Chest pain before and after laparoscopic cardiomyotomy for achalasia.

BACKGROUND: Laparoscopic cardiomyotomy usually achieves a good outcome for patients with achalasia. However, some patients continue to experience chest pain after surgery, even when symptoms such as dysphagia have resolved. In this study, we quantified chest pain and the impact of myotomy on this symptom. METHODS: In 108 patients who underwent laparoscopic cardiomyotomy, chest pain was assessed before and after surgery. A standardized questionnaire evaluated chest pain, other symptoms including odynophagia, dysphagia and regurgitation, and overall satisfaction with the outcome of surgery. RESULTS: The proportion of patients reporting chest pain was similar across all age groups and genders before and after surgery. Sixty-five (60.2%) patients reported some chest pain after surgery. Of these, 47 (72.3%) also reported dysphagia, 9 (13.8%) odynophagia and 23 (35.4%) acid regurgitation (62.3%, 11.6% and 21.7% before surgery). Following surgery, there was a significant reduction in the frequency of chest pain (daily chest pain declined from 26.9% to 5.6%). CONCLUSIONS: Chest pain is common before and after cardiomyotomy for achalasia, and it is frequently associated with dysphagia. Whilst it is less problematic after surgery, it persists in many patients. This information should be provided to individuals considering surgery for achalasia.

Five-year follow-up of a multicenter, double-blind randomized clinical trial of laparoscopic Nissen vs anterior 90 degrees partial fundoplication.

HYPOTHESIS: Laparoscopic 90 degrees anterior partial fundoplication for gastroesophageal reflux disease achieves equivalent results to laparoscopic Nissen fundoplication. DESIGN: A multicenter, prospective, double-blind randomized clinical trial with a minimum of 5 years' follow-up. SETTING: Nine university teaching hospitals in 6 major cities throughout Australia and New Zealand. PARTICIPANTS: One hundred twelve patients undergoing primary antireflux surgery were randomized to undergo either laparoscopic Nissen fundoplication (52 patients) or anterior 90 degrees partial fundoplication (60 patients). INTERVENTIONS: Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication. MAIN OUTCOME MEASURES: Blinded assessment at 1 and 5 years' follow-up of clinical outcome for postoperative heartburn, dysphagia, gas-related symptoms, and satisfaction with the surgical outcome. Analog scales ranging from 0 to 10 were used to assess symptom severity. RESULTS: Ninety-seven patients underwent follow-up at 5 years. Three others died during follow-up, 4 refused follow-up, and 8 were lost to follow-up; 89% remained at 5-years' follow-up. At 5 years' follow-up, mean analog scores for heartburn were 2.2 for anterior fundoplication vs 0.9 for Nissen fundoplication (P=.003). There were no significant differences between the groups for dysphagia scores. The mean score for outcome satisfaction was 7.1 after anterior fundoplication vs 8.1 after Nissen fundoplication (P=.18). Eighty-eight percent reported a good or excellent outcome following Nissen fundoplication vs 77% following anterior fundoplication. CONCLUSIONS: Laparoscopic Nissen and anterior 90 degrees partial fundoplication achieve similar levels of patient satisfaction at 5 years' follow-up, with similar adverse effect profiles. However, at 5 years' follow-up, laparoscopic Nissen fundoplication achieves superior control of reflux symptoms. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Register Identifier: ACTRN12607000298415.

Laparoscopic cardiomyotomy for achalasia: clinical outcomes beyond 5 years.

BACKGROUND: Laparoscopic cardiomyotomy is the most common surgical procedure for the treatment of achalasia, although few reports describe long-term surgical outcomes. METHODS: The outcomes for 155 patients who underwent a laparoscopic cardiomyotomy with anterior partial fundoplication more than 5 years ago (July 1992 to May 2004) were determined. Patients were followed prospectively at yearly time points using a structured questionnaire which evaluated symptoms of dysphagia, reflux, side-effects, and overall satisfaction with the clinical outcome. RESULTS: Clinical data were available for 125 patients. Thirteen patients died within 5 years of surgery, four were unable to complete the questionnaire, and one developed esophageal squamous cell carcinoma. Nine patients were lost to follow-up, and three would not answer the questionnaire (92.2% late follow-up). Postoperative dysphagia, odynophagia, chest pain, and heartburn was significantly improved at 1 year, 5 years, and late (5+ years) follow-up, with outcomes stable beyond 12 months. Seventy-seven percent of patients reported a good or excellent result (minimal or no symptoms) at 5 years and 73% at late follow-up. At late follow-up, 90% considered they had made the correct decision to undergo surgery. CONCLUSIONS: At minimum 5 years follow-up, laparoscopic cardiomyotomy for achalasia achieves effective and durable relief of symptoms, and most patients are satisfied with the outcome.

Minimally invasive versus open esophagectomy for patients with esophageal cancer.

BACKGROUND: Minimally invasive esophagectomy (MIE) compared with open esophagectomy (OE) has been shown to have clinical advantages, but selection bias is present. METHODS: All patients undergoing MIE or OE for cancer between 1999 and 2007 were eligible for analysis. To minimize selection bias, only patients who also met the selection criteria for the thoracoscopic approach were included in the open esophagectomy group. RESULTS: Fifty-six patients underwent MIE and 98 OE. No significant differences in demographics or pathologic data between groups occurred, with the exception of thoracic epidural analgesia (OE 98%, MIE 71.1%, p < 0.001), and neoadjuvant treatment (OE 50.5%, MIE 71.4%, p = 0.016). Morbidity and in-hospital death were not significantly different. Duration of surgery was longer in MIE (250 vs 209 minutes, p < 0.001) and blood loss less (320 mL vs 857 mL, p < 0.001). Intensive care unit stay was shorter in MIE (3.0 vs 6.8 days, p = 0.022). The relative risk (RR) for in-hospital death was 0.57 (p = 0.475) if the patients underwent MIE. After adjusting for thoracic epidural analgesia, the RR was 0.29 (p = 0.213) for the MIE group. The RR for surgical morbidity was 1.47 (p = 0.154) for patients undergoing MIE. Neoadjuvant treatment increased the RR for surgical morbidity to 1.78 (p = 0.028). No difference between the two groups concerning survival occurred. CONCLUSIONS: The MIE is comparable with the OE. In MIE, neoadjuvant treatment increased the risk of surgical morbidity. Thoracic epidural analgesia in MIE reduced the risk of in-hospital death and should be considered for all patients undergoing esophagectomy.

Defining a learning curve for laparoscopic cardiomyotomy.

BACKGROUND: This study was designed to determine whether there is a learning curve for laparoscopic cardiomyotomy for the treatment of achalasia. METHODS: All patients who underwent a primary laparoscopic cardiomyotomy for achalasia between 1992 and 2006 in our hospitals were identified from a prospective database. The institutional and the individual surgeon's learning experiences were assessed based on operative and clinical outcome parameters. The outcomes of cardiomyotomies performed by consultant surgeons versus supervised trainees also were compared. RESULTS: A total of 186 patients met the inclusion criteria; 144 procedures were undertaken by consultant surgeons and 42 by a surgical trainee. The length of operation decreased after the first ten cases in both the institutional and each individual experience. The rate of conversion to open surgery also was significantly higher in the first 20 cases performed. Intraoperative complications, overall satisfaction with the outcome, reoperation rate, and postoperative dysphagia were not associated with the institutional or the surgeon's operative experience. Although the length of the operation was greater for surgical trainees (93 versus 79 minutes; p < 0.01), no differences in outcome between the operations performed by consultant surgeons and surgical trainees were detected. CONCLUSION: An institutional (20 cases) and an individual (10 cases) learning curve for laparoscopic cardiomyotomy for achalasia can be defined. The clinical outcome for laparoscopic cardiomyotomy does not differ between supervised surgical trainees and consultant surgeons.

Laparoscopic antireflux surgery in the elderly.

BACKGROUND: Both gastroesophageal reflux and paraesophageal hernias are more common in the elderly, but often these patients are not referred for surgery because of their age. In this study we determined the outcome for laparoscopic antireflux surgery in patients aged 70 years or older, in whom either symptoms of gastroesophageal reflux or a large paraesophageal hernia was the indication for surgery. METHOD: From a prospectively maintained clinical database of patients undergoing laparoscopic antireflux surgery, all patients aged 70 years or older were identified and their outcome was determined. RESULTS: Two hundred ten patients were identified. In 129 a large paraesophageal hiatus hernia was the primary indication for surgery, and in 81 patients the indication was reflux. Mean operation time was significantly longer in patients undergoing surgery for a large hiatus hernia (109 vs. 72 min), and conversion to open surgery was required more often (11.6% vs. 4.4%), compared to patients with reflux alone. Follow-up information was available for 95% of patients. Postoperative symptom scores for heartburn and dysphagia improved significantly and patients' satisfaction with surgery was high. CONCLUSION: Laparoscopic antireflux surgery in patients aged 70 years or older has a satisfactory clinical outcome. Elderly patients should not be refused laparoscopic antireflux surgery only because of their age.

Quality of life following laparoscopic anterior 90 degrees versus Nissen fundoplication: results from a multicenter randomized trial.

BACKGROUND: The short-term clinical outcomes from a multicenter prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees partial fundoplication have been reported previously. These demonstrated a high level of satisfaction with the overall outcome following anterior 90 degrees fundoplication. However, the results of postoperative objective tests and specific clinical symptoms are not always consistent with an individual patient's functional status and general well being following surgery, and quality of life (QOL) is also an important outcome to consider following surgery for reflux. Hence, QOL information was collected in this trial to investigate the hypothesis: improvements in QOL following laparoscopic antireflux surgery are greater after anterior 90 degrees partial fundoplication than after Nissen fundoplication. METHODS: Patients undergoing a laparoscopic fundoplication for gastro-esophageal reflux at one of nine university teaching hospitals in six major cities in Australia and New Zealand were randomized to undergo either laparoscopic Nissen or anterior 90 degrees partial fundoplication. Quality of life before and after surgery was assessed using validated questionnaires - the Short Form 36 general health questionnaire (SF36) and an Illness Behavior Questionnaire (IBQ). Patients were asked to complete these questionnaires preoperatively and at 3, 6, 12 and 24 months postoperatively. RESULTS: One hundred and twelve patients were randomized to undergo a Nissen fundoplication (52) or a 90 degrees anterior fundoplication (60). Patients who underwent anterior fundoplication reported significant improvements in eight of the nine SF36 scales compared to four of the nine following a Nissen fundoplication. The majority of these improvements occurred early in the postoperative period. With respect to the illness behavior data, there were no significant differences between the two procedures. Both groups had a significant improvement in disease conviction scores at all time points compared to their preoperative scores. CONCLUSIONS: Patients undergoing laparoscopic anterior 90 degrees partial fundoplication reported more QOL improvements in the early postoperative period than patients undergoing a Nissen fundoplication. However, the QOL outcome for both procedures was similar at later follow-up.

Laparoscopic cardiomyotomy for achalasia: long-term outcomes.

BACKGROUND: Although the laparoscopic approach to oesophageal myotomy for achalasia is associated with reduced early postoperative morbidity compared with the open approach, most published reports describe relatively short-term follow up. For this reason, in a prospective cohort study, we determined the longer-term outcome for patients with uncomplicated achalasia who underwent a laparoscopic myotomy. In addition, we sought to identify preoperative factors predicting a good postoperative outcome. METHODS: The outcome for 167 patients who underwent a laparoscopic cardiomyotomy and anterior partial fundoplication at one of two teaching hospitals was determined. All patients underwent preoperative assessment with a contrast swallow radiology, gastroscopy and oesophageal manometry. Patients also underwent objective symptom evaluation before and after surgery using various outcome scales to determine dysphagia, reflux symptoms, side-effects and overall satisfaction with the clinical outcomes. Patients were followed prospectively at yearly time points and data were managed on a computerized database. Postoperative objective investigations were undertaken if clinically indicated. RESULTS: Median operating time was 78 min (range, 30-210 min). Most patients left the hospital within 72 h of surgery. Surgery was associated with a 5% complication rate and a 4% rate of conversion to open surgery. Five per cent of patients required a subsequent intervention during follow up. Over longer-term follow up (5 years or longer), 77% of patients had either no or minimal symptoms. At 1, 3 and 5 years, 96, 93 and 97% of patients indicated that they thought that they had made the correct decision to undergo surgery, although men consistently fared worse on their reported dysphagia outcome across a range of measures. CONCLUSION: Laparoscopic myotomy with anterior partial fundoplication achieves a good outcome for patients undergoing treatment of achalasia. Male patients do not perceive their outcome to be optimal in comparison with females but in the long term, they do not regret proceeding.

Outcome of oesophagectomy for adenocarcinoma of the oesophagus and oesophagogastric junction.

BACKGROUND: Oesophageal adenocarcinoma is becoming an increasingly important problem in the Western world. Its incidence is increasing and its prognosis is poor. Because most reports of outcomes following oesophagectomy include patients with squamous cell carcinoma, the outcome following oesophagectomy for adenocarcinoma was evaluated at Flinders Medical Centre, Royal Adelaide Hospital and associated private hospitals. METHODS: The study group consisted of 121 patients with oesophageal adenocarcinoma or adenocarcinoma of the oesophagogastric junction who underwent an attempted oesophagectomy between 1985 and 2003. Thirty-two of these patients underwent surgery before 1999 at the Royal Adelaide Hospital. These patients were reviewed retrospectively. In 1999 the recording of details of all patients undergoing oesophagectomy was commenced on a prospectively maintained database. From 1999 to 2003, 89 patients underwent oesophagectomy at either the Royal Adelaide Hospital, Flinders Medical Centre or associated private hospitals. Overall, there were 101 male and 20 female patients, with a median age at surgery of 63 years (range 36-80). Survival data were available for all patients. The present study analysed factors affecting survival in these patients. RESULTS: Tumours were located entirely within the oesophagus in 83 patients, and involved the gastro-oesophageal junction in 38. Eighty-nine underwent an Ivor Lewis oesophagectomy; 20, a cervico-thoraco-abdominal oesophagectomy; nine, a cervico-abdominal oesophagectomy (with either transhiatal or blunt oesophageal dissection); and four procedures were abandoned. Sixty-four per cent of patients had evidence of Barrett's oesophagus in the resection specimen. The overall resection rate was 97%. Significant postoperative morbidity occurred in 36%, and the in-hospital mortality rate was 5% (30-day mortality 3%). The overall 1-year survival rate was 80%, and the 5-year survival rate (including surgical deaths) was 20%. Poorer survival was associated with advanced T stage, and lymph node metastasis. The outcome following resection of tumours confined to the oesophagus was similar to that for tumours involving the gastro-oesophageal junction. Since 2000, the number of oesophagectomies performed in men for adenocarcinoma has doubled, whereas the number performed in women and for squamous cell carcinoma has remained constant. CONCLUSIONS: Oesophagectomy can be performed for patients with adenocarcinoma with an acceptable perioperative mortality rate. However, the longer term outlook following oesophagectomy for most patients with adenocarcinoma remains poor. Nevertheless, early stage tumours are associated with much better survival. For this reason, efforts to diagnose this disease at an early stage are likely to offer the best chance for improving outcomes.

Multicenter, prospective, double-blind, randomized trial of laparoscopic nissen vs anterior 90 degrees partial fundoplication.

HYPOTHESIS: Laparoscopic anterior 90 degrees partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication. DESIGN: A multicenter, prospective, double-blind, randomized controlled trial. SETTING: Nine university teaching hospitals in 6 major cities in Australia and New Zealand. PARTICIPANTS: One hundred twelve patients with proven gastroesophageal reflux disease presenting for laparoscopic fundoplication were randomized to undergo either a Nissen (52 patients) or an anterior 90 degrees partial procedure (60 patients). Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded from this study. INTERVENTIONS: Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, and overall satisfaction 1, 3, and 6 months after surgery using multiple clinical grading systems. Objective measurement of esophageal manometric parameters, esophageal acid exposure, and endoscopic assessment. RESULTS: Postoperative dysphagia, and wind-related adverse effects were less common after a laparoscopic anterior 90 degrees partial fundoplication. Relief of heartburn was better following laparoscopic Nissen fundoplication. Overall satisfaction was better after anterior 90 degrees partial fundoplication. Lower esophageal sphincter pressure, acid exposure, and endoscopy findings were similar for both procedures. CONCLUSIONS: At the 6-month follow-up, laparoscopic anterior 90 degrees culine partial fundoplication is followed by fewer adverse effects than laparoscopic Nissen fundoplication with full fundal mobilization, and it achieves a higher rate of satisfaction with the overall outcome. However, this is offset to some extent by a greater likelihood of recurrent gastroesophageal reflux symptoms.

Acute ruptured esophageal duplication cyst.

A 32-year-old man presented acutely with a ruptured esophageal duplication cyst. This is a rare complication from an unusual congenital condition. The case describes his clinical presentation, radiological investigation and surgical management. The pathology of the excised specimen is described and a literature review concludes that complete surgical resection of an esophageal duplication is always recommended, even if the condition is asymptomatic. Conventionally this is achieved via a thoracotomy, however thoracoscopic-assisted excision may have a role.

Endoscopic stapling for pharyngeal pouch: does it make the cut?

BACKGROUND: Endoscopic stapling to treat pharyngeal pouch is a relatively new technique with the potential to reduce the morbidity associated with the open approach for pharyngeal pouch. Despite enthusiasm for the endoscopic approach there have been no series reported in Australia, and descriptions of outcomes and benefits are currently anecdotal. The aim of the present study was to determine the outcome associated with endoscopic stapling of pharyngeal pouch in an Australian setting. METHODS: All patients admitted for endoscopic stapling for a pharyngeal pouch between 1998 and 2002 by surgeons from the Adelaide and Flinders Universities were identified, and their medical records were reviewed for clinical and operative details. All patients were interviewed by telephone using a structured questionnaire to determine symptom resolution and patient satisfaction. The Likert scale was used to assess the impact of preoperative and postoperative symptoms upon quality of life. RESULTS: A total of 31 patients were identified. The mean age of the group was 75 years (range: 35-91 years) and half the patients had an American Society of Anesthesiologists physical status score of 3 or greater. In four patients the procedure was abandoned; (for three because of inability to pass the diverticuloscope and for one because the pouch was too small). Standard open surgery was undertaken in these patients. Of the 27 procedures completed endoscopically, interview follow up was obtained in 23, at a mean follow up of 17 months (range: 2-68 months). Outcome was very good or excellent in 21 (91%), with significant symptom resolution, reduction in Likert scores and high patient satisfaction. Three patients had previously had pouch surgery and endoscopic stapling was straightforward in these patients. Recurrence of a symptomatic pouch occurred in three patients. There was no significant morbidity related to the procedure. CONCLUSIONS: The early experience of endoscopic stapling for pharyngeal pouch in Adelaide is encouraging. The procedure achieves excellent control of symptoms and can be undertaken with minimal morbidity. Recurrence may be a problem, although repeat endoscopic stapling can be undertaken without difficulty.

Damage control laparotomy in the Australian military.

Damage control laparotomy (DCL) is a physiological approach to the management of selected critically injured patients where the surgical technique is directed at minimising the metabolic insult, rather than restoring anatomic integrity. DCL consists of an abbreviated initial laparotomy that is limited to control of haemorrhage and contamination, intra-abdominal packing, and temporary closure. Secondary resuscitation continues in the intensive care unit for 24-48 h until normal physiology has been restored. The subsequent reoperation involves removal of the packing with definitive repair and closure. Using this approach 50% of civilian patients who would previously have died undergoing a definitive trauma laparotomy will survive. Doctrinal change in Australia has yet to enshrine a strong focus on restoration of key physiological variables as a major objective in treatment of all wartime casualties. Yet the philosophy of damage control is uniquely suited to the Australian military environment. However, transition of DCL to the military setting has to take account of operational constraints. The most important unresolved issue is how to provide adequate postoperative intensive care. An evacuation capability incorporating critical care transport teams needs to be present, as the patient must reach definitive care within 48 h.