Questions-Answers before Lap surgery-Achalasia

[Guest guest]

I recently met Dr.Palanivelu (PV) at Gem hospital-Coimbatore-India

to fix up surgery date for my son, Bimal.

Bimal is 25 years old and he had 2 dilatations in 1994.

He was quite okay till last May'06, when he faced swallowing

problem again so we went for the last- 3rd dilatation in June'06.

After 3rd dilatation he is fine now but dr. had advised us to go for

Hellers Myotomy by Oct/Nov'06.

I had gone to see Dr.PV with a list of all questions which I had in my

mind before deciding on this surgery. I learnt a lot from all you guys

on this wonderful site..

You can see below my questions and Dr's answers below;

All answers starts after -

Question : Looking at this latest Barium report, what is your opinion

on his condition ?

Answer - It's bad but Not too bad..it's a Sigmoid esophagus and needs

to cure by surgery only.

Is it advisable to go for surgery now ?/ or later ?

- Better to do it now..Oct/Nov is fine..

Will esophagus shrink after surgery ?

- Yes...over a period of time, say 6 months to 12 months..

Do you anticipate any complications during surgery ?

- No..

What is the risk if we delay this surgery ?

- It may lead to Esophagus cancer / removal of esophagus..

What type of surgery will be better for us- Open, Lap or VAT ??

- Lap is the right choice for this case..

Is it necessary to do fundoplication/wrap ?

-Yes...Toupet type wrap..

What could be the side-effects of this surgery ?

- Acid reflux, if the wrap is too tight but here also skill and

experience of doctor is very important to do a perfect wrap..neither

loose nor too tight..

What are the risks in this surgery ?

- Perforation...if some muscles are already damaged earlier during

dilatations, then there are chances of perforations..

( That's the reason why drs. normally prefer to carry out surgery

only after 6 months of dilatation..)

Is it necessary to carry out Manometry test ??

- Yes, we do it on an earlier day of surgery..

Is Manometry test very painful ??

- Not really, we insert a small wire and it doesn't take long time..

I saw many cases in USA where many people had to go for 2nd myotomy

surgery or some dilatations etc- Why ??

- If the cutting of muscles in esophagus is not completed/or

enough, the problem could come up again..

( He said that this can be described as a bad surgery or incomplete

job done....)

In all such Achalasia cases u have come across so far, did u find any

cases where patients had to go for esphagectomy

( removal of esphpagus ) ?

-Only 1 or 2 cases..in such cases, esophagus is too big and totally

deformed and/or cancer development..and there is no way to repair it

by surgery..

Is return of peristalis possible ?

- Usually it comes back to some extent after surgery , if not full

but over a period of time..

How may days patient has to stay in hospital ?

-Usually only 2 or 3 days are enough, but since u are coming from

Mumbai,we will keep for app 5 days, till patient starts taking solid food.

How long it will take to do this surgery ??

- less than 2 hours.

Can you assure me that there will be no need for the second surgery ?

- There are almost No chances of 2nd surgery.

How many such cases handled so far by you ??

- 250 + cases handled..

In how many cases, u had found complications during surgery

to go for Open or VAT surgery ?

- No such case so far..

In how many cases, these patients are perfectly okay after surgery ?

- app 95 %..

Are there any chances of reoccurance of the problem after surgery in

our case ?

-Very minimum chances..

What is to be done if we still face problem after this surgery ?

-There are very minimum chances for such re-occurance but if at all,

you need to go for dilatation and in the next stage, VTA-Thorasic surgery.

How can u make it very long lasting ??

- This is only due to surgical technique which differs from doctor to

doctor..In such surgery, experience and expertise of doctor is a key

factor for success..

My Comments :

I think the Most Important is the skill & experience of the surgeon.

Looking at his vast experience and expertise in lap surgery, I think

it is worth travelling to Coimbatore and stay there for 6 days but

then we are sure that we are in the best hands.

No doubt, PV is the best one in India..

I don't think any other doctor might have done so many lap surgeries

to treat Achalasia in last 9 years. ( he has been doing only lap since

9 years & he is considered a specialist for lap.)

Dr.Roy Patankar at Bombay is also good but his experience is app 70

as compared to 250+ in case of Dr.Palanivelu.

Plz let me know your views too...

Mukesh

[Guest guest]

Wow, Mukesh -- great job. This post should be uploaded to the files section so

that

others who are considering surgery can benefit from it.

>

> I recently met Dr.Palanivelu (PV) at Gem hospital-Coimbatore-India

> to fix up surgery date for my son, Bimal.

> Bimal is 25 years old and he had 2 dilatations in 1994.

> He was quite okay till last May'06, when he faced swallowing

> problem again so we went for the last- 3rd dilatation in June'06.

> After 3rd dilatation he is fine now but dr. had advised us to go for

> Hellers Myotomy by Oct/Nov'06.

>

> I had gone to see Dr.PV with a list of all questions which I had in my

> mind before deciding on this surgery. I learnt a lot from all you guys

> on this wonderful site..

>

> You can see below my questions and Dr's answers below;

> All answers starts after -

>

> Question : Looking at this latest Barium report, what is your opinion

> on his condition ?

>

> Answer - It's bad but Not too bad..it's a Sigmoid esophagus and needs

> to cure by surgery only.

>

>

> Is it advisable to go for surgery now ?/ or later ?

> - Better to do it now..Oct/Nov is fine..

>

> Will esophagus shrink after surgery ?

> - Yes...over a period of time, say 6 months to 12 months..

>

> Do you anticipate any complications during surgery ?

> - No..

>

> What is the risk if we delay this surgery ?

> - It may lead to Esophagus cancer / removal of esophagus..

>

> What type of surgery will be better for us- Open, Lap or VAT ??

> - Lap is the right choice for this case..

>

> Is it necessary to do fundoplication/wrap ?

> -Yes...Toupet type wrap..

>

> What could be the side-effects of this surgery ?

> - Acid reflux, if the wrap is too tight but here also skill and

> experience of doctor is very important to do a perfect wrap..neither

> loose nor too tight..

>

> What are the risks in this surgery ?

> - Perforation...if some muscles are already damaged earlier during

> dilatations, then there are chances of perforations..

>

> ( That's the reason why drs. normally prefer to carry out surgery

> only after 6 months of dilatation..)

>

> Is it necessary to carry out Manometry test ??

> - Yes, we do it on an earlier day of surgery..

>

> Is Manometry test very painful ??

> - Not really, we insert a small wire and it doesn't take long time..

>

> I saw many cases in USA where many people had to go for 2nd myotomy

> surgery or some dilatations etc- Why ??

>

> - If the cutting of muscles in esophagus is not completed/or

> enough, the problem could come up again..

> ( He said that this can be described as a bad surgery or incomplete

> job done....)

>

> In all such Achalasia cases u have come across so far, did u find any

> cases where patients had to go for esphagectomy

> ( removal of esphpagus ) ?

>

> -Only 1 or 2 cases..in such cases, esophagus is too big and totally

> deformed and/or cancer development..and there is no way to repair it

> by surgery..

>

> Is return of peristalis possible ?

> - Usually it comes back to some extent after surgery , if not full

> but over a period of time..

>

> How may days patient has to stay in hospital ?

> -Usually only 2 or 3 days are enough, but since u are coming from

> Mumbai,we will keep for app 5 days, till patient starts taking solid food.

>

> How long it will take to do this surgery ??

> - less than 2 hours.

>

> Can you assure me that there will be no need for the second surgery ?

> - There are almost No chances of 2nd surgery.

>

> How many such cases handled so far by you ??

> - 250 + cases handled..

>

> In how many cases, u had found complications during surgery

> to go for Open or VAT surgery ?

> - No such case so far..

>

> In how many cases, these patients are perfectly okay after surgery ?

> - app 95 %..

>

> Are there any chances of reoccurance of the problem after surgery in

> our case ?

> -Very minimum chances..

>

> What is to be done if we still face problem after this surgery ?

>

> -There are very minimum chances for such re-occurance but if at all,

> you need to go for dilatation and in the next stage, VTA-Thorasic surgery.

>

> How can u make it very long lasting ??

>

> - This is only due to surgical technique which differs from doctor to

> doctor..In such surgery, experience and expertise of doctor is a key

> factor for success..

>

> My Comments :

> I think the Most Important is the skill & experience of the surgeon.

> Looking at his vast experience and expertise in lap surgery, I think

> it is worth travelling to Coimbatore and stay there for 6 days but

> then we are sure that we are in the best hands.

> No doubt, PV is the best one in India..

> I don't think any other doctor might have done so many lap surgeries

> to treat Achalasia in last 9 years. ( he has been doing only lap since

> 9 years & he is considered a specialist for lap.)

>

> Dr.Roy Patankar at Bombay is also good but his experience is app 70

> as compared to 250+ in case of Dr.Palanivelu.

>

> Plz let me know your views too...

>

> Mukesh

>

[Guest guest]

Good grief Mukesh, Now that is what I call an informative post. You have asked many of the questions that a lot of those contemplating surgery will want to know the answers to. It is very good of you to share this with us and take the time to type it all out. You really gave the surgeon an ear-bashing didn't you? All the best for a good future for you and your son, With love from Ann in England XXmukeshshah_fine <mukeshshah_fine@...> wrote: I recently met Dr.Palanivelu (PV) at Gem hospital-Coimbatore-Indiato fix up surgery date for my son, Bimal.Bimal is 25 years old and he had 2 dilatations in 1994.He was quite okay till last May'06, when he faced swallowingproblem again so we went for the last- 3rd dilatation in June'06. After 3rd dilatation he is fine now but dr. had advised us to go forHellers Myotomy by Oct/Nov'06.I had gone to see Dr.PV with a list of all questions which I had in mymind before deciding on this surgery. I learnt a lot from all you guyson this wonderful site..You can see below my questions and Dr's answers below;All answers starts after -Question : Looking at this latest Barium report, what is your opinionon his condition ?Answer - It's bad but Not too bad..it's a Sigmoid esophagus and needsto cure

by surgery only.Is it advisable to go for surgery now ?/ or later ?- Better to do it now..Oct/Nov is fine..Will esophagus shrink after surgery ?- Yes...over a period of time, say 6 months to 12 months..Do you anticipate any complications during surgery ?- No..What is the risk if we delay this surgery ?- It may lead to Esophagus cancer / removal of esophagus..What type of surgery will be better for us- Open, Lap or VAT ??- Lap is the right choice for this case..Is it necessary to do fundoplication/wrap ?-Yes...Toupet type wrap..What could be the side-effects of this surgery ?- Acid reflux, if the wrap is too tight but here also skill andexperience of doctor is very important to do a perfect wrap..neitherloose nor too tight..What are the risks in this surgery ?- Perforation...if some muscles are already damaged earlier duringdilatations, then there are

chances of perforations..( That's the reason why drs. normally prefer to carry out surgeryonly after 6 months of dilatation..)Is it necessary to carry out Manometry test ??- Yes, we do it on an earlier day of surgery..Is Manometry test very painful ??- Not really, we insert a small wire and it doesn't take long time..I saw many cases in USA where many people had to go for 2nd myotomysurgery or some dilatations etc- Why ??- If the cutting of muscles in esophagus is not completed/orenough, the problem could come up again..( He said that this can be described as a bad surgery or incompletejob done....)In all such Achalasia cases u have come across so far, did u find anycases where patients had to go for esphagectomy ( removal of esphpagus ) ?-Only 1 or 2 cases..in such cases, esophagus is too big and totallydeformed and/or cancer development..and there is no way to

repair itby surgery..Is return of peristalis possible ?- Usually it comes back to some extent after surgery , if not fullbut over a period of time..How may days patient has to stay in hospital ?-Usually only 2 or 3 days are enough, but since u are coming fromMumbai,we will keep for app 5 days, till patient starts taking solid food.How long it will take to do this surgery ??- less than 2 hours.Can you assure me that there will be no need for the second surgery ?- There are almost No chances of 2nd surgery.How many such cases handled so far by you ??- 250 + cases handled..In how many cases, u had found complications during surgeryto go for Open or VAT surgery ?- No such case so far..In how many cases, these patients are perfectly okay after surgery ?- app 95 %..Are there any chances of reoccurance of the problem after surgery inour case ?-Very minimum

chances..What is to be done if we still face problem after this surgery ?-There are very minimum chances for such re-occurance but if at all,you need to go for dilatation and in the next stage, VTA-Thorasic surgery.How can u make it very long lasting ??- This is only due to surgical technique which differs from doctor todoctor..In such surgery, experience and expertise of doctor is a keyfactor for success..My Comments :I think the Most Important is the skill & experience of the surgeon.Looking at his vast experience and expertise in lap surgery, I thinkit is worth travelling to Coimbatore and stay there for 6 days butthen we are sure that we are in the best hands.No doubt, PV is the best one in India..I don't think any other doctor might have done so many lap surgeriesto treat Achalasia in last 9 years. ( he has been doing only lap since9 years & he is considered a specialist for

lap.)Dr.Roy Patankar at Bombay is also good but his experience is app 70as compared to 250+ in case of Dr.Palanivelu.Plz let me know your views too...Mukesh

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

[Guest guest]

Thanx..Ann & Peggy,

I learned about these matters from this site/group...so it raised many

questions..

I believe that I got the right answers from doctors ...

Mukesh .

Re: Questions-Answers before Lap surgery-Achalasia

Good grief Mukesh,

Now that is what I call an informative post. You have asked many of the

questions that a lot of those contemplating surgery will want to know the

answers to. It is very good of you to share this with us and take the time to

type it all out. You really gave the surgeon an ear-bashing didn't you?

All the best for a good future for you and your son,

With love from Ann in England XX

mukeshshah_fine <mukeshshah_fine@...> wrote:

I recently met Dr.Palanivelu (PV) at Gem hospital-Coimbatore-India

to fix up surgery date for my son, Bimal.

Bimal is 25 years old and he had 2 dilatations in 1994.

He was quite okay till last May'06, when he faced swallowing

problem again so we went for the last- 3rd dilatation in June'06.

After 3rd dilatation he is fine now but dr. had advised us to go for

Hellers Myotomy by Oct/Nov'06.

I had gone to see Dr.PV with a list of all questions which I had in my

mind before deciding on this surgery. I learnt a lot from all you guys

on this wonderful site..

You can see below my questions and Dr's answers below;

All answers starts after -

Question : Looking at this latest Barium report, what is your opinion

on his condition ?

Answer - It's bad but Not too bad..it's a Sigmoid esophagus and needs

to cure by surgery only.

Is it advisable to go for surgery now ?/ or later ?

- Better to do it now..Oct/Nov is fine..

Will esophagus shrink after surgery ?

- Yes...over a period of time, say 6 months to 12 months..

Do you anticipate any complications during surgery ?

- No..

What is the risk if we delay this surgery ?

- It may lead to Esophagus cancer / removal of esophagus..

What type of surgery will be better for us- Open, Lap or VAT ??

- Lap is the right choice for this case..

Is it necessary to do fundoplication/wrap ?

-Yes...Toupet type wrap..

What could be the side-effects of this surgery ?

- Acid reflux, if the wrap is too tight but here also skill and

experience of doctor is very important to do a perfect wrap..neither

loose nor too tight..

What are the risks in this surgery ?

- Perforation...if some muscles are already damaged earlier during

dilatations, then there are chances of perforations..

( That's the reason why drs. normally prefer to carry out surgery

only after 6 months of dilatation..)

Is it necessary to carry out Manometry test ??

- Yes, we do it on an earlier day of surgery..

Is Manometry test very painful ??

- Not really, we insert a small wire and it doesn't take long time..

I saw many cases in USA where many people had to go for 2nd myotomy

surgery or some dilatations etc- Why ??

- If the cutting of muscles in esophagus is not completed/or

enough, the problem could come up again..

( He said that this can be described as a bad surgery or incomplete

job done....)

In all such Achalasia cases u have come across so far, did u find any

cases where patients had to go for esphagectomy

( removal of esphpagus ) ?

-Only 1 or 2 cases..in such cases, esophagus is too big and totally

deformed and/or cancer development..and there is no way to repair it

by surgery..

Is return of peristalis possible ?

- Usually it comes back to some extent after surgery , if not full

but over a period of time..

How may days patient has to stay in hospital ?

-Usually only 2 or 3 days are enough, but since u are coming from

Mumbai,we will keep for app 5 days, till patient starts taking solid food.

How long it will take to do this surgery ??

- less than 2 hours.

Can you assure me that there will be no need for the second surgery ?

- There are almost No chances of 2nd surgery.

How many such cases handled so far by you ??

- 250 + cases handled..

In how many cases, u had found complications during surgery

to go for Open or VAT surgery ?

- No such case so far..

In how many cases, these patients are perfectly okay after surgery ?

- app 95 %..

Are there any chances of reoccurance of the problem after surgery in

our case ?

-Very minimum chances..

What is to be done if we still face problem after this surgery ?

-There are very minimum chances for such re-occurance but if at all,

you need to go for dilatation and in the next stage, VTA-Thorasic surgery.

How can u make it very long lasting ??

- This is only due to surgical technique which differs from doctor to

doctor..In such surgery, experience and expertise of doctor is a key

factor for success..

My Comments :

I think the Most Important is the skill & experience of the surgeon.

Looking at his vast experience and expertise in lap surgery, I think

it is worth travelling to Coimbatore and stay there for 6 days but

then we are sure that we are in the best hands.

No doubt, PV is the best one in India..

I don't think any other doctor might have done so many lap surgeries

to treat Achalasia in last 9 years. ( he has been doing only lap since

9 years & he is considered a specialist for lap.)

Dr.Roy Patankar at Bombay is also good but his experience is app 70

as compared to 250+ in case of Dr.Palanivelu.

Plz let me know your views too...

Mukesh

---------------------------------

All new " The new Interface is stunning in its simplicity and ease

of use. " - PC Magazine

[Guest guest]

Mukesh,

Thank you for a great post that will serve to guide many others not familiar enough with achalasia to know to ask all these questions.

Setting aside all the informative responses you received that appeared accurate, I have one comment on his response to one of the many excellent question you asked.

"Is return of peristalis possible ?

- Usually it comes back to some extent after surgery , if not fullbut over a period of time.."

Does this doctor know something that most other doctors do not?. While there might be isolated cases of the return of peristalsis (and maybe in people who did not really have achalasia), my understanding is that once you lose it, it never returns. The answer you received strongly seems to imply that some peristalsis will return to many people after surgery or eventually.

If I was a person facing surgery for the first time, I would think that my peristalsis would be returning from this surgery. How many people who post here on this board, or otherwise have had this happen?

If you have the opportunity to speak with him again, I would like if could possibly make sure that the answer you reported him saying was accurately quoted. As you know, I am way past that point now, but many others are not.

In a message dated 8/27/2006 9:54:09 A.M. Eastern Standard Time, mukeshshah_fine@... writes:

Thanx..Ann & Peggy,I learned about these matters from this site/group...so it raised many questions..I believe that I got the right answers from doctors ...Mukesh . Re: Questions-Answers before Lap surgery-AchalasiaGood grief Mukesh,Now that is what I call an informative post. You have asked many of the questions that a lot of those contemplating surgery will want to know the answers to. It is very good of you to share this with us and take the time to type it all out. You really gave the surgeon an ear-bashing didn't you?All the best for a good future for you and your son,With love from Ann in England XX

..

[Guest guest]

,

You are 100% Right...I also thought about this particular question while

returning back.

It does seem in contradiction to many from this group who said that it doesn't

return .

Next time, I will ask him in more details about this point.

One more question I got later is type of fundoplication -most on this site

refered to Dor and Belsey types..but TOUPET type fundoplication - I heard for

the first time..

Mukesh

Re: Questions-Answers before Lap surgery-Achalasia

Good grief Mukesh,

Now that is what I call an informative post. You have asked many of the

questions that a lot of those contemplating surgery will want to know the

answers

to. It is very good of you to share this with us and take the time to type

it all out. You really gave the surgeon an ear-bashing didn't you?

All the best for a good future for you and your son,

With love from Ann in England XX

..

[Guest guest]

Mukesh Shah wrote:

> One more question I got later is type of fundoplication -most on this

> site refered to Dor and Belsey types..but TOUPET type fundoplication -

> I heard for the first time..

The discussion here lately has been about Belsey because some of the

people here that had myotomies long ago had that, and it relates to

VATS. Most people now getting myotomies with a fundoplication will have

either Dor or Toupet. Dor is an anterior partial fundoplication. Toupet

is a posterior partial

fundoplication. The reported benefits of Dor is that it is easier to do

so you are in surgery for a shorter time. It also covers the myotomy so

if there was a perforation there is protection from it. The reported

benefit of Toupet is that instead of covering the myotomy it holds the

myotomy open. That helps to prevent the muscles from growing back

together and tightening.

See:

Chinese Medical Journal 2006

Laparoscopic Heller-Dor operation for patients with achalasia

http://www.cmj.org/Periodical/PDF/200632236571910.pdf#search=%22dor%20toupet%22

(See the Discussion section on page 3 (445). Other parts are also

interesting.)

Posterior Fundoplication Image

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1190864 & blobname=annsurg00\

028-0038-a.gif

Anterior Fundoplication Image

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1190864 & blobname=annsurg00\

028-0038-b.gif

notan

[Guest guest]

notan ostrich wrote:

Posterior Fundoplication Image

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1190864 & blobname=annsurg00028-0038-a.gif

Anterior Fundoplication Image

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1190864 & blobname=annsurg00028-0038-b.gif

Those images are not good. For better quality see:

Posterior Fundoplication Image

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1190864 & blobname=annsurg00028-0038-a.jpg

Anterior Fundoplication Image

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1190864 & blobname=annsurg00028-0038-b.jpg

notan

[Guest guest]

Dear Notan,

You are great...u have explained it so simply n perfectly ..it's very clear.

I wish you were our Surgeon..

Thanx a lot for this explanation .

Mukesh

Re: Questions-Answers before Lap surgery-Achalasia

Mukesh Shah wrote:

> One more question I got later is type of fundoplication -most on this

> site refered to Dor and Belsey types..but TOUPET type fundoplication -

> I heard for the first time..

The discussion here lately has been about Belsey because some of the

people here that had myotomies long ago had that, and it relates to

VATS. Most people now getting myotomies with a fundoplication will have

either Dor or Toupet. Dor is an anterior partial fundoplication. Toupet

is a posterior partial

fundoplication. The reported benefits of Dor is that it is easier to do

so you are in surgery for a shorter time. It also covers the myotomy so

if there was a perforation there is protection from it. The reported

benefit of Toupet is that instead of covering the myotomy it holds the

myotomy open. That helps to prevent the muscles from growing back

together and tightening.

See:

Chinese Medical Journal 2006

Laparoscopic Heller-Dor operation for patients with achalasia

http://www.cmj.org/Periodical/PDF/200632236571910.pdf#search=%22dor%20toupet%22

(See the Discussion section on page 3 (445). Other parts are also

interesting.)

Posterior Fundoplication Image

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1190864 & blobname=annsurg00\

028-0038-a.gif

Anterior Fundoplication Image

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1190864 & blobname=annsurg00\

028-0038-b.gif

notan

[Guest guest]

Thanks for the pictures.I always wanted to see exactly what the doctor

was describing.I've had achalasia for 27 years. It first felt like a

heart-attack, and the pain is still severe.

I had a laproscopic myotomy with funduplocation in the late '90's after

~5 dilatations, 4 botox injections into the l.e.s., calcium

channelblockers, nifedine, etc. MY sliced, diced and ripped L.e.s is a

mass of tight scar tissue. My esophagus is so sigmoid-shaped no GI

would want to doeven a endoscope for fear of perforation.