Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial.

BACKGROUND: The type of fundoplication that should be performed in conjunction with Heller myotomy for esophageal achalasia is controversial. We prospectively compared anterior fundoplication (Dor) with partial posterior fundoplication (Toupet) in patients undergoing laparoscopic Heller myotomy. METHODS: A multicenter, prospective, randomized-controlled trial was initiated to compare Dor versus Toupet fundoplication after laparoscopic Heller myotomy. Outcome measures were symptomatic GERD scores (0-4, five-point Likert scale questionnaire) and 24-h pH testing at 6-12 months after surgery. Data are mean ± SD. Statistical analysis was by Mann-Whitney U test, Wilcoxon signed rank test, and Freidman's test. RESULTS: Sixty of 85 originally enrolled and randomized patients who underwent 36 Dor and 24 Toupet fundoplications had follow-up data per protocol for analysis. Dor and Toupet groups were similar in age (46.8 vs. 51.7 years) and gender (52.8 vs. 62.5% male). pH studies at 6-12 months in 43 patients (72%: Dor n = 24 and Toupet n = 19) showed total DeMeester scores and % time pH < 4 were not significant between the two groups. Abnormal acid reflux was present in 10 of 24 Dor group patients (41.7%) and in 4 of 19 Toupet patients (21.0%) (p = 0.152). Dysphagia and regurgitation symptom scores improved significantly in both groups compared to preoperative scores. No significant differences in any esophageal symptoms were noted between the two groups preoperatively or at follow-up. SF-36 quality-of-life measures changed significantly from pre- to postoperative for five of ten domains in the Dor group and seven of ten in the Toupet patients (not significant between groups). CONCLUSION: Laparoscopic Heller myotomy provides significant improvement in dysphagia and regurgitation symptoms in achalasia patients regardless of the type of partial fundoplication. Although a higher percentage of patients in the Dor group had abnormal 24-h pH test results compared to those of patients who underwent Toupet, the differences were not statistically significant.

Return of esophageal function after treatment for achalasia as determined by impedance-manometry.

BACKGROUND: Treatment for achalasia is aimed at the lower esophageal sphincter (LES), although little is known about the effect, if any, of these treatments on esophageal body function (peristalsis and clearance). We sought to measure the effect of various treatments using combined manometry (peristalsis) with Multichannel Intraluminal Impedance (MII) (esophageal clearance). METHODS: We enrolled 56 patients with Achalasia referred to the University of Washington Swallowing Center between January 2003 and January 2006. Each was grouped according to prior treatment: 38 were untreated (untreated achalasia), 10 had undergone botox injection or balloon dilation (endoscopic treatment), and 16 a laparoscopic Heller myotomy. The preoperative studies for 8 of the myotomy patients were included in the untreated achalasia group. Each patient completed a dysphagia severity questionnaire (scale 0-10). Peristalsis was analyzed by manometry and esophageal clearance of liquid and viscous material by MII. RESULTS: Mean dysphagia severity scores were significantly better in patients after Heller Myotomy than in either of the other groups (2.0 vs. 5.3 in the endoscopic group and 6.5 in untreated achalasia, p < 0.05). Peristaltic contractions were observed in 63% of patients in the Heller myotomy group, compared with 40% in the endoscopic group and 8% in untreated achalasia (p < 0.05 for both treatment groups vs. untreated achalasia). Liquid clearance rates were significantly better in both treatment groups: 28% in Heller myotomy and 16% in endoscopic treatment compared to only 5% in untreated achalasia (p < 0.05). Similarly, viscous clearance rates were 19% in Heller myotomy and 11% in endoscopic treatment, vs. 2% in untreated achalasia (p < 0.05). In the subset of patients who underwent manometry/MII both pre- and postoperatively, peristalsis was observed more frequently postoperatively than in preop studies (63% of patients exhibiting peristalsis vs. 12%), as was complete clearance of liquid (35% of swallows vs. 14%) and viscous boluses (22% of swallows vs. 14%). These differences were not significant, however. In the patients who had a myotomy the return of peristalsis correlates with effective esophageal clearance (liquid bolus: r = 0.46, p = 0.09 and viscous bolus: r = 0.63, p < 0.05). There is no correlation between peristalsis and bolus clearance in the endoscopic treatment group. CONCLUSIONS: With treatment Achalasia patients exhibit some restoration in peristalsis as well as improved bolus clearance. After Heller Myotomy, the return of peristalsis correlates with esophageal clearance, which may partly explain its superior relief of dysphagia.

Análisis de la alimentación de los cuidadores de pacientes pediátricos con cáncer en el Hospital Infantil de México Federico Gómez / Dietary analysis of caregivers of pediatric cancer patients at the Hospital Infantil de México Federico Gómez

Introducción. El ingreso a un hospital representa un fenómeno social y cultural complejo, particularmente desde la perspectiva familiar. Sin embargo, es escasa la información sobre los cuidadores y sus necesidades básicas, como la alimentación. El objetivo de este trabajo fue evaluar la alimentación de los cuidadores de pacientes pediátricos con cáncer y describir cualitativamente las condiciones en que se realiza, ante un evento de hospitalización. Métodos. Se encuestó a 53 cuidadores de pacientes hospitalizados del servicio de Oncología del Hospital Infantil de México Federico Gómez. Se les aplicó un recordatorio de 24 horas (R24), todos los días, y se aplicó una encuesta con la finalidad de describir cualitativamente el proceso de alimentación durante dicho periodo. Resultados. Se identificó que los cuidadores fueron principalmente mujeres (n =43, 81%). El índice de masa corporal al inicio del periodo de estudio fue de 25.5 ± 5 kg/m² (x ± DE). El consumo de calorías por día de los cuidadores al inicio de la hospitalización se encontró por debajo de la recomendación para la población mexicana (1534 kcal versus 2500 kcal). En la descripción cualitativa se encontró que la mayoría de los cuidadores desayunan (86%) y sólo cena la tercera parte (32%). La forma más común de adquirir sus alimentos fue comprándolos; sin embargo, 71% comieron de la charola del paciente. Conclusiones. La población estudiada de cuidadores tenía sobrepeso, según su índice de masa corporal (≥ a 25 kg/m²). Las calorías consumidas, a pesar de ser menores a las recomendadas, cumplieron con la distribución sugerida para macronutrimentos. La mitad de los cuidadores realizaron tres tiempos de comida pero, en general, tendieron a prolongar el periodo de ayuno.

Background. When a family member is admitted to the hospital, this represents a complex social and cultural phenomenon. Little research about caregivers and their basic needs such as nutrition has been carried out. The aim of this study is to assess the diet of caregivers of pediatric patients with cancer and to qualitatively describe the conditions associated with eating during hospitalization of a family member. Methods. Fifty three caregivers of hospitalized patients in the Oncology Department at the Hospital Infantil de México Federico Gomez were surveyed. The 24 hours (R24) reminder was used every day throughout the process of hospitalization. Finally, surveys were conducted in order to qualitatively describe food intake of caregivers during the feeding process in a hospitalization period. Results. Women caregivers outnumbered men (n = 43, 81%). Body mass index (BMI) at the beginning of the study was 25.5 ± 5 kg/m² (X ± SD). Caloric intake per day of caregivers at the beginning of the hospitalization period was lower than medical recommendations for the Mexican population (2500 kcal). In the qualitative description, it was found that most caregivers eat breakfast (86%) and only a third have dinner (32%). Although 71% of caregivers ate something from the patients' food tray, the most common way to obtain food was by purchase. Conclusions. Study subjects were overweight according to their BMI (≥ 25 kg/m²). Despite caloric intake being lower than recommended, intake distribution was acceptable‚ according to the macronutrient distribution. Half of the caregivers studied had three meals but often experienced long periods of fasting.