Donald Thometz

Laparoscopic Heller Myotomy Provides Durable Relief From Achalasia and Salvages Failures After Botox or Dilation

Objective:To report outcome after laparoscopic Heller myotomy in a large number of patients. Summary Background Data:Laparoscopic Heller myotomy has been undertaken for over a decade, but most studies involve small numbers of patients with limited follow-up. Methods:Since 1992, 262 patients have undergone laparoscopic Heller myotomy and been prospectively followed. Concomitant fundoplication was undertaken for a patulous hiatus or large hiatal hernia or to buttress the repair of an esophagotomy until recently when it became routinely applied. With mean follow-up at 32months, symptoms were scored by patients on a Likert scale (frequency: 0 = Never to 10 = Every time I eat/always; severity: 0 = Not bothersome to 10 = Very bothersome). Results:Before myotomy, 79% received Botox or bag dilation: 52% had Botox, 59% underwent dilation, and 36% had both. Inadvertent esophagotomy occurred in 5%. Concomitant diverticulectomy was undertaken in 4%, and fundoplication was undertaken in 30%. Complications were infrequent. Median length of stay was 1 day. After myotomy, the frequency and severity of symptoms of achalasia and reflux significantly decreased. Eighty-eight percent of patients felt their symptoms were greatly improved or resolved, and 90% felt their outcome was satisfying or better. Ninety-three percent felt they would undergo myotomy again, if necessary. Conclusions:Laparoscopic Heller myotomy can safely and durably relieve symptoms of dysphagia while also reducing symptoms of reflux. Length of stay is short and patient satisfaction is very high with extended follow-up. Laparoscopic Heller myotomy is strongly encouraged for patients with symptomatic achalasia and is efficacious even after failures of dilation and/or Botox therapy.

H-graft portacaval shunts versus TIPS: ten-year follow-up of a randomized trial with comparison to predicted survivals.

Objective:To report long-term outcome of patients undergoing prosthetic 8-mm H-graft portacaval shunts (HGPCS) or TIPS and to compare actual with predicted survival data. Methods:A randomized trial comparing TIPS to HGPCS for bleeding varices began in 1993. Predicted survival was determined using MELD (Model for End-stage Liver Disease). Results:Patients undergoing TIPS (N = 66) or HGPCS (N = 66) were very similar by Childs class and MELD scores and predicted survival. After TIPS (P = 0.01) and HGPCS (P = 0.001), actual survival was superior to predicted survival. Through 24 months, actual survival after HGPCS was superior to actual survival after TIPS (P = 0.04). Compared with TIPS, survival was superior after HGPCS for patients of Childs class A and B (P = 0.07) and with MELD scores less than 13 (P = 0.04) with follow-up at 5 to 10 years. Shunt failure was less following HGPCS (P < 0.01). Conclusions:Predicted survival data for patients undergoing TIPS or HGPCS confirms an unbiased randomization. Actual survival following TIPS or HGPCS was superior to predicted survival. Shunt failure favored HGPCS, as did survival after shunting, particularly for the first few years after shunting and for patients of Childs class A or B or with MELD scores less than 13. This trial irrefutably establishes a role for surgical shunting, particularly HGPCS.

TIPS Versus Peritoneovenous Shunt in the Treatment of Medically Intractable Ascites: A Prospective Randomized Trial

Objective:We undertook a prospective randomized clinical trial comparing TIPS to peritoneovenous (PV) shunts in the treatment of medically intractable ascites to establish relative efficacy and morbidity, and thereby superiority, between these shunts. Methods:Thirty-two patients were prospectively randomized to undergo TIPS or peritoneovenous (Denver) shunts. All patients had failed medical therapy. Results:After TIPS versus peritoneovenous shunts, median (mean ± SD) duration of shunt patency was similar: 4.4 months (6 ± 6.6 months) versus 4.0 months (5 ± 4.6 months). Assisted shunt patency was longer after TIPS: 31.1 months (41 ± 25.9 months) versus 13.1 months (19 ± 17.3 months) (P < 0.01, Wilcoxon test). Ultimately, after TIPS 19% of patients had irreversible shunt occlusion versus 38% of patients after peritoneovenous shunts. Survival after TIPS was 28.7 months (41 ± 28.7 months) versus 16.1 months (28 ± 29.7 months) after peritoneovenous shunts. Control of ascites was achieved sooner after peritoneovenous shunts than after TIPS (73% vs. 46% after 1 month), but longer-term efficacy favored TIPS (eg, 85% vs. 40% at 3 years). Conclusion:TIPS and peritoneovenous shunts treat medically intractable ascites. Absence of ascites after either is uncommon. PV shunts control ascites sooner, although TIPS provides better long-term efficacy. After either shunt, numerous interventions are required to assist patency. Assisted shunt patency is better after TIPS. Treating medically refractory ascites with TIPS risks early shunt-related mortality for prospects of longer survival with ascites control. This study promotes the application of TIPS for medically intractable ascites if patients undergoing TIPS have prospects beyond short-term survival.

Esophagotomy during laparoscopic Heller myotomy cannot be predicted by preoperative therapies and does not influence long-term outcome.

The conventional wisdom is that inadvertent esophagotomy complicates laparoscopic Heller myotomy. This study was undertaken to determine if esophagotomy at myotomy can be predicted by preoperative therapy, and if esophagotomy and/or its repair jeopardizes outcomes. Of 222 laparoscopic Heller myotomies undertaken since 1992, inadvertent esophagotomy occurred in 16 patients (7%); 60 patients who underwent myotomy without esophagotomy were utilized for comparison. Dysphagia and reflux before/ after myotomy were scored by patients on a Likert scale (0-5). The median (mean _ SD) follow-up after myotomy with esophagotomy was 38.8 months (31.6 ± 21.9 months) versus 46.3 months (51.0 ± 21.2 months) after myotomy alone. All esophagotomies were immediately recognized and repaired. Patients who experienced esophagotomy were similar to those who did not in application of Botox (56% vs. 77%) or dilation (44% vs. 65%), years of dysphagia (7.3 ± 5.4 vs. 7.4 ± 6.0), and mean preoperative dysphagia score (4.9 ± 0.4 vs. 4.8 ± 0.4). Esophagotomy led to longer hospitalizations (5.2 days ± 2.5 days vs. 1.5 days ± 0.7 days, P < 0.05) but not different postoperative dysphagia scores (1.5 ± 1.7 vs. 2.1 ± 1.4), reflux scores (1.4 ± 1.7 vs. 2.3 ± 1.3), or good or excellent outcomes (86% vs 84%). Esophagotomy during laparoscopic Heller myotomy is infrequent and cannot be predicted by preoperative therapy or duration or severity of dysphagia. Furthermore, complications after esophagotomy are infrequent and outcomes are indistinguishable from those of patients undergoing uneventful myotomy.

Renal haemodynamics and function following partial portal decompression

BACKGROUND This study was undertaken to prospectively evaluate the impact of partial portal decompression on renal haemodynamics and renal function in patients with cirrhosis and portal hypertension. METHODS Fifteen consecutive patients (median age 49 years) with cirrhosis underwent partial portal decompression through portacaval shunting or transjugular intrahepatic portosystemic shunting (TIPS). Cirrhosis was caused by alcohol in 47%, hepatitis C in 13%, both in 33% and autoimmune factors in 7% of patients. Child class was A in 13%, B in 20% and C in 67% of patients. The median score on the Model for End-stage Liver Disease (MELD) was 14.0 (mean 15.0 +/- 7.7). Serum creatinine (SrCr) and creatinine clearance (CrCl) were determined pre-shunt, 5 days after shunting and 1 year after shunting. Colour-flow Doppler ultrasound of the renal arteries was also undertaken with calculation of the resistive index (RI) and pulsatility index (PI). Changes in the portal vein-inferior vena cava pressure gradient with shunting were determined. RESULTS With shunting, the portal vein-inferior vena cava gradients dropped significantly, with significant increases in PI in the early period after shunting. Creatinine clearance improved in the early post-shunt period. However, SrCr levels did not significantly improve. At 1 year after shunting, both CrCl and SrCr levels tended towards pre-shunt levels and the increase in PI did not persist. DISCUSSION Partial portal decompression improves mild to moderate renal dysfunction in patients with cirrhosis. Early improvements in renal function after shunting begin to disappear by 1 year after shunting.

Transduodenal Excision of Ampullary Polyp with Biliopancreatic Sphincteroplasty

In the past, surgeons developed experience with transduodenal excisions of duodenal and ampullary tumors, and sphincteroplasties for a variety of benign nonneoplastic disorders, including choledocholithiasis, benign stricture, and functional ampullary disorders. The advent of effective endoscopic therapies for these disorders, including endoscopic polypectomy and endoscopic sphincterotomy, as well as endobiliary and percutaneous biliary interventions has severely limited the experience of today s surgeons with transduodenal aproaches to the ampulla. Furthermore, benign neoplastic ampullary polyps are best treated by ampullectomy, which is likely curative; they are generally not amenable to endoscopic therapies. This presentation outlines important caveats in accomplishing a successful transduodenal ampullary excision. These include oblique duodenotomy overlying the ampullary orifice, control of the ampulla with traction sutures, and dissection in the submucosal plane, which leads to division of the biliary and pancreatic ducts. Equally important is the technique of reconstruction by biliopancreatic sphincteroplasty. The key element in reconstruction is the identification of the biliary and of the pancreatic duct, which is located at the 5 o clock position to the biliary orifice. Once these ducts are identified, careful reconstruction with a meticulous duct to mucosa technique is essential. As the numbers of operative biliary interventions undertaken continue to diminish, today s generation of surgeons will rely more on educational videos such as this to maintain their skills and knowledge in dealing with these complex and technically challenging operations.