Re: To fundo, or not to fundo...

[Guest guest]

Dear n,

Well, I don't want to be a gray cloud, but I looked up Dr. Patching in my favorite web-site... entrez pub med. Unless his name is sg, which is possible, but it didn't look like he is a published surgeon.

That does NOT mean he isn't good. Most of our surgeons and gi's are published and heads of major medical centers gi departments or surgical centers. Except HMO's.... they don't seem to publish that I can tell. That is another story, especially in CA. He just may not publish.

IN GENERAL, I would not tell a surgeon how to do the surgery or whether or not to use a fundo. He/she should do it the way the know and the best way in their experience. There is no way any of us can tell an individual surgeon how to do their job.

However, it is our calm assertive job to research the surgeons and doctors we use. Then ask questions and make them explain to us the differences in their opinions between other well-known achalasia specialists. If them Hmmm and Hawwwww like kids caught w/ their hands in the cookie jar or just bad mouth another technique, without know how to do that technique or why a doctor uses that technique, then I would run, run, run as fast as you can.

The fundo decision is generally more related to whether or not you have lap or VATS surgery, which is also minimally invasive. VATS surgery seems to only be done by Dr. Fuller @ Cedars in Los Angeles, in the Westen US, if not almost everywhere. He goes through your ribs, cuts higher up the E because he has better access than lap surgery, and less into the stomach, so he doesn't need a wrap or fundo. He thinks the fundo can cause more complications later. The VATS surgery is more complicated, more painful and probably a day longer in the hospital and a higher level of painkillers for slightly longer. His hope is that not have potential problems with the wrap in the long term is worth the difference between VATS and a lap surgery.

Lap surgeons, do not do through the ribs, instead go through the abdomen and can't apparently cut as high up the E, thus need to cut further into the stomach, then a wrap is needed.

I assume the total length of the cut is somewhat important to relieve the locked les.

I'd call Dr. Patti in San Francisco, and ask about Dr. Patching and I'd call Dr. Fuller at Cedars and also ask him. Then play the three against each other. Ask a lot of questions. Maybe Dr. Patching is experienced and we just haven't heard about him. I haven't heard of any HMO doctors around S. Cal doing any myotomies, but they just may not publicize and don't find this board. I would guess they do dialations in lieu of surgery. No other surgeons on the West Coast come to mind.

Just like whatever your skills are, surgeons are better with more experience. Everytime I even bake a cake I do it a little better. You can relate that to your job or hobbies also I assume. Surgeons are similar.

This decision you make will affect your health for the rest of your life. The first procedure, especially the first surgery has a much better chance of being your only surgery if you go to a well experienced doctor. Take the time and call them.

As I've repeated over and over. They will return your calls. They want us, they love us, we advance their experience and prestige. If they can say they are achalasia experts then they must also be gi or esophagus experts also, it reasons. More patients of rarer diseases show up on their couches. It is sometimes all about image and prestige.

I've been on this board for about 4 or 5 years and don't remember Dr. Patching, but I might have missed him. I'd keep looking.

Here is my favorite web site for researching medical information. It seems to have summaries of all medical publications. If you check it out be very aware of dates. Things have changed even in the last 3 or 4 years in recommendations, especially concerning minimally invasive surgery.

Sandy in So Cal.....

>> Greetings all, > First of all, thank you to everyone who participates in this site.> I've recently been diagnosed with "A" and it is **SO** comforting to> know there are folks out there who can relate to what I've been> experiencing. The information on this site has been both reassuring> and helpful in my decision making. Thanks...> > I do also have a couple of questions for you guys.> > My GE has recommended a Heller myotomy and referred me to a surgeon> (Dr. Patching, Sacramento, CA). I have not yet met with Dr.> Patching but my doctor seemed to think that the myotomy would NOT> require a fundoplication. His reasoning was that things are tight> enough, we don't want to further constrict the esophagous. GERD would> be controlled with PPI's and lifestyle changes. I may get a different> story from the surgeon but I was suprised given most of the> discussions I've seen on this site seem to couple myotomy with> fundoplication of one sort or another. I'd rather not have the> procedure if I can avoid it but (obviously) want to avoid chronic> reflux and the nastiness that can come with it. Has anyone out there> had the myotomy without the fundoplication? Have you suffered much> from GERD? > > I was also wondering if anyone has heard of, or been under the care of> Dr. Patching. I haven't seen his name pop up on this site. He> is highly recommended by my GE and is supposedly very experienced with> A. Again, I haven't met him yet to grill him about his track record> but thought this might be a good place to do a little background> checking...> > Thanks again, > > n>

[Guest guest]

Thanks for the red flags Sandy. I don't mind a grey cloud if it

improves the outcome of my treatment. Dr. Patching is part of the

Sutter network which may explain the lack of pubs. The Sutter website

emphasized the laproscopic, gastric bypass aspect to his practice and

not achalasia. Worrisome, but this may be due to the rarity of the

achalasia relative to gastric bypass so I will not discount him yet.

As I mentioned, I have yet to talk with him but rest assured the first

question out of my mouth will be " How many Heller myotomies have you

performed? " . I will post what I learn of Dr. Patching and will also

contact Patti and Fuller. Never thought of myself as a " comodity "

before... ;-)

Thanks also Carolyn and for your input, advice, and words of

encouragement.

cheers,

b

[Guest guest]

Hi n and welcome to our family: Sorry you have A. I have had a heller

myotomy

without a wrap. It was done thorascopically through a procedure called a VATS

(video

assisted thorascopic surgery) meaning that the surgery was performed by a chest

surgeon

who entered through my side and ribcage and cut the E muscle higher and did not

require

a wrap. I have had little or no sensation of heartburn or GERD. I don't take

any PPIs or

other meds. I will be having a barium swallow in August and a probable looksee

through

endoscopy after that to see if there is any damage from reflux.

Many of the procedures done laproscopically are recommended to have a wrap

because

they cut lower on the stomach than the VATS procedure. The VATS has a little

longer

recovery time because it is chest surgery, but I had great success.

Peggy from Lompoc, who visits Sacramento more than she likes -- where do you

reside?

>

> Greetings all,

> First of all, thank you to everyone who participates in this site.

> I've recently been diagnosed with " A " and it is **SO** comforting to

> know there are folks out there who can relate to what I've been

> experiencing. The information on this site has been both reassuring

> and helpful in my decision making. Thanks...

>

> I do also have a couple of questions for you guys.

>

> My GE has recommended a Heller myotomy and referred me to a surgeon

> (Dr. Patching, Sacramento, CA). I have not yet met with Dr.

> Patching but my doctor seemed to think that the myotomy would NOT

> require a fundoplication. His reasoning was that things are tight

> enough, we don't want to further constrict the esophagous. GERD would

> be controlled with PPI's and lifestyle changes. I may get a different

> story from the surgeon but I was suprised given most of the

> discussions I've seen on this site seem to couple myotomy with

> fundoplication of one sort or another. I'd rather not have the

> procedure if I can avoid it but (obviously) want to avoid chronic

> reflux and the nastiness that can come with it. Has anyone out there

> had the myotomy without the fundoplication? Have you suffered much

> from GERD?

>

> I was also wondering if anyone has heard of, or been under the care of

> Dr. Patching. I haven't seen his name pop up on this site. He

> is highly recommended by my GE and is supposedly very experienced with

> A. Again, I haven't met him yet to grill him about his track record

> but thought this might be a good place to do a little background

> checking...

>

> Thanks again,

>

> n

>

[Guest guest]

Hi n,

Myotomy with no fundoplication in December 2005. No GERD. 1 Prevacid

daily for the rest of my life. No regrets.

Best of luck in the decision process.

Jo

>

> Greetings all,

> First of all, thank you to everyone who participates in this site.

> I've recently been diagnosed with " A " and it is **SO** comforting

to

> know there are folks out there who can relate to what I've been

> experiencing. The information on this site has been both

reassuring

> and helpful in my decision making. Thanks...

>

> I do also have a couple of questions for you guys.

>

> My GE has recommended a Heller myotomy and referred me to a surgeon

> (Dr. Patching, Sacramento, CA). I have not yet met with Dr.

> Patching but my doctor seemed to think that the myotomy would NOT

> require a fundoplication. His reasoning was that things are tight

> enough, we don't want to further constrict the esophagous. GERD

would

> be controlled with PPI's and lifestyle changes. I may get a

different

> story from the surgeon but I was suprised given most of the

> discussions I've seen on this site seem to couple myotomy with

> fundoplication of one sort or another. I'd rather not have the

> procedure if I can avoid it but (obviously) want to avoid chronic

> reflux and the nastiness that can come with it. Has anyone out

there

> had the myotomy without the fundoplication? Have you suffered much

> from GERD?

>

> I was also wondering if anyone has heard of, or been under the

care of

> Dr. Patching. I haven't seen his name pop up on this site.

He

> is highly recommended by my GE and is supposedly very experienced

with

> A. Again, I haven't met him yet to grill him about his track record

> but thought this might be a good place to do a little background

> checking...

>

> Thanks again,

>

> n

>

[Guest guest]

Hi Peggy,

Thanks for the VATS info. Was yours also done by Dr. Fuller in LA (as

was Sandy's)? How long ago was the surgery? Are you pretty good about

watching what and when you eat?

cheers,

n-from

It was done thorascopically through a procedure called a VATS (video

> assisted thorascopic surgery) meaning that the surgery was performed

by a chest surgeon

> who entered through my side and ribcage and cut the E muscle higher

and did not require

> a wrap. I have had little or no sensation of heartburn or GERD. I

don't take any PPIs or

> other meds. I will be having a barium swallow in August and a

probable looksee through

> endoscopy after that to see if there is any damage from reflux.

>

> Many of the procedures done laproscopically are recommended to have

a wrap because

> they cut lower on the stomach than the VATS procedure. The VATS has

a little longer

> recovery time because it is chest surgery, but I had great success.

>

> Peggy from Lompoc, who visits Sacramento more than she likes --

where do you reside?

>

>

> >

> > Greetings all,

> > First of all, thank you to everyone who participates in this site.

> > I've recently been diagnosed with " A " and it is **SO** comforting to

> > know there are folks out there who can relate to what I've been

> > experiencing. The information on this site has been both reassuring

> > and helpful in my decision making. Thanks...

> >

> > I do also have a couple of questions for you guys.

> >

> > My GE has recommended a Heller myotomy and referred me to a surgeon

> > (Dr. Patching, Sacramento, CA). I have not yet met with Dr.

> > Patching but my doctor seemed to think that the myotomy would NOT

> > require a fundoplication. His reasoning was that things are tight

> > enough, we don't want to further constrict the esophagous. GERD would

> > be controlled with PPI's and lifestyle changes. I may get a different

> > story from the surgeon but I was suprised given most of the

> > discussions I've seen on this site seem to couple myotomy with

> > fundoplication of one sort or another. I'd rather not have the

> > procedure if I can avoid it but (obviously) want to avoid chronic

> > reflux and the nastiness that can come with it. Has anyone out there

> > had the myotomy without the fundoplication? Have you suffered much

> > from GERD?

> >

> > I was also wondering if anyone has heard of, or been under the care of

> > Dr. Patching. I haven't seen his name pop up on this site. He

> > is highly recommended by my GE and is supposedly very experienced with

> > A. Again, I haven't met him yet to grill him about his track record

> > but thought this might be a good place to do a little background

> > checking...

> >

> > Thanks again,

> >

> > n

> >

>

[Guest guest]

Thanks Jo,

Was your Myotomy open, lap, or VATS? Glad to hear that it's going well

for you.

cheers,

n

>

> Hi n,

>

> Myotomy with no fundoplication in December 2005. No GERD. 1 Prevacid

> daily for the rest of my life. No regrets.

>

> Best of luck in the decision process.

>

> Jo

>

>

>

> >

> > Greetings all,

> > First of all, thank you to everyone who participates in this site.

> > I've recently been diagnosed with " A " and it is **SO** comforting

> to

> > know there are folks out there who can relate to what I've been

> > experiencing. The information on this site has been both

> reassuring

> > and helpful in my decision making. Thanks...

> >

> > I do also have a couple of questions for you guys.

> >

> > My GE has recommended a Heller myotomy and referred me to a surgeon

> > (Dr. Patching, Sacramento, CA). I have not yet met with Dr.

> > Patching but my doctor seemed to think that the myotomy would NOT

> > require a fundoplication. His reasoning was that things are tight

> > enough, we don't want to further constrict the esophagous. GERD

> would

> > be controlled with PPI's and lifestyle changes. I may get a

> different

> > story from the surgeon but I was suprised given most of the

> > discussions I've seen on this site seem to couple myotomy with

> > fundoplication of one sort or another. I'd rather not have the

> > procedure if I can avoid it but (obviously) want to avoid chronic

> > reflux and the nastiness that can come with it. Has anyone out

> there

> > had the myotomy without the fundoplication? Have you suffered much

> > from GERD?

> >

> > I was also wondering if anyone has heard of, or been under the

> care of

> > Dr. Patching. I haven't seen his name pop up on this site.

> He

> > is highly recommended by my GE and is supposedly very experienced

> with

> > A. Again, I haven't met him yet to grill him about his track record

> > but thought this might be a good place to do a little background

> > checking...

> >

> > Thanks again,

> >

> > n

> >

>

[Guest guest]

>

> Hi..can u tell me- what is " fundo " or " fundoplication " ??

>

>

Here's a link that may help:

http://www.lifespan.org/mininvasive/revised/patient/reflux/surgery.htm

In a nutshell it's a surgery to prevent reflux by suturing part of the

stomach (the " fundus " ) to the esophagus.

[Guest guest]

That group sounds very slightly familiar.

If their website highlights gastric bypass, I'd hesitate. Most of "our" surgeons are GERD, Barrett's, cancer and more life threatening surgeons. That is not to say weight isn't life threatening... as I carry around a whole bunch of excess weight after successful surgery. If I thought there was any chance a surgeon would give me a gastric bypass I might slightly consider it.

Are you in the HMO system? If you CAN before you have a bunch more tests, could you switch to a PPO? Even if it is more expensive, you may find it more beneficial to you. If you can switch before they realize how serious and long term your health condition is, maybe a PPO will take you?

Just in case.... I do think HMO's have their place and provide great care in many instances. However, in California, there are a lot of horror stories of delayed service. Once a patient gets to a higher physician they can provide great care, the problem is getting there.

One of my neighbors was told to wait another 6 months to see what a 1" lump in her breast does, along with the lumps in her arm pit. I am horrified, but have gone hoarse talking to her about her HMO. She hears what she wants to hear, and calm assertiveness about her own health care hasn't yet appeared on her priority list.

n, maybe I've misunderstood and you have great insurance. All doctors are motivated partially by money and prestige. You are a rare commodity and you have to guard your good health from doctors who want to advance their careers and prestige with your commodity. Many will want you as a patient and hope to learn from you. I'd search for a doctor that is established as an authority in esophageal disorders. I've never had an HMO but my impression is they try really hard to keep you within their service. There very well could be an esophageal expert in their service. They just seem hard to find.

Peggy made great strides working w/ her HMO, then eventually switched to a PPO anyway.

Good luck.

Sandy in So Cal... nothing on tv and hiding from laundry and other realities.

>> Thanks for the red flags Sandy. I don't mind a grey cloud if it> improves the outcome of my treatment. Dr. Patching is part of the> Sutter network which may explain the lack of pubs. The Sutter website> emphasized the laproscopic, gastric bypass aspect to his practice and> not achalasia. Worrisome, but this may be due to the rarity of the> achalasia relative to gastric bypass so I will not discount him yet.> As I mentioned, I have yet to talk with him but rest assured the first> question out of my mouth will be "How many Heller myotomies have you> performed?". I will post what I learn of Dr. Patching and will also> contact Patti and Fuller. Never thought of myself as a "comodity"> before... ;-) > > Thanks also Carolyn and for your input, advice, and words of> encouragement. > > cheers,> b>

[Guest guest]

I had the dor fundoplication (with my heller myotomoty) which was

not discussed in that article.

It worked for me, no acid reflux

Dave

State of Jefferson (CA)

> >

> > Hi..can u tell me- what is " fundo " or " fundoplication " ??

> >

> >

>

> Here's a link that may help:

>

http://www.lifespan.org/mininvasive/revised/patient/reflux/surgery.ht

m

>

> In a nutshell it's a surgery to prevent reflux by suturing part of

the

> stomach (the " fundus " ) to the esophagus.

>

[Guest guest]

I had the dor fundoplication (with my heller myotomoty) which was

not discussed in that article.

It worked for me, no acid reflux

Dave

State of Jefferson (CA)

> >

> > Hi..can u tell me- what is " fundo " or " fundoplication " ??

> >

> >

>

> Here's a link that may help:

>

http://www.lifespan.org/mininvasive/revised/patient/reflux/surgery.ht

m

>

> In a nutshell it's a surgery to prevent reflux by suturing part of

the

> stomach (the " fundus " ) to the esophagus.

>

[Guest guest]

n wrote:

> His reasoning was that things are tight

> enough, we don't want to further constrict the esophagous. GERD would

> be controlled with PPI's and lifestyle changes.

A number of things come to mind here.

After a myotomy your LES (Lower Esophageal Sphincter) may be too tight,

too loose or just right, and it may change over time. So, a fundo may,

make one that is too tight worse, or not be needed for one that is just

right, or may be needed for one that is too loose. It is hard to get one

that is both loose enough to let food through into the stomach without

problems and yet be tight enough to keep acid reflux from coming up

through it. Part of the problem is that many people with achalasia do

not have peristalsis in the lower esophagus to push food through the

LES. This means that it has to be loose enough for gravity to do the

job. With it that loose it won't take much pressure in the reverse

direction to send reflux into the esophagus. Bending over or laying down

may be all it takes. Bad news when you don't have peristalsis to push it

back down.

It is known that people with achalasia have errant sensory nerves in the

esophagus. Symptoms of heartburn or the lack of them does not correlate

with the amount of acid in the esophagus detected by medical testing.

After a myotomy, or other treatment, you could have very bad reflux and

never feel any heartburn. You could also have what you think is very bad

heartburn and not have much reflux at all. People who should get testing

don't because they have no symptoms. Some surgeons believe it is better

to just give people a fundo and not worry about whether they will come

back for testing or not. Others just tell all their patients to take

PPIs. Others just tell them to return for testing every so often. Some

do some combination of those things.

One thing about PPIs, besides all the other things some people have

against them, is that they can be expensive. Your insurance may have

some trouble being convinced that you need them for life. Even with just

a copay, over time it adds up.

To cut high, as with VAT, or to cut low, as with lap. is controversial.

The " T " in VAT is for thoracic, which means, of or relating to the chest

or thorax. Lap. is an abbreviation for laparoscopic which is partly from

the Greek " laparo " (flank or loosely abdomen). In this case laparo

refers to the abdominal cavity. The diaphragm is a dome-shaped sheet of

skeletal muscle that separates the abdominal and thoracic cavities. VAT

surgery is done in the thoracic cavity. Lap. surgery is done in the

abdominal cavity. Part of the esophagus is in the thoracic cavity. The

lower end and the stomach are in the abdominal cavity. The LES sits

right at the diaphragm. This make the LES reachable by either VAT or

lap., but for doing a fundo the stomach is only reachable by lap.. This

means that if you want to extend the cut up on the esophagus above the

LES you will probably want to do it VAT, but if you want to extend the

cut below the LES unto the stomach, or you want to do a fundo, you will

have to do it lap.. Which, VAT or lap. gives the best view depends on

what you want to see.

When myotomies fail and are redone because food still hangs up, the redo

sometime extends the myotomy on the stomach to make it looser, or the

fundo is taken down or redone to make it looser. Sometimes a myotomy

fails because of scaring from acid damage. In this case a dilatation is

done to brake the scaring. A dilation can also be used to loosen the LES

if it was too tight after the myotomy.

No matter which way you go there is some risk that treatment will fail,

but the odds are very good that surgery done in any of these ways will

give very good results in most cases. I had a lap. myotomy which went

well onto the stomach and I also had a fundo. I think that for me it

gave me the best chance of not needing more than dilatations or PPIs

down the road. The things I would most want to avoid down the road are,

another myotomy or removal of part of the esophagus and cancer. The odds

of those are very small, I think.

notan

[Guest guest]

Dear n, A warm welcome to the site. Now you need never to be alone again. I notice that you have had many replies already, but I have not read them yet so forgive me if I repeat any info. But at least I will not be influenced by the other replies. I think the questions you have asked are very important ones and not simple to answer. The balance between the fundo being too loose and allowing acid back in to the O (its O in England and E in US, where they can't spell properly (lol) ) and being too tight and not allowing an easy passage of food, is quite fine. You need a surgeon who is experienced or adept, or both, enough to perform this

successfully. I would suspect that any surgeon who was worried about not getting this right may opt for the non-fundo anyway, although I am not at all suggesting that this is the only reason for not creating one. I personally have had the fundo and am also taking acid-suppressants. But this is me and what is right for me is not necessarily right for you. Your age and length of having this disease have to be considered. One thing that it is important to bear in mind is that because you have this disease, your O is not in the best of states anyway and you need to do everything you can to take care of it. Acid from the stomach must be avoided at all costs as this can, in extreme

circumstances lead to Barretts and even cancer, which you really do not want to have to face. You need to take the advice of your consultant on this, but get very wised up first so that you can take an active part in the discussion and not merely be told what you should do. It is very empowering to have this knowledge, which enables you to ask intelligent questions and ultimately be in control of your own health decisions. Good luck with your search, n, and please stay with us to receive and give support. Believe me, it will help you no end in your feelings and journey with achalasia. We are, in the main, a very upbeat and positive Group and are always ready to be there for others (and you may make

friendships here which could last forever). Love from Ann in England XXXbrendan518 <rnbriely@...> wrote: Greetings all, First of all, thank you to everyone who participates in this site.I've recently been diagnosed with "A" and it is **SO** comforting toknow there are folks out there who can relate to what I've beenexperiencing. The information on this site has been both

reassuringand helpful in my decision making. Thanks...I do also have a couple of questions for you guys.My GE has recommended a Heller myotomy and referred me to a surgeon(Dr. Patching, Sacramento, CA). I have not yet met with Dr.Patching but my doctor seemed to think that the myotomy would NOTrequire a fundoplication. His reasoning was that things are tightenough, we don't want to further constrict the esophagous. GERD wouldbe controlled with PPI's and lifestyle changes. I may get a differentstory from the surgeon but I was suprised given most of thediscussions I've seen on this site seem to couple myotomy withfundoplication of one sort or another. I'd rather not have theprocedure if I can avoid it but (obviously) want to avoid chronicreflux and the nastiness that can come with it. Has anyone out therehad the myotomy without the fundoplication? Have you suffered muchfrom GERD? I was also

wondering if anyone has heard of, or been under the care ofDr. Patching. I haven't seen his name pop up on this site. Heis highly recommended by my GE and is supposedly very experienced withA. Again, I haven't met him yet to grill him about his track recordbut thought this might be a good place to do a little backgroundchecking...Thanks again, n

All new "The new Interface is stunning in its simplicity and ease of use." - PC Magazine

[Guest guest]

Thanks n for that article. I found it useful for me to understand how it looked. You really are learning fast aren't you? - both about the disease and how to contribute to this Group. Good for you. XXbrendan518 <rnbriely@...> wrote: >> Hi..can u tell me- what is "fundo" or

"fundoplication " ??> >Here's a link that may help:http://www.lifespan.org/mininvasive/revised/patient/reflux/surgery.htmIn a nutshell it's a surgery to prevent reflux by suturing part of thestomach (the "fundus") to the esophagus.

Try the all-new . "The New Version is radically easier to use" – The Wall Street Journal

[Guest guest]

Dear n,

Try this surgeon DT Rideout in your group. Why, I don't know I looked up your group to see if it is an HMO. Dr. Rideout sounds very vaguely familiar to me. His bio says Canadian background, maybe that is why.

His speciality is thoracic surgery, both lap and VATS. It also lists esophageal etc. diseases. He sounds more logical than a bariatric surgeon.

I'm totally guessing the referring doctor just assumed stomach problem vs. esophageal problem. To be honest, my gut (unintentional pun) instincts are that you would be better off w/ an esophageal surgeon, not a weight management surgeon.

http://sutterdavis.org/ProviderSearch/?sitecfg=38 & action=providerdetail & masterid=15455 & isLevelOne=1

It is obvious to most of us, but to new members, what I did was type in achalasia in the Sutter Group website. (Not impressed, gave support groups to March of Dimes and Genetic Diseases.) One article, very basic.

Then I searched the available physicians for thoracic. Dr. Rideout's name came up. There is also another surgeon worth investigating.

This is a very basic search, but a good way, if you are searching medical centers close to you, to find doctors and read their bios. Their PR departments and the doctors spend a lot of time on these to attract the type of patients they want.

I then go to Pub Med and see if they published. NOT that publishing is a good litmus test, but if they are, then it shows their interest and specialities.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search & DB=pubmed

If you do this for yourself you will soon have a short list of surgeons and gi's that are possibilities for you.

I also search the medical centers where they work and I have even searched their co-writers or other co-workers to see what kind of work they do on their own websites.

By the time you have done this you have likely reorganized your list of possible doctors and are down to only a few. The choice then becomes financial and physical location. I'd do the search before I narrow down to financial and location and insurance. You may need to argue with your insurance company about who you want to see, if out of the network. This is NOT basic gall bladder surgery, it needs to be a specialist in esophageal diseases or you may need constant medical care the rest of your life, more expensive to your insurance company in the long run.

Sandy in So Cal.

> > >> > > Greetings all, > > > First of all, thank you to everyone who participates in this site.> > > I've recently been diagnosed with "A" and it is **SO** comforting to> > > know there are folks out there who can relate to what I've been> > > experiencing. The information on this site has been both reassuring> > > and helpful in my decision making. Thanks...> > > > > > I do also have a couple of questions for you guys.> > > > > > My GE has recommended a Heller myotomy and referred me to a surgeon> > > (Dr. Patching, Sacramento, CA). I have not yet met with Dr.> > > Patching but my doctor seemed to think that the myotomy would NOT> > > require a fundoplication. His reasoning was that things are tight> > > enough, we don't want to further constrict the esophagous. GERD would> > > be controlled with PPI's and lifestyle changes. I may get a different> > > story from the surgeon but I was suprised given most of the> > > discussions I've seen on this site seem to couple myotomy with> > > fundoplication of one sort or another. I'd rather not have the> > > procedure if I can avoid it but (obviously) want to avoid chronic> > > reflux and the nastiness that can come with it. Has anyone out there> > > had the myotomy without the fundoplication? Have you suffered much> > > from GERD? > > > > > > I was also wondering if anyone has heard of, or been under the care of> > > Dr. Patching. I haven't seen his name pop up on this site. He> > > is highly recommended by my GE and is supposedly very experienced with> > > A. Again, I haven't met him yet to grill him about his track record> > > but thought this might be a good place to do a little background> > > checking...> > > > > > Thanks again, > > > > > > n> > >> >>

[Guest guest]

Note on HMO's - I have Blue Shield HMO and Dr. Patti (at UCSF)

is 'in-network'.

Joy in San

> >

> > Thanks for the red flags Sandy. I don't mind a grey cloud if it

> > improves the outcome of my treatment. Dr. Patching is part of the

> > Sutter network which may explain the lack of pubs. The Sutter

website

> > emphasized the laproscopic, gastric bypass aspect to his

practice and

> > not achalasia. Worrisome, but this may be due to the rarity of

the

> > achalasia relative to gastric bypass so I will not discount him

yet.

> > As I mentioned, I have yet to talk with him but rest assured the

first

> > question out of my mouth will be " How many Heller myotomies have

you

> > performed? " . I will post what I learn of Dr. Patching and will

also

> > contact Patti and Fuller. Never thought of myself as a " comodity "

> > before... ;-)

> >

> > Thanks also Carolyn and for your input, advice, and

words of

> > encouragement.

> >

> > cheers,

> > b

> >

>

[Guest guest]

Yes, Dr. Fuller at Cedars Sinai. August 8 will be one year. Don't have to

worry about what

and when. I just eat, drinking water for peristalsis. Sandy can tell you, now

I have to diet.

Going back in to see Dr. Fuller next month for a one year check up but am doing

great!

Peg

> > >

> > > Greetings all,

> > > First of all, thank you to everyone who participates in this site.

> > > I've recently been diagnosed with " A " and it is **SO** comforting to

> > > know there are folks out there who can relate to what I've been

> > > experiencing. The information on this site has been both reassuring

> > > and helpful in my decision making. Thanks...

> > >

> > > I do also have a couple of questions for you guys.

> > >

> > > My GE has recommended a Heller myotomy and referred me to a surgeon

> > > (Dr. Patching, Sacramento, CA). I have not yet met with Dr.

> > > Patching but my doctor seemed to think that the myotomy would NOT

> > > require a fundoplication. His reasoning was that things are tight

> > > enough, we don't want to further constrict the esophagous. GERD would

> > > be controlled with PPI's and lifestyle changes. I may get a different

> > > story from the surgeon but I was suprised given most of the

> > > discussions I've seen on this site seem to couple myotomy with

> > > fundoplication of one sort or another. I'd rather not have the

> > > procedure if I can avoid it but (obviously) want to avoid chronic

> > > reflux and the nastiness that can come with it. Has anyone out there

> > > had the myotomy without the fundoplication? Have you suffered much

> > > from GERD?

> > >

> > > I was also wondering if anyone has heard of, or been under the care of

> > > Dr. Patching. I haven't seen his name pop up on this site. He

> > > is highly recommended by my GE and is supposedly very experienced with

> > > A. Again, I haven't met him yet to grill him about his track record

> > > but thought this might be a good place to do a little background

> > > checking...

> > >

> > > Thanks again,

> > >

> > > n

> > >

> >

>

[Guest guest]

A great explanation Notan -- maybe upload this one into the files or database

section for

others to access?

Peggy

> > His reasoning was that things are tight

> > enough, we don't want to further constrict the esophagous. GERD would

> > be controlled with PPI's and lifestyle changes.

>

> A number of things come to mind here.

>

> After a myotomy your LES (Lower Esophageal Sphincter) may be too tight,

> too loose or just right, and it may change over time. So, a fundo may,

> make one that is too tight worse, or not be needed for one that is just

> right, or may be needed for one that is too loose. It is hard to get one

> that is both loose enough to let food through into the stomach without

> problems and yet be tight enough to keep acid reflux from coming up

> through it. Part of the problem is that many people with achalasia do

> not have peristalsis in the lower esophagus to push food through the

> LES. This means that it has to be loose enough for gravity to do the

> job. With it that loose it won't take much pressure in the reverse

> direction to send reflux into the esophagus. Bending over or laying down

> may be all it takes. Bad news when you don't have peristalsis to push it

> back down.

>

> It is known that people with achalasia have errant sensory nerves in the

> esophagus. Symptoms of heartburn or the lack of them does not correlate

> with the amount of acid in the esophagus detected by medical testing.

> After a myotomy, or other treatment, you could have very bad reflux and

> never feel any heartburn. You could also have what you think is very bad

> heartburn and not have much reflux at all. People who should get testing

> don't because they have no symptoms. Some surgeons believe it is better

> to just give people a fundo and not worry about whether they will come

> back for testing or not. Others just tell all their patients to take

> PPIs. Others just tell them to return for testing every so often. Some

> do some combination of those things.

>

> One thing about PPIs, besides all the other things some people have

> against them, is that they can be expensive. Your insurance may have

> some trouble being convinced that you need them for life. Even with just

> a copay, over time it adds up.

>

> To cut high, as with VAT, or to cut low, as with lap. is controversial.

> The " T " in VAT is for thoracic, which means, of or relating to the chest

> or thorax. Lap. is an abbreviation for laparoscopic which is partly from

> the Greek " laparo " (flank or loosely abdomen). In this case laparo

> refers to the abdominal cavity. The diaphragm is a dome-shaped sheet of

> skeletal muscle that separates the abdominal and thoracic cavities. VAT

> surgery is done in the thoracic cavity. Lap. surgery is done in the

> abdominal cavity. Part of the esophagus is in the thoracic cavity. The

> lower end and the stomach are in the abdominal cavity. The LES sits

> right at the diaphragm. This make the LES reachable by either VAT or

> lap., but for doing a fundo the stomach is only reachable by lap.. This

> means that if you want to extend the cut up on the esophagus above the

> LES you will probably want to do it VAT, but if you want to extend the

> cut below the LES unto the stomach, or you want to do a fundo, you will

> have to do it lap.. Which, VAT or lap. gives the best view depends on

> what you want to see.

>

> When myotomies fail and are redone because food still hangs up, the redo

> sometime extends the myotomy on the stomach to make it looser, or the

> fundo is taken down or redone to make it looser. Sometimes a myotomy

> fails because of scaring from acid damage. In this case a dilatation is

> done to brake the scaring. A dilation can also be used to loosen the LES

> if it was too tight after the myotomy.

>

> No matter which way you go there is some risk that treatment will fail,

> but the odds are very good that surgery done in any of these ways will

> give very good results in most cases. I had a lap. myotomy which went

> well onto the stomach and I also had a fundo. I think that for me it

> gave me the best chance of not needing more than dilatations or PPIs

> down the road. The things I would most want to avoid down the road are,

> another myotomy or removal of part of the esophagus and cancer. The odds

> of those are very small, I think.

>

> notan

>

[Guest guest]

Hi Notan,

Wow, thanks for that information. This is certainly brining issues to

light that I would not have otherwise considered...

> People who should get testing

> don't because they have no symptoms. Some surgeons believe it is better

> to just give people a fundo and not worry about whether they will come

> back for testing or not. Others just tell all their patients to take

> PPIs. Others just tell them to return for testing every so often. Some

> do some combination of those things.

The whole GERD without symptoms is a scary concept... How often is

reflux testing typically done? Is this the " 24hr pH test " I keep

hearing about? I'm assuming if, as in my case, my doctor is advocating

myotomy without wrap testing is something I'm going to really want to

push for?

> To cut high, as with VAT, or to cut low, as with lap. is controversial.

So where to cut is totally dependent on the surgeon and is independent

of the patient??? I know that the manometry study identified where in

my E problems are occurring. Is there variability in this from patient

to patient and if so, shouldn't this dictate where cuts are made and

therefore what kind of surgery would provide a better outcome?

> The things I would most want to avoid down the road are,

> another myotomy or removal of part of the esophagus and cancer.

Amen...

Thanks for taking the time to write that extensive post Notan. I

appreciate the help I'm getting from ALL of you guys!

cheers,

b

[Guest guest]

>Dr. Rideout sounds very vaguely

> familiar to me. His bio says Canadian background, maybe that is why.

>

> His speciality is thoracic surgery, both lap and VATS. It also lists

> esophageal etc. diseases. He sounds more logical than a bariatric

> surgeon.

Thanks Sandy. I'll add him to the growing list of people to check out.

I appreciate all the help and insight from you guys.

>

> I'm totally guessing the referring doctor just assumed stomach problem

> vs. esophageal problem. To be honest, my gut (unintentional pun)

> instincts are that you would be better off w/ an esophageal surgeon, not

> a weight management surgeon.

Just for the record, Dr. Patching's page:

http://checksutterfirst.org/ProviderSearch/?sitecfg=39 & action=providerdetail & mas\

terid=5265 & isLevelOne=1

does indicate a " professional interest " in achalasia. How this

translates into number of surgeries performed remains to be seen...

I'll let you guys know.

cheers,

b

[Guest guest]

brendan518 wrote:

> This is certainly brining issues to

> light that I would not have otherwise considered...

What seems like bad news here is in a way good news. If one method was

clearly better than another there would be no controversy. There are

medical centers that do hundreds of myotomies a year. The doctors that

do lots of myotomies believe in what they do, even though they don't all

do the same thing. So, if you get one of these doctors he will most

likely, based on the vast experience he has, expect you yo do well with

the methods he uses. In this group we often tell people to get a good

surgeon with lots of experience and let him do it his way. If you just

can't go with the way he wants to do it find another doctor. Don't make

a surgeon do it your way. There are no guaranties and there are always

risks, statistically things go well but the statistics may not fit your

case.

> How often is

> reflux testing typically done? Is this the " 24hr pH test " I keep

> hearing about?

This is another area of controversy. Different doctors suggest different

tests and periods between testing. Some don't think the small risk of

problems justifies having everyone tested and only ask their patients to

be checked if they have symptoms. The best test for GERD is the 24hr pH

test. It doesn't tell you anything else though, and there are other

reasons to be tested. You may want to be checked for cancer, pre-cancer

and distention of the esophagus. Often testing is done by endoscopy. In

this case you would just be looking for damage or changes from reflux

instead of actually detecting it.

How about it, people? After your myotomies, what tests and how often

have you had them.

I was told to get checked if I have any problem but I don't have to get

checked otherwise.

One thing to keep in mind when you read accounts from people in this

group is that people who have had problems are more likely to take part

in a group like this and be more likely to stick around. Those that were

diagnosed and treated quickly and went on to live normal lives, are

unlikely to even find this group and may not even remember the name

" achalasia. " We should find these people, pin them down and make them

listen to our stories so they know how lucky they are. ;-)

> So where to cut is totally dependent on the surgeon and is independent

> of the patient??? I know that the manometry study identified where in

> my E problems are occurring. Is there variability in this from patient

> to patient and if so, shouldn't this dictate where cuts are made and

> therefore what kind of surgery would provide a better outcome?

The surgical treatment for achalasia is to cut through the LES muscle to

make it weaker. The LES is right at the junction of the esophagus and

stomach. Imagine a fist gripping your esophagus. The LES is a ring of

smooth muscle that acts like that fist. The problem is that the LES

won't relax when it should. There may be other problems with peristalsis

or the lack of it and muscles spasms beside the LES, but these problems

are not going to be treated surgically. So the treatment is at the LES

and maybe a little above or below it. The myotomy will cut the LES all

the way through the muscle being very careful to cut any deeper than the

muscle. If you think of the LES as a donut the cut that converts the

shape from an O to a C would be the cut for the myotomy but other tissue

still holds the O together. One more reason to do a fundo is to suture

the fundo to the edges of the myotomy to help hold them apart so they

don't reattach themselves together. We all get the LES cut. The rest of

the esophagus and the stomach also have smooth muscle. Most doctors

today feel that just cutting the LES is not enough. They either extend

the cut a little above the LES or a little onto the stomach. My

understanding, and it could be wrong, is that once they find a cut they

like they stick with it.

Check out this article about one method:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=1\

2742951 & dopt=Abstract

You may also notice in that article that there is more than one kind of

fundo. Which one is best is also controversial. I had a Toupet

fundoplication. I think most here have had a Dor fundoplication and

there are others. Maybe we should reference in a code with our

signatures what we have had so it would be easy to see what every one

has had. Mine would be 1D1MTf or just DMTf for one dilatation before one

myotomy with Toupet fundo. Someone else may be MDf2D for myotomy with

Dor fundo followed by 2 dilatations.

notan

DMTf

[Guest guest]

Dear Peggy, Can I take this opportunity to say how upbeat and welcome I always find your posts. You have been a source of encouragement to me and allowed me to see how wonderful life can be. I hope I meet you one day. How long is your flight to Ohio? (LOL) XXXXPeggy Cordero <pegster@...> wrote: Yes, Dr. Fuller at Cedars Sinai. August 8 will be one year. Don't have to worry about what and

when. I just eat, drinking water for peristalsis. Sandy can tell you, now I have to diet. Going back in to see Dr. Fuller next month for a one year check up but am doing great!Peg> > >> > > Greetings all, > > > First of all, thank you to everyone who participates in this site.> > > I've recently been diagnosed with

"A" and it is **SO** comforting to> > > know there are folks out there who can relate to what I've been> > > experiencing. The information on this site has been both reassuring> > > and helpful in my decision making. Thanks...> > > > > > I do also have a couple of questions for you guys.> > > > > > My GE has recommended a Heller myotomy and referred me to a surgeon> > > (Dr. Patching, Sacramento, CA). I have not yet met with Dr.> > > Patching but my doctor seemed to think that the myotomy would NOT> > > require a fundoplication. His reasoning was that things are tight> > > enough, we don't want to further constrict the esophagous. GERD would> > > be controlled with PPI's and lifestyle changes. I may get a different> > > story from the surgeon but I was suprised given most of the> > >

discussions I've seen on this site seem to couple myotomy with> > > fundoplication of one sort or another. I'd rather not have the> > > procedure if I can avoid it but (obviously) want to avoid chronic> > > reflux and the nastiness that can come with it. Has anyone out there> > > had the myotomy without the fundoplication? Have you suffered much> > > from GERD? > > > > > > I was also wondering if anyone has heard of, or been under the care of> > > Dr. Patching. I haven't seen his name pop up on this site. He> > > is highly recommended by my GE and is supposedly very experienced with> > > A. Again, I haven't met him yet to grill him about his track record> > > but thought this might be a good place to do a little background> > > checking...> > > > > > Thanks again, > > >

> > > n> > >> >>

Try the all-new . "The New Version is radically easier to use" – The Wall Street Journal

[Guest guest]

Actually, a flight to Ohio would probably take less time than the traffic ridden

passsage I

need to travel to get to Dr. Fuller in Los Angeles. I like in Santa Barbara

County, about 3

hours north when the traffic is lucky, which it never is!

Thanks for your sweet thoughts!

Peggy, who is figuring out how to get red wine stains out of beige carpet today

(not me,

the hubby)

> > > >

> > > > Greetings all,

> > > > First of all, thank you to everyone who participates in this site.

> > > > I've recently been diagnosed with " A " and it is **SO** comforting to

> > > > know there are folks out there who can relate to what I've been

> > > > experiencing. The information on this site has been both reassuring

> > > > and helpful in my decision making. Thanks...

> > > >

> > > > I do also have a couple of questions for you guys.

> > > >

> > > > My GE has recommended a Heller myotomy and referred me to a surgeon

> > > > (Dr. Patching, Sacramento, CA). I have not yet met with Dr.

> > > > Patching but my doctor seemed to think that the myotomy would NOT

> > > > require a fundoplication. His reasoning was that things are tight

> > > > enough, we don't want to further constrict the esophagous. GERD would

> > > > be controlled with PPI's and lifestyle changes. I may get a different

> > > > story from the surgeon but I was suprised given most of the

> > > > discussions I've seen on this site seem to couple myotomy with

> > > > fundoplication of one sort or another. I'd rather not have the

> > > > procedure if I can avoid it but (obviously) want to avoid chronic

> > > > reflux and the nastiness that can come with it. Has anyone out there

> > > > had the myotomy without the fundoplication? Have you suffered much

> > > > from GERD?

> > > >

> > > > I was also wondering if anyone has heard of, or been under the care of

> > > > Dr. Patching. I haven't seen his name pop up on this site. He

> > > > is highly recommended by my GE and is supposedly very experienced with

> > > > A. Again, I haven't met him yet to grill him about his track record

> > > > but thought this might be a good place to do a little background

> > > > checking...

> > > >

> > > > Thanks again,

> > > >

> > > > n

> > > >

> > >

> >

>

>

>

>

>

>

> ---------------------------------

> Try the all-new . " The New Version is radically easier to use " –

The Wall

Street Journal

>

[Guest guest]

Hi n

It was lap, so minimal pain. my biggest complaint is the pain of

spasms. Even so, it is like living a whole new life.

Jo

> > >

> > > Greetings all,

> > > First of all, thank you to everyone who participates in this

site.

> > > I've recently been diagnosed with " A " and it is **SO**

comforting

> > to

> > > know there are folks out there who can relate to what I've been

> > > experiencing. The information on this site has been both

> > reassuring

> > > and helpful in my decision making. Thanks...

> > >

> > > I do also have a couple of questions for you guys.

> > >

> > > My GE has recommended a Heller myotomy and referred me to a

surgeon

> > > (Dr. Patching, Sacramento, CA). I have not yet met with

Dr.

> > > Patching but my doctor seemed to think that the myotomy would

NOT

> > > require a fundoplication. His reasoning was that things are

tight

> > > enough, we don't want to further constrict the esophagous.

GERD

> > would

> > > be controlled with PPI's and lifestyle changes. I may get a

> > different

> > > story from the surgeon but I was suprised given most of the

> > > discussions I've seen on this site seem to couple myotomy with

> > > fundoplication of one sort or another. I'd rather not have the

> > > procedure if I can avoid it but (obviously) want to avoid

chronic

> > > reflux and the nastiness that can come with it. Has anyone out

> > there

> > > had the myotomy without the fundoplication? Have you suffered

much

> > > from GERD?

> > >

> > > I was also wondering if anyone has heard of, or been under the

> > care of

> > > Dr. Patching. I haven't seen his name pop up on this

site.

> > He

> > > is highly recommended by my GE and is supposedly very

experienced

> > with

> > > A. Again, I haven't met him yet to grill him about his track

record

> > > but thought this might be a good place to do a little

background

> > > checking...

> > >

> > > Thanks again,

> > >

> > > n

> > >

> >

>

[Guest guest]

> It was lap, so minimal pain. my biggest complaint is the pain of

> spasms. Even so, it is like living a whole new life.

>

When you say " spasms " do you mean immediately after the surgery or

have your NCCP's gotten worse since the surgery?

General question for everyone: I realize that myotomy is primarily to

relieve the dysphasia, but does it also remedy the spasms at all?

[Guest guest]

If you spill red wine and do nothing, the stain will probably last longer than the surface you've spilt it on; especially on clothes and carpets, which will be dyed forever. To avoid this: Act quickly. As long as the red wine is fresh, you can take it off completely. Open a bottle of white wine. Soak whatever you have spilt red wine on with plenty of white wine. Add lots of salt. Rub gently. If you have spilt the wine on the carpet, you should use a vacuum cleaner to clear up the salt. Any help Peggy? Peggy Cordero <pegster@...> wrote: Actually, a flight to Ohio would probably take less time than the traffic ridden passsage I need to travel to get to Dr. Fuller in Los Angeles. I like in Santa Barbara County, about 3 hours north when the traffic is lucky, which it never is!Thanks for your sweet thoughts!Peggy, who is figuring out how to get red wine stains out of beige carpet today (not me, the hubby)> > > >> > > > Greetings all, > > > > First of all, thank you to everyone who participates in this site.> > > > I've recently been diagnosed with "A" and it is **SO** comforting to> > > > know there are folks out there who can relate to what I've been> > > > experiencing. The information on this site has been both reassuring> > > > and helpful in my decision making. Thanks...> > > > > > > > I do also have a couple of questions for you guys.>

> > > > > > > My GE has recommended a Heller myotomy and referred me to a surgeon> > > > (Dr. Patching, Sacramento, CA). I have not yet met with Dr.> > > > Patching but my doctor seemed to think that the myotomy would NOT> > > > require a fundoplication. His reasoning was that things are tight> > > > enough, we don't want to further constrict the esophagous. GERD would> > > > be controlled with PPI's and lifestyle changes. I may get a different> > > > story from the surgeon but I was suprised given most of the> > > > discussions I've seen on this site seem to couple myotomy with> > > > fundoplication of one sort or another. I'd rather not have the> > > > procedure if I can avoid it but (obviously) want to avoid chronic> > > > reflux and the nastiness that can come with it. Has anyone

out there> > > > had the myotomy without the fundoplication? Have you suffered much> > > > from GERD? > > > > > > > > I was also wondering if anyone has heard of, or been under the care of> > > > Dr. Patching. I haven't seen his name pop up on this site. He> > > > is highly recommended by my GE and is supposedly very experienced with> > > > A. Again, I haven't met him yet to grill him about his track record> > > > but thought this might be a good place to do a little background> > > > checking...> > > > > > > > Thanks again, > > > > > > > > n> > > >> > >> >> > > > > > > ---------------------------------> Try the all-new . "The New

Version is radically easier to use" – The Wall Street Journal>

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