Laparoscopic myotomy vs endoscopic dilation in the treatment of achalasia.

BACKGROUND: The aim of this study was to compare the results obtained in 14 patients with achalasia who underwent laparoscopic Heller's myotomy and Dor's fundoplication with those of 16 patients who had endoscopic dilation. METHODS: The diagnosis of achalasia was confirmed by manometry, endoscopy, and barium swallow. Esophageal symptoms were quantified before and after treatment using a clinical scale. Six patients had had endoscopic dilation prior to surgery. RESULTS: Before treatment, the patients in the surgical group complained of more severe dysphagia (median, 5; range, 0-5 vs median 4; range, 3-5) and chest pain (median, 3; range, 0-5 vs median, 1.5; range, 0-5), but both groups were comparable with respect to regurgitation, heartburn, and manometric results. Both groups achieved significant clinical improvement. The severity score decreased from 5 (range, 0-5) to 1 (range, 0-3) (p < 0.05) for dysphagia to solids in the laparoscopic group and from 4 (range, 3-5) to 1 (range, 0-5) (p < 0.05) in the endoscopic group. Lower esophageal sphincter (LES) basal pressure decreased significantly in both groups (from 29.3 to 11.8 mmHg in the laparoscopic group and from 28.9 to 16.5 mmHg in the endoscopic group). After treatment, there were no significant clinical differences between the two groups. Two patients in the surgical group were converted to open surgery. CONCLUSION: Laparoscopic myotomy is as save and effective as endoscopic dilation in the treatment of achalasia.

Long-term survival in advanced ovarian cancer after cytoreduction and chemotherapy treatment.

Ninety-one patients with untreated epithelial ovarian cancer, stages III and IV, were treated according to a therapeutic protocol including cytoreductive surgery whenever possible, chemotherapy with CAP (cyclophosphamide, doxorubicin, and cisplatin) and second-look laparotomy for those patients achieving a clinical remission. Optimal cytoreductive surgery (residual tumor < 2 cm) was not performed in 66 patients (72.5%). A negative second-look laparotomy demonstrated a pathological complete remission in 26 patients (28.5%). After a median follow-up of 80 months, the disease-free survival is 19.7% (18 of 91 patients). Median survival was greater in optimal cytoreductive surgery patients (47 months) than in the rest of the patients (22 months) (P = 0.0000). Survival was also better in pathological complete remission patients (46 months) than in partial remission (PR) or no response patients (22 months) (P = 0.0001). Optimal secondary cytoreductive surgery was possible in 11 patients in PR after chemotherapy. Survival in this group was similar to that of pathological complete remission cases. Currently, 53% of patients with initial residual tumor < 2 cm and complete response at second-look remain free of disease. In a multivariate analysis, residual tumor > 2 cm and stage IV disease were the most significant prognostic factors. The same analysis indicates that response to chemotherapy at second laparotomy is not an independent prognostic factor. In conclusion, our study indicates that the two most important prognostic factors in advanced ovarian carcinoma are the extent of the initial surgery and stage.