Monday, October 24, 2011

Endoscopic and Surgical Treatments for Achalasia: A Systematic Review and Meta-Analysis


Annals of Surgery:
January 2009 - Volume 249 - Issue 1 - pp 45-57
doi: 10.1097/SLA.0b013e31818e43ab

Meta-Analysis

Abstract

Background: Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes mostly come from cohort studies.
Objective: To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia.
Methods: A systematic electronic Medline literature search of articles on esophageal achalasia. Treatment options reviewed included EBTI, EBD, and surgical myotomy using open and minimally invasive techniques. Main outcome measures were frequency of symptom relief, prevalence of post-treatment gastroesophageal reflux (GER), and complications. Outcome probability was estimated using weighted averages of the sample prevalence in each study, with weights equal to the number of patients. Outcomes, within or across studies, were compared using meta-analysis and meta-regression, respectively.
Results: A total of 105 articles reporting on 7855 patients were selected, tabulated and reviewed. Symptom relief after EBD was better than after EBTI (68.2% vs. 40.6%; OR 3.4; 95% CI, 1.2-9.8; P = 0.02), and the need for additional therapy was greater for patients receiving EBTI (46.6% vs. 25%; OR, 2.6; 95% CI, 1.05-6.5; P = 0.04). Laparoscopic myotomy, when combined with an antireflux procedure, provided better symptom relief (90%) than all endoscopic and other surgical approaches and a low complication rate (6.3%). The incidence of postoperative GER was lower when a fundoplication was added to a laparoscopic myotomy (31.5% without a fundoplication vs. 8.8% with; OR, 6.3; 95% CI, 2.0-19.4; P = 0.003).
Conclusions: EBD is superior to EBTI. Laparoscopic myotomy with fundoplication was the most effective surgical technique and can be considered the operative procedure of choice.

Sunday, October 23, 2011

CASE: Hiatus hernia with gastric volvuous - lap reduction, fundoplication, retrocolic seromascular GJ (fixation)

60 yrs female with recurrent gastric volvulous for last 5 yrs with eventration of diaphragm and large hiatus hernia:
SURGERY: Lap. Nissan's floppy fundoplication + retrocolic stomach fixation with jejunum.


CASE: Blunt trauma abdomen with bladder and DJ Flexure rupture

Young male with RTA, hemodynamically unstable
taken up for surgery , bladder injury repaired and hemoperitoneum drained, bladder repair and SPC,  PELVIC # Stabilized with external fixators,

Found Bile leak in abdominal drain on POD 2, next day CECT was done , did not reveled any liver, biliary injury. but gross free fluid, grade II injury near tail of pancreas,

Taken up for surgery with suspected DJ flexure separation , and was rightly found,
single layer interrupted extramucosal repair done. Patient started by  normal diet by day 5.



CASE: Mesentric tumor excision

Middle aged women with h/o corossive gastric outlet obstruction and GJ done 15 yrs back, operated for PILES - MIPH 2 yrs back for bleeding PR.

c/o pain in central abdomen,
USG : S/O Soft tissue tumor near neck of pancreas behind stomach

CECT:


EUS : FNAC / BX : S/O malignant tumor.
SURGERY: EXCISION OF TUMOR.









pt was discharged on POD 5, with normal DIET.  FINAL HPE with IHC awaited. 

CASE: Acute PV & SMV thrombosis + jejunal ischemia - staged approach for surgery

Middle aged male with c/o severe pain in abdomen, nausea, vomiting & constipation, rise TLC
CECT S/o: acute Portal, SMV, Splenic vein thrombosis with proximal jejunal ischemia/gangrene




PLAN:  Managed conservatively with Heparin and Anticoagulants --> gradually started on diet and discharged with close follow up. as suspected stricture in jejunum in coming days.

Readmitted with vomiting after 6 weeks, no pain, rest all Investigations normal.
CECT: S/o : Completely recanalised portal and SM vein, with stricture in proximal jejunum and dilated proximal bowels


PLAN: Taken up for surgery and resection with primary anastomosis of strictured segment. discharged on POD 6, With normal diet. 

Acute mesenteric venous gangrene/ischemia can be managed conservatively provided with normal arterial flow and patient being kept in ICU with proper monitoring, and later as they develop stricture can be managed with single stage surgery, avoiding stoma formation in case of management of gangrenous bowel, and doubtfull viability of bowel with thrombosed veins.

CASE: LAP Haller's myotomy & anterior fundal wrap (achalasia with hiatus hernia)

Middle aged female with progressive painless dysphagia
on investigation found to have achalasia cardia and hiatus hernia as well with 8 kg wt loss.
UGIE: no e/o malignancy

SURGERY: Lap haller's myotomy & anterior fundal wrap


Pt was discharged next day.
had 4 kg wt gain by the time to stitch removal only..