Manometric assessment of Heller-Dor operation for esophageal achalasia.

BACKGROUND/AIMS: The aim of this study was to evaluate changes occurring in esophageal motility through a systematic manometric study performed before, during and after Heller-Dor operation (8) and to correlate the possible post-operative symptoms to the manometric and pH-recording patterns detected, in order to provide useful elements that may optimize surgical therapy for esophageal achalasia. MATERIALS AND METHODS: Between January 1981 and January 1991, 27 patients affected by esophageal achalasia underwent Heller's operation with Dor's anti-reflux procedure. Assessment involved clinical, radiological and manometric investigations. RESULTS: Intra-operative manometry was performed on 11 patients, in whom LES pressure reached values lower than 5 mmHg. Post-operative control, performed 2 years after operation on 25 patients, showed the complete absence of dysphagia in 22 (88%) and occasional dysphagia in 3 (12%). Post-operative manometry in all the patients showed a decreased LES resting pressure (from 32.6 to 7.2 mmHg, p < 0.001), LES residual pressure (from 16.4 to 5.0 mmHg, p < 0.001) and esophageal tone (from 4.8 to -3.5 mmHg, p < 0.001). Patients free of dysphagia presented LES basal and residual pressures lower than the other patients (6.2 and 4.6 vs 15.1 and 7.7 mmHg respectively, p < 0.01 and p < 0.05). 24-hour-esophageal pH-metry showed pathologic reflux in 3 patients with reflux symptoms and in 1 without symptoms. All had LES basal and residual pressures equivalent to non refluxing patients (5.7 and 5.0 vs 7.5 and respectively 4.9 mmHg, p = n.s. and p = n.s.). On the contrary, a difference was found in abdominal LES length between the two groups (0.5 vs 1.6 cm, p < 0.01). Patients with intra-operative manometry presented a lower incidence of residual dysphagia than patients without it (0% vs 21.5%), but a higher incidence of reflux (18.2% vs 7.3%). CONCLUSION: Heller-Dor operation induces a definitive disappearance of dysphagia when it is complete in depth and length. Prevention of gastro-esophageal reflux requires the preservation of a sufficiently long portion of esophagus in the abdomen.

[Intraoperative manometry during functional surgery of the esophagus]. / La manometria intraoperatoria nella chirurgia funzionale dell'esofago.

The purpose of this investigation was to verify the suitability of intra-operative manometry in the course of functional surgery of the esophagus, especially with reference to the results obtained in terms of sphincter functionality, related to the overall changes in symptoms and pH-metry. The practice disclosed herein refers solely to the Heller-Dor operation for esophageal achalasia and to the Nissen Rossetti operation for gastro-esophageal reflux. The promising results obtained using this method to achieve a complete myotomy during Heller's operation, in our opinion testify in favor of its usefulness with this type of surgical procedure. On the contrary, for preparing a fundoplication we feel that method is of orientative value only, since there is no correspondence between the values obtained at the end of the fundoplication and those recorded 18 to 24 months after surgery. The predictive nature of the examination is thus denied.

[Esophago-gastro-intestinal manometry: study methods and potential clinical applications]. / La manometria esofago-gastro-intestinale: metodo di studio e possibili applicazioni cliniche.

Simultaneous manometry of the esophagus and stomach and/or of the jejunum is an unconventional investigative maneuver that, for the most part, maintains features typical of a physiopathologic inquiry rather than those of clinical testing. This method contemplates the radiologically guided installation of an 8-channel probe, with measuring sites spaced 5 cm one from the other. The proximal measuring site is generally positioned at the lower esophageal sphincter (LES), while the remaining are chosen in order to attain 3 or 4 tips in the stomach and 2 or 3 tips in the duodenum (in the jejunum following stomach resection). The examination lasts approximately 6 hours during digestive rest and 2 hours after administration of a solid test meal. Hence it is possible to evaluate the functional changes at the LES with reference to the phases of the Intestinal Migrating Motor Complex, as well as the possible adverse reactions of poor gastroduodenal motility on the sphincter, both during digestive rest and after a meal. The examination, besides the obvious interest of physiopathological nature, in the Authors' experience, has made it possible to attain quite helpful functional clarifications in identifying the clinical picture of patients with complex esophageal and gastric symptoms, reduced gastric emptying, whether or not associated with mixed reflux in the esophagus. This evaluation was found to be useful both in patients with an "intact" stomach and in those who experienced surgery of the initial portion of the digestive tract.

[Sphincter function after low anterior resection of the rectum]. / La funzionalità sfinteriale dopo resezione anteriore bassa del retto.

Until a few years ago, surgical technique and the age-old convictions of oncological radicality rejected very low rectal resections for cancer, particularly as the problem of postoperative incontinence did not exist. Currently, on the other hand, with the advent of mechanical staplers, the surgeon attempts increasingly to reconcile the possibility of using new sphincter-saving techniques with adequate oncological radicality, backed by accurate pre- and intraoperative staging. It is underlined that postoperative assessment of sphincter function in all its aspects, both clinical and instrumental, may be useful for the purpose of clarifying what anatomical structures should really be saved, delegated to retaining sphincter sensitivity and reflexes, so improving the functional results of operations. In addition, the almost rare identification of manifest or latent postoperative incontinence would make it possible to intervene in operated patients, for example by functional reeducation techniques as happens in the relatively recent biofeedback techniques.

[Functional evaluation of gastric and jejunal transplant after esophagectomy]. / Valutazione funzionale dell'impianto gastrico e digiunale dopo esofagectomia.

Increased survival rates after esophagectomy for cancer and the significant development of forms of therapy alternate to surgical treatment, today compel surgeons to devote far more attention to the methods will pursue in reconstructing the alimentary tract after removal of the esophagus. Nine patients with esophago-gastro-plasty and 6 with esophago-jejuno-plasty, after esophagectomy for cancer, experienced a study of esophageal function. The study consisted of extended esophago-gastro-intestinal manometry, performed both while at digestive rest after a semi-solid meal, and of scintigraphy, performed to investigate gastric emptying. 24-hours esophago-gastric pH-metry was also executed, along with basal and stimulated acidity metering in, patients with gastroplasty. The fundamental alterations, from the manometric point of view in esophago-gastro-plasty, are the absence of phase III of the IMMC interdigestively and in the absence of a motor response when ingesting the meal. Scintigraphically this coincides with a fundamental alteration of gastric tubule emptying. On the contrary, in jejunoplasty the jejunal loop retains adequate motility, both during the interdigestive phase and following a meal. Such strikingly diverse motor behavior explains the higher quality of life of patients with jejunoplasty versus patients in whom the stomach is used to substitute for the esophagus.

[Computerized analysis of esophageal manometry]. / Analisi computerizzata della manometria esofagea.

Computerized analysis of esophageal manometry should consider the following objectives: a) objectivation of data acquisition; b) precision in calculating the various parameters; c) speed of analysis; d) an easy-to-read and promptly understandable graphic display of the manometric data; e) computation of new parameters capable of defining normal and pathologic function. It is with these objectives in mind that we launched our research project. Five normal subjects and 10 patients, of whom 5 presented esophageal achalasia and 5 gastroesophageal reflux disease, underwent computerized esophageal manometry and were evaluated on the basis of both traditional and innovative parameters, of our own inception. Among the various indexes tested, the "Esophageal transport" parameter, calculated as the ratio of momentum (dp*dT) over speed of propagation of the esophageal contractions, gave rise to particular interest. In our opinion, this parameter can be used as an index of the dynamic function of the organ.

[Rationale of the surgical treatment of duodenogastroesophageal reflux]. / Rationale della terapia chirurgica del reflusso duodeno-gastro-esofageo.

Patients with "intact stomach" but more frequently patients operated on the esophago-gastric junction, vagus, stomach, can develope a duodeno-gastro-esophageal reflux syndrome. We propose a rationale of the surgical treatment based upon our experiences during these last 15 years in functional studies, mainly manometric, of the entire esophago-gastro-duodeno-jejunal tract. Patients with an intect stomach: a non-demolitive ("functional") technique may be proposed each time a correctable alteration of the gastro-duodenal motility is found during the manometric study. Such interventions are the association between a fundoplicatio and Extramucose Duodenal Myotomy, Duodenal Switch, Pylorectomy. On the other side when the motor alteration is too severe and uncorrectable (Prostigmine-Test) or in presence of morphological, nearly always pre-cancerous, alterations we can perform only demolitive procedures. The intervention preferred by the AA is Total Duodenal Diversion. Patients with operated stomach: the different possible surgical procedures and their results are strictly related to the intervention preceding the onset of the reflux syndrome. In fact the better results are related to bad management and to post-operative complications during the previous intervention, rather than to an ignored pre-existing motor disorder. The Total Duodenal Diversion seems to be the must reliable also in this case, both initially and in the operated patients (conversion from Billroth II to Roux). Between 1978 and 1993 we observed 604 refluxers at 24-hour pH-recording, 209 of them with alkaline or mixed gastro-esophageal reflux. On the basis of the morphologic and functional diagnostic evaluation 64 patients underwent surgery, 36 with intact stomach and 28 with operated stomach. Good results (disappearance of esophageal symptoms and improving in gastric symptoms) were obtained in 30 (83.3%) patients with intact stomach and in 25 (89.3%) with operated stomach.

[Heller's intervention for esophageal achalasia]. / L'intervento di Heller per acalasia esofagea.

From 1962 to 1992 sixtythree patients with esophageal achalasia underwent primary surgical treatment. The intervention performed was a cardiomiotomy according to Heller in 20 patients (Group A), a cardiomiotomy according to Heller with anti-reflux procedure according to Lortat-Jacob in 12 patients (Group B), a cardiomiotomy according to Heller with fundoplicatio according to Dor in 31 patients (Group C). Preoperative study was performed by radiological evaluation in patients of Group A, while patients of Group B and Group C were submitted also to endoscopy and esophageal manometry. Postoperative evaluation in Group A was performed by clinical and endoscopical controls, while in Groups B and C by clinical and radiological studies 6 months after the intervention and by clinical and endoscopical studies every two years. During the early two years after operation a functional study (esophageal manometry and esophagogastric pH-monitoring) was performed. The follow-up was complete for 13 patients of Group A, 10 patients of Group B and 28 patients of Group C. Good results (complete absence or slight dysphagia) have been obtained in 70% of Group A, in 90% of Group B and 90% of Group C. Esophageal manometry found a decrease of both resting pressure and length in every patient in Groups B and C. Gastro-esophageal reflux symptoms were found in 15% of Group A, 20% of Group B and 11% of Group C. A various degree of esophagitis was found by endoscopy in 40% of Group A, 50% of Group B and 18% of Group C. Esophago-gastric pH-monitoring, performed in Group C patients, showed pathologic refluxes in 22% of the subjects. The clinical and functional study demonstrates that Heller's cardiomiotomy, in the way it is performed nowadays (complete miotomy over 7 cm of the esophagus and 3-4 cm of the stomach), allows the complete disappearance of dysphagia. On the other side the anti-reflux procedures till now performed (including the 180 degrees fundoplicatio according to Dor) are not effective enough to avoid post-operative gastro-esophageal reflux.

[An application of mini-invasive surface surgery: the thyroid]. / Un'applicazione della chirurgia mini-invasiva di superficie: la tiroide.

Since its introduction, minimally-invasive surgery has been applied to structures contained in natural cavities such as abdomen, thorax and articulations. At present, its application to surface zones (plastic surgery) gives good results. For this reason, we tried to examine thyroid area through a video-assisted access in a 32 years old woman presenting a nodule with a diameter of about 1 cm, localized in the left parahistmic thyroid area. This approach allowed a good vision of the operative field. In our opinion, this technique could be useful especially to formulate the histological diagnosis of small thyroid nodules for whom the standard surgical biopsy should be considered too invasive.