Dilatation and myotomy redo after myotomy

[Guest guest]

This is for those that have been interested in which is better after a

myotomy has already been done, when problems return or continue, a

dilatation or a redo. It is also for those that have not yet had

treatment and may be thinking why have a myotomy if a dilation may still

be needed after the myotomy. Also, for those that wonder why these

treatments fail. There are a number of things to consider.

1) A dilatation after a myotomy is not doing exactly the same thing as a

dilatation before a myotomy. Before a myotomy the ring of circular

muscle at the lower esophageal sphincter (LES) is still a ring. The LES

in achalasia can be extra strong and the dilatation has to break enough

muscle fibers in the LES to overcome most of the pressure it can create.

The dilatation before a myotomy is just stretching the LES until fibers

in the ring of circular muscle at the LES break. After a myotomy the

ring of circular muscles at the LES have been cut and are no longer a

complete ring. Also, a myotomy will cut some of the sling muscles at the

LES and stomach and some of the circular muscle in the esophagus above

the LES. Depending on the myotomy technique more of the stomach and less

of the esophageal muscles will be cut (lap) or more esophageal muscles

and maybe little or no stomach muscle (VATS or POEM). Either way, the

LES will produce less pressure. With less pressure at the LES if there

are problems after the myotomy a dilatation does not have to reduce the

pressure as much as it would have before the myotomy. After a myotomy

some problems may be because of scar tissue not muscle. In this case the

dilatation stretches the scar tissue until fibers in it break and also

can stretch and break muscles fibers until the required diameter,

pressure and time are reached to lower pressure at the LES.

2) A dilatation before a myotomy does not do much about the sling

muscles at the LES or the circular muscles of the esophagus above the

LES. Therefore the dilatation may not be as effective in reducing the

stricture at the LES as a myotomy. The breaking of the muscle fibers in

the circular muscles may not make a clean division through them like the

cutting with a myotomy can. (POEM also only cuts the circular muscles

but it makes a clean cut through them). This may make it easier for the

muscles to heal or scar up forming a strong ring again. This may lead to

more dilatations or a myotomy. If a myotomy is done after dilatations

then the dilatation may have caused scarring (fibroses of the muscle and

inner layer of tissue) that will make the surgery more difficult. That

does not mean you can't get a good myotomy after dilatation but it may

not be the best it could have been and the risk of perforations in

surgery may be increased (harder to tell where the muscle layers stop

and where to stop cutting). Perforations from myotomy usually heal fine

but it can mean the surgery, hospital stay and recovery take longer.

Sometimes a dilatation will gives years of relief without needing

another or a myotomy. Sometimes they just don't work. The success rate

is reported by some to be almost as good as myotomy. There are different

dilatation techniques. Some, when successful may have better very

long-term results than myotomy. This is a debated topic.

3) Sometimes a myotomy is not complete. The myotomy was either not long

enough or some muscle fibers in the myotomy remain leaving a high

pressure point. Dilation is often tried at this point and often reduces

the pressure at the LES enough to make the myotomy work. If dilatation

does not work a redo myotomy may be tried. The redo may extend the

myotomy more onto the stomach or more up the esophagus, find and cut

fibers in the myotomy that left high pressure points. Sometimes a new

myotomy is created separate from the old one. Myotomy is often

considered the best first treatment option for achalasia but this is

debated by others suggesting dilatation may be as good.

4) Sometimes there is a problem with the fundoplication being too tight

after a myotomy. Again, dilatation may be tried. Sometimes a surgery is

done to either modify or take down the fundoplication. VATS and POEM

myotomies would most likely not have a fundoplication. VATS and POEM

myotomies rely on the muscles at the LES and stomach that they leave

intact to prevent reflux. Laparoscopic surgeons like to cut more onto

the stomach to decrease the likelihood that a myotomy would be

incomplete. VATS and POEM surgeons cut higher on the esophagus to insure

completeness. Some lap surgeons do not do fundoplication either. Those

that do are not convinced that even VATS and POEM should be done without

one. VATS is done in the chest. POEM is done in the esophagus.

Fundoplication are generally done in the abdomen and would be a problem

for VATS and POEM. VATS and POEM surgeons say the reason lap surgeon

need to do a fundoplication is because they have to cut more onto the

stomach because lap surgeons can't reach high enough on the esophagus

because it is in the chest. POEM surgeons also claim that they don't

need to make a fundoplication because they leave the longitudinal

muscles intact, which is something the VATS surgeons can not claim. The

debates on which is the best myotomy and the need for fundoplication

continue.

5) Achalasia is not the same in all of us. Some don't have high pressure

at the LES and some have partial relaxations of the LES. Some have high

pressure at the LES and some don't have anything close to a relaxation

of the LES. Some have a lot of problems with spasms while others don't.

Some have more peristalsis left in the esophagus than others. People

that have no spasms or have high LES pressure or no relaxation or have

more peristalsis are going to have better luck with treatments than the

others. For some, those with less peristalsis or more spasms the

problems swallowing are not just about the LES and lowing pressure at

the LES may not be enough to give them successful swallowing. If a

person does not have high LES pressure or has partial relaxations then

there isn't as much improvement to be made at the LES and they may have

problems in the esophagus that will not be improved enough. Sometimes

there is only so much that can be done with either dilatation or

myotomy. Also the diameter (dilation) and shape of the esophagus can

effect the results.

6) After treatment with a myotomy or even dilatation, acid reflux can be

a problem. Long-term reflux may cause scarring. The scarring can be

broken with dilatation. Sometimes people just ignore symptoms and the

stricture from the scarring leads to distention and dilation of the

esophagus. Therefore reflux may be the main long-term problem leading to

swallowing problems fallowing treatment.

7) Achalasia is a progressive disease but we don't all progress the same

or as much. In time after peristalsis ends the muscles may atrophy, sag

and dilate making it hard to get food though the esophagus. This may

lead to the need for an esophagectomy. Most of us will probably never

reach that point.

8) Not all esophagectomies in people with achalasia are done for reasons

related to those in 7 above. Some are done because of spasms, NCCPs,

repeated esophagitis and infections or cancer and the risk of cancer.

Esophagitis, infections, cancer and the risk of cancer are probably more

likely a reason when 6 or 7 are also true.

notan

[Guest guest]

Notan,

 

I have to ask, are you a doctor or in the medical field? You know a lot more

than my GP does. He was asking me the other day if in my 20's I had swallowing

issues and I said no. Jeez I am 42 and barely remember yesterday. Last May 1st

was the first time I ever had trouble swalowing and it went downhill fairly

quickly. More so after my first dilation without an Achalasia balloon. My second

dilation went better but my doctor also suggested less invasive then surgery.

Froedert Hospital in Milwaukee is where I go for my treatments. I think as I

was going through this I wasnt sure the right questions to ask, but what

questions should I be asking my GP  ( from Aurora Medical ) and my GI at

Froedert to decide what is best for me down the road? They are hoping this will

last 1-5 years but this is unlikely.

I am stage 2. I thought I had full access to my medical records online but got

nothing from that. I want to send their dysphagia clinic an email to get

information but want to ensure I am asking the right questions. This is

embarrassing but I take Miralax daily to keep regular and if I don't I am not. I

had my last dilation just over three months ago and am 5'3 124 lbs. I have

gained 9 pounds back and hope to not gain anymore. I was a little overweight

before I got A and my GP feels I need to gain at least 10 pounds to be healthy.

I feel if I didn't get A I would still be healthy like I was before. I think I

take the right amount of vitamins and learn more and more on this site and am

always up for taking better care of myself. I workout 3 days a week and also

walk around our building at work daily. So feeling good is important me me as

well as getting a better understanding of where I am actually at with A.

I am going to email Froedert for more info -any suggestions on what I should

ask?

By the way, the nurse there told me Dr Massey practically wrote the book on

Achalasia, where can I find more information about him?

Any information is appreciated.

Thanks

 

Kim A

________________________________

From: notan ostrich <notan_ostrich@...>

achalasia

Sent: Saturday, February 4, 2012 4:03 PM

Subject: Dilatation and myotomy redo after myotomy

 

This is for those that have been interested in which is better after a

myotomy has already been done, when problems return or continue, a

dilatation or a redo. It is also for those that have not yet had

treatment and may be thinking why have a myotomy if a dilation may still

be needed after the myotomy. Also, for those that wonder why these

treatments fail. There are a number of things to consider.

1) A dilatation after a myotomy is not doing exactly the same thing as a

dilatation before a myotomy. Before a myotomy the ring of circular

muscle at the lower esophageal sphincter (LES) is still a ring. The LES

in achalasia can be extra strong and the dilatation has to break enough

muscle fibers in the LES to overcome most of the pressure it can create.

The dilatation before a myotomy is just stretching the LES until fibers

in the ring of circular muscle at the LES break. After a myotomy the

ring of circular muscles at the LES have been cut and are no longer a

complete ring. Also, a myotomy will cut some of the sling muscles at the

LES and stomach and some of the circular muscle in the esophagus above

the LES. Depending on the myotomy technique more of the stomach and less

of the esophageal muscles will be cut (lap) or more esophageal muscles

and maybe little or no stomach muscle (VATS or POEM). Either way, the

LES will produce less pressure. With less pressure at the LES if there

are problems after the myotomy a dilatation does not have to reduce the

pressure as much as it would have before the myotomy. After a myotomy

some problems may be because of scar tissue not muscle. In this case the

dilatation stretches the scar tissue until fibers in it break and also

can stretch and break muscles fibers until the required diameter,

pressure and time are reached to lower pressure at the LES.

2) A dilatation before a myotomy does not do much about the sling

muscles at the LES or the circular muscles of the esophagus above the

LES. Therefore the dilatation may not be as effective in reducing the

stricture at the LES as a myotomy. The breaking of the muscle fibers in

the circular muscles may not make a clean division through them like the

cutting with a myotomy can. (POEM also only cuts the circular muscles

but it makes a clean cut through them). This may make it easier for the

muscles to heal or scar up forming a strong ring again. This may lead to

more dilatations or a myotomy. If a myotomy is done after dilatations

then the dilatation may have caused scarring (fibroses of the muscle and

inner layer of tissue) that will make the surgery more difficult. That

does not mean you can't get a good myotomy after dilatation but it may

not be the best it could have been and the risk of perforations in

surgery may be increased (harder to tell where the muscle layers stop

and where to stop cutting). Perforations from myotomy usually heal fine

but it can mean the surgery, hospital stay and recovery take longer.

Sometimes a dilatation will gives years of relief without needing

another or a myotomy. Sometimes they just don't work. The success rate

is reported by some to be almost as good as myotomy. There are different

dilatation techniques. Some, when successful may have better very

long-term results than myotomy. This is a debated topic.

3) Sometimes a myotomy is not complete. The myotomy was either not long

enough or some muscle fibers in the myotomy remain leaving a high

pressure point. Dilation is often tried at this point and often reduces

the pressure at the LES enough to make the myotomy work. If dilatation

does not work a redo myotomy may be tried. The redo may extend the

myotomy more onto the stomach or more up the esophagus, find and cut

fibers in the myotomy that left high pressure points. Sometimes a new

myotomy is created separate from the old one. Myotomy is often

considered the best first treatment option for achalasia but this is

debated by others suggesting dilatation may be as good.

4) Sometimes there is a problem with the fundoplication being too tight

after a myotomy. Again, dilatation may be tried. Sometimes a surgery is

done to either modify or take down the fundoplication. VATS and POEM

myotomies would most likely not have a fundoplication. VATS and POEM

myotomies rely on the muscles at the LES and stomach that they leave

intact to prevent reflux. Laparoscopic surgeons like to cut more onto

the stomach to decrease the likelihood that a myotomy would be

incomplete. VATS and POEM surgeons cut higher on the esophagus to insure

completeness. Some lap surgeons do not do fundoplication either. Those

that do are not convinced that even VATS and POEM should be done without

one. VATS is done in the chest. POEM is done in the esophagus.

Fundoplication are generally done in the abdomen and would be a problem

for VATS and POEM. VATS and POEM surgeons say the reason lap surgeon

need to do a fundoplication is because they have to cut more onto the

stomach because lap surgeons can't reach high enough on the esophagus

because it is in the chest. POEM surgeons also claim that they don't

need to make a fundoplication because they leave the longitudinal

muscles intact, which is something the VATS surgeons can not claim. The

debates on which is the best myotomy and the need for fundoplication

continue.

5) Achalasia is not the same in all of us. Some don't have high pressure

at the LES and some have partial relaxations of the LES. Some have high

pressure at the LES and some don't have anything close to a relaxation

of the LES. Some have a lot of problems with spasms while others don't.

Some have more peristalsis left in the esophagus than others. People

that have no spasms or have high LES pressure or no relaxation or have

more peristalsis are going to have better luck with treatments than the

others. For some, those with less peristalsis or more spasms the

problems swallowing are not just about the LES and lowing pressure at

the LES may not be enough to give them successful swallowing. If a

person does not have high LES pressure or has partial relaxations then

there isn't as much improvement to be made at the LES and they may have

problems in the esophagus that will not be improved enough. Sometimes

there is only so much that can be done with either dilatation or

myotomy. Also the diameter (dilation) and shape of the esophagus can

effect the results.

6) After treatment with a myotomy or even dilatation, acid reflux can be

a problem. Long-term reflux may cause scarring. The scarring can be

broken with dilatation. Sometimes people just ignore symptoms and the

stricture from the scarring leads to distention and dilation of the

esophagus. Therefore reflux may be the main long-term problem leading to

swallowing problems fallowing treatment.

7) Achalasia is a progressive disease but we don't all progress the same

or as much. In time after peristalsis ends the muscles may atrophy, sag

and dilate making it hard to get food though the esophagus. This may

lead to the need for an esophagectomy. Most of us will probably never

reach that point.

8) Not all esophagectomies in people with achalasia are done for reasons

related to those in 7 above. Some are done because of spasms, NCCPs,

repeated esophagitis and infections or cancer and the risk of cancer.

Esophagitis, infections, cancer and the risk of cancer are probably more

likely a reason when 6 or 7 are also true.

notan