A Controversy That Has Been Tough to Swallow: Is the Treatment of Achalasia Now Digested?

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux

A new "perforator-grinder-aspirator apparatus (PGAA)" for the minimal access surgery of cystic liver hydatidosis

Despite that minimal access surgery is a feasible, effective and viable option for radical surgical treatment of cystic hydatidosis, the laparoscopic approach is not widely accepted because of the risk of recurrence and the risk of severe complications, such as anaphylaxis and/or contamination of the peritoneal cavity related with the spillage

Minimally-invasive treatment of hepatic hydatid disease with Perforator-Grinder-Aspirator Apparatus and follow-up of 42 patients

Introduction : The gold standard treatment for hydatid cyst (HC) is surgery. In surgical practice, open procedures still remain as the first option but in this minimally-invasive era, the frequency of laparoscopic procedures is increasing. The aim of this study is to evaluate the results of 42 patients with HC who underwent surgery with Perforator-Grinder-Aspirator-Apparatus (PGAA) and demonstrate the success and reliability of this technique

Mesh infections after laparoscopic inguinal hernia repair

Several complications like hematoma and seroma have been reported after laparoscopic inguinal hernia repair (LH). Sepsis due to infection of the patch is an uncommon complication. Tn this retrospective trial, we evaluated three male patients who developed postoperative mesh infection after LH by transabdominal preperitoneal patch (TAPP) technique in two institutions. Diagnosis was confirmed by clinical symptoms, signs, ultrasonography, and computerized tomography (CT), and definitive treatment was provided by removing the mesh. In the first case, mesh infection occurred 10 months after laparoscopic left inguinal hernia repair with TAPP for recurrence. The infection manifested itself as an external fistula at the drain site. The mesh was removed laparoscopically due to persistent suppuration. Tn the second case, mesh infection occurred 3 months after transabdominal preperitoneal hernia repair on the left. The patch was removed because of the persistent suppuration despite repetitive drainage and lavage, Tn the third case, mesh infection occurred in 15 days after transabdominal preperitoneal hernia repair on the right. External drainage was performed under CT guidance, but suppuration could not be stopped. Thus the mesh was removed. In three cases, infection could not be stopped after diagnosis despite drainage and antibiotic coverage, and then it was decided to remove the mesh, The meshes were removed under general anesthesia for the first two cases and under local anesthesia for the third one. During the follow-up period. no recurrences were noted. The mesh infections of these three cases, resistant to conservative treatment methods, completely disappeared after mesh removal

Video thoracoscopic truncal vagotomies: Technique and preliminary results

Background/Aims: This report presents the technique and preliminary results of a prospective trial of videothoracoscopic bilateral truncal vagotomy without a drainage procedure in a series of selected patients having elective surgery for chronic non obstructive duodenal ulcer

Video endoscopic truncal vagotomies without gastric drainage

The authors report 32 patients with chronic duodenal ulcer treated by bilateral truncal vagotomy (BTV) performed via laparoscopy or thoracoscopy. All cases were resistant to medical treatment and chosen with selective indication regarding endoscopic/radiologic and laboratory examination for absence of pyloric obstruction and presence of hyperacidity. Only one patient had partial pyloric stenosis preoperatively due to chronic duodenal ulcer. No drainage procedure was used after BTV, and an endoscopic pyloric balloon dilatation (PBD) was performed at the same time as vagotomy for 20 cases; 12 patients were followed without dilatation as a prospective trial. Semiliquid diet and promotility medication were started 24 h after surgery. All patients tolerated pure truncal vagotomy without any problem, except for two patients: one in whom open drainage procedure was required end one in whom PBD was performed. Basal acid output and peak acid output were measured the day before and 1 week after the operation. A mean decrease of hyperacidity was found: 70.6% for basal and 79.5% for peak acid output. Four patients suffered from moderate symptoms of diarrhea occurring intermittently and responded to medical treatment or recovered spontaneously. Median hospital stay was 4.8 days (range 3-10 days). Endoscopic control performed for 28 patients 2 and 6 months after the operation showed healing of the ulcer. But the patient who had partial pyloric stenosis and was operated on with BTV and PBD required an open drainage procedure (Jaboulay gastrojejunostomy) in spite of repeated PBD. There was no other gastropyloric outlet obstruction in this preliminary study with mean follow-up of 22 months (range 6-42 months)

Laparoscopic vagotomy using mini-instruments in the rat: A new laparoscopic small animal model

Purpose. Animal models are necessary for research, technical developments, and training purposes in laparoscopic surgery. Although various operations on small animals have been described, there is still a need for a simple and practical laparoscopic small animal model. We acknowledged truncal vagotomy as a simple procedure, and aimed to develop a model of laparoscopic truncal vagotomy (LTV) in the rat, an inexpensive and easily available animal

Thoracoscopic diaphragm plication in children and indications for conversion to open thoracotomy

Thoracoscopic plication of the diaphragm has been recently described as an alternative treatment for eventration. It is considered to be much less traumatic than the conventional method. We attempted thoracoscopic diaphragm plication on three patients. Two patients were treated successfully by the minimally invasive technique and were discharged from hospital on the second postoperative day. In the third case, the presence of a mobile intrathoracic kidney due to previous diaphragmatic hernia repair necessitated conversion to open thoracotomy. This patient was discharged on postoperative day six following an uneventful recovery. All patients are well and asymptomatic on followup. We advocate thoracoscopic diaphragm plication in children as a safe procedure with less morbidity and excellent cosmetic results

The changes in serum nitric oxide levels in rats undergoing laparoscopic versus open bilateral truncal vagotomy

Laparoscopic surgery necessitates the description and definition of the various biochemical and physiological effects of pneumoperitoneum in the body. We report the preliminary results of an experimental study investigating the changes in serum nitric oxide levels in rats undergoing laparoscopic (LBTV) versus open (OBTV) bilateral truncal vagotomy. Thirty-six Wistar-albino rats were divided into 3 groups including the control (n:6), laparoscopy (n:15) and open (n:15) group. Controls underwent laparotomy with a 5 cm midline incision and were sacrificed after blood was drawn from inferior vena cava for baseline values. LBTV was effected with 3 mini-trocars. Pneumoperitoneum was maintained at 6-7 mm Hg. OBTV was performed with a 5 cm midline incision. Both of the procedures lasted 30-35 minutes. In each group, laparotomy was performed either 6 hours (n:5), 12 hours (n:5), or 24 hours (n:5) after the first operation and blood for analysis was obtained by puncturing inferior vena cava. Serum NO2-/NO3- (stabile end-products of NO) levels were determined spectrophotometrically by the Griess reaction, As a results, serum nitrate and nitrite levels were found to be depressed on both the LBTV and OBTV groups at 12 hours compared to controls, however, this difference was statistically significant only in the OBTV group (6.79 +/- 0.81 mu M versus 16.46 +/- 7.43 mu M, respectively: p 0.05, Mann-Whitney U). These preliminary results suggest that bilateral truncal vagotomy performed by the open technique inhibits NO synthetase in contrast to laparoscopic bilateral truncal vagotomy. This effect may be attributable to inhibitory mediatory released from the larger trauma in the open procedure