Re: surgery and esophageal peristalsis

January 13, 2004

In a message dated 1/13/2004 4:44:49 PM Eastern Standard Time, heiser@... writes:

Surgery will simply open up the LES so food can go through once it gets there, but you'll still need to use gravity and water to get it down to that point. Most of the results I've seen on the site for people who have had a successful myotomy is that they can eat just about anything they want to, but that they have to have plenty of liquid to "wash it down."

Question:

Since many patients who have the myotomy surgery also have a fundoplication,(Nissen or Toupet), how does the food slide by the "wrapped", but wider LES?

Jan in Northern KY

January 13, 2004

Genia, at this point in time there is no way to get the peristalsis to return.

Surgery will simply open up the LES so food can go through once it gets there, but you'll still need to use gravity and water to get it down to that point. Most of the results I've seen on the site for people who have had a successful myotomy is that they can eat just about anything they want to, but that they have to have plenty of liquid to "wash it down."

They're supposedly doing research for something that would be implanted (like a pacemaker) to electrically stimulate the muscles to contract in peristaltic waves, but that's a decade or so down the road according to the last GI I talked to about it.

Debbi

January 13, 2004

Hi Genia,

Unfortunately, once the nerves have died resulting in no peristalsis, muscle contractions do not return. That is why so much food builds up and you always hear about people in the group drinking so much water. Personally, I drink a liter of milk every day with my food instead of water. It's not really a huge issue though. Gravity works well

Good luck,

.

-- surgery and esophageal peristalsis

I am curious.I am suppose to meet with a surgeon on Monday, (If he knows how to do the surgery and does it often). I have been thinking, I basically have lost all m my esophageal peristalsis, when I get the surgery, does any of the muscle contraction come back in my esophagus?what are your results from the surgery?Thanks,Genia from Michigan

January 13, 2004

---

Genia,

Please don't be too upset about the paristalsis in your E.

You just won't be able to eat laying down, I can think

of a lot worse. Your not suppose to eat while laying

down anyway! ha ha

Jenifer

In achalasia , " lotsalaughs34 " <lotsalaughs34@y...>

wrote:

> I am curious.

> I am suppose to meet with a surgeon on Monday, (If he knows how to

do

> the surgery and does it often). I have been thinking, I basically

> have lost all m my esophageal peristalsis, when I get the surgery,

> does any of the muscle contraction come back in my esophagus?

> what are your results from the surgery?

>

> Thanks,

> Genia from Michigan

January 13, 2004

Genia,

My understanding is that the loss of peristalsis is due to the muscles of the esophagus being stretched out and not due to nerve loss. If I'm right about that, then at least theoretically some perstalisis could return. I know that my esophagus was quite distended prior to surgery. I can feel that I do currently have some peristalisis. What I can't say is whether it is more than I had pre surgery.

As others have posted, it doesn't matter much as long as I don't eat while laying down or do space travel. Gravity and liquids works just fine. In resteraunts I've learned to always ask for water and often order iced tea (which is ussually free refills for some odd reason!).

I suggest you ask this question to your surgeon and let us know what she/he says....I'll be interested to hear.

Good luck with it all...

Aloha,

surgery and esophageal peristalsis

I am curious.I am suppose to meet with a surgeon on Monday, (If he knows how to do the surgery and does it often). I have been thinking, I basically have lost all m my esophageal peristalsis, when I get the surgery, does any of the muscle contraction come back in my esophagus?what are your results from the surgery?Thanks,Genia from Michigan

January 13, 2004

---

Hi ,

I think you may be right because when I asked one of

the surgeons I consulted with if I would ever regain

peristalsis he told me probably not but maybe. This

was a doctor at the Cleveland Clinic.

Jenifer

In achalasia , " Dr. L. " <@D...>

wrote:

> Genia,

>

> My understanding is that the loss of peristalsis is due to the

muscles of the esophagus being stretched out and not due to nerve

loss. If I'm right about that, then at least theoretically some

perstalisis could return. I know that my esophagus was quite

distended prior to surgery. I can feel that I do currently have some

peristalisis. What I can't say is whether it is more than I had pre

surgery.

>

> As others have posted, it doesn't matter much as long as I don't

eat while laying down or do space travel. Gravity and liquids works

just fine. In resteraunts I've learned to always ask for water and

often order iced tea (which is ussually free refills for some odd

reason!).

>

> I suggest you ask this question to your surgeon and let us know

what she/he says....I'll be interested to hear.

>

> Good luck with it all...

>

> Aloha,

> surgery and esophageal peristalsis

>

> I am curious.

> I am suppose to meet with a surgeon on Monday, (If he knows how

to do

> the surgery and does it often). I have been thinking, I basically

> have lost all m my esophageal peristalsis, when I get the

surgery,

> does any of the muscle contraction come back in my esophagus?

> what are your results from the surgery?

>

> Thanks,

> Genia from Michigan

>

January 13, 2004

Hello-

My Achalasia is due to nerve loss so I have no perstalisis in the lower

half of my E. The top half still works some. My E is stretched out due

to the pushing of food down without release of the LES. So, I will not

have any return of perstalisis in the lower half. Shows how different

everyone is here. I have a myotomy scheduled for next week.

>>> @... 01/13/04 05:56PM >>>

Genia,

My understanding is that the loss of peristalsis is due to the muscles

of the esophagus being stretched out and not due to nerve loss. If I'm

right about that, then at least theoretically some perstalisis could

return. I know that my esophagus was quite distended prior to surgery.

I can feel that I do currently have some peristalisis. What I can't say

is whether it is more than I had pre surgery.

As others have posted, it doesn't matter much as long as I don't eat

while laying down or do space travel. Gravity and liquids works just

fine. In resteraunts I've learned to always ask for water and often

order iced tea (which is ussually free refills for some odd reason!).

I suggest you ask this question to your surgeon and let us know what

she/he says....I'll be interested to hear.

Good luck with it all...

Aloha,

surgery and esophageal peristalsis

I am curious.

I am suppose to meet with a surgeon on Monday, (If he knows how to do

the surgery and does it often). I have been thinking, I basically

have lost all m my esophageal peristalsis, when I get the surgery,

does any of the muscle contraction come back in my esophagus?

what are your results from the surgery?

Thanks,

Genia from Michigan

January 13, 2004

Hi ;

I had asked my Specialist several years ago about the reasons for loss of peristalsis. He specifically told me it was caused from the nerve damage. I had no peristalsis before my esophagus was stretched. On my very first scope, he had a hard time because everything was so narrow. Also, 12 years later, I am still numb all around my incision get the occasional shooting pain from scar tissue when I stretch. Maybe he was wrong, who knows, but I thought I'd add what I was told.

Hope you're getting a nice tan! I'm freezing in Thunder bay. -32 Celsius

.

-- Re: surgery and esophageal peristalsis

Genia,

My understanding is that the loss of peristalsis is due to the muscles of the esophagus being stretched out and not due to nerve loss. If I'm right about that, then at least theoretically some perstalisis could return. I know that my esophagus was quite distended prior to surgery. I can feel that I do currently have some peristalisis. What I can't say is whether it is more than I had pre surgery.

As others have posted, it doesn't matter much as long as I don't eat while laying down or do space travel. Gravity and liquids works just fine. In resteraunts I've learned to always ask for water and often order iced tea (which is ussually free refills for some odd reason!).

I suggest you ask this question to your surgeon and let us know what she/he says....I'll be interested to hear.

Good luck with it all...

Aloha,

surgery and esophageal peristalsis

I am curious.I am suppose to meet with a surgeon on Monday, (If he knows how to do the surgery and does it often). I have been thinking, I basically have lost all m my esophageal peristalsis, when I get the surgery, does any of the muscle contraction come back in my esophagus?what are your results from the surgery?Thanks,Genia from Michigan

January 13, 2004

-

Before I had my surgery I had to drink a lot of water

when I ate. Now I can eat with no liquid. The only

time I feel the need to wash it down is if I eat

something like doughnuts.

Jenifer

-- In achalasia , JMB000001@a... wrote:

> In a message dated 1/13/2004 4:44:49 PM Eastern Standard Time,

> heiser@t... writes:

> Surgery will simply open up the LES so food can go through once it

gets

> there, but you'll still need to use gravity and water to get it

down to that point.

> Most of the results I've seen on the site for people who have had

a

> successful myotomy is that they can eat just about anything they

want to, but that

> they have to have plenty of liquid to " wash it down. "

>

> Question:

> Since many patients who have the myotomy surgery also have a

> fundoplication,(Nissen or Toupet), how does the food slide by

the " wrapped " , but wider LES?

> Jan in Northern KY

January 13, 2004

,

Thanks for the info. The last time I talked to an MD about A was so long ago. Hopefully they understand better now. As some posts are pointing out, we may have different situations. I guess the only thing I "know" is that sometimes it feels as though I have parrastollisis (sp?) and sometimes I don't. When I see my new MD I'll ask for an oppinion.

Aloha,

surgery and esophageal peristalsis

I am curious.I am suppose to meet with a surgeon on Monday, (If he knows how to do the surgery and does it often). I have been thinking, I basically have lost all m my esophageal peristalsis, when I get the surgery, does any of the muscle contraction come back in my esophagus?what are your results from the surgery?Thanks,Genia from Michigan

January 13, 2004

wrote:

> As some posts are pointing

> out, we may have different situations. I guess the only thing I " know " is

> that sometimes it feels as though I have parrastollisis (sp?) and

> sometimes I don't. When I see my new MD I'll ask for an oppinion.

Just wanted to clear up something. In many of us in this group, the

" peristaltic contractions " seem to vary. I've always been able to see my

manometry (I've had maybe 6-10 in the past decade.... kinda lost count!)

and I've always discussed it with the technician and/or the physician. It

was very obvious from looking at my manometry what was happening in my

esophagus when I swallowed.

For the purposes of this (over-simplified) illustration, think of the

" regions " of an esophagus labeled A, B, C, and D, with A being closest to

the top and D being the LES. In a normal person, when they first swallow

food, they'll get a contraction at the top (A), then further down (,

then further down © and a little more (D) and finally the LES will open

and the food will pass into the stomach.

In just one 45-minute session, I can have a swallow where ABCD all

contract simultaneously. Another swallow will have A and C together, but

no activity by B and D. Sometimes they'll contract in a random pattern,

maybe something like A B D B C A D B D B C B C A D B (this one is really

neat to watch on video from fluoroscopy (video x-rays)... I call it the

" ping-pong " effect, b/c you can see the barium bouncing up and down, back

and forth.) Sometimes no regions contract at all, or they do enough to

make a teeny bump on the manometry, but nothing like the big MOUNTAIN bump

you'd get from a normal person. And sometimes I'll get a funky

contraction when I wasn't even swallowing.

For people who say they have " no peristalsis " I think it would be good to

clarify what you mean, b/c not everyone interprets that the same. I think

for the purposes of this discussion, it's being interpreted to mean NO

contractions at all, and it would help if everyone could clarify what we

mean so we're all on the same page.

Technically, peristalsis is defined as " successive waves of involuntary

contraction passing along the walls of a hollow muscular structure (as the

esophagus or intestine) and forcing the contents onward " (according to

Merriam-Webster.) By definition, then, " aperistalsis " is not the complete

absence of ANY contractions, but rather the absence of SUCCESSIVE WAVES of

contraction (as in A then B then C then D.)

My " ping pong " contractions are, indeed, contractions, and they do move

the bolus (swallowed food/liquid) around inside my esophagus, but they are

*not* defined as PERISTALTIC contractions, because they don't occur in the

A B C D order like they are supposed to, and they don't properly propel

the food along my esophagus towards the end goal of having the food reach

the stomach.

We also have peristaltic contractions throughout our GI tract... that's

what propels the food through the small and large intestines as it's being

digested.

Debbi in Michigan, also cold but not nearly as cold as in Thunder Bay!

January 14, 2004

Hi Debbi,

I have no peristalsis - zero muscle movement - from 2 thirds of the way down - about the level of your B. This is also because I have a huge diverticulum at that point [ a break in the oesophageal wall where the wall balloons outwards]

I had a video barium swallow and it was fascinating to watch it all, but from level B there was definitely no movement and the barium came down slowly by gravity.

Possibly it will depend on the amount of damage done to the oesopageal wall prior to having a relase procedure done, wheter peristalsis returns. There could be nerve damage and the wall muscles could have become overstretched.

It as hot as Hades here right now - come and visit!

Joan

Johannesburg South Africajpearse@...

Re: surgery and oesophageal peristalsis

wrote:> As some posts are pointing> out, we may have different situations. I guess the only thing I "know" is> that sometimes it feels as though I have peristalsis (sp?) and> sometimes I don't. When I see my new MD I'll ask for an oppinion.Just wanted to clear up something. In many of us in this group, the"peristaltic contractions" seem to vary. I've always been able to see mymanometry (I've had maybe 6-10 in the past decade.... kinda lost count!)and I've always discussed it with the technician and/or the physician. Itwas very obvious from looking at my manometry what was happening in myesophagus when I swallowed.For the purposes of this (over-simplified) illustration, think of the"regions" of an esophagus labeled A, B, C, and D, with A being closest tothe top and D being the LES. In a normal person, when they first swallowfood, they'll get a contraction at the top (A), then further down (,then further down © and a little more (D) and finally the LES will openand the food will pass into the stomach.In just one 45-minute session, I can have a swallow where ABCD allcontract simultaneously. Another swallow will have A and C together, butno activity by B and D. Sometimes they'll contract in a random pattern,maybe something like A B D B C A D B D B C B C A D B (this one is reallyneat to watch on video from fluoroscopy (video x-rays)... I call it the"ping-pong" effect, b/c you can see the barium bouncing up and down, backand forth.) Sometimes no regions contract at all, or they do enough tomake a teeny bump on the manometry, but nothing like the big MOUNTAIN bumpyou'd get from a normal person. And sometimes I'll get a funkycontraction when I wasn't even swallowing.For people who say they have "no peristalsis" I think it would be good toclarify what you mean, b/c not everyone interprets that the same. I thinkfor the purposes of this discussion, it's being interpreted to mean NOcontractions at all, and it would help if everyone could clarify what wemean so we're all on the same page.Technically, peristalsis is defined as "successive waves of involuntarycontraction passing along the walls of a hollow muscular structure (as theesophagus or intestine) and forcing the contents onward" (according toMerriam-Webster.) By definition, then, "aperistalsis" is not the completeabsence of ANY contractions, but rather the absence of SUCCESSIVE WAVES ofcontraction (as in A then B then C then D.)My "ping pong" contractions are, indeed, contractions, and they do movethe bolus (swallowed food/liquid) around inside my esophagus, but they are*not* defined as PERISTALTIC contractions, because they don't occur in theA B C D order like they are supposed to, and they don't properly propelthe food along my esophagus towards the end goal of having the food reachthe stomach.We also have peristaltic contractions throughout our GI tract... that'swhat propels the food through the small and large intestines as it's beingdigested.Debbi in Michigan, also cold but not nearly as cold as in Thunder Bay!

January 14, 2004

Joan, I'm on a plane right now -- what's your address!!! Hehehehe

We're getting about 3-5" of snow right now.... want me to send you some???

Hi Debbi,

I have no peristalsis - zero muscle movement - from 2 thirds of the way down - about the level of your B. This is also because I have a huge diverticulum at that point [ a break in the oesophageal wall where the wall balloons outwards]

I had a video barium swallow and it was fascinating to watch it all, but from level B there was definitely no movement and the barium came down slowly by gravity.

Possibly it will depend on the amount of damage done to the oesopageal wall prior to having a relase procedure done, wheter peristalsis returns. There could be nerve damage and the wall muscles could have become overstretched.

It as hot as Hades here right now - come and visit!

Joan

Johannesburg South Africa

January 14, 2004

Jan wrote:

Question:

Since many patients who have the myotomy surgery also have a fundoplication,(Nissen or Toupet), how does the food slide by the "wrapped", but wider LES?

Jan, I may be wrong but I don't think that most people end up with a fundoplication anymore, from what I've seen in this group over the past year or so. Offhand I'd guess that half or less get "wrapped."

For those who do have a fundoplication with the Heller Myotomy, the grand majority either have the Toupet or Dor - the Nissen is generally only done for GERD patients, not for those w/ achalasia. Both Toupet and Dor are "partial" fundoplication, with Toupet being a posterior (around the back) wrap and Dor being an anterior (around the front) wrap. Neither of these go all the way around (as the Nissen does) -- I believe the Toupet goes around 270-degrees and the Dor only goes around 180-degrees, instead of the full 360-degrees to go completely around the esophagus. This gives a much looser wrap than the Nissen... I've seen reference to it being called a "floppy fundoplication" even.

Below is an interesting write-up, excerpted from http://www.tcd.ie/tsmj/2003/achcardia.htm

This originates in Ireland, so they use the UK-style of spelling esophagus as oesophagus, so it can catch you off guard when you forget about the variation in spelling. LOS in the article is LES to North Americans.... GOR is our GERD, etc.

As you can see, there is some question whether a fundoplication needs to be done at all (I believe that's why more and more people are now having the Heller Myotomy w/ no wrap at all -- in the past it was assumed to be necessary, but now some docs aren't convinced and they don't do it anymore.)

But to answer your main question, a PARTIAL wrap isn't as tight as the untreated, clamped-shut LES, so food can indeed go through even without peristalsis.

Hope that helps a bit!Debbi

THE CONTROVERSY

In the surgical treatment of achalasia, a balance must be found - there must be a sufficient decrease in oesophageal obstruction to provide symptomatic relief, but an excessive decrease in LOS pressure results in GOR. An anti-reflux procedure is sometimes added to avoid this. Laparoscopic procedures are either combined with a Floppy Toupet Fundoplication attached to the sides of the myotomy or a Dor fundoplication, known as the laparoscopic Heller-Dor fundoplication. There is, nonetheless, considerable debate surrounding the actual therapeutic value of such an addition.

Arguments against an Anti-reflux procedure after oesophageal myotomy:

It is clear that adding a complete fundoplication increases resistance at the GO junction and defeats the objective of the myotomy i.e. to decrease this resistance. There is, however, evidence that even partial fundoplication procedures, e.g. Toupet and Dor techniques, increase LOS resistance and could compromise the effectiveness of the myotomy. Ellis et al. (1984) have achieved excellent relief of dysphagia with Heller myotomy alone, with only 9-15% of patients having unsatisfactory results.31

s et al. (1999) studied gastroesophageal reflux in 75 patients who had been treated by myotomy without fundoplication. They discovered that there was only a very weak correlation between patients’ perceptions of their GOR (heartburn symptoms), as evaluated by a questionnaire, and objective measurement of reflux by a distal pH sensor.32 This proves that heartburn symptoms are not a reliable indicator of GOR in achalasia patients and should not be used as a justification to perform a fundoplication procedure with myotomy.

Furthermore, the same author found that confirmed pathological acid reflux, present in only 13% of patients, does not conform to the usual Gastro-Oesophageal Reflux Disease (GORD) pattern. Reflux events in achalasia patients occur less frequently, are of a longer duration and happen predominantly when the patient is supine.33 This suggests that it is inadequate clearance of fermented food and/or refluxed acid, rather than true acid reflux, which is responsible for post-myotomy heartburn. This theory is strengthened by the finding, corroborated by Ellis, that the patients most likely to have such symptoms were those with the highest LOS pressures i.e. higher resistance across the GO junction.34 Thus a fundoplication procedure, aimed at increasing this resistance, could potentially worsen heartburn symptoms. Indeed, pathological acid reflux following myotomy with fundoplication has been found by Patti et al.(2001) and by Csendes et al.(1981) in 17% and 19% of patients respectively. This (shows that fundoplication clearly does not fully solve the problem of post-myotomy reflux. Bonavina et al (1992)., meanwhile, achieved a very impressive 8.6% incidence of reflux when myotomy was performed without an anti-reflux procedure.37

Finally, the risk-benefit ratio of adding an anti-reflux procedure must be considered. Patti et al. noteed a risk of technical problems with a Dor fundoplication and suggest that these may be avoided by skilled surgery and meticulous attention to detail.35 However, surgeons may not perform these procedures with sufficient regularity to ensure this. A simpler procedure plainly reduces the risk of technical hitches.

As previously mentioned, s et al.(2001) report pathological acid reflux in 13% of patients when myotomy is performed without an associated fundoplication.33 Routine addition of an anti-reflux procedure would thus treat 87% of patients needlessly. This is particularly pointless when one considers the fact that medication frequently suffices to control reflux symptoms in this 13%. The dysphagia which results from an insufficiently lowered LOS pressure, meanwhile, requires far more drastic treatment measures, namely pneumatic dilatation or even further surgery.

Arguments in favour of an Anti-reflux procedure after oesophageal myotomy:

Iatrogenic GORD has only recently been given proper consideration and recognition. There are therefore a limited number of studies objectively documenting oesophageal acid exposure after treatment for achalasia. Those that are available reveal some interesting trends (Tables 1 and 2).

Table 1. Postoperative pH studies after transthoracic limited myotomy without fundoplication for the treatment of achalasia

Table 2. Postoperative pH studies following laparoscopic myotomy and fundoplication for the treatment of achalasia

Relevant to the "pro-anti-reflux procedure" argument is the fact that reflux-induced stricture after an oesophageal myotomy is a severe problem, and usually requires oesophagectomy for relief of symptoms.

Long-term data stress the need for anti-reflux protection. Malthaner et al. (1994) reported on long-term clinical results in 35 patients with achalasia.22 These patients had undergone primary oesophageal myotomy and Belsey hemifundoplication at Toronto General Hospital. The minimum follow up time was 10 years. Excellent results were found in 95% of patients at 1 year, declining to 68% after 10 years. It was concluded that there was a deterioration of the initially good results after surgical myotomy and hiatal repair, and that most of the deterioration was due to the complication of GOR.38 In another study, Ellis reported his experience with transthoracic short oesophageal myotomy without an anti-reflux procedure. 179 patients were analysed at a mean follow-up of 9 years, ranging from 6 months to 20 years. Overall, 89 % of patients were improved at 9 years post-operatively. Ellis also noted deterioration in good results with time. The fact that his clinical data was similar to findings in the Toronto study suggests the likelihood that reflux played a significant role in his results as well.34

Another relevant finding of several recent studies is that a post-treatment sphincter pressure of less than 10mmHg is required for long term relief of dysphagia.39,40 This is relevant because it shows that near complete disruption of the sphincter is required to relieve dysphagia in the long term.

In one of the largest studies reported yet, Bonavina et al. (1992) report good to excellent results with transabdominal myotomy and Dor fundoplication. 94% of 198 patients had excellent/good outcomes after a mean follow-up of 5.4 years. A remarkable 81% of patients returned for post-operative 24-hour pH studies, of which only 7 (8.6%) had a positive test result. Oesophageal diameter was significantly decreased post myotomy, as was LOS pressure (40.5 +/- 9.7 to 11.7 +/- 4.7 mmHg).37

Zaninotto et al. (2000) reported results in 100 patients who underwent a laparoscopic Heller-Dor procedure. 70% of patients reported no dysphagia and 22 % complained of only occasional difficulty swallowing. 7 patients were salvaged by post-operative pneumatic dilatation. Of note, 24-hour oesophageal pH monitoring showed abnormal reflux in only 5 (6.5%) of 63 patients tested.41

These studies confirm that laparoscopic Heller-Dor fundoplication achieves excellent medium-term results.

Patti et al. (1999) compared the outcome of 30 patients who had undergone laparoscopic myotomy with a Dor anterior fundoplication to that of 30 patients who had undergone thoracoscopic myotomy without anti-reflux repair. Dysphagia was well-relieved by both the laparoscopic and thoracoscopic groups (77% and 70% success rates respectively). 20% of patients in the group who did not have a fundoplication had a positive post-operative 24-hour pH study result compared to only 3% following the Heller-Dor procedure.30

CONCLUSION

GOR is uncommon in achalasia patients who have not undergone surgery and most evidence suggests that pH proved-reflux is minimised by the addition of a partial fundoplication to a myotomy. Studies show that abdominal myotomy combined with fundoplication provides excellent symptomatic outcomes in both the short- and the long-term in patients with achalasia. Perhaps it is better to perform a partial fundoplication with a myotomy in a single operation, and thereby reduce the risk of reflux, than to risk post-operative reflux, its complications and with them, further radical surgery.

On the other hand, why complicate a surgical procedure with addition of fundoplication when such an addition risks compromising the very outcome of the surgery (i.e. by re-increasing the LOS pressure reduced by the myotomy)? Also, the fundoplication procedure has not yet been definitely proven to prevent GOR and, in any case, may be unnecessary in the majority of patients.

It is evident that there is an urgent need for in-depth study of this question. Only a randomised controlled trial of Heller myotomy, with and without an anti-reflux procedure, including full patient evaluation by questionnaire, manometry and 24 hour pH studies can provide a satisfactory answer.

January 14, 2004

-

I had a partial wrap and have no problem eating. I think I

would be afraid of not having a partial wrap because I would

be afraid of reflux and all that acid in my E.

Jenifer

-- In achalasia , " Debbi Heiser " <heiser@t...> wrote:

> Jan wrote:

> Question:

> Since many patients who have the myotomy surgery also have a

fundoplication,(Nissen or Toupet), how does the food slide by

the " wrapped " , but wider LES?

>

> Jan, I may be wrong but I don't think that most people end up with

a fundoplication anymore, from what I've seen in this group over the

past year or so. Offhand I'd guess that half or less get " wrapped. "

>

> For those who do have a fundoplication with the Heller Myotomy, the

grand majority either have the Toupet or Dor - the Nissen is

generally only done for GERD patients, not for those w/ achalasia.

Both Toupet and Dor are " partial " fundoplication, with Toupet being a

posterior (around the back) wrap and Dor being an anterior (around

the front) wrap. Neither of these go all the way around (as the

Nissen does) -- I believe the Toupet goes around 270-degrees and the

Dor only goes around 180-degrees, instead of the full 360-degrees to

go completely around the esophagus. This gives a much looser wrap

than the Nissen... I've seen reference to it being called a " floppy

fundoplication " even.

>

> Below is an interesting write-up, excerpted from

http://www.tcd.ie/tsmj/2003/achcardia.htm

>

> This originates in Ireland, so they use the UK-style of spelling

esophagus as oesophagus, so it can catch you off guard when you

forget about the variation in spelling. LOS in the article is LES to

North Americans.... GOR is our GERD, etc.

>

> As you can see, there is some question whether a fundoplication

needs to be done at all (I believe that's why more and more people

are now having the Heller Myotomy w/ no wrap at all -- in the past it

was assumed to be necessary, but now some docs aren't convinced and

they don't do it anymore.)

>

> But to answer your main question, a PARTIAL wrap isn't as tight as

the untreated, clamped-shut LES, so food can indeed go through even

without peristalsis.

>

> Hope that helps a bit!

>

> Debbi

>

> THE CONTROVERSY

>

> In the surgical treatment of achalasia, a balance must be found -

there must be a sufficient decrease in oesophageal obstruction to

provide symptomatic relief, but an excessive decrease in LOS pressure

results in GOR. An anti-reflux procedure is sometimes added to avoid

this. Laparoscopic procedures are either combined with a Floppy

Toupet Fundoplication attached to the sides of the myotomy or a Dor

fundoplication, known as the laparoscopic Heller-Dor fundoplication.

There is, nonetheless, considerable debate surrounding the actual

therapeutic value of such an addition.

>

> Arguments against an Anti-reflux procedure after oesophageal

myotomy:

>

> It is clear that adding a complete fundoplication increases

resistance at the GO junction and defeats the objective of the

myotomy i.e. to decrease this resistance. There is, however, evidence

that even partial fundoplication procedures, e.g. Toupet and Dor

techniques, increase LOS resistance and could compromise the

effectiveness of the myotomy. Ellis et al. (1984) have achieved

excellent relief of dysphagia with Heller myotomy alone, with only 9-

15% of patients having unsatisfactory results.31

>

> s et al. (1999) studied gastroesophageal reflux in 75

patients who had been treated by myotomy without fundoplication. They

discovered that there was only a very weak correlation between

patients' perceptions of their GOR (heartburn symptoms), as evaluated

by a questionnaire, and objective measurement of reflux by a distal

pH sensor.32 This proves that heartburn symptoms are not a reliable

indicator of GOR in achalasia patients and should not be used as a

justification to perform a fundoplication procedure with myotomy.

>

> Furthermore, the same author found that confirmed pathological acid

reflux, present in only 13% of patients, does not conform to the

usual Gastro-Oesophageal Reflux Disease (GORD) pattern. Reflux

events in achalasia patients occur less frequently, are of a longer

duration and happen predominantly when the patient is supine.33 This

suggests that it is inadequate clearance of fermented food and/or

refluxed acid, rather than true acid reflux, which is responsible for

post-myotomy heartburn. This theory is strengthened by the finding,

corroborated by Ellis, that the patients most likely to have such

symptoms were those with the highest LOS pressures i.e. higher

resistance across the GO junction.34 Thus a fundoplication

procedure, aimed at increasing this resistance, could potentially

worsen heartburn symptoms. Indeed, pathological acid reflux following

myotomy with fundoplication has been found by Patti et al.(2001) and

by Csendes et al.(1981) in 17% and 19% of patients respectively. This

(shows that fundoplication clearly does not fully solve the problem

of post-myotomy reflux. Bonavina et al (1992)., meanwhile, achieved

a very impressive 8.6% incidence of reflux when myotomy was performed

without an anti-reflux procedure.37

>

> Finally, the risk-benefit ratio of adding an anti-reflux procedure

must be considered. Patti et al. noteed a risk of technical problems

with a Dor fundoplication and suggest that these may be avoided by

skilled surgery and meticulous attention to detail.35 However,

surgeons may not perform these procedures with sufficient regularity

to ensure this. A simpler procedure plainly reduces the risk of

technical hitches.

>

> As previously mentioned, s et al.(2001) report pathological

acid reflux in 13% of patients when myotomy is performed without an

associated fundoplication.33 Routine addition of an anti-reflux

procedure would thus treat 87% of patients needlessly. This is

particularly pointless when one considers the fact that medication

frequently suffices to control reflux symptoms in this 13%. The

dysphagia which results from an insufficiently lowered LOS pressure,

meanwhile, requires far more drastic treatment measures, namely

pneumatic dilatation or even further surgery.

>

> Arguments in favour of an Anti-reflux procedure after oesophageal

myotomy:

>

> Iatrogenic GORD has only recently been given proper consideration

and recognition. There are therefore a limited number of studies

objectively documenting oesophageal acid exposure after treatment for

achalasia. Those that are available reveal some interesting trends

(Tables 1 and 2).

>

> Table 1. Postoperative pH studies after transthoracic limited

myotomy without fundoplication for the treatment of achalasia

>

> Table 2. Postoperative pH studies following laparoscopic myotomy

and fundoplication for the treatment of achalasia

>

> Relevant to the " pro-anti-reflux procedure " argument is the fact

that reflux-induced stricture after an oesophageal myotomy is a

severe problem, and usually requires oesophagectomy for relief of

symptoms.

>

> Long-term data stress the need for anti-reflux protection.

Malthaner et al. (1994) reported on long-term clinical results in 35

patients with achalasia.22 These patients had undergone primary

oesophageal myotomy and Belsey hemifundoplication at Toronto General

Hospital. The minimum follow up time was 10 years. Excellent results

were found in 95% of patients at 1 year, declining to 68% after 10

years. It was concluded that there was a deterioration of the

initially good results after surgical myotomy and hiatal repair, and

that most of the deterioration was due to the complication of GOR.38

In another study, Ellis reported his experience with transthoracic

short oesophageal myotomy without an anti-reflux procedure. 179

patients were analysed at a mean follow-up of 9 years, ranging from 6

months to 20 years. Overall, 89 % of patients were improved at 9

years post-operatively. Ellis also noted deterioration in good

results with time. The fact that his clinical data was similar to

findings in the Toronto study suggests the likelihood that reflux

played a significant role in his results as well.34

>

> Another relevant finding of several recent studies is that a post-

treatment sphincter pressure of less than 10mmHg is required for long

term relief of dysphagia.39,40 This is relevant because it shows that

near complete disruption of the sphincter is required to relieve

dysphagia in the long term.

>

> In one of the largest studies reported yet, Bonavina et al. (1992)

report good to excellent results with transabdominal myotomy and Dor

fundoplication. 94% of 198 patients had excellent/good outcomes after

a mean follow-up of 5.4 years. A remarkable 81% of patients returned

for post-operative 24-hour pH studies, of which only 7 (8.6%) had a

positive test result. Oesophageal diameter was significantly

decreased post myotomy, as was LOS pressure (40.5 +/- 9.7 to 11.7 +/-

4.7 mmHg).37

>

> Zaninotto et al. (2000) reported results in 100 patients who

underwent a laparoscopic Heller-Dor procedure. 70% of patients

reported no dysphagia and 22 % complained of only occasional

difficulty swallowing. 7 patients were salvaged by post-operative

pneumatic dilatation. Of note, 24-hour oesophageal pH monitoring

showed abnormal reflux in only 5 (6.5%) of 63 patients tested.41

>

> These studies confirm that laparoscopic Heller-Dor fundoplication

achieves excellent medium-term results.

>

> Patti et al. (1999) compared the outcome of 30 patients who had

undergone laparoscopic myotomy with a Dor anterior fundoplication to

that of 30 patients who had undergone thoracoscopic myotomy without

anti-reflux repair. Dysphagia was well-relieved by both the

laparoscopic and thoracoscopic groups (77% and 70% success rates

respectively). 20% of patients in the group who did not have a

fundoplication had a positive post-operative 24-hour pH study result

compared to only 3% following the Heller-Dor procedure.30

>

> CONCLUSION

>

> GOR is uncommon in achalasia patients who have not undergone

surgery and most evidence suggests that pH proved-reflux is minimised

by the addition of a partial fundoplication to a myotomy. Studies

show that abdominal myotomy combined with fundoplication provides

excellent symptomatic outcomes in both the short- and the long-term

in patients with achalasia. Perhaps it is better to perform a partial

fundoplication with a myotomy in a single operation, and thereby

reduce the risk of reflux, than to risk post-operative reflux, its

complications and with them, further radical surgery.

>

> On the other hand, why complicate a surgical procedure with

addition of fundoplication when such an addition risks compromising

the very outcome of the surgery (i.e. by re-increasing the LOS

pressure reduced by the myotomy)? Also, the fundoplication procedure

has not yet been definitely proven to prevent GOR and, in any case,

may be unnecessary in the majority of patients.

>

> It is evident that there is an urgent need for in-depth study of

this question. Only a randomised controlled trial of Heller myotomy,

with and without an anti-reflux procedure, including full patient

evaluation by questionnaire, manometry and 24 hour pH studies can

provide a satisfactory answer.

January 14, 2004

The surgeon I'm going to is doing the dor fundoplication for me.

So I guess it depends on the surgeons preference or opinion.