Ann Thorac Surg 1996;62:330
© 1996 The Society of Thoracic Surgeons
Discussion
Discussion
See also page 327.
DR ALEX G. LITTLE (Las Vegas, NV): Doctor Ferguson, I enjoyed your presentation and appreciate the recognition. There was a patient I operated on in Chicago who had previously undergone an apparently uneventful dilation, but a few days afterward had an upper gastrointestinal hemorrhage. When he finally came to operation several months later we unexpectedly found a very developed fibrous stricture, which I presume was a resolution of a submucosal hematoma. Therefore, I would suggest that if you ever see the scenario of a postdilation bleed, you should be a little cautious about such a patient.
I have a few questions. Perhaps I misread the abstract, and if I understood correctly, you said it a little differently in the presentation, but I thought the abstract said that the symptom analysis in patients who had not had previous perforation resulted in a score of 1.2 but in those who had had previous dilations it was 1.7. This would suggest at least the possibility of a beta error, and I was going to ask you to comment on whether in fact what we are seeing is a trend of something that might turn out to be a difference.
And then finally, you ended appropriately, I think, speculating on both the present and the future. What is your present approach? If it were possible to sit down in the same room with a patient and a gastroenterologist and decide on initial therapy, what would you recommend at the present time, to go with dilation or to move toward a more minimally invasive approach as a competitive alternative?
DR FERGUSON: The patient that you mentioned was not included in this series because it was not entirely clear on our review that he had, in fact, suffered a perforation at the time of his dilation. These are difficult patients to manage, as you suggest. In fact, this patient's myotomy, probably because of the fibrous stricture, failed several years after its performance and he subsequently underwent a resection and jejunal interposition.
With regard to the potential beta error, I think the results that you see in the abstract do not match the results that I presented or that are found in the manuscript because of subsequent follow-up information obtained on a relatively large number of patients through a questionnaire that was mailed out.
How we deal with patients today in the real world depends on which institution you work at and the expertise of the individuals within the institution. I work with a skilled gastroenterologist who does pneumatic dilation successfully and safely, and my tendency is to recommend patients to have dilation as a first step. On the other hand, our gastroenterologist is becoming more and more enthusiastic about minimally invasive approaches. The final algorithm clearly has not quite been sorted out yet.
Related Article
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Results of Myotomy and Partial Fundoplication After Pneumatic Dilation for Achalasia
- Mark K. Ferguson, Laurie B. Reeder, and Jemi Olak
Ann. Thorac. Surg. 1996 62: 327-330.
[Abstract]
[Full Text]
