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Ann Thorac Surg 1997;64:789
© 1997 The Society of Thoracic Surgeons
DR GLENN E. SISLER (New Brunswick, NJ): I really appreciated this study because we have been working very hard on achalasia by the video-assisted thoracic surgical (VATS) technique. We are very pleased with our results using VATS. We do not perform an antireflux procedure. In reviewing the literature, there is a great disparity of opinion regarding the use of antireflux procedures. We believe that by going through the chest, limiting the amount of disruption to the pharyngoesophageal area, and, particularly, having an endoscopist simultaneously view the esophagus, we can limit the amount of myotomy onto the stomach and, hopefully, limit the amount of reflux produced. Only time will tell. The patients who achieve good to excellent results early (ie, for 5 to 10 years) often revert to having dysphagia later. The question is whether they have dysphagia because of reflux and stricture or because of deterioration of motor function, trying to get over even a floppy repair or any kind of antireflux procedure.
I am particularly pleased by your presentation, because if we as surgeons can take the pain and cost out of doing myotomy, then I think we are going to see a lot more of these patients in the future. Thank you very much.
DR ROBERT J. KEENAN (Pittsburgh, PA): Congratulations on an excellent series. Our experience with minimally invasive techniques for myotomies would suggest that we have gone back from a VATS approach through the chest to the abdomen for these procedures because we can perform an excellent myotomy and add an antireflux procedure without too much difficulty.
However, I would like to ask you about the fact that your operative time has shortened nicely with your learning curve, but your hospital stay remains somewhat long. In the United States, where there is tremendous pressure to get patients out of the hospital faster, we are seeing centers, such as ours and others, essentially performing outpatient antireflux procedures and Nissen fundoplications.
Why did your patients require a hospitalization of more than 24 to 48 hours? With this length of stay, you start losing the benefits of the laparoscopic approach in terms of hospital costs and return to function.
DR GRAHAM: Certainly, I agree with those comments. During our initial experience, we were very conservative. We had the patients leave the operating room with a nasogastric tube in place. They underwent a day 1 postoperative gastrograffin study to rule out a perforation. As our experience has increased and we have gained confidence in the procedure, we no longer leave a nasogastric tube in place and we begin a full fluid diet on the first day after operation.
We have begun to discharge patients on day 3 or 4, but certainly our initial study showed us that we needed to improve in that regard. I am not sure that we will improve much on getting them home before day 3, to be honest, but time may tell.
DR TONI E. LERUT (Leuven, Belgium): You had 4 patients with symptoms of heartburn after the myotomy. Did you perform pH studies on those 4 patients?
DR GRAHAM: No. Only 2 of the 4 symptomatic patients are included in the group that underwent pH studies, unfortunately. The 2 symptomatic patients had normal study results.
DR LERUT: There are some patients with achalasia who do not have the typical manometric achalasia characteristics, but who have a mixed form, and also some in whom the achalasia is changing into a mixed pattern. How do you know that your myotomy is proximally high enough? Do you rely for this on the manometric tracings, or do you decide to perform them by VATS?
DR GRAHAM: We have not used the VATS approach since our initial experience. We have avoided patients with atypical achalasia so far, but that is certainly a good question. We have just performed the extent of the myotomy that we can achieve within the abdomen. We have not based the extent of the myotomy on manometric studies, but that is a good point and something we will have to consider for the future.
Related Article
Ann. Thorac. Surg. 1997 64: 785-789.
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