Wednesday, July 25, 2007

Laparoscopic Myotomy

Overview
Laparoscopy describes a group of operations performed with the aid of a camera placed in the abdomen. The laparoscope was first combined with a video camera in the 1980s, an accomplishment that helped free up the surgeons' hands, so they could better work with their instruments. The laparoscope also allows doctors to perform minor surgeries with just a small cut in the abdomen. This technique is known as laparoscopic-assisted surgery.
Laparoscopic myotomy refers to a laparoscopic-assisted surgical procedure in which a muscle is cut. The case that I observed in the OR involved the cutting of the muscle from the esophagus to the stomach (a disorder called esophageal achalasia). Achalasia is a disorder of the esophagus. The esophagus is less able to move food toward the stomach, and the muscle from the esophagus to the stomach does not relax as much as it needs to during swallowing. This relaxation is needed to allow food to enter the stomach.


Diagnosis
Barium Swallow - Patients are asked to swallow a liquid which will be visible on an X-ray. A series of X-rays are then taken. Achalasia patients will often demonstrate abnormal valve relaxation and an absence of normal contractions.
Esophageal Manometry - Pressure recordings are assessed in this exam through a small catheter placed into the esophagus. Characteristic findings in patients with achalasia include an elevated lower valve pressure and failure of the valve to relax with swallowing.
Endoscopy - This is a procedure in which a small, flexible telescope is passed through the mouth into the esophagus. The lining of the esophagus can then be examined and biopsied.
Treatment
Medical therapy for achalasia with drugs that relieve the spasm of the sphincter (the muscle between esophagus and stomach) has largely been unsuccessful and associated with numerous side effects. The classical method for treatment remains endoscopic balloon dilatation and surgery. While dilatation can achieve a good result in up to 60% of patients, the results are frequently not durable. Also, dilatation carries the risk of esophageal perforation which would require emergency surgery.
Historically, definitive surgical treatment for patients with achalasia included a formal rib spreading incision to perform an esophageal myotomy or splitting of the abnormally thickened esophageal muscle at the lower sphincter. Recent improvements in laparoscopy have allowed for significant advances in the treatment of achalasia. NYP is currently performing a laparoscopic myotomy for most of the achalasia patients. This approach requires small abdominal incisions for the placement of a camera and telescopic instruments. The abnormally thickened muscle surrounding the esophagus is incised to allow for improved swallowing. After completion of this myotomy a loose stomach wrap is created around the esophagus to minimize reflux.
Length of stay has been reduced to two days with minimal post-operative discomfort. Also, patients are tolerating regular food at the time of discharge.



1 comment:

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