Preoperative Dysphagia Research Articles

PP181-M0N THE EFFECT OF A PREOPERATIVE ASSESSMENT SCALE OF DYSPHAGIA RISK FOR ELDERLY PERSONS ON PREDICTING POSTOPERATIVE SWALLOWING DYSFUNCTION FOLLOWING LUNG RESECTION SURGERY UNDER GENERAL ANESTHESIA

Conclusion:Preoperative dysphagia risk was associated with postoperative swallowing dysfunction after lung resection surgery under general anesthesia. The patients with high dysphagia risk should be evaluated postoperative swallowing functions before starting oral intakes after surgery.

Integrated intervertebral device for anterior cervical fusion: An initial experience

Objective:To analyze the clinical and radiographic results following the use of integrated intervertebral implant in patients with cervical spine degenerative disease.Background:Though excellent results have been reported following anterior cervical discectomy and fusion using iliac crest autograft/allograft with plating, the morbidity associated with autograft harvest and small chances of complications with plating always exists. Recently, there has been development of a cervical stand-alone cage with integrated fixation for cervical fusion and stabilization with a possible low morbidity and optimal clinical outcome.Materials and Methods:A retrospective study of 16 patients who underwent anterior cervical discectomy and fusion using the integrated intervertebral device was performed. Intra-operative parameters, clinical features [Neck Disability Index (NDI), visual analog scale (VAS) score for neck/arm pain], and presence or absence of dysphagia was recorded. Radiographs were evaluated for assessment of implant failure and fusion.Results:Mean age of patients was 54 years (range: 38-84 years) with male: female ratio of 1:3. Follow-up ranged from 6 to 12 months (mean: 10 months). In the early postoperative period, 2 of the 15 patients (13%) patients had mild dysphagia that resolved during follow-up with no patient having complaints of dysphagia at 3-month follow-up. One of the patients with diffuse idiopathic skeletal hyperostosis (DISH) and severe preoperative dysphagia had significant improvement in swallowing function at 3-month follow-up that was stable at 1-year follow-up. There was no evidence of implant failure, with fusion occurring in 95% (19/20) of operated levels. Analysis of follow-up VAS and NDI scores showed significant reduction in VAS score for neck pain (P < 0.019), radicular arm pain (P < 0.003), and NDI score (P < 0.007) in 77, 92, and 77% of patients, respectively, at a mean follow-up of 10 months (6-12 months).Conclusions:Our preliminary results with the use of this cervical stand-alone anterior fusion device with integrated screw fixation show its efficacy in anterior cervical decompression and fusion with stabilization with optimal clinical and radiographic outcome. Lower chances of dysphagia with no device-related complications are appealing, which needs to be verified in larger studies.

The evaluation of esophageal motility in patients with persistent dysphagia after fundoplication

Persistent postoperative dysphagia (PPD) is a relatively rare but troublesome complication of laparoscopic fundoplication in patients with gastroesophageal reflux disease. Although it is mainly attributed to impaired distal esophageal body (EB) function, it may develop in patients with preserved motility as well. Since little is known about the pre- and postoperative motility patterns of such patients we aimed to compare the esophageal motor function in patients with PPD and a matched control group of patients without swallowing problems after fundoplication. Patients, Methods: Eleven patients (M/F 3/8, mean age: 52.6 ys., BMI: 24.2) with PPD after laparoscopic fundoplication were evaluated. Standard water perfusion esophageal manometry was performed before and 3 months after fundoplication in all subjects and results were compared to an age, sex, BMI and preoperative dysphagia score matched group of 11 control patients without PPD. Results: Preoperative esophageal manometry showed similar lower esophageal sphincter (LES) length, pressure, relaxation time, and EB peristaltic wave duration in both groups. The amplitude of contractions in the distal EB were also similar, while patients with PPD had significantly lower amplitudes in the proximal esophagus than controls after dry (25.5 vs. 61.8mmHg, p=0.01) and wet (45.1 vs. 76.7mmHg, p=0.05) swallows. Propagation velocity of the contractions were slower in patients with PPD after wet swallows (2.56 vs. 3.27cm/s, p=0.05). The number of simultaneous contractions tended to be higher in PPD. Postoperatively both groups had similarly improved LES function. In the EB, distal contraction amplitudes were decreased in patients with PPD (95.6 vs. 75.5mmHg, p=0.05) but not in controls, compared to the preoperative values. After fundoplication the number of simultaneous contractions were significantly higher in patients with PPD than in controls. Conclusions: In patients with preserved distal EB contraction amplitudes, decreased peristaltic wave propagation velocity, and proximal amplitudes may be predictive for PPD after fundoplication. Patients with PPD have decreased distal EB contraction amplitudes after fundoplication compared to their preoperative results. TÁMOP421/B09/1, ETT340/09

Laparoscopic Heller myotomy plus Dor fundoplication in 137 achalasic patients: results on symptoms relief and successful outcome predictors

Aim of this study was to review our experience with laparoscopic Heller-Dor (LHD) intervention and identify possible success predictors. LHD is an effective and safe treatment for achalasia. However, open debates are still held on which antireflux procedure should be added and on how long the myotomy on to the stomach should be. A lot of successful outcome predictors have been investigated with sometimes conflicting results. 137 achalasic patients underwent LHD at our institution. Pre-operatively all underwent a complete morphologic and functional work-up. Follow-up visits were scheduled at 1, 3, 6months and then every year. Median follow-up was 65months. Pre-operatively dysphagia was present in 100% cases, regurgitation in 84.6% and mean lower esophageal sphincter (LES) resting pressure was 29.1mmHg. We observed 3 mucosal perforations. Mortality was null. The median of oral food intake resumption was second post-operative day and mean post-operative hospital stay was 3.4days. Dysphagia was treated with success in 94.78% cases and regurgitation in 82.84%. Post-operative mean LES resting pressure was 13.64mmHg. New-onset heartburn was observed in 10.9% of patients. 9.7% of cases required pneumatic dilations and 1.5% a laparoscopic re-do myotomy. An high pre-operative dysphagia score resulted to be the only statistically significant prognostic factor. Sex, age, dysphagia duration and LES resting pressure did not reach statistical significance. LHD is a safe procedure with good results in about 90% of patients even at a long-term follow-up. Predictors of successful outcome are still poorly plain and sometimes conflicting in literature.

Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling. A retrospective comparison of outcomes

Transoral stapled diverticulo-esophagostomy (TSDE) has gained increased popularity in surgical treatment of Zenker diverticulum (ZD). One of the advantages of this approach is early rehabilitation with significant decrease in patient morbidity and time to resumption of oral intake as compared with open treatment. The section of the septum between the diverticulum and the esophagus with a flexible endoscopic (ES) approach has also been proposed since mid-90s as an alternative for treatment of ZD. Both these approaches are a minimally invasive approach to treat ZD. We compared the TSDE management of ZD versus the ES treatment in a retrospective consecutive series of patients who were referred to either the ES or surgical unit of our Institute. Fifty-eight consecutive patients underwent treatment for ZD either by TSDE or ES. The two techniques were evaluated for length of hospital stay, diverticulum size, resumption of oral intake, resolution of dysphagia, and complications. Clinical outcome was evaluated throughout a symptom score from 0 to 3, calculated before and after the procedure. The two groups were compared on the various parameters using a Mann--Whitney test. Twenty-eight patients underwent ES and 30 TSDE for ZD. In both groups, a significant decrease in postoperative versus preoperative dysphagia was reported. The average length of hospital stay wasn't significantly different in the two groups (3.38 days for TSDE vs. 2.42 days for ES). The overall complication rate was similar in the two groups. There were two cases in the ES group and three cases in the TDSE group that required an ES revision to take down a residual diverticular wall that produced a mild but persistent dysphagia. Minimally invasive treatment of ZD both with ES and with TSDE is a valuable option for this disease: both techniques are safe and effective, with similar outcome in terms of hospital stay, symptom reduction, and complication rate. Long-term results have to be evaluated.

Reoperative antireflux surgery for dysphagia

Troublesome dysphagia is a common indication for redo antireflux surgery (Re-ARS). This study is aimed to analyze the efficacy of Re-ARS in resolving dysphagia and to identify risk factors for persistent or new-onset dysphagia after Re-ARS. A prospectively maintained database was retrospectively reviewed to identify patients after Re-ARS. Dysphagia severity was graded on a scale of 0 to 3 before and after Re-ARS based on responses to a standardized questionnaire. Patients reporting grade 2 or 3 symptoms were considered to have significant dysphagia. Satisfaction was graded using a 10-point analog scale. Between December 2003 and July 2008, 106 patients underwent Re-ARS. Significant preoperative dysphagia was reported by 54 patients, and impaired esophageal motility was noted in 31 patients. Remedial surgery included redo fundoplication (n = 87), Collis gastroplasty with redo fundoplication (n = 16), and takedown of the fundoplication or hiatal closure alone (n = 3). At least 1 year follow-up period (mean 21.8 months) was available for 92 patients. For patients with significant preoperative dysphagia (n = 46), the mean symptom score declined from 2.35 to 0.78 (p < 0.0001). Persistent dysphagia was reported by 13 patients and new-onset dysphagia by 4 patients. No patients reported grade 3 dysphagia after Re-ARS. Dilations were used to treat 11 patients. Multivariate logistic regression analysis identified Collis gastroplasty (p = 0.03; adjusted odds ratio [OR], 5.74) and preoperative dysphagia (p = 0.01; adjusted OR, 6.80) as risk factors for significant postoperative dysphagia. The overall satisfaction score was 8.3, but certain subsets had significantly lower satisfaction scores. These subsets included patients with esophageal dysmotility (7.1; p = 0.04), patients who required Collis gastroplasty (7.0; p = 0.09), and patients with esophageal dysmotility who required Collis gastroplasty (5.0; p < 0.01). Although dysphagia is a common symptom among patients requiring Re-ARS, intervention provides a significant benefit. Patients with preoperative dysphagia, especially those requiring Collis gastroplasty, are at increased risk for persistent dysphagia and decreased satisfaction after Re-ARS.

Identification of risk factors for postoperative dysphagia after primary anti-reflux surgery

Transient postoperative dysphagia is not uncommon after antireflux surgery and usually runs a self-limiting course. However, a subset of patients report long-term dysphagia. The purpose of this study was to determine the risk factors for persistent postoperative dysphagia at 1 year after surgery. All patients who underwent antireflux surgery were entered into a prospectively maintained database. After obtaining institutional review board approval, the database was queried to identify patients who underwent primary antireflux surgery and were at least 1 year from surgery. Postoperative severity of dysphagia was evaluated using a standardized questionnaire (scale 0-3). Patients with scores of 2 or 3 were defined as having significant dysphagia. A total of 316 consecutive patients underwent primary antireflux surgery by a single surgeon. Of these, 219 patients had 1 year postoperative symptom data. Significant postoperative dysphagia at 1 year was reported by 19 (9.1%) patients. Thirty-eight patients (18.3%) required postoperative dilation for dysphagia. Multivariate logistic regression analysis identified preoperative dysphagia (odds ratio (OR), 4.4; 95% confidence interval (CI), 1.2-15.5; p = 0.023) and preoperative delayed esophageal transit by barium swallow (OR, 8.2; 95% CI, 1.6-42.2; p = 0.012) as risk factors for postoperative dysphagia. Female gender was a risk factor for requiring dilation during the early postoperative period (OR, 3.6; 95% CI, 1.3-10.2; p = 0.016). No correlations were found with preoperative manometry. There also was no correlation between a need for early dilation and persistent dysphagia at 1 year of follow-up (p = 0.109). Patients with preoperative dysphagia and delayed esophageal transit on preoperative contrast study were significantly more likely to report moderate to severe postoperative dysphagia 1 year after antireflux surgery. This study confirms that the manometric criteria used to define esophageal dysmotility are not reliable to identify patients at risk for postfundoplication dysphagia, and that there is need for standardization of contrast swallow assessment of esophageal function.

Outcome After Percutaneous Endoscopic Gastrostomy in Children and Young Adults

Factors predicting outcome after percutaneous endoscopic gastrostomy (PEG) in large pediatric cohorts are not well defined. We hypothesized that definable preoperative clinical factors predict the need for further intervention to provide enteral access after PEG. Our aim was to identify factors associated with PEG outcome. A retrospective review of 760 (407 boys and 353 girls) patients was performed after PEG at the Johns Hopkins Children's Center from 1994 to 2005. Logistic or multiple linear regression was used to analyze indication; diagnosis; age; prematurity; neurological impairment; weight-for-age z scores; modified barium swallow; postoperative complications; need for fundoplication (FP), gastrojejunal tube, or jejunostomy; and length of hospital stay. The median age was 1 year (range 0-26 years). The most common indications given for PEG were failure to thrive (n = 373) and dysphagia (n = 27). Postoperative FP, gastrojejunal tube, or jejunostomy were performed in 66 (10%), 24 (4%), and 9 (1%) patients, respectively. Preoperative report indicated that dysphagia and direct aspiration on modified barium swallow was strongly associated with patients undergoing FP after PEG, 10.6% of patients (P = 0.008, odds ratio 2.4) and 11.2% of patients (P = 0.013, odds ratio 2.8), respectively. Younger preoperative age was also associated with the need for FP (P = 0.0006; median age of 5.8 vs 14 months). Patients with preoperative dysphagia had a longer median length of hospital stay: 8 versus 3 days (P < 0.00001). Patients with neurological impairment demonstrated greater weight gain than neurologically normal patients after PEG (P = 0.04). Minor postoperative complications (most commonly wound infection) were observed in 4% (27/747) of children before hospital discharge from PEG and in 20% of children (138/682) after discharge. There were only 2 major complications (gastric separation and gastrocolonic fistula.). There were no fatalities. Preoperative diagnosis, indication, prematurity, and neurological impairment did not influence postoperative complications.

Endoscopic minimally invasive thyroidectomy: first clinical experience

Background Since Theodor Kocher reduced the mortality rate of thyroidectomy from the 40% reported by Billroth to 0.2% in 1895, a collar incision with open removal of the thyroid gland is the standard procedure [1, 2]. In the past decade, efforts were made to reduce incision size and surgical access trauma by the use of endoscopic techniques. A first attempt was replacement of the central “Kocher incision” with lateral neck incisions and endoscopic removal of a thyroid lobe by Huscher on 8 July 1996 [3]. This lateral access was limited to removing only one lobe of the gland. The most common technique to date is the one developed by Miccoli et al. [4]. These authors reduced the incision to a size of 20 to 25 mm and operated on the thyroid by the use of video-endoscopic assistance (MIVAT). Several groups have described an access outside the frontal neck region via a chest [5–8], axillary [9], or combined axillary bilateral breast approach [10]. These accesses only moved the entry point from the frontal neck region to other regions, where they are still visible. The aforementioned minimally invasive approach and the conventional open approach do not respect anatomically given surgical planes and may therefore result in patient complaints, especially swallowing disorders after the scaring of the subcutaneous tissues. These extracervical approaches are associated with an extensive dissection in the access area and thus are maximally invasive. Therefore, we developed an exclusively endoscopic approach for thyroid resection [11] with standard instruments used for minimally invasive surgery (diameter, 3.5 mm). This endoscopic minimally invasive thyroidectomy (eMIT) technique was evaluated carefully by anatomic and cadaver dissections as well as ultrasound studies for technical realization and needs for instrument design [12]. To verify the safety and feasibility of the method, an animal trial was conducted in August 2008. Surgery was performed securely on five pigs, with very low blood loss. The postoperative behavior with special regard for feeding and pain reaction was normal until dissection. Especially, no local infection in the oral cavity or cervical spaces was noted.

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

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

Laparoscopic Fundoplication in Patients with a Hypertensive Lower Esophageal Sphincter

BackgroundA small proportion of patients evaluated with manometry prior to a fundoplication have a high-pressure lower esophageal sphincter (LES). This paper examines the outcome of laparoscopic fundoplication for these patients. Material and MethodsBetween October 1991 and December 2006, 1,886 patients underwent primary laparoscopic fundoplication. Those with a high-pressure LES on preoperative manometry (LESP ≥30 mm Hg at end expiration) were identified from a prospective database. Long-term outcomes were determined using analogue symptom scores (0–10) for heartburn, dysphagia, and patient satisfaction and compared to those of a matched control group. ResultsThirty patients (1.6%), nine men and 21 women, median age 51 years, had a hypertensive LES (mean, 36 mmHg; range, 30–55). Median follow-up after fundoplication was 99 (12–182) months. These patients had similar mean symptom scores to 30 matched controls for heartburn (2.3 vs. 2.2, P = 0.541), dysphagia (2.7 vs. 3.1, P = 0.539), and satisfaction (7.4 vs. 7.6, P = 0.546). Five patients required revision for dysphagia compared to no control patients (P = 0.005). These patients had a higher preoperative dysphagia score (6.6 vs. 3.1, P = 0.036). ConclusionLaparoscopic fundoplication can be performed with good long-term results for patients with reflux and a hypertensive LES. However, those with preoperative dysphagia have a higher failure rate.

Surgical management of achalasia in Zaria, Northern Nigeria.

Achalasia of the cardia is generally considered a rare disease. Because the cause is uncertain, treatment is palliative and directed at relieving distal oesophageal obstruction. In developed countries, several treatment options are available, but in developing countries, achalasia is usually treated by open surgical myotomy. We reviewed the outcome of management of achalasia in our patients and the influencing factors. We retrospectively reviewed all adult patients treated for achalasia between 1991 and 2006. Diagnosis was based on clinical symptoms and barium swallow examination. The severity and frequency of dysphagia were determined before and after treatment. Barium examination was repeated 2 weeks after surgery or when the patient had recurrence of dysphagia, regurgitation or heartburn. Treatment was by modified Heller's operation, transabdominally without complementary antireflux procedure. Logistic regression modelling was performed to identify factors predictive of poor outcome. There were 47 patients, 31 (66.0%) males and 16 females, mean age (+/- standard deviation (SD) 34.6+/-9.8 years. All patients presented with dysphagia, which was severe in 31 cases (66.0%) and moderate in 14 (29.8%). Preoperative maximum oesophageal diameter ranged from 34 to 89 mm, mean 67.4+/-12.7mm. In 30 (63.8%) of the patients, the maximum diameter was >70 mm. Postoperative maximum diameter ranged from 28 to 72 mm, mean 37.5+/-8.2 mm (p=0.001). The mean preoperative diameter of the narrowest distal oesophagus was 4.6+/-2.5 mm, compared with the postoperative figure of 11.6+/-1.8 mm (p=0.015). Following surgery, 41 (87.2%) patients had complete relief of dysphagia, regurgitation and heartburn. Four patients continued to have heartburn after surgery. Patients with severe dysphagia or preoperative oesophageal dilatation >70 mm had the greatest likelihood of incomplete relief of symptoms after treatment. Achalasia can be accurately diagnosed on the basis of clinical symptoms and barium swallow examination. A modified Heller's operation provides lasting relief of symptoms. Patients with severe preoperative dysphagia or oesophageal dilatation are more likely to have poor outcome of treatment.

Role of Plate Thickness as a Cause of Dysphagia After Anterior Cervical

Prospective radiographic analysis with clinical correlates. The purpose of this study was to determine whether patients with cervical plates protruding off the vertebral body more prominently than pre-existing osteophytes had higher rates of dysphagia, suggesting a mechanical role. Plate prominence due to mechanical causes has been implicated as a cause of dysphagia after anterior cervical fusion. This study therefore assessed the potential of plate prominence as a cause of dysphagia after anterior cervical fusion and the predictive role of preoperative osteophyte heights. Osteophyte heights measured on the preoperative radiographs of 63 patients, 41 males and 23 females with mean age 54 years (range, 31 to 75), who underwent anterior fusion (2 mm SYNTHES CSLP plates). After surgery, the distance of the plate from the vertebral body was measured and compared with preoperative osteophyte heights. Group I contained 30 patients who had cervical plates protrude less than or equal to the height of the tallest preoperative osteophyte. Group II contained 34 patients who had plates protrude greater than the height of the tallest preoperative osteophyte. No patients had preoperative dysphagia. Five of 30 Group I patients had dysphagia (>1 month). Six of 34 group II patients had dysphagia. There was no difference between groups I and II in rate of dysphagia (beta > 0.90). Plates at C3 and shorter cervical constructs trended higher rates of dysphagia. Long-term postoperative dysphagia in Group I patients and the lack of a difference in rates of dysphagia between group I and group II, made it improbable plate thickness of 2 mm or prominence between 3 and 7 mm consistently played roles in dysphagia. Preoperative osteophyte height did not predict which patients developed postoperative dysphagia. Plates at the C3 and shorter constructs trended to have higher rates of dysphagia.

Long-Term Outcomes After Laparoscopic Antireflux Surgery

We studied the long-term outcomes of laparoscopic antireflux surgery (LARS) and the factors that determine it, as neither has been previously well established. From September 1993 (start of our program) to September 1999, 441 patients underwent LARS. Preoperative symptoms and the results of esophageal functional studies as well as details of the operation and follow-up were recorded prospectively in our database. In 2004, with the help of a private investigator, we were able to contact 288 (65%). There were no differences in presentation profiles of those patients contacted and those we could not. At a median follow-up of 69 months, individual symptoms, among those who had it preoperatively, were as follows: heartburn (N = 282) improved in 254 (90%) and resolved in 188 (67%); regurgitation (N = 258) improved in 238 (92%) and resolved 199 (70%); dysphagia (N = 123) improved in 96 (78%) and resolved in 76 (62%); cough (N = 119) improved in 82 (69%) and resolved in 48 (40%); and hoarseness (N = 106) improved in 73 (69%) and resolved in 50 (47%). Univariate regression analysis showed that the presence of heartburn (P= 0.02), male gender (P= 0.03), and younger age (P= 0.04) predicted symptom resolution, whereas preoperative dysphagia (P= 0.03), airway manifestations (P= 0.03), bloating (P= 0.04), and defective esophageal motility (P= 0.08) were negative predictive factors. By multivariate analysis, male gender, dysphagia, and age remained significant (P < 0.05). Seven patients (2%) developed a new onset of dysphagia; 32 patients (11%) developed new or increased diarrhea and 27 patients (9%) developed bloating postoperatively. One hundred nineteen patients (41%) were taking some form of antacid medication; 66 (23%) patients were using PPIs and 10 (3%) had undergone reoperation. LARS provides effective long-term relief of GERD. Younger patients, men, and those without dysphagia are predictors of superior outcomes.

Persistent dysphagia after laparoscopic fundoplication for gastro-esophageal reflux disease

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

Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication

Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility. A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions. In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 +/- 5.2 mmHg (range, 6.0-30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% +/- 8.3% (range, 70-100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett's progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1-46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results. The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360 degrees fundoplication should not be contraindicated for patients with severe esophageal dysmotility.

Prospective randomized trial of Nissen fundoplication and Angelchik prosthesis in the surgical treatment of medically refractory gastro-oesophageal reflux disease

Fifty patients with gastro-oesophageal reflux disease refractory to multiple courses of medical therapy were entered into a prospective randomized trial comparing Nissen fundoplication with the Angelchick prosthesis as a primary surgical procedure. The two groups were matched for age, sex, duration of symptoms before surgery, type of medical therapy, pattern of symptom presentation, endoscopic grade of oesophageal inflammation, manometric lower oesophageal pressure and 24-h pH profile. Twenty-five patients were randomized to each of the Nissen fundoplication and Angelchik prosthesis groups. Operation time and hospital stay were similar in both groups. Persistent dysphagia was reported in five of the patients with an Angelchik prosthesis compared with none in the Nissen fundoplication group. Three prostheses were removed because of severe dysphagia while no Nissen fundoplication required revision. No patient with preoperative dysphagia because of stricture reported swallowing difficulties after operation. At clinical assessment at 3, 6, 12 and 24 months after operation, 85-88 per cent of the patients having a Nissen fundoplication were graded Visick 1 or 2 compared with 60-72 per cent of patients in the Angelchik group.

Laparoscopic Heller Myotomy With Toupet Fundoplication

This study was performed to assess the intermediate-term outcomes after laparoscopic Heller myotomy and posterior Toupet fundoplication in a single-surgeon series with the expectation of identifying patient and disease factors associated with poor outcomes. Retrospective analysis of prospectively collected data. Tertiary care teaching hospital with a comprehensive esophageal physiology laboratory. A total of 121 patients undergoing laparoscopic Heller myotomy with Toupet fundoplication (between December 1, 1996, and December 31, 2004) for achalasia were included. All patients had preoperative objective documentation of achalasia. A 5- to 6-cm-long myotomy was performed on the distal esophagus. The myotomy incision was extended 2 cm onto the stomach. A partial (270 degrees ) posterior Toupet fundoplication was performed as an antireflux mechanism in all patients. Data on preoperative and postoperative symptoms, manometry, and 24-hour ambulatory pH were prospectively collected. Symptoms were recorded with a standardized assessment tool. Patients with postoperative dysphagia scores of 2 or greater were considered treatment failure. Logistic regression modeling was performed to identify variables significant for poor outcomes. Preoperatively, 89 patients (73.6%) had severe dysphagia (dysphagia score, 3 or 4) and 32 patients (26.4%) had mild or moderate dysphagia (dysphagia score, 1 or 2). After a median follow-up period of 9 months, 102 patients (84.3%) (P<.001) had excellent relief of dysphagia (dysphagia score, 0 or 1). Eight additional patients (6.6%) demonstrated a significant (25%-75% [P=.01]) improvement in dysphagia scores. Only 11 patients (9.0%) had either no change or worse dysphagia. Postoperatively, all patients with manometry had a normal lower esophageal sphincter pressure (mean +/- SD, 14.7 +/- 6.6 mm Hg; P<.001) and good lower esophageal sphincter relaxation. Odds of failure were greatest for patients with severe preoperative dysphagia, male patients, and patients with classic amotile achalasia. Of the 60 patients having heartburnlike symptoms preoperatively (mean +/- SD score, 2.52 +/- 1.00), 19 (31.7%) continued to have similar symptoms after surgery. Sixteen (33.3%) of the 48 patients having postoperative pH studies demonstrated objective reflux (DeMeester score, >14.7). Five (31.2%) of these patients had symptoms of their reflux. Dysphagia improves in most patients after laparoscopic Heller myotomy with partial fundoplication. Patients with severe preoperative dysphagia, esophageal dilation, or amotile achalasia may have greater chances of a poor outcome.

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

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

Esophagotomy during laparoscopic Heller myotomy cannot be predicted by preoperative therapies and does not influence long-term outcome

The conventional wisdom is that inadvertent esophagotomy complicates laparoscopic Heller myotomy. This study was undertaken to determine if esophagotomy at myotomy can be predicted by preoperative therapy, and if esophagotomy and/or its repair jeopardizes outcomes. Of 222 laparoscopic Heller myotomies undertaken since 1992, inadvertent esophagotomy occurred in 16 patients (7%); 60 patients who underwent myotomy without esophagotomy were utilized for comparison. Dysphagia and reflux before/after myotomy were scored by patients on a Likert scale (0-5). The median (mean +/- SD) follow-up after myotomy with esophagotomy was 38.8 months (31.6 +/- 21.9 months) versus 46.3 months (51.0 +/- 21.2 months) after myotomy alone. All esophagotomies were immediately recognized and repaired. Patients who experienced esophagotomy were similar to those who did not in application of Botox (56% vs. 77%) or dilation (44% vs. 65%), years of dysphagia (7.3 +/- 5.4 vs. 7.4 +/- 6.0), and mean preoperative dysphagia score (4.9 +/- 0.4 vs. 4.8 +/- 0.4). Esophagotomy led to longer hospitalizations (5.2 days +/- 2.5 days vs. 1.5 days +/- 0.7 days, P < 0.05) but not different postoperative dysphagia scores (1.5 +/- 1.7 vs. 2.1 +/- 1.4), reflux scores (1.4 +/- 1.7 vs. 2.3 +/- 1.3), or good or excellent outcomes (86% vs 84%). Esophagotomy during laparoscopic Heller myotomy is infrequent and cannot be predicted by preoperative therapy or duration or severity of dysphagia. Furthermore, complications after esophagotomy are infrequent and outcomes are indistinguishable from those of patients undergoing uneventful myotomy.