- Email: [email protected]
Long myotomy with antireflux operation for esophageal spastic disorders
symptom relief was durable, out to four years of follow up. These results are significantly better than those reported for endoluminal therapies, even in this most favorable group of GERD patients. Percentageof patientsreportingmedicationuse or symptomsover time
preoperative one month one year two years four years
Medication Use Heartburn
Regurgitation ChestPain
100% 10%* 11%* 7%* 7%*
81% 4%* 5%* 5%* 7%*
87% 5%* 7%* 5%* 7%*
44% 9%* 70/0* 5%" 7%"
*p
Objective:Surgical treatment is controversial in patients who have reflux symptoms but normal 24 hour pH monitoring and endoscopic evaluation.The objective of this study was to determine the clinical outcome of patients who are referred for antireflux surgery and have normal ambulatory 24 hr pH test results. Methods: 490 patients were referred to our esophageal motility lab for esophageal studies between March 1998 and September 1999, and 174 had complete 24 hour ambulatory pH evaluations. 24 hr pH monitoring was performed with single (167) or double (7) transducer probes. Symptom diaries were kept and symptoms recorded on the portable data collection units. Results were analyzedby proprietary software (Medtronics). Nineteen of the 174 (12%) had normal results, and constitute the patient cohort for this retrospective study. Clinical follow-up data were obtained from a clinical outcomes database or by telephone interview. A standardized symptom assessment tool was administered as part of follow-up in all patients. Ftesu/ts:19 patients had normal 24 hr pH studies and GERD symptoms. Meanfollow up was 16.3 months (range 4-26). Nine patients (47%) had subsequent surgery: three for gastric problems, one Heller myotomy for achaiasia, and five antireflux surgeries. Six patients were maintained on medical therapy. Four (21%) patients had symptom resolution without intervention. Of four patients having non-antireflux surgery, three were improved and one was worse. Of five patients having antirctlux surgery, two (40%) were improved, two have continued foregut complains and one was worse. Conclusion: Normal 24 hr pH studies are found on a minodly of patients referred for antireflux surgery. Many of these patients are found to have pathology other than gastroesophageatreflux disease as an explanation for their symptoms. Patients who do go on to have antireflux surgery have poor clinical outcomes compared to patients who have abnormal pH test results. 2430 Long Myotomy with Antireflux Operation for Esophageal Spastic Disorders Dimitrios Nastos,, Long-Qi Chen,, Pasquale Ferraro,, Raymond Taillefer, Andre C. Duranceau,, Ctr Hospitalier Univesifaire de Montreal, Montreal Canada OBJECTIVE: Report the long-term subjective and objective results of esophageal myctomy and fundoplicatlon by thoracotomy Jn treating esophagealspastic disorders. METHODS:From 1977 to 1995, 16 patients with esophageal spastic disorders underwent a myotomy with an added partial (12) or total (4) fundoplication. The median follow-up is 6 years. Assessments include clinical evaluation, esophagogram, radionuclide emptying, manometry, 24-hour pH, and endoscopy. From global results, patients with pure spastic disorders (8) were compared to patients with spastic disorders and an epiphrenic diverticulum (8). RESULTS: There is no mortality and minimal morbidity. Results are summarized in table 1. Failure (Persistant symptoms, reflux damage or obstruction to emptying) was observed in 1 patient with a diverticulum at 9 years and in 4 patients with pure spastic disorder at 2, 3, 6, and 8 years after the operation (Log-rank test, p=0.029). CONCLUSIONS: Long myotomy and fundoplication for spastic disorders: • Reduces dysphagia and chest pain;. Reduces distal peak contraction pressures and peristalsis; . Decreases LES pressures. • Improves LES relaxation.. Spastic disorder patients with a diverticulum, when compared to pure spastic disorder patients, show better clinical results, better esophageal function.
2431 The Anatomy of Paraesophageal Hernia. Implications for Surgery baniela Molena, Marco G. Patti, Karen Whang, Plero M. Fisichella, David Suh, Hiro Yamada, Silvana Perretta. Lawrence W. Way, UCSF, San Francisco, CA Background: Paraesophageal hiatal hernia (PEH) is defined as herniation of the stomach alongside a fixed or relatively fixed gastroesophageal junction. Although usually referred to as if if were a single entity, PEH actually includes a wide variety of anatomic configurations, a phenomenon that has not been well studied. We analyzed80 patients with PEH to determine the spectrum of anatomic variation and how major differences affect the clinical findings, diagnosis, and operative treatment. Methods: For each patient the following were analyzed: hadom swallow, endoscopic findings, manometry, pH monitoring, and the videotape of the operation. There were 80 patients (38 women and 42 men, median age 69 years), who had been symptomatic for an average of 60 months. Symptoms included heartburn (56%), regurgitation (41%), and manifestations of obstruction (44%). Median follow up was 14 months. Results: The amount of herniated stomach was seen to be greater at surgery than on the radiographs in 27% of cases; in the rest, the two were similar. There were 2 types of hernia sac: type A (40 pts) was a mobile diaphragm attached to the esophageal hiatus; these hernias ware completely reducible. Type B (40 pts) was deeper and formed the walls of a fixed mediastinal cavity; in these cases the herniated stomach was incompletely reducible until the sac was disconnected from the stomach and distal esophagus. Efforts were rarely (8%) made to totally excise these sacs. Reconstruction involved reducing the size of the hiatus and a fundoplication. Group A Group 8 p value Prs op heartburn (% pts)70 37 <0.05 Entire stomach herniated (% pts) 8 35 <0.05 Width of esophageal hiatus (cm) 4_+15_+2 <0.05 Excision of sac (% pts) 100 8 <0.05 Duration of operation (min) 168_+49 193_+67 0.06 Post op asymptomatic pts (%)79 94 NS Conclusions:Thesedata show that: 1) radiographs underestimated the size of the hernia in 27% of pts; 2) in 50% of pts the hernia sac was attached to mediastinal structures and was not reducible. In the latter group: a) heartburn was less common; b) the entire stomach was often herniated; c) the esophageal hiatus was larger, and d) the sac was transected at the level of the diaphragm but not excised. The clinical outcome was similar in the 2 groups. Complete excision of the hernia sac in group B was dearly unnecessary; no unsatisfactory results were attributable to its retention. 2432 Laparessople Repair of Pareesophageal Hernia Is Subject to Recurrence but Rarely Requires Rsoperetion Samer G. Mattar, Stephen P. Bowers, W Nan Bradshaw, Kathy D. Galloway, Maria L. Terry, John G. Hunter, C Daniel Smith, Emory Univ, Atlanta, GA Background: Although laparnscopic repair of paraesophagealhernias (LPH) results in effective symptomatic relief, there is concern regarding the rate of hiatal hernia recurrence; especially asymptoma~c recurrence. Method: We reviewed our experiencewith 136 patients undergoing LPH repair over a six year period. All patients beyond 1 year of LPH in whom an esophogram was obtained were identified. Concurrently, symptom scores (SS) for chest pain, heartburn, regurgitation, and dysphagia were obtained and the highest score reported by the patient was tabulated (0 = no symptoms; I = mild symptoms; 2 = moderate; and 3 = severe symptoms). Additionally, a measure of patient satisfaction, frequency of medication use, and the need for extraordinary physician visits or hospitalizations were documented. Results: In 42 patients, a barium swallow at a mean of 45 months (range 20 - 82 months) after LPH repair were available or obtained. There were 14 males and 20 females with an average age of 63.2 years (range 42 90 years). Thirty-eight patients completed symptom questionnaires with 90% expressing satisfaction with the results of the operation. Twenty-eight patients (74%) were off medications and 5 (13%) had visited a physician with related symptoms. Fourteen patients (33%) had an anatomic recurrence on esophogram, but only 3 of these patients reported more than mild symptoms. The symptom scores of those with anatomic recurrence were not significantly different than in those without recurrence (see graph). Only one patient with recurrence has undergone reoperation for postprandial pain. Conclusion: At long-term follow up, anatomic recurrence following LPH repair is high. Many of these are asymptomatic and of questionable clinicat significance. The relevanceof recurrent asymptomatic paraesophageal hernia remains unclear, and at this time it is difficult to recommend reoperation for these patients.
Operative Results for Esophageal Spastic Disorders ~
Observation Dysphagia Chest Pain Stasis at 2 Min. (%) Body Contraction (mmHg) Body Peristalsis (%) LES Gradient (mmHg) LES Relaxation (%) Acid Exposure(time%) Esophagitls / Ulcer
Before Operation Dirt(*) Dirt(-) 7 6 26.1 70,1 61.4 23.1 95.9 10.0 0
8 6 39.0 78.8 36.3 22.9 63.9 0.0 t
After Operation DM(+) Dt~t(-)
P Value
1 0 20.2 35.0 30.0 8.2 100.0 6.3 2
=0.002 =0.021 >0.25 <0.001 =0.016 <0.001 =0.005 >0.25 >0.25
3 3 44.6 33.4 18.8 6.9 100.0 11.5 2
0 0 1 Severity of ~
2
3 prom
"Not sionFscant
2433
A Comparison Between Subjective and Objective Outcomes of Laparessopic Hofler Myofomy and Toupof Fundoplication for Achalasia Robert E. Glasgow, Yashodhan S. Khajanchee, David R. Urbach, Paul D. Hansen, Lee L. Swanstrom, Legacy Health System, Portland, OR Objective: Laparoscopic cardiomyotomy is an effective treatment for the symptoms of achalasia. However, no studies have evaluated how improvements in symptoms correlate to the results of esophagealfunction tests. The aim of this study was to compare patient's subjective outcomes to the results of postoperative esophagealfunction tests after laparoscopic treatment of achalasia. Methods: This was a review of a prospectively maintained database of patients who had a laparoscopic Heller myotomy with Toupet fundoplication for achalasia at a tertiary referral center. Data included pre- and post-operative assessment of quality of life, patient symptoms, esophageal manometry, and 24-hr pH studies. Results: Complete quality of life and objective outcome data were available for 17 of 42 patients who had surgery between
A-478
preoperative one month one year two years four years
Medication Use Heartburn
Regurgitation ChestPain
100% 10%* 11%* 7%* 7%*
81% 4%* 5%* 5%* 7%*
87% 5%* 7%* 5%* 7%*
44% 9%* 70/0* 5%" 7%"
*p
Objective:Surgical treatment is controversial in patients who have reflux symptoms but normal 24 hour pH monitoring and endoscopic evaluation.The objective of this study was to determine the clinical outcome of patients who are referred for antireflux surgery and have normal ambulatory 24 hr pH test results. Methods: 490 patients were referred to our esophageal motility lab for esophageal studies between March 1998 and September 1999, and 174 had complete 24 hour ambulatory pH evaluations. 24 hr pH monitoring was performed with single (167) or double (7) transducer probes. Symptom diaries were kept and symptoms recorded on the portable data collection units. Results were analyzedby proprietary software (Medtronics). Nineteen of the 174 (12%) had normal results, and constitute the patient cohort for this retrospective study. Clinical follow-up data were obtained from a clinical outcomes database or by telephone interview. A standardized symptom assessment tool was administered as part of follow-up in all patients. Ftesu/ts:19 patients had normal 24 hr pH studies and GERD symptoms. Meanfollow up was 16.3 months (range 4-26). Nine patients (47%) had subsequent surgery: three for gastric problems, one Heller myotomy for achaiasia, and five antireflux surgeries. Six patients were maintained on medical therapy. Four (21%) patients had symptom resolution without intervention. Of four patients having non-antireflux surgery, three were improved and one was worse. Of five patients having antirctlux surgery, two (40%) were improved, two have continued foregut complains and one was worse. Conclusion: Normal 24 hr pH studies are found on a minodly of patients referred for antireflux surgery. Many of these patients are found to have pathology other than gastroesophageatreflux disease as an explanation for their symptoms. Patients who do go on to have antireflux surgery have poor clinical outcomes compared to patients who have abnormal pH test results. 2430 Long Myotomy with Antireflux Operation for Esophageal Spastic Disorders Dimitrios Nastos,, Long-Qi Chen,, Pasquale Ferraro,, Raymond Taillefer, Andre C. Duranceau,, Ctr Hospitalier Univesifaire de Montreal, Montreal Canada OBJECTIVE: Report the long-term subjective and objective results of esophageal myctomy and fundoplicatlon by thoracotomy Jn treating esophagealspastic disorders. METHODS:From 1977 to 1995, 16 patients with esophageal spastic disorders underwent a myotomy with an added partial (12) or total (4) fundoplication. The median follow-up is 6 years. Assessments include clinical evaluation, esophagogram, radionuclide emptying, manometry, 24-hour pH, and endoscopy. From global results, patients with pure spastic disorders (8) were compared to patients with spastic disorders and an epiphrenic diverticulum (8). RESULTS: There is no mortality and minimal morbidity. Results are summarized in table 1. Failure (Persistant symptoms, reflux damage or obstruction to emptying) was observed in 1 patient with a diverticulum at 9 years and in 4 patients with pure spastic disorder at 2, 3, 6, and 8 years after the operation (Log-rank test, p=0.029). CONCLUSIONS: Long myotomy and fundoplication for spastic disorders: • Reduces dysphagia and chest pain;. Reduces distal peak contraction pressures and peristalsis; . Decreases LES pressures. • Improves LES relaxation.. Spastic disorder patients with a diverticulum, when compared to pure spastic disorder patients, show better clinical results, better esophageal function.
2431 The Anatomy of Paraesophageal Hernia. Implications for Surgery baniela Molena, Marco G. Patti, Karen Whang, Plero M. Fisichella, David Suh, Hiro Yamada, Silvana Perretta. Lawrence W. Way, UCSF, San Francisco, CA Background: Paraesophageal hiatal hernia (PEH) is defined as herniation of the stomach alongside a fixed or relatively fixed gastroesophageal junction. Although usually referred to as if if were a single entity, PEH actually includes a wide variety of anatomic configurations, a phenomenon that has not been well studied. We analyzed80 patients with PEH to determine the spectrum of anatomic variation and how major differences affect the clinical findings, diagnosis, and operative treatment. Methods: For each patient the following were analyzed: hadom swallow, endoscopic findings, manometry, pH monitoring, and the videotape of the operation. There were 80 patients (38 women and 42 men, median age 69 years), who had been symptomatic for an average of 60 months. Symptoms included heartburn (56%), regurgitation (41%), and manifestations of obstruction (44%). Median follow up was 14 months. Results: The amount of herniated stomach was seen to be greater at surgery than on the radiographs in 27% of cases; in the rest, the two were similar. There were 2 types of hernia sac: type A (40 pts) was a mobile diaphragm attached to the esophageal hiatus; these hernias ware completely reducible. Type B (40 pts) was deeper and formed the walls of a fixed mediastinal cavity; in these cases the herniated stomach was incompletely reducible until the sac was disconnected from the stomach and distal esophagus. Efforts were rarely (8%) made to totally excise these sacs. Reconstruction involved reducing the size of the hiatus and a fundoplication. Group A Group 8 p value Prs op heartburn (% pts)70 37 <0.05 Entire stomach herniated (% pts) 8 35 <0.05 Width of esophageal hiatus (cm) 4_+15_+2 <0.05 Excision of sac (% pts) 100 8 <0.05 Duration of operation (min) 168_+49 193_+67 0.06 Post op asymptomatic pts (%)79 94 NS Conclusions:Thesedata show that: 1) radiographs underestimated the size of the hernia in 27% of pts; 2) in 50% of pts the hernia sac was attached to mediastinal structures and was not reducible. In the latter group: a) heartburn was less common; b) the entire stomach was often herniated; c) the esophageal hiatus was larger, and d) the sac was transected at the level of the diaphragm but not excised. The clinical outcome was similar in the 2 groups. Complete excision of the hernia sac in group B was dearly unnecessary; no unsatisfactory results were attributable to its retention. 2432 Laparessople Repair of Pareesophageal Hernia Is Subject to Recurrence but Rarely Requires Rsoperetion Samer G. Mattar, Stephen P. Bowers, W Nan Bradshaw, Kathy D. Galloway, Maria L. Terry, John G. Hunter, C Daniel Smith, Emory Univ, Atlanta, GA Background: Although laparnscopic repair of paraesophagealhernias (LPH) results in effective symptomatic relief, there is concern regarding the rate of hiatal hernia recurrence; especially asymptoma~c recurrence. Method: We reviewed our experiencewith 136 patients undergoing LPH repair over a six year period. All patients beyond 1 year of LPH in whom an esophogram was obtained were identified. Concurrently, symptom scores (SS) for chest pain, heartburn, regurgitation, and dysphagia were obtained and the highest score reported by the patient was tabulated (0 = no symptoms; I = mild symptoms; 2 = moderate; and 3 = severe symptoms). Additionally, a measure of patient satisfaction, frequency of medication use, and the need for extraordinary physician visits or hospitalizations were documented. Results: In 42 patients, a barium swallow at a mean of 45 months (range 20 - 82 months) after LPH repair were available or obtained. There were 14 males and 20 females with an average age of 63.2 years (range 42 90 years). Thirty-eight patients completed symptom questionnaires with 90% expressing satisfaction with the results of the operation. Twenty-eight patients (74%) were off medications and 5 (13%) had visited a physician with related symptoms. Fourteen patients (33%) had an anatomic recurrence on esophogram, but only 3 of these patients reported more than mild symptoms. The symptom scores of those with anatomic recurrence were not significantly different than in those without recurrence (see graph). Only one patient with recurrence has undergone reoperation for postprandial pain. Conclusion: At long-term follow up, anatomic recurrence following LPH repair is high. Many of these are asymptomatic and of questionable clinicat significance. The relevanceof recurrent asymptomatic paraesophageal hernia remains unclear, and at this time it is difficult to recommend reoperation for these patients.
Operative Results for Esophageal Spastic Disorders ~
Observation Dysphagia Chest Pain Stasis at 2 Min. (%) Body Contraction (mmHg) Body Peristalsis (%) LES Gradient (mmHg) LES Relaxation (%) Acid Exposure(time%) Esophagitls / Ulcer
Before Operation Dirt(*) Dirt(-) 7 6 26.1 70,1 61.4 23.1 95.9 10.0 0
8 6 39.0 78.8 36.3 22.9 63.9 0.0 t
After Operation DM(+) Dt~t(-)
P Value
1 0 20.2 35.0 30.0 8.2 100.0 6.3 2
=0.002 =0.021 >0.25 <0.001 =0.016 <0.001 =0.005 >0.25 >0.25
3 3 44.6 33.4 18.8 6.9 100.0 11.5 2
0 0 1 Severity of ~
2
3 prom
"Not sionFscant
2433
A Comparison Between Subjective and Objective Outcomes of Laparessopic Hofler Myofomy and Toupof Fundoplication for Achalasia Robert E. Glasgow, Yashodhan S. Khajanchee, David R. Urbach, Paul D. Hansen, Lee L. Swanstrom, Legacy Health System, Portland, OR Objective: Laparoscopic cardiomyotomy is an effective treatment for the symptoms of achalasia. However, no studies have evaluated how improvements in symptoms correlate to the results of esophagealfunction tests. The aim of this study was to compare patient's subjective outcomes to the results of postoperative esophagealfunction tests after laparoscopic treatment of achalasia. Methods: This was a review of a prospectively maintained database of patients who had a laparoscopic Heller myotomy with Toupet fundoplication for achalasia at a tertiary referral center. Data included pre- and post-operative assessment of quality of life, patient symptoms, esophageal manometry, and 24-hr pH studies. Results: Complete quality of life and objective outcome data were available for 17 of 42 patients who had surgery between
A-478