laparoscopic or thoracoscopic?

[Guest guest]

I met with the surgeon today and I do think the myotomy is the way to

go for me. But the only surgeon in the group that is covered by my

insurance that performs the operation is a thoracic surgeon. Most of

what I've read about myotomy deals with laparoscopic surgery. Does

anyone have experience with or know about a thoracoscopic approach?

The surgeon explained that he'll go in under the ribs on the left side

of my body. Are the results/risks/benefits the same?

[Guest guest]

HI Kathleen:

About a year ago, I had a thoracic procedure called a VATS -- video-assisted

thoracic

surgery done at Cedars Sinai in LA by Fuller. The procedure was the same,

a heller

myotomy, but I did not have a wrap. Chest surgeons come at the LES from the

chest

cavity, after entering from the left underarm, collapsing a lung and pushing

aside the

aortic artery. They have a complete view of the E, so they have alot of control

over the

precision of the cut.

Hospitalization is a day or so longer and you have a chest tube for the first

day after, but

otherwise recovery and outcome was just or more successful than a lap procedure,

at least

for me.

Outcome studies are mixed in terms of pointing strongly to either lap or vats as

a

preference, so it is really up to what the surgeon does and is best at.

Hope this helps. Others will undoubtedly chime in.

Peggy from Lompoc, CA

>

> I met with the surgeon today and I do think the myotomy is the way to

> go for me. But the only surgeon in the group that is covered by my

> insurance that performs the operation is a thoracic surgeon. Most of

> what I've read about myotomy deals with laparoscopic surgery. Does

> anyone have experience with or know about a thoracoscopic approach?

> The surgeon explained that he'll go in under the ribs on the left side

> of my body. Are the results/risks/benefits the same?

>

[Guest guest]

Dear Kathleen,

I also had VATS from Dr. Fuller. His name is about the only one that comes up with VATS that I know of, but there are surely more.

The advantage of VATS is that because the surgeon can cut higher up the esophagus than a LAP surgery they don't have to cut as far into the stomach. There are some thoughts that the total length is important. Because the diaphragm is in the way w/ lap they can't cut as high as VATS and most cut further into the stomach, then do a wrap.

With less cut into the stomach they don't need a wrap. Dr. Fuller and his colleagues feel that the wrap causes problems down the road either from scarring or being too tight or too loose. He wants to avoid the wrap as much as possible. Many people w/ lap surgery need to take Prevacid type medication the rest of their life. With VATS, that isn't usually necessary.

I also see hesitation for people to go back to surgeons if the first heller is "wearing off" after a few years, or even 20 years. If you wait to go back for a dilation or a redo, there is a high risk of stretching the esophagus, which opens up a whole bunch of problems. If Dr. Fuller is right, then maybe (fingers crossed) the VATS will have a lower need for redos. Only time will tell. That is a whole area of surgical discussions and strong opinions.

I think many thoracic surgeons also do lap surgeries. But as achalasia is rare, there are few doctors that are well experienced in it. I wouldn't force either type of surgery on my surgeon (ha, like you could force them to do anything), or pick a surgeon only because of the type of surgery they do.

I'd look for the absolutely best surgeon with achalasia experience that is physically and financially available to you. Go some distance if you have to. Follow their advice.

I advocate VATS because it worked so well for me, 2+ years and I eat almost everything, with stickage only w/ pancakes. I do need to rinse things down at the end of a meal. No reflux, and no medication.

The absolutely most important thing is to go to the best expert you can find.

These surgeons will call you back, many within hours. You are a treasure chest of information and they love us. Don't hesitate to call and get free time with them.

The recovery, is a little longer. It isn't as much a difference as a c-section is from the v birth, but it is somewhat similar in that you take stronger meds for a little longer, and one more day in the hospital usually. LAP surgery seems to have pain because of the trapped gas, VATS surgery has pain because the tools go through your ribs.

All in all, you forget the pain when you eat again... similar to babies. But again, it isn't as much a difference. There are strong spasms that many seen to get w/i the first week after either surgery. Those are more painful than spasms before surgery for some. I envision it as the esophagus fighting the cuts and finally giving up with a scream.

Sandy in So Cal....

>> I met with the surgeon today and I do think the myotomy is the way to > go for me. But the only surgeon in the group that is covered by my > insurance that performs the operation is a thoracic surgeon. Most of > what I've read about myotomy deals with laparoscopic surgery. Does > anyone have experience with or know about a thoracoscopic approach? > The surgeon explained that he'll go in under the ribs on the left side > of my body. Are the results/risks/benefits the same?>

[Guest guest]

Kathleen,

Dr. Rice (that many here have talked about) is a thoracic

surgeon. He does LOTS of lap surgeries a year. Good luck in your

search for a good surgeon!

in Michigan

>

> I met with the surgeon today and I do think the myotomy is the way to

> go for me. But the only surgeon in the group that is covered by my

> insurance that performs the operation is a thoracic surgeon. Most of

> what I've read about myotomy deals with laparoscopic surgery. Does

> anyone have experience with or know about a thoracoscopic approach?

> The surgeon explained that he'll go in under the ribs on the left side

> of my body. Are the results/risks/benefits the same?

>

[Guest guest]

Kathleen

I had this done about 14 years ago. At the time it was the only way to go.

It was the very first surgery I've ever had, and was scared to death. The

main issue that I had was that I had a collapsed lung during surgery. I

also hate the scar that was left behind. My incision is on my left side, it

starts on my back underneath my left shoulder blade, and runs in a " J " back

to the front and ends almost directly under the nipple. The surgery was

long, it was morning when I went in, and was evening when I came out, but

like I said, that was 14 yrs ago. I had the laproscopic 2 years ago this

coming Christmas. Everything went extremely well, and I've not had any

problems until a couple of weeks ago. I'm in the process of going back to

the Cleveland Clinic to see Dr. Rice to see if its stress from work, or if

we need to do a dilatation. I hope all is well and if you need anything

email me.

>From: " Kathleen R. " <eringobrough2@...>

>Reply-achalasia

>achalasia

>Subject: laparoscopic or thoracoscopic?

>Date: Thu, 17 Aug 2006 23:25:44 -0000

>

>I met with the surgeon today and I do think the myotomy is the way to

>go for me. But the only surgeon in the group that is covered by my

>insurance that performs the operation is a thoracic surgeon. Most of

>what I've read about myotomy deals with laparoscopic surgery. Does

>anyone have experience with or know about a thoracoscopic approach?

>The surgeon explained that he'll go in under the ribs on the left side

>of my body. Are the results/risks/benefits the same?

>

>

>

[Guest guest]

Kathleen ,

Thanks for raising this question .

I have been reading many posts here where many people are facing swallowing

problems again after laparoscopic surgery. So sometimes , I wonder if one should

consider Open surgery or VAT thorasic surgery !

I am not sure if we can decide about which surgery we should go for...or it is

the condition of esophagus which decides what type of surgery is needed.

Are we sacrificing any important issues by choosing laparoscopic surgery against

Open or Thorasic/VATS surgeries ??

Mukesh

laparoscopic or thoracoscopic?

I met with the surgeon today and I do think the myotomy is the way to

go for me. But the only surgeon in the group that is covered by my

insurance that performs the operation is a thoracic surgeon. Most of

what I've read about myotomy deals with laparoscopic surgery. Does

anyone have experience with or know about a thoracoscopic approach?

The surgeon explained that he'll go in under the ribs on the left side

of my body. Are the results/risks/benefits the same?

[Guest guest]

My surgery was through my ribs, left side, about 5-6 inch scar.

Recovery time 2-3 weeks. Lots of soreness, chest tube...on and on.

Results....AWESOME. Dr.? Rice. He's priceless, people. Well, not

priceless...

DAWN IN OHIO

> >

> > I met with the surgeon today and I do think the myotomy is the

way to

> > go for me. But the only surgeon in the group that is covered by

my

> > insurance that performs the operation is a thoracic surgeon.

Most of

> > what I've read about myotomy deals with laparoscopic surgery.

Does

> > anyone have experience with or know about a thoracoscopic

approach?

> > The surgeon explained that he'll go in under the ribs on the

left side

> > of my body. Are the results/risks/benefits the same?

> >

>

[Guest guest]

P.S. surgery date with rice....13 yrs ago sept. 10th!!! wOOt! Dawn

in OHIO

> > >

> > > I met with the surgeon today and I do think the myotomy is the

> way to

> > > go for me. But the only surgeon in the group that is covered

by

> my

> > > insurance that performs the operation is a thoracic surgeon.

> Most of

> > > what I've read about myotomy deals with laparoscopic surgery.

> Does

> > > anyone have experience with or know about a thoracoscopic

> approach?

> > > The surgeon explained that he'll go in under the ribs on the

> left side

> > > of my body. Are the results/risks/benefits the same?

> > >

> >

>

[Guest guest]

Do you mean five or six 1" scars or just one scar? If one scar, then I assume that is thoracic surgery. VATS is minimally invasive w/ 5 holes where they put in tools and cameras etc. Just like a lap surgery.

Sandy in So CAL

> > >> > > I met with the surgeon today and I do think the myotomy is the > way to > > > go for me. But the only surgeon in the group that is covered by > my > > > insurance that performs the operation is a thoracic surgeon. > Most of > > > what I've read about myotomy deals with laparoscopic surgery. > Does > > > anyone have experience with or know about a thoracoscopic > approach? > > > The surgeon explained that he'll go in under the ribs on the > left side > > > of my body. Are the results/risks/benefits the same?> > >> >>

[Guest guest]

Most of the time, it is done keyhole now -- I have five very small incisions

under my arm

and side, no J scar.

>

> Kathleen

>

> I had this done about 14 years ago. At the time it was the only way to go.

> It was the very first surgery I've ever had, and was scared to death. The

> main issue that I had was that I had a collapsed lung during surgery. I

> also hate the scar that was left behind. My incision is on my left side, it

> starts on my back underneath my left shoulder blade, and runs in a " J " back

> to the front and ends almost directly under the nipple. The surgery was

> long, it was morning when I went in, and was evening when I came out, but

> like I said, that was 14 yrs ago. I had the laproscopic 2 years ago this

> coming Christmas. Everything went extremely well, and I've not had any

> problems until a couple of weeks ago. I'm in the process of going back to

> the Cleveland Clinic to see Dr. Rice to see if its stress from work, or if

> we need to do a dilatation. I hope all is well and if you need anything

> email me.

>

>

> >From: " Kathleen R. " <eringobrough2@...>

> >Reply-achalasia

> >achalasia

> >Subject: laparoscopic or thoracoscopic?

> >Date: Thu, 17 Aug 2006 23:25:44 -0000

> >

> >I met with the surgeon today and I do think the myotomy is the way to

> >go for me. But the only surgeon in the group that is covered by my

> >insurance that performs the operation is a thoracic surgeon. Most of

> >what I've read about myotomy deals with laparoscopic surgery. Does

> >anyone have experience with or know about a thoracoscopic approach?

> >The surgeon explained that he'll go in under the ribs on the left side

> >of my body. Are the results/risks/benefits the same?

> >

> >

> >

>

[Guest guest]

You guys are wonderful! Thank you so much for your replies and

input. Having a good surgeon is so important. The surgeon, Dr.

Kantamneni, was recently voted (by his peers) one of the best thoraic

surgeons in the area. He's done this operation for 15 years on

hundreds of patients. He's said he only had to convert to an open

surgery once because of a perferation. But he only does it

thoracoscopic -- he says a 5-6 inch incision on the left side instead

of the 5 smaller cuts. And he says I shouldn't need a wrap since I

had no problems of reflux before the achalasia.

Still I think I might talk to another surgeon at the University of

Wisconsin that has experience with achalasia. Her name is

Toth. Has anyone heard of her? She is a general surgeon and I think

she does the laparoscopic approach. I figure it can't hurt to get a

second opinion.

Thanks again for your input. I'm very interested in what anyone has

to say about either approach.

[Guest guest]

ONE scar. 5-6 inches in length on left side of body..towards back.

ONE chest tube scar...1 inch. Dawn in OHIO

> > > >

> > > > I met with the surgeon today and I do think the myotomy is

the

> > way to

> > > > go for me. But the only surgeon in the group that is covered

by

> > my

> > > > insurance that performs the operation is a thoracic surgeon.

> > Most of

> > > > what I've read about myotomy deals with laparoscopic surgery.

> > Does

> > > > anyone have experience with or know about a thoracoscopic

> > approach?

> > > > The surgeon explained that he'll go in under the ribs on the

> > left side

> > > > of my body. Are the results/risks/benefits the same?

> > > >

> > >

> >

>

[Guest guest]

Kathleen R. wrote:

> Does

> anyone have experience with or know about a thoracoscopic approach?

Other have give the pro VATS opinions, so I am going to skip that and

give the pro Lap. opinion.

The advantages of Lap. are that it gives a better view of the junction

of the stomach and esophagus allowing the surgeon to cut down onto the

stomach, and it allows them to provide a fundoplication, which can not

be done VATS. Many surgeons believe that VATS does not allow for the cut

to be done far enough onto the stomach which lead to failures and a need

to redo the myotomy later to extend it onto the stomach. Many surgeons

also believe that a myotomy done either by Lap. or VATS without a

fundoplication risks damage to the esophagus from acid reflux.

That needs some explaining. The problem that a myotomy is suppose to fix

is that the LES (Lower Esophageal Sphincter, a ring/tube of muscle) is

continuously providing strong constricting pressure at the junction of

the esophagus and stomach, not relaxing to let food pass easily into the

stomach. The myotomy (cutting of muscle) is done to reduce the pressure

created by the LES. However, the amount of pressure that causes problems

is not that much more than a pressure that is so low it lets acid to go

up into the esophagus. This means that a myotomy without a

fundoplication needs be just right. Cut to short and the pressure will

be too strong. Cut too long and the pressure will be weak. The muscle in

the esophagus right above the LES and also right below in the stomach

can can contribute to the pressure at the LES. This means you can cut a

little longer up (VATS) or a little longer down (Lap.) to reduce the

pressure at the LES when you cut there.

Those that favor VATS say that they can get the pressure just right by

cutting a little longer above. Some surgeons that do Lap. say they can

get the pressure just right by cutting a little longer down. Other

Surgeons say that either of these can be too loose or too tight. They

favor cutting longer onto the stomach, even longer than some other Lap.

surgeons, to make sure the pressure is on the low side and then add a

fundoplication to stop acid reflux. Now a fundoplication can also be too

tight or too loose. These surgeons figure it is easier to get the

fundoplication right than to get the myotomy right without a

fundoplication. Also, they say the fundoplication helps to hold the

myotomy apart so that it does not grow back together. They also figure

most problems after a fundoplication can be fixed by dilatation. On the

other hand, a myotomy without fundoplication has a greater risk of

needing surgery to have the myotomy extended, making it longer to reduce

pressure. If you don't get a fundoplication and then need a dilatation

you have no protection from acid reflux if the dilatation causes the

pressure to become to weak. And, any way you go, with or without a

fundoplication, with or without the need for a dilatation after the

myotomy, you may still have acid reflux, even after VATS. You can also

have problem swallowing after any of the methods. So, who is right?

Nobody really knows.

One more thing. Not many people have achalasia, but many people get

fundoplications for GERD. There is a lot of knowledge about

fundoplications. The ones used for achalasia are modified from the GERD

versions. Even for GERD fundoplications can fail, but they are generally

very trusted now. That is, if they are done by skilled surgeons. The

same is true for achalasia. The skill of the surgeon is the most

important factor for success.

notan

[Guest guest]

Notan.Thanks for a very nice & detailed information..Your posts are always very informative for all..I fully agree with you..Skill of the surgeon is most important..After reading your msg, I have decided to travel to Coimbatore( South India)for this lap surgery, which I was earlier planning to get it done at Mumbai( West India ), just bczo it was closer to my home..Thanks again for all these details ...Mukeshnotan ostrich <notan_ostrich@...> wrote: Kathleen R. wrote: >

Does > anyone have experience with or know about a thoracoscopic approach? Other have give the pro VATS opinions, so I am going to skip that and give the pro Lap. opinion. The advantages of Lap. are that it gives a better view of the junction of the stomach and esophagus allowing the surgeon to cut down onto the stomach, and it allows them to provide a fundoplication, which can not be done VATS. Many surgeons believe that VATS does not allow for the cut to be done far enough onto the stomach which lead to failures and a need to redo the myotomy later to extend it onto the stomach. Many surgeons also believe that a myotomy done either by Lap. or VATS without a fundoplication risks damage to the esophagus from acid reflux. That needs some explaining. The problem that a myotomy is suppose to fix is that the LES (Lower Esophageal Sphincter, a ring/tube of muscle) is continuously providing

strong constricting pressure at the junction of the esophagus and stomach, not relaxing to let food pass easily into the stomach. The myotomy (cutting of muscle) is done to reduce the pressure created by the LES. However, the amount of pressure that causes problems is not that much more than a pressure that is so low it lets acid to go up into the esophagus. This means that a myotomy without a fundoplication needs be just right. Cut to short and the pressure will be too strong. Cut too long and the pressure will be weak. The muscle in the esophagus right above the LES and also right below in the stomach can can contribute to the pressure at the LES. This means you can cut a little longer up (VATS) or a little longer down (Lap.) to reduce the pressure at the LES when you cut there. Those that favor VATS say that they can get the pressure just right by cutting a little longer above. Some surgeons that do

Lap. say they can get the pressure just right by cutting a little longer down. Other Surgeons say that either of these can be too loose or too tight. They favor cutting longer onto the stomach, even longer than some other Lap. surgeons, to make sure the pressure is on the low side and then add a fundoplication to stop acid reflux. Now a fundoplication can also be too tight or too loose. These surgeons figure it is easier to get the fundoplication right than to get the myotomy right without a fundoplication. Also, they say the fundoplication helps to hold the myotomy apart so that it does not grow back together. They also figure most problems after a fundoplication can be fixed by dilatation. On the other hand, a myotomy without fundoplication has a greater risk of needing surgery to have the myotomy extended, making it longer to reduce pressure. If you don't get a fundoplication and then need a dilatation

you have no protection from acid reflux if the dilatation causes the pressure to become to weak. And, any way you go, with or without a fundoplication, with or without the need for a dilatation after the myotomy, you may still have acid reflux, even after VATS. You can also have problem swallowing after any of the methods. So, who is right? Nobody really knows. One more thing. Not many people have achalasia, but many people get fundoplications for GERD. There is a lot of knowledge about fundoplications. The ones used for achalasia are modified from the GERD versions. Even for GERD fundoplications can fail, but they are generally very trusted now. That is, if they are done by skilled surgeons. The same is true for achalasia. The skill of the surgeon is the most important factor for success. notan

[Guest guest]

notan wrote:

> ... a fundoplication, which can not

> be done VATS. Many surgeons believe that VATS does not allow for the cut

> to be done far enough onto the stomach ...

I did say that, but I am thinking this can not be right on two points.

First, I see that some surgeons do a Belsey fundoplication VATS. They

have to pull part of the stomach up through the diaphragm to do it.

Second, if they can pull enough of the stomach up to do that, then why

not be able to cut longer onto the stomach if they wish? Perhaps there

is something I am missing here. I do wonder if they did do a

fundoplication VATS how they would secure the stomach so that it didn't

twist the esophagus. This may go to that discussion we had a few days

back about a " traditional twist " done by surgeons. As I remember that

person had a Belsey fundoplication.

notan

[Guest guest]

Dear Notan,

As I understood Dr. Fuller, the whole idea of doing VATS is to avoid a wrap. He feels very strongly that the wrap causes problems later. He also wants to avoid reflux, thus doesn't want to cut further into the stomach. It is probably a very delicate decision as to how far to cut either way, thus the need for expertise.

I suppose if a wrap was necessary with a VATS procedure, there isn't any reason they couldn't poke a few more holes to do a wrap under the diaphragm.

I do not mean to have a stand off about lap vs. VATS. My guess is by chance Dr. Fuller made a few decisions in his career that led to a lot of experience with the esophagus, he did manometries for a year. Not many doctors do that. He and his group also do somewhat controversial VATS surgery for lung issues. Within that group he must have done a lot of esophagus surgeries.

When he explains why he wants to avoid the wrap it makes it very clear. But the surgeons who explain why they want the wrap it must be as clear to others.

I'm so very fortunate to be doing so well after I was so miserable I hate to see others suffer.

I still firmly believe that people must search for the surgeon that is physically and financially feasible. I'm prejudiced toward VATS because I am doing so well. Many people who do well w/ lap probably don't haunt this website like I do.

Sandy in So Cal> > > ... a fundoplication, which can not> > be done VATS. Many surgeons believe that VATS does not allow for the cut> > to be done far enough onto the stomach ...> > I did say that, but I am thinking this can not be right on two points. > First, I see that some surgeons do a Belsey fundoplication VATS. They > have to pull part of the stomach up through the diaphragm to do it. > Second, if they can pull enough of the stomach up to do that, then why > not be able to cut longer onto the stomach if they wish? Perhaps there > is something I am missing here. I do wonder if they did do a > fundoplication VATS how they would secure the stomach so that it didn't > twist the esophagus. This may go to that discussion we had a few days > back about a "traditional twist" done by surgeons. As I remember that > person had a Belsey fundoplication.> > notan>

[Guest guest]

Hello Sandy.

....the

whole idea of doing VATS is to avoid a wrap. ...

Yes, I understand the theory. As you know there are also Lap. surgeons

that have similar beliefs who believe they can get things just right

without a wrap. However the VATS surgeons believe you have to cut too

much of the stomach or risk too short of a myotomy to do it without a

wrap with Lap.. I think I understand that idea. What I am having

trouble with is criticism, by an author of an article, about the VATS

method that said it was "convenient" that VATS surgeons claimed that a

wrap was not needed with the VATS method. It sounded like if they did

believe it was necessary they would either have to decline doing the

surgery or do it Lap.. Now I am wondering what "convenient" meant. I

need to find that article again.

I

suppose if a wrap was

necessary with a VATS procedure, there isn't any reason they couldn't

poke a few more holes to do a wrap under the diaphragm.

If I understand what you are saying I think that would mean having both

a VATS and a Lap. procedure done.

....

My guess is by chance Dr. Fuller made a few decisions in his career

that led to a lot of experience with the esophagus, ...

To me this just makes him one expert among others.

When

he explains why he

wants to avoid the wrap it makes it very clear. But the surgeons who

explain why they want the wrap it must be as clear to others.

I think so.

I'm

so very fortunate to be doing so well after I was so miserable I hate

to see others suffer.

Yes, it feels good anytime one of us reports feeling better. It is hard

not to favor what has worked for us and want to share it.

....

I'm prejudiced toward VATS because I am doing so well. ...

It is hard to argue with success. It is good that VATS has you to

present the case for it. I think it is good that the Lap. case also be

made. If you don't do it someone should. We differ in that I am less

sure than you that something will work as well for others as it works

for me. Too often they don't. I present the Lap. case because someone

should, and if the VATS view says something about the Lap. method, the

Lap. view on that should be given. Those views aren't about you and me

and if it sounds like a debate it is because we each are expressing the

views of experts who are part of a debate in the medical world. They

are having a good and useful debate. If two people each present one

side it will sound like a debate. I hope you don't mind. I don't.

notan

[Guest guest]

Dear Notan,

I love a good debate. You are always balanced and fair, yet knowledgeable. You've gone through the information process and learned what needs to be learned to head the team to manage your health. That is a good thing.

I do wonder why no other surgeons even present VATS as an alternative. If a patient comes to a doctor and says they are concerned about wraps, for instance, I'm fascinated why or if lap surgeons, who also may do VATS surgeries for other diseases, don't mention it as an alternative. Seems like it is worth mentioning even if only 5% of the patients have it. I totally understand that lap is more popular and the majority of surgeons recommend it. Seems like it could be offered as an alternative then the lap surgeon could state why they don't recommend it. They mention botox then say it isn't recommended. Hopefully if we are informed about VATS there is questioning exactly why lap is preferred, the whole issue about how far to cut into the stomach etc. I think the chosen surgeon should be well informed about VATS to know lap is better, if that is their view. Just stating older articles say it isn't as good wouldn't be enough for me. Esophageal surgeons know each and their reputations, I'd throw out the names and ask what they think of their procedures. Of course there is the protective net over all of them.

I agree completely that not all procedures will work on all people. That is the reason to go to a highly experienced surgeon who has seen many cases and can differentiate between different types of wraps, for example, based on the individual condition.

This issue is interesting to me for future health issues. If someone close to me develops any condition and a procedure is recommended, I'll ask what are the alternatives, and make them dig out the ones that are contrary to their recommendation if they come from highly regarded medical centers maybe even weird little medical centers. By investigating the successful, but rare ones you can really narrow down the expertise of a doctor when they have to defend their positon against an alternative view. Then I'll bounce between the two until I understand the differences and the logic for the different approaches.

That is why I continue to mention VATS, not that I think it is the only or even the best choice but it is a valid alternative to lap surgery and worth investigating. Sadly there aren't articles published yet by Dr. Fuller and his co-workers that directly address the differences. There are older articles, by others, but there are modifications Dr. Fuller does that are different from earlier VATS procedures. There aren't many of us that have had VATS so I continue here. As you said I feel so great and have no problems I can't help but want to offer it as a possibility. I totally understand not wanting the expense of coming to CA if you are on the East Coast, for instance.

All in all, the best thing is to go to the best surgeons and doctors you can find that are financially and physically possible for your situation. Call and email others. Probably you are talking about a major metropolitan area at least.

Sandy in So Cal.... wishing I had joined the debate team in HS.

[Guest guest]

Sandy,

Do you remember that I had talked to Dr. Fuller on the phone back

in February about doing a VATS long myotomy for 's DES? I was

impressed by him, just talking over the phone, by the way. Well, when

I mentioned this to Dr. Rice afterwards and asked if he thought this

was a good option for , he said, " At CCF, we do tens of thousands

of VATS surgeries. I just don't think it's the right thing to do in

this case. " I guess a lot of other places do VATS surgeries, just

maybe not VATS myotomies (or at least not long myotomies). I'm not

sure why.

in Michigan

>

>

> Dear Notan,

>

> I love a good debate. You are always balanced and fair, yet

> knowledgeable. You've gone through the information process and learned

> what needs to be learned to head the team to manage your health. That

> is a good thing.

>

> I do wonder why no other surgeons even present VATS as an alternative.

> If a patient comes to a doctor and says they are concerned about wraps,

> for instance, I'm fascinated why or if lap surgeons, who also may do

> VATS surgeries for other diseases, don't mention it as an alternative.

> Seems like it is worth mentioning even if only 5% of the patients have

> it. I totally understand that lap is more popular and the majority of

> surgeons recommend it. Seems like it could be offered as an alternative

> then the lap surgeon could state why they don't recommend it. They

> mention botox then say it isn't recommended. Hopefully if we are

> informed about VATS there is questioning exactly why lap is preferred,

> the whole issue about how far to cut into the stomach etc. I think the

> chosen surgeon should be well informed about VATS to know lap is better,

> if that is their view. Just stating older articles say it isn't as good

> wouldn't be enough for me. Esophageal surgeons know each and their

> reputations, I'd throw out the names and ask what they think of their

> procedures. Of course there is the protective net over all of them.

>

> I agree completely that not all procedures will work on all people.

> That is the reason to go to a highly experienced surgeon who has seen

> many cases and can differentiate between different types of wraps, for

> example, based on the individual condition.

>

> This issue is interesting to me for future health issues. If someone

> close to me develops any condition and a procedure is recommended, I'll

> ask what are the alternatives, and make them dig out the ones that are

> contrary to their recommendation if they come from highly regarded

> medical centers maybe even weird little medical centers. By

> investigating the successful, but rare ones you can really narrow down

> the expertise of a doctor when they have to defend their positon against

> an alternative view. Then I'll bounce between the two until I

> understand the differences and the logic for the different approaches.

>

> That is why I continue to mention VATS, not that I think it is the only

> or even the best choice but it is a valid alternative to lap surgery and

> worth investigating. Sadly there aren't articles published yet by Dr.

> Fuller and his co-workers that directly address the differences. There

> are older articles, by others, but there are modifications Dr. Fuller

> does that are different from earlier VATS procedures. There aren't many

> of us that have had VATS so I continue here. As you said I feel so

> great and have no problems I can't help but want to offer it as a

> possibility. I totally understand not wanting the expense of coming to

> CA if you are on the East Coast, for instance.

>

> All in all, the best thing is to go to the best surgeons and doctors you

> can find that are financially and physically possible for your

> situation. Call and email others. Probably you are talking about a

> major metropolitan area at least.

>

> Sandy in So Cal.... wishing I had joined the debate team in HS.

>

[Guest guest]

I remember you spoke, but don't remember what he suggested, likely he wanted to see the tests and see . It would be intimidating to ask Dr. Rice exactly why he didn't think VATS was right in 's case. Then go back to Dr. Fuller and try to remain diplomatic and tell him what Dr. Rice said and get his response. Please understand that takes some guts, you are almost turning into a divorce counselor. At that point they are both ready to tell you to get your own medical degree and block your phone number.

What this group is good for is educating yourselves on the pros and cons so that when you speak to these doctors you can ask the really deep questions first before they hate you and maybe do only one round of questions. Go for the main heartstopping questions first and skip the ones they have gone over a million times.

I got curious as I was putting the computer asleep last night about Dr. Pellegrini in Seattle. Guessing by his resume dates he is about 60ish, not that old. He has a young associate in his group that sounds likely, and I've seen his name around. Dr. Os... something long. Then I got curious about VATS and typed VATS into the UW med center website. That takes you to the thoracic surgery website. Another doctor (younger than some of my clothes) sounds innovative. He was bragging about going to Cedars in Los Angeles to be trained by Dr. McKenna in VATS and how quickly he learned. Dr. McKenna was at Cedars before Dr. Fuller and is also very skilled. As I've mentioned they specialize as a group in minimally invasive lung surgeries, usually for lung resections. Dr. Fuller slightly diverts to esophagus surgeries, but all three surgeons in the group probably do similar surgeries.

When TCC mentioned they do a lot of VATS surgeries, maybe they meant for lung diseases or even cardiac problems.

Again, I wouldn't go to a VATS surgeon and ask for a VATS myotomy if they weren't experienced.

I find it interesting that within hospitals they set up which group to go to if you type in a disease. Just thinking out loud, there is probably political turmoil in a hospital about which department to send people to on their websites if a disease it typed into the search. For instance it is prestigious for UW to have Dr. Pellegrini there so they wouldn't step on his toes and have an esophageal center that includes a VATS surgeon.

Probably from watching too many "Grey's Anatomy" shows it makes me realize everything has a political side with a lot of personality issues coming into play.

Please understand I'm not saying VATS myotomy is the only way to go, or even the best way. It is an example to me that doctors have their opinions and as a patient you really have to explore all avenues. For Jeanie, and others in the NW US, it would be interesting to call the VATS surgeon at UW and see what he says and balance that with what Dr. Pellegrini says. UW is very highly regarded on the West Coast and has an excellent reputation as a medical school. Distance is a factor for us, that is a reality. I suspect all doctors there will be careful not to step on each others' toes.

Sandy in So Cal>> Sandy,> Do you remember that I had talked to Dr. Fuller on the phone back> in February about doing a VATS long myotomy for 's DES? I was> impressed by him, just talking over the phone, by the way. Well, when> I mentioned this to Dr. Rice afterwards and asked if he thought this> was a good option for , he said, "At CCF, we do tens of thousands> of VATS surgeries. I just don't think it's the right thing to do in> this case." I guess a lot of other places do VATS surgeries, just> maybe not VATS myotomies (or at least not long myotomies). I'm not> sure why. >

[Guest guest]

Peggy and Sandy,

You both performed an excellent service here for anyone contemplating either surgery. As it has been said, surgeons must hear the same "dumb" (dumb to them, not to us) questions all the time. By giving each other an education here, patients can advance to a higher level of questioning and perhaps find the surgeons more responsive to more challenging questions.

PS: Now the question in my mind is why Dr. Altorki (NY) and Dr. Richter (Philly) did not mention esophagoplasty to me, and that Steve in the UK knew all about it?

Maybe the answer is that this is not new surgery, and many surgeons have not trained to perform "arcane" surgeries!

In a message dated 8/22/2006 9:20:28 P.M. Eastern Standard Time, pegster@... writes:

Now I am going to appear biased, regarding this friendly debate about the pros and cons of lap vs. VATS, but I think this discussion is an important one to continue as people make their choices, pursue information and so on in search of their best answer. Sandy has held the torch for VATS and I must speak up, as my experience is recent and I am feeling the euphoric effects of sedation from a colonoscopy earlier today!I just returned from my 1 year post op with Dr. Fuller after a barium swallow two weeks ago that showed superior results from my VATS myotomy no wrap. Dr. Fuller went on to mention there is no sign of reflux and I continue to have no symptoms. I am released from further follow-up, though I decided on the way home to reestablish with my community GI (the one who diagnosed me) to follow-up every couple of years.My esophagus is dilated a bit, but remains straight. Return of peristalsis was not obvious, however, Dr. Fuller feels that over the year, I have not progressed and he feels that the procedure arrested the progressive damage to my esophagus. Today, I continued to query Dr. Fuller on the pros and cons of the VATS no wrap procedure and I came away feeling good for my own outcome in terms of choosing a VATS approach with a skilled esophagist, who happens to be a lung surgeon. Further, I am unconvinced of his advice that going without regular follow-up, based upon what I have learned on these boards and my own lack of awareness of what was happening in my esophagus tell me.In looking at most of the outcome comparative studies on lap vs VATS it is pretty clear that both are viable treatments for achalasia and whoever publishes the study (lap or VATS specialist) can make the case that theirs is better than the other. Also, it has been said and I agree, that surgeons sell surgery, their specialty in particular, so buyer beware.I think we do a service to those on this board who are researching their best avenue for treatment to continue to bring up the benefits (and potential disadvantages) to both procedures -- VATS: clearer view of E and thus less need to wrap vs. longer hospital stay, some risk of reflux if cut is too long; LAP: able to do Dor wrap to prevent reflux risk and less hospital time, but risk of further damage to E due to a too tight wrap and need for a dilation (i.e., semi-controlled tear) to loosen it.I think that someone said that experience, expertise in a particular procedure is an important factor -- so don't ask your thoracic surgeon for a LAP and don't ask a LAP surgeon for VATS!My contribuion, since I can't drive until tomorrow!Peggy from Lompoc, CA> >> > Sandy,> > Do you remember that I had talked to Dr. Fuller on the phone back> > in February about doing a VATS long myotomy for 's DES? I was> > impressed by him, just talking over the phone, by the way. Well, when> > I mentioned this to Dr. Rice afterwards and asked if he thought this> > was a good option for , he said, "At CCF, we do tens of thousands> > of VATS surgeries. I just don't think it's the right thing to do in> > this case." I guess a lot of other places do VATS surgeries, just> > maybe not VATS myotomies (or at least not long myotomies). I'm not> > sure why.> >>

[Guest guest]

Now I am going to appear biased, regarding this friendly debate about the pros

and cons

of lap vs. VATS, but I think this discussion is an important one to continue as

people make

their choices, pursue information and so on in search of their best answer.

Sandy has held

the torch for VATS and I must speak up, as my experience is recent and I am

feeling the

euphoric effects of sedation from a colonoscopy earlier today!

I just returned from my 1 year post op with Dr. Fuller after a barium swallow

two weeks

ago that showed superior results from my VATS myotomy no wrap. Dr. Fuller went

on to

mention there is no sign of reflux and I continue to have no symptoms. I am

released

from further follow-up, though I decided on the way home to reestablish with my

community GI (the one who diagnosed me) to follow-up every couple of years.

My esophagus is dilated a bit, but remains straight. Return of peristalsis was

not obvious,

however, Dr. Fuller feels that over the year, I have not progressed and he feels

that the

procedure arrested the progressive damage to my esophagus. Today, I continued

to query

Dr. Fuller on the pros and cons of the VATS no wrap procedure and I came away

feeling

good for my own outcome in terms of choosing a VATS approach with a skilled

esophagist, who happens to be a lung surgeon. Further, I am unconvinced of his

advice

that going without regular follow-up, based upon what I have learned on these

boards and

my own lack of awareness of what was happening in my esophagus tell me.

In looking at most of the outcome comparative studies on lap vs VATS it is

pretty clear

that both are viable treatments for achalasia and whoever publishes the study

(lap or VATS

specialist) can make the case that theirs is better than the other. Also, it

has been said

and I agree, that surgeons sell surgery, their specialty in particular, so buyer

beware.

I think we do a service to those on this board who are researching their best

avenue for

treatment to continue to bring up the benefits (and potential disadvantages) to

both

procedures -- VATS: clearer view of E and thus less need to wrap vs. longer

hospital stay,

some risk of reflux if cut is too long; LAP: able to do Dor wrap to prevent

reflux risk and

less hospital time, but risk of further damage to E due to a too tight wrap and

need for a

dilation (i.e., semi-controlled tear) to loosen it.

I think that someone said that experience, expertise in a particular procedure

is an

important factor -- so don't ask your thoracic surgeon for a LAP and don't ask a

LAP

surgeon for VATS!

My contribuion, since I can't drive until tomorrow!

Peggy from Lompoc, CA

> >

> > Sandy,

> > Do you remember that I had talked to Dr. Fuller on the phone back

> > in February about doing a VATS long myotomy for 's DES? I was

> > impressed by him, just talking over the phone, by the way. Well, when

> > I mentioned this to Dr. Rice afterwards and asked if he thought this

> > was a good option for , he said, " At CCF, we do tens of thousands

> > of VATS surgeries. I just don't think it's the right thing to do in

> > this case. " I guess a lot of other places do VATS surgeries, just

> > maybe not VATS myotomies (or at least not long myotomies). I'm not

> > sure why.

> >

>

[Guest guest]

Peggy Cordero wrote:

> ... it has been said

> and I agree, that surgeons sell surgery, their specialty in

> particular, so buyer beware.

When I told my primary (who admitted to me that he knew nothing about

achalasia) about some GIs favoring dilatation while surgeon seemed to

think myotomy was the way to go. His response was surgeons are in the

business of doing surgeries, of course they favor myotomies. I think I

will keep him. ;-)

notan

[Guest guest]

I have to totally agree with . I appreciate everyone who

shared their experiences here. I came here a little scared and

knowing almost nothing about 'A', now I feel that I can advance to a

higher level when talking to the surgeons. I've already talked to the

surgeon recommended by my insurance company (the thoracic surgeon).

I'll be scheduling a meeting with another surgeon next week to talk

about the lap approach (hopefully I can get a waver from my insurance

company to talk to an out-of-network physician). I'm also working at

setting up a meeting with a third surgeon.

Thanks again everyone. Keep up the good work!

-Kathleen in Madison