Toupet versus Dor as a procedure to prevent reflux after cardiomyotomy for achalasia: Results of a randomised clinical trial

AbstractBackgroundThe optimal anti-reflux procedure after Heller cardiomyotomy for oesophageal achalasia remains unclear. The most commonly used procedure is the anterior partial fundoplication according to Dor, although during recent years the posterior counterpart (Toupet) has become popular.MethodsPatients with newly diagnosed achalasia and referred for cardiomyotomy were randomised to receive either an anterior or partial posterior fundoplication following a classical cardiomyotomy. The effect of surgery was assessed during the first postoperative year by Eckardt scores, EORTC QLQ-OES18 scores and HRQL questionnaires. Timed barium oesophagogram (TBO) and ambulatory 24-h pH monitoring were performed to determine oesophageal emptying and the degree of reflux control, respectively.ResultsForty-two patients were randomised into Dor (n = 20) and Toupet (n = 22) groups. Eckardt scores improved dramatically with both procedures, but the EORTC QLQ-OES18 (functional scales) scores revealed significantly better relative improvements in the Toupet group compared to the Dor repair (P = 0.044). Corresponding advantages in favour of Toupet were observed postoperatively in the percentage of oesophageal emptying at TBO (P = 0.011 in height and P = 0.018 in area), an effect not observed in the Dor group. There were no other significant differences recorded between the study groups concerning HRQL evaluations and objective assessment of gastro-oesophageal acid reflux.ConclusionsA partial posterior fundoplication after cardiomyotomy seems to achieve more improvement in oesophageal emptying and EORTC QLQ-OES18 functional scale scores than the anterior fundoplication. Otherwise no differences between the two anti-reflux repairs were noted.Trial registration numberClinicalTrials.gov Identifier: NCT01933373

Physical workload in various types of work: Part I. Wrist and forearm

The quantitative relationship between exposure to physical risk factors and upper extremity work-related musculoskeletal disorders (UE-WMSDs) is virtually unknown. To explore the variation, objective measurements were derived in 43 types of work (686 individuals), using goniometry for the wrists and electromyography (EMG) for the forearm extensor muscles. The variations due to work were great for wrist movements, wrist positions, muscular rest, as well as peak load, ranging 1.4-54 degrees/s (flexion velocity; 50th percentile), -30 degrees-3 degrees (flexion angle; 50th percentile), 0.2-23% of time, and 3.4-41% of maximal EMG (90th percentile), respectively. Even within work categories, e.g. "repetitive industrial", there were large variations for all measures. Hence, classification without measurements has limited value. All movement measures were highly correlated (vertical bar r(s)vertical bar=0.82-0.99), but only weakly so to positions (vertical bar r(s)vertical bar = 0.01-0.43). Muscular rest and "static load" (10th percentile), were highly correlated (r(s) = -0.92), but not associated to peak load (90th percentile; vertical bar r(s)vertical bar= 0.05 and 0.08, respectively). Most low-velocity work was accompanied by much muscular rest; however, the low velocity for mouse-intensive computer-work meant very little rest. Technical measurements are suitable as exposure measures in epidemiological studies, as well as a base for decisions about interventions. The multidimensional character of exposure - wrist movements, wrist postures, muscular recovery, and peak load - has to be considered. Relevance to industry: Direct measurements provide objective and quantitative measures of the main physical risk factors for UE-WMSDs, appropriate for estimating the risk, as well as giving priority to, and evaluating, interventions. (c) 2008 Elsevier B.V. All rights reserved

Physical workload in various types of work: Part II. Neck, shoulder and upper arm

To explore the correlation between, and the variation in, various measures of exposure to potential risk factors for work-related upper extremity musculoskeletal disorders (UE-WMSDs), physical workload was measured in 43 types of work (713 individuals), using inclinometry for the head and upper arms, and electromyography (EMG) for the trapezius muscles. Many exposure measures were highly correlated. Head flexion (90th percentile), extension (1st percentile), and movements (50th percentile); arm elevation (99th percentile) and movements (50th percentile); trapezius muscular rest (fraction of time) and peak load (90th percentile), constitute main exposure dimensions. The variations were large: head: flexion 9 degrees-63 degrees, extension -39 degrees-4 degrees, movements 2.3-33 degrees/s; arm: elevation 49 degrees-124 degrees, movements 3.0-103 degrees/s; trapezius: muscular rest 0.8%-52% of time, peak load 3.1%-24% of maximal EMC. Even within work categories, e.g. "repetitive industrial", there were large variations. Somewhat higher loads were recorded on the right as compared to the left side (differences: arm elevation 2, arm movements 19%; trapezius peak load 18%), but these were small compared to the differences due to work. There were high correlations between movements of arm and head (r(s) = 0.96), as well as arm and wrist (r(s) = 0.92), and between, on the one hand, trapezius muscular rest and peak load, and on the other, arm and head movements (vertical bar r(s)vertical bar = 0.47-0.62), as well as arm elevation (vertical bar r(s)vertical bar = 0.54-0.85), which has to be considered when assessing exposure-response relations. Relevance to industry: Direct measurements provide objective and quantitative data of the main physical risk factors for UE-WMSDs, appropriate for estimating the risk, as well as giving priority to and evaluating interventions. (C) 2009 Elsevier B.V. All rights reserved