Leena Khaitan

Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial.

Objective:We sought to determine the impact of the addition of Dor fundoplication on the incidence of postoperative gastroesophageal reflux (GER) after Heller myotomy. Summary Background Data:Based only on case series, many surgeons believe that an antireflux procedure should be added to the Heller myotomy. However, no prospective randomized data support this approach. Patients and Methods:In this prospective, randomized, double-blind, institutional review board-approved clinical trial, patients with achalasia were assigned to undergo Heller myotomy or Heller myotomy plus Dor fundoplication. Patients were studied via 24-hour pH study and manometry at 6 months postoperatively. Pathologic GER was defined as distal esophageal time acid exposure time greater than 4.2% per 24-hour period. The outcome variables were analyzed on an intention-to-treat basis. Results:Forty-three patients were enrolled. There were no differences in the baseline characteristics between study groups. Pathologic GER occurred in 10 of 21 patients (47.6%) after Heller and in 2 of 22 patients (9.1%) after Heller plus Dor (P = 0.005). Heller plus Dor was associated with a significant reduction in the risk of GER (relative risk 0.11; 95% confidence interval 0.02–0.59; P = 0.01). Median distal esophageal acid exposure time was lower in the Heller plus Dor (0.4%; range, 0–16.7) compared with the Heller group (4.9%; range, 0.1–43.6; P = 0.001). No significant difference in surgical outcome between the 2 techniques with respect to postoperative lower-esophageal sphincter pressure or postoperative dysphagia score was observed. Conclusions:Heller Myotomy plus Dor Fundoplication was superior to Heller myotomy alone in regard to the incidence of postoperative GER.

100 Consecutive Minimally Invasive Heller Myotomies: Lessons Learned

ObjectiveTo evaluate the authors’ first 100 patients treated for achalasia by a minimally invasive approach. MethodsBetween November 1992 and February 2001, the authors performed 95 laparoscopic and 5 thoracoscopic Heller myotomies in 100 patients (age 49.5 ± 1.5 years) with manometrically confirmed achalasia. Before presentation, 51 patients had previous dilation, 23 had been treated with botulinum toxin (Botox), and 4 had undergone prior myotomy. Laparoscopic myotomy was performed by incising the distal 4 to 6 cm of esophageal musculature and extended 1 to 2 cm onto the cardia under endoscopic guidance. Fifteen patients underwent antireflux procedures. ResultsThere were eight intraoperative perforations and only four conversions to open surgery. Follow-up is 10.8 ± 1 months; 75% of the patients have been followed up for at least 14 months. Outcomes assessed by patient questionnaires revealed satisfactory relief of dysphagia in 93 patients and “poor” relief in 7 patients. Postoperative heartburn symptoms were reported as “moderate to severe” in 14 patients and “none or mild” in 86 patients. Fourteen patients required postoperative procedures for continued symptoms of dysphagia after myotomy. Esophageal manometry studies revealed a decrease in lower esophageal sphincter pressure (LESP) from 37 ± 1 mm Hg to 14 ± 1 mm Hg. Patients with a decrease in LESP of more than 18 mm Hg and whose absolute postoperative LESP was 18 or less were more likely to have relief of dysphagia after surgery. Thirty-one patients who underwent Heller alone were studied with a 24-hour esophageal pH probe and had a median Johnson-DeMeester score of 10 (normal <22.0). Mean esophageal acid exposure time was 3 ± 0.6% (normal 4.2%). Symptoms did not correlate with esophageal acid exposure. ConclusionsThe results after minimally invasive treatment for achalasia are equivalent to historical outcomes with open techniques. Satisfactory outcomes occurred in 93% of patients. Patients whose postoperative LESP was less than 18 mm Hg reported the fewest symptoms. After myotomy, patients rarely have abnormal esophageal acid exposure, and the addition of an antireflux procedure is not required.

Paradigm Shift in the Management of Gastroesophageal Reflux Disease

ObjectiveTo compare the short-term results of the radiofrequency treatment of the gastroesophageal junction known as the Stretta procedure versus laparoscopic fundoplication (LF) in patients with gastroesophageal reflux disease (GERD). Summary Background DataThe Stretta procedure has been shown to be safe, well tolerated, and highly effective in the treatment of GERD. MethodsAll patients presenting to Vanderbilt University Medical Center for surgical evaluation of GERD between August 2000 and March 2002 were prospectively evaluated under an IRB-approved protocol. All patients underwent esophageal motility testing and endoscopy that documented GERD preoperatively, either by a positive 24-hour pH study or biopsy-proven esophagitis. Patients were offered the Stretta procedure if they had documented GERD and did not have a hiatal hernia larger than 2 cm, LES pressure less than 8 mmHg, or Barrett’s esophagus. Patients with larger hiatal hernias, LES pressure less than 8 mmHg, or Barrett’s were offered LF. All patients were studied pre- and postoperatively with validated GERD-specific quality-of-life questionnaires (QOLRAD) and short-form health surveys (SF-12). Current medication use and satisfaction with the procedure was also obtained. ResultsResults are reported as mean ± SEM. Seventy-five patients (age 49 ± 14 years, 44% male, 56% female) underwent LF and 65 patients (age 46 ± 12 years, 42%, 58% female) underwent the Stretta procedure. Preoperative esophageal acid exposure time was higher in the LF group. Preoperative LES pressure was higher in the Stretta group. In the LF group, 41% had large hiatal hernias (>2 cm), 8 patients required Collis gastroplasty, 6 had Barrett’s esophagus, and 10 had undergone previous fundoplication. At 6 months, the QOLRAD and SF-12 scores were significantly improved within both groups. There was an equal magnitude of improvement between pre- and postoperative QOLRAD and SF-12 scores between Stretta and LF patients. Fifty-eight percent of Stretta patients were off proton pump inhibitors, and an additional 31% had reduced their dose significantly; 97% of LF patients were off PPIs. Twenty-two Stretta patients returned for 24-hour pH testing at a mean of 7.2 ± 0.5 months, and there was a significant reduction in esophageal acid exposure time. Both groups were highly satisfied with their procedure. ConclusionsThe addition of a less invasive, endoscopic treatment for GERD to the surgical algorithm has allowed the authors to stratify the management of GERD patients to treatment with either Stretta or LF according to size of hiatal hernia, LES pressure, Barrett’s esophagus, and significant pulmonary symptoms. Patients undergoing Stretta are highly satisfied and have improved GERD symptoms and quality of life comparable to LF. The Stretta procedure is an effective alternative to LF in well-selected patients.

Laparoscopic parastomal hernia repair using a nonslit mesh technique

BackgroundThe management of parastomal hernia is associated with high morbidity and recurrence rates (20–70%). This study investigated a novel laparoscopic approach and evaluated its outcomes.MethodsA consecutive multi-institutional series of patients undergoing parastomal hernia repair between 2001 and 2005 were analyzed retrospectively. Laparoscopy was used with modification of the open Sugarbaker technique. A nonslit expanded polytetrafluoroethylene (ePTFE) mesh was placed to provide 5-cm overlay coverage of the stoma and defect. Transfascial sutures secured the mesh, allowing the stoma to exit from the lateral edge. Five advanced laparoscopic surgeons performed all the procedures. The primary outcome measure was hernia recurrence.ResultsA total of 25 patients with a mean age of 60 years and a body mass index of 29 kg/m2 underwent surgery. Six of these patients had undergone previous mesh stoma revisions. The mean size of the hernia defect was 64 cm2, and the mean size of the mesh was 365 cm2. There were no conversions to open surgery. The overall postoperative morbidity was 23%, and the mean hospital length of stay was 3.3 days. One patient died of pulmonary complications; one patient had a trocar-site infection; and one patient had a mesh infection requiring mesh removal. During a median follow-up period of 19 months (range, 2–38 months), 4% (1/25) of the patients experienced recurrence.ConclusionOn the basis of this large case series, the laparoscopic nonslit mesh technique for the repair of parastomal hernias seems to be a promising approach for the reduction of hernia recurrence in experienced hands.

Increases in Adiponectin Predict Improved Liver, but Not Peripheral, Insulin Sensitivity in Severely Obese Women During Weight Loss

Obesity-related glucose intolerance is a function of hepatic (homeostatic model assessment-insulin resistance [HOMA-IR]) and peripheral insulin resistance (Si) and β-cell dysfunction. We determined relationships between changes in these measures, visceral (VAT) and subcutaneous (SAT) adipose tissue, and systemic adipocytokine biomarkers 1 and 6 months after surgical weight loss. HOMA-IR decreased significantly (−50%) from baseline by 1 month and decreased further (−67%) by 6 months, and Si was improved by 6 months (2.3-fold) weight loss. Plasma concentrations of leptin decreased and adiponectin increased significantly by 1 month, and decreases in interleukin-6, C-reactive protein (CRP), and tumor necrosis factor-α were observed at 6 months of weight loss. Longitudinal decreases in CRP (r = −0.53, P < 0.05) were associated with increases in Si, and decreases in HOMA-IR were related to increases in adiponectin (r = −0.37, P < 0.05). Decreases in VAT were more strongly related to increases in adiponectin and decreases in CRP than were changes in general adiposity or SAT. Thus, in severely obese women, specific loss of VAT leads to acute improvements in hepatic insulin sensitivity mediated by increases in adiponectin and in peripheral insulin sensitivity mediated by decreases in CRP.

Initial Experience with the Stretta Procedure for the Treatment of Gastroesophageal Reflux Disease

BACKGROUND The Stretta device (Curon Medical, Sunnyvale, CA) is a balloon-tipped four-needle catheter that delivers radiofrequency (RF) energy to the smooth muscle of the gastroesophageal junction. It can be used for the endoscopic treatment of gastroesophageal reflux disease (GERD). PATIENTS AND METHODS Data prospectively collected on the first 25 consecutive patients undergoing the Stretta procedure at Vanderbilt University Medical Center between August 2000 and March 2001 are reported. Patient evaluation included esophageal manometry, ambulatory 24-hour pH testing, a standard GERD-specific quality-of-life survey (QOLRAD), a general quality-of-life survey (SF12), and endoscopy. Stretta surgery was performed following a standardized protocol. Thermocouple-controlled RF energy was delivered to the lower esophageal sphincter (LES) after endoscopic location of the z-line. Patients were followed up 3 months after endoscopic treatment. Results are presented as mean +/- SEM. RESULTS Prior to treatment, patients had a mean DeMeester score of 31.0+/-11.4, an LES pressure of 24+/-2 mm Hg, and normal esophageal peristalsis. Of the 25 outpatient procedures, 19 were done under conscious sedation and 6 under general anesthesia. There was a small learning curve (76+/-8 min for the first three procedures; 50+/-2 min for the subsequent 22). The mild to moderate pain during the first 24 postoperative hours was controlled with over-the-counter medication. Two complications were noted: one patient presented with ulcerative esophagitis and gastroparesis 10 days after the Stretta treatment, and one patient developed pancreatitis on postoperative day 27, which was probably unrelated to the Stretta procedure. Eight of the thirteen patients (62%) available for 3-month follow-up were off all antisecretory medication. The other five patients were still taking medications but had been able to reduce the amount considerably. The average daily dose of proton pump inhibitors was 43.0+/-5.0 mg/preoperatively and 6.4+/-2.2 mg/3 months postoperatively (P < 0.001). Other classes of GERD treatment such as metoclopramide had been completely abandoned. In all patients, QOLRAD scores improved (3.5+/-0.4 to 5.5+/-0.5; P < 0.001) as did SF12 physical (23.7+/-3.0 to 31.0+/-3.4; P < 0.008) and mental (40.5+/-2.9 to 47.7+/-3.2, P < 0.017) scores. All patients would undergo a Stretta procedure again except one 78-year-old man with progressive Alzheimers disease. CONCLUSION The Stretta procedure is a promising new modality in the management of GERD. It can be safely performed in one short session with gastroesophageal endoscopy under conscious sedation in an outpatient setting. It improves GERD symptoms and quality-of-life scores in patients at 3 months and eliminates or significantly reduces the need for antisecretory drugs.

Symptoms, Quality of Life, Videolaryngoscopy, and Twenty-Four-Hour Triple-Probe Ph Monitoring in Patients with Typical and Extraesophageal Reflux

A prospective study was designed to characterize patients with typical and extraesophageal reflux (EER) symptoms and seek predictive patterns for each group. Fifteen subjects without symptoms, 16 patients with symptomatic gastroesophageal reflux disease (GERD), and 37 patients with symptomatic EER were evaluated with outcomes tools, videolaryngoscopy, and 24-hour triple-probe pH monitoring. Higher symptom scores, Voice Handicap Index scores, and Gastrointestinal Symptom Rating Scale scores, as well as similarly decreased quality of life as measured by the Short Form 36, were noted among the two symptomatic groups. Patients with clinically diagnosed EER were more likely to have multiple abnormalities on laryngoscopy. There was a trend toward more pharyngeal reflux episodes in EER patients (6.9 ± 8.9) as compared to GERD patients (6.0 ± 9) and asymptomatic subjects (1.1 ± 1.9). On the basis of the pH monitoring of asymptomatic subjects, we define pathological pharyngeal reflux as more than 5 episodes in 24 hours. Pharyngeal acid exposure is more common in patients presumed to have EER, but some pharyngeal reflux does occur in asymptomatic subjects. Neither symptom scores nor videolaryngoscopic findings were predictive of pathological EER as indicated by pH monitoring.

Response to Periodontal Therapy in Patients Who Had Weight Loss After Bariatric Surgery and Obese Counterparts: A Pilot Study

BACKGROUND Periodontitis and obesity are both chronic health problems, and the literature supports an association between the two. Weight loss after bariatric surgery (BS) has been shown to decrease overall mortality as well as the development of new health-related conditions in morbidly obese patients. The present study aims to assess whether significant weight loss would improve the response to non-surgical periodontal therapy in obese patients. METHODS This study included 30 obese (body mass index >30 kg/m(2)) patients affected with chronic periodontitis. Of these, 15 patients had previously undergone BS and lost ≥40% of their excess weight for ≥6 months after surgery. The other 15 patients were also obese but did not have the surgery, nor did they lose weight to serve as a control group. All participants received non-surgical periodontal therapy (scaling and root planing and oral hygiene instructions). Probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), gingival index (GI), and plaque index were measured at baseline and at 4 to 6 weeks after the periodontal treatment. Descriptive statistics, linear mixed-effects models, and linear regression models were used for data analysis. RESULTS The mean age of the study participants was 47.1 ± 11.5 years, and 36.7% of the participants were males. There was a statistically significant improvement after periodontal therapy in the BS compared with the obese group (P <0.05). The PD had a mean reduction of 0.45 mm in the BS group versus 0.28 mm in the control group. The reduction in CAL was 0.44 mm versus 0.30 mm, percentage of BOP sites was 16% versus 15%, and GI was 1.03 versus 0.52 in the BS and control groups, respectively. CONCLUSION An improved response to non-surgical periodontal therapy is observed in obese patients who had significant weight loss after BS compared with obese patients who did not have such a surgery.

Laparoscopic Adhesiolysis and Placement of Seprafilm™: A New Technique and Novel Approach to Patients with Intractable Abdominal Pain

Patients who suffer from chronic abdominal pain as a result of postoperative adhesion formation are challenging to treat. Many surgeons argue that operative treatment of these patients exacerbates symptoms because of the continued adhesion formation following each procedure. Seprafilm (Genzyme, Tucker, GA, USA), a bioresorbable membrane of sodium hyaluronate and carboxymethylcellulose, and laparoscopic surgery have both been shown to significantly decrease postoperative adhesion formation. Although the utility of laparoscopy is controversial in the treatment of these patients, the combination of laparoscopy and Seprafilm can provide excellent relief in this difficult patient population. We report a new technique, laparoscopic adhesiolysis and Seprafilm placement, for patients with intractable abdominal pain secondary to adhesions.

Heller myotomy vs Heller myotomy plus Dor fundoplication: cost-utility analysis of a randomized trial.

BackgroundThe addition of a Dor antireflux procedure reduces the risk of pathologic gastroesophageal reflux (GER) by ninefold following laparoscopic Heller myotomy for achalasia. It is not clear, however, how these benefits compare with the increased cost of the fundoplication. The objective of this study was to estimate the cost-effectiveness of Heller myotomy plus Dor fundoplication compared with Heller alone in patients with achalasia.MethodsWe conducted a cost–utility analysis using the Markov simulation model to examine the two treatment alternatives. The model estimated the total expected costs of each strategy over a 10-year time horizon. Data for the model were derived from our randomized clinical trial. The strategies were compared using the method of incremental cost-effectiveness analysis.ResultsThe incidence of pathologic GER was 47.6% (10 of 21 patients) in the Heller group and 9.1% (2 of 22 patients) in the Heller plus Dor group using an intention-to-treat analysis (p = 0.005). Heller plus Dor was associated with a significant reduction in the risk of GERD (relative risk 0.11; 95% confidence interval 0.02–0.59; p = 0.01). The cost of surgery was significantly higher for Heller plus Dor than for Heller alone (mean difference