Marco G. Patti

Minimally invasive surgery for achalasia: an 8-year experience with 168 patients.

BACKGROUND Seven years ago, the authors reported on the feasibility and short-term results of minimally invasive surgical methods to treat esophageal achalasia. In this report, they describe the evolution of the surgical technique and the clinical results in a large group of patients with long follow-up. PATIENTS AND METHODS Between January 1991 and October 1998, 168 patients (96 men, 72 women; mean age 45 years, median duration of symptoms 48 months), who fulfilled the clinical, radiographic, endoscopic, and manometric criteria for a diagnosis of achalasia, underwent esophagomyotomy by minimally invasive techniques. Forty-eight patients had marked esophageal dilatation (diameter >6.0 cm). Thirty-five patients had a left thoracoscopic myotomy, and 133 patients had a laparoscopic myotomy plus a partial fundoplication. Follow-up to October 1998 was complete in 145 patients (86%). RESULTS Median hospital stay was 72 hours for the thoracoscopic group and 48 hours for the laparoscopic group. Eight patients required a second operation for recurrent or persistent dysphagia, and two patients required an esophagectomy. There were no deaths. Good or excellent relief of dysphagia was obtained in 90% of patients (85% after thoracoscopic and 93% after laparoscopic myotomy). Gastroesophageal reflux developed in 60% of tested patients after thoracoscopic myotomy and in 17% after laparoscopic myotomy plus fundoplication. Laparoscopic myotomy plus fundoplication corrected reflux present before surgery in five of seven patients. Patients with a dilated esophagus had excellent relief of dysphagia after laparoscopic myotomy; none required an esophagectomy. CONCLUSIONS Minimally invasive techniques provided effective and long-lasting relief of dysphagia in patients with achalasia. The authors prefer the laparoscopic approach for three reasons: it more effectively relieved dysphagia, it was associated with a shorter hospital stay, and it was associated with less postoperative reflux. Laparoscopic Heller myotomy and partial fundoplication should be considered the primary treatment for esophageal achalasia.

A hospital's annual rate of esophagectomy influences the operative mortality rate

The reported operative mortality rate for esophagectomy for malignancy ranges from 2% to 30%. The goal of this retrospective study was to evaluate the relationship between a hospital’s annual rate of esophagectomy for esophageal cancer and the clinical outcome of the operation. Discharge abstracts of 1561 patients who had undergone esophagectomy for malignancy at acute care hospitals in California from 1990 through 1994 were obtained from the Office of Statewide Health Plating and Development. The hospitals were grouped according to the number of esophagectomies performed during the S-year period, and a mortality rate was calculated for each group. Logistic regression analysis was used to determine the relationship between a hospital’s rate of esophagectomy and the mortality rate. Esophageal resections were performed in 273 hospitals. An average of two or fewer resections were performed annually in 88% of hospitals, which accounted for 50% of all patients treated. The mortality rate in hospitals with more than 30 esophagectomies for the S-year period was 4.8%, compared with 16% for hospitals with fewer than 30 esophagectomies. This could not be accounted for by other health variables affecting the patients’ risk for surgery. There was a striking correlation between a hospital’s frequency of esophagectomy and the outcome of this operation. The results support the proposition that high-risk general surgical procedures, such as esophagectomy for malignancy, should be restricted to hospitals that can exceed a yearly minimum experience.

Correlation of paired liver biopsies in morbidly obese patients with suspected nonalcoholic fatty liver disease

In the absence of surrogate markers, the evaluation of suspected nonalcoholic fatty liver disease (NAFLD) is highly dependent on histological examination. The extent of sampling variability affecting the reliability of a single liver biopsy in patients with suspected NAFLD is poorly characterized. This prospective study aimed to correlate precise histological findings in paired biopsies—right and left lobe—in the diagnosis of NAFLD in morbidly obese subjects undergoing bariatric surgery employing both Brunt and Matteoni classifications and the NAFLD Activity Score (NAS). We also aimed to determine whether the composite histopathological findings of the two biopsies would improve diagnostic accuracy. Consecutive subjects had an intraoperative biopsy from both right and left lobes, evaluated and scored in a blinded manner. Intraobserver agreement was also assessed. Kappa coefficients of agreement were calculated. Forty‐one subjects had acceptable biopsies. Agreement for steatosis was excellent and moderate for fibrosis. Concordance was only fair for most features of necroinflammation. Intraobserver agreement was only moderate for lobular inflammation. Excellent agreement was seen for the diagnosis of NASH using Brunt criteria and good agreement when using Matteoni and NAS scoring systems. Composite biopsy data particularly improved identification of hepatocyte ballooning. The diagnostic accuracy also improved substantially when composite features were compared with single‐sided biopsy features, especially for the Matteoni and NAS scoring systems. In conclusion, significant sampling variability occurs in NAFLD, particularly for features of necroinflammation. This should be factored into the design of clinical trials and studies of the natural history of the disease. (HEPATOLOGY 2006;44:874–880.)

Hiatal hernia size affects lower esophageal sphincter function, esophageal acid exposure, and the degree of mucosal injury

Background Since the role of a hiatal hernia in the pathophysiology of gastroesophageal reflux disease (GERD) has not been fully elucidated, we studied the effects of hiatal hernias on the function of the lower esophageal sphincter (LES) and esophageal acid clearance. Patients and methods Ninety-five consecutive patients with GERD diagnosed by 24-hour pH monitoring underwent upper gastrointestinal series (UGI), endoscopy, and esophageal manometry. Based on the presence (H+) or absence (H-) of a hiatal hernia on UGI series, they were divided into two groups: H+ (n = 51) and H- (n = 44). Then, using the size of the hiatal hernia, the H+ group was divided into three subgroups: I, H 5 cm (n = 6). Results Esophageal manometry showed that patients with larger hiatal hernias (groups II and III) had a weaker and shorter LES and less effective peristalsis compared to patients with a small or no hiatal hernia. Prolonged pH monitoring showed that patients with larger hiatal hernias were exposed to more refluxed acid and had more severely abnormal acid clearance. Endoscopy showed more severe esophagltis among patients with GERD and hiatal hernia compared with GERD patients without hiatal hernia, and the degree of esophagitis was proportionate to the size of the hernia. Conclusions Among patients with proven GERD, those with a small hiatal hernia and those with no hiatal hernia had similar abnormalities of LES function and acid clearance. In patients with larger hiatal hernias, however, the LES was shorter and weaker, the amount of reflux was greater, and acid clearance was less efficient. Consequently, the degree of esophagitis was worse in the presence of a large hiatal hernia.

Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change

BACKGROUND Twenty years ago an average of 1.5 Heller myotomies were performed per year in our hospital, mostly for patients whose dysphagia did not improve following balloon dilatation or whose esophagus had been perforated during a balloon dilatation. Ten years ago we started using minimally invasive surgery to treat this disease. STUDY DESIGN This study measures the impact of minimally invasive surgery with regard to the following: the number of patients referred for treatment; the number of patients who came to surgery without previous treatment; and the results of surgical treatment. Between 1991 and 2001, 149 patients had minimally invasive surgery for achalasia: 25 patients (17%) had thoracoscopic Heller myotomy and 124 (84%) had laparoscopic Heller myotomy and Dor fundoplication. Of the 149 patients, 79 patients (53%) had previous treatment (56 patients [71%], balloon dilatation; 7 patients [9%], botulinum toxin injection; 16 patients [20%], both) and 70 patients (43%) had none of these treatments. Mean postoperative followup was 59 +/- 36 months. Patients were divided into two groups: group A, operated on between 1991 and 1995; and group B, operated on between 1996 and 2001. RESULTS In the past decade, the number of patients referred for surgery has increased substantially--group A, 48; group B, 101; an increasing proportion of patients were referred for surgery without previous treatment--group A, 38%; group B, 51%; and the outcomes of the operation progressively improved--group A, 87%; group B, 95%. CONCLUSIONS These data show that the high success rate of laparoscopic Heller myotomy for achalasia has brought a shift in practice; surgery has become the preferred treatment of most gastroenterologists and other referring physicians. This has followed documentation that laparoscopic treatment outperforms balloon dilatation and botulinum toxin injection.

Effects of Previous Treatment on Results of Laparoscopic Heller Myotomy for Achalasia

Until recently, pneumatic dilatation andintrasphincteric injection of botulinum toxin (Botox)have been used as initial treatments for achalasia, withmyotomy reserved for patients with residual dysphagia. It is unknown, however, whether thesenonsurgical treatments affect the performance of asubsequent myotomy. We compared the results oflaparoscopic Heller myotomy and Dor fundoplication in 44patients with achalasia who had been treated withmedications (group A, 16 patients), pneumatic dilatation(group B, 18 patients), or botulinum toxin (group C, 10patients). The last group was further subdivided according to whether there was (C2, 4 patients)or was not (C1, 6 patients) a response to the treatment.Results for groups A, B, C1, and C2, respectively, were:anatomic planes identified at surgery (% of patients) — 100%, 89%, 100%, and 25%;esophageal perforation (% of patients) — 0%, 5%,0%, and 50%; hospital stay (hrs)-26 ± 8, 38± 25, 26 ± 11, and 72 ± 65; andexcellent/good results (% of patients) — 87%, 95%, 100%, and50%. These results show that: (1) previous pneumaticdilatation did not affect the results of myotomy; (2) inpatients who did not respond to botulinum toxin, the myotomy was technically straightforward and theoutcome was excellent; (3) in patients who responded tobotulinum toxin, the LES muscle had become fibrotic(perforation occurred more often in this setting, and dysphagia was less predictably improved);and (4) myotomy relieved dysphagia in 91% of patientswho had not been treated with botulinum toxin. Thesedata support a strategy of reserving botulinum toxin for patients who are not candidates forpneumatic dilatation or laparoscopic Hellermyotomy.

Esophageal dysmotility and gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) produces a spectrum of symptoms ranging from mild to severe. While the role of the lower esophageal sphincter in the pathogenesis of GERD has been studied extensively, less attention has been paid to esophageal peristalsis, even though peristalsis governs esophageal acid clearance. The aim of this study was to evaluate the following in patients with GERD: (1) the nature of esophageal peristalsis and (2) the relationship between esophageal peristalsis and gastroesophageal reflux, mucosal injury, and symptoms. One thousand six consecutive patients with GERD confirmed by 24-hour pH monitoring were divided into three groups based on the character of esophageal peristalsis as shown by esophageal manometry: (1) normal peristalsis (normal amplitude, duration, and velocity of peristaltic waves); (2) ineffective esophageal motility (IEM; distal esophageal amplitude <30 mm Hg or >30% simultaneous waves); and (3) nonspecific esophageal motility disorder (NSEMD; motor dysfunction intermediate between the other two groups). Peristalsis was classified as normal in 563 patients (56%), IEM in 216 patients (2l%), and NSEMD in 227 patients (23%). Patients with abnormal peristalsis had worse reflux and slower esophageal acid clearance. Heartburn, respiratory symptoms, and mucosal injury were all more severe in patients with IEM. These data show that esophageal peristalsis was severely impaired (IEM) in 21 % of patients with GERD, and this group had more severe reflux, slower acid clearance, worse mucosal injury, and more frequent respiratory symptoms. We conclude that esophageal manometry and pH monitoring can be used to stage the severity of GERD, and this, in turn, should help identify those who would benefit most from surgical treatment.

Changing management of gallstone disease during pregnancy

AbstractBackground: Symptomatic gallstones may be problematic during pregnancy. The advisability of laparoscopic cholecystectomy (LC) is uncertain. The objective of this study is to define the natural history of gallstone disease during pregnancy and evaluate the safety of LC during pregnancy. Methods: Review of medical records of all pregnant patients with gallstone disease at the University of California, San Francisco, from 1980 to 1996. Results: Of approximately 29,750 deliveries, 47 (0.16%) patients were treated for gallstone disease, including biliary colic in 33, acute cholecystitis in 12, and pancreatitis in two. Conservative treatment was attempted in all patients but failed in 17 (36%) cases. Two patients required combined preterm Cesarean-section cholecystectomy and 10 required surgery in the early postpartum period for persistent symptoms. Seventeen patients required cholecystectomy during pregnancy for biliary colic (10), acute cholecystitis (six), and pancreatitis (one). Three patients were treated with open cholecystectomy. Fourteen patients underwent LC at a mean gestational age of 18.6 weeks, mean OR time of 74 min, and mean length of stay of 1.2 days. Hasson cannulation was utilized in 11 patients. Reduced-pressure pneumoperitoneum (6–10 mmHg) was used in seven patients. Prophylactic tocolytics were used in seven patients, with transient postoperative preterm labor observed in one. There were no open conversions, preterm deliveries, fetal loss, teratogenicity, or maternal morbidity. Conclusions: In past years, symptomatic gallstones during pregnancy were managed conservatively or with open cholecystectomy. LC is a feasible and safe method for treating severely symptomatic patients.

Laparoscopic Repair of Paraesophageal Hiatal Hernias

BACKGROUND Regardless of symptoms, paraesophageal hiatal hernias should be repaired in order to prevent complications. This study reports the University of California San Francisco experience with laparoscopic repair of paraesophageal hiatal hernias, emphasizing the technical steps essential for good results. PATIENTS AND METHODS From May 1993 to September 1997, 55 patients, 27 women and 28 men, with a mean age of 67 years (range, 35-102 years) underwent laparoscopic repair of paraesophageal hernias at the University of California San Francisco. Symptoms, which had been present an average of 85 months before surgery, consisted mainly of pain (55%), heartburn (52%), dysphagia (45%), and regurgitation (41%). Of the four patients who presented with acute illness, two had gastric obstruction, one had severe dyspnea, and one had gastric bleeding. Endoscopy demonstrated esophagitis in 25 (69%) of 36 patients, and 24-hour pH-monitoring demonstrated acid reflux in 22 (67%) of 33 patients. Manometry detected severely impaired distal esophageal peristalsis in 17 (52%) of 33 patients. The preferred operation consisted of reduction of the hernia, excision of the sack and the gastric fat pad, closure of the enlarged hiatus without mesh, and construction of a fundoplication anchored by sutures within the abdomen. RESULTS Of the 55 patients, the operations of 49 were completed laparoscopically using the following reconstructions: Guarner (270-degree) fundoplication (30 patients); Nissen fundoplication (10 patients); and gastropexy (9 patients). Five (9%) operations were converted to laparotomies. The average operating time was 219 minutes; the average blood loss was less than 25 mL; resumption of an unrestricted diet, 27 hours; and mean hospital stay, 58 hours. Intraoperative technical complications occurred in five (9%) patients. One patient died during surgery from a sudden pulmonary embolus. Two (4%) patients required a second operation for recurrent paraesophageal hernias. CONCLUSIONS Laparoscopic repair of paraesophageal hiatal hernias is safe and effective, but the operation is difficult and good results hinge on details of the operative technique and the surgeons experience. In this series, the crus could always be closed securely without using mesh. We realized early that a fundoplication should be a routine step, because it corrects reflux and is the best method to secure the gastroesophageal junction in the abdomen.

Thoracoscopic esophageal myotomy in the treatment of achalasia

We treated 24 patients with achalasia using thoracoscopic (22 patients) or laparoscopic (2 patients) esophagomyotomy. The only operative complications were mucosal lacerations, which occurred in 3 patients and required conversion to an open procedure in 2. Twenty-two (91%) patients were eating by the second postoperative day. Analgesics were only required for the management of pain from the chest tube, which remained in place for a median time of 24 hours. The median postoperative hospital stay was 3 days (range, 20 to 14 days). The myotomy proved to be incomplete in the first 3 patients, who required a second myotomy; this was done laparoscopically in 2. One patient had a paraesophageal hernia repaired 6 months after the myotomy, and 1 patient required an esophagectomy 1 year after the myotomy for a large nonfunctioning esophagus. Late follow-up showed that swallowing was excellent in 17 (71%) and fair to good in 4 (17%). Sixteen (66%) of these 24 patients have regained their original weight. Thus, excellent to good results were ultimately obtained in nearly 90% of the patients. These results suggest that esophageal myotomy performed using minimally invasive techniques appears to be the treatment of choice for achalasia.