hypertension due to Liver Cirrhosis

Introduction. Portosystemic shunting interventions in the treatment of life-threatening complications of portal hypertension allow to avoid a patient’s death but they decrease the portal blood perfusion which may lead to fatal hepatic failure. The adapting portal decompression (APD) using selective vasoconstrictors preoperatively is reasonable to prevent this complication. Methods. 103 patients had undergone transjugular intrahepatic portosystemic shunt (TIPS) placement and divided on two comparable groups. 52 patients of I group who received a common standard of preoperative treatment were compared with 60 patients of II group who had pre-TIPS APD (octreotide 300 mcg subcutaneously 2 times a day during 3–5 wk) in addition of standard therapy. Postoperative complications, 6-week and 1-year mortality rate and cumulative survival were comparably evaluated. Results. Intraoperative manometry revealed a decrease of portal pressure in the group of patients who received pre-TIPS APD (II group) comparably to patients of I group (р &lt; 0.05). As result the clinical and laboratory improvement in II group was found. 6-week mortality in I group was 1.9 % (1 patient after increasing of incidence of hepatorenal syndrome). At II group was no mortality. In 1-year period after TIPS 15 patients (28.8 %) of I group and 8 (13.3 %) of II group died. Conclusion. It’s reasonable to make the pre-TIPS APD for prevention of hepatic failure as a result of decreasing of portal blood perfusion. These findings suggest the need for selective vasoconstrictor octreotide use.

Real-time Continuous Esophageal High-resolution Manometry (HRM) During Laparoscopic Heller Myotomy and Dor Fundoplication for the Treatment of Achalasia. A Promising Novelty in Regards of Perfecting Surgical Technique: Could It Guide Surgical Technique Toward Excellent Results?

High-resolution manometry (HRM) is the gold-standard diagnostic tool for achalasia of the esophagus. Laparoscopic Heller-Dor technique is the preferred surgical approach with success rate estimated 90%. The use of intraoperative HRM provides real-time estimation of intraluminal esophageal pressures and identifies the exact points of esophageal luminal pressure during laparoscopy. Ten patients with achalasia underwent surgery. All patients preoperatively completed 1 manometric study and Quality of Life questionnaires (EORTC QLQ-C30 version 3.0) with Eckardt scores. We collected intraoperative manometry data and repeated manometric studies, EORTC QLQ-C30, and Eckardt scores postoperatively. Median Eckardt score was decreased from 7.5 to 0.5, mean resting pressure decreased from 51.4 to 11.9 mm Hg, whereas mean residual pressure diminished from 45.9 to 9.5 mm Hg postoperatively. The simultaneous use of HRM during the Heller-Dor technique may lead to an individualized management of the disease.

Bilateral Internal Mammary Grafts With Preservation of Sternum Blood Supply

We have prospectively collected data from 43 patients who underwent coronary artery bypass surgery and received bilateral internal thoracic artery (ITA) graft. Left ITA was harvested on full length from ostium to bifurcation. Right ITA harvesting included mobilization of only its proximal stump (5-6 cm long), that allowed its distal segment to remain intact. Proximal stump of right ITA was lengthened by radial artery or large subcutaneous vein grafts in order to reach various parts of coronary vascular bed. After comparative intraoperative manometry of ante- and retrograde pressures in right ITA patients were divided into two groups. In group 1patients (n=28) difference between ante- and retrograde systolic pressure (112.5+/-17.4 and 92.4+/-19.6 mm Hg, respectively) was <30%; in group 2 patients (n=15) difference between ante- and retrograde pressure (110.2+/-14.1 and 68.9+/-12.3 mm Hg, respectively) was more or equal 30%. Lower limb and carotid (arteries stenotic lesions (stenosis >60-70%) were more frequent in group 2 (n=8; 18.6%) than in group 1 (n=4; 9%). However postoperative ultrasound study detected no significant differences between two groups in systolic retrograde blood flow velocity in intact portion of right ITA (29.8+/-8.7 and 23.1+/-8.0 cm/s, respectively, p>0.05). Absence of sternal wound healing complications confirmed efficacy of sternal retrograde blood supply through lower and upper epigastric arteries. Patency rate of composite grafts according to angiography (n=19) performed in 3+/-0.8 years after surgery was high (94.7%). Our data confirm high functionality of bilateral ITA grafts with preservation of sternal supply.

Long-term results of the Heller–Dor operation with intraoperative manometry for the treatment of esophageal achalasia

Quality of outcome of the Heller-Dor operation is sometimes different between studies, likely because of technical reasons. We analyze the details of myotomy and fundoplication in relation to the results achieved over a 30-year single center's experience. From 1979-2008, a long esophagogastric myotomy and a partial anterior fundoplication to protect the surface of the myotomy was routinely performed with intraoperative manometry in 202 patients (97 men; median age, 55.5 years; interquartile range, 43.7-71 years) through a laparotomy and in 60 patients (24 men; median age, 46 years; interquartile range, 36.2-63 years) through a laparoscopy. The follow-up consisted of periodical interview, endoscopy, and barium swallow, and a semiquantitative scale was used to grade results. Mortality was 1 of 202 in the laparotomy group and 0 of 60 in the laparoscopy group. Median follow-up was 96 months (interquartile range, 48-190.5 months) in the laparotomy group and 48 months (interquartile range, 27-69.5 months) in the laparoscopy group. At intraoperative manometry, complete abolition of the high-pressure zone was obtained in 100%. The Dor-related high-pressure zone length and mean pressure were 4.5± 0.4 cm and 13.3± 2.2 mm Hg in the laparotomy group and 4.5± 0.5 cm and 13.2± 2.2 mm Hg in the laparoscopy group (P=.75). In the laparotomy group poor results (19/201 [9.5%]) were secondary to esophagitis in 15 (7.5%) of 201 patients (in 2 patients after 184 and 252 months, respectively) and to recurrent dysphagia in 4 (2%) of 201 patients, all with end-stage sigmoid achalasia. In the laparoscopy group 2 (3.3%) of 60 had esophagitis. A long esophagogastric myotomy protected by means of Dor fundoplication cures or substantially reduces dysphagia in the great majority of patients affected by esophageal achalasia and effectively controls postoperative esophagitis. Intraoperative manometry is likely the key factor for achieving the reported results.

Can intraoperative manometry during laparoscopic fundoplication predict postoperative dysphagia?

Many trials have used intraesophageal manometry (IEM) to measure the adequacy of fundoplication. This pilot study aimed to assess the value of IEM in predicting postoperative dysphagia. A series of 40 patients underwent IEM studies before operative correction of gastroesophageal reflux disease and repeat studies 3 months after the procedure. During the operation, IEM studies were undertaken before pneumoperitoneum was established, after pneumoperitoneum, after pneumoperitoneum with fundoplication, and after fundoplication without pneumoperitoneum. All the patients were followed up 1, 6, and 12 months after the procedure for assessment to detect persistent reflux and postfundoplication dysphagia. Three patients demonstrated persistent dysphagia at the 12-month follow-up point. No statistically significant differences in preoperative manometry findings were observed in the dysphagic and nondysphagic groups, with the dysphagic group showing higher pressures. However, at the operation, statistically significant differences in the lower esophageal sphincter pressures were observed after anesthesia and no pneumoperitoneum (30.3 vs. 13.4 cm H(2)O; p =0.002), after anesthesia with pneumoperitoneum (40.3 vs. 18.3 cm H(2)O; p < 0.001), and after fundoplication with pneumoperitoneum (47.3 vs. 23.4 cm H(2)O; p = 0.001). No statistically significant differences were demonstrated in postoperative manometry at the 3-month follow-up point. Intraoperative manometry may be a useful tool compared with postoperative manometry in identifying patients who may experience postfundoplication dysphagia.

Laparoscopic Heller-Dor Surgery for Esophageal Achalasia: Impact of Intraoperative Real-Time Manometric Feedback on Postoperative Outcomes

Background: Laparoscopic Heller myotomy with Dor fundoplication (LHD) is one of the most established surgical procedures for esophageal achalasia. Preoperative esophageal manometry has been reported as useful to evaluate lower esophageal sphincter (LES) pressure. However, the feasibility, safety, and impact of its intraoperative use have not been fully evaluated, especially when enhanced with real-time 3-D pressure imaging. Methods: LHD was attempted on 24 consecutive patients with esophageal achalasia. Manometry was performed at 3 time points during LHD: before myotomy, after myotomy, and after fundoplication. Investigations included esophagography, manometry, and 24-hour esophageal pH monitoring in the preoperative, short-term (0–5 months) and long-term (1–3 years) follow-up periods. Results: The 3-D intraoperative manometric images were presented to the surgical crew on a monitor screen immediately after each measurement in all attempted cases (n = 13). Any residual high pressure zone of the LES was easily recognized and resolved with additional myotomy. Postoperative esophagographies showed resolution of esophageal dilatation. Manometric examination revealed significant reduction of LES pressure in the short-/long-term follow-up periods. PH monitoring showed no increase in acid reflux. Overall outcomes were satisfactory (symptom relief = 95%). Conclusion: Intraoperative manometry with real-time pressure feedback is a feasible, safe, and useful adjunct in LHD.

Approach to the Child Who Has Persistent Dysphagia After Surgical Treatment for Esophageal Achalasia

Approach to the Child Who Has Persistent Dysphagia After Surgical Treatment for Esophageal Achalasia