Case Presentation, Management, Discussion and Sharing of Information on Dysphagia Jonathan R....

Case Presentation, Management, Discussion and Sharing of Information on Dysphagia

Jonathan R. Malabanan, M.D. Surgery Resident

OMMC

DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER

“Towards Patient Safety in Surgery”

General Data:

• F.D. 60 y.o Female

• Sta. Ana, Manila.



Chief Complaint

Dysphagia



History of Present Illness:

• 9 months PTA→ (+) dysphagia to solids

(+) Chest pain

(+) normal ECG

• 5 months PTA→ (+) weight loss

(+) dysphagia to liquids and solids



• 2 wks PTA →(+) feeling of regurgitation

(+) progression of above conditions

consulted at private Hospital

→(+) normal CXR



→Esophagogram

(+) Dilated esophagus with non passage of barium into the stomach.

→EGD:

Tight contraction of G.E jxn

scope inserted up to D2

no mucosal irregularity

no mass



→Advised to undergo surgery and consulted our hospital due to financial constraint.



PAST MEDICAL HISTORY:

• S/P Ex- lap, Ectopic Pregancy, 1966



PHYSICAL EXAMINATION:• GEN SURVEY:

Conscious,coherent,oriented

BP=120/80 CR=80 RR=21 T=36.5• HEENT: Pink conjunctivae, anicteric

sclerae, no cervical lymphadenopathies

• CHEST: SCE, clear breath sounds



PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:

• CARDIAC: Normal rate, regular rhythm, no murmur

• ABDOMEN: Flabby, NABS, soft, no palpable mass

• EXTREMITIES: Full and equal pulses,no deformities



Salient Features:• 60 y.o Female

• (+) Progressive dysphagia

• (+) non cardiac chest pain

• (+) weight loss

• (+) Feeling of regurgitation



Salient Features:

• (+) Esophagogram Findings:

dilated esophagus with non passage of barium into the stomach

• (+) EGD: Tight contraction of G.E junction,

scope inserted up to D2, no mucosal

irregularity, no mass



AlgorithmProgressive dysphagia

Barium swallow

Dilated esophagus, non passage of barium

Achalasia Tumor StrictureEndoscopy:

• no intraluminal mass• tight GE junction

• no mucosal irregularity



Clinical Diagnosis

DIAGNOSIS CERTAINTY TREATMENT

PRIMARY Achalasia 95% Surgical MedicalMechanical

SECONDARY Stricture 5% Surgical



PARACLINICAL DIAGNOSTICPROCEDURE

• Do I need a paraclinical diagnostic procedure?

No.



Pretreatment Diagnosis:

Achalasia



Goals of Treatment1. Complete resolution of functional distal

esophageal obstruction

2. Better long term improvement and prevent complication



Pre Treatment OptionsBENEFIT RISK COST AVAILABI

LITYMechanical (Pneumatic Dilation)

SR:40-78%RR:20-50% (5 yrs)

-Perforation (3-15%)-Scarring

P20-30 thou Not available

Surgical (myotomy)

SR:95% -Perforation (1%)-Hemorrhage

P30-40 thou Available

Medical(Botox, ISDN, Nifedipine)

Short duration of effect SR (botox):38%

-Hemorrhage-Scarring

P20-30 thou Botox:Not available



DAVID VANDERPOOL, MD, MATTHEW V. WESTMORELAND, MD, AND ERIC FETNER, MD. Achalasia: Willis or Heller? Department of Surgery, Baylor University Medical Center, Dallas, Texas. 1999;12:227-2

Treatment Plan

• Surgical

• What Approach?

• Abdominal or Thoracic?



Treatment Goal

• Better exposure of gastro-esophageal

junction



Pre Treatment OptionsBENEFIT RISK COST AVAILABILI

TY

Thoracic Inadequateexposure ofGastro- esophagealjunction

PerforationmediastinitisCTT

P40 thou Available

Abdominal better accessto gastro- esophagealjxn

Perforation P30 thou Available



Treatment Plan

• Abdominal Approach

• Esophagomyotomy alone or Esophagomyotomy plus fundoplication?



Treatment Goal

• Reduce incidence of gastro -esophageal reflux



Pre Treatment OptionsBENEFIT RISK COST AVAILABILI

TY

Esophagomyotomy alone

Same incidence of gastroesophageal reflux

PerforationHemorrhage

P30 thou Available

Esophagomyotomy plus fundoplication

Reduce incidence of gastro -esophageal refluxBy nine fold

PerforationHemorrhage

P30 thou Available



Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004;240(3):405–412; discussion 412–415.

Treatment Plan

• Esophagomyotomy plus fundoplication



Plan of Operation

• Esophagomyotomy with fundoplication



PREOPERATIVE PREPARATION

• 1. Informed Consent

• 2. Psychosocial Support

• 3. Optimize Patient’s Physical Health

• 4. Screening For Other Medical Problem

• 5. Prepare Materials For OR



Operative Maneuvers

• Patient supine under GA

• Asepsis antisepsis

• Sterile drapes placed

• Subxiphoid midline incision carried down to the peritoneum

• Liver inspected, stomach identified



Operative Maneuvers

• Left triangular ligament and falciform ligament cut

• Liver deflected laterally exposing the esophagus.

• Esophagus gently encircled with the index finger



Intraop- findings

• Constricted LES

• Marked dilatation of

lower esophagus



Operative Maneuvers

Left vagus nerve deflected out of area of dissection

Myotomy performed extending distally over the stomach 2 cm below the GE junction and 5 cm proximally



Operative Maneuvers

Note of dilatation of

the LES area post myotomy

-Posterior fundoplication carried out

-Hemostasis -OS and instrument

checked -Layer by layer closure -Dry sterile dressing placed



Operation Done:

• Esophagomyotomy with posterior fundoplication



Final DiagnosisAchalasia

S/P Esophagomyotomy with Posterior Fundoplication



Post op Management:• Maintained on NPO

• Adequate analgesia given

• Antibiotics continued (24 hrs)

• Adequate pulmonary support

• Chest physiotherapy

• Monitoring of early complications



Sharing of Information



Achalasia-disorder of lower esophagogastric motility

due to failure of the lower esophageal

sphincter to relax with swallowing.

-Incidence of 1 in 100,000 per year



Signs & Symptoms

• Vomiting

• Progressive dysphagia

• Weight loss



Theories

• Neurogenic

• Myogenic

• Hormonal



Pathogenesis

• Neurogenic/Myogenic Theory:

• Degeneration of ganglion cells in the myenteric plexus and loss of nerves innervating the smooth muscle cells of the lower esophageal sphincter.



Pathogenesis

• Hormonal cause:

• Reduced VIP( Vasoactive Intestinal Polypeptide) major inhibitory released at the intramural postganglionic neurons of the lower esophageal sphincter



Diagnostics• CXR:

widened mediastinum

esophageal air fluid level

or absence of gastric air



Diagnostics

• Barium Swallow:

- esophageal dilatation with tapering at the esophageal junction “birds beak

deformity”



Diagnostics

• Manometry:

• Characteristic Findings

1. hypertensive lower esophageal sphincter resting pressure

2. absence of peristalsis

3. incomplete or abnormal LES relaxation

4. elevated intraesophageal pressure



Diagnostics

• Endoscopy:

• assess the presence of:– inflammation– mucosal irregularity– or tumors in the esophagus



Treatment• Medical

– early stage of disease– patients who are high risk for surgery

• Isosorbide dinitrate– 5-10mg– reduces LES pressure 66% for 90 min

• Nifedipine– 10-20mg– reduces LES 30-40% for >1 hour



Treatment

• Botulinum toxin A (Botox)– 80μg injected in 4 aliquots LES– potent inhibitor of achetylcholine released

from nerve endings– decreasing unopposed LES stimulation



Treatment• Mechanical

pneumatic dilation

• Surgerymyotomy



References:

• DAVID VANDERPOOL, MD, MATTHEW V. WESTMORELAND, MD, AND ERIC FETNER, MD. Achalasia: Willis or Heller? Department of Surgery, Baylor University Medical Center, Dallas, Texas. 1999;12:227-230

• Jedediah A. Kaufman, M.D., Dave R. Lal, M.D. and Brant K. Oelschlager, M.D. Surgical treatment for achalasia. GI Motility online (2006) doi:10.1038/gimo53Published 16 May 2006

• Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004;240(3):405–412; discussion 412–415.



MCQ1. The following are Theories in the

pathophysiology of achalasia except?

a. Myogenic

b. Neurogenic

c. Immunologic

d. Hormonal

e. NOTA



MCQ2. The following are characteristic

manometric findings in Achalasia except?

a. increased lower esophageal sphincter

b. absence of peristalsis

c. widened mediastinum

d. incomplete or abnormal LES relaxation

e. elevated intraesophageal pressure



MCQ3. Act as a potent inhibitor of achetylcholine

release from nerve endings thereby decreasing unopposed LES stimulation?

a. Isosorbide dinitrate

b. Atropine Sulfate

c. Nifedipine

d. Metoprolol

e. Botox



MCRDirection: Write

“A” if 1, 2, and 3 are valid statements.

“B” if only 1 and 3 are valid statements.

“C” if only 2 and 4 are valid statements.

“D” if only 4 is a valid statement.

“E” if all are valid statements.



MCR4. All of the following are involve in the

treatment for Achalasia except?

1. Isosorbide dinitrate

2. Atropine Sulfate

3. Nifedipine

4. Metoprolol



MCRC.4. All of the following are involve in the

treatment for Achalasia except?

1. Isosorbide dinitrate

2. Atropine Sulfate

3. Nifedipine

4. Metoprolol



MCR5. Achalasia can be described by which of the

following?

1. It is failure or lack of relaxation of the LES.

2. Dysphagia, regurgitation and nocturnal asthma are included in the classic triad

3. A barium esophagogram may demonstrate birds beak configuration at the GE junction.



MCR5. Achalasia can be described by which of

the following?

4. T. cruzi that causes Chaga’s disease destroys Auerbach’s plexus only in

the esophagus resulting in failure of LES to relax



MCRB. 5. Achalasia can be described by which of

the following?

1. It is failure or lack of relaxation of the LES.

2. Dysphagia, regurgitation and nocturnal asthma are included in the classic triad

3. A barium esophagogram may demonstrate birds beak configuration at the GE junction.



MCR5. Achalasia can be described by which of

the following?

4. T. cruzi that causes Chaga’s disease destroys Auerbach’s plexus only in

the esophagus resulting in failure of LES to relax



Thank You!



Journal Appraisal

Heller Myotomy Versus Heller Myotomy With Dor Fundoplication for Achalasia: A

Prospective Randomized Double-Blind Clinical Trial

William O. Richards, MD,* Alfonso Torquati, MD, MSCI,* Michael D. Holzman, MD, MPH,* Leena Khaitan, MD, MPH,* Daniel Byrne, MS,† Rami Lutfi, MD,* and Kenneth

W. Sharp, MD*

Departments of Surgery and †Medicine and Biostatistics, Vanderbilt University, Medical School, Nashville, Tennessee.



• Objective:

– We sought to determine the impact of the addition of Dor fundoplication on the incidence of postoperative gastroesophageal reflux (GER) after Heller myotomy.



• Summary Background Data:

– Based only on case series, many surgeons believe that an antireflux procedure should be added to the Heller myotomy. However, no prospective randomized data support this approach.



• Patients and Methods:

• In this prospective, randomized, double-blind, institutional review board-approved clinical trial, patients with achalasia were assigned to undergo Heller myotomy or Heller myotomy plus Dor fundoplication.



• Patients and Methods:

• Patients were studied via 24-hour pH study and manometry at 6 months postoperatively. Pathologic GER was defined as distal esophageal time acid exposure time greater than 4.2% per 24-hour period. The outcome variables were analyzed on an intention-to-treat basis.



• Results:

• Forty-three patients were enrolled. There were no differences in the baseline characteristics between study groups.



Pathologic GER Incidence

Heller myotomy 47.6% 10/21

Heller myotomy plus Dor fundoplication

9.1% 2/22

• Results:

• Heller plus Dor was associated with a significant reduction in the risk of GER (relative risk 0.11; 95% confidence interval 0.02–0.59; P = 0.01).



• Results:

• Median distal esophageal acid exposure time was lower in the Heller plus Dor (0.4%; range, 0–16.7) compared with the Heller group (4.9%; range, 0.1–43.6; P = 0.001).



• Results:

• No significant difference in surgical outcome between the 2 techniques with respect to postoperative lower-esophageal sphincter pressure or postoperative dysphagia score was observed.



• Conclusions:

• Heller Myotomy plus Dor Fundoplication was superior to Heller myotomy alone in regard to the incidence of postoperative GER.



• Clinical Question:

• In Achalasia patients, should Heller Myotomy plus Dor Fundoplication be done to decrease the incidence of postoperative GER?



• Tentative Answer

• Yes. In Achalasia patients, Heller Myotomy plus Dor Fundoplication should be done to decrease the incidence of postoperative GER.



Are the results of the study valid?

Primary Guides:

1. Was the assignment of patients to treatment randomized?

Yes.




Primary Guides:

2. Were all patients who entered the trial properly accounted for and attributed at its conclusion?

Yes.




Secondary Guides:

3. Were patients, their clinicians, and study personnel "blind" to treatment?

Yes




Secondary Guides:

4. Were the groups similar at the start of the trial?

Yes.




Secondary Guides:

5. Aside from the experimental intervention, were the groups treated equally?

Yes.



• Conclusion

In Achalasia patients, Heller Myotomy plus Dor Fundoplication should be done to decrease the incidence of postoperative GER.



God bless



Case Presentation, Management, Discussion and Sharing of Information on Dysphagia Jonathan R....

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