Re: Deborah update.... Fine

[Guest guest]

Hello, and thanks for the updates.

Sandy wrote:

That is one

drawback of the VATS surgery. The advantage is that the surgeon can

actually see the esophagus and where he/she is cutting and doesn't have

to do a wrap.

I what I have written bellow sounds antagonistic. I don't mean it

that way though.

The "advantages" depend on who you listen to. Compare your statement

to the fallowing quotes from:

Treatment of Achalasia

Jedediah A. Kaufman, MD and Brant K. Oelschlager, MD

Current Treatment Options in Gastroenterology 2005, 8:59-69

http://www.treatment-options.com/article.cfm?PubID=GA08-1-2-03 & Type=Article & KeyWords=

"Several authors propose the laparoscopic

approach superior due to

improved visualization of the esophageal muscle layers, better access

to longer myotomy through extended mediastinal dissection, and great

reduction in postoperative pain, morbidity, and mortality."

"At the University of Washington, we converted from a thoracoscopic

approach to a laparoscopic Heller myotomy in 1994 for two distinct

reasons. First, we recognized that a limited gastric myotomy (0.5 to

1.0 cm) did not protect the patient from gastroesophageal reflux. In

fact, when pH monitoring was performed, 80% of patients had

pathological reflux .

Second, many (17% in our studies) patients returned with recurrent

dysphagia, half of them requiring an extension of the myotomy. The

laparoscopic approach allowed for a longer esophageal myotomy and it

could be extended onto the stomach (1.5 to 2.0 cm)."

" Most importantly, in the subsequent 7 years, no patient has required

surgical intervention for recurrent dysphagia." (With lap., longer cut

on the stomach and wrap. notan)

"No existing technique exists that consistently relieves dysphagia

without resultant reflux unless a fundoplication is also performed."

"Recurrent dysphagia in up to 14% of patients is avoided and increased

reflux is minimized when a 3 cm cardiomyotomy and partial

fundoplication is performed. This is shown by the results of the

thoracoscopic approach which produces GERD in most patients, even while

limiting the gastric myotomy to 0.5 cm."

See also:

The laparoscopic approach with antireflux surgery is superior to the

thoracoscopic approach for the treatment of esophageal achalasia.

Experience of a single surgical unit.

Ramacciato G, Mercantini P, Amodio PM, Corigliano N, Barreca M, Stipa

F, Ziparo V.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=12072992 & dopt=Abstract

Comparison of thoracoscopic and laparoscopic Heller myotomy for

achalasia.

Patti MG, Arcerito M, De Pinto M, Feo CV, Tong J, Gantert W, Way LW.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=10457314 & dopt=Abstract

You can also find articles that agree with what you said, but I leave

that you. I am thinking that people coming to this group may want to

know when a treatment has experts that disagree about if it is the best

or not. (Not that your post said VAT was best, and I know you support

the choices of others who go lap. and you have said so). In this case

there is disagreement. Likewise to claims made about treatments, such

as, better view, or wrap not needed. BTW: I read one article where the

author said that he thought it was suspect and convenient that a wrap

is not needed with VAT because it would be very hard to do a wrap VAT

even if it is needed. Likewise the short gastric myotomy. I don't claim

to know which is better. I went Lap. with a wrap and I am happy with

it, but I don't claim to know that it is best for everyone or that the

experts that support it are correct. I also don't claim to know that

the experts that say VAT is better than lap. are wrong.

On a related note, and some my find this hard to believe, the

"official" diagnostic requirement for achalasia is now aperistalsis of

the lower esophagus. A high LES pressure or a failure of the LES to

relax are not required, though they would be supportive. High pressure

or relaxation failure without aperistalsis is Isolated Hypertensive

LES, but some articles lump all this into achalasia. All this used to

be achalasia. This leads to the point that it is easier to understand

with the new definitions why some people with untreated, but diagnosed,

achalasia have GERD (acid reflux). I think these people would want a

wrap with their treatments.

notan