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Query: UMLS:C0017168 (gastroesophageal reflux disease)
 11,783 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Heller's myotomy for esophageal achalasia was performed on 64 patients in the 24 yr up to 1988. After follow-up averaging 13 yr, 46 patients were reexamined with endoscopy, biopsy, and manometry. Barrett's metaplasia of the distal esophagus was found in four patients 6, 13, 20, and 23 yr after the myotomy. These four also underwent ambulatory 24-h pH monitoring. They had the lowest distal esophageal sphincter pressures (1-5 mm Hg), and all four had symptoms of gastroesophageal reflux and pathologic pH values (< 4 in the distal esophagus for 32-62% of the total recording time). Because of heightened risk for the development of Barrett's metaplasia following cardiomyotomy for esophageal achalasia, with increased liability to carcinoma of the esophagus, regular endoscopic surveillance of these patients is advisable.
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PMID:Barrett's esophagus after cardiomyotomy for esophageal achalasia. 798 Aug 29

The possibilities of laparoscopic surgery in the treatment of functional esophageal diseases (gastroesophageal reflux, achalasia and epiphrenic diverticula) are illustrated with special emphasis on the technical aspects, including intraoperative complications and postoperative care. Results are discussed on the ground of the following experience. Thirty-seven laparoscopic fundoplications were performed with 13% conversion rate, 2.7% postoperative morbidity (1 slipped Nissen requiring redo laparoscopic surgery). Median operative time was 140 min. One patient complained of dysphagia relieved by endoscopic dilation (2.7%). All patients are not asymptomatic after a median follow-up of 16 months although one has gastroesophageal reflux (GER) at 24-hrs pH monitoring. forty laparoscopic Heller-Dor procedures: 7% conversions, 5% postoperative morbidity. Median duration 120 min. One patient complained of persistent dysphagia requiring endoscopic dilation (2.5%) and asymptomatic GER was detected in 8% of patients. Finally, 2 patients underwent laparoscopic diverticulectomy, esophagomyotomy and Dor fundoplication without morbidity and excellent postoperative result. Laparoscopic treatment of functional diseases of the esophagus is safe and effective, provided it is performed by an experienced surgeon with respect for some important technical details. Further follow-up is needed to evaluate long-term results.
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PMID:Laparoscopic treatment of functional diseases of the esophagus. 874 Jun 80

An analysis of 29 patients who collectively required 33 reoperations for failed Heller's esophagocardiomyotomy performed during the period between 1972 and 1992 was conducted. In the majority of patients, the reoperation was necessitated because the original myotomy was not long or deep enough, or because of iatrogenic gastroesophageal reflux and its sequelae such as strictures. Identification of the exact cause of failure requires careful analysis of the patient's symptoms and of the findings of various diagnostic examinations. The treatment for inadequate myotomy generally involves performing a second myotomy, which is completed by adding a nonobstructive antireflux repair. It appears that abolition of the "sigmoid sac" is essential even when the esophagogastric junction has a sufficiently large diameter. A so-called esophagoplication was performed in 3 patients,and an interposition at the site of esophageal resection, using an isoperistaltic esophagojejunogastric loop of appropriate length, was performed in 14 patients. There were no deaths following reoperation. In fact, the results were excellent or good in 23 cases and fair in 3.
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PMID:Management of failed Heller's operations. 884 Apr 39

The study's aim was to assess the functional results of laparoscopically performed Heller's myotomy and Dor's fundoplication in our first few cases of esophageal achalasia. Four male patients (mean age: 61 years) with long-standing symptoms of achalasia (documented on esophagogram and esophageal manometry) and not responding to several sessions of pneumatic dilatation, had laparoscopic Heller's myotomy and Dor's fundoplication. Myotomy was facilitated by distending the esophagus. The mean duration of the operation was 99 min. The third patient developed a leak from the exposed esophageal mucosa on the 5th postoperative day while at home. The leak was attributed to late desloughing of a mucosal burn, and was sealed spontaneously 15 days later after drainage. The remaining three patients were discharged after resuming diet within the first 2 postoperative days. By 1 year postoperatively, dysphagia was abolished in all cases, and there were no gastroesophageal reflux symptoms. The esophagogram showed no reflux, which was also confirmed on ambulatory 24-h esophageal pH measurement. On manometry, lower esophageal sphincter (LES) pressure dropped significantly postoperatively (preop: 56 +/- 7 SD mm Hg, postop: 5 +/- 1 SD mm Hg, p < 0.001). In conclusion, laparoscopic Heller's myotomy with Dor's fundoplication for esophageal achalasia is a feasible procedure, offering clinical and laboratory results similar to the open approach, but with better patient tolerance.
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PMID:Laparoscopic Heller's cardiomyotomy and Dor's fundoplication for esophageal achalasia. 887 45

After a wide revision of the Literature, the most frequent causes of failure in the surgical therapy of esophageal achalasia are described. Above all there is the uncorrect execution of the Heller's myotomy as for its upward and downward extension or its deepness. An uncorrect myotomy, in fact, might cause the persistence or relapse of pre-operative symptoms, such as dysphagia and regurgitation. A correct myotomy, according to the authors, should be always carried out with the aid of intraoperative manometry (IEM), which allows the documentation of the alterations caused by surgery in the area of the high pressure zone, which corresponds to the sphincter (LES). A correct myotomy must produce the complete annulment of such a pressure. This technique creates the conditions sufficient to the genesis of gastroesophageal reflux (GER), which is one of the most frequent causes of failure in the surgery of achalasia. In fact, it causes a reflux esophagitis which can quickly evolve into a stricture with the reappearance of dysphagia. It is essential, therefore, to combine always the Heller's procedure with an antireflux procedure, which can protect the esophagus from GER and at the same time does not produce a mechanical obstacle to deglutition. The Authors report their last experience based on 114 primary operations of Heller's myotomy + Nissen fundoplication, performed since 1985 to date. IEM has been always used both for controlling the completeness of the myotomy and for the "calibration" of the Nissen's. Two patients, which had undergone elsewhere a Heller's myotomy alone, have been operated of re-myotomy + Nissen fundoplication. One patient, also operated elsewhere of myotomy of the esophageal body for diffuse esophageal spasm (DES), complained of dysphagia and had manometrical evidence of LES dischalasia; this patient has been reoperated of Heller's myotomy + Nissen fundoplication; another patient suffering from a reflux stricture after a Heller's myotomy without antireflux procedure, has been treated with a Roux esophago-jejunostomy. A last patient operated by Heller's myotomy + Dor fundoplication presented alkaline esophagitis without dysphagia; the treatment consisted in a Roux gastro-jejunostomy + bilateral troncular vagotomy. These data bring to the conclusion that the best treatment of achalasia relapses is their prevention, only obtainable by a good primary therapeutic approach and the routine use of IEM. The IEM avoids incomplete myotomies and inadequate antireflux procedures related to the incompetence (reflux) or hypercompetence (dysphagia recurrence) of the fundoplication.
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PMID:[Failure of surgical treatment for achalasia: diagnosis and treatment]. 894 95

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.
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PMID:[Heller's intervention for esophageal achalasia]. 894 94

From 1974 to 1995, 19 children with achalasia of the esophagus have been treated at our institution. Presenting symptoms included vomiting (n = 14), dysphagia (n = 13), failure to thrive (n = 6), and odynophagia (n = 1). Diagnosis was established by a barium swallow in 19, with eight also undergoing esophageal manometry. Six boys and 13 girls with an average age of 10 years (range, 1.3 to 17.6) underwent a transthoracic, modified anterior Heller esophagomyotomy (HM). Five underwent a concomitant, modified, Belsey fundoplication (BF). Follow-up ranging from 6 months to 21 years (mean, 9 years) was accomplished in all 19 patients by both office visits and telephone interviews. Early postoperative follow-up showed initial swallowing difficulty in two (14%) patients with a HM alone and in four out of five (80%) patients treated with a HM and BF. All patients (n = 5) with a HM and BF and one with a HM alone required one esophageal dilation during the first postoperative year. These initial swallowing difficulties resolved in all six patients during this first postoperative year. Late postoperative follow-up, however, indicates occasional, mild dysphagia in two out of five with an HM and BF resulting in complete relief of presenting symptoms in 17 of the 19 patients (90%). All patients rated their overall result as either excellent (68%) or good (32%) with none rating it as fair or poor. None of the 19 patients had clinical evidence of gastroesophageal reflux, although five patients had evidence of nonpathologic reflux noted during upper gastrointestinal x-ray. Recurrent vomiting, asthma, wheezing, or esophagitis symptoms have not been reported by any patients. No patients required reoperation, and there were no deaths or postoperative complications. Modified Heller esophagomyotomy is safe (0% mortality) and effective (90% relief of symptoms) in children with achalasia. A concurrent modified Belsey fundoplication results in early and late mild postoperative dysphagia that was responsive to esophageal dilation. The transthoracic, modified Heller esophagomyotomy without a fundoplication is currently our treatment of choice for achalasia in children.
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PMID:Efficacy of the transthoracic modified Heller myotomy in children with achalasia--a 21-year experience. 904 49

In order to improve the results of functional surgical procedures on the esophagus, the authors, after a number of experimental studies, proposed the use of intraoperative esophageal manometry (IEM). The technique was performed for the first time in 1972. IEM has been employed in the course of Heller's cardiamyotomies and Nissen-Rossetti (N-R) fundoplications, respectively, to document the ablation of the lower esophageal sphincter (LES) high-pressure zone (HPZ) and to calibrate the pressure of the fundal wrap between values ranging from 20 to 40 mmHg ('hypercalibrated Nissen'). This hypercalibration resulted from the retrospective evaluation of a former series when, at the beginning of our experience, we used to calibrate the fundoplication to pressure values similar to those of a normal sphincter ('normocalibrated Nissen': 10-20 mmHg). This experience, in fact, was followed by a high rate of gastroesophageal reflux (GER) recurrence (28.5%) in the first 12 months after surgery. Since 1985 to date, IEM has been employed in the course of 309 functional surgical procedures on the esophagus. This paper, however, reports on 281 patients: 144 with achalasia treated with Heller's myotomy + Nissen-Rossetti fundoplication and 137 with gastroesophageal reflux disease (GER-D) submitted to Nissen-Rossetti fundoplication. Our data suggest that IEM can be a useful tool in the field of functional surgery of the esophagus, and its routine use seems to be able to improve the postoperative results. In this series, in fact, IEM was able to detect the persistence of an HPZ in 15.2% of apparently complete myotomies, all performed with the aid of intraoperative endoscopy. As regards the manometric calibration of the n-HPZ, our results seem to confirm the validity of the technique, yet some findings still remain unexplained: i.e. two patients with a hypotonic n-HPZ and GER recurrence and two with an n-HPZ, exceeding 20 mmHg with postoperative persistent dysphagia. Finally, we would like to emphasize that the concept of a 'hypercalibrated Nissen' contrasts with the 'floppy Nissen' of Donahue and DeMeester; our wrap is also loose around the esophagus and does not impair the esophagogastric transit.
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PMID:Intraoperative esophageal manometry: our experience. 945 52

We retrospectively reviewed 30 patients with achalasia (18 males, 12 females) undergoing laparoscopic Heller myotomy without antireflux procedure to determine relief of dysphagia and prevalence of postoperative gastroesophageal reflux. Preoperative symptoms were obtained by history alone before 1996 and by standardized questionnaire after September 1996. Twenty-nine patients (97%) had dysphagia, 22 patients (73%) had regurgitation, 21 patients (70%) had weight loss, 7 patients (23%) had heartburn, and 4 patients (13%) had nocturnal aspiration. The first 3 patients were done thoracoscopically, with the subsequent 27 patients performed laparoscopically; 4 cases (13%; 1 thoracoscopic and 3 laparoscopic) were converted. The mean postoperative stay was 1.9 days (1-6 days). One patient underwent repeat laparoscopic myotomy for persistent dysphagia. Twenty-eight patients (93%) were available for follow-up. Patients were asked on a standardized questionnaire to grade their relief of dysphagia, regurgitation, and heartburn. Good to excellent relief of dysphagia was obtained in 25 patients (89%), whereas 3 patients (11%) continued to have significant dysphagia postoperatively. Twenty-four patients (86%) had little or no regurgitation. Four patients (14%) had frequent regurgitation. Twenty-four patients (89%) reported little or no heartburn. Three patients (11%) reported significant postoperative heartburn. Laparoscopic Heller esophagomyotomy without antireflux procedure provides excellent symptomatic relief of dysphagia in patients with achalasia. Early follow-up suggests that minimal occurrence of symptomatic postoperative reflux can be achieved without performing an antireflux procedure.
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PMID:The outcome of laparoscopic Heller myotomy without antireflux procedure in patients with achalasia. 961 71

Achalasia is an esophageal motility disorder characterized by increased lower esophageal sphincter pressure and absence of peristalsis in the lower esophagus. Patients typically present with complaints of progressive difficulty swallowing over a period of several years. Diagnosis is confirmed by esophageal manometry. Complications of achalasia include esophagitis, aspiration and possibly an increased risk of esophageal carcinoma. Medical treatment options include pneumatic dilatation, esophageal bougienage, nitrates, calcium channel blockers and botulinum toxin injections. The primary method of surgical treatment is the Heller myotomy, in which longitudinal incisions are made in the muscle fibers of the lower esophageal sphincter to reduce sphincter pressure. Frequently, a fundoplication is performed in addition to the myotomy to decrease the likelihood of development of gastroesophageal reflux. In recent years, the Heller myotomy has been performed both thoracoscopically and laparoscopically. An additional development has been the placement of an endoscope in the esophagus to provide transillumination during surgery; intraoperative endoscopy allows improved assessment of the depth of myotomy incisions and reduces the risk of esophageal perforation. The case report below describes a 64-year-old-man with achalasia who presented with persistent dysphagia despite multiple attempts at medical treatment. A laparoscopic Heller myotomy with Toupet fundoplication was performed with subsequent eradication of symptoms. A discussion of the epidemiology, etiology, clinical presentation, diagnosis and treatment of achalasia follows the case report.
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PMID:Achalasia in a sixty-four-year-old man. 971 52


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