Re: MedPage Today on Dilation vs. Surgery

[Guest guest]

wrote:

>

> I like it when I can read clear data that define " success " .

>

Yes, it has been a problem in comparing dilatation studies to myotomy

studies. Also, most studies being about just dilatation or just myotomy

there could be a question about how the subjects for each were selected.

In this study they studied both and randomly assigned patients to

treatment options so the two groups should be very similar.

One thing to note is that they were not just studying just any kind of

dilatation but a specific dilatation protocol where the patient has two

dilatations one to three weeks apart. I would say that is a " graded "

dilatation protocol. Not every one that does dilatation does graded

dilatations or does graded dilatation that way. For the surgery I don't

see what the protocol was. We know different surgeons do things

differently. Some like to cut longer onto the the stomach than others.

Some do different fundoplications and there are things that can be done

or not done to straighten the esophagus. Some of those point may be

covered in the full report but I only found the abstract online:

Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic

achalasia

http://www.ncbi.nlm.nih.gov/pubmed/21561346

Also, the main comparison between the groups were their outcomes at two

years. It would be nice to see the 5 and 10 year outcomes, or more. Even

so, this study goes a long way toward showing that for many dilatation,

at least graded dilatation, can be a good option.

>

> http://www.medpagetoday.com/Pulmonology/GeneralPulmonary/26467

>

> Action Points

>

> * Point out that this study found that achalasia outcomes with

> laparoscopic myotomy were not superior to those with pneumatic

> dilation and suggest that graded dilation is a reasonable protocol for

> pneumatic dilation.

>

> * Note that there was a greater need for redilation in patients

> younger than 40 in the pneumatic-dilation group which may suggest that

> younger patients should be treated preferentially with laporoscopic

> myotomy.

>

Young male patient were especially noted as possibly doing better with

surgery. That has been found in other studies also. I have to wonder if

a sigmoid or dilated esophagus made a difference. In the abstract they

indicate that with the surgery patients the LES pressure tended to be

less and the hight of barium in timed barium was shorter. They didn't

find those results to be statistically significant but in my mind the

two seem likely to go together and that would be in line with some other

studies. If so, I would think that could make a difference in difficult

cases like sigmoid or dilated esophagus.

notan

[Guest guest]

Dear " A " Group,

I am just curious if there has been a study or survey done here with the

group to compare a lap Heller myotomy with fundo verses a VATS heller

myotomy. Here are my specific questions:

After a Lap Heller Myotomy with fundo there seems to be problems where

another myotomy is required, acid reflux, esophagectomy, or other Achalasia

symptoms...is this true? For how many? How many years can you expect to

live " normally " or eat normally after this procedure?

Now the same questions with a VATS heller myotomy? Has anyone had this

procedure followed by more problems or more surgeries?

I would think that people would want to pick the surgery with the most

lasting results. I don't know a lot about this...just looking for info.

Marci

[Guest guest]

Hi Marci,

Good idea!  In my own personal research, I have found that both Vats ( which

does not have a wrap) and Heller Myotomy with fundo, could have similar

outcomes.  Much depends on the surgeon doing it and much depends on the patient

and what condition they are dealing with.  The Vats has no fundo/wrap, so many

of these patients can have reflex problems because it depends on the surgeon to

do it just right!  Then again, many with the wrap can have problems with reflex

and/or the wrap is done to tight and they still will have swallowing issues, or

if done to loose then it's the reflex.....it's a gamble that is why the surgeon

is the key, MHO!

I can only speak for myself, when I met with my surgeon at UCLA, we had a LONG

face to face talk.  I asked her if she immediately started her patients on

antacid medications after surgery.  She said no because most of her patients

didn't need it.  That gave me some hope.  I also asked her how she did the

" cut "

(this was too see if she knew how to do a complete cut), she answered me in

detail of why she cuts and how long the cut needs to be for achalasia patients

to benefit. 

I also asked her how long this surgery can last, I figured maybe like 10yrs or

more.  She told me, you are DONE, this should be it for you!!!  That sounded

extremely good. 

Of course my case is my case, we are all different.  I had the Heller/Dor and

have been doing great.  I had A for 22yrs prior to surgery and could barely

swallow water when I finally got to her!!! 

An interesting fact that I learned during my research was that a surgeon that

does a specific surgery will learn the most after they have done at least 50

(that is the learning curve), most mistakes will take place at that time.  That

is why we say have a GREAT doctor, one that does hundreds of these rare

surgeries. 

Julee So Calif.

________________________________

From: Marcene Rainey <marcenerainey@...>

achalasia

Sent: Tue, May 17, 2011 10:21:14 AM

Subject: Re: MedPage Today on Dilation vs. Surgery

 

Dear " A " Group,

I am just curious if there has been a study or survey done here with the

group to compare a lap Heller myotomy with fundo verses a VATS heller

myotomy. Here are my specific questions:

After a Lap Heller Myotomy with fundo there seems to be problems where

another myotomy is required, acid reflux, esophagectomy, or other Achalasia

symptoms...is this true? For how many? How many years can you expect to

live " normally " or eat normally after this procedure?

Now the same questions with a VATS heller myotomy? Has anyone had this

procedure followed by more problems or more surgeries?

I would think that people would want to pick the surgery with the most

lasting results. I don't know a lot about this...just looking for info.

Marci

[Guest guest]

Marci wrote:

>

> I am just curious if there has been a study or survey done here with the

> group to compare a lap Heller myotomy with fundo verses a VATS

> heller

> myotomy.

>

There actually have been a number of them.

First understand that there is not much difference in the myotomy in

that they are both an incision along the esophagus at the LES through

the muscle layers. The VATS myotomy starts a little higher on the

esophagus and does not go as far down onto the stomach. That is because

the myotomy is done inside the chest and the LES is in, and filling, the

hiatus (opening) of the diaphragm between the chest and the abdomen.

With VATS it is easier to extend the myotomy higher but harder to extend

it lower. With laparoscopic the myotomy is done inside the abdomen. The

stomach is easy to get to by lap but it is harder to extend the myotomy

higher above the LES. So, the myotomy is in the same place on the LES

but extends up or down a little depending on if it is VATS or lap.

Here is a study that looked at eight others.

Can thoracoscopic Heller's myotomy give equivalent results to the more

usual laparoscopic Heller's myotomy in the treatment of achalasia?

http://www.ncbi.nlm.nih.gov/pubmed/21498789

" The overall postoperative morbidity of THM is not significantly

different from that of LHM. An advantage of LHM over THM that is

demonstrated is that LHM offers a shorter hospital stay and reduced

operative time. "

One of the studies look at in the above study was this one:

Endoscopic and Surgical Treatments for Achalasia

A Systematic Review and Meta-Analysis

http://gidiv.ucsf.edu/course/things/Campos.pdf

Look at the tables in that study 5 to 8. 5 and 6 are for open

Transabdomina and open Transthoracic. 7 and 8 are Thoracoscopic and

Laparoscopic. I like being able to compare the open versions because one

of the arguments that come up is that one version gives a better view

than another. The view going open are as good as it gets as far a access

goes. The image on a screen can at times actually be better than what

you can get with your eye though. Either way, we have both results here.

One of the claims that comes up, by some, is that a VATS myotomy does

not need a fundoplication because it is up higher. The test of this is

how much GastroEsophageal Reflux (GER) there is. The tables show the GER

results. It has been implied, by one author, that the VATS surgeons may

be guilty of making a conclusion of convenience because it would be hard

to add a fundoplication to a VATS myotomy. If you believe in

fundoplication you are going to do it open or lap. You will notice that

the table for Thoracoscopic has no column for " with fundoplication. "

A criticism of the studies above is that they rely on old data and new

techniques in VATS and lap are not being compared. Studies can only tell

what has been done and with achalasia a lot of centers are going to have

to take some time to have enough subjects to study and follow-up. Here

is a relatively recent abstract of a long-term study on VATS.

Long-term clinical results of thoracoscopic Heller's myotomy in the

treatment of achalasia.

http://www.ncbi.nlm.nih.gov/pubmed/18490172

It was published in 2008 but some of the surgeries go back to 1992. He

makes the conclusion, based on his fifty-six patients, that VATS results

in less GER. He has a result of 16.9% with GER but it is not clear to me

if all were tested or just those that complained. Compare that 16.9% to

the results in table 7 in the other study. There only one VATS study had

a result that low and the mean was 28.3% and went as high as 60%. So, do

you take his conclusion based on just his patients or do you take the

results of other surgeons into the conclusion as they do in the above

studies. Also, is 16.9% low enough that you want to risk going without a

fundoplication? The mean for lap in table 8 was only 14.9% with a

fundoplication and 31.5 without (not much different from 28.3%). It

isn't like VATS means no risk of GER or that lap guarantees GER. One

thing you probably would get with VATS is a harder recovery and more

time in the hospital.

Now some patients and surgeons may claim that there is a special

technique (as far as I can tell unpublished) by which curtain surgeons

can get just the right VATS myotomy to enable swallowing while

preventing GER without the need for a fundoplication. They say you can't

compare the result of other VATS surgeons to these VATS surgeons. ... Maybe.

To me GER is the nut to crack here. If VATS is not better for GER then

why have it? If you don't want a fundoplication you can have a myotomy

done lap without one. Some lap surgeons do not believe in myotomies

either. Even so they still choose to do their myotomies lap not VATS.

So, the questions to be asked are: is VATS better than lap without a

fundoplication and do you need or want a fundoplication? Remember that

the myotomy is really not different either way. Just extended a little

up or down.

Sometimes we are told that often the fundoplication becomes to tight and

needs to be undone. I just don't see that being the case in the

published studies. Yes it does happen but it is not nearly the main

reason for myotomy failure. To me it seems, from reading studies, that

GER and incomplete myotomies are the main causes of myotomy failure. So,

you have to weigh the risk of the myotomy with fundoplication going bad

because of the fundoplication or GER against the myotomy failing because

of GER due to a lack of fundoplication. I worded it that way because a

myotomy with fundoplication can still go bad due to GER. A

fundoplication may become looser over time allowing more GER. Some

surgeons feel strongly that a fundoplication should be done. Some feel

that a fundoplication should not be done. Of those some of them use lap

and some use VATS but neither can guarantee that you will not get GER

they just believe long-term the risks are less even with the risk of GER.

Some lap surgeons believe that extending the myotomy more onto the

stomach reduces problems swallowing and reduces the number of incomplete

myotomies. Other lap surgeons feel that it increases the chances of GER.

Those that don't do a fundoplication may do less of the myotomy on the

stomach making the myotomy shorter which may increase the chances of it

failing because of being incomplete. Understand that the top of the

stomach also functions as part of the LES. It adds to the pressure at

the LES and also helps to block GER as the LES is suppose to do. VATS

can't extend as far onto the stomach but they still have to make sure

they get the pressure at the LES low enough. Their method of doing

that is by extending it higher. It seems to work but it isn't clear that

it works as well in all cases.

When a dilatation is done the muscle of the esophagus in the LES are

stretched until they start to break their fibers. The muscle of the

stomach that are part of the LES are not stretched as much and don't

break their fibers. Dilatation are known for not having as much GER

problems, perhaps because these stomach muscles remain untreated.

Dilatations are also know to often not be as successful, possibly

because these muscles are untreated. But graded dilatation seems to do

well but long-term studies are needed to better compare it with surgery.

In the earlier post today about graded dilatation that study found a 15%

occurrence of GER even in the dilatation patients. So even dilatation

does not guarantee much lower occurrence of GER. It makes it hard to

draw conclusions and the best that one may be able to do is look at the

studies using the old data.

Remember too that one can always treat GER with medication though there

are risks with that option too.

notan