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1.
Surg Endosc ; 31(9): 3510-3518, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28039638

RESUMO

BACKGROUND: Esophageal achalasia can be classified on the grounds of three distinct manometric patterns that correlate well with final outcome after laparoscopic Heller-Dor myotomy (LHM). No analytical data are available, however, on the postoperative picture and its possible correlation with final outcome. The aims of this study were: (a) to investigate whether manometric patterns change after LHM for achalasia; (b) to ascertain whether postoperative patterns and/or changes can predict final outcome; and (c) to test the hypothesis that the three known patterns represent different stages in the evolution of the disease. METHODS: During the study period, we prospectively enlisted 206 consecutive achalasia patients who were assessed using high-resolution manometry (HRM) before undergoing LHM. Symptoms were scored using a detailed questionnaire. Barium swallow, endoscopy and HRM were performed, before and again 6 months after surgery. RESULTS: Preoperative HRM revealed the three known patterns with statistically different esophageal diameters (pattern I having the largest), and patients with pattern I had the highest symptom scores. The surgical treatment failed in 10 cases (4.9%). The only predictor of final outcome was the preoperative manometric pattern (p = 0.01). All patients with pattern I preoperatively had the same pattern afterward, whereas nearly 50% of patients with pattern III before LHM had patterns I or II after surgery. There were no cases showing the opposite trend. CONCLUSIONS: Neither a change of manometric pattern after surgery nor a patient's postoperative pattern was a predictor of final outcome, whereas preoperative pattern confirmed its prognostic significance. The three manometric patterns distinguishable in achalasia may represent different stages in the disease's evolution, pattern III and pattern I coinciding with the early and final stages of the disease, respectively.


Assuntos
Acalasia Esofágica/cirurgia , Motilidade Gastrointestinal/fisiologia , Miotomia de Heller , Laparoscopia , Adulto , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/fisiopatologia , Feminino , Seguimentos , Miotomia de Heller/métodos , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
2.
J Gastrointest Surg ; 21(1): 17-22, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27364725

RESUMO

INTRODUCTION: The most common complication after laparoscopic Heller-Dor (LHD) is gastroesophageal reflux disease (GERD). The present study aimed (a) to analyze the true incidence of postoperative reflux by objectively assessing a large group of LHD patients and (b) to see whether the presence of typical GERD symptoms correlates with the real incidence of postoperative reflux. METHODS: After LHD, patients were assessed by means of a symptom score, endoscopy, esophageal manometry, and 24-h pH monitoring. Patients were assigned to three groups: those did not accept to perform 24-h pH monitoring (group NP); those with normal postoperative pH findings (group A); and those with pathological postoperative acid exposure (group B). RESULTS: Four hundred sixty-three of the 806 LHD patients agreed to undergo follow-up 24-h pH monitoring. Normal pH findings were seen in 423 patients (group A, 91.4 %), while 40 (8.6 %) had a pathological acid exposure (group B). The median symptom scores were similar: 3.0 (IQR 0-8) in group A and 6.0 (IQR 0-10) in group B (p = 0.29). At endoscopy, the percentage of esophagitis was also similar (11 % in group A, 19 % in group B; p = 0.28). CONCLUSIONS: This study demonstrated that, after LHD was performed by experienced surgeons, the true incidence of postoperative GERD is very low. The incidence of this possible complication should be assessed by pH monitoring because endoscopic findings and symptoms may be misleading.


Assuntos
Acalasia Esofágica/cirurgia , Fundoplicatura/efeitos adversos , Refluxo Gastroesofágico/diagnóstico , Adulto , Feminino , Fundoplicatura/métodos , Refluxo Gastroesofágico/etiologia , Refluxo Gastroesofágico/cirurgia , Humanos , Incidência , Laparoscopia , Masculino , Manometria , Pessoa de Meia-Idade
3.
J Gastrointest Surg ; 20(1): 125-31; discussion 131, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26519153

RESUMO

BACKGROUND: A new high-resolution manometry (HRM) parameter, the integrated relaxation pressure (IRP), has been proposed for the assessment of esophageal-gastric junction (EGJ) relaxation. Our aim was to assess the effect of Heller myotomy on IRP in achalasia patients. METHODS: We prospectively collected data on achalasia patients who underwent HRM between 2009-2014. Barium swallow was used to assess esophageal diameter and shape. Manometric diagnoses were performed by using the Chicago Classification v3. All patients with a confirmed diagnosis of achalasia were treated surgically with Heller Myotomy RESULTS: One hundred thirty-nine consecutive achalasia patients (M:F = 72:67) represented the study population. All the patients had 100% simultaneous waves but 11 had an IRP < 15 mmHg. At median follow-up of 28 months, the median of IRP was significantly lower after surgery (27.4 [IQR 20.4-35] vs 7.1 [IQR 4.4-9.8]; p < 0.001), and so were the lower esophageal sphincter (LES) resting pressure (27 [IQR 18-33] vs 6 [IQR 3-11]; p < 0.001). At univariate analysis, IRP correlated with the gender, LES resting residual pressure, and dysphagia score. CONCLUSIONS: This is the first study to have examined the role of IRP in achalasia, and how it changes after surgical treatment. An increased preoperative IRP correlated directly with a more severe dysphagia. The IRP was restored to normal by Heller myotomy.


Assuntos
Acalasia Esofágica/fisiopatologia , Acalasia Esofágica/cirurgia , Junção Esofagogástrica/fisiopatologia , Esôfago/cirurgia , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/cirurgia , Acalasia Esofágica/diagnóstico , Feminino , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Pressão
4.
J Gastrointest Surg ; 20(12): 1923-1930, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27688213

RESUMO

BACKGROUND: The aims of the study were (a) to examine the final outcome in patients experiencing accidental mucosal perforation during laparoscopic Heller myotomy with Dor fundoplication (LHD) and (b) to evaluate whether perforation episodes might influence the way in which surgeons subsequently approached the LHD procedure. METHODS: We studied all consecutive patients that underwent LHD between 1992 and 2015. Patients were divided into two main groups: those who experienced an intraoperative mucosal perforation (group P) and those whose LHD was uneventful (group NP). Two additional groups were compared: group A, which consisted of patients operated by a given surgeon immediately before a perforation episode occurred, and group B, which included those operated immediately afterwards. RESULTS: Eight hundred seventy-five patients underwent LHD; a mucosal perforation was detected in 25 patients (2.9 %), which was found unrelated to patients' symptom's score and age, radiological stage, manometric pattern, or the surgeon's experience. The median postoperative symptom score was similar for the two groups as the failure rate: 92 failures in group NP (10.8 %) and 4 in group P (16 %) (p = 0.34); moreover, symptoms recurred in 2 patients of group A (10 %) and 3 patients of group B (15 %) (p = 0.9). CONCLUSIONS: Accidental perforation during LHD is infrequent and impossible to predict on the grounds of preoperative therapy or the surgeon's personal experience. Despite a longer surgical procedure and hospital stay, the outcome of LHD is much the same as for patients undergoing uneventful myotomy. A recent mucosal perforation does not influence the surgeon's subsequent performance.


Assuntos
Acalasia Esofágica/cirurgia , Perfuração Esofágica/etiologia , Miotomia de Heller/efeitos adversos , Complicações Intraoperatórias/etiologia , Laparoscopia/efeitos adversos , Mucosa/lesões , Adulto , Idoso , Competência Clínica , Feminino , Fundoplicatura/efeitos adversos , Fundoplicatura/métodos , Miotomia de Heller/métodos , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Recidiva , Avaliação de Sintomas , Resultado do Tratamento
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