Transcervical heller myotomy using flexible endoscopy.

PubMed

Spaun, Georg O; Dunst, Christy M; Arnold, Brittany N; Martinec, Danny V; Cassera, Maria A; Swanström, Lee L

2010-12-01

Esophageal achalasia is most commonly treated by laparoscopic myotomy. Transesophageal approaches using flexible endoscopy have recently been described. We hypothesized that using techniques and flexible instruments from our NOTES experience through a small cervical incision would be a safer and less traumatic route for esophageal myotomy. The purpose of this study was to evaluate the feasibility, safety, and success rate of using flexible endoscopes to perform anterior or posterior Heller myotomy via a transcervical approach. This animal (porcine) and human cadaver study was conducted at the Legacy Research and Technology Center. Mediastinal operations on ten live, anesthetized pigs and two human cadavers were performed using standard flexible endoscopes through a small incision at the supra-sternal notch. The esophagus was dissected to the phreno-esophageal junction using balloon dilatation in the peri-esophageal space followed by either anterior or posterior distal esophageal myotomy. Success rate was recorded of esophageal dissection to the diaphragm and proximal stomach, anterior and posterior myotomy, perforation, and complication rates. Dissection of the esophagus to the diaphragm and performing esophageal myotomy was achieved in 100% of attempts. Posterior Heller myotomy was always extendable onto the gastric wall, while anterior gastric extension of the myotomy was found to be more difficult (4/4 and 2/8, respectively; P = 0.061). Heller myotomy through a small cervical incision using flexible endoscopes is feasible. A complete Heller myotomy was performed with a higher success rate posteriorly possibly due to less anatomic interference.

Laparoscopic Heller myotomy for achalasia: results after 10 years.

PubMed

Cowgill, Sarah M; Villadolid, Desiree; Boyle, Robert; Al-Saadi, Sam; Ross, Sharona; Rosemurgy, Alexander S

2009-12-01

Laparoscopic Heller myotomy was first undertaken in the early 1990s, and appreciable numbers of patients with 10-year follow-up periods are now available. This study was undertaken to determine long-term outcomes after laparoscopic Heller myotomy used to treat achalasia. Of 337 patients who have undergone laparoscopic Heller myotomy since 1992, 47 who underwent myotomy more than 10 years ago have been followed through a prospectively maintained registry. Among many symptoms, patients scored dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn before and after myotomy using a Likert scale with choices ranging from 0 (never/not bothersome) to 10 (always/very bothersome). Symptom scores before and after myotomy were compared using a Wilcoxon matched-pairs test. Data are reported as median (mean ± standard deviation). The median length of the hospital stay was 2 days (mean, 3 ± 8.6 days; range, 1-60 days). Notable complications were infrequent after myotomy. There were no perioperative deaths. One patient required a redo myotomy after 5 years due to recurrence of symptoms. At this writing, 33 patients (70%) are still alive. The causes of death after discharge were unrelated to myotomy. The frequency and severity scores for dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn all decreased significantly after laparoscopic Heller myotomy (p < 0.0001 for all). Laparoscopic Heller myotomy can be undertaken with few complications. This procedure significantly decreases the frequency and severity of achalasia symptoms without promoting heartburn. The symptoms of achalasia are durably ameliorated by laparoscopic Heller myotomy during long-term follow-up evaluation, thereby promoting application of this procedure.

A Conversation with Adam Heller.

PubMed

Heller, Adam; Cairns, Elton J

2015-01-01

Adam Heller, Ernest Cockrell Sr. Chair in Engineering Emeritus of the John J. McKetta Department of Chemical Engineering at The University of Texas at Austin, recalls his childhood in the Holocaust and his contributions to science and technology that earned him the US National Medal of Technology and Innovation in a conversation with Elton J. Cairns, Professor of Chemical and Biomolecular Engineering at the University of California, Berkeley. Dr. Heller, born in 1933, describes the enslavement of his father by Hungarians in 1942; the confiscation of his family's home, business, and all its belongings in 1944; and his incarceration in a brick factory with 18,000 Jews who were shipped by the Hungarians to be gassed by Germans in Auschwitz. Dr. Heller and his immediate family survived the Holocaust and arrived in Israel in 1945. He studied under Ernst David Bergmann at the Hebrew University, and then worked at Bell Laboratories and GTE Laboratories, where he headed Bell Lab's Electronic Materials Research Department. At GTE Laboratories, he built in 1966 the first neodymium liquid lasers and in 1973 with Jim Auborn conceived and engineered the lithium thionyl chloride battery, one of the first to be manufactured lithium batteries, which is still in use. After joining the faculty of engineering of The University of Texas at Austin, he cofounded with his son Ephraim Heller TheraSense, now a major part of Abbott Diabetes Care, which produced a microcoulometer that made the monitoring of glucose painless by accurately measuring the blood glucose concentration in 300 nL of blood. He also describes the electrical wiring of enzymes, the basis for Abbott's state-of-the-art continuous glucose monitoring system. He discusses his perspective of reducing the risk of catastrophic global warming in a wealth-accumulating, more-energy-consuming world and provides advice for students entering careers in science or engineering.

[Laparoscopic Heller myotomy for esophageal achalasia].

PubMed

Ibáñez, Luis; Butte, Jean Michel; Pimentel, Fernando; Escalona, Alex; Pérez, Gustavo; Crovari, Fernando; Guzmán, Sergio; Llanos, Osvaldo

2007-04-01

Achalasia is characterized by an incomplete relaxation of the lower esophageal sphincter. The best treatment is surgical and the laparoscopic approach may have good results. To assess the results of laparoscopic Heller myotomy among patients with achalasia. Prospective study of patients subjected to a laparoscopic Heller myotomy between 1995 and 2004. Clinical features, early and late operative results were assessed. Twenty seven patients aged 12 to 74 years (12 females) were operated. All had disphagia lasting for a mean of 32 months. Mean lower esophageal sphincter pressure ranged from 18 to 85 mmHg. Eight patients received other treatments prior to surgery but symptoms persisted or reappeared. The preoperative clinical score was 7. No patient died and no procedure had to be converted to open surgery. In a follow up of 21 to 131 months, all patients are satisfied with the surgical results and the postoperative clinical score is 1. Only one patient with a mega esophagus maintained a clinical score of six. In this series of patients, laparoscopic Heller myotomy was an effective and safe treatment for esophageal achalasia.

Endoscopic Therapy for Achalasia Before Heller Myotomy Results in Worse Outcomes Than Heller Myotomy Alone

PubMed Central

Smith, C Daniel; Stival, Alessandro; Howell, D Lee; Swafford, Vickie

2006-01-01

Objective: Heller myotomy has been shown to be an effective primary treatment of achalasia. However, many physicians treating patients with achalasia continue to offer endoscopic therapies before recommending operative myotomy. Herein we report outcomes in 209 patients undergoing Heller myotomy with the majority (74%) undergoing myotomy as secondary treatment of achalasia. Methods: Data on all patients undergoing operative management of achalasia are collected prospectively. Over a 9-year period (1994–2003), 209 patients underwent Heller myotomy for achalasia. Of these, 154 had undergone either Botox injection and/or pneumatic dilation preoperatively. Preoperative, operative, and long-term outcome data were analyzed. Statistical analysis was performed with multiple χ2 and Mann-Whitney U analyses, as well as ANOVA. Results: Among the 209 patients undergoing Heller myotomy for achalasia, 154 received endoscopic therapy before being referred for surgery (100 dilation only, 33 Botox only, 21 both). The groups were matched for preoperative demographics and symptom scores for dysphagia, regurgitation, and chest pain. Intraoperative complications were more common in the endoscopically treated group with GI perforations being the most common complication (9.7% versus 3.6%). Postoperative complications, primarily severe dysphagia, and pulmonary complications were more common after endoscopic treatment (10.4% versus 5.4%). Failure of myotomy as defined by persistent or recurrent severe symptoms, or need for additionally therapy including redo myotomy or esophagectomy was higher in the endoscopically treated group (19.5% versus 10.1%). Conclusion: Use of preoperative endoscopic therapy remains common and has resulted in more intraoperative complications, primarily perforation, more postoperative complications, and a higher rate of failure than when no preoperative therapy was used. Endoscopic therapy for achalasia should not be used unless patients are not candidates for

Videoscopic Heller myotomy for achalasia--results beyond short-term follow-up.

PubMed

Bloomston, M; Boyce, W; Mamel, J; Albrink, M; Murr, M; Durkin, A; Rosemurgy, A

2000-08-01

Heller myotomy has long been utilized for patients failing nonoperative management of achalasia. Videoscopy has been advocated to decrease the morbidity of Heller myotomy; however, few reports document outcome beyond 1 year after videoscopic Heller myotomy. To determine perioperative morbidity, relief of dysphagia, and the incidence of postoperative reflux symptoms following videoscopic Heller myotomy with follow-up to over 4 years. Patients with achalasia documented by barium esophogram and esophageal manometry underwent videoscopic Heller myotomy beginning in 1992. Intraoperative peroral endoscopy was utilized to guide the cephalad and caudad extent of myotomy. A barium esophogram was undertaken in the immediate postoperative period to evaluate for subclinical leak and assess esophageal emptying. Seventy-eight patients underwent videoscopic Heller myotomy. The mean age was 51 years +/- 19 (range 14 to 91). Most (62%) patients had undergone pneumatic dilation prior to surgical consultation and 54% had previous botox injections. All patients complained of dysphagia and 40% had symptoms of heartburn prior to myotomy. After myotomy, 91% of patients stated that their swallowing was improved with myotomy. Thirteen patients (18%) experience heartburn more than once per week after myotomy. The average length of stay was 2 +/- 2 days, with 72% of patients spending 2 days or fewer in the hospital. Six (7.7%) major complications occurred: five esophageal perforations and one enterotomy without long-term sequellae. Three procedures (3.8%) were converted to "open" procedures. No deaths occurred. We conclude that videoscopic Heller myotomy is safe and efficacious, with low morbidity and mortality. Videoscopic myotomy provides relief beyond the short term for dysphagia due to achalasia with minimal reflux symptoms. We advocate videoscopic Heller myotomy in the treatment of severe dysphagia due to achalasia not adequately palliated by or amenable to nonoperative management

Does concomitant anterior fundoplication promote dysphagia after laparoscopic Heller myotomy?

PubMed

Tapper, Donovan; Morton, Connor; Kraemer, Emily; Villadolid, Desiree; Ross, Sharona B; Cowgill, Sarah M; Rosemurgy, Alexander S

2008-07-01

Concerns for gastroesophageal reflux after laparoscopic Heller myotomy for achalasia justify considerations of concomitant anterior fundoplication. This study was undertaken to determine if concomitant anterior fundoplication reduces symptoms of reflux after myotomy without promoting dysphagia. From 1992 to 2004, 182 patients underwent laparoscopic Heller myotomy without fundoplication. After a prospective randomized trial justified its concomitant application, anterior fundoplication was undertaken with laparoscopic Heller myotomy in 171 patients from 2004 to 2007. All patients have been prospectively followed. Pre and postoperatively, patients scored the frequency and severity of symptoms of achalasia (including dysphagia, choking, vomiting, regurgitation, chest pain, and heartburn) using a Likert Scale (0 = never/not bothersome to 10 = always/very bothersome). Before myotomy, symptoms of achalasia were frequent and severe for all patients. After myotomy, the frequency and severity of all symptoms of achalasia significantly decreased for all patients (P < 0.001, Wilcoxon matched pairs test). Notably, relative to patients undergoing laparoscopic Heller myotomy alone, concomitant anterior fundoplication led to significantly less frequent and severe heartburn after myotomy (P < 0.05, Mann-Whitney Test) and to less frequent and severe dysphagia and choking (P < 0.05, Mann-Whitney Test). Laparoscopic Heller myotomy reduces the frequency and severity of symptoms of achalasia. Concomitant anterior fundoplication decreases the frequency and severity of heartburn and dysphagia after laparoscopic Heller myotomy. Concomitant anterior fundoplication promotes salutary relief in the frequency and severity of symptoms after myotomy and is warranted.

Laparoscopic Heller Myotomy for Achalasia Technical Aspects.

PubMed

Schlottmann, Francisco; Allaix, Marco E; Patti, Marco G

2018-04-01

Esophageal achalasia is a primary esophageal motility disorder defined by the lack of esophageal peristalsis, and by a lower esophageal sphincter that fails to relax in response to swallowing. Patients' symptoms include dysphagia, regurgitation, aspiration, heartburn, and chest pain. Achalasia is a chronic condition without cure, and treatment options are aimed at providing symptomatic relief, improving esophageal emptying, and preventing the development of megaesophagus. Presently, a laparoscopic Heller myotomy with a partial fundoplication is considered the best treatment modality. A properly executed operation is key for the success of a laparoscopic Heller myotomy.

Defining the learning curve of laparoendoscopic single-site Heller myotomy.

PubMed

Ross, Sharona B; Luberice, Kenneth; Kurian, Tony J; Paul, Harold; Rosemurgy, Alexander S

2013-08-01

Initial outcomes suggest laparoendoscopic single-site (LESS) Heller myotomy with anterior fundoplication provides safe, efficacious, and cosmetically superior outcomes relative to conventional laparoscopy. This study was undertaken to define the learning curve of LESS Heller myotomy with anterior fundoplication. One hundred patients underwent LESS Heller myotomy with anterior fundoplication. Symptom frequency and severity were scored using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Symptom resolution, additional trocars, and complications were compared among patient quartiles. Median data are presented. Preoperative frequency/severity scores were: dysphagia = 10/8 and regurgitation = 8/7. Additional trocars were placed in 12 patients (10%), of whom all were in the first two quartiles. Esophagotomy/gastrotomy occurred in three patients. Postoperative complications occurred in 9 per cent. No conversions to "open" operations occurred. Length of stay was 1 day. Postoperative frequency/severity scores were: dysphagia = 2/0 and regurgitation = 0/0; scores were less than before myotomy (P < 0.001). There were no apparent scars, except where additional trocars were placed. LESS Heller myotomy with anterior fundoplication well palliates symptoms of achalasia with no apparent scar. Placement of additional trocars only occurred early in the experience. For surgeons proficient with the conventional laparoscopic approach, the learning curve of LESS Heller myotomy with anterior fundoplication is short and safe, because proficiency is quickly attained.

Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study.

PubMed

Zhou, P H; Li, Q L; Yao, L Q; Xu, M D; Chen, W F; Cai, M Y; Hu, J W; Li, L; Zhang, Y Q; Zhong, Y S; Ma, L L; Qin, W Z; Cui, Z

2013-01-01

Recurrence/persistence of symptoms occurs in approximately 20 % of patients after Heller myotomy for achalasia. Controversy exists regarding the therapy for patients in whom Heller myotomy has failed. The aim of the current study was to evaluate the efficacy and feasibility of peroral endoscopic myotomy (POEM), a new endoscopic myotomy technique, for patients with failed Heller myotomy. A total of 12 patients with recurrence/persistence of symptoms after Heller myotomy, as diagnosed by established methods and an Eckardt score of ≥ 4, were prospectively included. The primary outcome was symptom relief during follow-up, defined as an Eckardt score of ≤ 3. Secondary outcomes were procedure-related adverse events, lower esophageal sphincter (LES) pressure on manometry, reflux symptoms, and medication use before and after POEM. All 12 patients underwent successful POEM after a mean of 11.9 years (range 2 - 38 years) from the time of the primary Heller myotomy. No serious complications related to POEM were encountered. During a mean follow-up period of 10.4 months (range 5 - 14 months), treatment success was achieved in 11/12 patients (91.7 %; mean score pre- vs. post-treatment 9.2 vs. 1.3; P < 0.001). Mean LES pressure was 29.4 mmHg pre-treatment and 13.5 mmHg post-treatment (P < 0.001). One patient developed mild reflux symptoms and required intermittent medication with proton pump inhibitors. POEM seems to be a promising new treatment for failed Heller myotomy resulting in short-term symptom relief in > 90 % of cases. Previous Heller myotomy may make subsequent endoscopic remyotomy more challenging, but does not prevent successful POEM. © Georg Thieme Verlag KG Stuttgart · New York.

Revisiting regression in autism: Heller's dementia infantilis. Includes a translation of Über Dementia Infantilis.

PubMed

Westphal, Alexander; Schelinski, Stefanie; Volkmar, Fred; Pelphrey, Kevin

2013-02-01

Theodor Heller first described a severe regression of adaptive function in normally developing children, something he termed dementia infantilis, over one 100 years ago. Dementia infantilis is most closely related to the modern diagnosis, childhood disintegrative disorder. We translate Heller's paper, Über Dementia Infantilis, and discuss similarities in presentation between Heller's cases, and a group of children with childhood disintegrative disorder. In particular we discuss a prodromal period of affective dysregulation described by Heller, and also evident in our sample, but not previously described in any detail since the publication of Über Dementia Infantilis.

[Józef Heller-one of organizers of Polish biochemistry in 1942-1973].

PubMed

Zarebska, Zofia

2011-01-01

The article commemorates the activity of Józef Heller starting in 1921 with Jakub Parnas's group in Lvov which investigated the phosphorolysis of glycogen. The unknown events of His biography were disclosed, like military service in the Piłsudski's Legions at the rebirth of the Polish State and, subsequently, during the Nazi occupation of Poland--participation in the clandestine teaching of medical students. In the post-war times Józef Heller undertook teaching of medical students in Wrocław and next in Warsaw. In 1954 He begun to organize the Institute of Biochemistry and Biophysics of the Polish Academy of Sciences--it now continues its activity. Professor Heller initiated the publication in Poland of three major biochemical journals, including Postepy Biochemii (1954). Thanks to His leadership the first Polish Medical Dictionary was published (1981). The article summarizes the pursuit of Józef Heller in various branches of academic life, which were and still are appreciated by subsequent generations of Polish biochemists.

A single institution's experience with more than 500 laparoscopic Heller myotomies for achalasia.

PubMed

Rosemurgy, Alexander S; Morton, Connor A; Rosas, Melissa; Albrink, Michael; Ross, Sharona B

2010-05-01

Long-term symptom relief and patient satisfaction after Heller myotomy are being reported. Herein, we report the largest experience of laparoscopic Heller myotomy for the treatment of achalasia. Since 1992, 505 patients have been prospectively followed after laparoscopic Heller myotomy. Until 2004, concomitant fundoplication was undertaken for a patulous hiatus, a large hiatal hernia, or to buttress the repair of an esophagotomy, then concomitant fundoplication became routinely applied. More recently, laparo-endoscopic single site (LESS) Heller myotomy has been performed when possible to improve cosmesis. Before and after myotomy, patients scored their symptoms. Before myotomy, 60% of patients underwent endoscopic therapy; of these patients, 27% had Botox (Allergan) therapy alone, 52% underwent dilation therapy alone, and 21% had both. Esophagotomy occurred in 7% of patients. Concomitant diverticulectomy was undertaken in 7%, fundoplication was performed in 59%, and LESS Heller myotomy was done in 12%. Median length of stay was 1 day. With mean follow-up at 31 months, the severity of all symptoms improved significantly. After myotomy, 95% experienced symptoms less than once per week, 86% believed their outcome is satisfying or better, and 92% would undergo myotomy again, if necessary. Symptoms after myotomy are similar with or without fundoplication and regardless of the laparoscopic approach used. Laparoscopic Heller myotomy safely and durably relieves symptoms of dysphagia. Confinement is short and satisfaction is very high. Relief of esophageal obstruction is paramount; the approach used or the application of a fundoplication has a lesser impact. Laparoscopic Heller myotomy, preferably with anterior fundoplication using a single site laparoscopic approach, is strongly encouraged for patients with symptomatic achalasia and is efficacious even after failures of dilation and/or Botox therapy. Copyright 2010 American College of Surgeons. Published by Elsevier Inc

Videoscopic Heller Myotomy with Intraoperative Endoscopy Promotes Optimal Outcomes

PubMed Central

Bloomston, Mark; Brady, Patrick

2002-01-01

Background and Objectives: Minimally invasive surgical techniques are applicable to achalasia, but the optimum approach to intraoperative assessment of adequacy of myotomy remains unestablished. We set out to show that videoscopic Heller myotomy with concurrent endoscopy ensures adequacy of myotomy while limiting postoperative clinically apparent reflux. Methods: Seventy-eight consecutive patients with achalasia underwent videoscopic Heller myotomy with concomitant endoscopy between 1992 and 1998. Fundoplication was not routinely undertaken. Results: Preoperative symptoms consisted of dysphagia (100%), emesis/regurgitation (68%), heartburn (58%), and postprandial chest pain (49%). Following myotomy, significant improvement (P < 0.0001) was seen in dysphagia (43%), postprandial chest pain (13%), and emesis/regurgitation (9%) at a mean follow-up of 33 ± 2.2 months. Mean reflux score (scale 0 to 5) improved from 3.7 ± 0.3 to 1.5 ± 0.2 (P < 0.0001). Improvement in symptoms was reported in 96% of patients. Fundoplication was used in 8 patients as part of hiatus reconstruction (n = 6) or repair of esophageal perforation (n = 2). Conclusions: Intraoperative endoscopy during video-scopic Heller myotomy guides the extent and adequacy of myotomy. By utilizing a focused dissection with preservation of the natural antireflux mechanisms around the gastroesophageal junction and limiting the extent of myotomy along the cardia, postoperative reflux symptoms are minimized. We advocate concomitant endoscopy during Heller myotomy to guide myotomy and submit that routine fundoplication is clinically unnecessary. PMID:12113416

The role of laparoscopic Heller myotomy in the treatment of achalasia.

PubMed

Zonca, P; Cambal, M; Labas, P; Hrbaty, B; Jacobi, C A

2014-01-01

To evaluate the results of laparoscopic Heller myotomy in our group of patients. A retrospective clinical trial was carried out to evaluate the indication, technique and controversies of laparoscopic Heller myotomy in the achalasia treatment. The following symptoms were evaluated prior and after Heller myotomy: dysphagia, heartburn, nausea/vomiting after meal and asthma/coughing. The patients were evaluated by the use of Likert score. Statistical analysis was performed by using Student t test. The intra-operative (operation time, intraoperative complications, blood loss, conversion rate), and peri-operative parameters (morbidity, mortality, hospital stay) were evaluated as well. The patients who underwent laparoscopic Heller myotomy were included in the trial. All patients were perioperatively managed by a multidisciplinary team. The evaluation of fourteen patients was performed (average age: 53.2 yrs., eleven men, two women, BMI 23.6 kg/m(2)). The patients were indicated for surgery in all of the stages (I-III). Previous semiconservative therapeutic modalities were performed in thirteen patients. The standard laparoscopic technique for Heller myotomy with semifundoplication was applied. All the observed symptoms were statistically improved after the surgery (p=0.05). The average operating time was 89 minutes. Intraoperative blood loss was below 20 ml. There was no conversion to open surgery. An average hospital stay was 4.3 days. Morbidity was 14.3 % and mortality 0 %. In one patient esophageal mucosa perforation was intra-operatively identified and sutured. Post-operative course in this patient was without any complications. The laparoscopic Heller myotomy has become the "gold standard" procedure for achalasia. It is an excellent method allowing precise operation technique with good visualization of the esophagogastric junction. The operation with this approach is safe, efficient, and with excellent reproducible operative results. The correct and early indication

Laparoscopic Heller myotomy with or without partial fundoplication: A matter of debate

PubMed Central

Ramacciato, G; D’Angelo, FA; Aurello, P; Gaudio, M Del; Varotti, G; Mercantini, P; Bellagamba, R; Ercolani, G

2005-01-01

AIM: To present our experience of laparoscopic Heller stretching myotomy followed by His angle reconstruction as surgical approach to esophageal achalasia. METHODS: Thirty-two patients underwent laparoscopic Heller myotomy; an anterior partial fundoplication in 17, and angle of His reconstruction in 15 cases represented the antireflux procedure of choice. RESULTS: There were no morbidity and mortality recorded in both anterior funduplication and angle of His reconstruction groups. No differences were detected in terms of recurrent dysphagia, p.o. reflux or medical therapy. CONCLUSION: To reduce the incidence of recurrent achalasia after laparoscopic Heller myotomy, we believe that His’ angle reconstruction is a safe and effective alternative to the anterior fundoplication. PMID:15770738

Dissatisfaction after laparoscopic Heller myotomy: The truth is easy to swallow.

PubMed

Rosemurgy, Alexander; Downs, Darrell; Jadick, Giavanna; Swaid, Forat; Luberice, Kenneth; Ryan, Carrie; Ross, Sharona

2017-06-01

Although laparoscopic Heller myotomy has been shown to well palliate symptoms of achalasia, we have observed a small subset of patients who are "Dissatisfied". This study was undertaken to identify the causes of their dissatisfaction. Patients undergoing laparoscopic Heller myotomy from 1992 to 2015 were prospectively followed. Using a Likert scale, patients rated their symptom frequency/severity before and after the procedure. Patients graded their experience from "Very Satisfying" to "Very Unsatisfying." 647 patients underwent laparoscopic Heller myotomy. Fifty (8%) patients, median age 57 years and BMI 24 kg/m 2 reported dissatisfaction at follow-up subsequent to myotomy. "Dissatisfied" patients were more likely to have undergone prior abdominal operations (p = 0.01) or previous myotomies (p = 0.02). "Dissatisfied" patients had a greater incidence of diverticulectomy (p = 0.03) and had longer postoperative LOS (p = 0.01). Symptom frequency/severity persisted after myotomy for dissatisfied patients (p > 0.05). Dissatisfaction after laparoscopic Heller myotomy is directly related to persistent/recurrent symptoms. Previous abdominal operations/myotomies, diverticulectomies, and longer LOS are predictors of dissatisfaction. With this understanding, we can identify patients who might be more prone to dissatisfaction. Copyright © 2017 Elsevier Inc. All rights reserved.

Operative interventions for failed heller myotomy: a single institution experience.

PubMed

Pallati, Pradeep K; Mittal, Sumeet K

2011-03-01

Recurrent dysphagia and/or gastroesophageal reflux (GER) are failures of treatment after Heller myotomy for achalasia. We present our single center experience with surgical interventions for these failures. We did a retrospective analysis of a prospectively collected database. Based on preoperative symptoms and endoscopy, esophagogram, and manometry results, patients were divided into three groups to guide management. Telephone follow-up was done using a structured foregut questionnaire. Between December 2003 and June 2009, 16 patients underwent operative interventions for disabling symptoms after previous Heller myotomy. Eight patients presented primarily with recurrent dysphagia and underwent transabdominal Heller myotomy with partial fundoplication. Seven patients reported good to excellent symptom relief at mean follow-up of 42 months. One patient reported no relief and eventually required esophageal bypass with retrosternal gastric pull-up. Four patients presented with uncontrolled GER. Two patients who underwent redo partial fundoplication reported poor symptomatic outcome and one patient has since undergone short limb Roux-en-y gastric bypass (SLRNYGB) with excellent symptom relief. The other two patients underwent SLRNYGB with excellent relief at 10 months. Four patients had end stage achalasia and underwent esophageal resection with reconstruction. All reported excellent symptom relief at mean follow-up of 36 months. Transabdominal redo Heller myotomy for dysphagia has good outcomes. Redo fundoplication for GER after previous myotomy has poor results and SLRNYGB is an effective option in these patients. Esophageal resection remains an effective, albeit morbid, option for end-stage achalasia.

Improvement of respiratory symptoms following Heller myotomy for achalasia.

PubMed

Khandelwal, Saurabh; Petersen, Rebecca; Tatum, Roger; Sinan, Huseyin; Aaronson, Daniel; Mier, Fernando; Martin, Ana V; Pellegrini, Carlos A; Oelschlager, Brant K

2011-02-01

Although patients with achalasia complain mainly of dysphagia, we have observed that they also have a high rate of respiratory problems. We hypothesized that the latter may be due to poor esophageal clearance leading to aspiration. This study examines the effect of Heller myotomy on these symptoms. We studied the course of 111 patients with achalasia who underwent Heller myotomy between 1994 and 2008 and who agreed to participate in this study. All patients completed a questionnaire postoperatively assessing the preoperative and postoperative prevalence and severity of symptoms using visual analog scales. Patients were divided into two groups: one that included all those with respiratory symptoms (dyspnea, hoarseness, cough, wheezing, sore throat, and/or a history of asthma or pneumonia) prior to myotomy and one that included those without those symptoms. All patients presented with dysphagia as their primary complaint, and 63 (57%) reported respiratory symptoms or disease prior to surgery. There were no significant differences in preoperative characteristics between those with and without respiratory manifestations. After a median follow-up of 71 months (range 9-186 months), 55 (87%) patients reported durable improvement of dysphagia. The frequency and severity of all respiratory symptoms decreased significantly. Twenty-four of the 29 patients (82%) who reported a history of pneumonia prior to surgery did not experience recurrent episodes after Heller myotomy. A Heller myotomy is effective in improving esophageal emptying in patients with achalasia. This results in sustained improvement of dysphagia and associated respiratory symptoms/diseases. This suggests that respiratory symptoms/diseases in these patients are likely caused by esophageal retention of food and secretions, and then aspiration.

Laparoscopic heller myotomy for achalasia cardia-initial experience in a teaching institute.

PubMed

Kaman, Lileswar; Iqbal, Javid; Kochhar, Rakesh; Sinha, Saroj

2013-10-01

Laparoscopic Heller cardiomyotomy and Dor fundoplication is the surgical procedure of choice for esophageal achalasia. The aim of our study was to investigate the clinical outcome and safety of laparoscopic Heller-Dor procedure performed by using Hook electrocautery and as a teaching module for advanced laparoscopic surgery. Between January 2005 and December 2010, 25 consecutive patients with achalasia underwent laparoscopic Heller-Dor operation by a single surgeon. All the patients received upper gastrointestinal series (barium swallow), esophagogastroscopy, and esophageal manometry to exclude esophageal carcinoma and to confirm the diagnosis. All the patients were operated by laparoscopic modified Heller myotomy with Dor fundoplication by using hook electrocautery. Among 25 operated patients, 14 were male and 11 were female with a median age of 43 years (range 18-72 years). The mean operative time was 93.3 min (range 50-50 min), the mean operative blood loss was 90 ml (range 40-200 ml), the median time to oral feeding was 2 days (2-4 days), and the median hospital stay was 4 days (4-7 days). There was no conversion to open surgery. Intraoperative mucosal perforation was encountered in three patients and was repaired in all of them by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication and had excellent clinical response (96 %) during follow-up. Laparoscopic Heller-Dor operation using hook electrocautery is safe, inexpensive, and effective treatment for achalasia which is useful for teaching and training surgical residents in advanced laparoscopic surgery.

Long-term outcome of peroral endoscopic myotomy for esophageal achalasia in patients with previous Heller myotomy.

PubMed

Kristensen, Helle Ø; Kirkegård, Jakob; Kjær, Daniel Willy; Mortensen, Frank Viborg; Kunda, Rastislav; Bjerregaard, Niels Christian

2017-06-01

Peroral endoscopic myotomy (POEM) is an emerging procedure in the treatment of esophageal achalasia, a primary motility disorder. However, the long-term outcome of POEM in patients, who have previously undergone a Heller myotomy, is unknown. Using a local database, we identified patients with esophageal achalasia, who underwent POEM. We compared patients with a previous Heller myotomy to those, who had received none or only non-surgical therapy prior to the POEM procedure. We conducted follow-up examinations at 3, 12, and 24 months following the procedure. We included 66 consecutive patients undergoing POEM for achalasia, of which 14 (21.2 %) had undergone a prior Heller myotomy. In both groups, the preoperative Eckardt score was 7. Postoperatively, the non-Heller group experienced a more pronounced symptom relief at both 3-, 12-, and 24-month follow-up compared with the Heller group, and there was a tendency for the effect of POEM to reduce over time. We suggest that there is a correlation between preoperative measurements of gastroesophageal sphincter pressures and the chance of a successful POEM. POEM has a place in the treatment of esophageal achalasia in patients with a prior Heller myotomy and persistent symptoms as it is a safe procedure with acceptable long-term results.

Fundoplication after heller myotomy: a retrospective comparison between nissen and dor.

PubMed

Cuttitta, Antonello; Tancredi, Antonio; Andriulli, Angelo; De Santo, Ermelinda; Fontana, Andrea; Pellegrini, Fabio; Scaramuzzi, Roberto; Scaramuzzi, Gerardo

2011-12-01

A retrospective comparison between Nissen and Dor fundoplication after laparoscopic Heller myotomy for achalasia. From 1998 to 2004 a first group of 48 patients underwent Heller myotomy and Nissen fundoplication for idiopathic achalasia (H+N group). From 2004 to 2010 a second group of 40 patients underwent Heller myotomy followed by Dor fundoplication (H+D group). Some patients received a previous endoscopic treatment with pneumatic dilatation or endoscopic injection of botulinum toxin that provided them only a temporary clinical benefit. Changes in clinical and instrumental examinations from before to after surgery were evaluated in all patients. Clinical evaluation was carried out using a modified DeMeester symptom score system. Dor fundoplication treatment reduced both dysphagia and regurgitation severity scores significantly more than Nissen fundoplication (p<0.0001). Indeed, the incidence of dysphagia was significantly higher in patients treated with floppy-Nissen than in those treated with Dor fundoplication: by defining dysphagia as a DeMeester score equal to 3 (arbitrary cut-off), at the end of follow-up dysphagia occurred in 17.65% and 0% (p=0.037) of patients belonging to the H+N and H+D groups, respectively. Heller myotomy followed by Dor fundoplication is a safe and valuable treatment. The procedure showed a lower incidence of postoperative dysphagia versus Nissen fundoplication and a negligible incidence of postoperative GERD in a long-term postoperative follow-up.

Minimally invasive Heller's myotomy in children: safe and effective.

PubMed

Askegard-Giesmann, Johanna R; Grams, Jayleen M; Hanna, Angela M; Iqbal, Corey W; Teh, Swee; Moir, Christopher R

2009-05-01

The aim of the study was to review a single institution experience of minimally invasive Heller's myotomy in pediatric patients with achalasia. An institutional review board-approved retrospective review from 1999 to 2005 identified patients 18 years old and younger who underwent a minimally invasive Heller's myotomy for achalasia. Twenty-six patients were identified with a mean age of 15 (range, 4-18 years). There were 11 female and 15 male patients. There were 3 intraoperative complications (2 esophageal mucosal injuries and 1 aspiration). There was no mortality. All 26 surgeries were completed laparoscopically. Two patients had Dor fundoplication, whereas 23 patients had Toupet fundoplication. Average length of hospital stay was 2.7 days (range, 1-4 days) excluding the 3 patients with intraoperative complications and 3.5 days for all patients (range, 1-17 days). Postoperative follow-up ranged from 0 to 75 months (mean, 20 months). Postoperatively, one patient developed reflux symptoms (incidence 4%). Seven patients (27%) had recurrence of symptoms at a mean of 13 months (range, 1-66 months) after their operation. Laparoscopic Heller's myotomy with fundoplication is a safe and effective treatment of symptomatic achalasia in the pediatric population. Complications were low in this group of patients and comparable to other published reports in the literature.

Fundoplication After Heller Myotomy: A Retrospective Comparison Between Nissen and Dor

PubMed Central

Cuttitta, Antonello; Tancredi, Antonio; Andriulli, Angelo; De Santo, Ermelinda; Fontana, Andrea; Pellegrini, Fabio; Scaramuzzi, Roberto; Scaramuzzi, Gerardo

2011-01-01

Objective: A retrospective comparison between Nissen and Dor fundoplication after laparoscopic Heller myotomy for achalasia. Materials and Methods: From 1998 to 2004 a first group of 48 patients underwent Heller myotomy and Nissen fundoplication for idiopathic achalasia (H+N group). From 2004 to 2010 a second group of 40 patients underwent Heller myotomy followed by Dor fundoplication (H+D group). Some patients received a previous endoscopic treatment with pneumatic dilatation or endoscopic injection of botulinum toxin that provided them only a temporary clinical benefit. Changes in clinical and instrumental examinations from before to after surgery were evaluated in all patients. Clinical evaluation was carried out using a modified DeMeester symptom score system. Results: Dor fundoplication treatment reduced both dysphagia and regurgitation severity scores significantly more than Nissen fundoplication (p<0.0001). Indeed, the incidence of dysphagia was significantly higher in patients treated with floppy-Nissen than in those treated with Dor fundoplication: by defining dysphagia as a DeMeester score equal to 3 (arbitrary cut-off), at the end of follow-up dysphagia occurred in 17.65% and 0% (p=0.037) of patients belonging to the H+N and H+D groups, respectively. Conclusion: Heller myotomy followed by Dor fundoplication is a safe and valuable treatment. The procedure showed a lower incidence of postoperative dysphagia versus Nissen fundoplication and a negligible incidence of postoperative GERD in a long-term postoperative follow-up. PMID:25610181

Results after laparoscopic Heller-Dor operation for esophageal achalasia in 100 consecutive patients.

PubMed

Tsuboi, Kazuto; Omura, Nobuo; Yano, Fumiaki; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2009-01-01

The laparoscopic Heller-Dor operation has been the procedure of choice for the treatment of achalasia. However, because the incidence of achalasia is low, reports on the outcome of surgical treatment for achalasia are limited. In this study, the therapeutic results after laparoscopic Heller-Dor operation for achalasia at a single university hospital were evaluated. Between August 1994 and July 2006, 100 consecutive patients underwent laparoscopic Heller-Dor operation. The therapeutic results after laparoscopic Heller-Dor operation were assessed based on complications, operation time, blood loss, postoperative hospital stay, and the standardized questionnaire for satisfaction by telephone or outpatient clinic interview. With respect to perioperative complications, lower esophageal mucosal perforation occurred in 14 patients, but all of them could be suture-obliterated laparoscopically. One patient was converted to laparotomy because of uncontrolled bleeding from the short gastric artery. The mean operative time was 169 minutes, and the mean perioperative blood loss was 22 mL. The median postoperative hospital stay was 7 days. Reflux esophagitis, which was seen in five patients, was treated successfully with a proton pump inhibitor. According to the standardized questionnaire for satisfaction, 77 patients rated their recovery as 'excellent', 17 as 'good', 4 as 'fair', and 2 as 'poor'; thus, the overall success rate was 94%. There were no significant differences in surgical outcomes by morphologic type and severity of esophageal dilatation; however, the success rate deteriorated significantly with progression of the morphologic type. Laparoscopic Heller-Dor operation is a safe and effective surgical treatment for achalasia.

Twenty-year trends in the utilization of Heller myotomy for achalasia in the United States.

PubMed

Haisley, Kelly R; Preston, Jennifer F; Dolan, James P; Diggs, Brian S; Hunter, John G

2017-08-01

Trends in the utilization of Heller myotomy for achalasia in the U.S. over time have not been previously described. Using the Nationwide Inpatient Sample (NIS) database, we analyzed patients undergoing Heller myotomy for achalasia over a 20-year period (1992-2011) to estimate rates of Heller myotomy, locations where the procedures were performed (rural, urban or teaching) and changes in technique (laparoscopic vs open) as well as outcomes of length of stay and in-hospital mortality. Over the last 20 years, the total number of Heller myotomies performed in the U.S. has increased (1576 cases in 1992 to 5046 cases in 2011, p = 0.001). These procedures are now being performed laparoscopically (0.9%-67.0%, p < 0.001) and at urban teaching hospitals (45.4%-77.1%, p < 0.001). In-hospital mortality has decreased (0.9%-0.3%, p = 0.006). Hospital length of stay has decreased from 7 days to 2 days (p < 0.001). These data show a trend of increasing utilization of laparoscopic Heller myotomy at teaching institutions with decreased in-hospital mortality and shorter LOS. Copyright © 2017. Published by Elsevier Inc.

Recurrent dysphagia after Heller myotomy: is esophagectomy always the answer?

PubMed

Loviscek, Maximiliano F; Wright, Andrew S; Hinojosa, Marcelo W; Petersen, Rebecca; Pajitnov, Dmitry; Oelschlager, Brant K; Pellegrini, Carlos A

2013-04-01

Esophagectomy has been recommended for patients when recurrent dysphagia develops after Heller myotomy for achalasia. My colleagues and I prefer to correct the specific anatomic problem with redo myotomy and preserve the esophagus. We examined the results of this approach. We analyzed the course of 43 patients undergoing redo Heller myotomy for achalasia between 1994 and 2011 with at least 1-year of follow-up. In 2012, a phone interview and a symptoms questionnaire were completed by 24 patients. Forty-three patients underwent redo Heller myotomy. All patients had dysphagia, 80% had had multiple dilations. Manometry confirmed the diagnosis, lower esophageal sphincter pressure averaged 17 mmHg; 24-hour pH monitoring was not useful because of fermentation; patients were divided into 4 groups according to findings on upper gastrointestinal series. Three patients underwent take down of previous fundoplication only, the remainder 40 had that and a redo myotomy with 3-cm gastric extension. Two mucosal perforations were repaired with primary closure and Dor fundoplication. At a median follow-up of 63 months, 19 of 24 patients reported improvement in dysphagia, with median overall satisfaction rating of 7 (range 3 to 10); 4 patients required esophagectomy for persistent dysphagia. The majority of failures after Heller myotomy present with dysphagia associated with esophageal narrowing. Upper gastrointestinal series is most useful to plan therapy and predicts outcomes. With few exceptions, patients improve substantially with redo myotomy, which can be accomplished laparoscopically with relatively low risk. These findings challenge the previously held concept that all myotomy failures need to be treated by an esophagectomy. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Laparoscopic Heller myotomy for achalasia: changing trend toward "true" day-case procedure.

PubMed

Agrawal, Sanjay; Super, Paul

2008-12-01

Laparoscopic Heller myotomy is the most effective therapy for achalasia. All case series have reported a minimum length of stay of more than 1 day. "True" day-case laparoscopic Heller myotomy has not been reported, so far. The aim of this study was to review our results with laparoscopic Heller myotomy with respect to the length of stay following the procedure. All patients undergoing laparoscopic Heller myotomy between August 2000 and July 2007 under the care of one surgeon were included in the study. This was performed by incising 6 cm of distal esophageal musculature, extending to 2 cm below the gastroesophageal junction. The myotomy was covered by an anterior fundoplication. All patients were reviewed in the clinic at a median of 6 weeks after surgery and, thereafter, if necessary. Over the 7-year period, 24 consecutive patients with achalasia were treated in this manner. There were 13 women and 11 men, with an age range of 12-73 years. Intraoperative complications included mucosal perforation in 2 patients (sutured immediately) with no postoperative complications or conversion to open surgery. There were no deaths. The average length of stay was 1.9 days (range, 0-4). The last 2 patients were discharged on the same day, and the 5 previous to this were discharged within 23 hours of surgery. There were no adverse outcomes related to early discharge, and there were no readmissions. All patients reported good to excellent results with a relief of dysphagia on follow-up. Three patients (12%) developed recurrent dysphagia after an initial improvement, requiring dilatation only several months later. Based on our own experience, we believe that laparoscopic Heller myotomy with anterior partial fundoplication is safe and achieves a good outcome in the treatment of achalasia. It is well tolerated and can be considered a true day-case procedure.

Surgical Treatment for Achalasia of the Esophagus: Laparoscopic Heller Myotomy

PubMed Central

Torres-Villalobos, Gonzalo; Martin-del-Campo, Luis Alfonso

2013-01-01

Achalasia is an esophageal motility disorder that leads to dysphagia, chest pain, and weight loss. Its diagnosis is clinically suspected and is confirmed with esophageal manometry. Although pneumatic dilation has a role in the treatment of patients with achalasia, laparoscopic Heller myotomy is considered by many experts as the best treatment modality for most patients with newly diagnosed achalasia. This review will focus on the surgical treatment of achalasia, with special emphasis on laparoscopic Heller myotomy. We will also present a brief discussion of the evaluation of patients with persistent or recurrent symptoms after surgical treatment for achalasia and emerging technologies such as LESS, robot-assisted myotomy, and POEM. PMID:24348542

Trends of Heller myotomy hospitalizations for achalasia in the United States, 1993-2005: effect of surgery volume on perioperative outcomes.

PubMed

Wang, Y Richard; Dempsey, Daniel T; Friedenberg, Frank K; Richter, Joel E

2008-10-01

Achalasia is a rare chronic disorder of esophageal motor function. Single-center reports suggest that there has been greater use of laparoscopic Heller myotomy for achalasia in the United States since its introduction in 1992. We aimed to study the trends of Heller myotomy and the relationship between surgery volume and perioperative outcomes. The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) is a 20% stratified sample of all hospitalizations in the United States. It was used to study the macro-trends of Heller myotomy hospitalizations during 1993-2005. We also used the NIS 2003-2005 micro-data to study the perioperative outcomes of Heller myotomy hospitalizations, using other achalasia and laparoscopic cholecystectomy hospitalizations as control groups. The generalized linear model with repeated observations from the same unit was used to adjust for multiple hospitalizations from the same hospital. The national estimate of Heller myotomy hospitalizations increased from 728 to 2,255 during 1993-2005, while its mean length of stay decreased from 9.9 to 4.3 days. Of the 1,117 Heller myotomy hospitalizations in the NIS 2003-2005, 10 (0.9%) had the diagnosis of esophageal perforation at discharge. Length of stay was negatively correlated with a hospital's number of Heller myotomy per year (correlation coefficient -0.171, P < 0.001). In multivariate log-linear regressions with a control group, a hospital's number of Heller myotomy per year was negatively associated with length of stay (coefficient -0.215 to -0.119, both P < 0.001) and total charges (coefficient -0.252 to -0.073, both P < 0.10). These findings were robust in alternative statistical models, specifications, and subgroup analyses. On a national level, the introduction of laparoscopic Heller myotomy for achalasia was associated with greater use of surgery and shorter length of stay. A larger volume of Heller myotomy in a hospital was associated with better perioperative outcomes

Laparoscopic Heller myotomy and fundoplication in patients with Chagas' disease achalasia and massively dilated esophagus.

PubMed

Pantanali, Carlos A R; Herbella, Fernando A M; Henry, Maria A; Mattos Farah, Jose Francisco; Patti, Marco G

2013-01-01

Laparoscopic Heller myotomy and fundoplication is considered today the treatment of choice for achalasia. The optimal treatment for end-stage achalasia with esophageal dilation is still controversial. This multicenter and retrospective study aims to evaluate the outcome of laparoscopic Heller myotomy in patients with a massively dilated esophagus. Eleven patients (mean age, 56 years; 6 men) with massively dilated esophagus (esophageal diameter greater than 10 cm) underwent a laparoscopic Heller myotomy and anterior fundoplication between 2000 and 2009 at three different institutions. Preoperative workup included upper endoscopy, esophagram, and esophageal manometry in all patients. Average follow-up was 31.5 months (range, 3 to 60 months). Two patients (18%) had severe dysphagia, four patients (36%) had mild and occasional dysphagia to solid food, and five patients (45%) were asymptomatic. All patients gained or kept body weight, except for the two patients with severe dysphagia. Of the two patients with severe dysphagia, one underwent esophageal dilatation and the other a laparoscopic esophagectomy. They are both doing well. Heller myotomy relieves dysphagia in the majority of patients even when the esophagus is massively dilated.

Limited Hiatal Dissection Without Fundoplication Results in Comparable Symptomatic Outcomes to Laparoscopic Heller Myotomy with Anterior Fundoplication.

PubMed

DeHaan, Reece K; Frelich, Matthew J; Gould, Jon C

2016-07-01

Previous randomized controlled trials have demonstrated that partial fundoplication following Heller myotomy results in less pathologic acid exposure to the esophagus when compared to myotomy without fundoplication. Recent studies have questioned the necessity of a fundoplication, especially when a limited hiatal dissection (LHD) is performed and the angle of His is preserved. This is a retrospective review of prospectively maintained data. All patients underwent primary Heller myotomy for achalasia over a 30-month period. In select patients, an LHD was performed anteriorly. Symptomatic outcomes were assessed up to 2 years postoperation using the Achalasia Severity Questionnaire (ASQ), Gastrointestinal Quality of Life Index (GIQLI), and Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL). A total of 31 patients underwent Heller myotomy during the study interval. The majority of patients underwent Heller myotomy with full hiatal dissection (FHD) (21, 68%). Intraoperative mucosal perforations occurred in 3 (14%) patients undergoing FHD. Patient demographics, surgery details, and baseline symptomatic outcomes did not differ significantly preoperatively. At greater than 1 year postoperation, there was no significant difference between the groups for ASQ, GERD-HRQL, and GIGLI (P = .76, .78, and .33, respectively). Heller myotomy with LHD and no fundoplication and Heller myotomy with FHD and partial fundoplication result in similar GERD-related quality of life outcomes. Further studies (including pH studies) are necessary to determine if fundoplication is a necessary step in selected patients in whom an LHD is possible.

Case Study of Childhood Disintegrative Disorder--Heller's Syndrome.

ERIC Educational Resources Information Center

Bray, Melissa A.; Kehle, Thomas J.; Theodore, Lea A.; Broudy, Matthew S.

2002-01-01

Discusses the case of a 25-year-old male with childhood disintegrative disorder (CDD), or Heller's syndrome, in terms of differential diagnosis, progression of the disorder, and suggestions for home- and school-based interventions. Documents the progressive deterioration of cognitive and social competencies. (Contains 23 references.) (GCP)

Laparoscopic Heller myotomy provides durable relief from achalasia and salvages failures after botox or dilation.

PubMed

Rosemurgy, Alexander; Villadolid, Desiree; Thometz, Donald; Kalipersad, Candice; Rakita, Steven; Albrink, Michael; Johnson, Milton; Boyce, Worth

2005-05-01

To report outcome after laparoscopic Heller myotomy in a large number of patients. Laparoscopic Heller myotomy has been undertaken for over a decade, but most studies involve small numbers of patients with limited follow-up. Since 1992, 262 patients have undergone laparoscopic Heller myotomy and been prospectively followed. Concomitant fundoplication was undertaken for a patulous hiatus or large hiatal hernia or to buttress the repair of an esophagotomy until recently when it became routinely applied. With mean follow-up at 32 months, symptoms were scored by patients on a Likert scale (frequency: 0 = Never to 10 = Every time I eat/always; severity: 0 = Not bothersome to 10 = Very bothersome). Before myotomy, 79% received Botox or bag dilation: 52% had Botox, 59% underwent dilation, and 36% had both. Inadvertent esophagotomy occurred in 5%. Concomitant diverticulectomy was undertaken in 4%, and fundoplication was undertaken in 30%. Complications were infrequent. Median length of stay was 1 day. After myotomy, the frequency and severity of symptoms of achalasia and reflux significantly decreased. Eighty-eight percent of patients felt their symptoms were greatly improved or resolved, and 90% felt their outcome was satisfying or better. Ninety-three percent felt they would undergo myotomy again, if necessary. Laparoscopic Heller myotomy can safely and durably relieve symptoms of dysphagia while also reducing symptoms of reflux. Length of stay is short and patient satisfaction is very high with extended follow-up. Laparoscopic Heller myotomy is strongly encouraged for patients with symptomatic achalasia and is efficacious even after failures of dilation and/or Botox therapy.

Response: Heller's "In Praise of Amateurism--A Friendly Critique of Moje's "Call for Change" in Secondary Literacy"

ERIC Educational Resources Information Center

Moje, Elizabeth Birr

2010-01-01

This article presents the author's response to Rafael Heller's critique of her commentary on foregrounding the disciplines in secondary school literacy teaching and learning. Heller challenges the idea of approaching secondary literacy instruction from a disciplinary perspective by arguing that rather than teach young people the literate practices…

Heller Myotomy for Achalasia: Quality of Life Comparison of Laparoscopic and Open Approaches

PubMed Central

Katilius, Marius

2001-01-01

Background: Achalasia is a relatively rare disorder with a variety of treatment options. Although laparoscopic Heller myotomy has become the surgical treatment of choice, little data exist on the overall quality of life of patients undergoing this technique versus standard open approaches. Methods: We prospectively evaluated all patients surgically treated for achalasia by a single surgeon. Laparoscopic Heller myotomy consisted of a long (≥ 6 cm) esophageal cardiomyotomy extending at least 2 cm onto the gastric cardia, with a concomitant Dor fundoplication. Patients were evaluated preoperatively and postoperatively for symptoms and quality of life using the SF-36, a standardized, generic quality of life instrument. Results: A total of 23 patients were surgically treated: 15 patients had a planned laparoscopic procedure, with 3 conversions; 8 had planned open procedures. Dysphagia resolved in 20 of 21 patients, with 1 patient in the laparoscopic group requiring reoperation due to an inadequate gastric myotomy. Compared with preoperative scores, a statistically significant improvement occurred in the general health domain of the SF-36 (70 to 82, P = 0.04). Compared with that in patients undergoing open surgery, the laparoscopic group had better scores in the domains of physical functioning and bodily pain. Conclusions: Laparoscopic Heller myotomy has comparable success to open Heller myotomy, and causes less early detriment to quality of life. This should be the primary treatment in all fit surgical patients with achalasia. PMID:11548827

Laparoscopic Heller-Dor for primary esophageal achalasia: outcomes in 173 patients.

PubMed

Rosati, Riccardo; Fumagalli Romario, Uberto; Ceolin, Martina; Massaron, Simonetta; Peracchia, Alberto

2013-01-01

Laparoscopic Heller myotomy combined with anterior (Dor) fundoplication is the most widely-used surgical procedure for treating esophageal achalasia in Europe From November 1992 through May 2010 we performed laparoscopic Heller-Dor on 173 patients Conversion to laparotomy was required in three cases (1.7%) at the beginning of the experience (for mucosal) perforation which was the most frequent intraoperative complication, managed laparoscopically with the increasing experience. Five (2.9%) cases had minor postoperative complications. Clinical results were satisfactory in 99.4% of cases. One patient (0.6%) had severe persistent dysphagia. Mean esophageal diameter decreased from 50 mm ± 12 (range 20- 90) to 25 mm ± 7 (range 15-80). Lower esophageal sphincter pressure decreased from 32 mmHg (median, range 10- 93) pre-operatively to 11 mmHg (median, range 5-21) at one year follow up and residual pressure from 12 mmHg (median, range 3-30) to 4 mmHg (median, range 1-8). Impedance and pH monitoring showed normal levels in 39/47 (83%) patients who agreed to testing. The good outcomes of this experience, in part due to careful adherence to technical aspects of the operation, confirm that the laparoscopic Heller-Dor is the gold standard surgical treatment for esophageal achalasia.

Robotic-assisted Heller myotomy versus laparoscopic Heller myotomy for the treatment of esophageal achalasia: a case-control study.

PubMed

Sánchez, Alexis; Rodríguez, Omaira; Nakhal, Elias; Davila, Hugo; Valero, Rair; Sánchez, Renata; Pena, Romina; Visconti, Maria F

2012-09-01

Minimally invasive surgery has become the gold standard for the treatment of achalasia. The incorporation of robotic technology can improve many limitations of laparoscopic surgery, through, for example, the availability of three-dimensional vision, increasing the degrees of movement, avoiding the fulcrum effect and optimizing ergonomics. The aim of this study was to compare robotic-assisted laparoscopic Heller myotomy (RAHM) with laparoscopic Heller myotomy (LHM) in terms of efficacy and safety. Thirty-one patients with diagnosis of achalasia confirmed by esophagogram and manometry were included. Dysphagia and weight loss were the main complaints in both groups. 18 patients were treated with LHM and 13 patients with RAHM. There was no difference in mean operative time (76 ± 13 vs. 79 ± 20 min; P = 0.73). Intraoperative complications were less frequent in the robotic-assisted procedures (5.5% vs. 0%); however, this was a non-significant difference. 94.5-100% of patients had relief of their symptoms. We conclude that RAHM is a safe and effective procedure. The operative time is no longer than in LHM, but it is necessary to evaluate the technique in randomized clinical trials to determine its advantages in terms of intraoperative complications.

Laparoscopic Heller Myotomy Provides Durable Relief From Achalasia and Salvages Failures After Botox or Dilation

PubMed Central

Rosemurgy, Alexander; Villadolid, Desiree; Thometz, Donald; Kalipersad, Candice; Rakita, Steven; Albrink, Michael; Johnson, Milton; Boyce, Worth

2005-01-01

Objective: To report outcome after laparoscopic Heller myotomy in a large number of patients. Summary Background Data: Laparoscopic Heller myotomy has been undertaken for over a decade, but most studies involve small numbers of patients with limited follow-up. Methods: Since 1992, 262 patients have undergone laparoscopic Heller myotomy and been prospectively followed. Concomitant fundoplication was undertaken for a patulous hiatus or large hiatal hernia or to buttress the repair of an esophagotomy until recently when it became routinely applied. With mean follow-up at 32months, symptoms were scored by patients on a Likert scale (frequency: 0 = Never to 10 = Every time I eat/always; severity: 0 = Not bothersome to 10 = Very bothersome). Results: Before myotomy, 79% received Botox or bag dilation: 52% had Botox, 59% underwent dilation, and 36% had both. Inadvertent esophagotomy occurred in 5%. Concomitant diverticulectomy was undertaken in 4%, and fundoplication was undertaken in 30%. Complications were infrequent. Median length of stay was 1 day. After myotomy, the frequency and severity of symptoms of achalasia and reflux significantly decreased. Eighty-eight percent of patients felt their symptoms were greatly improved or resolved, and 90% felt their outcome was satisfying or better. Ninety-three percent felt they would undergo myotomy again, if necessary. Conclusions: Laparoscopic Heller myotomy can safely and durably relieve symptoms of dysphagia while also reducing symptoms of reflux. Length of stay is short and patient satisfaction is very high with extended follow-up. Laparoscopic Heller myotomy is strongly encouraged for patients with symptomatic achalasia and is efficacious even after failures of dilation and/or Botox therapy. PMID:15849508

Per-Oral Endoscopic Myotomy (POEM) After Previous Laparoscopic Heller Myotomy Is Feasible and Safe in a Porcine Model.

PubMed

Miles, Luke F; Frelich, Matthew J; Gould, Jon C; Dua, Kulwinder S; Jensen, Eric S; Kastenmeier, Andrew S

2015-10-01

We sought to evaluate the feasibility, safety, and difficulty of performing the per-oral endoscopic myotomy (POEM) procedure in the setting of a prior Heller myotomy using a survival porcine model. Four pigs underwent laparoscopic Heller myotomy with Dor partial anterior fundoplication followed by the POEM performed 4 weeks later. Two additional pigs served as controls, undergoing only the POEM. All procedures were completed without complications. The revisional POEM was not significantly more difficult than POEM controls based on procedure time, POEM procedure components, or procedure difficulty scores. Revisional POEM had a longer mean operative time when compared with Heller myotomy (126.0 vs. 83.8 min; P<0.01) but had a lower total difficulty score (28.6 vs. 52.1; P≪0.01). A POEM after previous Heller myotomy is safe and feasible in the porcine model and has potential as an option for patients suffering from recurrent or persistent symptoms after failed surgical myotomy.

Efficacy of pneumodilation in achalasia after failed Heller myotomy.

PubMed

Saleh, C M G; Ponds, F A M; Schijven, M P; Smout, A J P M; Bredenoord, A J

2016-11-01

Heller myotomy is an effective treatment for the majority of achalasia patients. However, a small proportion of patients suffer from persistent or recurrent symptoms after surgery and they are usually subsequently treated with pneumodilation (PD). Data on the efficacy of PD as secondary treatment for achalasia are scarce. Therefore, this study aimed to investigate the efficacy of PD as treatment for achalasia patients suffering from persistent or recurrent symptoms after Heller myotomy. Patients with recurrent or persistent symptoms (Eckardt score >3) after Heller myotomy were selected. Patients were treated with PD, using a graded distension protocol with balloon sizes ranging from 30 to 40 mm. After each dilation symptoms were assessed to evaluate whether a subsequent dilation with a larger balloon size was required. Patients with recurrent or persistent symptoms (Eckardt score >3) after treatment with a 40-mm balloon were identified as failures. Twenty-four patients were included in total; 15 patients with achalasia type I, seven with achalasia type II and two with achalasia type III. Median relapse time was 2.5 years after Heller myotomy (IQR: 9 years and 3 months). Three patients were not suitable for PD; one patient was morbidly obese and not fit for any form of sedation and two had a siphon-shaped esophagus leaving 21 patients to treat. Eight patients were successfully treated with a single 30-mm balloon dilation (median follow-up time: 6.5 years; IQR: 7.5 years). Four patients required dilations with 30- and 35-mm balloons (median follow-up time: 11 years; IQR: 3 years). Nine patients failed on the 35-mm balloon dilation and underwent a subsequent dilation with a 40-mm balloon, and all failed on this balloon as well. Thus, PD was successful in 12 of the 21 treatable patients, resulting in a success rate of 57% for treatable patients or 50% for all patients. Baseline Eckardt scores were also higher in those that failed (median: 8; IQR: 2) than those that

Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results.

PubMed

Rebecchi, Fabrizio; Giaccone, Claudio; Farinella, Eleonora; Campaci, Roberto; Morino, Mario

2008-12-01

To compare in a prospective, randomized trial the long-term results of laparoscopic Heller myotomy plus Dor fundoplication versus laparoscopic Heller myotomy plus floppy-Nissen for achalasia. Anterior fundoplication is usually performed after Heller myotomy to control GER; however, the incidence of postoperative GER ranges between 10% and 30%. Total fundoplication may aid in reducing GER rates. From December 1993 to September 2002, 153 patients with achalasia underwent Heller laparoscopic myotomy plus antireflux fundoplication. Of these, 9 were excluded from the study. The remaining 144 patients were randomly assigned to 2 treatment groups: Heller laparoscopic myotomy plus anterior fundoplication (Dor procedure) or Heller laparoscopic myotomy plus total fundoplication (floppy-Nissen procedure). The primary end point was incidence of clinical and instrumental GER after a minimum of 60 months follow-up. The secondary end point was recurrence of dysphagia. Follow-up clinical assessments were performed at 1, 3, 12, and 60 months using a modified DeMeester Symptom Scoring System (MDSS). Esophageal manometry and 24-hour pH monitoring were performed at 3, 12, and 60 months postoperative. Of the 144 patients originally included in the study, 138 were available for long-term analysis: 71 (51%) underwent antireflux fundoplication plus a Dor procedure (H + D group) and 67 (49%) antireflux fundoplication plus a Nissen procedure (H + N group). No mortality was observed. The mean follow-up period was 125 months. No statistically significant differences in clinical (5.6% vs. 0%) or instrumental GER (2.8% vs. 0%) were found between the 2 groups; however, a statistically significant difference in dysphagia rates was noted (2.8% vs. 15%; P < 0.001). Although both techniques achieved long-term GER control, the recurrence rate of dysphagia was significantly higher among the patients who underwent Nissen fundoplication. This evidence supports the use of Dor fundoplication as the

The early efficacy of Heller myotomy in the treatment of Iranian patients with achalasia.

PubMed

Abdi, Saeed; Forotan, Mojgan; Nikzamir, Abdolrahim; Zomorody, Saeedeh; Jahani-Sherafat, Somayeh

2016-01-01

The purpose of this study was to determine the efficacy of Heller myotomy for the treatment of achalasia in a referral center in Tehran, and investigate the clinical characteristics, manometric results and treatment responses among three achalasia subtypes in Iranian patients. Esophageal achalasia is an unusual swallowing disorder, characterized by high pressure in the lower esophageal sphincter (LES) on swallowing, failure relaxation of the LES and the absence of peristalsis in esophageal. In this cross sectional study, clinical symptom and esophageal manometry before and 2 months after treating with Heller myotomy in 20 patients with achalasia who were referred to Taleghani Hospital, Tehran, in 2013 were evaluated. Patients' demographic, clinical features and response to treatment were analyzed using SPSS software (version 20, Chicago, IL, USA). All the diagnostic criteria measured after the treatment were significantly different (P<0.05) before and after the therapy. The average decline in the length of the esophagus was 1.8 cm and dysphasia score was 7.25 units. Also an average decline in LES Resting Pressure, LES Residual Pressure, PIP, and IRP were 23.2 mmHg, 14.3 mmHg, 3.4 mmHg and 17.8 mmHg, respectively. Results of this study showed that the Heller myotomy is highly effective in relieving dysphasia in patients with achalasia. Also, type II achalasia is the most common subtype of achalasia with a better response to Heller myotomy compared to the other types.

Laparoscopic Heller myotomy can be used as primary therapy for esophageal achalasia regardless of age.

PubMed

Salvador, Renato; Costantini, Mario; Cavallin, Francesco; Zanatta, Lisa; Finotti, Elena; Longo, Cristina; Nicoletti, Loredana; Capovilla, Giovanni; Bardini, Romeo; Zaninotto, Giovanni

2014-01-01

Laparoscopic Heller-Dor surgery is the current treatment of choice for patients with esophageal achalasia, but elderly patients are generally referred for less invasive treatments (pneumatic dilations or botulinum toxin injections). To assess the effect of age on the surgical outcome of patients receiving laparoscopic Heller-Dor as primary treatment. Demographic and clinical findings were prospectively collected on patients undergoing laparoscopic Heller-Dor from 1992 to 2012. Patients were classified in three age brackets: group A (≤45 years), group B (45-70), and group C (≥70). Treatment was defined as a failure if the postoperative symptom score was >10th percentile of the preoperative score (i.e., >8). We consecutively performed the Heller-Dor in 571 achalasia patients, 305 (53.4 %) in group A, 226 (39.6 %) in group B, and 40 (7 %) in group C. The mortality was nil; the conversion and morbidity rates were both 1.1 %. Group C patients had higher preoperative symptom scores (p = 0.02), while the symptom duration was similar in all three groups. Mucosal tears occurred in 17 patients (3 %): 6 (2 %) in group A, 8 (3.5 %) in group B, and 3 (7.5 %) in group C (p = 0.09). The postoperative hospital stay was slightly longer for group C (p = 0.06). The treatment failure rate was quite similar: 31 failures in group A (10.1 %), 19 in group B (8.4 %), and 3 in group C (7.5 %; p = 0.80). These failures were seen more in manometric pattern III (22.2 %, p = 0.002). Laparoscopic Heller-Dor can be used as the first therapeutic approach to achalasia even in elderly patients with an acceptable surgical risk.

Computer-enhanced robotic telesurgery minimizes esophageal perforation during Heller myotomy.

PubMed

Melvin, W Scott; Dundon, John M; Talamini, Mark; Horgan, Santiago

2005-10-01

Laparoscopic Heller myotomy has emerged as the treatment of choice for achalasia. However, intraoperative esophageal perforation remains a significant complication. Computer-enhanced operative techniques have the potential to improve outcomes for certain operative procedures. Robotic, computer-enhanced laparoscopic telemanipulators using 3-dimensional magnified imaging and motion scaling are designed uniquely to facilitate certain operations requiring fine-tissue manipulation. We hypothesized that computer-enhanced robotic Heller myotomy would reduce intraoperative complications compared with laparoscopic techniques. All patients undergoing an operation for achalasia at 3 institutions with a robotic surgery system (DaVinci; Intuitive Surgical Corporation, Sunnyvale, Calif) were followed-up prospectively. Demographics, perioperative course, complications, and hospital stay were recorded. Follow-up evaluation was obtained via a standardized symptom survey, office visits, and medical records. Data were compared with preoperative symptoms using a Mann-Whitney U test, and operating times were compared using the ANOVA test. Between August 2000 and August 2004 there were 104 patients who underwent a robotic Heller myotomy with partial fundoplicaton. There were 53 women and 51 men. All patients were symptomatic. The operative time was 140.55 minutes overall, but improved from 162.63 minutes to 113.50 minutes from 2000-2002 to 2003-2004 (P = .0001). There were no esophageal perforations. There were 8 minor complications and 1 patient required conversion to an open operation. Sixty-six (62.3%) patients were discharged on the first postoperative day and the average hospital stay was 1.5 days. A symptom survey was completed in 79 of 104 patients (76%) at follow-up evaluation. Symptoms improved in all patients with an average follow-up symptom score of 0.48 compared with 5.0 before the operation (P = .0001). Forty-three of the 79 patients from whom follow-up data were collected

Laparoscopic Heller Myotomy with Anterior Fundoplication Improves Frequency and Severity of Symptoms of Achalasia, Regardless of Preoperative Severity Determined by Esophagography.

PubMed

Rosemurgy, Alexander; Downs, Darrell; Luberice, Kenneth; Rodriguez, Christian; Swaid, Forat; Patel, Krishen; Toomey, Paul; Ross, Sharona

2018-02-01

This study was undertaken to determine whether postoperative outcomes after laparoscopic Heller myotomy with anterior fundoplication could be predicted by preoperative findings on esophagography. Preoperative barium esophagograms of 135 patients undergoing laparoscopic Heller myotomy with anterior fundoplication were reviewed. The number of esophageal curves, esophageal width, and angulation of the gastroesophageal junction (GEJ) were determined; correlations between these determined parameters and symptoms were assessed using linear regression analysis. The number of esophageal curves correlated with the preoperative frequency of dysphagia, vomiting, chest pain, regurgitation, and heartburn. The width of the esophagus negatively correlated with the preoperative frequency of regurgitation. The angulation of the GEJ did not correlate with preoperative symptoms. Laparoscopic Heller myotomy with anterior fundoplication significantly reduced the frequency and severity of all symptoms, regardless of the number of esophageal curves, esophageal width, or angulation of the GEJ. Laparoscopic Heller myotomy with anterior fundoplication provides dramatic palliation for achalasia. More esophageal curves on preoperative esophagography correlate well with the frequency of a broad range of preoperative symptoms, including the frequency of dysphagia and regurgitation. Patients experience dramatically improved frequency and severity of symptoms after laparoscopic Heller myotomy with anterior fundoplication for achalasia regardless of the number of esophageal curves, esophageal width, or the angulation of the GEJ. Findings on barium esophagogram, in evaluating achalasia, should not deter the application of laparosocopic Heller myotomy with anterior fundoplication.

How robotic-assisted surgery can decrease the risk of mucosal tear during Heller myotomy procedure?

PubMed

Ballouhey, Quentin; Dib, Nabil; Binet, Aurélien; Carcauzon-Couvrat, Véronique; Clermidi, Pauline; Longis, Bernard; Lardy, Hubert; Languepin, Jane; Cros, Jérôme; Fourcade, Laurent

2017-06-01

We report the first description of robotic-assisted Heller myotomy in children. The purpose of this study was to improve the safety of Heller myotomy by demonstrating, in two adolescent patients, the contribution of the robot to the different steps of this procedure. Due to the robot's freedom of movement and three-dimensional vision, there was an improvement in the accuracy, a gain in the safety regarding different key-points, decreasing the risk of mucosal perforation associated with this procedure.

Long-term results of Heller myotomy without an antireflux procedure in achalasic patients.

PubMed

Cortesini, Camillo; Cianchi, Fabio; Pucciani, Filippo

2002-01-01

Both open and laparoscopic myotomies have been used in the treatment of achalasia. Postoperative gastro-oesophageal reflux is among the commonly reported side effects of myotomy. The addition of an antireflux procedure to the standard surgical approach has given rise to controversy. The objective of our study was to determine whether or not an antireflux procedure should be used in addition to Heller myotomy. Over the period from 1980 to 1990, 94 patients (mean age: 47.9 years) with achalasia underwent Heller myotomy calibrated by intraoperative oesophageal manometry without fundoplication. In 1999-2000, all patients filled in a clinical questionnaire: all underwent radiographic oesophageal imaging, oesophageal manometry, ambulatory 24-h oesophageal pH monitoring, and oesophagogastroduodenoscopy, when necessary. Ten healthy age-matched subjects were compared in the manometric and radiological studies. Myotomy improved the clinical profiles and instrumental data results in all patients. Gastro-oesophageal reflux was present in 10 patients (10.6%); none of these 10 subjects presented oesophagitis. Heller open myotomy yields good long-term results. Intraoperative manometric calibration reduces the side effects of myotomy, such as gastro-oesophageal reflux. The addition of fundoplication is not justified in all patients.

The early efficacy of Heller myotomy in the treatment of Iranian patients with achalasia

PubMed Central

Abdi, Saeed; Forotan, Mojgan; Nikzamir, Abdolrahim; Zomorody, Saeedeh; Jahani-Sherafat, Somayeh

2016-01-01

Aim: The purpose of this study was to determine the efficacy of Heller myotomy for the treatment of achalasia in a referral center in Tehran, and investigate the clinical characteristics, manometric results and treatment responses among three achalasia subtypes in Iranian patients. Background: Esophageal achalasia is an unusual swallowing disorder, characterized by high pressure in the lower esophageal sphincter (LES) on swallowing, failure relaxation of the LES and the absence of peristalsis in esophageal. Patients and methods: In this cross sectional study, clinical symptom and esophageal manometry before and 2 months after treating with Heller myotomy in 20 patients with achalasia who were referred to Taleghani Hospital, Tehran, in 2013 were evaluated. Patients’ demographic, clinical features and response to treatment were analyzed using SPSS software (version 20, Chicago, IL, USA). Results: All the diagnostic criteria measured after the treatment were significantly different (P<0.05) before and after the therapy. The average decline in the length of the esophagus was 1.8 cm and dysphasia score was 7.25 units. Also an average decline in LES Resting Pressure, LES Residual Pressure, PIP, and IRP were 23.2 mmHg, 14.3 mmHg, 3.4 mmHg and 17.8 mmHg, respectively. Conclusion: Results of this study showed that the Heller myotomy is highly effective in relieving dysphasia in patients with achalasia. Also, type II achalasia is the most common subtype of achalasia with a better response to Heller myotomy compared to the other types. PMID:26744612

Robotic heller myotomy and Dor fundoplication for achalasia in a woman with morbid obesity.

PubMed

Bedirli, Abdulkadir; Dogan, Ibrahim; Kozan, Ramazan

2012-12-01

Achalasia is a relatively rare condition with a prevalence estimated at less than 0.001 %. Laparoscopic or robotic Heller myotomy is an effective surgical treatment for achalasia. We present the first published case of a morbidly obese achalasia patient treated with robotic Heller myotomy and Dor fundoplication. The operative time was 175 min, with an estimated blood loss of 110 ml. The patient had a normal bowel transit on postoperative day 2, and he was discharged on postoperative day 4 on a liquid diet. A follow-up at 2 months showed significant resolved symptoms of achalasia.

After laparoscopic Heller myotomy, do emergency department visits or readmissions predict poor long-term outcomes?

PubMed

Ross, Sharona; Villadolid, Desiree; Al-Saadi, Sam; Boyle, Robert; Cowgill, Sarah M; Rosemurgy, Alexander

2008-12-01

Laparoscopic Heller myotomy is a first-line treatment for achalasia. To improve outcomes after myotomy and to determine if poor early results predict later outcomes, emergency department (ED) visits and readmissions within 60 days following laparoscopic Heller myotomy were studied. Since 1992, 352 patients have undergone laparoscopic Heller myotomy and are followed through a prospectively maintained registry. Causes of ED visits and readmissions within 60 days after myotomy were determined. Patients scored their symptoms of achalasia before myotomy and at last follow-up; scores were compared to determine if the reasons leading to ED visits and/or readmissions impacted long-term outcome after myotomy. Fourteen (4%) patients had ED visits, and 18 (5%) patients had readmissions within 60 days following myotomy. Sixty-four percent of ED visits were for dysphagia/vomiting and 36% were for abdominal/chest pain, while 37% of readmissions were for dysphagia/vomiting. Pneumonia was complicated by empyema in four patients, all without leaks; two patients expired. Despite ED visits/readmissions, achalasia symptom (e.g., dysphagia, regurgitation, choking, heartburn, and chest pain) frequency and severity scores improved after myotomy (p < 0.05 for all). ED visits and readmissions are infrequent following laparoscopic Heller myotomy. ED visits were generally due to complaints related to achalasia or edema after myotomy, while readmissions were generally related to complications of operative intervention or chronic ill health. Despite ED visits or readmissions early after myotomy, symptoms of achalasia are well palliated by myotomy long-term.

Heller myotomy with esophageal diverticulectomy: an operation in need of improvement.

PubMed

Bowman, Ty A; Sadowitz, Benjamin D; Ross, Sharona B; Boland, Andrew; Luberice, Kenneth; Rosemurgy, Alexander S

2016-08-01

This study was undertaken to evaluate the outcomes after laparoscopic Heller myotomy with anterior fundoplication and diverticulectomy for patients with achalasia and esophageal diverticula. 634 patients undergoing laparoscopic Heller myotomy and anterior fundoplication from 1992 to 2015 are prospectively followed up; patients were stratified for those undergoing concomitant diverticulectomy. Patients graded symptom frequency and severity before and after myotomy, using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Median data are presented (mean ± SD). Forty-four patients, age 70 years (65 ± 14.2), underwent laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy. Operative time was 182 min (183 ± 54.6). Fifty percentage of patients had a postoperative complication: Most notable were leaks at the diverticulectomy site (n = 8) and pulmonary complications (n = 11; 10 effusion, 1 empyema). Length of stay (LOS) was 3 days (5 ± 8.3). All leaks occurred after discharge and resolved without sequelae using transthoracic catheter drainage and parenteral nutrition; two patients received endoscopic esophageal stents. Median follow-up is 39 months. Symptoms amelioration was significant postoperatively, including severity of dysphagia [6 (6 ± 3.9) to 2(4 ± 3.6)]. Seventy-six percentage of patients rated their symptoms at last follow-up as satisfying/very satisfying. Seventy-seven percentage of patients had symptoms once per week or less. Eighty-one percentage would have the operation again knowing what they know now. Laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy well palliate the symptoms of achalasia with accompanying esophageal diverticulum. The operations are generally longer than those without diverticulectomy and are accompanied by a relatively longer LOS. Complications are relatively frequent and severe (e.g., leaks and pneumonia). In particular, leaks at the

Revisional surgery after heller myotomy for treatment of achalasia: a comparative analysis focusing on operative approach.

PubMed

Gouda, Biswanath P; Nelson, Thomas; Bhoyrul, Sunil

2012-08-01

Surgical myotomy is the gold standard in therapy for achalasia, but treatment failures occur and require revisional surgery. A MEDLINE search of peer-reviewed articles published in English from 1970 to December 2008 was performed using the following terms: esophageal achalasia, Heller myotomy, and revisional surgery. Thirty-three articles satisfied our inclusion criteria. A total of 12,727 patients, with mean age of 43.3 years (males 46% and females 50%), underwent Heller myotomy (open 94.8% and laparoscopic 5.2%). Revisional surgery was performed in 6.19%. Procedures performed included revision of the original myotomy or creation of a new myotomy with or without an antireflux procedure or esophagectomy. Reasons for reoperation were incomplete myotomy (51.8%), onset of reflux (34%), megaesophagus (16.2%), and esophageal carcinoma (3.04%). Systematic review of the literature for revisional surgery following Heller myotomy revealed a 6.19% rate of reoperation with a low mortality rate.

Peroral Endoscopic Myotomy Versus Heller Myotomy for Achalasia: Pros and Cons.

PubMed

Tefas, Cristian; Ababneh, Rami; Tanţău, Marcel

2018-01-01

Achalasia is an esophageal motor disorder that has multiple endoscopic and surgical methods of treatment. However, there is no consensus on optimal therapy in patients suffering from this disorder. This review discusses two therapies with similar but technically different concepts, peroral endoscopic myotomy and Heller surgical myotomy. After a brief introduction to the basic problems of achalasia, technical considerations, intra and postprocedural complications are presented and the advantages and disadvantages of the two procedures are discussed, based on the relevant articles in the literature. Heller surgical myotomy and peroral endoscopic myotomy appear to be similar in performance with similar results in terms of gastroesophageal reflux rates. However, with experience being gained in the field of endoscopic myotomy, this procedure seems more advantageous, with similar success rates to those of the established surgical technique, but offering shorter operating times, shorter hospitalizations and, ultimately, lower costs. Celsius.

Laparoscopic reoperation with total fundoplication for failed Heller myotomy: is it a possible option? Personal experience and review of literature.

PubMed

Rossetti, Gianluca; del Genio, Gianmattia; Maffettone, Vincenzo; Fei, Landino; Brusciano, Luigi; Limongelli, Paolo; Pizza, Francesco; Tolone, Salvatore; Di Martino, Maria; del Genio, Federica; del Genio, Alberto

2009-01-01

Laparoscopic Heller myotomy with antireflux procedure seems the procedure of choice in the treatment of patients with esophageal achalasia. Persistent or recurrent symptoms occur in 10% to 20% of patients. Few reports on reoperation after failed Heller myotomy have been published. No author has reported the realization of a total fundoplication in these patient groups. The aim of this study is to evaluate the efficacy of laparoscopic reoperation with the realization of a total fundoplication after failed Heller myotomy for esophageal achalasia. From 1992 to December 2007, 5 out of a series of 242 patients (2.1%), along with 2 patients operated elsewhere, underwent laparoscopic reintervention for failed Heller myotomy. Symptoms leading to reoperation included persistent dysphagia in 3 patients, recurrent dysphagia in another 3, and heartburn in 1 patient. Mean time from the first to the second operation was 49.7 months (range, 4-180 months). Always, the intervention was completed via a laparoscopic approach and a Nissen-Rossetti fundoplication was realized or left in place after a complete Heller myotomy. Mean operative time was 160 minutes (range, 60-245 minutes). Mean postoperative hospital stay was 3.1 +/- 1.5 days. No major morbidity or mortality occurred. At a mean follow-up of 16.1 months, reoperation must be considered successful in 5 out of 7 patients (71.4%). The dysphagia DeMeester score fell from 2.71 +/- 0.22 to 0.91 +/- 0.38 postoperatively. The regurgitation score changed from 2.45 +/- 0.34 to 0.68 +/- 0.23. Laparoscopic reoperation for failed Heller myotomy with the realization of a total fundoplication is safe and is associated with good long-term results if performed by an experienced surgeon in a center with a long tradition of esophageal surgery.

Asymptotic treatment of the Elenbaas-Heller equation

NASA Astrophysics Data System (ADS)

Kuiken, H. K.

1991-04-01

When the maximum temperatures within a high-pressure gas discharge arc are lower than the ionization temperature of the gas molecules by an order of magnitude, an asymptotic treatment of the temperature equation is possible. This is illustrated by means of the Elenbaas-Heller equation [e.g., M. F. Hoyaux, Arc Physics (Springer, Berlin, 1968), p. 36] for a nonradiating wall-stabilized arc. The asymptotics lead to a closed-form expression for the relationship between the arc current and the axis temperature. An expression for the heat loss per unit length is also given.

The Impact of Heller Myotomy on Integrated Relaxation Pressure in Esophageal Achalasia.

PubMed

Salvador, Renato; Savarino, Edoardo; Pesenti, Elisa; Spadotto, Lorenzo; Capovilla, Giovanni; Cavallin, Francesco; Galeazzi, Francesca; Nicoletti, Loredana; Merigliano, Stefano; Costantini, Mario

2016-01-01

A new high-resolution manometry (HRM) parameter, the integrated relaxation pressure (IRP), has been proposed for the assessment of esophageal-gastric junction (EGJ) relaxation. Our aim was to assess the effect of Heller myotomy on IRP in achalasia patients. We prospectively collected data on achalasia patients who underwent HRM between 2009-2014. Barium swallow was used to assess esophageal diameter and shape. Manometric diagnoses were performed by using the Chicago Classification v3. All patients with a confirmed diagnosis of achalasia were treated surgically with Heller Myotomy One hundred thirty-nine consecutive achalasia patients (M:F = 72:67) represented the study population. All the patients had 100% simultaneous waves but 11 had an IRP < 15 mmHg. At median follow-up of 28 months, the median of IRP was significantly lower after surgery (27.4 [IQR 20.4-35] vs 7.1 [IQR 4.4-9.8]; p < 0.001), and so were the lower esophageal sphincter (LES) resting pressure (27 [IQR 18-33] vs 6 [IQR 3-11]; p < 0.001). At univariate analysis, IRP correlated with the gender, LES resting residual pressure, and dysphagia score. This is the first study to have examined the role of IRP in achalasia, and how it changes after surgical treatment. An increased preoperative IRP correlated directly with a more severe dysphagia. The IRP was restored to normal by Heller myotomy.

The outcome of laparoscopic Heller myotomy for achalasia is not influenced by the degree of esophageal dilatation.

PubMed

Sweet, Matthew P; Nipomnick, Ian; Gasper, Warren J; Bagatelos, Karen; Ostroff, James W; Fisichella, Piero M; Way, Lawrence W; Patti, Marco G

2008-01-01

In the past, a Heller myotomy was considered to be ineffective in patients with achalasia and a markedly dilated or sigmoid-shaped esophagus. Esophagectomy was the standard treatment. The aims of this study were (a) to evaluate the results of laparoscopic Heller myotomy and Dor fundoplication in patients with achalasia and various degrees of esophageal dilatation; and (b) to assess the role of endoscopic dilatation in patients with postoperative dysphagia. One hundred and thirteen patients with esophageal achalasia were separated into four groups based on the maximal diameter of the esophageal lumen and the shape of the esophagus: group A, diameter<4.0 cm, 46 patients; group B, esophageal diameter 4.0-6.0 cm, 32 patients; group C, diameter>6.0 cm and straight axis, 23 patients; and group D, diameter>6.0 cm and sigmoid-shaped esophagus, 12 patients. All had a laparoscopic Heller myotomy and Dor fundoplication. The median length of follow-up was 45 months (range 7 months to 12.5 years). The postoperative recovery was similar among the four groups. Twenty-three patients (20%) had postoperative dilatations for dysphagia, and five patients (4%) required a second myotomy. Excellent or good results were obtained in 89% of group A and 91% of groups B, C, and D. None required an esophagectomy to maintain clinically adequate swallowing. These data show that (a) a laparoscopic Heller myotomy relieved dysphagia in most patients with achalasia, even when the esophagus was dilated; (b) about 20% of patients required additional treatment; (c) in the end, swallowing was good in 90%.

Identification of risk factors for mucosal injury during laparoscopic Heller myotomy for achalasia.

PubMed

Tsuboi, Kazuto; Omura, Nobuo; Yano, Fumiaki; Hoshino, Masato; Yamamoto, Se-Ryung; Akimoto, Shusuke; Masuda, Takahiro; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2016-02-01

Mucosal injury during myotomy is the most frequent complication seen with the Heller-Dor procedure for achalasia. The present study aimed to examine risk factors for such mucosal injury during this procedure. This was a retrospective analysis of patients who underwent the laparoscopic Heller-Dor procedure for achalasia at a single facility. Variables for evaluation included patient characteristics, preoperative pathophysiological findings, and surgeon's operative experience. Logistic regression was used to identify risk factors. We also examined surgical outcomes and the degree of patient satisfaction in relation to intraoperative mucosal injury. Four hundred thirty-five patients satisfied study criteria. Intraoperative mucosal injury occurred in 67 patients (15.4%). In univariate analysis, mucosal injury was significantly associated with the patient age ≥60 years, disease history ≥10 years, prior history of cardiac diseases, preoperative esophageal transverse diameter ≥80 mm, and surgeon's operative experience with fewer than five cases. In multivariate analysis involving these factors, the following variables were identified as risk factors: age ≥60 years, esophageal transverse diameter ≥80 mm, and surgeon's operative experience with fewer than five cases. The mucosal injury group had significant extension of the operative time and increased blood loss. However, there were no significant differences between the two groups in the incidence of reflux esophagitis or the degree of symptom alleviation postoperatively. The fragile esophagus caused by advanced patient age and/or dilatation were risk factor for mucosal injury during laparoscopic Heller-Dor procedure. And novice surgeon was also identified as an isolated risk factor for mucosal injury.

Redo Heller Myotomy for Achalasia in a Patient with Down Syndrome: a Case Report.

PubMed

Sosa-Stanley, Jessica; Vandendool, KellyAnn; Kiev, Jonathan

2015-01-01

Up to 77% of Down syndrome (DS) patients have associated structural or functional gastrointestinal abnormalities. Functional disturbances, such as processes affecting the enteric nervous system, can often affect the outcome of corrective surgical procedures. Recently, an association between DS and achalasia has been reported. In this report we present a 28-year-old male patient with a history of Down syndrome and achalasia, who presented with recurrent dysphagia, gastroesophageal reflux, and recurrent aspirations. The patient had previously undergone a laparoscopic Heller myotomy with Dor fundoplication. Unfortunately, despite this surgery, he continued to require multiple esophageal dilations, and intraesophageal administration of Botox therapy. Additionally, there were numerous subsequent hospital admissions for recurrent aspiration pneumonia. Evaluation revealed an incomplete myotomy and a revision long Heller myotomy was successfully performed intraabdominally and he is now symptom and aspiration free.

The evaluation of functional results before and after laparoscopic Heller myotomy for achalasia: a single center experience.

PubMed

Pooshani, Abdollah; Frootan, Mojgan; Abdi, Saeed; Jahani-Sherafat, Somayeh; Kamani, Freshteh

2017-01-01

The aim of this study was to evaluate and compare the functional results before and after laparoscopic Heller myotomy for Iranian patients with achalasia. Achalasia is a severe neuromuscular disorder of the esophagus, characterized by the loss of peristalsis and an inability of the lower esophageal sphincter (LES) to reach optimal relaxation. In this cross sectional study, patients who underwent Heller myotomy for achalasia via laparoscopy in Taleghani Hospital Tehran, Iran were evaluated. Symptoms including pressure of residual, integrated relaxation sphincter (IRP), pressure of free drinking, pressure of LES, dysphasia score and peristalsis movement was measured and recorded by manometry before and after (2 months) treating with Heller myotomy. In this study, 23 patients with achalasia (12 females and 11 males) with a mean age of 30±3.5 years (minimum 20, maximum 44 years) who met the inclusion criteria of the study were examined. Results of this study showed that, all the diagnostic criteria that were measured before the treatment was significantly different from after the treatment (P<0.05). The average decline in LES, IRP, Residual Pressure, Free drinking esophagus, and dysphasia score were 23.1 mmHg, 16.24 mmHg, 18,7 mmHg, 18.9 mmHg, and 5.0 unit, respectively. Also the average increase of the peristalsis movement was 8.26±13.7 in 8 patients. Considering the results of Heller myotomy surgery can be as a treatment of choice for achalasia. Free Drinking pressure can be a suitable criteria after treatment for evaluation and prediction of the reducing the dysphasia score after the surgery.

The evaluation of functional results before and after laparoscopic Heller myotomy for achalasia: a single center experience

PubMed Central

Pooshani, Abdollah; Frootan, Mojgan; Abdi, Saeed; Jahani-Sherafat, Somayeh; Kamani, Freshteh

2017-01-01

Aim: The aim of this study was to evaluate and compare the functional results before and after laparoscopic Heller myotomy for Iranian patients with achalasia. Background: Achalasia is a severe neuromuscular disorder of the esophagus, characterized by the loss of peristalsis and an inability of the lower esophageal sphincter (LES) to reach optimal relaxation. Methods: In this cross sectional study, patients who underwent Heller myotomy for achalasia via laparoscopy in Taleghani Hospital Tehran, Iran were evaluated. Symptoms including pressure of residual, integrated relaxation sphincter (IRP), pressure of free drinking, pressure of LES, dysphasia score and peristalsis movement was measured and recorded by manometry before and after (2 months) treating with Heller myotomy. Results: In this study, 23 patients with achalasia (12 females and 11 males) with a mean age of 30±3.5 years (minimum 20, maximum 44 years) who met the inclusion criteria of the study were examined. Results of this study showed that, all the diagnostic criteria that were measured before the treatment was significantly different from after the treatment (P<0.05). The average decline in LES, IRP, Residual Pressure, Free drinking esophagus, and dysphasia score were 23.1 mmHg, 16.24 mmHg, 18,7 mmHg, 18.9 mmHg, and 5.0 unit, respectively. Also the average increase of the peristalsis movement was 8.26±13.7 in 8 patients. Conclusion: Considering the results of Heller myotomy surgery can be as a treatment of choice for achalasia. Free Drinking pressure can be a suitable criteria after treatment for evaluation and prediction of the reducing the dysphasia score after the surgery. PMID:29511469

Multimedia manuscript. Heller myotomy and intraluminal fundoplication: a NOTES technique.

PubMed

Perretta, Silvana; Dallemagne, Bernard; Allemann, Pierre; Alleman, Pierre; Marescaux, Jacques

2010-11-01

It is generally accepted that the most effective treatment of achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 30% of patients. The aim of this study was to explore a transoral incisionless stepwise approach to both esophageal Heller myotomy and fundoplication. The first step consisted of creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the esophagogastric junction (EGJ). The mucosa on the right posterolateral esophageal wall was cut with the needle-knife 15 cm above the lower esophageal sphincter (LES) and then dilated with blunt dissection to introduce the scope. A submucosal tunnel was created distally with CO(2) and blunt dissection. Once the gastroesophageal junction (GEJ) and the clasp fibers were identified, the muscular layer was cut. The scope was withdrawn into the lumen and the mucosal flap was sealed with endoscopic clips. The adequacy of the myotomy was evaluated using pre- and postoperative manometry and by comparing the EGJ distensibility before, during, and after the division of the esophageal muscular fibers using the functional lumen imaging probe, EndoFLIP®. The second step, consisted of building a transoral incisionless fundoplication 4 weeks postoperatively using the EsophyX™. Both Heller myotomy and endoscopic fundoplication were accomplished successfully with no injury to the esophageal mucosa. Postoperative manometry demonstrated a 50% loss in mean LES pressure (mean preoperative LES pressure = 22.2 mmHg; mean postoperative LES pressure = 10 mmHg, P < 0.005). The EndoFLIP® showed a preoperative minimal diameter of 6 mm with a cross-sectional area of 28 mm(2). Postoperatively, the junction was more compliant (minimal diameter = 15 mm; cross-sectional area = 177 mm(2)), with the main improvement in distensibility occurring when the clasps fibers were removed. A stepwise transoral incisionless approach to

Heller myotomy for achalasia. From the open to the laparoscopic approach.

PubMed

Allaix, Marco E; Patti, Marco G

2015-07-01

The last three decades have witnessed a progressive evolution in the surgical treatment of esophageal achalasia, with a shift from open to a minimally invasive Heller myotomy. The laparoscopic approach is currently the standard of care with better short-term outcomes and similar long-term functional results when compared to open surgery. More recently, the laparoscopic single-site approach and the use of the robot have been proposed to further improve the surgical outcome in achalasia patients.

Laparoscopic Heller Myotomy and Dor Fundoplication for Esophageal Achalasia: Technique and Perioperative Management.

PubMed

Andolfi, Ciro; Fisichella, P Marco

2016-11-01

Surgical correction of achalasia using laparoscopic Heller myotomy with Dor fundoplication is argued to be the gold standard treatment for patients with achalasia. The goal of this technical report is to illustrate our preferred approach to patients with achalasia and to provide the reader with a detailed description of our operative technique, its rationale, and our pre and postoperative management.

Achalasia-Specific Quality of Life After Pneumatic Dilation or Laparoscopic Heller Myotomy With Partial Fundoplication: A Multicenter, Randomized Clinical Trial.

PubMed

Chrystoja, Caitlin C; Darling, Gail E; Diamant, Nicholas E; Kortan, Paul P; Tomlinson, George A; Deitel, Wayne; Laporte, Audrey; Takata, Julie; Urbach, David R

2016-11-01

Achalasia is a chronic, progressive, and incurable esophageal motility disease. There is clinical uncertainty about which treatment should be recommended as first-line therapy. Our objective was to evaluate the effectiveness of pneumatic dilation compared with laparoscopic Heller myotomy with partial fundoplication in improving achalasia-specific quality of life. This was a prospective, multicenter, randomized trial at five academic hospitals in Canada. Fifty previously untreated adults with a clinical diagnosis of primary achalasia, confirmed by manometric testing, were enrolled between November 2005 and March 2010, and followed for 5 years after treatment. Randomization was stratified by site, in random blocks of size four and with balanced allocation. Patients were treated with pneumatic dilation or laparoscopic Heller myotomy with partial fundoplication. The primary outcome was the difference between the treatments in the mean improvement of the achalasia severity questionnaire (ASQ) score at 1 year from baseline. Prespecified secondary outcomes included general and gastrointestinal quality of life, symptoms, esophageal physiology measures (lower esophageal sphincter relaxation and pressure, esophageal emptying, abnormal esophageal acid exposure), complications, and incidence of retreatment. Functional and imaging studies were performed blinded and all outcome assessors were blinded. There were no significant differences between treatments in the improvement of ASQ score at 1 year from baseline (27.5 points in the Heller myotomy arm vs. 20.2 points in the pneumatic dilation arm; difference 7.3 points, 95% confidence interval -4.7 to 19.3; P=0.23). There were no differences between treatments in improvement of symptoms, general and gastrointestinal quality of life, or measures of esophageal physiology. Improvements in ASQ score diminished over time for both interventions. At 5 years, there were no differences between treatments in improvement of ASQ score

Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial.

PubMed

Rawlings, Arthur; Soper, Nathaniel J; Oelschlager, Brant; Swanstrom, Lee; Matthews, Brent D; Pellegrini, Carlos; Pierce, Richard A; Pryor, Aurora; Martin, Valeria; Frisella, Margaret M; Cassera, Maria; Brunt, L Michael

2012-01-01

The type of fundoplication that should be performed in conjunction with Heller myotomy for esophageal achalasia is controversial. We prospectively compared anterior fundoplication (Dor) with partial posterior fundoplication (Toupet) in patients undergoing laparoscopic Heller myotomy. A multicenter, prospective, randomized-controlled trial was initiated to compare Dor versus Toupet fundoplication after laparoscopic Heller myotomy. Outcome measures were symptomatic GERD scores (0-4, five-point Likert scale questionnaire) and 24-h pH testing at 6-12 months after surgery. Data are mean ± SD. Statistical analysis was by Mann-Whitney U test, Wilcoxon signed rank test, and Freidman's test. Sixty of 85 originally enrolled and randomized patients who underwent 36 Dor and 24 Toupet fundoplications had follow-up data per protocol for analysis. Dor and Toupet groups were similar in age (46.8 vs. 51.7 years) and gender (52.8 vs. 62.5% male). pH studies at 6-12 months in 43 patients (72%: Dor n = 24 and Toupet n = 19) showed total DeMeester scores and % time pH < 4 were not significant between the two groups. Abnormal acid reflux was present in 10 of 24 Dor group patients (41.7%) and in 4 of 19 Toupet patients (21.0%) (p = 0.152). Dysphagia and regurgitation symptom scores improved significantly in both groups compared to preoperative scores. No significant differences in any esophageal symptoms were noted between the two groups preoperatively or at follow-up. SF-36 quality-of-life measures changed significantly from pre- to postoperative for five of ten domains in the Dor group and seven of ten in the Toupet patients (not significant between groups). Laparoscopic Heller myotomy provides significant improvement in dysphagia and regurgitation symptoms in achalasia patients regardless of the type of partial fundoplication. Although a higher percentage of patients in the Dor group had abnormal 24-h pH test results compared to those of patients who underwent Toupet

100 consecutive minimally invasive Heller myotomies: lessons learned.

PubMed

Sharp, Kenneth W; Khaitan, Leena; Scholz, Stefan; Holzman, Michael D; Richards, William O

2002-05-01

To evaluate the authors' first 100 patients treated for achalasia by a minimally invasive approach. Between November 1992 and February 2001, the authors performed 95 laparoscopic and 5 thoracoscopic Heller myotomies in 100 patients (age 49.5 +/- 1.5 years) with manometrically confirmed achalasia. Before presentation, 51 patients had previous dilation, 23 had been treated with botulinum toxin (Botox), and 4 had undergone prior myotomy. Laparoscopic myotomy was performed by incising the distal 4 to 6 cm of esophageal musculature and extended 1 to 2 cm onto the cardia under endoscopic guidance. Fifteen patients underwent antireflux procedures. There were eight intraoperative perforations and only four conversions to open surgery. Follow-up is 10.8 +/- 1 months; 75% of the patients have been followed up for at least 14 months. Outcomes assessed by patient questionnaires revealed satisfactory relief of dysphagia in 93 patients and "poor" relief in 7 patients. Postoperative heartburn symptoms were reported as "moderate to severe" in 14 patients and "none or mild" in 86 patients. Fourteen patients required postoperative procedures for continued symptoms of dysphagia after myotomy. Esophageal manometry studies revealed a decrease in lower esophageal sphincter pressure (LESP) from 37 +/- 1 mm Hg to 14 +/- 1 mm Hg. Patients with a decrease in LESP of more than 18 mm Hg and whose absolute postoperative LESP was 18 or less were more likely to have relief of dysphagia after surgery. Thirty-one patients who underwent Heller alone were studied with a 24-hour esophageal pH probe and had a median Johnson-DeMeester score of 10 (normal <22.0). Mean esophageal acid exposure time was 3 +/- 0.6% (normal 4.2%). Symptoms did not correlate with esophageal acid exposure. The results after minimally invasive treatment for achalasia are equivalent to historical outcomes with open techniques. Satisfactory outcomes occurred in 93% of patients. Patients whose postoperative LESP was less than 18

Laparoscopic calibrated total vs partial fundoplication following Heller myotomy for oesophageal achalasia

PubMed Central

Martino, Natale Di; Brillantino, Antonio; Monaco, Luigi; Marano, Luigi; Schettino, Michele; Porfidia, Raffaele; Izzo, Giuseppe; Cosenza, Angelo

2011-01-01

AIM: To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia. METHODS: Fifty-six patients (26 men, 30 women; mean age 42.8 ± 14.7 years) presenting for minimally invasive surgery for oesophageal achalasia, were enrolled. All patients underwent laparoscopic Heller myotomy followed by a 180° anterior partial fundoplication in 30 cases (group 1) and calibrated Nissen-Rossetti fundoplication in 26 (group 2). Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication. A 6-mo follow-up period with symptomatic evaluation and barium swallow was undertaken. One and two years after surgery, the patients underwent symptom questionnaires, endoscopy, oesophageal manometry and 24 h oesophago-gastric pH monitoring. RESULTS: At the 2-year follow-up, no significant difference in the median symptom score was observed between the 2 groups (P = 0.66; Mann-Whitney U-test). The median percentage time with oesophageal pH < 4 was significantly higher in the Dor group compared to the Nissen-Rossetti group (2; range 0.8-10 vs 0.35; range 0-2) (P < 0.0001; Mann-Whitney U-test). CONCLUSION: Laparoscopic Dor and calibrated Nissen-Rossetti fundoplication achieved similar results in the resolution of dysphagia. Nissen-Rossetti fundoplication seems to be more effective in suppressing oesophageal acid exposure. PMID:21876635

Symptomatic outcome following laparoscopic Heller's cardiomyotomy with Dor fundoplication versus laparoscopic Heller's cardiomyotomy with angle of His accentuation: results of a randomized controlled trial.

PubMed

Balakrishna, Pavithra; Parshad, Rajinder; Rohila, Jitender; Saraya, Anoop; Makharia, Govind; Sharma, Raju

2015-08-01

The type of anti-reflux procedure to be used as an adjunct to laparoscopic Heller's cardiomyotomy (LHCM) in Achalasia cardia is controversial. We compared Angle of His accentuation and Dor fundoplication in a randomized controlled trial. From May 2010 to October 2013, 62 patients undergoing LHCM were randomized to receive either Dor fundoplication (Dor group) or Angle of His accentuation (AOH group) as an anti-reflux procedure. Symptomatic outcome was evaluated using modified Mellow and Pinkas scale for dysphagia and modified DeMeester's score for regurgitation and heartburn. Achalasia-specific quality-of-life (QOL) questionnaire was used to assess quality of life. The primary outcome was symptomatic relief and the secondary outcome was postoperative heartburn. Statistical analysis was done using SPSS software. All the procedures were completed laparoscopically with no mortality. Morbidity was similar in the two groups (6.4 %). Median operative time was higher in Dor group (170 vs 130 min). At a median follow-up of 21 months relief of dysphagia, regurgitation, and heartburn was seen in 87, 90.3, and 90.3 % patients in Dor group versus 93.5, 96.7, and 77.4 % in AOH group patients with significant improvement in symptom scores. Improvement was similar in both groups with no statistically significant difference in the symptom scores (p = 0.48 for dysphagia, p = 0.37 for regurgitation, and p = 0.19 for heartburn). The QOL improved in both groups [62.3 to 12.3 (p = 0.02) in Dor group and 63.9-13 (p = 0.02) in AOH group] with no statistically significant difference between the two groups (p = 0.96). There was no statistically significant difference in the postoperative heartburn between the two groups (p = 0.19). Laparoscopic Heller's cardiomyotomy with either Angle of His accentuation or Dor fundoplication leads to similar improvement in symptoms and quality of life.

Sperm ultrastructure of shrimps from the family Penaeidae (Crustacea: Dendrobranchiata) in a phylogenetic context.

PubMed

Camargo, Tavani Rocha; Rossi, Natalia; Castilho, Antonio L; Costa, Rogério C; Mantelatto, Fernando L; Zara, Fernando José

2017-07-01

We describe the sperm ultrastructure of six penaeid species, including at least one member of each tribe (Penaeini, Parapenaeini and Trachypenaeini). Fragments of the vas deferens of the Penaeidae Farfantepenaeus brasiliensis, Farfantepenaeus paulensis, Litopenaeus schmitti, Parapenaeus americanus, Rimapenaeus constrictus and Xiphopenaeus kroyeri were fixed and processed according to the routine for transmission electron microscopy. The morphological results were contextualized in an evolutionary perspective using molecular markers for the phylogenetic reconstruction of this group. A phylogram was proposed by Bayesian inference based on 1007 bp of 33 sequences of the combined genes (16S rDNA and COI mtDNA) from 27 dendrobranchiate specimens. Our findings show that morphological differences in the sperm ultrastructures of members among the tribes of Penaeidae can be used as a baseline to understand their evolutionary relationships. Individuals from the Penaeini tribe show plesiomorphic characteristics in the sperm ultrastructure compared to the Trachypenaeini tribe from which they were derived, such as shrimp from family Sicyoniidae. The morphological complexity of the sperm of the different penaeid members corroborated with the genetic phylogeny, which showed different clades for each tribe and the close relationship with Sicyoniidae. The sperm features of the selected species studied here reflected their evolutionary history. These features confirm the previous phylogenetic hypothesis and question the monophyly of Penaeidae, which should be verified in the future with a more complete set of representative members of each tribe. Copyright © 2017 Elsevier Ltd. All rights reserved.

How does the robot affect outcomes? A retrospective review of open, laparoscopic, and robotic Heller myotomy for achalasia.

PubMed

Shaligram, Abhijit; Unnirevi, Jayaraj; Simorov, Anton; Kothari, Vishal M; Oleynikov, Dmitry

2012-04-01

Robotic techniques are routinely used in urological and gynecological procedures; however, their role in general surgical procedures is limited. A robotic technique has been successfully adopted for a minimally invasive Heller myotomy procedure for achalasia. This study aims to compare perioperative outcomes following open, laparoscopic, and robotic Heller myotomy. This study is a multicenter, retrospective analysis utilizing a large administrative database. The University Health System Consortium (UHC) is an alliance between academic medical centers and affiliate hospitals. The UHC database was accessed using International Classification of Diseases, Ninth Revision, Clinical Modification codes and analyzed. 2,683 patients with achalasia underwent Heller myotomy between October 2007 and June 2011. Myotomy was performed by open surgery (OM) in 418 patients, by laparoscopic approach (LM) in 2,116, and by robotic approach (RM) in 149. Comparison between LM and RM groups demonstrated no significant difference in mortality (0.14 vs. 0.0%; P = 1), morbidity (5.19 vs. 4.02%; P = 0.7), intensive care unit (ICU) admission (6.62 vs. 3.36%; P = 0.12), length of stay (LOS) (2.70 ± 3.87 days vs. 2.42 ± 2.69 days; P = 0.34), or 30-day readmission (1.41 vs. 2.84%; P = 0.27). However, hospital costs were significantly lower for the LM group (US $7,441 ± 7,897 vs. US $9,415 ± 5,515; P = 0.0028). Comparison between OM and RM demonstrated significant lower morbidity (9.08 vs. 4.02%; P = 0.02), ICU admission rate (14.01 vs. 3.36%, P = 0.0002), and LOS (4.42 ± 5.25 days vs. 2.42 ± 2.69 days; P = 0.0001). The perioperative outcomes are superior in LM and RM groups when compared with OM. The outcomes for the LM and RM group are comparable, with the robotic group having slightly improved results, although with increased costs. We conclude that robotic surgery is equivalent in safety and efficacy to laparoscopic Heller myotomy, and feel that the increased cost should come down as

Achalasia and Respiratory Symptoms: Effect of Laparoscopic Heller Myotomy.

PubMed

Andolfi, Ciro; Kavitt, Robert T; Herbella, Fernando A M; Patti, Marco G

2016-09-01

Dysphagia and regurgitation are considered typical symptoms of achalasia. However, there is mounting evidence that some achalasia patients may also experience respiratory symptoms such as cough, wheezing, and hoarseness. The aims of this study were to determine: (1) what percentage of achalasia patients experience respiratory symptoms and (2) the effect of a laparoscopic Heller myotomy and Dor fundoplication on the typical and respiratory symptoms of achalasia. Between May 2008 and December 2015, 165 patients with achalasia were referred for treatment to the Center for Esophageal Diseases of the University of Chicago. Patients had preoperatively a barium swallow, endoscopy, and esophageal manometry. All patients underwent a Heller myotomy and Dor fundoplication. Based on the presence of respiratory symptoms, patients were divided into two groups: group A, 98 patients (59%) without respiratory symptoms and group B, 67 patients (41%) with respiratory symptoms. The preoperative Eckardt score was similar in the two groups (6.5 ± 2.1 versus 6.4 ± 2.0). The mean esophageal diameter was 27.7 ± 10.8 mm in group A and 42.6 ± 20.1 mm in group B (P < .05). The operation consisted of a myotomy that extended for 5 cm on the esophagus and 2.5 cm onto the gastric wall. At a median postoperative follow-up of 17 months, the Eckardt score improved significantly and similarly in the two groups (0.3 ± 0.8 versus 0.3 ± 1.0). Respiratory symptoms improved or resolved in 62 patients (92.5%). The results of this study showed that: (1) respiratory symptoms were present in 41% of patients; (2) patients with respiratory symptoms had a more dilated esophagus; and (3) surgical treatment resolved or improved respiratory symptoms in 92.5% of patients. This study underlines the importance of investigating the presence of respiratory symptoms along with the more common symptoms of achalasia and of early treatment before lung damage occurs.

Post-Surgical Quality of Life, Psychological State and what Patients Think about the Effectiveness of Heller Myotomy in the Treatment of Achalasia.

PubMed

Vale-Fonseca, Telma; Ferreira-Pinto, Luis; Figueiredo-Braga, Margarida; Carneiro, Silvestre

2016-02-01

The disruption of esophageal motility that characterizes achalasia typically provokes dysphagia, pain, loss of weight and malnutrition. Therefore, patients frequently report a reduction in quality of life and negative emotional states. Laparoscopic Heller myotomy proved to be an effective therapy, enabling the resumption of good quality of life. The authors studied 45 patients previously submitted to laparoscopic Heller myotomy. Postoperative evaluation was performed using a customized version of the achalasia disease-specific quality of life questionnaire. Quality of life and the presence of depressive and anxiety symptoms were assessed using the Portuguese versions of the Medical Outcomes Study SF-36 and the Hospital Anxiety and Depression Scale. Thirty-one patients responded to the survey. Dysphagia was the main clinical symptom before surgery. A clear improvement in dysphagia, regurgitation, pain and weight loss was found after surgery (p < 0.001). The Mental Health domain of SF-36 presented a Pearson correlation coefficient of -0.689 with HADS-D and of -0.557 with HADS-A (p < 0.001 and p = 0.002, respectively). This study demonstrates that the Heller myotomy is associated with a good quality of life in patients with achalasia and strengthens the evidence that this is a safe and reliable procedure.

Peter Heller's a Child Analysis with Anna Freud: the significance of the case for the history of child psychoanalysis.

PubMed

Midgley, Nick

2012-02-01

A Child Analysis with Anna Freud, a collection of Anna Freud's detailed case notes of her treatment of the young Peter Heller between 1929 and 1932, was first published in English in 1990. Not only does this work give us direct access to Anna Freud's ways of thinking and working at a crucial period in the early history of child analysis; it is also one of the few records of an adult reflecting in depth on the experience of being in analysis as a child. Yet to date this work has received little attention in the psychoanalytic literature. In an attempt to redress this neglect, the Heller case study is placed in the context of Anna Freud's emerging ideas about child analysis. In particular, its significance in the development of her psychoanalytic thinking is investigated in the light of her 1927 book, The Technique of Child Analysis.

Assessment of Pneumatic Balloon Dilation in Patients with Symptomatic Relapse after Failed Heller Myotomy: A Single Center Experience.

PubMed

Amani, Mohammad; Fazlollahi, Narges; Shirani, Shapour; Malekzadeh, Reza; Mikaeli, Javad

2016-01-01

BACKGROUND Although Heller myotomy is one of the most effective treatments for achalasia, it may be associated with early or late symptom relapse in some patients. Therefore, additional treatment is required to achieve better control of symptoms. To evaluate the safety and efficacy of pneumatic balloon dilation (PBD) in patients with symptom relapse after Heller myotomy. METHODS Thirty six post-myotomy patients were evaluated from 1993 to 2013. Six patients were excluded from the analysis because of comorbid diseases or epiphrenic diverticula. Thirty patients were treated with PBD. Primary outcome was defined as a decrease in symptom score to 4 or less and a reduction greater than 80% from the baseline in the volume of barium in timed barium esophagogram in 6 weeks. Achalasia symptom score (ASS) was assessed at 1.5, 3, 6, and 12 months after treatment and then every six months in all patients and PBD was repeated in case of symptom relapse (ASS>4). RESULTS The mean age of the patients was 45.5±13.9 years (range: 21-73). Primary outcome was observed in 25 patients (83%). The mean ASS of the patients dropped from 7.8 before treatment to 1.3±2.0 at 1.5 months after treatment (p=0.0001). The mean volume and height of barium decreased from 43.1±33.4 and 7.1±4.7 to 6.0±17.1 and 1.1±2.2, respectively (p=0.003, p=0.003). The mean duration of follow-up was 11.8±6.3 years. At the end of the study, 21 patients (70%) reported sustained good response. No major complications such as perforation or gross bleeding were seen. CONCLUSION PBD is an effective and safe treatment option for achalasia in patients with symptom relapse after Heller myotomy.

Treatment of esophageal achalasia with Heller myotomy: retrospective evaluation of patient satisfaction and disease-specific quality of life

PubMed Central

Dang, Yen; Mercer, C. Dale

2006-01-01

Background Prospective randomized studies have suggested that surgery palliates esophageal achalasia more effectively than pneumatic dilatation, but for some dilatation is still the procedure of choice for initial treatment. We decided to compare achalasia symptoms before and after Heller myotomy by means of postoperative questionnaires. Methods The study included 22 patients who underwent Heller myotomy for achalasia at the Hotel Dieu Hospital, Queen's University, Kingston, Ont., since July 1990; 5 of them required repeat myotomy for symptom recurrence, for a total of 9 open and 18 laparoscopic procedures. Median follow-up was 43 (range 6–109) months. Preoperative and postoperative data regarding dysphagia, regurgitation, chest pain and overall patient satisfaction were gathered. Symptom scores were calculated by adding severity (0 = none, 2 = mild, 4 = moderate, 6 = severe) to frequency (0 = never, 1 = occasionally, 2 = once a month, 3 = every week, 4 = twice a week, 5 = daily). Patients having a repeat procedure were instructed to evaluate symptoms with respect to their initial myotomy. Results Seventeen (77%) patients were successfully contacted, 4 of them had subsequent repeat myotomy for symptom recurrence. Initially, overall symptom scores decreased for all but 1 patient, with mean preoperative and postoperative values of 23.1 and 7.3 respectively (p < 0.001). The patient in whom symptoms did not improve is a candidate for a repeat procedure. Repeat myotomy was performed after a median of 38 (range 23–75) months, corresponding to an overall 3-year positive outcome in 13 (76%) of the 17 patients. Fifteen (88%) patients considered their myotomies a success and 16 (94%) would choose to have this procedure again given the outcome. Conclusion Heller myotomy appears to be effective in alleviating the symptoms of achalasia. Repeat myotomy is occasionally required. PMID:16948885

Economic evaluation of the randomized European Achalasia trial comparing pneumodilation with Laparoscopic Heller myotomy.

PubMed

Moonen, A; Busch, O; Costantini, M; Finotti, E; Tack, J; Salvador, R; Boeckxstaens, G; Zaninotto, G

2017-11-01

A recent multicenter randomized trial in achalasia patients has shown that pneumatic dilation resulted in equivalent relief of symptoms compared to laparoscopic Heller myotomy. Additionally, the cost of each treatment should be also taken in consideration. Therefore, the aim of the present study was to perform an economic analysis of the European achalasia trial. Patients with newly diagnosed achalasia were enrolled from to 2003 to 2008 in 14 centers in five European countries and were randomly assigned to either pneumatic dilation (PD) or laparoscopic Heller (LHM). The economic analysis was performed in the three centers in three different countries where most patients were enrolled (Amsterdam [NL], Leuven, [B] and Padova [I]) and then applied to all patients included in the study. The total raw costs of the two treatments per patient include the initial costs, the costs of complications, and the costs of retreatments. Two hundred and one patients, 107 (57 males and 50 females, mean age 46 CI: 43-49 years) were randomized to LHM and 94 (59 males and 34 females, mean age 46 CI 43-50 years) to PD. The total cost of PD per patient was quite comparable in the three different centers; €3397 in Padova, €3259 in Amsterdam and €3792 in Leuven. For LHM, the total costs per patient were highest in Amsterdam: €4488 in Padova, €6720 in Amsterdam, and €5856 in Leuven. In conclusion, the strategy of treating achalasia starting with PD appears the most economic approach, independent of the health system. © 2017 John Wiley & Sons Ltd.

Robotic-assisted Heller myotomy: a modern technique and review of outcomes.

PubMed

Afaneh, Cheguevara; Finnerty, Brendan; Abelson, Jonathan S; Zarnegar, Rasa

2015-06-01

Achalasia is a debilitating esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and lack of peristalsis. Manometry is the gold standard for diagnosis and laparoscopic Heller myotomy has been the gold standard for definitive therapy. However, current advances in surgical technology have introduced the robotic platform as a viable approach for this procedure. The safety and efficacy has been clearly established with comparable operative times to laparoscopy in experienced hands. Importantly, the rate of resolution of dysphagia postoperatively is over 80% which is comparable to laparoscopic outcomes. Moreover, some literature suggests lower esophageal perforation rates utilizing the robotic platform. Nevertheless, costs remain one of the largest barriers to widespread use of the robotic platform and future studies should aim to identify strategies in cost reduction.

Thoracoscopic versus laparoscopic modified Heller Myotomy for achalasia: efficacy and safety in 87 patients.

PubMed

Stewart, K C; Finley, R J; Clifton, J C; Graham, A J; Storseth, C; Inculet, R

1999-08-01

The ideal treatment for achalasia permanently eliminates the dysfunctional lower esophageal sphincter, relieving dysphagia and regurgitation; prevents gastroesophageal reflux; and has an acceptable morbidity rate. Controversy exists concerning whether the thoracoscopic Heller Myotomy (THM) or laparoscopic Heller myotomy (LHM) technique is the best approach to a modified Heller myotomy for achalasia. We performed a retrospective comparison of the patient characteristics, operative results, postoperative symptoms, and the learning curves for the procedures of 24 patients undergoing THM and 63 patients undergoing LHM between 1991 and 1998. Preoperative patient variables in each group revealed similar distributions for age, gender, and prevalence of previous pneumatic dilation. Mean operating room (OR) times were 4.3 hours (range 2.9 to 5.6 hours) for THM and 3.0 hours (range 1.5 to 6.5 hours) for LHM (p = 0.01). Three esophageal perforations occurred in the THM group and two in the LHM group. Conversion to an open procedure took place in five THM operations (21%) and one LHM operation (2%) (p = 0.005). There were no postoperative esophageal leaks. Mean postoperative length of stay (LOS) for THM was 6.1 days (range 1 to 17 days) and for LHM was 4.0 days (range 1 to 12 days) (p = 0.03). Learning-curve analysis of the first 24 LHM patients compared with the most recent 24 revealed greater OR time in the first 24 mean 3.6 hours, (range 2.0 to 6.5 hours) versus mean 2.3 hours, (range 1.5 to 3.7 hours; p = 0.01), and greater LOS mean 5.5 days, (range 3 to 12 days) versus mean 3.1 days, (range 1 to 8 days; p < 0.01). One esophageal perforation occurred in each subgroup. A similar analysis in the first 12 THM patients compared with the most recent 12 revealed no significant improvement in OR times or LOS. Three esophageal perforations occurred in the latter subgroup only. All patients had preoperative daily dysphagia to solids. Followup data for LHM (n = 49) (median 17 months

Health-related quality of life after laparoscopic Heller myotomy and Dor fundoplication for achalasia.

PubMed

Asti, Emanuele; Sironi, Andrea; Lovece, Andrea; Bonavina, Giulia; Fanelli, Melania; Bonitta, Gianluca; Bonavina, Luigi

2017-04-01

In addition to symptom scores, a person's perception of health and quality of life assessment is an important indicator of quality of treatment and can provide an efficient index to compare different therapeutic modalities in chronic disease states. Only a few studies have investigated quality of life comprehensively in patients with achalasia, and therefore the controversy regarding the best treatment algorithm continues. The primary study outcome was pre- and postoperative quality of life in patients with achalasia undergoing laparoscopic Heller myotomy and Dor fundoplication. The study is a retrospective, observational cohort. The hospital registry and the updated research database were reviewed to identify all patients who were treated for achalasia between 2010 and 2015. Patients were eligible for the study if they had a minimum 1-year follow-up and had pre-and postoperative Eckardt, Short Form-36, and Gastro-Esophageal Reflux Disease Health-Related Quality of Life scores. Patients with previous operative and/or endoscopic treatments for achalasia were excluded. One-hundred and eighteen patients were identified. The median follow-up was 40 months (interquartile range 27). The proportion of patients with Eckardt stage II-III decreased from 94.9-13% (P < .001). The mean Eckardt score decreased from 6.9 ± 1.9 to 1.7 ± 1.2 (P < .001); the mean Short Form-36 scores significantly increased in all 8 domains; the mean Gastro-Esophageal Reflux Disease Health-Related Quality of Life score decreased from 13.9 ± 5.7 to 5.5 ± 5.4 (P < .001). Finally, 88% (confidence interval 81-93) of patients were satisfied regarding their present condition. Quality of life assessed with generic and disease-specific validated instruments significantly improved after laparoscopic Heller myotomy combined with Dor fundoplication. Copyright © 2016 Elsevier Inc. All rights reserved.

Laparoscopic Heller Myotomy and Fundoplication: What Is the Evidence?

PubMed

Rebecchi, Fabrizio; Allaix, Marco E; Schlottmann, Francisco; Patti, Marco G; Morino, Mario

2018-04-01

There is no agreement about the best type of fundoplication to add in patients undergoing laparoscopic Heller myotomy (LHM) for achalasia to reduce the risk of postoperative gastroesophageal reflux. This article reviews the current evidence about the outcomes in achalasia patients undergoing LHM with a partial anterior, a partial posterior, or a total fundoplication. We performed a review of the literature in PubMed/Medline electronic databases, which was evaluated according to the GRADE system. The results of the published randomized controlled trials show with a high level of evidence that the addition of a fundoplication reduces the risk of postoperative abnormal reflux, without impairing the food emptying of the esophagus. LHM with partial fundoplication is considered in most centers worldwide the standard of care for the treatment of patients with achalasia. The current evidence fails to show any significant difference between partial anterior and posterior fundoplication. In the absence of further large randomized controlled trial, the decision of performing an anterior or a posterior wrap is based on the surgeon's experience and preference. The addition of a partial fundoplication to LHM leads to a significantly lower rate of postoperative pathological reflux without impairing the esophageal emptying.

Laparoscopic Heller myotomy as the gold standard for treatment of achalasia.

PubMed

Nau, Peter; Rattner, David

2014-12-01

The recent introductions of novel methods for the treatment of achalasia as well as ongoing controversies about the merits of surgical and endoscopic treatment options have created controversy in identifying the optimal treatment for this condition. This lack of clarity prompted this review of 206 consecutive patients treated with a laparoscopic Heller (LH) myotomy over a 16-year period. A retrospective review of a prospectively collected database was performed of 206 consecutive LH performed by a single surgeon. In this cohort, 58 % of patients had undergone a prior therapeutic intervention. Over 90 % of patients had relief of dysphagia post-operatively. There was one intraoperative esophageal perforation. There were no mortalities. Only 4/206 patients sustained complications that required either post-op therapeutic intervention or delayed hospital discharge. This paper outlines an operative technique that has yielded outstanding results and may be used as a benchmark against which other therapies can be judged.

Peroral endoscopic myotomy achieves similar clinical response but incurs lesser charges compared to robotic heller myotomy.

PubMed

Khashab, Mouen A; Kumbhari, Vivek; Tieu, Alan H; El Zein, Mohamad H; Ismail, Amr; Ngamruengphong, Saowanee; Singh, Vikesh K; Kalloo, Anthony N; Clarke, John O; Stein, Ellen M

2017-01-01

Several uncontrolled studies comparing peroral endoscopic myotomy (POEM) and Heller myotomy have demonstrated equivalent short-term efficacy and safety. However, no data exists rergarding the cost of POEM and how it compares to that of robotic Heller myotomy (RHM). The primary aim of this study was to compare the inpatient charges incurred in patients who underwent POEM or RHM for the treatment of achalasia. A retrospective single center review was conducted among 52 consecutive POEM patients (2012-2014) and 52 consecutive RHM patients (2009-2014). All RHM procedures included a Toupet fundoplication and were performed via a transabdominal approach. All POEM procedures were performed by a gastroenterologist in the endoscopy unit. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤I. All procedural and facility charges were obtained from review of the hospital finance records. There was no difference between POEM and RHM with regards to age, gender, symptom duration, achalasia subtype, manometry findings, or Eckardt symptom stage. There was no significant difference in the rate of adverse events (19.2% vs 9.6%, P = 0.26) or the length of stay (1.9 vs. 2.3, P = 0.18) between both groups. Clinical response rate of patients in the POEM groups was similar to that in the RHM group (94.3% vs. 88.5%, P = 0.48). POEM incurred significantly less total charges compared to LHM ($14481 vs. $17782, P = 0.02). POEM when performed in an endoscopy unit was similar in efficacy and safety to RHM. However, POEM was associated with significant cost savings ($3301/procedure).

Peroral Endoscopic Myotomy Achieves Similar Clinical Response but Incurs Lesser Charges Compared to Robotic Heller Myotomy

PubMed Central

Khashab, Mouen A.; Kumbhari, Vivek; Tieu, Alan H.; El Zein, Mohamad H.; Ismail, Amr; Ngamruengphong, Saowanee; Singh, Vikesh K.; Kalloo, Anthony N.; Clarke, John O.; Stein, Ellen M.

2017-01-01

Background/Aim: Several uncontrolled studies comparing peroral endoscopic myotomy (POEM) and Heller myotomy have demonstrated equivalent short-term efficacy and safety. However, no data exists rergarding the cost of POEM and how it compares to that of robotic Heller myotomy (RHM). The primary aim of this study was to compare the inpatient charges incurred in patients who underwent POEM or RHM for the treatment of achalasia. Patients and Methods: A retrospective single center review was conducted among 52 consecutive POEM patients (2012–2014) and 52 consecutive RHM patients (2009–2014). All RHM procedures included a Toupet fundoplication and were performed via a transabdominal approach. All POEM procedures were performed by a gastroenterologist in the endoscopy unit. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤I. All procedural and facility charges were obtained from review of the hospital finance records. Results: There was no difference between POEM and RHM with regards to age, gender, symptom duration, achalasia subtype, manometry findings, or Eckardt symptom stage. There was no significant difference in the rate of adverse events (19.2% vs 9.6%, P = 0.26) or the length of stay (1.9 vs. 2.3, P = 0.18) between both groups. Clinical response rate of patients in the POEM groups was similar to that in the RHM group (94.3% vs. 88.5%, P = 0.48). POEM incurred significantly less total charges compared to LHM ($14481 vs. $17782, P = 0.02). Conclusions: POEM when performed in an endoscopy unit was similar in efficacy and safety to RHM. However, POEM was associated with significant cost savings ($3301/procedure). PMID:28361839

Systematic Review and Meta-Analysis of Perioperative Outcomes of Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy (LHM) for Achalasia.

PubMed

Awaiz, Aiman; Yunus, Rossita M; Khan, Shahjahan; Memon, Breda; Memon, Muhammed A

2017-06-01

Laparoscopic Heller myotomy (LHM) is the preferred surgical method for treating achalasia. However, peroral endoscopic myotomy (POEM) is providing good short-term results. The objective of this systematic review and meta-analysis was to compare the safety and efficacy of LHM and POEM. A search of PubMed, Cochrane database, Medline, Embase, Science Citation Index, and current contents for English-language articles comparing LHM and POEM between 2007 and 2016 was performed. Variables analyzed included prior endoscopic treatment, prior medical treatment, prior Heller myotomy, operative time, overall complications rate, postoperative gastroesophageal reflux disease (GERD), length of hospital stay, postoperative pain score, and long-term GERD. Seven trials consisting of 483 (LHM=250, POEM=233) patients were analyzed. Preoperative variables, for example, prior endoscopic treatment [odds ratio (OR), 1.32; 95% confidence interval (CI), 0.23-4.61; P=0.96], prior medical treatment [weighted mean difference (WMD), 1.22; 95% CI, 0.52-2.88; P=0.65], and prior Heller myotomy (WMD, 0.47; 95% CI, 0.13-1.67; P=0.25) were comparable. Operative time was 26.28 minutes, nonsignificantly longer for LHM (WMD, 26.28; 95% CI, -11.20 to 63.70; P=0.17). There was a comparable overall complication rate (OR, 1.25; 95% CI, 0.56-2.77; P=0.59), postoperative GERD rate (OR, 1.27; 95% CI, 0.70-2.30; P=0.44), length of hospital stay (WMD, 0.30; 95% CI, -0.24 to 0.85; P=0.28), postoperative pain score (WMD, -0.26; 95% CI, -1.58 to 1.06; P=0.70), and long-term GERD (WMD, 1.06; 95% CI, 0.27-4.1; P=0.08) for both procedures. There was a significantly higher short-term clinical treatment failure rate for LHM (OR, 9.82; 95% CI, 2.06-46.80; P<0.01). POEM compares favorably to LHM for achalasia treatment in short-term perioperative outcomes. However, there was a significantly higher clinical treatment failure rate for LHM on short-term postoperative follow-up. Presently long-term postoperative follow

Recurrent achalasia treated with Heller myotomy: A review of the literature

PubMed Central

Wang, Lan; Li, You-Ming

2008-01-01

AIM: To evaluate the efficacy and safety of Heller myotomy (HM) for recurrent achalasia, performed after different methods of first-line treatment. METHODS: We searched for studies published in PubMed from 1966 to March 2008 on treatment of recurrent achalasia with HM after failure with different methods of first-line treatment. The efficacy of HM was assessed by a pooled estimate of response rate with individual studies weighted proportionally to sample size. RESULTS: Sixteen studies were eligible and included in the review. The results showed that HM has a better remission rate for recurrent achalasia after failure of HM [weighted mean (SD)] of 86.9% (21.8%) compared with 81.6% (23.8%) for pneumatic dilatation (PD). One study evaluated the efficacy of HM after failure of PD combined with botulinum toxin injection (83%). The most common complications were perforation and gastroesophageal reflux. CONCLUSION: HM has the best efficacy in patients with recurrent achalasia who were treated with HM as first-line treatment. Future studies should focus on how to increase the success rate and decrease the complications of HM. PMID:19084921

Laparoscopic Heller Myotomy versus Per Oral Endoscopic Myotomy: Evidence-Based Approach to the Treatment of Esophageal Achalasia.

PubMed

Schlottmann, Francisco; Patti, Marco G

2018-04-01

Esophageal achalasia is a rare disorder characterized by a failure of the lower esophageal sphincter to relax during swallowing, combined with aperistalsis of the esophageal body. Treatment is not curative, but aims to eliminate the outflow resistance caused by the nonrelaxing lower esophageal sphincter. Current evidence suggests that both laparoscopic Heller myotomy and per oral endoscopic myotomy (POEM) are very effective in the relief of symptoms in patients with achalasia. Specifically, for type III achalasia, POEM may achieve higher success rates. However, POEM is associated to a very high incidence of pathologic reflux, with the risk of exchanging one disease-achalasia-with another-gastroesophageal reflux.

Laparoscopic Heller Myotomy for Non-Dilated Esophageal Achalasia in Children with Intraoperative Stepped Dilation Under Image Guidance: Attempting Complete Myotomy.

PubMed

Miyano, Go; Miyake, Hiromu; Koyama, Mariko; Morita, Keiichi; Kaneshiro, Masakatsu; Nouso, Hiroshi; Yamoto, Masaya; Fukumoto, Koji; Urushihara, Naoto

2016-05-01

This study presents a modified surgical approach to laparoscopic myotomy for achalasia using stepped dilation with a Rigiflex balloon and contrast medium under image guidance. A 10-year-old boy with persistent dysphagia and vomiting had ingested only liquids for 3 months, losing >10 kg in body weight. Barium swallow and esophageal manometry diagnosed esophageal achalasia with mild esophageal dilatation. After failed pneumatic dilatation, laparoscopic Heller myotomy with Dor fundoplication was performed. Prior to surgery, a Rigiflex balloon dilator was placed within the esophagus near the diaphragmatic hiatus. A four-port technique was used, and mobilization of the esophagus was limited to the anterior aspect. A 5-cm Heller myotomy was performed, extending another 2 cm onto the anterior gastric wall. During myotomy, the Rigiflex balloon was serially dilated from 30 to 50 mL, and filled with contrast medium under fluoroscopic image guidance in order to maintain appropriate tension on the esophagus to facilitate myotomy, and to confirm adequate myotomy with sufficient release of lower esophageal sphincter by resecting residual circular muscle fibers. Residual circular muscle fibers can be simultaneously visualized under both fluoroscopic image guidance and direct observation through the laparoscope, and they were cut precisely until the residual notch fully disappeared. Dor fundoplication was completed. The operative time was 180 minutes, and oral intake was started after esophagography on postoperative day 1. As of the 12-month follow-up, the patient has not shown any symptoms, and his postoperative course appeared satisfactory.

Self-expandable metal stent placement in a child for treatment of achalasia after failed Heller myotomy.

PubMed

Gugig, Roberto; Muñoz Jurado, Guillermo; Huang, Clifton; Oleas, Roberto; Robles-Medranda, Carlos

2018-01-01

Background and study aims  Childhood achalasia treatment remains inconclusive. What is next after myotomy failure? Repeated pneumatic-dilation put patients at greater risk of perforation with possible symptom recurrence. We report on a 12-year-old patient with a 1-year history of achalasia whom underwent Heller myotomy with fundoplication and recurred with symptoms 1 week after surgery. Pneumatic dilatation was considered but not done because of the risk of esophageal perforation. The decision was made to place a fully covered self-expanding metallic stent (FC-SEMS) for 3 months, which resolved the stenosis as confirmed by esophagram. The patient has remained asymptomatic since the procedure was performed 2 years ago. FC-SEMS is an alternative for treatment of refractory achalasia in children who do not respond to conventional treatment.

Efficacy and durability of robotic Heller myotomy for achalasia: patient symptoms and satisfaction at long-term follow-up.

PubMed

Perry, Kyle A; Kanji, Aliyah; Drosdeck, Joseph M; Linn, John G; Chan, Anthony; Muscarella, Peter; Melvin, W Scott

2014-11-01

Laparoscopic Heller myotomy (LHM) has become the standard treatment for achalasia in the USA. Robot-assisted Heller myotomy (RHM) has emerged as an alternative approach due to improved visualization and fine motor control, but long-term follow-up studies have not been reported. We sought to report the long-term outcomes of RHM and compare them to those of LHM. A retrospective cohort study was performed for patients who underwent laparoscopic or RHM between 1995 and 2006. Long-term follow-up was performed via mail or telephone questionnaire. The primary outcome measure was durable relief of dysphagia without need for further intervention. Secondary outcomes included gastroesophageal reflux symptoms, disease-specific quality of life, and patient satisfaction with their operation. Seventy-five patients underwent laparoscopic (n = 19) or robotic (n = 56) myotomy during the study period. Long-term follow-up was obtained in 53 (71 %) patients with a median interval of 9 years. RHM was associated with a decreased mucosal injury rate (0 vs. 16 %, p = 0.01) and median hospital stay (1 vs. 2 days, p < 0.01) compared to conventional laparoscopy. All patients reported initial dysphagia relief, and 80 % required no further intervention. This did not differ between groups. Sixty-two percent required medications to control reflux symptoms at long-term follow-up, including 56 % following robotic myotomy and 80 % after laparoscopic myotomy (p = 0.27). Overall, 95 % of patients were satisfied with their operation, and 91 % would choose surgery again given the benefit of hindsight. There is a dearth of long-term follow-up data to support the effectiveness of RHM. This study demonstrates durable dysphagia relief in the vast majority of patients with a high degree of patient satisfaction and a low rate of esophageal mucosal injury. While a significant proportion of patients report reflux symptoms, these symptoms are well controlled with medical acid suppression.

Peroral endoscopic myotomy as salvation technique post-Heller: International experience.

PubMed

Tyberg, Amy; Sharaiha, Reem Z; Familiari, Pietro; Costamagna, Guido; Casas, Fernando; Kumta, Nikhil A; Barret, Maximilien; Desai, Amit P; Schnoll-Sussman, Felice; Saxena, Payal; Martínez, Guadalupe; Zamarripa, Felipe; Gaidhane, Monica; Bertani, Helga; Draganov, Peter V; Balassone, Valerio; Sharata, Ahmed; Reavis, Kevin; Swanstrom, Lee; Invernizzi, Martina; Seewald, Stefan; Minami, Hitomi; Inoue, Haruhiro; Kahaleh, Michel

2018-01-01

Treatment for achalasia has traditionally been Heller myotomy (HM). Despite its excellent efficacy rate, a number of patients remain symptomatic post-procedure. Limited data exist as to the best management for recurrence of symptoms post-HM. We present an international, multicenter experience evaluating the efficacy and safety of post-HM peroral endoscopic myotomy (POEM). Patients who underwent POEM post-HM from 13 centers from January 2012 to January 2017 were included as part of a prospective registry. Technical success was defined as successful completion of the myotomy. Clinical success was defined as an Eckardt score of ≤3 on 12-month follow up. Adverse events (AE) including anesthesia-related, operative, and postoperative complications were recorded. Fifty-one patients were included in the study (mean age 54.2, 47% male). Technical success was achieved in 100% of patients. Clinical success on long-term follow up was achieved in 48 patients (94%), with a mean change in Eckardt score of 6.25. Seven patients (13%) had AE: six experienced periprocedural mucosal defect treated endoscopically and two patients developed mediastinitis treated conservatively. For patients with persistent symptoms after HM, POEM is a safe salvation technique with good short-term efficacy. As a result of the challenge associated with repeat HM, POEM might become the preferred technique in this patient population. Further studies with longer follow up are needed. © 2017 Japan Gastroenterological Endoscopy Society.

Training model for laparoscopic Heller and Dor fundoplication: a tool for laparoscopic skills training and assessment-construct validity using the GOALS score.

PubMed

Bellorin, Omar; Kundel, Anna; Sharma, Saurabh; Ramirez-Valderrama, Alexander; Lee, Paul

2016-08-01

Laparoscopic training demands practice. The transfer of laparoscopic skills from training models to real surgical procedures has been proven. The global operative assessment of laparoscopic skills (GOALS) score is a 5-item global rating scale developed to evaluate laparoscopic skills by direct observation. This scale has been used to demonstrate construct validity of several laparoscopic training models. Here, we present a low-cost model of laparoscopic Heller-Dor for advanced laparoscopic training. The aim of this study was to determine the capability of a training model for laparoscopic Heller-Dor to discriminate between different levels of laparoscopic expertise. The performance of two groups with different levels of expertise, novices (<30 laparoscopic procedures PGY1-2) and experts (>300 laparoscopic procedures PGY4-5) was assessed. All participants were instructed to perform two tasks (esophageal myotomy and fundoplication). All the performances were recorded in a digital format. A laparoscopic expert who was blinded to subject's identity evaluated the recordings using the GOALS score. Autonomy, one of the five items of GOALS, was removed since the evaluator and the trainee did not have interaction. The time required to finish each task was also recorded. Performance was compared using the Mann-Whitney U test (p < 0.05 was significant). Twenty subjects were evaluated: ten in each group, using the GOALS score. The mean total GOALS score for novices was 7.5 points (SD: 1.64) and 13.9 points (SD: 1.66) for experts (p < 0.05).The expert group was superior in each domain of the GOALS score compared to novices: depth perception (mean: 3.3 vs 2 p < 0.05), bimanual dexterity (mean 3.4 vs 2.1 p < 0.05), efficiency (mean 3.4 vs 1.7 p < 0.05) and tissue handling (mean 3.6 vs 1.7 p < 0.05). With regard to time, experts were superior in task 1 (mean 9.7 vs 14.9 min p < 0.05) and task 2 (mean 24 vs 47.1 min p < 0.05) compared to novices. The laparoscopic

Learning curve for laparoscopic Heller myotomy and Dor fundoplication for achalasia

PubMed Central

Omura, Nobuo; Tsuboi, Kazuto; Hoshino, Masato; Yamamoto, Seryung; Akimoto, Shunsuke; Masuda, Takahiro; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2017-01-01

Purpose Although laparoscopic Heller myotomy and Dor fundoplication (LHD) is widely performed to address achalasia, little is known about the learning curve for this technique. We assessed the learning curve for performing LHD. Methods Of the 514 cases with LHD performed between August 1994 and March 2016, the surgical outcomes of 463 cases were evaluated after excluding 50 cases with reduced port surgery and one case with the simultaneous performance of laparoscopic distal partial gastrectomy. A receiver operating characteristic (ROC) curve analysis was used to identify the cut-off value for the number of surgical experiences necessary to become proficient with LHD, which was defined as the completion of the learning curve. Results We defined the completion of the learning curve when the following 3 conditions were satisfied. 1) The operation time was less than 165 minutes. 2) There was no blood loss. 3) There was no intraoperative complication. In order to establish the appropriate number of surgical experiences required to complete the learning curve, the cut-off value was evaluated by using a ROC curve (AUC 0.717, p < 0.001). Finally, we identified the cut-off value as 16 surgical cases (sensitivity 0.706, specificity 0.646). Conclusion Learning curve seems to complete after performing 16 cases. PMID:28686640

Learning curve for laparoscopic Heller myotomy and Dor fundoplication for achalasia.

PubMed

Yano, Fumiaki; Omura, Nobuo; Tsuboi, Kazuto; Hoshino, Masato; Yamamoto, Seryung; Akimoto, Shunsuke; Masuda, Takahiro; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2017-01-01

Although laparoscopic Heller myotomy and Dor fundoplication (LHD) is widely performed to address achalasia, little is known about the learning curve for this technique. We assessed the learning curve for performing LHD. Of the 514 cases with LHD performed between August 1994 and March 2016, the surgical outcomes of 463 cases were evaluated after excluding 50 cases with reduced port surgery and one case with the simultaneous performance of laparoscopic distal partial gastrectomy. A receiver operating characteristic (ROC) curve analysis was used to identify the cut-off value for the number of surgical experiences necessary to become proficient with LHD, which was defined as the completion of the learning curve. We defined the completion of the learning curve when the following 3 conditions were satisfied. 1) The operation time was less than 165 minutes. 2) There was no blood loss. 3) There was no intraoperative complication. In order to establish the appropriate number of surgical experiences required to complete the learning curve, the cut-off value was evaluated by using a ROC curve (AUC 0.717, p < 0.001). Finally, we identified the cut-off value as 16 surgical cases (sensitivity 0.706, specificity 0.646). Learning curve seems to complete after performing 16 cases.

Is Heller myotomy better than balloon dilation? A meta-analysis.

PubMed

Illés, Anita; Farkas, Nelli; Hegyi, Péter; Garami, András; Szabó, Imre; Solymár, Margit; Pétervári, Erika; Balaskó, Márta; Pár, Gabriella; Sarlós, Patrícia; Bajor, Judit; Szűcs, Ákos; Czimmer, József; Szemes, Kata; Vincze, Áron

2017-06-01

Endoscopic balloon dilation (EBD) and laparoscopic Heller myotomy (LHM) are the most commonly performed treatment options for achalasia. Decision between these treatment options is difficult. The aim of this meta-analysis was to evaluate the efficacy of EBD compared to LHM. The electronic databases PubMed, Embase and Cochrane Controlled Trials Registry were systematically searched for the period between January 1, 1976 and December 31, 2015. Meta-analysis was performed using the PICOS (problem, intervention, comparison, outcome, study design) format. Efficacy and safety of EBD were compared to LHM. Forest plot analyses were used to illustrate the success rate, perforation rate and post-procedural gastroesophageal reflux. Using the search strategy, eight studies met the selection criteria and were included in the meta-analysis. The total number of patients included was 749 (360 in the EBD group and 389 in the LHM group). The success rate was lower in the EBD group than in the LHM group (OR=0.486; CI: 0.304-0.779; p=0.003). The rate of perforation did not differ significantly between the EBD and LHM group (RR= 0.635, CI: 0.340-1.186, p=0.154). The incidence of post-procedural symptomatic gastroesophageal reflux did not differ between the two treatment groups (RR=0.663, CI: 0.328-1.343, p=0.254). Our data suggest that the efficacy of LHM is superior to that of EBD, while there is no difference in safety between the two treatment groups.

Laparoscopic limited Heller myotomy without anti-reflux procedure does not induce significant long-term gastroesophageal reflux.

PubMed

Zurita Macías Valadez, L C; Pescarus, R; Hsieh, T; Wasserman, L; Apriasz, I; Hong, D; Gmora, S; Cadeddu, M; Anvari, M

2015-06-01

Laparoscopic Heller myotomy with partial fundoplication is the gold standard treatment for achalasia. Laparoscopic limited Heller myotomy (LLHM) with no anti-reflux procedure is another possible option. A review of prospectively collected data was performed on patients who underwent LLHM from January 1998 to December 2012. Evaluation included gastroscopy, esophageal manometry, 24-h pH-metry, and the Short Form(36) Health Survey(SF-36) questionnaire at baseline and 6 months, as well as the global symptom score at baseline, 6 months, and 5 years post-surgery. Comparison between outcomes was performed with a paired t student's test. 126 patients underwent LLHM. Of these, 60 patients had complete pre and post-operative motility studies. 57 % were female, patient mean age was 45.7 years, with a mean follow-up of 10.53 months. Mean operative time was 56.1 min, and the average length of stay was 1.7 days. At 6 months, a significant decrease in the lower esophageal sphincter resting pressure (29.1 vs. 7.1 mmHg; p < 0.001) and nadir (16.4 vs. 4.3 mmHg; p < 0.001) was observed. Normal esophageal acid exposure (total pH < 4 %) was observed in 68.3 % patients. Nevertheless, of the remaining 31.7 % with abnormal pH-metry, only 21.6 % were clinically symptomatic and all were properly controlled with medical treatment without requiring anti-reflux surgery. Significant improvement in all pre-operative symptoms was observed at 6 months and maintained over 5 years. Dysphagia score was reduced from 9.8 pre-operatively to 2.6 at 5 years (p < 0.001), heartburn score from 3.82 to 2 (p < 0.01), and regurgitation score from 7.5 to 0.8 (p < 0.001). Only one patient (0.8 %) presented with recurrent dysphagia requiring reoperation. LLHM without anti-reflux procedure is an effective long-term treatment for achalasia and does not cause symptomatic GERD in three quarters of patients. The remaining patients are well controlled on anti-reflux medications. It is believed that similar clinical

Real-time Continuous Esophageal High-resolution Manometry (HRM) During Laparoscopic Heller Myotomy and Dor Fundoplication for the Treatment of Achalasia. A Promising Novelty in Regards of Perfecting Surgical Technique: Could It Guide Surgical Technique Toward Excellent Results?

PubMed

Triantafyllou, Tania; Doulami, Georgia; Papailiou, Joanna; Mantides, Apostolos; Zografos, Georgios; Theodorou, Dimitrios

2016-12-01

High-resolution manometry (HRM) is the gold-standard diagnostic tool for achalasia of the esophagus. Laparoscopic Heller-Dor technique is the preferred surgical approach with success rate estimated 90%. The use of intraoperative HRM provides real-time estimation of intraluminal esophageal pressures and identifies the exact points of esophageal luminal pressure during laparoscopy. Ten patients with achalasia underwent surgery. All patients preoperatively completed 1 manometric study and Quality of Life questionnaires (EORTC QLQ-C30 version 3.0) with Eckardt scores. We collected intraoperative manometry data and repeated manometric studies, EORTC QLQ-C30, and Eckardt scores postoperatively. Median Eckardt score was decreased from 7.5 to 0.5, mean resting pressure decreased from 51.4 to 11.9 mm Hg, whereas mean residual pressure diminished from 45.9 to 9.5 mm Hg postoperatively. The simultaneous use of HRM during the Heller-Dor technique may lead to an individualized management of the disease.

Per-Oral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia

PubMed Central

Zhang, Yuan; Wang, Hongjuan; Chen, Xingdong; Liu, Lan; Wang, Hongbo; Liu, Bin; Guo, Jianqiang; Jia, Hongying

2016-01-01

Abstract We aimed to assess the short-term outcomes of per-oral endoscopic myotomy (POEM) compared with laparoscopic Heller myotomy (LHM) for achalasia through a meta-analysis of nonrandomized comparative studies. We searched PubMed, Embase, Medline, Cochrane Library, and Google Scholar for studies that compared POEM and LHM for achalasia and were published between January 1, 2008 and December 31, 2014. The Methodological Index for Nonrandomized Studies (MINORS) was used to evaluate the quality of the studies. Random- and fixed-effects meta-analytical models were used, and between-study heterogeneity was assessed. Four nonrandomized comparative studies that included 317 patients (125 in the POEM group and 192 in the LHM group) met our research criteria and were assessed. There were no differences between the POEM and LHM groups in terms of sex, preoperative Eckhart score, length of myotomy, operation time, length of hospital stay, and complications. The patients in the POEM group were older than those in the LHM group (MD =2.81, 95% CI 0.27–5.35; P = 0.03) with high between-study homogeneity (χ2 = 1.96, df = 2, I2 = 0%; P = 0.38). The patients in the POEM group had a lower Eckardt score after surgery compared with those in the LHM group (MD = −0.30, 95% CI −0.42 to −0.18; P < 0.001) with high between-study homogeneity (χ2 = 0.00, df = 1, I2 = 0%; P = 1.00). The efficacy and safety of POEM appear to be comparable to those of LHM. Multicenter and randomized trials with larger sample size are needed to further compare the efficacy and safety of POEM and LHM for the treatment of achalasia. PMID:26871816

LATE EVALUATION OF DYSPHAGIA AFTER HELLER ESOPHAGEAL MYOTOMY WITH DOR FUNDOPLICATION FOR ACHALASIA.

PubMed

Câmara, Eduardo Rodrigues Zarco; Madureira, Fernando Athayde Veloso; Madureira, Delta; Salomão, Renato Manganelli; Iglesias, Antonio Carlos Ribeiro Garrido

2017-01-01

All available treatments for achalasia are palliative and aimed to eliminate the flow resistance caused by a hypertensive lower esophageal sphincter. To analyze the positive and negative prognostic factors in the improvement of dysphagia and to evaluate quality of life in patients undergoing surgery to treat esophageal achalasia by comparing findings before, immediately after, and in long follow-up. A total of 84 patients who underwent surgery for achalasia between 2001 and 2014 were retrospectively studied. The evaluation protocol with dysphagia scores compared preoperative, immediate (up to three months) postoperative and late (over one year) postoperative scores to estimate quality of life. The surgical procedure was Heller-Dor in 100% of cases, with 84 cases performed laparoscopically. The percent reduction in pre- and immediate postoperative lower esophageal sphincter pressurewas 60.35% in the success group and 32.49% in the failure group. Regarding the late postoperative period, the mean percent decrease was 60.15% in the success group and 31.4% in the failure group. The mean overall drop in dysphagia score between the pre- and immediate postoperative periods was 7.33 points, which represents a decrease of 81.17%. Reduction greater than 60% percent in lower esophageal sphincter pressurebetween the pre- and postoperative periods suggests that this metric is a predictor of good prognosis for surgical response. Surgical treatment was able to have a good affect in quality of life and drastically changed dysphagia over time.

Quality of life comparing dor and toupet after heller myotomy for achalasia.

PubMed

Tomasko, Jonathan M; Augustin, Toms; Tran, Tung T; Haluck, Randy S; Rogers, Ann M; Lyn-Sue, Jerome R

2014-01-01

Laparoscopic Heller cardiomyotomy (LHC) is standard therapy for achalasia. Traditionally, an antireflux procedure has accompanied the myotomy. This study was undertaken to compare quality-of-life outcomes between patients undergoing myotomy with Toupet versus Dor fundoplication. In addition, we investigated overall patient satisfaction after LHC in the treatment of achalasia. One hundred thirty-five patients who underwent LHC over a 13-year period were identified for inclusion. Symptoms queried included dysphagia, heartburn, and bloating using the Gastroesophageal Reflux Disease-Health-Related Quality of Life Scale and a second published scale for the assessment of gastroesophageal reflux disease and dysphagia symptoms. The patients' overall satisfaction after surgery was also rated. Data were compared on the basis of type of fundoplication. Symptom scores were analyzed using chi-square tests and Fisher's exact tests. Sixty-three patients completed the survey (47%). There were no perioperative deaths or reoperations. The mean length of stay was 2.8 days. The mean operative time for LHC with Toupet fundoplication was 137.3±30.91 minutes and for LHC with Dor fundoplication was 111.5±32.44 minutes (P=.006). There was no difference with respect to the incidence or severity of postoperative heartburn, dysphagia, or bloating. Overall satisfaction with Toupet fundoplication was 87.5% and with Dor fundoplication was 93.8% (P>.999). LHC with either Toupet or Dor fundoplication gave excellent patient satisfaction. Postoperative symptoms of heartburn and dysphagia were equivalent when comparing LHC with either antireflux procedure. Dor and Toupet fundoplication were found to have equivalent outcomes in the short term. We prefer Dor to Toupet fundoplication because of its decreased need for extensive dissection and better mucosal protection.

Feeding ecology of non-native Siberian prawns, Palaemon modestus (Heller, 1862) (Decapoda, Palaemonidae), in the lower Snake River, Washington, U.S.A.

USGS Publications Warehouse

Tiffan, Kenneth F.; Hurst, William

2016-01-01

We used both stomach content and stable isotope analyses to describe the feeding ecology of Siberian prawns Palaemon modestus (Heller, 1862), a non-native caridean shrimp that is a relatively recent invader of the lower Snake River. Based on identifiable prey in stomachs, the opossum shrimp Neomysis mercedis Holmes, 1896 comprised up to 34-55% (by weight) of diets of juvenile to adult P. modestus, which showed little seasonal variation. Other predominant items/taxa consumed included detritus, amphipods, dipteran larvae, and oligochaetes. Stable isotope analysis supported diet results and also suggested that much of the food consumed by P. modestus that was not identifiable came from benthic sources — predominantly invertebrates of lower trophic levels and detritus. Palaemon modestus consumption of N. mercedis may pose a competitive threat to juvenile salmon and resident fishes which also rely heavily on that prey.

Mucosal Perforation During Laparoscopic Heller Myotomy Has No Influence on Final Treatment Outcome.

PubMed

Salvador, Renato; Spadotto, Lorenzo; Capovilla, Giovanni; Voltarel, Guerrino; Pesenti, Elisa; Longo, Cristina; Cavallin, Francesco; Nicoletti, Loredana; Ruol, Alberto; Valmasoni, Michele; Merigliano, Stefano; Costantini, Mario

2016-12-01

The aims of the study were (a) to examine the final outcome in patients experiencing accidental mucosal perforation during laparoscopic Heller myotomy with Dor fundoplication (LHD) and (b) to evaluate whether perforation episodes might influence the way in which surgeons subsequently approached the LHD procedure. We studied all consecutive patients that underwent LHD between 1992 and 2015. Patients were divided into two main groups: those who experienced an intraoperative mucosal perforation (group P) and those whose LHD was uneventful (group NP). Two additional groups were compared: group A, which consisted of patients operated by a given surgeon immediately before a perforation episode occurred, and group B, which included those operated immediately afterwards. Eight hundred seventy-five patients underwent LHD; a mucosal perforation was detected in 25 patients (2.9 %), which was found unrelated to patients' symptom's score and age, radiological stage, manometric pattern, or the surgeon's experience. The median postoperative symptom score was similar for the two groups as the failure rate: 92 failures in group NP (10.8 %) and 4 in group P (16 %) (p = 0.34); moreover, symptoms recurred in 2 patients of group A (10 %) and 3 patients of group B (15 %) (p = 0.9). Accidental perforation during LHD is infrequent and impossible to predict on the grounds of preoperative therapy or the surgeon's personal experience. Despite a longer surgical procedure and hospital stay, the outcome of LHD is much the same as for patients undergoing uneventful myotomy. A recent mucosal perforation does not influence the surgeon's subsequent performance.

Achalasia symptom response after Heller myotomy segregated by high-resolution manometry subtypes.

PubMed

Patel, Amit; Patel, Ami; Mirza, Faiz A; Soudagar, Samad; Sayuk, Gregory S; Gyawali, C Prakash

2016-02-01

Achalasia is classified into three HRM subtypes that predict outcomes from diverse management strategies. We assessed if symptomatic response varied when a single management strategy-Heller myotomy (HM)-is employed. Treatment-naive subjects with achalasia referred for HM were followed in this observational cohort study. Chicago criteria designated achalasia subtypes (subtype I: no esophageal pressurization; subtype II: panesophageal pressurization in ≥20 % swallows; subtype III: premature contractions in ≥20 % swallows). Symptom questionnaires assessed symptom burden before and after HM on five-point Likert scales (0 = no symptoms, 4 = severe symptoms) and on 10-cm visual analog scales (global symptom severity, GSS); satisfaction with HM was recorded similarly. Data were analyzed to determine predictors of GSS change across subtypes. Sixty achalasia subjects (56.1 ± 2.4 years, 55 % female) fulfilled inclusion criteria, 15 % with subtype I, 58 % with subtype II, and 27 % with subtype III achalasia. Baseline symptoms included dysphagia (solids: 85 %, liquids: 73 %), regurgitation (84 %), and chest pain (35 %); mean GSS was 7.1 ± 0.3. Upon follow-up 2.1 ± 0.2 years after HM, GSS declined to 1.9 ± 0.4 (p < 0.001), with surgical satisfaction score of 8.7 ± 0.3 out of 10; these were similar across achalasia subtypes. On univariate analysis, female gender, Eckardt score, severity of transit symptoms, and maximal IRP predicted linear GSS improvement; female gender (p = 0.003) and dysphagia for liquids (p = 0.043) remained predictive on multivariate analysis. When a uniform surgical approach is utilized, symptomatic outcome and satisfaction with therapy are similar across achalasia subtypes. Female gender and severity of dysphagia for solids may predict better HM outcome.

Quality of Life Comparing Dor and Toupet After Heller Myotomy for Achalasia

PubMed Central

Tomasko, Jonathan M.; Augustin, Toms; Tran, Tung T.; Haluck, Randy S.; Rogers, Ann M.

2014-01-01

Background: Laparoscopic Heller cardiomyotomy (LHC) is standard therapy for achalasia. Traditionally, an antireflux procedure has accompanied the myotomy. This study was undertaken to compare quality-of-life outcomes between patients undergoing myotomy with Toupet versus Dor fundoplication. In addition, we investigated overall patient satisfaction after LHC in the treatment of achalasia. Methods: One hundred thirty-five patients who underwent LHC over a 13-year period were identified for inclusion. Symptoms queried included dysphagia, heartburn, and bloating using the Gastroesophageal Reflux Disease–Health-Related Quality of Life Scale and a second published scale for the assessment of gastroesophageal reflux disease and dysphagia symptoms. The patients' overall satisfaction after surgery was also rated. Data were compared on the basis of type of fundoplication. Symptom scores were analyzed using chi-square tests and Fisher's exact tests. Results: Sixty-three patients completed the survey (47%). There were no perioperative deaths or reoperations. The mean length of stay was 2.8 days. The mean operative time for LHC with Toupet fundoplication was 137.3 ± 30.91 minutes and for LHC with Dor fundoplication was 111.5 ± 32.44 minutes (P = .006). There was no difference with respect to the incidence or severity of postoperative heartburn, dysphagia, or bloating. Overall satisfaction with Toupet fundoplication was 87.5% and with Dor fundoplication was 93.8% (P > .999). Conclusions: LHC with either Toupet or Dor fundoplication gave excellent patient satisfaction. Postoperative symptoms of heartburn and dysphagia were equivalent when comparing LHC with either antireflux procedure. Dor and Toupet fundoplication were found to have equivalent outcomes in the short term. We prefer Dor to Toupet fundoplication because of its decreased need for extensive dissection and better mucosal protection. PMID:25392612

Per-oral endoscopic myotomy for achalasia. Are results comparable to laparoscopic Heller myotomy?

PubMed

Kumagai, Koshi; Tsai, Jon A; Thorell, Anders; Lundell, Lars; Håkanson, Bengt

2015-05-01

Per-oral endoscopic myotomy (POEM) has recently been introduced as a minimal invasive alternative to conventional treatment for achalasia. This study aimed to clarify the feasibility and the short-term clinical efficacy of POEM as compared to laparoscopic Heller myotomy (LHM). Treatment outcomes were prospectively recorded and compared between the procedures in a nonrandomized fashion. Reduction rate (RR) in timed barium esophagogram (TBE) was calculated at 1, 2 and 5 min after barium ingestion as: RR = 1- postoperative barium height/preoperative barium height. Risk factors for treatment failure defined as the proportion of patients with RR <0.5 (1 min) and gastroesophageal reflux (GER) after POEM were analyzed. Forty-two consecutive patients who underwent POEM were compared to 41 patients who had a LHM during the immediate time period prior to the introduction of POEM. Ninety percent of the cases reported complete symptom relief after POEM. The percentage of esophageal emptying and RR in TBE improved dramatically by both procedures without significant difference. A longer operation time (odds ratio [OR] 32.80, 95%CI 2.99-359.82, p = 0.004) and younger age (OR 26.81, 95%CI 2.09-344.03, p = 0.012) were the independent predictors of treatment failure after POEM. GER was observed in seven patients where previous dilatation (OR 8.59, 95%CI 1.16-63.45, p = 0.035) and higher body mass index (OR 8.69, 95%CI 1.13-66.63, p = 0.037) were the independent predictors for symptomatic GER after POEM. POEM seems to be a safe and effective treatment option for achalasia in the short-term perspective; an effect well comparable to LHM.

Comparison of treatment outcomes of endoscope-guided pneumatic dilation and laparoscopic Heller myotomy.

PubMed

Wang, Hsin-Ming; Tai, Wei-Chen; Chuah, Seng-Kee; Lu, Hung-I; Lu, Lung-Sheng; Liang, Chih-Ming; Kuo, Chung-Huang; Chiu, Yi-Chun; Wu, Keng-Liang; Changchien, Chi-Sin

2015-12-01

The debate on which is the better choice between laparoscopic Heller myotomy (LHM) and endoscopic pneumatic dilation (PD) for esophageal achalasia has been ongoing for decades. This study aims to compare the results of endoscope-guided PD and LHM in 42 patients with achalasia between May 1996 and August 2011. Twenty-one patients who had received PD and 21 who had received LHM were enrolled. The cumulative remission rate was analyzed using the Kaplan-Meier method with the assessment of symptom scores between grades before and after PD or LHM done at 6 weeks, 6 months, 1 year, and then every year thereafter. Possible confounding factors related to the remissions were analyzed by Cox's proportional hazard model. For PD, the cumulative remission rates were 81.0% (1 year), 76.2% (2), 66.7% (3), 61.9% (4), and 47.6% (5). For LHM, the cumulative remission rates were 90.5% every year from the 1(st) to the 5(th). The LHM patients had significantly better remission rates than the PD patients (p = 0.033, by log-rank test). The LHM group had a longer hospital stay than the PD group [median (interquartile range): 8 (6.5-10) days vs. 3 (2-3) days, p < 0.001) and had more reflux complications (52.4% vs. 19.0%, p = 0.024). No perforation occurred in either group. In conclusion, the 5-year cumulative effectiveness of LHM is better than that of PD despite the association of LHM with more reflux events (52.4%). Copyright © 2015. Published by Elsevier Taiwan.

Is Dor fundoplication optimum after laparoscopic Heller myotomy for achalasia? A meta-analysis.

PubMed

Wei, Ming-Tian; He, Ya-Zhou; Deng, Xiang-Bing; Zhang, Yuan-Chuan; Yang, Ting-Han; Jin, Cheng-Wu; Hu, Bing; Wang, Zi-Qiang

2013-11-21

To compare the outcome of acid reflux prevention by Dor fundoplication after laparoscopic Heller myotomy (LHM) for achalasia. Electronic database PubMed, Ovid (Evidence-Based Medicine Reviews, EmBase and Ovid MEDLINE) and Cochrane Library were searched between January 1995 and September 2012. Bibliographic citation management software (EndNote X3) was used for extracted literature management. Quality assessment of random controlled studies (RCTs) and non-RCTs was performed according to the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 and a modification of the Newcastle-Ottawa Scale, respectively. The data were analyzed using Review Manager (Version 5.1), and sensitivity analysis was performed by sequentially omitting each study. Finally, 6 studies, including a total of 523 achalasia patients, compared Dor fundoplication with other types of fundoplication after LHM (Dor-other group), and 8 studies, including a total of 528 achalasia patients, compared Dor fundoplication with no fundoplication after LHM (Dor-no group). Dor fundoplication was associated with a significantly higher recurrence rate of clinical regurgitation and pathological acid reflux compared with the other fundoplication group (OR = 7.16, 95%CI: 1.25-40.93, P = 0.03, and OR = 3.79, 95%CI: 1.23-11.72, P = 0.02, respectively). In addition, there were no significant differences between Dor fundoplication and no fundoplication in all subjects. Other outcomes, including complications, dysphagia, postoperative physiologic testing, and operation-related data displayed no significant differences in the two comparison groups. Dor fundoplication is not the optimum procedure after LHM for achalasia. We suggest more attention should be paid on quality of life among different fundoplications.

Long-term results of pneumatic dilatation for relapsing symptoms of achalasia after Heller myotomy.

PubMed

Legros, Ludivine; Ropert, Alain; Brochard, Charlène; Bouguen, Guillaume; Pagenault, Maël; Siproudhis, Laurent; Bretagne, Jean-François

2014-09-01

The aim of this study was to assess the efficacy and safety of pneumatic dilatation (PD) to treat symptom recurrence after Heller myotomy (HM). Consecutive patients receiving PD for relapsing symptoms following prior HM were included in this retrospective single-center study. Eckardt score ≤3 and/or ∆ Eckardt (difference between Eckardt score before and after dilatation) ≥3 defined the success of initial dilatation. Patients who maintained response longer than 2 months after initial dilatation were defined as short-term responders. Relapsers were offered further on-demand dilatation. Remission was defined as an Eckardt score ≤3 at the study endpoint. Kaplan-Meier survival curves were used to determine relapse rates. Eighteen patients (11 women, seven men) were included from January 2004 to January 2013. Ten patients had type I achalasia, and seven had type III, according to the Chicago classification. Thirty-nine PDs were performed (1.5 [1-2.25] per patient). All patients had short-term responses. The remission rate at the endpoint, after a median follow-up of 33 months, was 78%, but 44% were treated with on-demand PD during the follow-up interval. The proportions of patients without relapse and subsequent PD were 72% at 12 months, 65% at 24 and 36 months, and 49% at 48 months. No factors predictive of long-term response, particularly the type of achalasia, could be identified in this series. There were no perforations. In treating symptom recurrence following HM, PD was safe and effective over the long term when combined with subsequent PD. © 2014 John Wiley & Sons Ltd.

Comparison of outcomes of laparoscopic Heller myotomy versus per-oral endoscopic myotomy for management of achalasia

PubMed Central

Burdick, J. S.; Ogola, Gerald O.; Ontiveros, Estrellita

2017-01-01

Achalasia is a rare disorder that has several treatment options. The gold standard of treatment is a surgical myotomy called a laparoscopic Heller myotomy (LHM). More recently, an endoscopic myotomy has become an option as well, called per-oral endoscopic myotomy (POEM). An achalasia registry was queried for patients undergoing either LHM or POEM at Baylor University Medical Center at Dallas. Patient demographics, preoperative and postoperative data points, and Eckardt scores were collected. The patients were further stratified into their follow-up intervals, immediate postoperative and long-term follow-up, to assess surgical success. A subset analysis was done for success of treatment for patients who had redo surgery versus those undergoing the procedure for the first time. There were 12 patients in the POEM group and 11 patients in the LHM group. Both groups demonstrated mean lower esophageal sphincter pressures with failure to relax. Procedure length and hospital length of stay were similar between the two groups. There were three adverse events in each group, but none altered the patient's postoperative clinical course. Eckardt scores, used to assess success of the surgery, were 82% for POEM patients and 66% for LHM patients after 6 months. The outcomes for POEM and LHM in our early experience are similar to those reported in the literature for high-volume centers managing achalasia. PMID:28966450

Comparison of outcomes of laparoscopic Heller myotomy versus per-oral endoscopic myotomy for management of achalasia.

PubMed

Leeds, Steven G; Burdick, J S; Ogola, Gerald O; Ontiveros, Estrellita

2017-10-01

Achalasia is a rare disorder that has several treatment options. The gold standard of treatment is a surgical myotomy called a laparoscopic Heller myotomy (LHM). More recently, an endoscopic myotomy has become an option as well, called per-oral endoscopic myotomy (POEM). An achalasia registry was queried for patients undergoing either LHM or POEM at Baylor University Medical Center at Dallas. Patient demographics, preoperative and postoperative data points, and Eckardt scores were collected. The patients were further stratified into their follow-up intervals, immediate postoperative and long-term follow-up, to assess surgical success. A subset analysis was done for success of treatment for patients who had redo surgery versus those undergoing the procedure for the first time. There were 12 patients in the POEM group and 11 patients in the LHM group. Both groups demonstrated mean lower esophageal sphincter pressures with failure to relax. Procedure length and hospital length of stay were similar between the two groups. There were three adverse events in each group, but none altered the patient's postoperative clinical course. Eckardt scores, used to assess success of the surgery, were 82% for POEM patients and 66% for LHM patients after 6 months. The outcomes for POEM and LHM in our early experience are similar to those reported in the literature for high-volume centers managing achalasia.

A Matched Comparison of Per Oral Endoscopic Myotomy to Laparoscopic Heller Myotomy in the Treatment of Achalasia.

PubMed

Schneider, Andreas M; Louie, Brian E; Warren, Heather F; Farivar, Alexander S; Schembre, Drew B; Aye, Ralph W

2016-11-01

Per oral endoscopic myotomy (POEM) is increasingly utilized to treat patients with achalasia. Early results have demonstrated significant improvement of symptoms, but there are concerns about postoperative reflux. With only limited comparative data available, we sought to compare POEM to laparoscopic Heller myotomy (LHM) with partial fundoplication. This is a retrospective review of 42 POEM and 84 LHM patients undergoing primary myotomy for achalasia. Patients were matched by achalasia type, by Eckardt and dysphagia scores, and by quality of life (QOL) metrics. Analysis at 6-12-month follow-up evaluated these metrics, PPI use, pH, manometric, and endoscopic data. We matched 25 patients with achalasia types I (6), II (13), and III (6). Follow-up was longer for LHM at 158.1 (36.5-272.9) weeks versus 36.2 (22.2-41.2) weeks (p = 0.001). Eckardt scores, QOL metrics, and dysphagia significantly improved in both groups. DeMeester scores and total percent time less than 4 were abnormal in both groups and comparable (p = 0.925 and p = 0.838). Esophagitis was seen in 53.4 % (POEM) and 31.6 % (LHM) (Yates' p = 0.91), and PPI use was equivalent at 36 %. Early clinical outcomes are excellent with POEM and comparable to the standard of care LHM. Long-term follow-up is required as concerns for reflux persist.

Outcome of Peroral Endoscopic Myotomy (POEM) for Treating Achalasia Compared With Laparoscopic Heller Myotomy (LHM).

PubMed

Peng, Lijun; Tian, Shuni; Du, Chao; Yuan, Ziying; Guo, Mingxiao; Lu, Lin

2017-02-01

Peroral endoscopic myotomy (POEM) is an emerging endoscopic treatment for achalasia and the long-term efficacy of POEM remains to be evaluated. This study compared the outcomes of POEM with that of the standard laparoscopic Heller myotomy (LHM) for achalasia. Achalasia patients treated by POEM or LHM were retrospectively analyzed, with a minimum postoperative follow-up of 3 years. Perioperative outcomes and long-term outcomes including treatment success (Eckardt score ≤3), occurrence of gastroesophageal reflux disease (GERD) (GerdQ score ≥9) and quality of life (36-item short form) were compared. Thirteen patients who underwent POEM were compared with 18 patients who received LHM. These patients were similar in age, sex, symptoms duration, Eckardt score, and previous therapy (all P>0.05). Mean myotomy lengths were similar (P=0.73). Operation time was shorter in the POEM group (P=0.001). One patient (7.7%) developed pneumothorax after POEM and 1 patient (5.6%) experienced postoperative infection after LHM (P=1.00). Treatment success was achieved in 83.3% (9/12) of POEM patients and 80.0% (12/15) of LHM patients (P=1.00). Both POEM and LHM significantly reduced Eckardt score (both P=0.00). GERD rate was similar (8.3% vs. 6.7%, P=1.00). There was no difference in all aspects of quality of life between the 2 groups. Long-term outcomes indicate that POEM is an effective treatment that is comparable with LHM. More data of randomized trials comparing POEM with LHM will enrich the existing evidence.

Postoperative Gastroesophageal Reflux After Laparoscopic Heller-Dor for Achalasia: True Incidence with an Objective Evaluation.

PubMed

Salvador, Renato; Pesenti, Elisa; Gobbi, Laura; Capovilla, Giovanni; Spadotto, Lorenzo; Voltarel, Guerrino; Cavallin, Francesco; Nicoletti, Loredana; Valmasoni, Michele; Ruol, Alberto; Merigliano, Stefano; Costantini, Mario

2017-01-01

The most common complication after laparoscopic Heller-Dor (LHD) is gastroesophageal reflux disease (GERD). The present study aimed (a) to analyze the true incidence of postoperative reflux by objectively assessing a large group of LHD patients and (b) to see whether the presence of typical GERD symptoms correlates with the real incidence of postoperative reflux. After LHD, patients were assessed by means of a symptom score, endoscopy, esophageal manometry, and 24-h pH monitoring. Patients were assigned to three groups: those did not accept to perform 24-h pH monitoring (group NP); those with normal postoperative pH findings (group A); and those with pathological postoperative acid exposure (group B). Four hundred sixty-three of the 806 LHD patients agreed to undergo follow-up 24-h pH monitoring. Normal pH findings were seen in 423 patients (group A, 91.4 %), while 40 (8.6 %) had a pathological acid exposure (group B). The median symptom scores were similar: 3.0 (IQR 0-8) in group A and 6.0 (IQR 0-10) in group B (p = 0.29). At endoscopy, the percentage of esophagitis was also similar (11 % in group A, 19 % in group B; p = 0.28). This study demonstrated that, after LHD was performed by experienced surgeons, the true incidence of postoperative GERD is very low. The incidence of this possible complication should be assessed by pH monitoring because endoscopic findings and symptoms may be misleading.

Comparison of esophagogastric junction distensibility changes during POEM and Heller myotomy using intraoperative FLIP.

PubMed

Teitelbaum, Ezra N; Boris, Lubomyr; Arafat, Fahd O; Nicodème, Frédéric; Lin, Zhiyue; Kahrilas, Peter J; Pandolfino, John E; Soper, Nathaniel J; Hungness, Eric S

2013-12-01

Peroral endoscopic myotomy (POEM) is a novel endoscopic surgical procedure for the treatment of achalasia. The comparative effects of POEM and laparoscopic Heller myotomy (LHM) on esophagogastric junction (EGJ) physiology are unknown. A novel measurement catheter, the functional lumen imaging probe (FLIP), allows for intraoperative evaluation of EGJ compliance by measuring luminal geometry and pressure during volume-controlled distensions. Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by pressure) was measured with FLIP intraoperatively in patients undergoing LHM and POEM. Separate measurements were taken after each operative step. During LHM, measurements were performed after: (1) induction of anesthesia, (2) insufflation of pneumoperitoneum, (3) hiatal dissection and esophageal mobilization, (4) myotomy, (5) partial fundoplication, and (6) deinsufflation. During POEM, they were performed after: (1) induction of anesthesia, (2) submucosal tunnel creation, and (3) myotomy. Eleven LHM and 14 POEM patients underwent intraoperative FLIP. Baseline DI was similar between groups. LHM resulted in an overall increase in mean DI (pre 1.4 vs. post 7.6 mm(2)/mmHg, using a 40-ml distension volume; p < 0.001). Insufflation of pneumoperitoneum and hiatal dissection did not affect DI. Myotomy caused an increase in DI. Partial fundoplication (6 Toupet, 5 Dor) caused a decrease in DI, and deinsufflation caused an increase in DI. POEM also resulted in an overall increase in mean DI (pre 1.4 vs. post 7.9 mm(2)/mmHg; p < 0.001). Measured individually, both submucosal tunnel creation and myotomy caused increases in DI. When overall changes were compared, there were no differences in the amount of DI increase between LHM and POEM. POEM and LHM result in a similar improvement in EGJ distensibility intraoperatively. Further study is needed to correlate intraoperative FLIP measurements with postoperative symptomatic and physiologic outcomes.

Dor Vs Toupet Fundoplication After Laparoscopic Heller Myotomy: Long-Term Randomized Controlled Trial Evaluated by High-Resolution Manometry.

PubMed

Torres-Villalobos, Gonzalo; Coss-Adame, Enrique; Furuzawa-Carballeda, Janette; Romero-Hernández, Fernanda; Blancas-Breña, Blanca; Torres-Landa, Samuel; Palacios-Ramírez, Axel; Alejandro-Medrano, Edgar; Hernández-Ávila, Axel; Flores-Najera, Athenea; Ávila Escobedo, Lourdes Margarita; Ramírez Angulo, Cecilia; Rodríguez-Garcés, Angélica; Valdovinos, Miguel Ángel

2018-01-01

Laparoscopic Heller myotomy (LHM) with partial fundoplication is an effective treatment for achalasia. However, the type of fundoplication is still a subject of debate. The aim of the study is to identify which partial fundoplication leads to better control of acid exposure, manometric parameters, and symptoms scores. A randomized controlled trial was performed to compare Dor vs Toupet fundoplication after LHM. The preoperative diagnosis was made by high-resolution manometry (HRM), upper endoscopy, and barium esophagogram. Preoperative and postoperative symptoms were evaluated with Eckardt, GERD-HRQL, and EAT-10 questionnaires. Seventy-three patients were randomized, 38 underwent Dor and 35 Toupet. Baseline characteristics were similar between groups. Postoperative HRM showed that the integrated relaxation pressure (IRP) and basal lower esophageal sphincter (LES) pressure were similar at 6 and 24 months. The number of patients with abnormal acid exposure was significantly lower for Dor (6.9%) than that of Toupet (34.0%) at 6 months, but it was not different at 12 or 24 months. No differences were found in postoperative symptom scores at 1, 6, or 24 months. There were no differences in symptom scores or HRM between fundoplications in the long term. A higher percentage of abnormal 24-h pH test were found for the Toupet group, with no difference in the long term.

Laparoscopic Heller Myotomy vs Per Oral Endoscopic Myotomy: Patient-Reported Outcomes at a Single Institution.

PubMed

Hanna, Andrew N; Datta, Jashodeep; Ginzberg, Sara; Dasher, Kevin; Ginsberg, Gregory G; Dempsey, Daniel T

2018-04-01

Although laparoscopic Heller myotomy (LHM) has been the standard of care for achalasia, per oral endoscopic myotomy (POEM) has gained popularity as a viable alternative. This retrospective study aimed to compare patient-reported outcomes between LHM and POEM in a consecutive series of achalasia patients with more than 1 year of follow-up. We reviewed demographic and procedure-related data for patients who underwent either LHM or POEM for achalasia between January 2011 and May 2016. Phone interviews were conducted assessing post-procedure achalasia symptoms via the Eckardt score and achalasia severity questionnaire (ASQ). Demographics, disease factors, and survey results were compared between LHM and POEM patients using univariate analysis. Significant predictors of procedure failure were analyzed using univariate and multivariate analysis. There were no serious complications in 110 consecutive patients who underwent LHM or POEM during the study period, and 96 (87%) patients completed phone surveys. There was a nonsignificant trend toward better patient-reported outcomes with POEM. There were significant differences in patient characteristics including sex, achalasia type, mean residual lower esophageal pressure (rLESP), and follow-up time. The only univariate predictors of an unsatisfactory Eckardt score or ASQ were longer follow-up and lower rLESP, with follow-up length being the only predictor on multivariate analysis. There were significant demographic and clinical differences in patient selection for POEM vs LHM in our group. Although the 2 procedures have similar patient-reported effectiveness, subjective outcomes seem to decline as a result of time rather than procedure type. Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy.

PubMed

Ngamruengphong, Saowanee; Inoue, Haruhiro; Ujiki, Michael B; Patel, Lava Y; Bapaye, Amol; Desai, Pankaj N; Dorwat, Shivangi; Nakamura, Jun; Hata, Yoshitaka; Balassone, Valerio; Onimaru, Manabu; Ponchon, Thierry; Pioche, Mathieu; Roman, Sabine; Rivory, Jérôme; Mion, François; Garros, Aurélien; Draganov, Peter V; Perbtani, Yaseen; Abbas, Ali; Pannu, Davinderbir; Yang, Dennis; Perretta, Silvana; Romanelli, John; Desilets, David; Hayee, Bu; Haji, Amyn; Hajiyeva, Gulara; Ismail, Amr; Chen, Yen-I; Bukhari, Majidah; Haito-Chavez, Yamile; Kumbhari, Vivek; Saxena, Payal; Talbot, Michael; Chiu, Philip Wai-Yan; Yip, Hon-Chi; Wong, Vivien Wai-Yin; Hernaez, Ruben; Maselli, Roberta; Repici, Alessandro; Khashab, Mouen A

2017-10-01

In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM. We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non-HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months. POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non-HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non-HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non-HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups. POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups. Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.

Specific esophagogram to assess functional outcomes after Heller's myotomy and Dor's fundoplication for esophageal achalasia.

PubMed

Tsoukali, E; Gouvas, N; Tsiaoussis, J; Pechlivanides, G; Zervakis, N; Mantides, A; Xynos, E

2011-09-01

Esophageal emptying assessed at the 'timed barium' esophagogram correlates well with symptomatic outcomes after pneumatic dilation for esophageal achalasia, although 30% of patients with satisfactory outcome exhibit partial improvement in emptying. The aim of the study was to investigate any correlation of esophageal emptying to symptomatic response after laparoscopic Heller's myotomy and Dor's fundoplication. 'Bread and barium' (transit time of a barium opaque bread bolus) and 'timed barium' (height of esophageal barium column 5 minutes after ingestion of 200-250 mL of barium suspension) esophagogram was used to assess esophageal emptying in 73 patients with esophageal achalasia before 1 and 5 years (31 cases) after laparoscopic myotomy and anterior fundoplication. Symptoms assessment was based to a specific score. At 1-year follow-up, excellent and good symptomatic results were obtained in 95% of the cases. Esophageal maximum diameter, esophageal transit time, and esophageal barium column were significantly correlated to each other and to symptom score postoperatively (P < 0.001). Complete and partial (<90% and 50-90% postoperative reduction in barium column, respectively) emptying was seen in 55% and 31% of patients with excellent result. Patients with a pseudodiverticulum postoperatively had a more delayed esophageal emptying than those without. Symptomatic outcome and esophageal emptying did not deteriorate at 5-year follow-up. Esophageal emptying assessed by 'barium and bread' and 'timed barium' esophagogram correlated well with symptomatic outcome after laparoscopic myotomy for esophageal achalasia. Complete symptomatic relief does not necessarily reflect complete esophageal emptying. Outcomes do not deteriorate by time. Because of wide availability, esophagogram can be applied in follow-up of postmyotomy patients in conjunction with symptomatic evaluation. © 2011 Copyright the Authors. Journal compilation © 2011, Wiley Periodicals, Inc. and the

[Laparoscopic Heller myotomy after failed POEM and multiple balloon dilatations : Better late than never].

PubMed

Giulini, L; Dubecz, A; Stein, H J

2017-04-01

Despite the lack of long-term results, peroral endoscopic myotomy (POEM) has been increasingly propagated as a feasible alternative to pneumatic balloon dilatation (BD) and laparoscopic Heller myotomy (LHM) in patients with achalasia. After a long-term follow-up, a large percentage of patients reported recurrence of dysphagia. It is unclear which kind of procedure (redo POEM or LHM) should be utilized in these patients with failed POEM. We report the case of a 37-year-old female patient with type I achalasia who was successfully treated with LHM after a failed POEM procedure. After the manometric diagnosis of type I achalasia, the patient was treated with six balloon dilatations within a period of 5 months. Because of the persistence of symptoms a POEM procedure was performed with no relief and the patient was referred for surgical treatment. An esophagography showed a pronounced widening of the middle and the distal esophagus with a persistent narrowing of the lower esophageal sphincter (LES) and because of these indications LHM was performed. The intraoperative examination revealed extensive scarring of the submucosal layer with the muscularis mucosae of the distal esophagus; nevertheless, it was possible to carry out a 5 cm long cardiomyotomy without mucosal injury. The operation was completed with a Dor fundoplication. There were no postoperative complications. After surgery the patient reported an immediate and complete relief of dysphagia. The published experiences with POEM seem to show promising short-term results in terms of dysphagia relief; however, the few available mid-term analyses demonstrated no essential advantages when compared to LHM; therefore, the LHM must still be considered the gold standard procedure for definitive treatment of achalasia. According to our case report, LHM was shown to be a safe and effective although laborious treatment option due to scarring even after failed treatment by POEM.

Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis.

PubMed

Schlottmann, Francisco; Luckett, Daniel J; Fine, Jason; Shaheen, Nicholas J; Patti, Marco G

2018-03-01

To compare the outcome of per oral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia. Over the last 2 decades, LHM has become the primary form of treatment in many centers. However, since the first description of POEM in 2010, this technique has widely disseminated, despite the absence of long-term results and randomized trials. A systematic Medline literature search of articles on LHM and POEM for the treatment of achalasia was performed. The main outcomes measured were improvement of dysphagia and posttreatment gastroesophageal reflux disease (GERD). Linear regression was used to model the effect of each procedure on the different outcomes. Fifty-three studies reported data on LHM (5834 patients), and 21 articles examined POEM (1958 patients). Mean follow-up was significantly longer for studies of LHM (41.5 vs. 16.2 mo, P < 0.0001). Predicted probabilities for improvement in dysphagia at 12 months were 93.5% for POEM and 91.0% for LHM (P = 0.01), and at 24 months were 92.7% for POEM and 90.0% for LHM (P = 0.01). Patients undergoing POEM were more likely to develop GERD symptoms (OR 1.69, 95% CI 1.33-2.14, P < 0.0001), GERD evidenced by erosive esophagitis (OR 9.31, 95% CI 4.71-18.85, P < 0.0001), and GERD evidenced by pH monitoring (OR 4.30, 95% CI 2.96-6.27, P < 0.0001). On average, length of hospital stay was 1.03 days longer after POEM (P = 0.04). Short-term results show that POEM is more effective than LHM in relieving dysphagia, but it is associated with a very high incidence of pathologic reflux.

Major Complications of Pneumatic Dilation and Heller Myotomy for Achalasia: Single Center Experience and Systematic Review of the Literature

PubMed Central

Lynch, Kristle L; Pandolfino, John E; Howden, Colin W; Kahrilas, Peter J

2013-01-01

Background & Aims Pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) can be definitive therapies for achalasia; recent data suggest comparable efficacy. However, risk must also be considered. We reviewed the major complication rate of PD and LHM in a high volume center and reviewed the corresponding literature. Methods We reviewed 12 years of our institution’s achalasia treatment experience. During this interval a consistent technique of PD was used utilizing Rigiflex dilators. Medical records were reviewed for post-procedure complications. We administered a telephone survey and examined medical records to assess efficacy of treatment. We also performed a systematic review of the literature for comparable clinical data and examined 80 reports encompassing 12,494 LHM and PD procedures. Results At our center, 463 achalasia patients underwent 567 PD or LHM procedures. 78% of the PDs used a 30 mm Rigiflex dilator. 157/184 (85%) patients underwent 1 or 2 PD without any subsequent treatment. There were seven clinically significant perforations; one from PD and 6 from LHM. There were no resultant deaths from these perforations; two deaths occurred within 30 days of LHM from unrelated causes. Complications and deaths post-PD were significantly fewer than those post-LHM (p=.02). Conclusions Esophageal perforation from PD at our high-volume center was less common than often reported and lower than that associated with LHM. We conclude that, in the hands of experienced operators using conservative technique, PD has fewer major complications and deaths than LHM. PMID:23032978

Laparoscopic Heller myotomy is not superior to pneumatic dilation in the management of primary achalasia

PubMed Central

Cheng, Ji-Wei; Li, Yin; Xing, Wen-Qun; Lv, Hong-Wei; Wang, Hao-Ran

2017-01-01

Abstract Background: Achalasia is an esophageal motility disorder, of unknown cause, which results in increased lower esophageal sphincter tone and symptoms of difficulty swallowing. Current major therapeutic options include laparoscopic Heller myotomy (LHM) and pneumatic dilation (PD). We undertake a systematic review comparing the efficacy and safety of these 2 treatments in the treatment of esophageal achalasia. Methods: PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for randomized controlled trial investigating LHM versus PD in the treatment of primary achalasia. The primary outcome was symptom remission rates. The Mantel–Haenszel method with fixed-effect or random-effects model was used to calculate relative risks and 95% confidence intervals (CIs). Results: Five studies involving 498 participants were included. The cumulative remission rate was significantly higher with LHM at 3 months and 1 year (short-term), with a risk ratio of 1.16 (95% CI 1.01–1.35, P = 0.04) and 1.14 (95% CI 1.02–1.27, P = 0.02), respectively. There were no significant differences between LHM and PD in 2-year and 5-year remission rate (long-term), with a risk ratio of 1.05 (95% CI 0.91–1.22, P = 0.49) and 1.17 (95% CI 0.84–1.64, P = 0.34), respectively. Rates of major mucosal tears requiring subsequent intervention with LHM were significantly lower than those of esophageal perforation with PD requiring postprocedural medical or surgical therapy, with a risk ratio of 0.25 (95% CI 0.08–0.81, P = 0.02). Postprocedural rates of gastroesophageal reflux, lower esophageal sphincter pressures, and quality of life scores did not differ in trials with sufficient data. Conclusions: There were no significant differences between LHM and PD in 2-year and 5-year remission rate. This study indicates that either treatment can be proposed as initial treatment for achalasia. PMID:28207499

Per-Oral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Nonrandomized Comparative Studies.

PubMed

Zhang, Yuan; Wang, Hongjuan; Chen, Xingdong; Liu, Lan; Wang, Hongbo; Liu, Bin; Guo, Jianqiang; Jia, Hongying

2016-02-01

We aimed to assess the short-term outcomes of per-oral endoscopic myotomy (POEM) compared with laparoscopic Heller myotomy (LHM) for achalasia through a meta-analysis of nonrandomized comparative studies.We searched PubMed, Embase, Medline, Cochrane Library, and Google Scholar for studies that compared POEM and LHM for achalasia and were published between January 1, 2008 and December 31, 2014. The Methodological Index for Nonrandomized Studies (MINORS) was used to evaluate the quality of the studies. Random- and fixed-effects meta-analytical models were used, and between-study heterogeneity was assessed.Four nonrandomized comparative studies that included 317 patients (125 in the POEM group and 192 in the LHM group) met our research criteria and were assessed. There were no differences between the POEM and LHM groups in terms of sex, preoperative Eckhart score, length of myotomy, operation time, length of hospital stay, and complications. The patients in the POEM group were older than those in the LHM group (MD =2.81, 95% CI 0.27-5.35; P = 0.03) with high between-study homogeneity (χ = 1.96, df = 2, I = 0%; P = 0.38). The patients in the POEM group had a lower Eckardt score after surgery compared with those in the LHM group (MD = -0.30, 95% CI -0.42 to -0.18; P < 0.001) with high between-study homogeneity (χ = 0.00, df = 1, I = 0%; P = 1.00).The efficacy and safety of POEM appear to be comparable to those of LHM. Multicenter and randomized trials with larger sample size are needed to further compare the efficacy and safety of POEM and LHM for the treatment of achalasia.

Cost-effectiveness of per oral endoscopic myotomy relative to laparoscopic Heller myotomy for the treatment of achalasia.

PubMed

Greenleaf, Erin K; Winder, Joshua S; Hollenbeak, Christopher S; Haluck, Randy S; Mathew, Abraham; Pauli, Eric M

2018-01-01

Per oral endoscopic myotomy (POEM) has recently emerged as a viable option relative to the classic approach of laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia. In this cost-utility analysis of POEM and LHM, we hypothesized that POEM would be cost-effective relative to LHM. A stochastic cost-utility analysis of treatment for achalasia was performed to determine the cost-effectiveness of POEM relative to LHM. Costs were estimated from the provider perspective and obtained from our institution's cost-accounting database. The measure of effectiveness was quality-adjusted life years (QALYs) which were estimated from direct elicitation of utility using a visual analog scale. The primary outcome was the incremental cost-effectiveness ratio (ICER). Uncertainty was assessed by bootstrapping the sample and computing the cost-effectiveness acceptability curve (CEAC). Patients treated within an 11-year period (2004-2016) were recruited for participation (20 POEM, 21 LHM). During the index admission, the mean costs for POEM ($8630 ± $2653) and the mean costs for LHM ($7604 ± $2091) were not significantly different (P = 0.179). Additionally, mean QALYs for POEM (0.413 ± 0.248) were higher than that associated with LHM (0.357 ± 0.338), but this difference was also not statistically significant (P = 0.55). The ICER suggested that it would cost an additional $18,536 for each QALY gained using POEM. There was substantial uncertainty in the ICER; there was a 48.25% probability that POEM was cost-effective at the mean ICER. At a willingness-to-pay threshold of $100,000, there was a 68.31% probability that POEM was cost-effective relative to LHM. In the treatment of achalasia, POEM appears to be cost-effective relative to LHM depending on one's willingness-to-pay for an additional QALY.

The discovery of Caligus macrurus Heller, 1865 (Copepoda: Caligidae) in the Mediterranean Sea, and the recognition of Sciaenophilus van Beneden, 1852 as a junior synonym of Caligus Müller, 1785.

PubMed

Özak, Argun Akif; Yanar, Alper; Boxshall, Geoffrey Allan

2017-01-01

The siphonostomatoid parasitic copepod Caligus macrurus Heller, 1865 is redescribed based on new material collected from the gill filaments and pharynx of tripletail Lobotes surinamensis Bloch (Lobotidae) caught in Iskenderun Bay, Turkey. Key diagnostic characters and newly observed taxonomic features are reported, supported by light and scanning electron microscopy observations. This is the first report of C. macrurus from Mediterranean waters. Caligus macrurus is also recognised as conspecific with the better known Caligus bennetti Causey, 1953, found on the same host, which becomes a junior subjective synonym of C. macrurus. Caligus O.F. Müller, 1785 and Sciaenophilus van Beneden, 1852 have both been treated as valid genera within the family Caligidae although numerous doubts have been expressed over the validity of the latter. The morphological evidence does not support generic level distinction and we recommend the transfer of all species currently placed in Sciaenophilus into Caligus as C. tenuis (van Beneden, 1852), C. pharaonis von Nordmann, 1832, C. nibeae Shen, 1957 and C. macrurus.

Esophagogastric junction distensibility measurements during Heller myotomy and POEM for achalasia predict postoperative symptomatic outcomes

PubMed Central

Teitelbaum, Ezra N.; Soper, Nathaniel J.; Pandolfino, John E.; Kahrilas, Peter J.; Hirano, Ikuo; Boris, Lubomyr; Nicodème, Frédéric; Lin, Zhiyue; Hungness, Eric S.

2015-01-01

Background The functional lumen imaging probe (FLIP) is a novel diagnostic tool that can be used to measure esophagogastric junction (EGJ) distensibility. In this study we performed intraoperative FLIP measurements during laparoscopic Heller myotomy (LHM) and peroral esophageal myotomy (POEM) for treatment of achalasia and evaluated the relationship between EGJ distensibility and postoperative symptoms. Methods Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by distensive pressure) was measured with FLIP at two time points during LHM and POEM: 1) at baseline after induction of anesthesia, and 2) after operation completion. Results Measurements were performed in 20 patients undergoing LHM and 36 undergoing POEM. Both operations resulted in an increase in DI, although this increase was larger with POEM (7±3.1 vs. 5.1±3.4mm2/mmHg, p<.05). The two patients (both LHM) with the smallest increases in DI (1 and 1.6mm2/mmHg) both had persistent symptoms postoperatively and, overall, LHM patients with larger increases in DI had lower postoperative Eckardt scores. In the POEM group, there was no correlation between change in DI and symptoms; however, all POEM patients experienced an increase in DI of >3mm2/mmHg. When all patients were divided into thirds based on final DI, none in the lowest DI group (<6mm2/mmHg) had symptoms suggestive of reflux (i.e., GerdQ score >7), as compared with 20% in the middle third (6–9mm2/mmHg) and 36% in the highest third (>9mm2/mmHg). Patients within an “ideal” final DI range (4.5–8.5 mm2/mmHg) had optimal symptomatic outcomes (i.e. Eckardt≤1 and GerdQ≤7) in 88% of cases, compared with 47% in those with a final DI above or below that range (p<.05). Conclusions Intraoperative EGJ distensibility measurements with FLIP were predictive of postoperative symptomatic outcomes. These results provide initial evidence that FLIP has the potential to act as a useful calibration tool during operations

National outcomes of laparoscopic Heller myotomy: operative complications and risk factors for adverse events.

PubMed

Ross, Samuel W; Oommen, Bindhu; Wormer, Blair A; Walters, Amanda L; Matthews, Brent D; Heniford, B T; Augenstein, Vedra A

2015-11-01

Laparoscopic Heller myotomy (LHM) has supplanted an open approach due to decreased operative morbidity. Our goal was to quantify the incidence of peri-operative complications and identify risk factors for adverse outcomes in LHM. All LHM were queried from 2005 to 2011 from the National Surgical Quality Improvement Program database. Adverse outcomes were identified, and univariate and stepwise logistic regression (MVR) was then performed to quantify association. There were 1,237 LHM in the study period. Patient averages were: age 51.9 ± 16.8 years, BMI 27.3 ± 6.6 kg/m(2), Charlson comorbidity index (CCI) 0.2 ± 0.6. 15.3 % had >10 % body mass loss in the preoperative 6 months. During surgery, 10.2 % underwent concomitant EGD, and mean operative time was 141.6 ± 63.4 min. There were 7(0.06 %) wound complications, 22(1.8 %) general complications, and 30(2.4 %) major complications. Average length of stay (LOS) was 2.8 ± 5.5 days. The rate of readmission and reoperation were 3.1 and 2.3 %, respectively, and there were 4(0.03 %) deaths. General and major complications were associated with alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times (p < 0.05); however, these factors did not remain significant on MVR (p > 0.05). Operative time was found to be significantly longer by 35.3 min for inpatients, 43.1 min in functionally dependent patients, 50.0 min in preoperative septic patients, and 17.2 min with concomitant EGD (p < 0.01 for all). LOS was found to be longer by 1.9 days for inpatients, 1.8 days in ASA category ≥3, and 1.2 days per one point increase in CCI (p < 0.001 for all). LHM is being performed nationally with a low incidence of operative complications and mortality. General and major complications following LHM are associated with patient alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times

Development of a novel ex vivo porcine laparoscopic Heller myotomy and Nissen fundoplication training model (Toronto lap-Nissen simulator).

PubMed

Ujiie, Hideki; Kato, Tatsuya; Hu, Hsin-Pei; Bauer, Patrycja; Patel, Priya; Wada, Hironobu; Lee, Daiyoon; Fujino, Kosuke; Schieman, Colin; Pierre, Andrew; Waddell, Thomas K; Keshavjee, Shaf; Darling, Gail E; Yasufuku, Kazuhiro

2017-06-01

Surgical trainees are required to develop competency in a variety of laparoscopic operations. Developing laparoscopic technical skills can be difficult as there has been a decrease in the number of procedures performed. This study aims to develop an inexpensive and anatomically relevant model for training in laparoscopic foregut procedures. An ex vivo , anatomic model of the human upper abdomen was developed using intact porcine esophagus, stomach, diaphragm and spleen. The Toronto lap-Nissen simulator was contained in a laparoscopic box-trainer and included an arch system to simulate the normal radial shape and tension of the diaphragm. We integrated the use of this training model as a part of our laparoscopic skills laboratory-training curriculum. Afterwards, we surveyed trainees to evaluate the observed benefit of the learning session. Twenty-five trainees and five faculty members completed a survey regarding the use of this model. Among the trainees, only 4 (16%) had experience with laparoscopic Heller myotomy and Nissen fundoplication. They reported that practicing with the model was a valuable use of their limited time, repeating the exercise would be of additional benefit, and that the exercise improved their ability to perform or assist in an actual case in the operating room. Significant improvements were found in the following subjective measures comparing pre- vs. post-training: (I) knowledge level (5.6 vs. 8.0, P<0.001); (II) comfort level in assisting (6.3 vs. 7.6, P<0.001); and (III) comfort level in performing as the primary surgeon (4.9 vs. 7.1, P<0.001). The trainees and faculty members agreed that this model was of adequate fidelity and was a representative simulation of actual human anatomy. We developed an easily reproducible training model for laparoscopic procedures. This simulator reproduces human anatomy and increases the trainees' comfort level in performing and assisting with myotomy and fundoplication.

Difficult Myotomy Is Not Determined by Preoperative Therapy and Does Not Impact Outcome

PubMed Central

Villadolid, Desiree V.; Al-Saadi, Sam; Rosemurgy, Alexander S.

2007-01-01

Objectives: The impact of preoperative endoscopic therapy on the difficulty of laparoscopic Heller myotomy and the impact of the difficulty of the myotomy on long-term outcome has not been determined. This study was undertaken to determine whether preoperative therapy impacts the difficulty of laparoscopic Heller myotomy and whether preoperative therapy or difficulty of myotomy impacts long-term outcomes. Methods: Since 1992, 305 patients, 56% male, median age 49 years, underwent laparoscopic Heller myotomy and were prospectively followed. The difficulty of the laparoscopic Heller myotomy was scored by the operating surgeon for the most recent 170 consecutive patients on a scale of 1 (easiest) to 5 (most difficult). Patients scored their symptoms before and after myotomy using a Likert scale from 0 (never/not bothersome) to 10 (always/very bothersome). Results: Before myotomy, 66% of patients underwent endoscopic therapy: 33% dilation, 11% Botox, and 22% both. Preoperative endoscopic therapy did not correlate with the difficulty of the myotomy (P=NS). Median follow-up was 25 months. Regardless of the difficulty of the myotomy, dysphagia improved with myotomy (P<0.0001). By regression analysis, the frequency and severity of postmyotomy dysphagia correlated with neither preoperative endoscopic therapy nor the difficulty of the myotomy. Conclusions: Laparoscopic Heller myotomy improves the frequency and severity of dysphagia. The difficulty of laparoscopic Heller myotomy is not impacted by preoperative therapy, and neither preoperative therapy nor difficulty of the myotomy impact long-term outcome. PMID:17931516

Long-term results of the Heller-Dor operation with intraoperative manometry for the treatment of esophageal achalasia.

PubMed

Mattioli, Sandro; Ruffato, Alberto; Lugaresi, Marialuisa; Pilotti, Vladimiro; Aramini, Beatrice; D'Ovidio, Frank

2010-11-01

Quality of outcome of the Heller-Dor operation is sometimes different between studies, likely because of technical reasons. We analyze the details of myotomy and fundoplication in relation to the results achieved over a 30-year single center's experience. From 1979-2008, a long esophagogastric myotomy and a partial anterior fundoplication to protect the surface of the myotomy was routinely performed with intraoperative manometry in 202 patients (97 men; median age, 55.5 years; interquartile range, 43.7-71 years) through a laparotomy and in 60 patients (24 men; median age, 46 years; interquartile range, 36.2-63 years) through a laparoscopy. The follow-up consisted of periodical interview, endoscopy, and barium swallow, and a semiquantitative scale was used to grade results. Mortality was 1 of 202 in the laparotomy group and 0 of 60 in the laparoscopy group. Median follow-up was 96 months (interquartile range, 48-190.5 months) in the laparotomy group and 48 months (interquartile range, 27-69.5 months) in the laparoscopy group. At intraoperative manometry, complete abolition of the high-pressure zone was obtained in 100%. The Dor-related high-pressure zone length and mean pressure were 4.5 ± 0.4 cm and 13.3 ± 2.2 mm Hg in the laparotomy group and 4.5 ± 0.5 cm and 13.2 ± 2.2 mm Hg in the laparoscopy group (P = .75). In the laparotomy group poor results (19/201 [9.5%]) were secondary to esophagitis in 15 (7.5%) of 201 patients (in 2 patients after 184 and 252 months, respectively) and to recurrent dysphagia in 4 (2%) of 201 patients, all with end-stage sigmoid achalasia. In the laparoscopy group 2 (3.3%) of 60 had esophagitis. A long esophagogastric myotomy protected by means of Dor fundoplication cures or substantially reduces dysphagia in the great majority of patients affected by esophageal achalasia and effectively controls postoperative esophagitis. Intraoperative manometry is likely the key factor for achieving the reported results. Copyright © 2010 The

Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study.

PubMed

Onimaru, Manabu; Inoue, Haruhiro; Ikeda, Haruo; Yoshida, Akira; Santi, Esperanza Grace; Sato, Hiroki; Ito, Hiroaki; Maselli, Roberta; Kudo, Shin-ei

2013-10-01

Surgical Heller myotomy has high rates of successful long-term results, but failed cases still remain. Moreover, the treatment strategy in patients with surgical myotomy failure is controversial. Recently, peroral endscopic myotomy (POEM) was reported to be efficient and safe in primary treatment of achalasia. In this study, we aimed to evaluate the efficacy and safety of POEM for surgical myotomy failure as a rescue second-line treatment, and we discuss the treatment options adapted in achalasia recurrence. A total of 315 consecutive achalasia patients received POEM from September 2008 to December 2012 in our hospital. Eleven (3.5%) patients who had persistent or recurrent achalasia and had received surgical myotomy as a first-line treatment from other hospitals were included in this study. Patient background, barium swallow studies, esophagogastroduodenoscopy (EGD), manometry, and symptom scores were prospectively evaluated. In principle, all patients in whom surgical myotomy failed received pneumatic balloon dilatation (PBD) as the first line "rescue" treatment, and only if PBD failed were patients considered for rescue POEM. The PBD alone was effective in 1 patient, and in the remaining 10 patients, rescue POEM was performed successfully without complications. Three months after rescue POEM, significant reduction in lower esophageal sphincter (LES) resting pressures (22.1 ± 6.6 mmHg vs 10.9 ± 4.5 mmHg, p < 0.01) and Eckardt symptom scores (6.5 ± 1.3 vs 1.1 ± 1.3, p < 0.001) were observed. Short-term results of POEM for failed surgical myotomy were excellent. Long-term results are awaited. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Development of a novel ex vivo porcine laparoscopic Heller myotomy and Nissen fundoplication training model (Toronto lap-Nissen simulator)

PubMed Central

Ujiie, Hideki; Kato, Tatsuya; Hu, Hsin-Pei; Bauer, Patrycja; Patel, Priya; Wada, Hironobu; Lee, Daiyoon; Fujino, Kosuke; Schieman, Colin; Pierre, Andrew; Waddell, Thomas K.; Keshavjee, Shaf; Darling, Gail E.

2017-01-01

Background Surgical trainees are required to develop competency in a variety of laparoscopic operations. Developing laparoscopic technical skills can be difficult as there has been a decrease in the number of procedures performed. This study aims to develop an inexpensive and anatomically relevant model for training in laparoscopic foregut procedures. Methods An ex vivo, anatomic model of the human upper abdomen was developed using intact porcine esophagus, stomach, diaphragm and spleen. The Toronto lap-Nissen simulator was contained in a laparoscopic box-trainer and included an arch system to simulate the normal radial shape and tension of the diaphragm. We integrated the use of this training model as a part of our laparoscopic skills laboratory-training curriculum. Afterwards, we surveyed trainees to evaluate the observed benefit of the learning session. Results Twenty-five trainees and five faculty members completed a survey regarding the use of this model. Among the trainees, only 4 (16%) had experience with laparoscopic Heller myotomy and Nissen fundoplication. They reported that practicing with the model was a valuable use of their limited time, repeating the exercise would be of additional benefit, and that the exercise improved their ability to perform or assist in an actual case in the operating room. Significant improvements were found in the following subjective measures comparing pre- vs. post-training: (I) knowledge level (5.6 vs. 8.0, P<0.001); (II) comfort level in assisting (6.3 vs. 7.6, P<0.001); and (III) comfort level in performing as the primary surgeon (4.9 vs. 7.1, P<0.001). The trainees and faculty members agreed that this model was of adequate fidelity and was a representative simulation of actual human anatomy. Conclusions We developed an easily reproducible training model for laparoscopic procedures. This simulator reproduces human anatomy and increases the trainees’ comfort level in performing and assisting with myotomy and

An illustrated key to the soft-bottom caprellids (Crustacea: Amphipoda) of the Iberian Peninsula and remarks to their ecological distribution along the Andalusian coast

NASA Astrophysics Data System (ADS)

Guerra-García, José M.; Navarro-Barranco, Carlos; Corzo, Juan; Cobos-Muñoz, Vanessa; García-Adiego, Emilio M.; Giménez, Francisco Sempere; García-Gómez, J. Carlos

2013-06-01

The soft-bottom caprellids of the Iberian Peninsula are revised. Nineteen species have been reported so far, 42 % being endemic to the Mediterranean Sea. The lateral view of all of them is provided, together with an illustrated key for all the species. An ecological study was also conducted during 2007-2010 along the Andalusian coast to explore the relationships of caprellids with abiotic data. A total of 90 stations (0-40 m deep) were sampled and 40 contained caprellids. Along the Atlantic, caprellids were present in only 20 % of the stations, while along the Mediterranean coast, caprellids were present in the 75 % of the sampling sites. Furthermore, the abundance of caprellids was also higher in the Mediterranean coast. The dominant species was Pseudolirius kroyeri (present in 24 stations and showing the highest abundances with 1,780 ind/m2), followed by Phtisica marina (22 stations) and Pariambus typicus (11 stations). According to CCA and BIO-ENV, sediment type, P, pH and oxygen were the parameters that better explained the distribution of caprellids. Although the three dominant species were found in all types of sediment, the univariate approach showed that P. kroyeri was significantly more abundant in fine sediments (silt-clay and very fine sands) than in gross sediments (coarse and very coarse sands). The majority of studies dealing with caprellids from the Iberian Peninsula have been focused on shallow waters and further efforts are needed to explore biodiversity of deeper areas.

Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study.

PubMed

Kumbhari, Vivek; Tieu, Alan H; Onimaru, Manabu; El Zein, Mohammad H; Teitelbaum, Ezra N; Ujiki, Michael B; Gitelis, Matthew E; Modayil, Rani J; Hungness, Eric S; Stavropoulos, Stavros N; Shiwaku, Hiro; Kunda, Rastislav; Chiu, Philip; Saxena, Payal; Messallam, Ahmed A; Inoue, Haruhiro; Khashab, Mouen A

2015-06-01

Type III achalasia is characterized by rapidly propagating pressurization attributable to spastic contractions. Although laparoscopic Heller myotomy (LHM) is the current gold standard management for type III achalasia, peroral endoscopic myotomy (POEM) is conceivably superior because it allows for a longer myotomy. Our aims were to compare the efficacy and safety of POEM with LHM for type III achalasia patients. A retrospective study of 49 patients who underwent POEM for type III achalasia across eight centers were compared to 26 patients who underwent LHM at a single institution. Procedural data were abstracted and pre- and post-procedural symptoms were recorded. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤ 1. Secondary outcomes included length of myotomy, procedure duration, length of hospital stay, and rate of adverse events. Clinical response was significantly more frequent in the POEM cohort (98.0 % vs 80.8 %; P = 0.01). POEM patients had significantly shorter mean procedure time than LHM patients (102 min vs 264 min; P < 0.01) despite longer length of myotomy (16 cm vs 8 cm; P < 0.01). There was no significant difference between POEM and LHM in the length of hospital stay (3.3 days vs 3.2 days; P = 0.68), respectively. Rate of adverse events was significantly less in the POEM group (6 % vs 27 %; P < 0.01). POEM allows for a longer myotomy than LHM, which may result in improved clinical outcomes. POEM appears to be an effective and safe alternative to LHM in patients with type III achalasia.

Feasibility of Very Large Sparse Aperture Deployable Antennas

DTIC Science & Technology

2014-03-27

FEASIBILITY OF VERY LARGE SPARSE APERTURE DEPLOYABLE ANTENNAS THESIS Jason C. Heller, Captain...States. AFIT-ENY-14-M-24 FEASIBILITY OF VERY LARGE SPARSE APERTURE DEPLOYABLE ANTENNAS THESIS Presented to the Faculty...UNLIMITED AFIT-ENY-14-M-24 FEASIBILITY OF VERY LARGE SPARSE APERTURE DEPLOYABLE ANTENNAS Jason C. Heller, B.S., Aerospace

Angle of His Accentuation Is a Viable Alternative to Dor Fundoplication as an Adjunct to Laparoscopic Heller Cardiomyotomy: Results of a Randomized Clinical Study.

PubMed

Gupta, Prince; Parshad, Rajinder; Balakrishna, Pavithra; Saraya, Anoop; Makharia, Govind K; Sachdeva, Sanjeev; Sharma, Raju

2018-05-24

There is no consensus regarding the type of anti-reflux procedure to be used as an adjunct to laparoscopic Heller cardiomyotomy (LHCM). The aim of this study was to compare Angle of His accentuation (AOH) with Dor Fundoplication (Dor) as an adjunct to LHCM. A total of 110 patients with achalasia cardia presenting for LHCM from March 2010 to July 2015 were randomized to Dor and AOH. Symptom severity, achalasia-specific quality of life (ASQOL), new onset heartburn, and patient satisfaction were assessed using standardized scores preoperatively, at 3, 6 months, and then yearly. The primary outcome was relief of esophageal symptoms while secondary outcomes were new onset heartburn and ASQOL. Both groups were comparable with respect to the baseline demographic characteristics. There was no conversion to open and no mortality in either group. Median operative time was 128 min in AOH and 144 min in Dor group (p < 0.01). Mean follow-up was 36 months and was available in 98% patients. There was significant improvement in esophageal symptoms in both groups with no statistically significant difference between the two groups (p > 0.05). There was no difference in cumulative symptom scores between the two groups over the period of follow-up. New onset heartburn was seen in 11% in AOH and 9% in Dor group. Mean ASQOL score improved in both groups with no difference between the two groups (p = 0.83). Patient satisfaction was similar in both groups. AOH is similar to Dor as an adjunct to LHCM in safety and efficacy and can be performed in shorter time. CTRI: REF/2014/06/007146.

An extended proximal esophageal myotomy is necessary to normalize EGJ distensibility during Heller myotomy for achalasia, but not POEM

PubMed Central

Teitelbaum, Ezra N.; Soper, Nathaniel J.; Pandolfino, John E.; Kahrilas, Peter J.; Boris, Lubomyr; Nicodème, Frédéric; Lin, Zhiyue; Hungness, Eric S.

2015-01-01

Background For laparoscopic Heller myotomy (LHM), the optimal myotomy length proximal to the esophagogastric junction (EGJ) is unknown. In this study, we used a functional lumen imaging probe (FLIP) to measure EGJ distensibility changes resulting from variable proximal myotomy lengths during LHM and peroral esophageal myotomy (POEM). Methods Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by pressure) was measured with FLIP after each operative step. During LHM and POEM, each patient’s myotomy was performed in two stages: first, a myotomy ablating only the EGJ complex was created (EGJ-M), extending from 2cm proximal to the EGJ, to 3cm distal to it. Next, the myotomy was lengthened 4cm further cephalad to create an extended proximal myotomy (EP-M). Results Measurements were performed in 12 patients undergoing LHM and 19 undergoing POEM. LHM resulted in an overall increase in DI (1.6 ±1 vs. 6.3 ±3.4 mm2/mmHg, p<.001). Creation of an EGJ-M resulted in a small increase (1.6 to 2.3 mm2/mmHg, p<.01) and extension to an EP-M resulted in a larger increase (2.3 to 4.9 mm2/mmHg, p<.001). This effect was consistent, with 11 (92%) patients experiencing a larger increase after EP-M than after EGJ-M. Fundoplication resulted in a decrease in DI and deinsufflation an increase. POEM resulted in an increase in DI (1.3 ±1 vs. 9.2 ±3.9 mm2/mmHg, p<.001). Both creation of the submucosal tunnel and performing an EGJ-M increased DI, whereas lengthening of the myotomy to an EP-M had no additional effect. POEM resulted in a larger overall increase from baseline than LHM (7.9 ±3.5 vs. 4.7 ±3.3 mm2/mmHg, p<.05). Conclusions During LHM, an extended proximal myotomy was necessary to normalize distensibility, whereas during POEM, a myotomy confined to the EGJ complex was sufficient. In this cohort, POEM resulted in a larger overall increase in EGJ distensibility. PMID:24853854

An extended proximal esophageal myotomy is necessary to normalize EGJ distensibility during Heller myotomy for achalasia, but not POEM.

PubMed

Teitelbaum, Ezra N; Soper, Nathaniel J; Pandolfino, John E; Kahrilas, Peter J; Boris, Lubomyr; Nicodème, Frédéric; Lin, Zhiyue; Hungness, Eric S

2014-10-01

For laparoscopic Heller myotomy (LHM), the optimal myotomy length proximal to the esophagogastric junction (EGJ) is unknown. In this study, we used a functional lumen imaging probe (FLIP) to measure EGJ distensibility changes resulting from variable proximal myotomy lengths during LHM and peroral esophageal myotomy (POEM). Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by pressure) was measured with FLIP after each operative step. During LHM and POEM, each patient's myotomy was performed in two stages: first, a myotomy ablating only the EGJ complex was created (EGJ-M), extending from 2 cm proximal to the EGJ, to 3 cm distal to it. Next, the myotomy was lengthened 4 cm further cephalad to create an extended proximal myotomy (EP-M). Measurements were performed in 12 patients undergoing LHM and 19 undergoing POEM. LHM resulted in an overall increase in DI (1.6 ± 1 vs. 6.3 ± 3.4 mm(2)/mmHg, p < 0.001). Creation of an EGJ-M resulted in a small increase (1.6-2.3 mm(2)/mmHg, p < 0.01) and extension to an EP-M resulted in a larger increase (2.3-4.9 mm(2)/mmHg, p < 0.001). This effect was consistent, with 11 (92%) patients experiencing a larger increase after EP-M than after EGJ-M. Fundoplication resulted in a decrease in DI and deinsufflation an increase. POEM resulted in an increase in DI (1.3 ± 1 vs. 9.2 ± 3.9 mm(2)/mmHg, p < 0.001). Both creation of the submucosal tunnel and performing an EGJ-M increased DI, whereas lengthening of the myotomy to an EP-M had no additional effect. POEM resulted in a larger overall increase from baseline than LHM (7.9 ± 3.5 vs. 4.7 ± 3.3 mm(2)/mmHg, p < 0.05). During LHM, an EP-M was necessary to normalize distensibility, whereas during POEM, a myotomy confined to the EGJ complex was sufficient. In this cohort, POEM resulted in a larger overall increase in EGJ distensibility.

Midterm follow-up evaluation after a novel approach to anterior fundoplication for achalasia.

PubMed

Richardson, W S; Kennedy, C I; Bolton, J S

2006-12-01

This study aimed to compare the outcomes for Heller myotomy alone and combined with different partial fundoplications. The authors retrospectively reviewed their experience with 69 laparoscopic myotomies and 14 Heller myotomies, 80% of which were performed with partial fundoplication including 20 Toupet, 18 Dor, and 17 modified Dor procedures, in which the fundoplication is sutured to both sides of the crura and not the myotomy. The mean age of the study patients was 69 years (range, 15-80 years). Four mucosal perforations were repaired intraoperatively. There was one small bowel fistula in an area of open hernia repair distant from the myotomy. One patient with severe chronic obstructive pulmonary disease died of pneumonia. Phone follow-up evaluation was achieved in 68% of the cases at a mean of 37 months (range, 2-97 months). The results for no dysphagia and for heartburn requiring proton pump inhibitors, respectively, were as follows: Heller myotomy (85.7%, 28.5%), Toupet (66.6%, 33.3%), Dor (83.3%, 20%), and modified Dor (84.6%, 15.3%). Two patients with reflux strictures required annual dilation (Toupet, Dor). Two patients required revisions: one redo Heller myotomy (Dor) and one esophageal replacement (Toupet). Heller myotomy provides excellent dysphagia relief with or without fundoplication. Heartburn is a significant problem for a minority of patients. In the authors' hands, Toupet had the worst results and modified Dor was most protective for heartburn.

Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study

PubMed Central

Kumbhari, Vivek; Tieu, Alan H; Onimaru, Manabu; El Zein, Mohammad H.; Teitelbaum, Ezra N.; Ujiki, Michael B.; Gitelis, Matthew E.; Modayil, Rani J.; Hungness, Eric S.; Stavropoulos, Stavros N.; Shiwaku, Hiro; Kunda, Rastislav; Chiu, Philip; Saxena, Payal; Messallam, Ahmed A.; Inoue, Haruhiro; Khashab, Mouen A.

2015-01-01

Background and study aims: Type III achalasia is characterized by rapidly propagating pressurization attributable to spastic contractions. Although laparoscopic Heller myotomy (LHM) is the current gold standard management for type III achalasia, peroral endoscopic myotomy (POEM) is conceivably superior because it allows for a longer myotomy. Our aims were to compare the efficacy and safety of POEM with LHM for type III achalasia patients. Patients and methods: A retrospective study of 49 patients who underwent POEM for type III achalasia across eight centers were compared to 26 patients who underwent LHM at a single institution. Procedural data were abstracted and pre- and post-procedural symptoms were recorded. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤ 1. Secondary outcomes included length of myotomy, procedure duration, length of hospital stay, and rate of adverse events. Results: Clinical response was significantly more frequent in the POEM cohort (98.0 % vs 80.8 %; P = 0.01). POEM patients had significantly shorter mean procedure time than LHM patients (102 min vs 264 min; P < 0.01) despite longer length of myotomy (16 cm vs 8 cm; P < 0.01). There was no significant difference between POEM and LHM in the length of hospital stay (3.3 days vs 3.2 days; P = 0.68), respectively. Rate of adverse events was significantly less in the POEM group (6 % vs 27 %; P < 0.01). Conclusions: POEM allows for a longer myotomy than LHM, which may result in improved clinical outcomes. POEM appears to be an effective and safe alternative to LHM in patients with type III achalasia. PMID:26171430

The Challenge of Adaptation: The US Army in the Aftermath of Conflict, 1953-2000

DTIC Science & Technology

2008-03-01

on U.S. National Security Strategy, 21 June 2001, pp.4-5. Chaired by Senator Carl Levin (D-MI). Retrieved from LexisNexis Congressional Search...and Scott D. Sagan , Moving Targets: Nuclear Strategy and National Security (Princeton: Princeton University Press, 1989). 4. Boyd L. Dastrup, The...KS: Combat Studies Institute, July 1980), available at: http://www. cgsc.army.mil/ carl /resources/csi/heller2/heller2.asp. 13. Condit, HOSD, v.II: The

Carrying guns in public: legal and public health implications.

PubMed

Vernick, Jon S

2013-03-01

In District of Columbia v. Heller, the U.S. Supreme Court ruled that the Second Amendment protects an individual's right to own handguns in the home for protection, invalidating a Washington, D.C. law banning most handgun possession. The Heller decision, however, provided lower courts with little guidance regarding how to judge the constitutionality of gun laws other than handgun bans. Nevertheless, lower courts have upheld the vast majority of federal, state, and local gun laws challenged since Heller. One area in which some lower courts have disagreed has been the constitutionality of laws regulating the ability to carry firearms in public. This issue may be the next to be addressed by the Supreme Court under its evolving Second Amendment jurisprudence. Courts should carefully consider the negative public health and safety implications of gun carrying in public as they weigh the constitutionality of these laws. © 2013 American Society of Law, Medicine & Ethics, Inc.

Reduced postoperative pain scores and narcotic use favor per-oral endoscopic myotomy over laparoscopic Heller myotomy.

PubMed

Docimo, Salvatore; Mathew, Abraham; Shope, Alexander J; Winder, Joshua S; Haluck, Randy S; Pauli, Eric M

2017-02-01

Per-oral endoscopic myotomy (POEM) is a less invasive therapy for achalasia with a shorter hospitalization but with similar short- and long-term outcomes as a laparoscopic Heller myotomy (LHM). Previous literature comparing POEM to LHM has focused primarily on postoperative outcome parameters such as complications, dysphagia scores and gastro-esophageal reflux severity. This study specifically compares postoperative pain following POEM to pain following LHM, the current gold-standard operation. A retrospective review of all patients undergoing POEM or LHM for achalasia was performed from 2006 to 2015. Data collection included demographics, comorbidities, length of stay (LOS) and pain scores (arrival to the recovery room, 1 h postoperative, average first 24 h and upon discharge). Statistical analysis was performed using Student's t test and Chi-square test. Forty-four POEM patients and 122 LHM patients were identified. The average age (52.2 ± 20.75 vs 50.9 ± 17.89 years, p = 0.306) and BMI (28.1 ± 7.62 vs 27.6 ± 7.07 kg/m 2 , p = 0.824) did not differ between the POEM and LHM groups, respectively; however, the American Society of Anesthesiology scores were higher in the POEM patients (2.43 ± 0.62 vs 2.11 ± 0.71, p = 0.011). There were no differences in rates of smoking, diabetes, cardiac disease or pulmonary disease. The average pain scores upon arrival to the recovery room and 1 h postoperatively were lower in the POEM group (2.3 ± 3.014 vs 3.61 ± 3 0.418, p = 0.025 and 2.2 ± 2.579 vs 3.46 ± 3.063, p = 0.034, respectively). There was no difference in the average pain score over the first 24 h (2.7 ± 2.067 vs 3.29 ± 1.980, p = 0.472) or at the time of discharge (1.6 ± 2.420 vs 2.09 ± 2.157, p = 0.0657) between the POEM and LHM groups. After standardizing opioid administration against 10 mg of oral morphine, the POEM group used significantly less narcotics that the LHM group (35.8 vs 101.8 mg, p < 0

Pattern of esophageal eosinophilic infiltration in patients with achalasia and response to Heller myotomy and Dor fundoplication.

PubMed

Cools-Lartigue, J; Chang, S-Y; Mckendy, K; Mayrand, S; Marcus, V; Fried, G M; Ferri, L E

2013-01-01

Eosinophilic esophagitis (EoE) is now recognized as a common cause of dysphagia. Eosinophilic infiltration of the esophagus has also been associated with other conditions, such as gastroesophageal reflux disease (GERD); however, the incidence, pattern, and clinical significance of eosinophilic infiltration in achalasia are poorly documented. We sought to characterize this histological finding in patients undergoing Heller myotomy (HM) for achalasia. Ninety-six patients undergoing laparoscopic HM for primary achalasia between 1999 and 2008 were identified from a prospective database. Serial mid and distal per-endoscopic esophageal biopsies taken from patients before and after surgery were assessed for the presence of elevated intraepithelial eosinophils (EIEs). Slides from patients with reports suggestive of EIE were reviewed independently by two pathologists, and the highest eosinophil count/high-power field (eos/hpf) was recorded. Dysphagia scores (0 = none to 5 = severe dysphagia), GERD health-related quality of life scores (0 = best to 45 = worst), and 24-hour pH results were compared before and 3 months after surgery. We related the highest eos to the symptoms and response to HM. Data are presented as median (range). Paired t-test and Wilcoxon signed-rank test determined significance, *P < 0.05. Of 96 patients with achalasia, 50 had undergone pre-HM biopsies revealing EIE in 17/50 (34%), with a median of 3 eos/hpf (1-21). Two patients were found to have superimposed esophageal candidiasis. One patient met the pathologic criteria for EoE. Twenty-five of 50 (50%) postoperative biopsies demonstrated a median of 5 eos/hpf (1-62) for a total of 28/50 patients (56%) with EIE in either the preoperative or postoperative period. Four patients (8%) met the pathologic criteria for EoE, and two demonstrated persistent esophageal candidiasis. A decrease in eosinophils was found in 6/28 patients (21%) from 3/hpf (1-21) to 0.5/hpf (0-4). Increase in eosinophils was found in

The feasibility, safety and outcomes of laparoscopic re-operation for achalasia.

PubMed

James, David R C; Purkayastha, Sanjay; Aziz, Omer; Amygdalos, Iakovos; Darzi, Ara W; Hanna, George B; Zacharakis, Emmanouil

2012-05-01

Heller myotomy for achalasia is associated with a recurrence rate of around 10%, thus reoperative surgery is often necessitated. This paper aims to review the available literature on laparoscopic reoperation for achalasia in order to assess its feasibility and effectiveness. A Medline, Embase, Ovid, Cochrane database and Google(TM) Scholar search was performed with the following Mesh terms: "laparoscopic", "redo", "reoperative", "Heller's", "esophagomyotomy" and "achalasia". Outcomes of interest included patient demographics and details of primary procedure, operative details, intra- and post operative complications and symptom scores. Seven studies reported outcomes from 54 cases. Conversion occurred in 7% (4/54) of cases. Thirteen percent (7/54) of patients sustained intra-operative gastric or oesophageal perforation; however these were all noted and repaired intra-operatively leading to no subsequent morbidity. No deaths were reported. Pre- and post operative symptom scores were heterogeneous, however did appear to improve after the procedure. This review demonstrates that laparoscopic reoperation for achalasia is feasible and safe with complication rates comparable to the primary laparoscopic operation. It is recommended that laparoscopic reoperative Heller's myotomy should only be performed by surgeons with special interest in oesophagogastric surgery and adequate experience in laparoscopic surgery for achalasia.

Laparoscopic treatment in achalasia of the cardia.

PubMed

Ursut, B; Alecu, L; Tulin, A; Enciu, O

2014-01-01

Achalasia, although a rare disease (an incidence of 1 100 000 individuals each year) is one of the common causes of motor dysphagia and is characterized by loss of peristalsis in the esophageal body and lack of relaxation of the lower esophageal sphincter. The aim of our study was to perform a clinical,therapeutic and evolution evaluation in patients diagnosed with achalasia and operated in our department between 1997 and 2013. We performed a retrospective study using the clinical charts, operatory protocols, imagistic and video database of the 17 patients with achalasia operated in our department. We encountered an equal repartition in women and men and a predominance of urban provenience. Ages were between 24 and 86 years (with an average age of 51). There were two cases of recurrent achalasia at 2, respectively 5 years after the first operation. In all cases, Heller myotomy was used, with the addition of a Dor fundoplication in 12 cases and Toupet fundoplication in five cases, as an antireflux procedure. Mean operation time was 117.6 minutes.There were three iatrogenic perforations of the esophageal mucosa, all of them recognized and treated in the same operative time. No postoperative complications related to the Heller-Dor Heller-Toupet procedure were encountered.The follow-up was between 3 and 72 months. Laparoscopic approach in the treatment of achalasia provides the advantages of minimally invasive surgery, but also and very important, a good visualization of the abdominal esophagus and gastroesophageal junction.Heller esocardiomyotomy is usually associated with anantireflux procedure. A Dor fundoplication is generally used,although the Toupet fundoplication may also be used with the same advantages. It is important to monitor these patients on a yearly basis, knowing the risk of dysplasia carcinoma in achalasia. Celsius.

Wired enzyme electrodes--a retroperspective story about an exciting time at University of Texas at Austin and its impact on my scientific career.

PubMed

Lindquist, Sten-Eric

2013-07-22

The present paper features an exciting time in the late 1980s when I, as a visiting scientist, had the privilege to participate in the early and very exciting development of the in vivo redox-polymer-wired glucose sensor in Professor Adam Heller's laboratory at the Department of Chemical Engineering at University of Texas at Austin. This story is followed by an overview of the research my visit initiated at Uppsala University. In collaboration with Swedish colleagues, we explored a few of the many possibilities to form new biosensors by utilizing Prof. Heller's concept of cross-linked redox-polymer/redox-enzyme electrodes. Copyright © 2013 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

Recurrent achalasia after Heller-Toupet procedure: Laparoscopic extended redo heller myotomy and floppy Dor

PubMed Central

Golash, Vishwanath

2007-01-01

Recurrences of symptoms after the surgery for achalasia cardia are not uncommon. There are several causes of recurrences but the early recurrences are speculated to be secondary to incomplete myotomy and late recurrence due to fibrosis after the myotomy or megaesophagus. These recurrences can be managed by regular dilation failing which a redo surgery is indicated. Laparoscopic approach is now standard because of the obvious benefits for patients and surgeons. Extent of myotomy and addition of fundoplication are debatable issue in the management of achalasia cardia but evidence suggests that some kind of fundoplication would be necessary after the complete division of lower esophageal sphincter. We present our experience in a case of recurrent achalasia, secondary to incomplete myotomy managed laparoscopically by extended myotomy and a floppy anterior fundoplication. Patient is asymptomatic six months after the surgery and radiologically there is free passage of barium in the stomach. PMID:19789666

Per-oral endoscopic myotomy for achalasia: An American perspective

PubMed Central

Friedel, David; Modayil, Rani; Iqbal, Shahzad; Grendell, James H; Stavropoulos, Stavros N

2013-01-01

Achalasia is an uncommon esophageal motility disorder characterized by the selective loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower esophageal sphincter. Per-oral endoscopic myotomy (POEM) is a novel modality for the treatment of achalasia performed by gastroenterologists and surgeons. It represents a natural orifice transluminal endoscopic surgery (NOTES) approach to Heller myotomy. POEM has the minimal invasiveness of an endoscopic procedure that can duplicate results of the surgical Heller myotomy. POEM is conceptually similar to a surgical myotomy without the inherent external incisions and post-operative care associated with surgery. Initial high success and low complications rates promise a great future for this technique. In fact, POEM has been successfully performed on patients with end-stage achalasia as an initial treatment reserving esophagectomy for those without good response. The volume of POEMs performed worldwide has grown exponentially. In fact, surgeons who have performed Heller myotomy have embraced POEM as the preferred intervention for achalasia. However, the niche of POEM remains to be defined and long term results are awaited. We describe our experience with POEM having performed the first POEM outside of Japan in 2009, the evolution of our technique, and give our perspective on its future. PMID:24044040

Evaluation of Safety and Efficacy of the EndoLift Liver Retractor

ClinicalTrials.gov

2015-08-03

Minimally Invasive Surgical Procedure; Laparoscopic Gastric Banding; Laparoscopic Roux-en-Y Gastric Bypass; Laparoscopic Sleeve Gastrectomy; Laparoscopic Fundoplication Procedure; Laparoscopic Heller Myotomy; Laparoscopic Paraesophageal Hernia Repair; Laparoscopic Gastric Resection

Hydromorphone overdose

MedlinePlus

... Updated by: Jacob L. Heller, MD, MHA, Emergency Medicine, Emeritus, Virginia Mason Medical Center, Seattle, WA. ... as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is ...

Laparoscopic myotomy: technique and efficacy in treating achalasia.

PubMed

Ali, A; Pellegrini, C A

2001-04-01

Esophageal Heller myotomy and a partial antireflux procedure for achalasia are the ideal procedures to benefit from the advances in minimally invasive surgery. The magnified view of the operative field provided by the laparoscope allows precise division of the esophageal muscle fibers with excellent results. Laparoscopic Heller myotomy results in reduced postoperative pain, less morbidity, shorter hospitalization, better resolution of dysphagia, and less postoperative heartburn when compared with the open abdominal and even the thoracoscopic approach. A longer myotomy especially at the distal end, and a loose, well-formed partial fundoplication are the keys to a successful outcome. Superior long-term results after surgical myotomy when compared with nonsurgical interventions argue strongly in favor of surgery in any patient who is fit enough to undergo general anesthesia.

Thoracoscopic esophagomyotomy for achalasia: maximum gain, minimal pain.

PubMed

Maher, J W

1997-10-01

Achalasia can be effectively treated by either hydrostatic balloon dilatation or transthoracic modified Heller myotomy. The purpose of this study was to determine whether thoracoscopic methods could be used to achieve surgical results equal to the transthoracic approach with less pain. Twenty-one patients (10 men, 11 women; median age 42 years) had the diagnosis of achalasia confirmed by manometry, radiography, and endoscopy. All had dysphagia; five had weight loss. Median duration of symptoms was 12 months (range: 1 to 360 months). Eleven patients had undergone previous unsuccessful hydrostatic dilatation. Mean esophageal diameter was 5.5 +/- 2.2 cm. All patients underwent attempted modified Heller myotomy through a left thoracoscopic approach. Three patients required conversion to thoracotomy. The myotomy was extended < 1 cm past the squamocolumnar junction. There was one intraoperative perforation and no postoperative complications. All patients were begun on a regular diet on the first postoperative morning. Median length of stay was 2 days, Median follow-up was 22 months (range: 1 to 52 months). Sixteen patients (80%) had excellent relief of their dysphagia. Two patients (10%) had good relief, and two patients had only a fair result, although even they claim to be much improved. Thoracoscopic Heller myotomy reproduces the superior results of open esophagomyotomy with a reduced hospitalization and reduced incisional pain and disability.

Subcutaneous emphysema

MedlinePlus

... PA: Elsevier Saunders; 2016:chap 84. Eckstein M, Henderson SO. Thoracic trauma. In: Marx JA, Hockberger RS, ... by: Jacob L. Heller, MD, MHA, Emergency Medicine, Virginia Mason Medical Center, Seattle, WA. Also reviewed by ...

Bee poison

MedlinePlus

... are also much more likely to sting than European bees. Where Found Bee, wasp, hornet, and yellow ... Philadelphia, PA: Elsevier; 2016:chap 72. Review Date 7/10/2017 Updated by: Jacob L. Heller, MD, ...

Oral hypoglycemics overdose

MedlinePlus

... M. Hypoglycemic agent overdose. In: Adams JG, ed. Emergency Medicine: Clinical Essentials . 2nd ed. Philadelphia, PA: Elsevier Saunders; ... 2017 Updated by: Jacob L. Heller, MD, MHA, Emergency Medicine, Emeritus, Virginia Mason Medical Center, Seattle, WA. Also ...

Genetics Home Reference: cone-rod dystrophy

MedlinePlus

... Citation on PubMed Sergouniotis PI, McKibbin M, Robson AG, Bolz HJ, De Baere E, Müller PL, Heller ... qualified healthcare professional . About Selection Criteria for Links Data Files & API Site Map Subscribe Customer Support USA. ...

Meclofenamate overdose

MedlinePlus

... RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 9th ed. Philadelphia, PA: ... 2017 Updated by: Jacob L. Heller, MD, MHA, Emergency Medicine, Emeritus, Virginia Mason Medical Center, Seattle, WA. Also ...

Ketoprofen overdose

MedlinePlus

... RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 9th ed. Philadelphia, PA: ... 2017 Updated by: Jacob L. Heller, MD, MHA, Emergency Medicine, Emeritus, Virginia Mason Medical Center, Seattle, WA. Also ...

Amitriptyline hydrochloride overdose

MedlinePlus

... RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 9th ed. Philadelphia, PA: ... 2017 Updated by: Jacob L. Heller, MD, MHA, Emergency Medicine, Emeritus, Virginia Mason Medical Center, Seattle, WA. Also ...

Hydroxyzine overdose

MedlinePlus

... RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice . 9th ed. Philadelphia, PA: ... 2017 Updated by: Jacob L. Heller, MD, MHA, Emergency Medicine, Emeritus, Virginia Mason Medical Center, Seattle, WA. Also ...

The Strongsville Decision

ERIC Educational Resources Information Center

School Library Journal, 1976

1976-01-01

The suit claimed violation of First and Fourteenth Amendment rights in that the school board, disregarding the recommendation of faculty, refused to approve Joseph Heller's "Catch 22" and Kurt Vonnegut's "God Bless You, Mr. Rosewater" as texts or library books. (Author)

The choice of optimal antireflux procedure after laparoscopic cardiomyotomy: two decades of clinical experience in one center

PubMed Central

Kiudelis, Mindaugas; Sakalys, Egidijus; Jonaitis, Laimas; Mickevicius, Antanas; Endzinas, Zilvinas

2017-01-01

Introduction Two types of partial wrap are commonly performed in achalasia patients after Heller myotomy: the posterior 270° fundoplication (Toupet) and the anterior 180° fundoplication (Dor). The optimal type of fundoplication (posterior vs. anterior) is still debated. Aim To compare the long-term rates of dysphagia, reflux symptoms and patient satisfaction with current postoperative condition between two fundoplication groups in achalasia treatment. Material and methods Our retrospective study included 97 consecutive patients with achalasia: 37 patients underwent laparoscopic posterior Toupet (270°) fundoplication followed by Heller myotomy (group I); 60 patients underwent laparoscopic anterior partial Dor fundoplication followed by Heller myotomy (group II). Long-term follow-up results included evaluation of dysphagia symptoms, intensity of heartburn and patient satisfaction with current condition. Results Patients in these two groups did not differ according to age, weight, height, postoperative stay or follow-up period. Laparoscopic myotomy with posterior Toupet fundoplication was effective in 89% of patients, while laparoscopic myotomy with anterior Dor was effective in 93% of patients (p > 0.05). 11% of patients after posterior Toupet fundoplication had clinically significant heartburn vs. 35% of patients after anterior Dor fundoplication (p < 0.05). Overall patient satisfaction with current condition was 88%, with no significant difference between the groups. Conclusions According to our study results, the two laparoscopic techniques were similarly effective in reducing achalasia symptoms, but postoperative clinical manifestation of heartburn is significantly more frequent after anterior Dor fundoplication (35% vs. 11%). The majority of patients (88%) were satisfied with operation outcomes. PMID:29062443

Diagnosis and management of esophageal achalasia.

PubMed

Stavropoulos, Stavros N; Friedel, David; Modayil, Rani; Parkman, Henry P

2016-09-13

Achalasia is a rare esophageal motility disorder that is usually idiopathic in origin. It is characterized by dysphagia, and patients often have chest pain, regurgitation, weight loss, and an abnormal barium radiograph showing esophageal dilation with narrowing at the gastroesophageal junction. Abnormal or absent esophageal peristalsis and impaired relaxation of the lower esophageal sphincter (LES) are typically seen on esophageal manometry. The advent of high resolution manometry (HRM) has allowed more precise diagnosis of achalasia, subtype designation, and differentiation from other esophageal motor disorders with an initial seminal publication in 2008 followed by further refinements of what has been termed the Chicago classification. Potential treatments include drugs, endoscopic botulinum toxin injection, balloon dilation, traditional surgery (usually laparoscopic Heller myotomy; LHM), and a novel, less invasive, natural orifice transluminal endoscopic surgery (NOTES) approach to Heller myotomy termed peroral endoscopic myotomy (POEM). The first human POEM was performed in 2008, with the first publication appearing in 2010 and evidence now rapidly accumulating showing POEM to be comparable to traditional surgery in terms of clinical success and radiologic and manometric post-therapy outcomes. This review discusses the diagnosis and management of achalasia with particular emphasis on the recent developments of HRM and POEM, which arguably represent the most important advances in the field since the advent of laparoscopic Heller myotomy in the 1990s. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Treatment of achalasia in the era of high-resolution manometry

PubMed Central

Torresan, Francesco; Ioannou, Alexandros; Azzaroli, Francesco; Bazzoli, Franco

2015-01-01

Esophageal achalasia is a primary motility disorder characterized by impaired lower esophageal sphincter relaxation and absence of esophageal peristalsis leading to impaired bolus transit, manifested with symptoms such as dysphagia, regurgitation, retrosternal pain, and weight loss. The standard diagnostic tool is esophageal manometry which demonstrates incomplete relaxation of the lower esophageal sphincter and impaired esophageal peristalsis. Recently, a new advanced technique, high-resolution manometry (HRM) with the addition of pressure topography plotting, using multiple sensors to capture the manometric data as a spatial continuum, allows a detailed pressure recording of the esophageal motility. This technique, currently the gold standard for the diagnosis of achalasia, has led to a subclassification of three manometric types that seem to have different responsiveness to treatment. Because its pathogenesis is as yet unknown, achalasia treatment options are not curative. Type II achalasia patients respond better to treatment compared to those with types I and III. Low-risk patients with type I or II achalasia have good outcome with both graded pneumatic dilatations and laparoscopic Heller myotomy, while type III achalasia patients respond better to laparoscopic Heller myotomy. Although, type III achalasia patients responds less in comparison to types I and II to laparoscopic Heller myotomy. Peroral endoscopic myotomy is a promising new technique but long-term follow-up studies for its safety and efficacy must be performed. This article reviews the current therapeutic options, highlighting the impact of HRM to predict the outcome and the new insights for the treatment of achalasia. PMID:26130022

76 FR 29750 - Filing Dates for the Nevada Special Election in the 2nd Congressional District

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-23

... 2nd Congressional District AGENCY: Federal Election Commission. ACTION: Notice of filing dates for special election. SUMMARY: Nevada has scheduled a Special General Election on September 13, 2011, to fill... Heller. Committees required to file reports in connection with the Special General Election on September...

Cinnamon

MedlinePlus

... cinnamon marketed in Italy: a natural chemical hazard? Food Additives & Contaminants. Part A: Chemistry, Analysis, Control, Exposure & Risk Assessment. 2008;25(11):1297-1305. Wainstein J, Stern N, Heller S, et al. ... Journal of Medicinal Food. 2011;14(12):1505-1510. Woehrlin F, Fry ...

Achieving a Balance: Proceedings of the National Conference on Adapted Physical Activity (5th, Macomb, Illinois, April 3-5, 1997).

ERIC Educational Resources Information Center

Western Illinois Univ., Macomb. Coll. of Education and Human Services.

This proceedings include the following papers: "Developing a District Building Based Team" (Kathy Heller and Michelle Till); "Wheelchair Rhythmic Sportive Gymnastics" (Gertrude Krombholz and Atja Gotzova-Kumpf); "Team Building in Inclusion Settings" (Robert Weber); "Inclusion: Identifying Student Needs" (Jeff Runge); "Overview of the Role of…

Childhood Disintegrative Disorder: Issues for DSM-IV.

ERIC Educational Resources Information Center

Volkmar, Fred R.

1992-01-01

This paper presents evidence regarding the validity of the diagnostic concept of "autistic-like" childhood disintegrative disorder, also known as Heller syndrome or as disintegrative psychosis. Its inclusion in the DSM-IV (Diagnostic and Statistical Manual) is supported, and proposed criteria and narrative description are provided.…

Information Technology: Making It All Fit. Track III: Financial Impact and Considerations.

ERIC Educational Resources Information Center

CAUSE, Boulder, CO.

Seven papers from the 1988 CAUSE conference's Track III, Financial Impact and Considerations, are presented. They include: "Providing Applications Development Services in a Competitive Environment" (Donald E. Heller and Mary Ellen Bushnell); "The Cost of Not Staying Current" (Jack T. Tinsley and Betty R. Nyer); "Project…

Review of the genera of Conoderinae (Coleoptera, Curculionidae) from North America, Central America, and the Caribbean

PubMed Central

Anzaldo, Salvatore S.

2017-01-01

Abstract The thirty-nine extant genera of Conoderinae known to occur in North America, Central America, and the Caribbean are reviewed based on external morphology. An identification key is provided along with diagnoses, distributions, species counts, and natural history information, when known, for each genus. Morphological character systems of importance for weevil classification are surveyed, potential relationships among the tribes and genera are discussed, and groups most in need of taxonomic and phylogenetic attention are identified. The following genera are transferred to new tribes: Acoptus LeConte, 1876 from the Lechriopini to the Othippiini (new placement) and the South American genus Hedycera Pascoe, 1870 from the Lechriopini to the Piazurini (new placement). Philides Champion, 1906 and Philinna Champion, 1906 are transferred from the Lechriopini to Conoderinae incertae sedis (new placement) although their placement as conoderines is uncertain. The species Copturomimus cinereus Heller, 1895 is designated as the type species of the genus Copturomimus Heller, 1895. PMID:28769729

Communication: Overcoming the root search problem in complex quantum trajectory calculations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zamstein, Noa; Tannor, David J.

2014-01-28

Three new developments are presented regarding the semiclassical coherent state propagator. First, we present a conceptually different derivation of Huber and Heller's method for identifying complex root trajectories and their equations of motion [D. Huber and E. J. Heller, J. Chem. Phys. 87, 5302 (1987)]. Our method proceeds directly from the time-dependent Schrödinger equation and therefore allows various generalizations of the formalism. Second, we obtain an analytic expression for the semiclassical coherent state propagator. We show that the prefactor can be expressed in a form that requires solving significantly fewer equations of motion than in alternative expressions. Third, the semiclassicalmore » coherent state propagator is used to formulate a final value representation of the time-dependent wavefunction that avoids the root search, eliminates problems with caustics and automatically includes interference. We present numerical results for the 1D Morse oscillator showing that the method may become an attractive alternative to existing semiclassical approaches.« less

Grade 12 Diploma Examination, English 33. Part B: Reading (Multiple Choice). Readings Booklet.

ERIC Educational Resources Information Center

Alberta Dept. of Education, Edmonton.

Intended for students taking the Grade 12 Examination in English 33 in Alberta, Canada, this reading test (to be administered along with the questions booklet) contains short reading selections taken from fiction, nonfiction, poetry, and drama, including the following: an excerpt from "Catch-22" (Joseph Heller); "School Thief"…

Annual Review of Applied Linguistics, Volume 5, 1984.

ERIC Educational Resources Information Center

Kaplan, Robert B., Ed.

This volume of the annual review includes introductory remarks by G. Richard Tucker and these papers: "Current Issues in Bilingualism: An Update of Directions in Research" (Braj B. Kachru); "Psycholinguistics: Application. The Writing System as a Native Language for the Deaf" (Danny D. Steinberg); "Sociolinguistics: Theory" (Monica Heller);…

On Space and Time

NASA Astrophysics Data System (ADS)

Majid, Shahn; Connes, With contributions by Alain; Heller, Michael; Penrose, Roger; Polkinghorne, John; Taylor, Andrew

2008-09-01

Preface; 1. The dark universe A. N. Taylor; 2. Quantum spacetime and physical reality S. Majid; 3. Causality, quantum theory and cosmology R. Penrose; 4. On the fine structure of spacetime A. Connes; 5. Where physics meets metaphysics M. Heller; 6. The nature of time J. C. Polkinghorne; Index.

On Space and Time

NASA Astrophysics Data System (ADS)

Majid, Shahn; Polkinghorne, With contributions by John; Penrose, Roger; Taylor, Andrew; Connes, Alain; Heller, Michael

2012-03-01

Preface; 1. The dark universe A. N. Taylor; 2. Quantum spacetime and physical reality S. Majid; 3. Causality, quantum theory and cosmology R. Penrose; 4. On the fine structure of spacetime A. Connes; 5. Where physics meets metaphysics M. Heller; 6. The nature of time J. C. Polkinghorne; Index.

Who Should We Help? The Negative Social Consequences of Merit Scholarships.

ERIC Educational Resources Information Center

Heller, Donald E., Ed.; Marin, Patricia, Ed.

This is a collection of papers from a 2001 symposium at Harvard University entitled "State Merit Aid Programs: College Access and Equity." After a Foreword by Gary Orfield, the seven papers are (1) "State Merit Scholarship Programs: An Introduction" (Donald E. Heller); (2) "Merit Scholarships and College Access: Evidence…

Esophageal Achalasia: Predictive Value of Preoperative Resting Pressure of LES Correlated with Type of Fundoplication.

PubMed

Tancredi, Antonio; Cuttitta, Antonello; Scaramuzzi, Roberto; Scaramuzzi, Gerardo; Taurchini, Marco

2017-02-01

The aim of the present study is to show the predictive value of the preoperative resting pressure of the lower esophageal sphincter (LES) correlated with the type of fundoplication (Nissen or Dor) after Heller myotomy in our series. From January 1998 to June 2010, 88 patients affected by esophageal achalasia underwent surgery at our unit. However, our study focused on a sample of 36 patients, because many data were lost or was never recorded. Among these, 14 patients underwent laparoscopic Heller myotomy plus Nissen fundoplication (group N), whereas 22 patients underwent laparoscopic Heller myotomy plus Dor fundoplication (group D). Clinical evaluation was performed using a modified DeMeester symptom scoring system consisting of the assessment of three symptoms: dysphagia, regurgitation, and heartburn. To each symptom was assigned a score from 0 to 3, depending on its severity, and the reduction in the severity of each symptom after surgery was assessed. The surgical treatment is considered to be effective (p<0.0001). The preoperative resting pressures of LES were compared by Student's t-test, and it was found that patients who reported a greater improvement in the dysphagia symptom had a preoperative average pressure of LES that was significantly higher than that in other patients in both group N (p=0.03) and group D (p=0.01; p=0.003; p=0.001). The Dor treatment was shown to be more effective than the Nissen treatment (p<0.0001). The preoperative resting pressure of LES is a predictive factor of surgical success both before Dor fundoplication and before Nissen fundoplication, but its predictive power is influenced by the chosen type of fundoplication.

Age and Achalasia: How Does Age Affect Patient Presentation, Hospital Course, and Surgical Outcomes?

PubMed

Downs, Darrell J; Jadick, Giavanna; Swaid, Forat; Ross, Sharona B; Rosemurgy, Alexander S

2017-09-01

Heller myotomy is the "gold-standard" therapy for achalasia, alleviating symptoms by defunctionalizing the lower esophageal sphincter mechanism. Observation has suggested many differences between young and old patients with achalasia, raising the question: is achalasia in younger patients a different disorder than it is in older patients? This study was undertaken to answer this question. With Institutional Review Board approval, 648 patients undergoing laparoscopic Heller myotomy from 1992-2016 were prospectively followed up. Patients self-assessed symptom frequency/severity preoperatively and postoperatively using a Likert scale; 0 (never/not bothersome) to 10 (always/very bothersome). Before myotomy, frequency/severity of many symptoms (e.g., "dysphagia," "chest pain," and "regurgitation") inversely correlated with age (P < 0.01 each). Symptom duration and the number of previous abdominal operations correlated with age, as did intraoperative complications (e.g., gastrotomy), postoperative complications (e.g., atrial fibrillation), and length of stay (P < 0.01 for each). Patients experienced amelioration of all symptoms queried, regardless of age (P < 0.01 each). Age did affect outcome because older patients had less frequent and severe symptoms. Age did not affect improvement of symptoms (e.g., dysphagia) (i.e., differences between preoperative and postoperative scores) (P = 0.88). Age did not influence symptom resolution or patient satisfaction (P = 0.98 and P = 0.15, respectively). The presentation with achalasia, hospital course, and outcome after myotomy are significantly impacted by age, whereas patient improvement after myotomy is constant independent of age. Younger and older patients have different presentations, experiences, and outcomes; these patients seem to have "different disorders", but Heller myotomy provides similar significant amelioration of symptoms independent of age.

The Production of Bachelor's Degrees and Financial Aspects of State Higher Education Policy: A Dynamic Analysis

ERIC Educational Resources Information Center

Titus, Marvin A.

2009-01-01

Although several studies have examined the extent to which tuition influences college enrollment at the undergraduate level (e.g., Heller, 1999; Kane, 1995, 1999), there is no known research that examines how changes in financial aspects of state higher education policy affect the production of postsecondary degrees. Using state-level data…

Fragaria cascadensis K.E. Hummer: first investigation of volatile organic compounds of fruit

USDA-ARS?s Scientific Manuscript database

In 2012, Fragaria cascadensis was described as a decaploid strawberry species from the Oregon Cascade Mountains. The objective of this study was to examine the aroma patterns of fruits of this F. cascadensis in contrast to those of F. vesca ssp. bracteata (A. Heller) Staudt and F. virginiana ssp. pl...

Biological corridors and connectivity [Chapter 21

Treesearch

Samuel A. Cushman; Brad McRae; Frank Adriaensen; Paul Beier; Mark Shirley; Kathy Zeller

2013-01-01

The ability of individual animals to move across complex landscapes is critical for maintaining regional populations in the short term (Fahrig 2003; Cushman 2006), and for species to shift their geographic range in response to climate change (Heller & Zavaleta 2009). As organisms move through spatially complex landscapes, they respond to multiple...

Conversion of DST Group Shape Optimisation Software for Increased Portability across Computing Platforms

DTIC Science & Technology

2016-05-01

reduction achieved is small due to the starting shape being near optimal. The general arrangement and x-y coordinate system are shown in Figure 23...Optimization, Vol. 28, pp. 55–68, 2004. [3] M Heller, J Calero, S Barter , RJ Wescott, J Choi. Fatigue life extension program for LAU-7 missile launcher

Kafka: A Collection of Critical Essays. Twentieth Century Views Series.

ERIC Educational Resources Information Center

Gray, Ronald, Ed.

One of a series of works aimed at presenting contemporary critical opinion on major authors, this collection includes essays by Ronald Gray, Edwin Muir, Friedrich Beissner, R. O. C. Winkler, Johannes Pfeiffer, Caroline Gordon, Idris Parry, Edmund Wilson, Erich Heller, Austin Warren, Eliseo Vivas, Albert Camus, Martin Buber, and H. S. Reiss--all…

How expert mentoring can pave the way to successful leadership.

PubMed

Holliday, Laura; Dawson, Paula; Hall, Carol

2017-04-11

It is vital for the healthcare system that nurses of children and young people have the ability and courage to lead. These qualities can affect all elements of healthcare, from direct care through service commissioning ( Royal College of Nursing 2014 ) to staff satisfaction and retention ( Kerfoot 2000 , Corning 2002 , Heller et al 2004 ).

Heller Public Firearms Range Act of 2014

THOMAS, 113th Congress

Rep. Stockman, Steve [R-TX-36

2014-11-20

House - 12/02/2014 Referred to the Subcommittee on Fisheries, Wildlife, Oceans, and Insular Affairs. (All Actions) Tracker: This bill has the status IntroducedHere are the steps for Status of Legislation:

[Surgical treatment of achalasia - endoscopic or laparoscopic? : Proposal for a tailored approach].

PubMed

Rahden, B H A von; Filser, J; Al-Nasser, M; Germer, C-T

2017-03-01

Primary idiopathic achalasia is the most common form of the rare esophageal motility disorders. A curative therapy which restores the normal motility does not exist; however, the therapeutic principle of cardiomyotomy according to Ernst Heller leads to excellent symptom control in the majority of cases. The established standard approach is Heller myotomy through the laparoscopic route (LHM), combined with Dor anterior fundoplication for reflux prophylaxis/therapy. At least four meta-analyses of randomized controlled trials (RCTs) have demonstrated superiority of LHM over pneumatic dilation (PD); therefore, LHM should be used as first line therapy (without prior PD) in all operable patients. Peroral endoscopic myotomy (POEM) is a new alternative approach, which enables Heller myotomy to be performed though the endoscopic submucosal route. The POEM procedure has a low complication rate and also leads to good control of dysphagia but reflux rates can possibly be slightly higher (20-30%). Long-term results of POEM are still scarce and the results of the prospective randomized multicenter trial POEM vs. LHM are not yet available; however, POEM seems to be the preferred treatment option for certain indications. Within the framework of the tailored approach for achalasia management of POEM vs. LHM established in Würzburg, we recommend long-segment POEM for patients with type III achalasia (spasmodic) and other hypercontractile motility disorders and potentially type II achalasia (panesophageal compression) with chest pain as the lead symptom, whereas LHM can also be selected for type I. For sigmoid achalasia, especially with siphon-like transformation of the esophagogastric junction, simultaneous hiatal hernia and epiphrenic diverticula, LHM is still the preferred approach. The choice of the procedure for revisional surgery in case of recurrent dysphagia depends on the suspected mechanism (morphological vs. functional/neuromotor).

Laparoscopic surgery for esophageal achalasia: Multiport vs single-incision approach.

PubMed

Fukuda, Shuichi; Nakajima, Kiyokazu; Miyazaki, Yasuhiro; Takahashi, Tsuyoshi; Makino, Tomoki; Kurokawa, Yukinori; Yamasaki, Makoto; Miyata, Hiroshi; Takiguchi, Shuji; Mori, Masaki; Doki, Yuichiro

2016-02-01

SILS can potentially improve aesthetic outcomes without adversely affecting treatment outcomes, but these outcomes are uncertain in laparoscopic Heller-Dor surgery. We determined if the degree of patient satisfaction with aesthetic outcomes progressed with the equivalent treatment outcomes after the introduction of a single-incision approach to laparoscopic Heller-Dor surgery. We retrospectively reviewed 20 consecutive esophageal achalasia patients (multiport approach, n = 10; single-incision approach, n = 10) and assessed the treatment outcomes and patient satisfaction with the aesthetic outcomes. In the single-incision approach, thin supportive devices were routinely used to gain exposure to the esophageal hiatus. No statistically significant differences in the operating time (210.2 ± 28.8 vs 223.5 ± 46.3 min; P = 0.4503) or blood loss (14.0 ± 31.7 vs 16.0 ± 17.8 mL; P = 0.8637) were detected between the multiport and single-incision approaches. We experienced no intraoperative complications. Mild dysphagia, which resolved spontaneously, was noted postoperatively in one patient treated with the multiport approach. The reduction rate of the maximum lower esophageal sphincter pressure was 25.1 ± 34.4% for the multiport approach and 21.8 ± 19.2% for the single-incision approach (P = 0.8266). Patient satisfaction with aesthetic outcomes was greater for the single-incision approach than for the multiport approach. When single-incision laparoscopic Heller-Dor surgery was performed adequately and combined with the use of thin supportive devices, patient satisfaction with the aesthetic outcomes was higher and treatment outcomes were equivalent to those of the multiport approach. © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.

Teaching Sport Skills to Brain-Injury Students: An Example in Swimming

ERIC Educational Resources Information Center

Driver, Simon; Kelly, Luke

2005-01-01

The number of people who experience a brain injury increases every year, and 40 percent of all cases involve children (Hill, 1999). In fact, this high rate has led brain injury to become the most commonly acquired disability among children (Bigge, Best, & Heller, 2001), leading to a variety of primary disabilities that affect cognition,…

Cholesterol Reduction in an ’At-Risk Population

DTIC Science & Technology

1989-05-17

effective than pamphlets or video tapes. This viewpoint is supported in a review by Glanz 203 tAat looked at nutrition education for low-fat diets. She...Helgeland, A., Hjermann, I., & Holme, I. 1983. MRFIT and the Oslo study. JAMA 249:893-894. 120. Rose, G., Tunstall- Pedoe , H.D., & Heller, R.F. 1983

Accountability through Assessment of Administrative Organizations in Higher Education

ERIC Educational Resources Information Center

Kniola, David J.

2013-01-01

Accountability is among the least understood policy issues in higher education (Burke 2005). The rapid rise in tuition costs in both public and private institutions (Heller 2006) in all corners of the globe (Altbach, Reisberg, and Rumbley 2009) has challenged the idea of higher education as a public good. Student learning outcomes is one…

"Teach Reading? but I'm Not a Reading Teacher!"

ERIC Educational Resources Information Center

Hurst, Beth; Pearman, Cathy J.

2013-01-01

A critical issue in education today is that many middle and high school students are not able to read on grade level (Alvermann & Rush, 2004; Biancarosa & Snow, 2010; Heller & Greenleaf, 2007; Houge, Geier, & Peyton, 2008). In an effort to deal with the problem, many schools encourage all teachers, regardless of their subject area,…

Casualties of War: Combat Trauma and the Return of the Combat Veteran

ERIC Educational Resources Information Center

Kiely, Denis O.; Swift, Lisa

2009-01-01

The experience of the combat soldier and the road back to civilian life are recurrent themes in American literature and cinema. Whether the treatment is tragic (Stephen Crane's "Red Badge of Courage", Tim O'Brien's "The Things They Carried", or Tony Scott's "Blackhawk Down"), satirical (Joseph Heller's "Catch Twenty-Two" and Robert Altman's…

Mothers, Workers and Students: Examining the Experiences of Single Mothers Transferring from Community Colleges into Universities

ERIC Educational Resources Information Center

Robinson, Emily Erin Peterson

2010-01-01

Single parent households are on the rise, and female headed households are more likely to live in poverty than other single parent households (Holyfield, 2002). Many single mothers who do not have an undergraduate degree see education as a way out of poverty (Holyfield, 2002; Heller & Bjorklund, 2004). This research was undertaken to highlight…

Peroral endoscopic myotomy (POEM) for treating esophageal motility disorders

PubMed Central

Wong, Ian

2017-01-01

Pneumatic dilatation and Heller myotomy have been thoroughly studied as the most viable treatment options for achalasia. The pendulum, however, is shifting to the minimally invasive approach. Since Inoue et al. published the experience of the first 17 cases of peroral endoscopic myotomy (POEM) in 2010, there have been at least 5,000 cases performed worldwide and the number is increasing exponentially. Experts across the globe have been extending the indications to various esophageal motility disorders, to patients of extremes of age, sigmoidal esophagus and re-operated patients. There are a few variations in technique across different centers in defining the gastroesophageal junction (GEJ) and adequacy of myotomy, the optimal length, site of myotomy and whether the full thickness of the muscle wall should be cut. Large case series demonstrated its promising efficacy & reasonable complication profile. Randomized controlled trial in comparison with the gold standard, Heller myotomy, is ongoing. The future application of submucosal tunnelling technique is thrilling with its extension in tumour resection, antropyloromyotomy and other natural orifice transluminal endoscopic surgery (NOTES). PMID:28616407

Laparoscopic esophagomyotomy for achalasia in children: A review

PubMed Central

Pandian, T Kumar; Naik, Nimesh D; Fahy, Aodhnait S; Arghami, Arman; Farley, David R; Ishitani, Michael B; Moir, Christopher R

2016-01-01

Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy (LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multi-institutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term (> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care. PMID:26839646

Reoperations for esophageal achalasia.

PubMed

Omura, Nobuo; Kashiwagi, Hideyuki; Yano, Fumiaki; Tsuboi, Kazuto; Yanaga, Katsuhiko

2012-11-01

To define the factors predisposing to recurrence and evaluate the results of reoperations for achalasia. We reviewed the medical records of ten patients (4 men and 6 women; mean age, 51.5 ± 11.0 years), who underwent reoperations for achalasia between August 1994 and August 2010. The primary surgical procedures were Heller-Dor (HD) cardioplasty in nine patients and Heller myotomy in one patient. The factors contributing to failure of the primary operation included inadequate myotomy (n = 2), recurrent adhesion after myotomy (n = 2), reflux esophagitis (n = 2), difficulty in passage caused by tortuosity of the esophagus (n = 2), difficulty in passage through the thoracic esophagus (n = 1), and severe chest pain (n = 1). The reoperations included repeated HD procedures (n = 4), repair of an esophageal hiatal hernia (n = 2), thoracic esophageal myotomy (n = 2), straightening of the lower esophagus with gastropexy (n = 1), and subtotal esophagectomy (n = 1). The success rate of the reoperations for resolving symptoms was 90 % (9 patients). Selecting surgical procedures based on the causes and conditions of recurrence led to symptomatic improvement and acceptable outcomes.

Duck and Cover, Little Lady: Women and Campus Carry

ERIC Educational Resources Information Center

Somers, Patricia; Fry, Jessica; Fong, Carlton J.

2017-01-01

In 2008, in the case of the "District of Columbia vs. Heller," which involved a district law banning most handguns, the U. S. Supreme Court declared that the Second Amendment protects citizens' rights to self-defense and that the federal government cannot prohibit guns in homes. Two years later, the Court further made clear that the…

Catch-22 and Property Rights

Treesearch

Warren A. Flick

1998-01-01

Almost everone knows Catch-22 situations where the inherenct logic of something creates an absurdity or self-contridiction. Author Joesph Heller's original was a military rule designed to thwart airmen from pleading insanity to escape bombing missions--the rule said any airman rational enough to want to be grounded could not possibly be insane and therefore had to...

Endoscopic Pneumatic Dilation for Esophageal Achalasia.

PubMed

Markar, Sheraz; Zaninotto, Giovanni

2018-04-01

Pneumatic dilation is a well-established treatment modality that has withstood the test of time. Prospective and randomized trials have shown that in expert hands, it provides results similar to a laparoscopic Heller myotomy with fundoplication. In addition, it should be considered the primary form of treatment in patients who experience recurrence of symptoms after a surgical myotomy.

A Universal Model of Giftedness--An Adaptation of the Munich Model

ERIC Educational Resources Information Center

Jessurun, J. H.; Shearer, C. B.; Weggeman, M. C. D. P.

2016-01-01

The Munich Model of Giftedness (MMG) by Heller and his colleagues, developed for the identification of gifted children, is adapted and expanded, with the aim of making it more universally usable as a model for the pathway from talents to performance. On the side of the talent-factors, the concept of multiple intelligences is introduced, and the…

Lichenological studies in Puerto Rico: history and current status

Treesearch

Joel A. Mercado-Diaz; Eugenio Santiago-Valentin

2010-01-01

European scientists initiated lichenology in Puerto Rico in the 19th century. Activity of the discipline increased notably on the island during the first three decades of the 20th century, primarily by the field explorations and publications of the New York Botanical Garden scientists and associates (A. A. Heller, N. L. and E. G. Britton, L. W. Riddle), and by the work...

Annotated Bibliography on Human Factors in Software Development

DTIC Science & Technology

1979-06-01

Information Sciences, 1976, 5, 123-143. Shneiderman. B., Mayer, R., McKay, D., & Heller, P. Experimental investi- gations of the utility of flowcharts ...REPRESENTATIONS OF PROGRAMS, PRODUCTION SCHEDULIWG, AUTOMATIC FLOWCHARTING , -MAPFSR,- AND CERTIFICATION TECHNIQUES. EXAMPLES OF HOW THSSE AIOS AND METHODS CAN...PROCiSS ARE PRESENTED, AND THE ANALYSIS Of THREE SPECIFIC MODELS IS REVIEWED. (0)SP, 5R. . 65 FLOWCHARTING CHAPIN, N. FLOWCHARTING WITH THE ANSI

Armed To Learn: Aiming At California K 12 School Gun Policy

DTIC Science & Technology

2016-03-01

involvement in, or presence of, any militia. In District of Columbia v. Heller in 2008, the Supreme Court changed the long-standing collective rights...research focused on decision-making processes that are based on risk management principles fostered by the Insurance Institute of America. Risk...Management, 3rd ed. (Malvern, PA: Insurance Institute of America, 2003), http://www.theinstitutes.org/guide/designations/associate-risk-management

Evaluating the impact of seismic prospecting on artisanal shrimp fisheries

NASA Astrophysics Data System (ADS)

Andriguetto-Filho, José M.; Ostrensky, Antonio; Pie, Marcio R.; Silva, Ubiratã A.; Boeger, Walter A.

2005-09-01

The constant need to discover new hydrocarbon deposits is causing the use of air-guns to become a very widespread method of seismic prospecting. However, there is still disagreement regarding their impact on the marine environment. This uncertainty is particularly severe in the case of shellfish, which account for a substantial share of commercial fisheries and seafood trade in many parts of the world. In this paper we report on the first study to explicitly assess the impact of seismic prospecting on shrimp resources. We measured bottom trawl yields of a nonselective commercial shrimp fishery comprising the Southern white shrimp, Litopenaeus schmitti, the Southern brown shrimp, Farfantepenaeus subtilis, and the Atlantic Seabob, Xyphopenaeus kroyeri (Decapoda: Penaeidae), before and after the use of an array of four synchronized air-guns, each with 635 in 3 of total capacity, 2.000 psi, and peak pressure of 196 dB (re 1 μPa at 1 m). Our results did not detect significant deleterious impact of seismic prospecting on the studied species, suggesting that shrimp stocks are resilient to the disturbance by air-guns under our experimental conditions.

Draft Software Metrics Panels Final Report. Papers Presented at the 30 June 1980 Meeting on Software Metrics, Washington DC.

DTIC Science & Technology

1980-06-01

measuring program understanding. Shneiderman, Mayer, McKay, and Heller [241 found that flowcharts are redundant and have a potential negative affect on...dictionaries of program variables are superior to macro flowcharts as an aid to understand program control and data structures. Chrysler [5], using no...procedures as do beginners . Also; guaranteeing that groups of begining programmers have equal ability is not trivial. 3-10 The problem with material

Social Resources that Preserve Functional Independence after Memory Loss

DTIC Science & Technology

2014-05-01

older adults. Ann Behav Med 2005;29:166–173. 15. Klijs B, Mackenbach JP, Kunst AE. Obesity, smoking, alcohol consumption and years lived with disability...Konig, S. G. Riedel-Heller, Prediction of institutionalisation in dementia. A systematic review. Dementia and geriatric cognitive disorders 26, 65...patients living in the community. International journal of geriatric psychiatry 20, 471 (May, 2005). 3. A. M. Jette, Toward a common language for

Robotic technological aids in esophageal surgery.

PubMed

Rebecchi, Fabrizio; Allaix, Marco E; Morino, Mario

2017-01-01

Robotic technology is an emerging technology that has been developed in order to overcome some limitations of the standard laparoscopic approach, offering a stereoscopic three-dimensional visualization of the surgical field, increased maneuverability of the surgical tools with consequent increased movement accuracy and precision and improved ergonomics. It has been used for the surgical treatment of most benign esophageal disorders. More recently, it has been proposed also for patients with operable esophageal cancer. The current evidence shows that there are no real benefits of the robotic technology over conventional laparoscopy in patients undergoing a fundoplication for gastroesophageal reflux disease (GERD), hiatal closure for giant hiatal hernia, or Heller myotomy for achalasia. A few small studies suggest potential advantages in patients undergoing redo surgery for failed fundoplication or Heller myotomy, but large comparative studies are needed to better clarify the role of the robotic technology in these patients. Robot-assisted esophagectomy seems to be safe and effective in selected patients; however, there are no data showing superiority of this approach over both conventional laparoscopic and open surgery. The short-term and long-term oncologic results of ongoing randomized controlled trials (RCTs) are awaited to validate this approach for the treatment of esophageal cancer.

Lateralization of high-frequency transposed stimuli under conditions of binaural interference

NASA Astrophysics Data System (ADS)

Bernstein, Leslie R.; Trahiotis, Constantine

2005-04-01

The purpose of this study was to determine whether binaural interference would occur if ITD-based extents of laterality were measured using high-frequency transposed stimuli as targets. The results of an earlier study [L. R. Bernstein and C. Trahiotis, J. Acoust. Soc. Am. 116, 3062-3069 (2004)], which focused on threshold-ITDs rather than extents of laterality, suggested that high-frequency transposed stimuli might be immune to binaural interference effects resulting from the addition of a spectrally-remote, low-frequency interferer. In contrast to the earlier findings, the data from this study indicate that high-frequency transposed targets can, indeed, be susceptible to binaural interference. High-frequency transposed targets, even when presented along with an interferer, yielded greater extents of ITD-based laterality than did Gaussian noise targets presented in isolation. That is, the enhanced potency of ITDs conveyed by transposed stimuli persisted even in the presence of a low-frequency interferer. Predictions made using an extension of the model of Heller and Trahiotis [L. M. Heller and C. Trahiotis, J. Acoust. Soc. Am. 99, 3632-3637 (1996)] accounted well for binaural interference obtained with conventional Gaussian noise targets but generally over-predicted the amounts of interference found with the transposed targets.

Measures of extents of laterality for high-frequency ``transposed'' stimuli under conditions of binaural interference

NASA Astrophysics Data System (ADS)

Bernstein, Leslie R.; Trahiotis, Constantine

2005-09-01

Our purpose in this study was to determine whether across-frequency binaural interference would occur if ITD-based extents of laterality were measured using high-frequency transposed stimuli as targets. The results of an earlier study [L. R. Bernstein and C. Trahiotis, J. Acoust. Soc. Am. 116, 3062-3069 (2004)], which focused on threshold-ITDs, rather than extents of laterality, suggested that high-frequency transposed stimuli might be ``immune'' to binaural interference effects resulting from the addition of a spectrally remote, low-frequency interferer. In contrast to the earlier findings, the data from this study indicate that high-frequency transposed targets are susceptible to binaural interference. Nevertheless, high-frequency transposed targets, even when presented along with an interferer, yielded greater extents of ITD-based laterality than did high-frequency Gaussian noise targets presented in isolation. That is, the ``enhanced potency'' of ITDs conveyed by transposed stimuli persisted, even in the presence of a low-frequency interferer. Predictions made using an extension of the model of Heller and Trahiotis [L. M. Heller and C. Trahiotis, J. Acoust. Soc. Am. 99, 3632-3637 (1996)] accounted well for across-frequency binaural interference obtained with conventional Gaussian noise targets but, in all but one case, overpredicted the amounts of interference found with the transposed targets.

Robotic technological aids in esophageal surgery

PubMed Central

Allaix, Marco E.; Morino, Mario

2017-01-01

Robotic technology is an emerging technology that has been developed in order to overcome some limitations of the standard laparoscopic approach, offering a stereoscopic three-dimensional visualization of the surgical field, increased maneuverability of the surgical tools with consequent increased movement accuracy and precision and improved ergonomics. It has been used for the surgical treatment of most benign esophageal disorders. More recently, it has been proposed also for patients with operable esophageal cancer. The current evidence shows that there are no real benefits of the robotic technology over conventional laparoscopy in patients undergoing a fundoplication for gastroesophageal reflux disease (GERD), hiatal closure for giant hiatal hernia, or Heller myotomy for achalasia. A few small studies suggest potential advantages in patients undergoing redo surgery for failed fundoplication or Heller myotomy, but large comparative studies are needed to better clarify the role of the robotic technology in these patients. Robot-assisted esophagectomy seems to be safe and effective in selected patients; however, there are no data showing superiority of this approach over both conventional laparoscopic and open surgery. The short-term and long-term oncologic results of ongoing randomized controlled trials (RCTs) are awaited to validate this approach for the treatment of esophageal cancer. PMID:29078570

The current state of per oral endoscopic myotomy for achalasia

PubMed Central

Smith, Shane P.

2017-01-01

Achalasia is an acquired neuromuscular disorder that has been treated using a variety of modalities throughout medical history. Recently, the technique of per oral endoscopic myotomy (POEM) was introduced to treat the disease using a truly minimally invasive, natural orifice technique that is rapidly being adopted across the world. This review outlines the development of POEM, the technique itself, and gives a comparison to other procedures, specifically laparoscopic Heller myotomy (LHM). PMID:29078682

Long Cycle Life Secondary Lithium Cells Utilizing Tetrahydrofuran.

DTIC Science & Technology

1984-04-01

Rosenwasser) Code RD-I Washington, D.C. 20360 Washington, D.C. 20380 Naval Civil Engineering Laboratory 1 Dean William Tolles Attn: Dr. R. W. Drisko...Ocean Systems Center 11 apel Street San Diego, California 92152 wton, Massachusetts 02158 Dr. J. J. Auborn Dr. Adam Heller Bell Laboratories Bell...University Research Triangle Park, NC 27709 Evanston, Illinois 60201 Dr. William Ayers Dr. Aaron Fletcher ECD Inc. Naval Weapons Center P.O. Box 5357 Code

Transportability Testing of the Joint Modular Intermodal Platform (JMIP), TP-94-01, Transportability Testing Procedures

DTIC Science & Technology

2006-11-01

Serial #: T-018447EFJM Weight: 19,340 pounds 4. Semitrailer, flatbed , breakbulk/container transporter, 34 ton Model #: M872A1 Manufactured by Heller...WILL BE USED WHENEVER POS- SIBLE WHEN NAILS ARE DRIVEN INTO JOINTS OF DUNNAGE AS- SEMBLIES OR WHEN LAMINATING DUNNAGE. ADDITIONALLY, THE NAILING...PATTERN FOR AN UPPER PIECE OF LAMINATED DUNNAGE WILL BE ADJUSTED AS REQUIRED SO THAT A NAIL FOR THAT PIECE WILL NOT BE DRIVEN THROUGH, ONTO, OR RIGHT

Pulsed Electric Fields for Biological Weapons Defense

DTIC Science & Technology

2008-09-30

multifunctional biological transporters and near - infrared agents for selective cancer cell destruction. Proc Natl Acad Sci U S A 102, 11600-5. 45. Heller, D. A...controlled biochemical manipulation. Nanotechnology 14,551-556. 47. Cherukuri, P., Bachilo, S. M., Litovsky, S. H., and Weisman, R. B. (2004). Near - infrared ...Pulsed Electric Fields for Biological Weapons Defense AFOSR Grant No. FA9550-05-1-0081 P.I. Martin Gundersen atrophaeus and isolates from dental patients

A Modified Constant-Stress Coupon for Enhanced Natural Crack Start during Fatigue Testing

DTIC Science & Technology

2016-05-01

improved numerically controlled manufacture. DSTO Research Report DSTO-RR-0340, July 2009. Wescott R, M Jones, M Heller. Stress analysis for design of...has been confirmed by Yu et al. (2014) through experimental strain measurement as well as fatigue tests under spectrum loading. However, as designed ...the results of analyses of a variety of typical non -optimal non -constant stress dog-bone coupon designs . One of those designs has in fact previously

[Focus on Achalasia].

PubMed

Guillaumot, Marie-Anne; Barret, Maximilien; Leblanc, Sarah; Leconte, Mahaut; Dousset, Bertrand; Oudjit, Ammar; Prat, Frédéric; Chaussade, Stanislas

2018-01-01

The pathophysiology of achalasia is largely unknown, and involves the destruction of ganglion cell in the esophageal myenteric plexus. High-resolution esophageal manometry is the key investigation. Endoscopic pneumodilatation and laparoscopic Heller myotomy have comparable short-term success rates, around 90%. The main complication after pneumodilatation is esophageal perforation, occurring in about 1% of cases. Peroral endoscopic myotomy is a promising treatment modality, however with frequent post-procedural gastroesophageal reflux. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Minimally invasive surgery for esophageal motility disorders.

PubMed

Balaji, Nagammapudur S; Peters, Jeffrey H

2002-08-01

Laparoscopic Heller myotomy has emerged as an excellent primary treatment for patients with dysphagia secondary to achalasia. A laparoscopic rather than thoracoscopic approach has stood the test of time. An antireflux procedure combined with the myotomy is crucial to the maintenance of the antireflux barrier. Thoracoscopic long myotomy offers effective relief for spastic disorders of the esophagus. Endoscopic stapled diverticulotomy is a safe and effective procedure for Zenker's diverticulum and has potential advantages over the open approach.

Final Environmental Impact Report/Environmental Impact Statement. Cullinan Ranch Specific Plan. Chapter 13. Comments and Responses.

DTIC Science & Technology

1984-05-01

energy- intensive crop, and agricultural advisors expect alfalfa prices to rise significantly in the future. Sonoma County Dairy Advisor Dr. Richard...Bermon Alfred Heller John Tuteur. Jr James D Hobbs* Volker E#1ee Sonoma County I. Michael Heyman Mrs Robert Watson Alemo County JunO Foote Marilyn...86 ,. Sunnyvale 5 571 Sonoma County 56 21,266 i Class C -- Little or no protection of diked baylands at local level Alameda County 1 228 Alameda 2 71

Optimization of Capillary Electrophoresis With Laser Induced Fluorescent (CE-LIF) Detection for the Analysis of Double Standed DNA Polymerase Chain Reaction Products from the Telomeric Repeat Amplification Protocol

DTIC Science & Technology

2000-12-06

Fluorescent Milligram (10ŗ) Milliliter (10ŗ) vm ^g Microgram (10") 1*1 Microliter (10" 6) MMA Master Mix A MMB Master Mix B NSCLC Non-Small-Cell...little effect on heat dissipation, the mixing helped to smooth out the convection gradients (see Weinberger 1993). The use of smaller i.d...clogging may occur (Heller 1998a). The gels must be covalently bound to the capillary wall to avoid extrusion from the capillary by electroosmotic flow

Free-Inertial and Damped-Inertial Navigation Mechanization and Error Equations

DTIC Science & Technology

1975-04-18

AD-A014 356 FREE-INERTIAL AND DAMPED-INERTIAL NAVIGATION MECHANIZATION AND ERROR EQUATIONS Warren G. Heller Analytic Sciences Corporation Prepared...IHI IL JI -J THE ANALYTIC SCIENCES CORPORATION TR-312-1-1 FREE-INERTIAL AND DAMPED-INERTIAL NAViGATION MECHANIZATION AND ERROR EQUATIONS Ap~ril 18...PERIOO COVC/REO Fr-,- 1wer l and Dmped-Inertial Navigation Technical Mechanization and Error Equations 8/20-73 - 8/20/74 S. PjLtFORJ4djNjOjO, REPORT

Weiße und Braune Zwerge zeigen sich unwirtlich

NASA Astrophysics Data System (ADS)

Heller, René

2013-02-01

Mehr als 850 Exoplaneten haben Astronomen seit dem Jahr 1992 nachgewiesen. Die meisten von ihnen umkreisen normale Hauptreihensterne, aber es wurden auch Trabanten im Umlauf um Braune oder Weiße Zwerge aufgespürt. Nun haben Rory Barnes von der University of Washington in Seattle und René Heller am Leibniz-Institut für Astrophysik Potsdam die Bewohnbarkeit möglicher Planeten um solche Objekte untersucht und dabei festgestellt, dass sie für Leben, wie wir es kennen, ungeeignet sind.

Evaluation Transportability Testing of the Joint Modular Intermodal Platform (JMIP) Unit #4 TP-94-01, Revision 2, June 2004, Transportability Testing Procedures

DTIC Science & Technology

2007-07-01

Weight: 19,340 lbs 3-1 5. Semitrailer, flatbed , breakbulk/container transporter, 34 ton Model #: M872A1 Manufactured by Heller Truck Body Corporation...REQD). LAMINATE TO BEARING PIECE W/6-10d NAILS EVENLY SPACED. SIDE STRAPPING BOARD ASSEMBLY (4 RECD) EPAGE 5 NOTE: PRODUCE EQUAL QUANTITES OF ASSEMBLY...A AND ASSEMBLY B. EACH JMIP LOAD REQUIRES iWO OF EACH (4 TOTAL). STEEL EDGE PROTECTORS (2 REQD). LAMINATE TO BEARING AND CORNER PIECES W/4-6d NALS AND

[Surgical treatment of esophageal achalasia--20 years experience].

PubMed

Yaramov, N; Sokolov, M; Angelov, K; Toshev, S; Petrov, B

2009-01-01

Achalasia comes from a Greek word that means "failure to relax." Cardiospasm and achalasia refer to the same condition. This report addresses esophageal achalasia--its history, diagnosis, pathophysiology, and treatment options. We report our experience in treating this disorder surgically using modified Heller myotomy combined or not with partial gastric fundoplication. 47 patients with achalasia surgically operated in 20-years period are reported by authors. These features make it reasonable to reasses the relative indications for surgery and nonsurgical therapy in achalasia of the esophagus.

Surgical management of esophageal achalasia: Evolution of an institutional approach to minimally invasive repair.

PubMed

Petrosyan, Mikael; Khalafallah, Adham M; Guzzetta, Phillip C; Sandler, Anthony D; Darbari, Anil; Kane, Timothy D

2016-10-01

Surgical management of esophageal achalasia (EA) in children has transitioned over the past 2 decades to predominantly involve laparoscopic Heller myotomy (LHM) or minimally invasive surgery (MIS). More recently, peroral endoscopic myotomy (POEM) has been utilized to treat achalasia in children. Since the overall experience with surgical management of EA is contingent upon disease incidence and surgeon experience, the aim of this study is to report a single institutional contemporary experience for outcomes of surgical treatment of EA by LHM and POEM, with regards to other comparable series in children. An IRB approved retrospective review of all patients with EA who underwent treatment by a surgical approach at a tertiary US children's hospital from 2006 to 2015. Data including demographics, operative approach, Eckardt scores pre- and postoperatively, complications, outcomes, and follow-up were analyzed. A total of 33 patients underwent 35 operative procedures to treat achalasia. Of these operations; 25 patients underwent laparoscopic Heller myotomy (LHM) with Dor fundoplication; 4 patients underwent LHM alone; 2 patients underwent LHM with Thal fundoplication; 2 patients underwent primary POEM; 2 patients who had had LHM with Dor fundoplication underwent redo LHM with takedown of Dor fundoplication. Intraoperative complications included 2 mucosal perforations (6%), 1 aspiration, 1 pneumothorax (1 POEM patient). Follow ranged from 8months to 7years (8-84months). There were no deaths and no conversions to open operations. Five patients required intervention after surgical treatment of achalasia for recurrent dysphagia including 3 who underwent between 1 and 3 pneumatic dilations; and 2 who had redo LHM with takedown of Dor fundoplication with all patients achieving complete resolution of symptoms. Esophageal achalasia in children occurs at a much lower incidence than in adults as documented by published series describing the surgical treatment in children. We

Laparoscopic extended cardiomyotomy in children: an effective procedure for the treatment of esophageal achalasia.

PubMed

Tannuri, Ana Cristina Aoun; Tannuri, Uenis; Velhote, Manoel Carlos Prieto; Romão, Rodrigo Luiz Pinto

2010-07-01

Achalasia of the esophagus is characterized by aperistalsis and incomplete relaxation of the lower esophageal sphincter in response to swallowing. The objective of the present study is to present the experience of a modified Heller myotomy via a laparoscopic approach for the treatment of children who had this condition. A retrospective review of medical records of all patients who underwent this procedure from 2000 to 2009 was performed. The procedure consisted of an extended esophagomyotomy beginning on the lower part of the lower esophageal sphincter and continuing 5 to 6 cm above on the lower third of the esophagus, and then extended 3 to 4 cm below to the stomach, associated with an anterior 180-degree hemi-fundoplication according to Dor's technique. Fifteen patients were included in the study. There were 8 female and 7 male patients. Mean operating time was 190 minutes with no intraoperative complications and 1 conversion to open surgery because of difficulty in dissecting an inflamed distal esophagus. In a mean follow-up period of 32.3 months, 2 patients had recurrence of mild dysphagia that disappeared spontaneously, and 1 required a single botulinum toxin injection with complete resolution of symptoms. We conclude that the laparoscopic extended Heller myotomy with Dor fundoplication is a safe and effective method for the treatment for achalasia in the pediatric population even in advanced cases. Copyright 2010 Elsevier Inc. All rights reserved.

Glycogen metabolism and the homeostatic regulation of sleep.

PubMed

Petit, Jean-Marie; Burlet-Godinot, Sophie; Magistretti, Pierre J; Allaman, Igor

2015-02-01

In 1995 Benington and Heller formulated an energy hypothesis of sleep centered on a key role of glycogen. It was postulated that a major function of sleep is to replenish glycogen stores in the brain that have been depleted during wakefulness which is associated to an increased energy demand. Astrocytic glycogen depletion participates to an increase of extracellular adenosine release which influences sleep homeostasis. Here, we will review some evidence obtained by studies addressing the question of a key role played by glycogen metabolism in sleep regulation as proposed by this hypothesis or by an alternative hypothesis named "glycogenetic" hypothesis as well as the importance of the confounding effect of glucocorticoïds. Even though actual collected data argue in favor of a role of sleep in brain energy balance-homeostasis, they do not support a critical and direct involvement of glycogen metabolism on sleep regulation. For instance, glycogen levels during the sleep-wake cycle are driven by different physiological signals and therefore appear more as a marker-integrator of brain energy status than a direct regulator of sleep homeostasis. In support of this we provide evidence that blockade of glycogen mobilization does not induce more sleep episodes during the active period while locomotor activity is reduced. These observations do not invalidate the energy hypothesis of sleep but indicate that underlying cellular mechanisms are more complex than postulated by Benington and Heller.

Hospitalization for esophageal achalasia in the United States.

PubMed

Molena, Daniela; Mungo, Benedetto; Stem, Miloslawa; Lidor, Anne O

2015-09-25

To assess the outcome of different treatments in patients admitted for esophageal achalasia in the United States. This is a retrospective analysis using the Nationwide Inpatient Sample over an 8-year period (2003-2010). Patients admitted with a primary diagnosis of achalasia were divided into 3 groups based on their treatment: (1) Group 1: patients who underwent Heller myotomy during their hospital stay; (2) Group 2: patients who underwent esophagectomy; and (3) Group 3: patients not undergoing surgical treatment. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS), discharge destination and total hospital charges. Among 27141 patients admitted with achalasia, nearly half (48.5%) underwent Heller myotomy, 2.5% underwent esophagectomy and 49.0% had endoscopic or other treatment. Patients in group 1 were younger, healthier, and had the lowest mortality when compared with the other two groups. Group 2 had the highest LOS and hospital charges among all groups. Group 3 had the highest mortality (1.2%, P < 0.001) and the lowest home discharge rate (78.8%) when compared to the other groups. The most frequently performed procedures among group 3 were esophageal dilatation (25.9%) and injection (13.3%). Among patients who died in this group the most common associated morbidities included acute respiratory failure, sepsis and aspiration pneumonia. Surgery for achalasia carries exceedingly low mortality in the modern era; however, in complicated patients, even less invasive treatments are burdened by significant mortality and morbidity.

Autism and esophageal achalasia in childhood: a possible correlation? Report on three cases.

PubMed

Betalli, P; Carretto, E; Cananzi, M; Zanatta, L; Salvador, R; Galeazzi, F; Guariso, G; Gamba, P; Costantini, M

2013-04-01

Chronic gastrointestinal symptoms are commonly reported in autistic patients. Dysphagia is often present, and it is generally related to behavioral eating disorders. The association between autism and esophageal achalasia has not been described in literature yet. We report our experience with three cases of autistic children we recently treated for esophageal achalasia. In the first case (a 14-year-old male), achalasia was diagnosed with barium swallow and esophageal manometry and was successfully treated with three pneumatic endoscopic dilatations (follow-up: 3 years). In the second case (a 12-year-old female), achalasia was diagnosed with barium swallow and esophageal manometry and was treated with Heller myotomy after two unsuccessful pneumatic endoscopic attempts (follow-up: 3 months). In the last case, a 15-year-old male underwent barium swallow and endoscopy that confirmed achalasia. He was treated with Heller myotomy, and he is asymptomatic at a 6-month follow-up. To our knowledge, this is the first report of a possible association between autism and esophageal achalasia. Because of the rarity of both diseases, their association in the same patient is unlikely to be casual even if speculation on their common etiology is impossible at present. This finding needs further confirmation, but it is sufficient, in our opinion, to indicate proper evaluation with barium swallow and/or manometry in any autistic children with eating difficulty. © 2012 Copyright the Authors. Journal compilation © 2012, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

The exact eigenfunctions and eigenvalues of a two-dimensional rigid rotor obtained using Gaussian wave packet dynamics

NASA Technical Reports Server (NTRS)

Reimers, J. R.; Heller, E. J.

1985-01-01

Exact eigenfunctions for a two-dimensional rigid rotor are obtained using Gaussian wave packet dynamics. The wave functions are obtained by propagating, without approximation, an infinite set of Gaussian wave packets that collectively have the correct periodicity, being coherent states appropriate to this rotational problem. This result leads to a numerical method for the semiclassical calculation of rovibrational, molecular eigenstates. Also, a simple, almost classical, approximation to full wave packet dynamics is shown to give exact results: this leads to an a posteriori justification of the De Leon-Heller spectral quantization method.

Chemical Bonding, Interdiffusion and Electronic Structure at InP, GaAs, and Si-Metal Interfaces.

DTIC Science & Technology

1985-10-01

4. H.H. Wieder, J. Vac. Sci. Technol. 15, 1498 (1978). C. 5. W.E. Spicer, 1. Lindau, P. Skeath, C.Y. Su, and P. Chye , Phys. Rev. Lett. 44, 10 420...Spicer, Solid State Electron. 28 307 (1985). 25. N. Newman, K.K. Chin , W.G. Petro, T. Kendelewicz, M.D. Williams, C.E. McCants, and W.E. Spicer, J. Vac...Technol. 19, 661 (1981). 11. Y. Shapira, L.J. Brillson and A. Heller, J. Vac. Sci. U Technol., Al, 766 (1983). 12. P.W. Chye , I. Lindau, P. Pianetta, C.M

The evolution of the treatment of esophageal achalasia: a look at the last two decades.

PubMed

Allaix, Marco E; Herbella, Fernando A; Patti, Marco G

2012-09-01

Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a revolution in the treatment of benign esophageal disorders, particularly for esophageal achalasia. This has brought a shift in the treatment algorithm of this disease, as today a laparoscopic Heller myotomy with partial fundoplication is considered the primary form of treatment in most Centers in North America. This article reviews the evolution of the treatment of esophageal achalasia during the last two decades, with particular stress on the key technical elements of this operation.

Excalibur Strategic Configured Load (SCL) for the Heavy Expanded Mobility Tactical Truck (HEMTT). Testing IAW TP-94-01, Revision 2, June 2004, Transportability Testing Procedures

DTIC Science & Technology

2008-06-01

2-1 PART 3 - TEST EQUIPMENT 1. Semitrailer, flatbed , breakbulk/container transporter, 34 ton Model #: M872A1 Manufactured by Heller Truck Body... LAMINATING DUNNAGE. ADDITIONALLY, THE NAILING PATTERN FOR AN UP- DA39 PALLET UNITS CENTERED ON TOP OF PRIOR DA39 PALLET UNITS, PER PIECE OF LAMINATED ...ai FT (APPWO HEADER I" X V’ X 7-4- (AS RECID, 1 SHOWYN). LAMINATE EACH HEADER TO PREVIOUS HEADER W/9-10d NAILS. HEADER 2" x 8" x r-" (AS RECID, 3 SHOWN

Minimally invasive surgery for esophageal achalasia

PubMed Central

Bonavina, Luigi

2006-01-01

Esophageal achalasia is the most commonly diagnosed primary esophageal motor disorder and the second most common functional esophageal disorder. Current therapy of achalasia is directed toward elimination of the outflow resistance caused by failure of the lower esophageal sphincter to relax completely upon swallowing. The advent of minimally invasive surgery has nearly replaced endoscopic pneumatic dilation as the first-line therapeutic approach. In this editorial, the rationale and the evidence supporting the use of laparoscopic Heller myotomy combined with fundoplication as a primary treatment of achalasia are reviewed. PMID:17009388

Diagnosis and management of esophageal achalasia in children: analysis of 13 cases.

PubMed

Zhang, Yin; Xu, Chun-Di; Zaouche, Abdehaman; Cai, Wei

2009-02-01

Esophageal achalasia is a rare disease and there have been very few reports about it, especially in children. We reviewed our experience in dealing with esophageal achalasia in 13 children. Thirteen children (6 boys and 7 girls), who had been diagnosed with achalasia over a 12-year period between May 1993 and October 2005, were analysed with regard to clinical manifestations, esophageal manometry, endoscopic findings, and treatment. Their age ranged from 3 years to 14 years and 5 months (average 10.3 years) at the time of diagnosis. In the 13 children, 3 had a family history of esophageal achalasia, 2 of them were sisters. All the 3 children suffered from achalasia/alacrimia/ACTH deficiency. Dysphagia was the most common symptom in the affected children. Vomiting/regurgitation, retrosternal pain, retarded growth, and respiratory symptoms were also observed in some patients. Heller's esophagocardiomyotomy was performed in 9 (69.23%) children, among whom 3 had an antireflux operation at the same time. In the remaining 4 children, 3 received a pneumatic dilatation and 1 received regular administration of nifedipine. Twelve patients were followed up: 8 patients by surgery were cured and have been in perfect condition until now, 3 patients recovered fairly, and 1 patient showed improvement. Esophageal manometry combined with X-ray examination proves to be an effective diagnostic method for achalasia. It is also effective in evaluating the result of treatment. Heller's esophagocardiomyotomy is a treatment of choice for children with achalasia because of its safety and long-term effective results after surgery.

Long-term results of laparoscopic treatment of esophageal achalasia in children: a multicentric survey.

PubMed

Esposito, Ciro; Riccipetitoni, Giovanna; Chiarenza, Salvatore Fabio; Roberti, Agnese; Vella, Claudio; Alicchio, Francesca; Fava, Giorgio; Escolino, Maria; De Pascale, Teresa; Settimi, Alessandro

2013-11-01

This report describes three Italian centers' experience in the treatment of children with esophageal achalasia. Between June 2000 and June 2012, 31 children (13 girls and 18 boys, with a median age of 8.4 years) affected by esophageal achalasia were treated in three different institutions with an esophagomyotomy according to Heller's procedure via laparoscopy associated with a Dor antireflux procedure. Between 2000 and 2005 (for 14 patients) we used mono- or bipolar coagulation to perform myotomy; after 2005 (for 17 patients) we used the new hemostatic devices to perform it. Median length of surgery was 120 minutes. Median hospital stay was 4 days. We recorded eight complications in our series: 3 patients (9.6%) had a mucosal perforation, and 5 children (16.1%) presented dysphagia after surgery. When comparing the data before and after 2005, it seems that the new hemostatic devices statistically shortened the length of surgery (P<.01, Student's t test). On the basis of our experience, laparoscopic Heller's myotomy associated with an antireflux procedure is a safe and effective method for the treatment of achalasia in the pediatric population. Intraoperative complications were <10%, and they occurred mostly at the beginning of our experience. Residual dysphagia occurred in about 16% of cases. The use of the new hemostatic devices seems to reduce the length of surgery and intraoperative bleeding. Considering the rarity of this pathology, we believe that patients with achalasia have to be treated only at centers with a strong experience in the treatment of this pathology.

Hospitalization for esophageal achalasia in the United States

PubMed Central

Molena, Daniela; Mungo, Benedetto; Stem, Miloslawa; Lidor, Anne O

2015-01-01

AIM: To assess the outcome of different treatments in patients admitted for esophageal achalasia in the United States. METHODS: This is a retrospective analysis using the Nationwide Inpatient Sample over an 8-year period (2003-2010). Patients admitted with a primary diagnosis of achalasia were divided into 3 groups based on their treatment: (1) Group 1: patients who underwent Heller myotomy during their hospital stay; (2) Group 2: patients who underwent esophagectomy; and (3) Group 3: patients not undergoing surgical treatment. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS), discharge destination and total hospital charges. RESULTS: Among 27141 patients admitted with achalasia, nearly half (48.5%) underwent Heller myotomy, 2.5% underwent esophagectomy and 49.0% had endoscopic or other treatment. Patients in group 1 were younger, healthier, and had the lowest mortality when compared with the other two groups. Group 2 had the highest LOS and hospital charges among all groups. Group 3 had the highest mortality (1.2%, P < 0.001) and the lowest home discharge rate (78.8%) when compared to the other groups. The most frequently performed procedures among group 3 were esophageal dilatation (25.9%) and injection (13.3%). Among patients who died in this group the most common associated morbidities included acute respiratory failure, sepsis and aspiration pneumonia. CONCLUSION: Surgery for achalasia carries exceedingly low mortality in the modern era; however, in complicated patients, even less invasive treatments are burdened by significant mortality and morbidity. PMID:26421106

Treatment of esophageal motility disorders based on the chicago classification.

PubMed

Maradey-Romero, Carla; Gabbard, Scott; Fass, Ronnie

2014-12-01

The Chicago Classification divides esophageal motor disorders based on the recorded value of the integrated relaxation pressure (IRP). The first group includes those with an elevated mean IRP that is associated with peristaltic abnormalities such as achalasia and esophagogastric junction outflow obstruction. The second group includes those with a normal mean IRP that is associated with esophageal hypermotility disorders such as distal esophageal spasm, hypercontractile esophagus (jackhammer esophagus), and hypertensive peristalsis (nutcracker esophagus). The third group includes those with a normal mean IRP that is associated with esophageal hypomotility peristaltic abnormalities such as absent peristalsis, weak peristalsis with small or large breaks, and frequent failed peristalsis. The therapeutic options vary greatly between the different groups of esophageal motor disorders. In achalasia patients, potential treatment strategies comprise medical therapy (calcium channel blockers, nitrates, and phosphodiesterase 5 inhibitors), endoscopic procedures (botulinum toxin A injection, pneumatic dilation, or peroral endoscopic myotomy) or surgery (Heller myotomy). Patients with a normal IRP and esophageal hypermotility disorder are candidates for medical therapy (nitrates, calcium channel blockers, phosphodiesterase 5 inhibitors, cimetropium/ipratropium bromide, proton pump inhibitors, benzodiazepines, tricyclic antidepressants, trazodone, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors), endoscopic procedures (botulinum toxin A injection and peroral endoscopic myotomy), or surgery (Heller myotomy). Lastly, in patients with a normal IRP and esophageal hypomotility disorder, treatment is primarily focused on controlling the presence of gastroesophageal reflux with proton pump inhibitors and lifestyle modifications (soft and liquid diet and eating in the upright position) to address patient's dysphagia.

[Work reality and the construction process of the nurse's identity].

PubMed

Netto, Laura Filomena Santos de Araújo; Ramos, Flávia Regina Souza

2002-01-01

This study tries to understand the relation between the reality of the nurse's everyday work and the construction process of this identity, using Agnes Heller's sociological theory of everyday life as the main reference. The possibilities of the worker's expression and fulfillment occur through objective and subjective elements of job reality which comes upon the worker as people who put order and tension in their everyday job; these job determinants imprint and produce impacts, giving sense to the work quality and constructing concrete possibilities to the worker to manifest him/herself as Whole being, guiding the construction of his/her identity.

Early Program Development

NASA Image and Video Library

1961-01-01

As presented by Gerhard Heller of Marshall Space Flight Center's Research Projects Division in 1961, this chart illustrates three basic types of electric propulsion systems then under consideration by NASA. The ion engine (top) utilized cesium atoms ionized by hot tungsten and accelerated by an electrostatic field to produce thrust. The arc engine (middle) achieved propulsion by heating a propellant with an electric arc and then producing an expansion of the hot gas or plasma in a convergent-divergent duct. The electromagnetic, or MFD engine (bottom) manipulated strong magnetic fields to interact with a plasma and produce acceleration.

Surgery or Peroral Esophageal Myotomy for Achalasia

PubMed Central

Marano, Luigi; Pallabazzer, Giovanni; Solito, Biagio; Santi, Stefano; Pigazzi, Alessio; De Luca, Raffaele; Biondo, Francesco Giuseppe; Spaziani, Alessandro; Longaroni, Maurizio; Di Martino, Natale; Boccardi, Virginia; Patriti, Alberto

2016-01-01

Abstract To date very few studies with small sample size have compared peroral esophageal myotomy (POEM) with the current surgical standard of care, laparoscopic Heller myotomy (LHM), in terms of efficacy and safety, and no recommendations have been proposed. To investigate the efficacy and safety of POEM compared with LHM, for the treatment of achalasia. The databases of Pubmed, Medline, Cochrane, and Ovid were systematically searched between January 1, 2005 and January 31, 2015, with the medical subject headings (MeSH) and keywords “achalasia,” “POEM,” “per oral endoscopic myotomy,” and “peroral endoscopic myotomy,” “laparoscopic Heller myotomy” (LHM), “Heller myotomy.” All types of study designs including adult patients with diagnosis of achalasia were selected. Studies that did not report the comparison between endoscopic and surgical treatment, experimental studies in animal models, single case reports, technical reports, reviews, abstracts, and editorials were excluded. The total number of included patients was 486 (196 in POEM group and 290 in LHM group). There were no differences between POEM and LHM in reduction in Eckardt score (MD = −0.659, 95% CI: −1.70 to 0.38, P = 0.217), operative time (MD = −0.354, 95% CI: −1.12 to 0.41, P = 0.36), postoperative pain scores (MD = −1.86, 95% CI: −5.17 to 1.44, P = 0.268), analgesic requirements (MD = −0.74, 95% CI: −2.65 to 1.16, P = 0.445), and complications (OR = 1.11, 95% CI: 0.5–2.44, P = 0.796). Length of hospital stay was significantly lower for POEM (MD = −0.629, 95% CI: −1.256 to −0.002, P = 0.049). There was a trend toward significant reduction in symptomatic gastroesophageal reflux rate in favors of LHM compared to POEM group (OR = 1.81, 95% CI: 1.11–2.95, P = 0.017). All included studied were not randomized. Furthermore all selected studies did not report the results of follow-up longer than 1 year and

The role of Heller myotomy and POEM for nonachalasia motility disorders.

PubMed

Schlottmann, F; Shaheen, N J; Madanick, R D; Patti, M G

2017-04-01

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders such as Diffuse Esophageal Spasm (DES), Nutcracker Esophagus (NE) and the Hypertensive Lower Esophageal Sphincter (HTN-LES). Most patients with DES and HTN-LES who complain of dysphagia improve after a myotomy. Patients with NE whose main complaint is chest pain, often do not have relief of the pain and can even develop dysphagia as a consequence of the myotomy. POEM is a relatively new procedure, and there are no studies with long-term follow-up and no prospective and randomized trials comparing it to surgical myotomy. Overall, the key to success is based on a complete evaluation and a careful patient selection. The best results, regardless of the technique, are in fact obtained in patients with outflow obstruction and impaired esophageal emptying, a picture similar to achalasia. © The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

The preoperative manometric pattern predicts the outcome of surgical treatment for esophageal achalasia.

PubMed

Salvador, Renato; Costantini, Mario; Zaninotto, Giovanni; Morbin, Tiziana; Rizzetto, Christian; Zanatta, Lisa; Ceolin, Martina; Finotti, Elena; Nicoletti, Loredana; Da Dalt, Gianfranco; Cavallin, Francesco; Ancona, Ermanno

2010-11-01

A new manometric classification of esophageal achalasia has recently been proposed that also suggests a correlation with the final outcome of treatment. The aim of this study was to investigate this hypothesis in a large group of achalasia patients undergoing laparoscopic Heller-Dor myotomy. We evaluated 246 consecutive achalasia patients who underwent surgery as their first treatment from 2001 to 2009. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored and barium swallow X-ray, endoscopy, and esophageal manometry were performed before and again at 6 months after surgery. Patients were divided into three groups: (I) no distal esophageal pressurization (contraction wave amplitude <30 mmHg); (II) rapidly propagating compartmentalized pressurization (panesophageal pressurization >30 mmHg); and (III) rapidly propagating pressurization attributable to spastic contractions. Treatment failure was defined as a postoperative symptom score greater than the 10th percentile of the preoperative score (i.e., >7). Type III achalasia coincided with a longer overall lower esophageal sphincter (LES) length, a lower symptom score, and a smaller esophageal diameter. Treatment failure rates differed significantly in the three groups: I = 14.6% (14/96), II = 4.7% (6/127), and III = 30.4% (7/23; p = 0.0007). At univariate analysis, the manometric pattern, a low LES resting pressure, and a high chest pain score were the only factors predicting treatment failure. At multivariate analysis, the manometric pattern and a LES resting pressure <30 mmHg predicted a negative outcome. This is the first study by a surgical group to assess the outcome of surgery in 3 manometric achalasia subtypes: patients with panesophageal pressurization have the best outcome after laparoscopic Heller-Dor myotomy.

Communication: HK propagator uniformized along a one-dimensional manifold in weakly anharmonic systems

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kocia, Lucas, E-mail: lkocia@fas.harvard.edu; Heller, Eric J.

2014-11-14

A simplification of the Heller-Herman-Kluk-Kay (HK) propagator is presented that does not suffer from the need for an increasing number of trajectories with dimensions of the system under study. This is accomplished by replacing HK’s uniformizing integral over all of phase space by a one-dimensional curve that is appropriately selected to lie along the fastest growing manifold of a defining trajectory. It is shown that this modification leads to eigenspectra of quantum states in weakly anharmonic systems that can outperform the comparatively computationally cheap thawed Gaussian approximation method and frequently approach the accuracy of spectra obtained with the full HKmore » propagator.« less

Achalasia.

PubMed

Islam, Saleem

2017-04-01

Achalasia is a rare neurogenic motility disorder of the esophagus, occurring in approximately 0.11 cases per 100,000 children. The combination of problems (aperistalsis, hypertensive lower esophageal sphincter (LES), and lack of receptive LES relaxation) results in patients having symptoms of progressive dysphagia, weight loss, and regurgitation. Treatment modalities have evolved over the past few decades from balloon dilation and botulinum toxin injection to laparoscopic Heller myotomy and endoscopic myotomy. Most data on achalasia management is extrapolated to children from adult experience. This article describes understanding of the pathogenesis and discusses newer therapeutic techniques as well as controversies in management. Copyright © 2017 Elsevier Inc. All rights reserved.

Laparoscopic diverticulectomy with the aid of intraoperative gastrointestinal endoscopy to treat epiphrenic diverticulum.

PubMed

Yu, Lei; Wu, Ji-Xiang; Chen, Xiao-Hong; Zhang, Yun-Feng; Ke, Ji

2016-01-01

Most researchers believe that the presence of large epiphrenic diverticulum (ED) with severe symptoms should lead to the consideration of surgical options. The choice of minimally invasive techniques and whether Heller myotomy with antireflux fundoplication should be employed after diverticulectomy became points of debate. The aim of this study was to describe how to perform laparoscopic transhiatal diverticulectomy (LTD) and oesophagomyotomy with the aid of intraoperative gastrointestinal (GI) endoscopy and how to investigate whether the oesophagomyotomy should be performed routinely after LTD. From 2008 to 2013, 11 patients with ED underwent LTD with the aid of intraoperative GI endoscopy at our department. Before surgery, 4 patients successfully underwent oesophageal manometry: Oesophageal dysfunction and an increase of the lower oesophageal sphincter pressure (LESP) were found in 2 patients. There were 2 cases of conversion to an open transthoracic procedure. Six patients underwent LTD, Heller myotomy and Dor fundoplication; and 3 patients underwent only LTD. The dysphagia and regurgitation 11 patients experienced before surgery improved significantly. Motor function studies showed that there was no oesophageal peristalsis in 5 patients during follow-up, while 6 patients showed seemingly normal oesophageal motility. The LESP of 6 patients undergoing LTD, myotomy and Dor fundoplication was 16.7 ± 10.2 mmHg, while the LESPs of 3 patients undergoing only LTD were 26 mmHg, 18 mmHg and 21 mmHg, respectively. In 4 cases experiencing LTD, myotomy and Dor fundoplication, the gastro-oesophageal reflux occurred during the sleep stage. LTD constitutes a safe and valid approach for ED patients with severe symptoms. As not all patients with large ED have oesophageal disorders, according to manometric and endoscopic results, surgeons can categorise and decide whether or not myotomy and antireflux surgery after LTD will be conducted.

Value of routine timed barium esophagram follow-up in achalasia after myotomy.

PubMed

Kachala, Stefan S; Rice, Thomas W; Baker, Mark E; Rajeswaran, Jeevanantham; Thota, Prashanthi N; Murthy, Sudish C; Blackstone, Eugene H; Zanoni, Andrea; Raja, Siva

2018-03-08

The value of routine timed barium esophagram (TBE) in longitudinal follow-up of achalasia after Heller myotomy is unknown. We prospectively prescribed a yearly follow-up TBE. Purposes were to characterize esophageal emptying over time after myotomy, identify preoperative TBE measures associated with follow-up TBE, and characterize follow-up TBE over time in relationship to reintervention. From March 1995 to April 2013, 635 patients underwent Heller myotomy for achalasia; 559 had at least 1 follow-up TBE. Temporal trends of 1335 follow-up TBEs in all nonreintervention and reintervention patients were assessed. Multivariable longitudinal analysis identified preoperative TBE measures associated with follow-up TBE. On average, TBE height and width at 1 and 5 minutes decreased approximately 50% and 60%, respectively, at first postoperative follow-up, and remained stable or slightly decreased for up to 5 years. Wider TBE width at 5 minutes was associated with greater follow-up TBE height and width at 1 minute. Of 118 patients undergoing reintervention, 64 (57%) had only 1 reintervention, with follow-up TBE returning to that of nonreintervention patients. Patients whose follow-up TBE remained abnormal underwent a further reintervention, some normalizing on subsequent TBE, and some not. Follow-up TBE is valuable postmyotomy, particularly if there is substantial esophageal dilatation preoperatively. Follow-up TBE reassures patients with stable or decreasing TBE measures, permitting decreased follow-up intensity. Reintervention should not be considered a myotomy failure, because a successful, single, nonsurgical reintervention often results in long-term successful palliation. More than 1 reintervention requires intensification of TBE follow-up, facilitating treatment planning. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Changing the constitutional landscape for firearms: the US Supreme Court's recent Second Amendment decisions.

PubMed

Vernick, Jon S; Rutkow, Lainie; Webster, Daniel W; Teret, Stephen P

2011-11-01

In 2 recent cases-with important implications for public health practitioners, courts, and researchers-the US Supreme Court changed the landscape for judging the constitutionality of firearm laws under the Constitution's Second Amendment. In District of Columbia v Heller (2008), the court determined for the first time that the Second Amendment grants individuals a personal right to possess handguns in their home. In McDonald v City of Chicago (2010), the court concluded that this right affects the powers of state and local governments. The court identified broad categories of gun laws-other than handgun bans-that remain presumptively valid but did not provide a standard to judge their constitutionality. We discuss ways that researchers can assist decision makers.

Checklist of host associations of European bat flies (Diptera: Nycteribiidae, Streblidae).

PubMed

Szentiványi, Tamara; Estók, Péter; Földvári, Mihály

2016-12-05

Bat flies are obligate blood-sucking ectoparasites of bats. They are divided into two families: Nycteribiidae and Streblidae. Europe has 17 species of bat flies and 45 species of bats (Mammalia: Chiroptera). This checklist is based on both published records and our own field data and provides updated information on all associations between bat flies and their hosts in Europe. The host-parasite association between Basilia italica Theodor and Plecotus auritus (Linnaeus) is reported for the first time. Moreover, our records of B. italica on Myotis alcathoe Helversen & Heller, B. nana Theodor & Moscona on Plecotus auritus, Nycteribia kolenatii Theodor & Moscona on M. bechsteinii (Kuhl) and Penicillidia dufourii (Westwood) on M. daubentonii (Kuhl) represent new host associations for Hungary.

Symmetry and conservation laws in semiclassical wave packet dynamics

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ohsawa, Tomoki, E-mail: tomoki@utdallas.edu

2015-03-15

We formulate symmetries in semiclassical Gaussian wave packet dynamics and find the corresponding conserved quantities, particularly the semiclassical angular momentum, via Noether’s theorem. We consider two slightly different formulations of Gaussian wave packet dynamics; one is based on earlier works of Heller and Hagedorn and the other based on the symplectic-geometric approach by Lubich and others. In either case, we reveal the symplectic and Hamiltonian nature of the dynamics and formulate natural symmetry group actions in the setting to derive the corresponding conserved quantities (momentum maps). The semiclassical angular momentum inherits the essential properties of the classical angular momentum asmore » well as naturally corresponds to the quantum picture.« less

Changing the Constitutional Landscape for Firearms: The US Supreme Court's Recent Second Amendment Decisions

PubMed Central

Rutkow, Lainie; Webster, Daniel W.; Teret, Stephen P.

2011-01-01

In 2 recent cases—with important implications for public health practitioners, courts, and researchers—the US Supreme Court changed the landscape for judging the constitutionality of firearm laws under the Constitution's Second Amendment. In District of Columbia v Heller (2008), the court determined for the first time that the Second Amendment grants individuals a personal right to possess handguns in their home. In McDonald v City of Chicago (2010), the court concluded that this right affects the powers of state and local governments. The court identified broad categories of gun laws—other than handgun bans—that remain presumptively valid but did not provide a standard to judge their constitutionality. We discuss ways that researchers can assist decision makers. PMID:21940936

[Health equity: a critical analysis of concepts].

PubMed

Vieira-da-Silva, Ligia Maria; Almeida Filho, Naomar de

2009-01-01

Health inequalities have been studied mainly from an epidemiological perspective, with limited attention to conceptual issues. The terms 'equity' and 'equality' have often been used as synonyms, as have their opposites, 'inequity' and 'inequality'. The few attempts to establish their meanings have been either purely descriptive or have failed to add to an understanding of the underlying dynamics in health-disease-related phenomena. The present essay explores the semantic series that includes difference, diversity, distinction, inequality, and inequity and its relationship to health phenomena in light of Perelman's concept of equity, Bourdieu's sociology, and some arguments in Heller's theory of justice, with the aim of contributing to the development of these concepts, while discussing their implications for policymaking in health.

Coupled wave-packets for non-adiabatic molecular dynamics: a generalization of Gaussian wave-packet dynamics to multiple potential energy surfaces

DOE PAGES

White, Alexander James; Tretiak, Sergei; Mozyrsky, Dima V.

2016-04-25

Accurate simulation of the non-adiabatic dynamics of molecules in excited electronic states is key to understanding molecular photo-physical processes. Here we present a novel method, based on a semiclassical approximation, that is as efficient as the commonly used mean field Ehrenfest or ad hoc surface hopping methods and properly accounts for interference and decoherence effects. This novel method is an extension of Heller's thawed Gaussian wave-packet dynamics that includes coupling between potential energy surfaces. By studying several standard test problems we demonstrate that the accuracy of the method can be systematically improved while maintaining high efficiency. The method is suitablemore » for investigating the role of quantum coherence in the non-adiabatic dynamics of many-atom molecules.« less

Per-oral endoscopic myotomy (POEM) for esophageal achalasia.

PubMed

Pescarus, Radu; Shlomovitz, Eran; Swanstrom, Lee L

2014-01-01

Per-oral endoscopic myotomy (POEM) is a new minimally invasive endoscopic treatment for achalasia. Since the first modern human cases were published in 2008, around 2,000 cases have been performed worldwide. This technique requires advanced endoscopic skills and a learning curve of at least 20 cases. POEM is highly successful with over 90 % improvement in dysphagia while offering patients the advantage of a low impact endoscopic access. The main long-term complication is gastroesophageal reflux (GER) with an estimated incidence of 35 %, similar to the incidence of GER post-laparoscopic Heller with fundoplication. Although POEM represents a paradigm shift in the treatment of achalasia, more long-term data are clearly needed to further define its role in the treatment algorithm of this rare disease.

Twenty years of Medicare and Medicaid: Covered populations, use of benefits, and program expenditures

PubMed Central

Gornick, Marian; Greenberg, Jay N.; Eggers, Paul W.; Dobson, Allen

1985-01-01

Marian Gornick is Director, Division of Beneficiary Studies, in the Office of Research, Health Care Financing Administration. She has been involved in research studies relating to Medicare and Medicaid since the programs were first implemented. Jay N. Greenberg is on the faculty of the Heller Graduate School, Brandeis University. Dr. Greenberg serves as the Associate Director for Research of the school's Health Policy Center. Paul W. Eggers is Chief, Program Evaluation Branch, in the Office of Research, Health Care Financing Administration (HCFA). Dr. Eggers’ research activities involve the evaluation of the impact of HCFA programs on the beneficiaries. Allen Dobson is Director, Office of Research, Health Care Financing Administration. Dr. Dobson is responsible for directing the planning and development of the Agency's research agenda. PMID:10311371

Crocidurobia faini n. sp. (Acariformes: Myobiidae), a new mite species parasitising shrews of the genus Crocidura Wagler (Soricomorpha: Soricidae) in DR Congo.

PubMed

Bochkov, Andre V; Mbalitini, Sylvestre G; Verheyen, Erik

2016-06-01

A new species Crocidurobia faini n. sp. (Acariformes: Myobiidae) recorded on Crocidura denti Dollman (type-host) (Soricomorpha: Soricidae), Crocidura cf. niobe Thomas, Crocidura cf. littoralis Heller, and Crocidura sp. from DR Congo is described. This new species differs in both sexes from all other species of the subgenus Crocidurobia Jameson, 1970 by short setae c2, more than three times shorter than setae se. Females of the new species differ from those of the close species Crocidurobia toroensis Dusbabek, 1983 by setal bases e2 situated slightly anterior to the level of setal bases e1; males of the new species differ by the genital shield bearing five pairs of setae situated anterior to the level of setal bases d1.

Per oral endoscopic myotomy vs. laparoscopic Heller myotomy, does gastric extension length matter?

PubMed

Ramirez, Mauricio; Zubieta, Cecilia; Ciotola, Franco; Amenabar, Alfredo; Badaloni, Adolfo; Nachman, Fabio; Nieponice, Alejandro

2018-01-01

To report our experience in POEM vs. LHM, with particular focus on myotomy extension. POEM has been adopted worldwide as a treatment for achalasia. While resolution of dysphagia is above 90%, postoperative reflux ranges from 10 to 57%. Myotomy length has been a controversial topic. Thirty-five cases of POEM were prospectively analyzed and compared retrospectively to the last 35 patients that underwent LHM, from December 2010 to August 2016. Mean follow-up was 10 months (6/32) for POEM and 20 months (6/68) for LHM. All patients with LHM had a myotomy extension ≥3 cm on the gastric side. In POEM cases, extension was defined by direct vision (Hill type II) and never exceeded 2 cm. Follow-up was completed in 100% of patients. Efficacy (ES ≤ 3) was 33/35 (94.2%) for POEM and 32/35 (91.4%) for LHM in a short-term follow-up (p = 1.000) and 31/35 (88.6%) and 27/35 (77.1%), respectively, in a long-term follow-up (p = 1.000), with average ES drop from 9 to 1.2 (p = 0.0001) in POEM vs. 9.2 to 1.3 (p = 0.0001) in LHM. Major Postoperative complications occurred in 1 patient (leak) for LHM and 1 patient (massive capnothorax) in POEM. Hospital stay was shorter for POEM than for LHM (1.3 vs. 2.1, respectively) (p = 0.0001). Symptomatic reflux cases included 7/35 POEM (20%) vs. 6/35 LHM (17.1%) (p = 0.4620). Esophagitis signs in endoscopy appeared in 1/21 POEM (4.7%) vs. 1/22 LHM (4.5%) (p = 1.000). Patients requiring PPI included 8/35 POEM (22.8%) vs. 7/35 LHM (20%) (p = 0.6642). Further treatment (endoscopic dilation) was performed in 10/35 POEM (28.5%) vs. 8/35 LHM (22.8%). A shorter myotomy on the gastric side in POEM may contribute to an acceptable reflux rate with comparable relief of dysphagia. Although our follow-up for POEM is shorter than for LHM, the trends are promising and warrant future prospective studies to address this topic.

Per-oral endoscopic myotomy (POEM): a new endoscopic treatment for achalasia.

PubMed

Miranda García, Pablo; Casals Seoane, Fernando; Gonzalez, Jean-Michel; Barthet, Marc; Santander Vaquero, Cecilio

2017-10-01

Per-oral endoscopic myotomy (POEM) is a new minimally invasive technique to treat achalasia. We performed a review of the literature of POEM with a special focus on technical details and the results obtained with this technique in patients with achalasia and other esophageal motility disorders. Thousands of POEM procedures have been performed worldwide since its introduction in 2008. The procedure is based on the creation of a mucosal entry point in the proximal esophagus to reach the cardia through a submucosal tunnel and then perform a myotomy of the muscular layers of the cardia, esophagogastric junction and distal esophagus, as performed in a Heller myotomy. The clinical remission rate ranges from 82 to 100%. Although no randomized studies exist and available data are from single-center studies, no differences have been found between laparoscopic Heller myotomy (LHM) and POEM in terms of perioperative outcomes, short-term outcomes (12 months) and long-term outcomes (up to three years). Procedure time and length of hospital stay were lower for POEM. Post-POEM reflux is a concern, and controversial data have been reported compared to LHM. The technique is safe, with no reported deaths related to the procedure and an adverse event rate comparable to surgery. Potential complications include bleeding, perforation, aspiration and insufflation-related adverse events. Thus, this is a complex technique that needs specific training even in expert hands. The indication for this procedure is widening and other motor hypercontractil esophageal disorders have been treated by POEM with promising results. POEM can be performed in complicated situations such as in pediatric patients, sigmoid achalasia or after failure of previous treatments. POEM is an effective treatment for achalasia and is a promising tool for other motor esophageal disorders. It is a safe procedure but, due to its technical difficulty and possible associated complications, the procedure should be performed

Revisional surgery after failed esophagogastric myotomy for achalasia: successful esophageal preservation.

PubMed

Veenstra, Benjamin R; Goldberg, Ross F; Bowers, Steven P; Thomas, Mathew; Hinder, Ronald A; Smith, C Daniel

2016-05-01

Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10 % of patients, most of whom will seek repeat surgical intervention. These reoperations are technically challenging, and as such, there exist only limited reports of reoperation with esophageal preservation. We retrospectively reviewed the records of patients who sought operative intervention from March 1998 to December 2014 for obstructed swallowing after esophagogastric myotomy. All patients underwent a systematic approach, including complete hiatal dissection, takedown of prior fundoplication, and endoscopic assessment of myotomy. Patterns of failure were categorized as: fundoplication failure, inadequate myotomy, fibrosis, and mucosal stricture. A total of 58 patients underwent 65 elective reoperations. Four patients underwent esophagectomy as their initial reoperation, while three patients ultimately required esophagectomy. The remainder underwent reoperations with the goal of esophageal preservation. Of these 58, 46 were first-time reoperations; ten were second time; and two were third-time reoperations. Forty-one had prior operations via a trans-abdominal approach, 11 via thoracic approach, and 6 via combined approaches. All reoperations at our institution were performed laparoscopically (with two conversions to open). Inadequate myotomy was identified in 53 % of patients, fundoplication failure in 26 %, extensive fibrosis in 19 %, and mucosal stricture in 2 %. Intraoperative esophagogastric perforation occurred in 19 % of patients and was repaired. Our postoperative leak rate was 5 %. Esophageal preservation was possible in 55 of the 58 operations in which it was attempted. At median follow-up of 34 months, recurrent dysphagia after reoperation was seen in 63 % of those with a significant fibrosis versus 28 % with inadequate myotomy, 25 % with failed wrap, and 100 % with mucosal stricture (p = 0.10). Laparoscopic reoperation with esophageal preservation is

Minimally Invasive Surgical Treatment of Esophageal Achalasia

PubMed Central

Mercantini, Paolo; Amodio, Pietro M.; Stipa, Francesco; Corigliano, Nicola; Ziparo, Vincenzo

2003-01-01

Background and Objectives: A minimally invasive approach is considered the treatment of choice for esophageal achalasia. We report the evolution of our experience from thoracoscopic Heller myotomy (THM) to laparoscopic Heller myotomy (LHM). Our objective is to define the efficacy and safety of these 2 approaches. Methods: Between March 1993 and December 2001, 36 patients underwent minimally invasive surgery for achalasia. Sixteen patients underwent THM without an antireflux procedure, and 20 patients underwent LHM with partial anterior fundoplication (n=13) or closure of the angle of His (n=7). Results: Mean operative time and mean hospital stay were significantly shorter for LHM compared with that of THM (148.3±38.7 vs 222±46.1 min, respectively; P=0.0001) and (2.06±0.65 days vs 5.06±0.85 days, respectively; P=0.0001). Six of 16 patients (37.5%) in the THM group experienced persistent or recurrent dysphagia compared with 1 of 20 patients (5%) in the LHM group (P=0.01). Heartburn developed in 5 patients (31.2%) after THM and in 1 patient (5%) after LHM (P=0.06). Regurgitation developed in 4 patients (25%) after THM and in 2 patients (10%) after LHM (P=0.2). Lower esophageal sphincter (LES) basal pressure decreased significantly from 30.1±5.07 to 15.3±2.1 after THM and from 31.8±6.2 to 10.4±1.7 after LHM (P=0.0001). Mean esophageal diameter was significantly reduced after LHM compared with that after THM (from 53.9±5.9 mm to 27.2±3.3 mm vs 50.8±7.6 mm to 37.2±6.9 mm respectively; P=0.0001). Conclusion: In our experience, LHM is associated with better short-term results and is superior to THM in relieving dysphagia. LHM with partial anterior fundoplication should be considered the treatment of choice for achalasia. PMID:14558709

patients

PubMed

Hernández-Mondragón, Oscar Víctor; Solórzano-Pineda, Omar Michel; Blancas-Valencia, Juan Manuel; González-Martínez, Marina Alejandra

2017-01-01

Esophageal achalasia is a primary motor disorder of the esophagus characterized by impair relaxation of the lower esophageal sphincter and absent of esophageal peristalsis. Per-oral endoscopic myotomy is an alternative treatment to surgical Heller myotomy in patients over 65 years old. The aim of this paper was to describe the results of peroral endoscopic myotomy (POEM) or the treatment of achalasia in geriatric patients. We included patients over 65 years old with POEM, from retrospective cohort review, in which POEM was performed with a standardized technique in our department. 12 patients were included, the procedure was successful in 98% of patients, minor adverse events occurred without mortality. POEM is a safe and effective technique for the treatment of achalasia, the results of the study are similar to those reported in The literature.

Cardiomyotomy.

PubMed

Patti, M G; Tamburini, A; Pellegrini, C A

1999-12-01

During the last decade, minimally invasive surgery has replaced open surgery in the treatment of esophageal achalasia. This new approach, in fact, determines results similar to the open approach, but is associated to a shorter hospital stay, minimal postoperative discomfort, and faster return to regular activity. Between 1991 and 1998, 168 patients underwent a cardiomyotomy by minimally invasive techniques. Good or excellent results were obtained in 85% of patients after thoracoscopic myotomy, and 93% of patients after laparoscopic myotomy and partial fundoplication. The latter procedure was followed by a lower incidence of postoperative gastroesophageal reflux (60% versus 17%). Laparoscopic Heller myotomy and partial fundoplication has emerged as the procedure of choice for esophageal achalasia, and it should be considered today the primary form of treatment for this disease.

Esophageal achalasia: current diagnosis and treatment.

PubMed

Schlottmann, Francisco; Patti, Marco G

2018-05-27

Esophageal achalasia is a primary esophageal motility disorder of unknown origin, characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The goal of treatment is to eliminate the functional obstruction at the level of the gastroesophageal junction Areas covered: This comprehensive review will evaluate the current literature, illustrating the diagnostic evaluation and providing an evidence-based treatment algorithm for this disease Expert commentary: Today we have three very effective therapeutic modalities to treat patients with achalasia - pneumatic dilatation, per-oral endoscopic myotomy and laparoscopic Heller myotomy with fundoplication. Treatment should be tailored to the individual patient, in centers where a multidisciplinary approach is available. Esophageal resection should be considered as a last resort for patients who have failed prior therapeutic attempts.

[Clinical experience of combined laparoscopic-endoscopic Heller myotomy and modified Dor fundoplication for cardiochalasia].

PubMed

Qiao, Xiaofang; Li, Jinlong; Xu, Hua; Wan, Xin; Zhu, Jiaming

2017-08-25

To investigate the efficacy of combined laparoscopic-endoscopic lower esophageal sphincterotomy and modified Dor fundoplication for cardiochalasia patients. Clinical data of 11 cardiochalasia patients who underwent combined laparoscopic-endoscopic lower esophageal sphincterotomy and modified Dor fundoplication by the same medical team from January 2015 to December 2016 at The Second Hospital of Jilin University were retrospectively analyzed. The procedure was as follows: an incision was made in the anterior wall of esophagus and dissection of esophageal muscular layer was performed, then the bulged esophageal mucosa was covered by the fundus after 180 degrees fold to the right (fundoplication), finally the gastric fundus was joined to the right diaphragmatic foot by 3 to 5 knotted suture. The efficacy was judged by the Eckardt scoring standard: the postoperative Eckardt score ≤3 points indicated effectiveness, otherwise the treatment was invalid. Combined laparoscopic-endoscopic lower esophageal sphincterotomy and modified Dor fundoplication was completed successfully in all the 11 patients without any subsequent laparotomy and death. The mean operative time was 85 (78 to 137) min, blood loss was 15 (5 to 35) ml, and no upper digestive tract perforation occurred. The mean postoperative hospital stay was 7.0(6 to 9) d. After the operation, the pressure of lower esophageal sphincter decreased significantly compared to that before operation [(5.31±6.23) mmHg vs. (35.72±17.13) mmHg, P<0.05], and the Eckardt score decreased significantly as well (0.53±0.56 vs. 6.17±1.17, P<0.05). During the follow-up of 2 to 23 months, there was no postoperative mortality. One case experienced mild gastroesophageal reflux 6 months after operation, and another patient had recurrent dysphagia 17 months after operation, who both were improved after receiving proton pump inhibitors or gastric dynamic drugs, and balloon dilation. Combined laparoscopic-endoscopic lower esophageal sphincterotomy and modified Dor fundoplication is an effective and safe surgical procedure for cardiochalasia with minimal invasion and fast recovery.

Understanding the autistic dental patient.

PubMed

Green, Danielle; Flanagan, Dennis

2008-01-01

Autism spectrum disorder (ASD) is one of many pervasive developmental disorders (PDD); others include Rett syndrome, childhood disintegrative disorder (also known as Heller's syndrome), pervasive developmental disorder not otherwise specified (PDD-NOS), and the higher functioning Asperger's syndrome. Because ASD is the most common of the developmental disabilities, it is not unusual for dentists to have ASD patients among their patient population. As the name indicates, ASD varies widely in its clinical manifestations; however, dentists are likely to encounter difficulties with communication and socialization. Although communication may be difficult, it is not impossible. A thorough understanding of this complex neurological disorder and displaying patience are vital for the dentist. This article seeks to familiarize readers with ASD characteristics and co-morbid conditions that may affect dental treatment and provide some management strategies for this unique population.

A Gaussian Wave Packet Propagation Approach to Vibrationally Resolved Optical Spectra at Non-Zero Temperatures.

PubMed

Reddy, Ch Sridhar; Prasad, M Durga

2016-04-28

An effective time dependent approach based on a method that is similar to the Gaussian wave packet propagation (GWP) technique of Heller is developed for the computation of vibrationally resolved electronic spectra at finite temperatures in the harmonic, Franck-Condon/Hertzberg-Teller approximations. Since the vibrational thermal density matrix of the ground electronic surface and the time evolution operator on that surface commute, it is possible to write the spectrum generating correlation function as a trace of the time evolved doorway state. In the stated approximations, the doorway state is a superposition of the harmonic oscillator zero and one quantum eigenfunctions and thus can be propagated by the GWP. The algorithm has an O(N(3)) dependence on the number of vibrational modes. An application to pyrene absorption spectrum at two temperatures is presented as a proof of the concept.

A simplified model for the determination of current-voltage characteristics of a high pressure hydrogen plasma arc

NASA Astrophysics Data System (ADS)

Gueye, P.; Cressault, Y.; Rohani, V.; Fulcheri, L.

2017-02-01

This paper focuses on the modeling of a hydrogen arc column at very high pressure (20 bar). The problem is solved from Elenbaas-Heller equation where the radiation is carefully considered with the net emission coefficient. The absorption spectrum requires the integration of background continuum, molecular bands, and line spectra. This work directly aims to predict the electric current-voltage characteristics which is key for the design of new processes. We propose also a new analytic solution which generalizes the channel model of electric arc to the case when the volume radiation makes a significant contribution to the energy balance. The presented formalism allows a better determination of the plasma thickness parameter Rp for net emission coefficient method in cylindrical arcs and gives satisfactory results in comparison to earlier experimental works on high pressure hydrogen plasma.

Landslide/reservoir interaction: 3D numerical modelling of the Vajont rockslide and generated water wave

NASA Astrophysics Data System (ADS)

Crosta, G.; Imposimato, S.; Roddeman, D.; Frattini, P.

2012-04-01

Fast moving landslides can be originated along slopes in mountainous terrains with natural and artificial lakes, or fjords at the slope foot. This landslides can reach extremely high speed and the impact with the immobile reservoir water can be influenced by the local topography and the landslide mass profile. The impact can generate large impulse waves and landslide tsunami. Initiation, propagation and runup are the three phases that need to be considered. The landslide evolution and the consequent wave can be controlled by the initial mass position (subaerial, partially or completely submerged), the landslide speed, the type of material, the subaerial and subaqueous slope geometry, the landslide depth and length at the impact, and the water depth. Extreme events have been caused by subaerial landslides: the 1963 Vajont rockslide (Italy), the 1958 Lituya Bay event (Alaska), the Tafjord and the Loen multiple events event (Norway), also from volcanic collapses (Hawaii and Canary islands). Various researchers completed a systematic experimental work on 2D and 3D wave generation and propagation (Kamphuis and Bowering, 1970; Huber, 1980; Müller, 1995; Huber and Hager, 1997; Fritz, 2002; Zweifel, 2004; Panizzo et al., 2005; Heller, 2007; Heller and Kinnear, 2010; Sælevik et al., 2009), using both rigid blocks and deformable granular" masses. Model data and results have been used to calibrate and validate numerical modelling tools (Harbitz, 1992; Jiang and LeBlond, 1993; Grilli et al., 2002; Grilli and Watts, 2005; Lynett and Liu, 2005; Tinti et al., 2006; Abadie et al., 2010) generally considering simplified rheologies (e.g. viscous rheologies) for subaerial subaqueous spreading. We use a FEM code (Roddeman, 2011; Crosta et al., 2006, 2009, 2010, 2011) adopting an Eulerian-Lagrangian approach to give accurate results for large deformations. We model both 2D and fully 3D events considering different settings. The material is considered as a fully deformable elasto

Magnetostatics Analysis, Design, and Construction of a Loudspeaker

NASA Astrophysics Data System (ADS)

Galeriu, Calin

2010-11-01

Making a loudspeaker is a very rewarding hands-on activity that can be used to teach about electro-magnetism and sound waves. Several loudspeaker designs have been described in this magazine.1-4 The simplest loudspeaker4 has only a magnet, a coil, and three plastic cups. The simpler devices3,4 require a powerful amplified output, e.g., from a boom box. The more complex devices1,2 can operate using the smaller electric current from a CD player earphone output. Unfortunately, the procedure to make a more efficient loudspeaker is lengthy and less recommended to some high school students, involving a hot glue gun, a safety razor, five-minute epoxy, etc. Our loudspeaker, a variation of Heller's,2 is both simple in construction and efficient in operation. An analysis of the magnetic field distribution helped us in the design of this loudspeaker.

[Robots in general surgery: present and future].

PubMed

Galvani, Carlos; Horgan, Santiago

2005-09-01

Robotic surgery is an emerging technology. We began to use this technique in 2000, after it was approved by the Food and Drug Administration. Our preliminary experience was satisfactory. We report 4 years' experience of using this technique in our institution. Between August 2000 and December 2004, 399 patients underwent robotic surgery using the Da Vinci system. We performed 110 gastric bypass procedures, 30 Lap band, 59 Heller myotomies, 12 Nissen fundoplications, 6 epiphrenic diverticula, 18 total esophagectomies, 3 esophageal leiomyoma resections, 1 pyloroplasty, 2 gastrojejunostomies, 2 transduodenal sphincteroplasties, 10 adrenalectomies and 145 living-related donor nephrectomies. Operating times for fundoplications and Lap band were longer. After the learning curve, the operating times and morbidity of the remaining procedures were considerably reduced. Robot-assisted surgery allows advanced laparoscopic procedures to be performed with enhanced results given that it reduces the learning curve as measured by operating time and morbidity.

ERDA authorization, Fiscal Year 1977. Part I. Conservation. Hearings before the Subcommittee on Energy Research, Development and Demonstration of the Committee on Science and Technology, U. S. House of Representatives, Ninety-Fourth Congress, Second Session

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

1976-01-01

The hearing was the first in a series of nine before the subcommittee in connection with the fiscal year 1977 ERDA authorization bill. The ERDA conservation program and its funding are reviewed and Representative Ray Thornton, presiding, announced that Congress was expected to pass significant energy conservation legislation to augment the existing ERDA program. Included here is a statement on the issue by Mr. Austin N. Heller, Asst. Administrator for Conservation, ERDA, who was accompanied by his division directors--Mr. Francis Parry, Mr. John Brogan, Dr. Maxine Savitz, Dr. John Belding, and Mr. George Murray. Another statement was presented by Rogermore » W. Sant, Asst. Administrator for Energy, FEA. Additional statements are presented in Appendix I by Mr. Lowell Endahl, National Rural Electric Cooperative Association, and Mr. Wes Uhlman, Mayor of Seattle, Wash. Additional information is presented in three other appendixes. (MCW)« less

Antagonism and antibiotic resistance drive a species-specific plant microbiota differentiation in Echinacea spp.

PubMed

Maggini, Valentina; Miceli, Elisangela; Fagorzi, Camilla; Maida, Isabel; Fondi, Marco; Perrin, Elena; Mengoni, Alessio; Bogani, Patrizia; Chiellini, Carolina; Mocali, Stefano; Fabiani, Arturo; Decorosi, Francesca; Giovannetti, Luciana; Firenzuoli, Fabio; Fani, Renato

2018-06-14

A key factor in the study of plant-microbes interaction is the composition of plant microbiota, but little is known about the factors determining its functional and taxonomic organization. Here we investigated the possible forces driving the assemblage of bacterial endophytic and rhizospheric communities, isolated from two congeneric medicinal plants, Echinacea purpurea (L.) Moench and Echinacea angustifolia (DC) Heller, grown in the same soil, by analyzing bacterial strains (isolated from three different compartments, i.e. rhizospheric soil, roots, and stem/leaves) for phenotypic features such as antibiotic resistance, extracellular enzymatic activity, siderophore, and indole 3-acetic acid production, as well as cross antagonistic activities. Data obtained highlighted that bacteria from different plant compartments were characterized by specific antibiotic resistance phenotypes and antibiotic production, suggesting that the bacterial communities themselves could be responsible for structuring their own communities by the production of antimicrobial molecules selecting bacterial adaptive phenotypes for plant tissue colonization.

Simulations of Atmospheric Plasma Arcs

NASA Astrophysics Data System (ADS)

Pearcy, Jacob; Chopra, Nirbhav; Jaworski, Michael

2017-10-01

We present the results of computer simulation of cylindrical plasma arcs with characteristics similar to those predicted to be relevant in magnetohydrodynamic (MHD) power conversion systems. These arcs, with core temperatures on the order of 1 eV, place stringent limitations on the lifetime of conventional electrodes used in such systems, suggesting that a detailed analysis of arc characteristics will be crucial in designing more robust electrode systems. Simulations utilize results from NASA's Chemical Equilibrium with Applications (CEA) program to solve the Elenbaas-Heller equation in a variety of plasma compositions, including approximations of coal-burning plasmas as well as pure gas discharges. The effect of carbon dioxide injection on arc characteristics, emulating discharges from molten carbonate salt electrodes, is also analyzed. Results include radial temperature profiles, composition maps, and current-voltage (IV) characteristics of these arcs. Work supported by DOE contract DE-AC02-09CH11466.

Copepods of Hatschekiidae (Copepoda, Siphonostomatoida) new to Korean fauna, with description of a new species

NASA Astrophysics Data System (ADS)

Moon, Seong Yong; Kim, Il-Hoi

2013-03-01

Eight species of the Hatschekiidae are recorded as parasites of marine fishes from southern coast of Korea. One new species, Hatschekia jejuensis, parasitic on Cheilodactylus zonatus Cuvier is included. The remaining seven species are new to Korean fauna: Hatschekia iridescens Wilson, 1913, H. japonica Jones, 1985, H. monacanthi Yamaguti, 1939, H. tenuis (Heller, 1865) H. pseudolabri Yamaguti, 1953, H. cylindrica Shiino, 1957, and Pseudocongericola chefoonensis Yü, 1933. Hatschekia jejuensis n. sp. has a combination of characteristics in the female where the trunk is 2.35 times as long as the cephalothorax and displays a pair of posterolateral bulges on both sides, the antennules is 5-segmented, the mandible bears six teeth, and the armature formulae of the legs are I-0; III (exopod) and 0-0; II (endopod) for leg 1 and I-0; I (exopod) and 0-0; II (endopod) for leg 2.

Per-oral endoscopic myotomy: Major advance in achalasia treatment and in endoscopic surgery

PubMed Central

Friedel, David; Modayil, Rani; Stavropoulos, Stavros N

2014-01-01

Per-oral endoscopic myotomy (POEM) represents a natural orifice endoscopic surgery (NOTES) approach to laparoscopy Heller myotomy (LHM). POEM is arguably the most successful clinical application of NOTES. The growth of POEM from a single center in 2008 to approximately 60 centers worldwide in 2014 with several thousand procedures having been performed attests to the success of POEM. Initial efficacy, safety and acid reflux data suggest at least equivalence of POEM to LHM, the previous gold standard for achalasia therapy. Adjunctive techniques used in the West include impedance planimetry for real-time intraprocedural luminal assessment and endoscopic suturing for challenging mucosal defect closures during POEM. The impact of POEM extends beyond the realm of esophageal motility disorders as it is rapidly popularizing endoscopic submucosal dissection in the West and spawning offshoots that use the submucosal tunnel technique for a host of new indications ranging from resection of tumors to pyloromyotomy for gastroparesis. PMID:25548473

Bio-foam enhances larval retention in a free-spawning marine tunicate

PubMed Central

Castilla, Juan Carlos; Manríquez, Patricio H.; Delgado, Alejandro P.; Gargallo, Ligia; Leiva, Angel; Radic, Deodato

2007-01-01

Here we report a mechanism that reduces dispersal of early developing stages and larvae in a free-spawning intertidal and shallow subtidal tunicate, Pyura praeputialis (Heller 1878), in the Bay of Antofagasta, Chile. The spawning of gametes by the tunicate into the naturally turbulent aerated seawater decreases their surface tension and induces the formation of a bio-foam. Water collected from foamy intertidal pools and tide channels showed a high concentration of P. praeputialis early developing stages and tadpole larvae in the foam. Because gametes are synchronically spawned for external fertilization and larvae settle near adults, our results suggest that this bio-foam increases fertilization success and effective settlement of their short-lived larvae in the vicinity of the adults spawning the gametes. This mechanism reinforces published evidence suggesting that local retention of intertidal and inshore marine invertebrate larvae may be more common than previously thought, offering, for instance, new perspectives for the design and networking of marine protected and management areas. PMID:17984045

Bio-foam enhances larval retention in a free-spawning marine tunicate.

PubMed

Castilla, Juan Carlos; Manríquez, Patricio H; Delgado, Alejandro P; Gargallo, Ligia; Leiva, Angel; Radic, Deodato

2007-11-13

Here we report a mechanism that reduces dispersal of early developing stages and larvae in a free-spawning intertidal and shallow subtidal tunicate, Pyura praeputialis (Heller 1878), in the Bay of Antofagasta, Chile. The spawning of gametes by the tunicate into the naturally turbulent aerated seawater decreases their surface tension and induces the formation of a bio-foam. Water collected from foamy intertidal pools and tide channels showed a high concentration of P. praeputialis early developing stages and tadpole larvae in the foam. Because gametes are synchronically spawned for external fertilization and larvae settle near adults, our results suggest that this bio-foam increases fertilization success and effective settlement of their short-lived larvae in the vicinity of the adults spawning the gametes. This mechanism reinforces published evidence suggesting that local retention of intertidal and inshore marine invertebrate larvae may be more common than previously thought, offering, for instance, new perspectives for the design and networking of marine protected and management areas.

Achalasia: current therapeutic options

PubMed Central

Arora, Zubin; Thota, Prashanthi N.; Sanaka, Madhusudhan R.

2017-01-01

Achalasia is a chronic incurable esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and loss of esophageal peristalsis. Although rare, it is currently the most common primary esophageal motility disorder, with an annual incidence of around 1.6 per 100,000 persons and prevalence of around 10.8/100,000 persons. Symptoms of achalasia include dysphagia to both solids and liquids, regurgitation, aspiration, chest pain and weight loss. As the underlying etiology of achalasia remains unclear, there is currently no curative treatment for achalasia. Management of achalasia mainly involves improving the esophageal outflow in order to provide symptomatic relief to patients. The most effective treatment options for achalasia include pneumatic dilation, Heller myotomy and peroral endoscopic myotomy (POEM), with the latter increasingly emerging as the treatment of choice for many patients. This review focusses on evidence for current and emerging treatment options for achalasia with a particular emphasis on POEM. PMID:28717439

Childhood disintegrative disorder: distinction from autistic disorder and predictors of outcome.

PubMed

Rosman, N Paul; Bergia, Berta M

2013-12-01

Childhood disintegrative disorder, a rare, relentlessly progressive neurologic disorder, first described by Heller in 1908, remains a condition of great interest. It has long been debated whether it is a discrete disorder or simply a late-onset variant of childhood autism. We have studied 6 cases of childhood disintegrative disorder, collected over 8 years, and followed for 2.5 to 22 years (mean 8.6 years). Childhood disintegrative disorder begins later in life than autism, and following a period of entirely normal development; the regression is more global and more severe than in autism; seizures are more frequent than in autism, yet demonstrable organicity in childhood disintegrative disorder is decidedly rare. Lastly, the prognosis is usually much worse than in autism, but in those cases with neither seizures nor epileptiform activity on electroencephalography (EEG), the outcome may be more favorable. Childhood disintegrative disorder should be viewed as a condition distinct from childhood autism.

Hell and High Water: Practice-Relevant Adaptation Science

DOE Office of Scientific and Technical Information (OSTI.GOV)

Moss, Richard H.; Meehl, G.; Lemos, Maria Carmen

2013-11-08

Recent extreme weather such as Hurricane Sandy and the 2012 drought demonstrate the vulnerability of the United States to climate extremes in the present and point to the potential for increased future damages under a changing climate. They also provide lessons for reducing harm and realizing any potential benefits. Preparedness measures – also referred to as adaptation – can cost-effectively increase resilience today and in the future. The upfront costs will be more than offset by reductions in property damage, lives and livelihoods lost, and expensive post-disaster recovery processes. While others have addressed use of science for adaptation in specificmore » sectors including biodiversity (Heller and Zavaleta, 2009) and freshwater ecosystem management (Wilby et al., 2010), or by simply taking a more pragmatic approach to adaptation under uncertainty (Hallegatte, 2009), here the authors make the case that a new, comprehensive approach is needed to create and use science to inform adaptations with applicable and sound knowledge (Kerr et al., 2011).« less

Branched flow and caustics in random media with magnetic fields

NASA Astrophysics Data System (ADS)

Metzger, Jakob; Fleischmann, Ragnar; Geisel, Theo

2009-03-01

Classical particles as well as quantum mechanical waves exhibit complex behaviour when propagating through random media. One of the dominant features of the dynamics in correlated, weak disorder potentials is the branching of the flow. This can be observed in several physical systems, most notably in the electron flow in two-dimensional electron gases [1], and has also been used to describe the formation of freak waves [2]. We present advances in the theoretical understanding and numerical simulation of classical branched flows in magnetic fields. In particular, we study branching statistics and branch density profiles. Our results have direct consequences for experiments which measure transport properties in electronic systems [3].[1] e.g. M. A. Topinka et al., Nature 410, 183 (2001), M. P. Jura et al., Nature Physics 3, 841 (2007)[2] E. J. Heller, L. Kaplan and A. Dahlen, J. Geophys. Res., 113, C09023 (2008)[3] J. J. Metzger, R. Fleischmann and T. Geisel, in preparation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zanetti, F.M.; Vicentini, E.; Luz, M.G.E. da

It was proposed about a decade ago [M.G.E. da Luz, A.S. Lupu-Sax, E.J. Heller, Phys. Rev. E 56 (1997) 2496] a simple approach for obtaining scattering states for arbitrary disconnected open or closed boundaries C, with different boundary conditions. Since then, the so called boundary wall method has been successfully used to solve different open boundary problems. However, its applicability to closed shapes has not been fully explored. In this contribution we present a complete account of how to use the boundary wall to the case of billiard systems. We review the general ideas and particularize them to single connectedmore » closed shapes, assuming Dirichlet boundary conditions for the C's. We discuss the mathematical aspects that lead to both the inside and outside solutions. We also present a different way to calculate the exterior scattering S matrix. From it, we revisit the important inside-outside duality for billiards. Finally, we give some numerical examples, illustrating the efficiency and flexibility of the method to treat this type of problem.« less

Current Status of Peroral Endoscopic Myotomy

PubMed Central

Cho, Young Kwan; Kim, Seong Hwan

2018-01-01

Peroral endoscopic myotomy (POEM) has been established as an optional treatment for achalasia. POEM is an endoluminal procedure that involves dissection of esophageal muscle fibers followed by submucosal tunneling. Inoue first attempted to use POEM for the treatment of achalasia in humans. Expanded indications of POEM include classic indications such as type I, type II, type III achalasia, failed prior treatments, including Botulinum toxin injection, endoscopic balloon dilation, laparoscopic Heller myotomy, and hypertensive motor disorders such as diffuse esophageal spasm, jackhammer esophagus. Contraindications include prior radiation therapy to the esophagus and prior extensive esophageal mucosal resection/ablation involving the POEM field. Most of the complications are minor and self-limited and can be managed conservatively. As POEM emerged as the main treatment for achalasia, various adaptations to tunnel endoscopic surgery have been attempted. Tunnel endoscopic surgery includes POEM, peroral endoscopic tumor resection, gastric peroral endoscopic pyloromyotomy. POEM has been widely accepted as a treatment for all types of achalasia, even for specific cases such as achalasia with failed prior treatments, and hypertensive motor disorders. PMID:29397656

Endoscopic approaches to treatment of achalasia

PubMed Central

Friedel, David; Modayil, Rani; Iqbal, Shahzad; Grendell, James H.

2013-01-01

Endoscopic therapy for achalasia is directed at disrupting or weakening the lower esophageal sphincter (LES). The two most commonly utilized endoscopic interventions are large balloon pneumatic dilation (PD) and botulinum toxin injection (BTI). These interventions have been extensively scrutinized and compared with each other as well as with surgical disruption (myotomy) of the LES. PD is generally more effective in improving dysphagia in achalasia than BTI, with the latter reserved for infirm older people, and PD may approach treatment results attained with myotomy. However, PD may need to be repeated. Small balloon dilation and endoscopic stent placement for achalasia have only been used in select centers. Per oral endoscopic myotomy is a newer endoscopic modality that will likely change the treatment paradigm for achalasia. It arose from the field of natural orifice transluminal endoscopic surgery and represents a scarless endoscopic approach to Heller myotomy. This is a technique that requires extensive training and preparation and thus there should be rigorous accreditation and monitoring of outcomes to ensure safety and efficacy. PMID:23503707

Current Therapeutic Options for Esophageal Motor Disorders as Defined by the Chicago Classification.

PubMed

Zerbib, Frank; Roman, Sabine

2015-07-01

With the development of high-resolution manometry and specific metrics to characterize esophageal motility, the Chicago Classification has become the gold standard for the diagnosis of esophageal motor disorders. Major and significant disorders, that is, never observed in healthy subjects, are achalasia, esophagogastric junction outflow obstruction, distal esophageal spasm, absent peristalsis, and hypercontractile (Jackhammer) esophagus. Achalasia subtyping is relevant to predict the response to endoscopic and surgical therapies as several studies suggest that, pneumatic dilation is less effective than Heller myotomy, in type III achalasia. Peroral endoscopic myotomy, initially developed in expert centers, is a promising technique for the treatment of achalasia. The medical therapeutic options for distal esophageal spasm and hypercontractile esophagus are smooth muscle relaxants and pain modulators. Intraesophageal injection of botulinum toxin might be an interesting option for treatment of these disorders but further studies are required to determine the optimal injection protocol and the best candidates based on manometric patterns. The treatment of hypotensive motility disorders is disappointing and relies mainly on dietary and lifestyle changes as no effective esophageal prokinetic is currently available.

Current Status of Peroral Endoscopic Myotomy.

PubMed

Cho, Young Kwan; Kim, Seong Hwan

2018-01-01

Peroral endoscopic myotomy (POEM) has been established as an optional treatment for achalasia. POEM is an endoluminal procedure that involves dissection of esophageal muscle fibers followed by submucosal tunneling. Inoue first attempted to use POEM for the treatment of achalasia in humans. Expanded indications of POEM include classic indications such as type I, type II, type III achalasia, failed prior treatments, including Botulinum toxin injection, endoscopic balloon dilation, laparoscopic Heller myotomy, and hypertensive motor disorders such as diffuse esophageal spasm, jackhammer esophagus. Contraindications include prior radiation therapy to the esophagus and prior extensive esophageal mucosal resection/ablation involving the POEM field. Most of the complications are minor and self-limited and can be managed conservatively. As POEM emerged as the main treatment for achalasia, various adaptations to tunnel endoscopic surgery have been attempted. Tunnel endoscopic surgery includes POEM, peroral endoscopic tumor resection, gastric peroral endoscopic pyloromyotomy. POEM has been widely accepted as a treatment for all types of achalasia, even for specific cases such as achalasia with failed prior treatments, and hypertensive motor disorders.

Semiclassical Wigner theory of photodissociation in three dimensions: Shedding light on its basis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Arbelo-González, W.; CNRS, Institut des Sciences Moléculaires, UMR 5255, 33405 Talence; Université Bordeaux, Institut des Sciences Moléculaires, UMR 5255, 33405 Talence

2015-04-07

The semiclassical Wigner theory (SCWT) of photodissociation dynamics, initially proposed by Brown and Heller [J. Chem. Phys. 75, 186 (1981)] in order to describe state distributions in the products of direct collinear photodissociations, was recently extended to realistic three-dimensional triatomic processes of the same type [Arbelo-González et al., Phys. Chem. Chem. Phys. 15, 9994 (2013)]. The resulting approach, which takes into account rotational motions in addition to vibrational and translational ones, was applied to a triatomic-like model of methyl iodide photodissociation and its predictions were found to be in nearly quantitative agreement with rigorous quantum results, but at a muchmore » lower computational cost, making thereby SCWT a potential tool for the study of polyatomic reaction dynamics. Here, we analyse the main reasons for this agreement by means of an elementary model of fragmentation explicitly dealing with the rotational motion only. We show that our formulation of SCWT makes it a semiclassical approximation to an approximate planar quantum treatment of the dynamics, both of sufficient quality for the whole treatment to be satisfying.« less

Giant fibrovascular esophageal polyp misdiagnosed as achalasia.

PubMed

Cordoş, I; Istrate, A; Codreşi, M; Bolca, C

2012-01-01

A 59 years old woman was admitted in our unit accusing longtime dysphagia and regurgitation. On admission, the patient was wearing a 3 month old definitive feeding gastrostomy tube. The contrast swallow, endoscopy and esophageal manometry established the diagnostic--achalasia. We removed the gastrostomy tube and we performed an open Heller myotomy. The postoperative period was uneventful and the patient was discharged one week later with affirmatively unimpaired deglutition. One month later, the patient was admitted via emergency with a giant fibrous tumor arising from her mouth after an episode of strong coughing and vomiting. The repeated endoscopy showed a giant esophageal polyp that was missed by the previous investigations, originating from pharingoesophageal junction. The esophageal polyp was resected by cervical approach with good postoperative outcome. The polyp's particular extreme dimensions (27 cm) prevented the acute asphyxia by blockage at the laryngeal level, possibly provoked by smaller tumors. As postoperative one month barium swallow showed a normal esophageal aspect, a final question remains--was achalasia real or an erroneous diagnosis was established the second time too?

Peroral endoscopic myotomy: An emerging minimally invasive procedure for achalasia

PubMed Central

Vigneswaran, Yalini; Ujiki, Michael B

2015-01-01

Peroral endoscopic myotomy (POEM) is an emerging minimally invasive procedure for the treatment of achalasia. Due to the improvements in endoscopic technology and techniques, this procedure allows for submucosal tunneling to safely endoscopically create a myotomy across the hypertensive lower esophageal sphincter. In the hands of skilled operators and experienced centers, the most common complications of this procedure are related to insufflation and accumulation of gas in the chest and abdominal cavities with relatively low risks of devastating complications such as perforation or delayed bleeding. Several centers worldwide have demonstrated the feasibility of this procedure in not only early achalasia but also other indications such as redo myotomy, sigmoid esophagus and spastic esophagus. Short-term outcomes have showed great clinical efficacy comparable to laparoscopic Heller myotomy (LHM). Concerns related to postoperative gastroesophageal reflux remain, however several groups have demonstrated comparable clinical and objective measures of reflux to LHM. Although long-term outcomes are necessary to better understand durability of the procedure, POEM appears to be a promising new procedure. PMID:26468336

Gastrointestinal robot-assisted surgery. A current perspective.

PubMed

Lunca, Sorinel; Bouras, George; Stanescu, Alexandru Calin

2005-12-01

Minimally invasive techniques have revolutionized operative surgery. Computer aided surgery and robotic surgical systems strive to improve further on currently available minimally invasive surgery and open new horizons. Only several centers are currently using surgical robots and publishing data. In gastrointestinal surgery, robotic surgery is applied to a wide range of procedures, but is still in its infancy. Cholecystectomy, Nissen fundoplication and Heller myotomy are among the most frequently performed operations. The ZEUS (Computer Motion, Goleta, CA) and the da Vinci (Intuitive Surgical, Mountain View, CA) surgical systems are today the most advanced robotic systems used in gastrointestinal surgery. Most studies reported that robotic gastrointestinal surgery is feasible and safe, provides improved dexterity, better visualization, reduced fatigue and high levels of precision when compared to conventional laparoscopic surgery. Its main drawbacks are the absence of force feedback and extremely high costs. At this moment there are no reports to clearly demonstrate the superiority of robotics over conventional laparoscopic surgery. Further research and more prospective randomized trials are needed to better define the optimal application of this new technology in gastrointestinal surgery.

An Overview of Achalasia and Its Subtypes

PubMed Central

Patel, Dhyanesh A.; Lappas, Brian M.

2017-01-01

Achalasia is one of the most studied esophageal motility disorders. However, the pathophysiology and reasons that patients develop achalasia are still unclear. Patients often present with dysphagia to solids and liquids, regurgitation, and varying degrees of weight loss. There is significant latency prior to diagnosis, which can have nutritional implications. The diagnosis is suspected based on clinical history and confirmed by esophageal high-resolution manometry testing. Esophagogastroduodenoscopy is necessary to rule out potential malignancy that can mimic achalasia. Recent data presented in abstract form suggest that patients with type II achalasia may be most likely, and patients with type III achalasia may be least likely, to report weight loss compared to patients with type I achalasia. Although achalasia cannot be permanently cured, palliation of symptoms is possible in over 90% of patients with the treatment modalities currently available (pneumatic dilation, Heller myotomy, or peroral endoscopic myotomy). This article reviews the clinical presentation, diagnosis, and management options in patients with achalasia, as well as potential insights into histopathologic differences and nutritional implications of the subtypes of achalasia. PMID:28867969

[Primary esophageal motility disorders; especially about esophageal achalasia].

PubMed

Miyazaki, Tatsuya; Sohda, Makoto; Sakai, Makoto; Tanaka, Naritaka; Suzuki, Shigemasa; Yokobori, Takehiko; Inose, Takanori; Nakajima, Masanobu; Fukuchi, Minoru; Kato, Hiroyuki; Kusano, Motoyasu; Kuwano, Hiroyuki

2011-07-01

Esophageal motility disorders are classified primary and secondary, and primary esophageal motility disorders are classified esophageal achalasia and other diseases by manometry. An esophageal emptying disorder associated with insufficient relaxation of the lower esophageal sphincter (LES) and elimination of peristaltic waves on the esophageal body is the major abnormality of achalasia. Esophagogram, endoscopy, and manometry are used for diagnosis. As pharmacological therapy, administration of a calcium channel blocker or nitrate is useful. The pharmacological therapy is not recommended as long-term basic therapy but as a temporary treatment. At 1st, the balloon dilation method is chosen in treatment of achalasia Surgical treatment is indicated in the following cases: (1) Patients uneffected by balloon dilation, (2) Flask type with grade II to III dilation, and sigmoid type, (3) the gradual progression to the pathophysiological stage, (4) young patients, (5) complicated with esophageal cancer. Laparoscopic Heller-Dor procedure is the most popular surgical procedure, recently. It is somewhat difficult to perform surgical treatment for this functional disease. We should select the most suitable individualized treatment with efficient comprehension of the pathophysiological situation.

Spectrophotometric evaluation of stability constants of 1:1 weak complexes from continuous variation data.

PubMed

Sayago, Ana; Asuero, Agustin G

2006-09-14

A bilogarithmic hyperbolic cosine method for the spectrophotometric evaluation of stability constants of 1:1 weak complexes from continuous variation data has been devised and applied to literature data. A weighting scheme, however, is necessary in order to take into account the transformation for linearization. The method may be considered a useful alternative to methods in which one variable is involved on both sides of the basic equation (i.e. Heller and Schwarzenbach, Likussar and Adsul and Ramanathan). Classical least squares lead in those instances to biased and approximate stability constants and limiting absorbance values. The advantages of the proposed method are: the method gives a clear indication of the existence of only one complex in solution, it is flexible enough to allow for weighting of measurements and the computation procedure yield the best value of logbeta11 and its limit of error. The agreement between the values obtained by applying the weighted hyperbolic cosine method and the non-linear regression (NLR) method is good, being in both cases the mean quadratic error at a minimum.

Examining gender differences on FCI performance in algebra and calculus based physics courses

NASA Astrophysics Data System (ADS)

Kreutzer, Kimberley; Boudreaux, Andrew

2009-05-01

The Force Concept Inventory (FCI) has been widely used to asses student understanding of Newtonian principles. Studies have shown a marked difference in the performance of men and women on both pre- and post-tests [1,2] and also indicate that experiential based instruction may lead to a reduction in this gender gap [1,3]. This poster presents FCI data collected at Western Washington University. Initial analysis of gender differences are consistent with those reported nationally. We also discuss factors that may contribute to the differences in performance and propose instructional strategies that are designed to address the gender gap. [4pt] [1] M. Lorenzo, et. al., ``Reducing the gender gap in the physics classroom,'' AJP 74(2), 118-122 (2006) [0pt] [2] J. Docktor and K. Heller, ``Gender Differences in Both Force Concept Inventory and Introductory Physics Performance,'' Proceedings at the 2008 PERC [0pt] [3] S. Pollack, et. al., ``Reducing the gender gap in the physics classroom: How sufficient is interactive engagement?'' PRST-PER 3 (2007)

Single Molecule Detection in Living Biological Cells using Carbon Nanotube Optical Probes

NASA Astrophysics Data System (ADS)

Strano, Michael

2009-03-01

osmotic pressure gradients will be discussed, as well as its potential as a unique transduction mechanism for a new class of implantable sensors. [4pt] [1] Saito, R., Dresselhaus, G. & Dresselhaus, M. S. Physical Properties of Carbon Nanotubes (Imperial College Press, London, 1998). [0pt] [2] Barone, P. W., Baik, S., Heller, D. A. & Strano, M. S. Near-Infrared Optical Sensors Based on Single-Walled Carbon Nanotubes. Nature Materials 4, 86-92 (2005). [0pt] [3] Jeng, E. S., Moll, A. E., Roy, A. C., Gastala, J. B. & Strano, M. S. Detection of DNA hybridization using the near infrared band-gap fluorescence of single-walled carbon nanotubes. Nano Letters 6, 371-375 (2006). [0pt] [4] Heller, D. A. et al. Optical detection of DNA conformational polymorphism on single-walled carbon nanotubes. Science 311, 508-511 (2006).

Clinical management of achalasia: current state of the art

PubMed Central

Krill, Joseph T; Naik, Rishi D; Vaezi, Michael F

2016-01-01

Achalasia is a primary disorder of esophageal motility. It classically presents with dysphagia to both solids and liquids but may be accompanied by regurgitation and chest pain. The gold standard for the diagnosis of achalasia is esophageal motility testing with manometry, which often reveals aperistalsis of the esophageal body and incomplete lower esophageal sphincter relaxation. The diagnosis is aided by complimentary tests, such as esophagogastroduodenoscopy and contrast radiography. Esophagogastroduodenoscopy is indicated to rule out mimickers of the disease known as “pseudoachalasia” (eg, malignancy). Endoscopic appearance of a dilated esophagus with retained food or saliva and a puckered lower esophageal sphincter should raise suspicion for achalasia. Additionally, barium esophagography may reveal a dilated esophagus with a distal tapering giving it a “bird’s beak” appearance. Multiple therapeutic modalities aid in the management of achalasia, the decision of which depends on operative risk factors. Conventional treatments include medical therapy, botulinum toxin injection, pneumatic dilation, and Heller myotomy. The last two are defined as the most definitive treatment options. New emerging therapies include peroral endoscopic myotomy, placement of self-expanding metallic stents, and endoscopic sclerotherapy. PMID:27110134

Endoscopic treatment of esophageal achalasia

PubMed Central

Esposito, Dario; Maione, Francesco; D’Alessandro, Alessandra; Sarnelli, Giovanni; De Palma, Giovanni D

2016-01-01

Achalasia is a motility disorder of the esophagus characterized by dysphagia, regurgitation of undigested food, chest pain, weight loss and respiratory symptoms. The most common form of achalasia is the idiopathic one. Diagnosis largely relies upon endoscopy, barium swallow study, and high resolution esophageal manometry (HRM). Barium swallow and manometry after treatment are also good predictors of success of treatment as it is the residue symptomatology. Short term improvement in the symptomatology of achalasia can be achieved with medical therapy with calcium channel blockers or endoscopic botulin toxin injection. Even though few patients can be cured with only one treatment and repeat procedure might be needed, long term relief from dysphagia can be obtained in about 90% of cases with either surgical interventions such as laparoscopic Heller myotomy or with endoscopic techniques such pneumatic dilatation or, more recently, with per-oral endoscopic myotomy. Age, sex, and manometric type by HRM are also predictors of responsiveness to treatment. Older patients, females and type II achalasia are better after treatment compared to younger patients, males and type III achalasia. Self-expandable metallic stents are an alternative in patients non responding to conventional therapies. PMID:26839644

Intra and post-operative complications of esophageal achalasia.

PubMed

Pugliese, Luigi; Peri, Andrea; Tinozzi, Francesco Paolo; Zonta, Sandro; di Stefano, Michele; Meloni, Federica; Pietrabissa, Andrea

2013-01-01

To evaluate and discuss all the potential complications affecting morbidity of patients treated with surgery for primary achalasia. A review of the available English literature published to date has been conducted. All articles reporting surgical experience in achalasia were examined and then were selected only those specifically inherent to the topic at issue. Mucosal perforation is the main intra-operative complication while persistence or recurrence of the disease and gastro-esophageal reflux are those mostly affecting patients afterwards, even at long-term follow-up. A few other less common morbidities, as well as the technical considerations useful to minimize and manage each complication mentioned, are reported. Minimally invasive surgery for achalasia consent to treat patients with a low rate of perioperative complications that can be managed with conservative approach in the majority of cases. Risk of esophageal cancer exists in these patients and remains although surgical therapy. Laparoscopic Heller myotomy along with partial fundoplication is a safe and effective procedure that should be considered as the treatment of choice at first evaluation of achalasic patients rather than endoscopic techniques. Robotic technology may add further contribution in diminishing perioperative complications.

The Treatment of Achalasia in Obese Patients.

PubMed

Wesp, Julie A; Farrell, Timothy M

2018-04-01

Epidemiological studies have demonstrated that obesity is frequently associated with esophageal motility disorders. Morbid obesity and achalasia may coexist in the same patient. The management of the morbidly obese patient with achalasia is complex and the most effective treatment remains controversial. The aim of this study is to review the pathophysiology, clinical presentation, diagnostic evaluation, and treatment of achalasia in morbidly obese patients. PubMed search from January 1990 to July 2017, including the following terms: achalasia, morbid obesity, bariatric, and treatment. Achalasia in the setting of morbid obesity may be successfully treated by endoscopic or surgical methods. Surgeons may choose to add a bariatric procedure, with various strategies present in the literature. A review of the present literature suggests that the preferred approach to achalasia in the morbidly obese patient is to address both disease processes simultaneously with a laparoscopic Heller myotomy and a Roux-en-Y gastric bypass. Roux-en-Y gastric bypass is cited by most experts as the bariatric procedure of choice, given its antireflux benefits. A well-powered study, comparing the various approaches to the treatment of achalasia in the setting of morbid obesity, is required to establish a consensus.

Laparoscopic treatment for esophageal achalasia: experience at a single center.

PubMed

Agrusa, A; Romano, G; Bonventre, S; Salamone, G; Cocorullo, G; Gulotta, G

2013-01-01

Achalasia is a not frequent esophageal disorder characterized by the absence of esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter (LES). Its cause is unknown. The aim of treatment is to improve the symptoms. We report the results of the treatment of this condition achieved in one center. We conducted a retrospective study of patients with esophageal achalasia. In the period 2010-2012 we observed 64 patients, of whom 19 were referred for medical treatment. Three of the remaining patients underwent botulinum toxin injection, 17 underwent multiple endoscopic dilation procedures and 25 underwent laparoscopic surgery. There were no complications in the group undergoing endoscopic therapy, but symptom remission was only temporary. Patients undergoing surgery showed a significant improvement in symptoms and no recurrence throughout the follow-up period, that is still ongoing (3 years). There were no major complications in any case and no morbidity or mortality. Surgical treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor fundoplication gives the best and longest-lasting results in suitably selected patients. The extension of the myotomy and reduction in LES pressure are the most important parameters to achieve a good result.

Endoscopic treatment of esophageal achalasia.

PubMed

Esposito, Dario; Maione, Francesco; D'Alessandro, Alessandra; Sarnelli, Giovanni; De Palma, Giovanni D

2016-01-25

Achalasia is a motility disorder of the esophagus characterized by dysphagia, regurgitation of undigested food, chest pain, weight loss and respiratory symptoms. The most common form of achalasia is the idiopathic one. Diagnosis largely relies upon endoscopy, barium swallow study, and high resolution esophageal manometry (HRM). Barium swallow and manometry after treatment are also good predictors of success of treatment as it is the residue symptomatology. Short term improvement in the symptomatology of achalasia can be achieved with medical therapy with calcium channel blockers or endoscopic botulin toxin injection. Even though few patients can be cured with only one treatment and repeat procedure might be needed, long term relief from dysphagia can be obtained in about 90% of cases with either surgical interventions such as laparoscopic Heller myotomy or with endoscopic techniques such pneumatic dilatation or, more recently, with per-oral endoscopic myotomy. Age, sex, and manometric type by HRM are also predictors of responsiveness to treatment. Older patients, females and type II achalasia are better after treatment compared to younger patients, males and type III achalasia. Self-expandable metallic stents are an alternative in patients non responding to conventional therapies.

2011 update on esophageal achalasia.

PubMed

Chuah, Seng-Kee; Hsu, Pin-I; Wu, Keng-Liang; Wu, Deng-Chyang; Tai, Wei-Chen; Changchien, Chi-Sin

2012-04-14

There have been some breakthroughs in the diagnosis and treatment of esophageal achalasia in the past few years. First, the introduction of high-resolution manometry with pressure topography plotting as a new diagnostic tool has made it possible to classify achalasia into three subtypes. The most favorable outcome is predicted for patients receiving treatment for type II achalasia (achalasia with compression). Patients with type I(classic achalasia) and type III achalasia (spastic achalasia) experience a less favorable outcome. Second, the first multicenter randomized controlled trial published by the European Achalasia Trial group reported 2-year follow-up results indicating that laparoscopic Heller myotomy was not superior to endoscopic pneumatic dilation (PD). Although the follow-up period was not long enough to reach a convincing conclusion, it merits the continued use of PD as a generally available technique in gastroenterology. Third, the novel endoscopic technique peroral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and cautious evaluation. Despite all this good news, the bottom line is a real breakthrough from the basic studies to identify the actual cause of achalasia that may impede treatment success is still anticipated.

2011 update on esophageal achalasia

PubMed Central

Chuah, Seng-Kee; Hsu, Pin-I; Wu, Keng-Liang; Wu, Deng-Chyang; Tai, Wei-Chen; Changchien, Chi-Sin

2012-01-01

There have been some breakthroughs in the diagnosis and treatment of esophageal achalasia in the past few years. First, the introduction of high-resolution manometry with pressure topography plotting as a new diagnostic tool has made it possible to classify achalasia into three subtypes. The most favorable outcome is predicted for patients receiving treatment for type II achalasia (achalasia with compression). Patients with typeI(classic achalasia) and type III achalasia (spastic achalasia) experience a less favorable outcome. Second, the first multicenter randomized controlled trial published by the European Achalasia Trial group reported 2-year follow-up results indicating that laparoscopic Heller myotomy was not superior to endoscopic pneumatic dilation (PD). Although the follow-up period was not long enough to reach a convincing conclusion, it merits the continued use of PD as a generally available technique in gastroenterology. Third, the novel endoscopic technique peroral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and cautious evaluation. Despite all this good news, the bottom line is a real breakthrough from the basic studies to identify the actual cause of achalasia that may impede treatment success is still anticipated. PMID:22529685

Surgical management for achalasia after coronary artery bypass graft using the right gastroepiploic artery: a case report.

PubMed

Muranushi, Ryo; Miyazaki, Tatsuya; Saito, Hideyuki; Kuriyama, Kengo; Yoshida, Tomonori; Kumakura, Yuji; Honjyo, Hiroaki; Yokobori, Takehiko; Sakai, Makoto; Sohda, Makoto; Kuwano, Hiroyuki

2017-12-01

The right gastroepiploic artery is commonly used in coronary artery bypass grafting. Appropriate strategies are required when performing upper abdominal surgeries after the right gastroepiploic artery has been used in coronary artery bypass grafting because compressing or injuring the graft may cause myocardial ischemia and fatal arrhythmias. To our knowledge, this is the first reported case of surgery for achalasia performed after coronary artery bypass grafting using the right gastroepiploic artery. We have discussed the surgical procedure and particular intraoperative considerations. A 62-year-old man who had undergone coronary artery bypass grafting using the right gastroepiploic artery presented with achalasia. Because medication and balloon dilation had been ineffective and he was having difficulty ingesting food, we performed a Heller-Dor procedure via laparotomy. The right gastroepiploic artery was not damaged during this surgery, and there were no perioperative cardiovascular complications. Adequate control of symptoms was achieved. When performing upper abdominal surgeries after coronary artery bypass grafting with the right gastroepiploic artery, it is necessary to investigate the patient carefully preoperatively and adapt the intraoperative procedure to minimize risk of injury to the graft and consequent cardiovascular complications.

The new AP Physics exams: Integrating qualitative and quantitative reasoning

NASA Astrophysics Data System (ADS)

Elby, Andrew

2015-04-01

When physics instructors and education researchers emphasize the importance of integrating qualitative and quantitative reasoning in problem solving, they usually mean using those types of reasoning serially and separately: first students should analyze the physical situation qualitatively/conceptually to figure out the relevant equations, then they should process those equations quantitatively to generate a solution, and finally they should use qualitative reasoning to check that answer for plausibility (Heller, Keith, & Anderson, 1992). The new AP Physics 1 and 2 exams will, of course, reward this approach to problem solving. But one kind of free response question will demand and reward a further integration of qualitative and quantitative reasoning, namely mathematical modeling and sense-making--inventing new equations to capture a physical situation and focusing on proportionalities, inverse proportionalities, and other functional relations to infer what the equation ``says'' about the physical world. In this talk, I discuss examples of these qualitative-quantitative translation questions, highlighting how they differ from both standard quantitative and standard qualitative questions. I then discuss the kinds of modeling activities that can help AP and college students develop these skills and habits of mind.

Profilicollis novaezelandensis n. sp. (Polymorphidae) and two other acanthocephalan parasites from shore birds (Haematopodidae and Scolopacidae) in New Zealand, with records of two species in intertidal crabs (Decapoda: Grapsidae and Ocypodidae).

PubMed

Brockerhoff, A M; Smales, L R

2002-05-01

Profilicollis novaezelandensis n. sp. (Acanthocephala: Polymorphidae) is described from the South Island pied oystercatcher Haematopus ostralegus finschi Martens (Haematopodidae) and the intertidal crab Hemigrapsus crenulatus (Milne Edwards) (Brachyura: Grapsidae) from the South Island of New Zealand. The new species can be distinguished from all the other species of the genus by a combination of the following characters: long neck (13% of total body length for adults) and a subspherical proboscis with 14-16 longitudinal rows of 7-8 hooks. The mud crabs Helice crassa Dana (Grapsidae) and Macrophthalmus hirtipes (Heller) (Ocypodidae) were also harbouring cystacanths and the bar-tailed godwit Limosa lapponica (Linnaeus) (Scolopacidae) juveniles of P. novaezelandensis. This is the first record of brachyuran decapods as intermediate hosts of Acanthocephala from New Zealand. P. antarcticus is recorded from three crab species (Helice crassa, Hemigraspus crenulatus and Macrophthalmus hirtipes) and two bird species (Haematopus o. finschi and Limosa lapponica) in New Zealand. An unidentified species of Plagiorhynchus was also found in two bird species (H. o. finschi and H. unicolor Forster). P. antarcticus and P. novaezelandensis are the first records of Profilicollis from New Zealand.

77 FR 67784 - Endangered and Threatened Wildlife and Plants; 90-Day Finding on a Petition to List the Heller...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-14

..., and any other interested parties. We seek information on: (1) The species' biology, range, and... bodies of freshwater.'' As for diet, some species eat plant material, others eat micro-organisms, and...

Treatment choices and outcomes of patients with manometrically diagnosed achalasia.

PubMed

Yeung, J C; Finley, C; Hanna, W C; Miller, L; Ferri, L; Urbach, D R; Darling, G E

2016-07-01

This prospective population-based study was designed to evaluate treatment choices in patients with new manometrically diagnosed achalasia and their outcomes. Patients referred to the esophageal function laboratory were enrolled after a new manometric diagnosis of achalasia. Patients completed an initial achalasia symptom score validated questionnaire on their symptom severity, duration, treatment pre-diagnosis and Medical Outcomes Study 36-item Short-Form (SF-36) survey. Treatment decisions were made by the referring physician and the patient. Follow-up questionnaires were completed every 3 months for 1 year. Patients who chose not to undergo treatment at 1-year follow-up completed another questionnaire after 5 years. Between January 2004 and January 2005, 83 of 124 eligible patients were enrolled. Heller myotomy was performed on 31 patients, three patients received botulinum toxin injections, and 25 patients received 29 pneumatic balloon dilatations. Twenty-four patients chose to receive no treatment. Following treatment, patients treated with surgery, dilatation and botulinum toxin had an average improvement in achalasia symptom score of 23 +/- 12.2, 17 +/- 10.9, and 9 +/- 14, respectively. Patients receiving no treatment had worsening symptoms with a symptom score change of -3.5 +/- 11.4. Surgery and dilatation resulted in significant improvement (P < 0.01) relative to no treatment. In univariate logistic regression, symptom severity score (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.00 to 1.08), sphincter tone (OR 1.04, 95% CI 1.00 to 1.09), difficulty swallowing liquids (OR 3.21, 95% 1.15 to 8.99), waking from sleep (OR 2.75, 95% 1.00 to 7.61), and weight loss (OR 5.99, 95% CI 1.93 to 18.58) were all significant in predicting that patients would select treatment. In the multivariate analysis, older age (OR 1.05, 95% CI 1.01 to 1.09) and weight loss (OR 3.91, 95% CI 1.02 to 15.2) were statistically significant for undergoing treatment. At 5 years

Finding the Right Treatment for Achalasia Treatment: Risks, Efficacy, Complications.

PubMed

Moonen, An; Boeckxstaens, Guy

2016-12-01

Achalasia is a primary esophageal motor disorder of the esophagus that is characterized by the absence of esophageal peristalsis and a failure of the lower esophageal sphincter (LES) to relax upon swallowing. The defective relaxation leads to symptoms of dysphagia for solids and liquids, regurgitation, aspiration, chest pain, and weight loss. Achalasia is believed to result from a selective loss of enteric inhibitory neurons, most likely due to an autoimmune phenomenon in genetic susceptible individuals. As there is no curative treatment for achalasia, treatment is confined to disruption of the LES to improve bolus passage. The two most commonly used treatment modalities available are the endoscopic pneumodilation (PD) and the surgical laparoscopic Heller myotomy (LHM). A recent European randomized controlled trial showed that both treatment modalities have comparable success rates after a follow-up of at least 5 years. In view of these data, both treatments can be used as an initial therapy in achalasia and the choice should be based on the expertise available. Recently, a new endoscopic technique, peroral endoscopic myotomy (POEM), has been introduced with excellent short-term success rates. However, longer follow-up and data from randomized controlled trials are needed before accepting this technique as a new treatment option for achalasia in clinical practice.

Surgery for achalasia: 1998.

PubMed

Shiino, Y; Filipi, C J; Awad, Z T; Tomonaga, T; Marsh, R E

1999-01-01

Technical controversies abound regarding the surgical treatment of achalasia. To determine the value of a concomitant antireflux procedure, the best antireflux procedure, the correct length for gastric myotomy, the optimal surgical approach (thoracic or abdominal), and the equivalency of minimally invasive surgery, a literature review was carried out. The review is based on 23 articles on open transabdominal or transthoracic myotomy, 14 articles on laparoscopic myotomy, and four articles on thoracoscopic myotomy. Postoperative results of traditional open thoracic or transabdominal myotomy as determined by symptomatology were better with fundoplication than without fundoplication. The incidence of postoperative reflux as proved by pH monitoring was high in patients who had an open transabdominal myotomy without fundoplication. The type of antireflux procedure used and the length of gastric myotomy had little effect on results. The results of transthoracic Heller myotomy do not require a concomitant fundoplication. Laparoscopic and thoracoscopic myotomy had excellent results at short-term follow-up. A fundoplication must be added if the myotomy is performed transabdominally. A randomized prospective study is required to determine the best fundoplication and the extent of gastric myotomy. Although minimally invasive surgery for achalasia has excellent initial results, longer follow-up in a larger population of patients is needed.

Laparoscopic treatment for esophageal achalasia: experience at a single center

PubMed Central

AGRUSA, A.; ROMANO, G.; BONVENTRE, S.; SALAMONE, G.; COCORULLO, G.; GULOTTA, G.

2013-01-01

Summary Background Achalasia is a not frequent esophageal disorder characterized by the absence of esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter (LES). Its cause is unknown. The aim of treatment is to improve the symptoms. We report the results of the treatment of this condition achieved in one center. Patients and methods We conducted a retrospective study of patients with esophageal achalasia. In the period 2010–2012 we observed 64 patients, of whom 19 were referred for medical treatment. Three of the remaining patients underwent botulinum toxin injection, 17 underwent multiple endoscopic dilation procedures and 25 underwent laparoscopic surgery. Results There were no complications in the group undergoing endoscopic therapy, but symptom remission was only temporary. Patients undergoing surgery showed a significant improvement in symptoms and no recurrence throughout the follow-up period, that is still ongoing (3 years). There were no major complications in any case and no morbidity or mortality. Conclusions Surgical treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor fundoplication gives the best and longest-lasting results in suitably selected patients. The extension of the myotomy and reduction in LES pressure are the most important parameters to achieve a good result. PMID:24091178

Independent component processes underlying emotions during natural music listening

PubMed Central

Zollinger, Nina; Elmer, Stefan; Jäncke, Lutz

2016-01-01

The aim of this study was to investigate the brain processes underlying emotions during natural music listening. To address this, we recorded high-density electroencephalography (EEG) from 22 subjects while presenting a set of individually matched whole musical excerpts varying in valence and arousal. Independent component analysis was applied to decompose the EEG data into functionally distinct brain processes. A k-means cluster analysis calculated on the basis of a combination of spatial (scalp topography and dipole location mapped onto the Montreal Neurological Institute brain template) and functional (spectra) characteristics revealed 10 clusters referring to brain areas typically involved in music and emotion processing, namely in the proximity of thalamic-limbic and orbitofrontal regions as well as at frontal, fronto-parietal, parietal, parieto-occipital, temporo-occipital and occipital areas. This analysis revealed that arousal was associated with a suppression of power in the alpha frequency range. On the other hand, valence was associated with an increase in theta frequency power in response to excerpts inducing happiness compared to sadness. These findings are partly compatible with the model proposed by Heller, arguing that the frontal lobe is involved in modulating valenced experiences (the left frontal hemisphere for positive emotions) whereas the right parieto-temporal region contributes to the emotional arousal. PMID:27217116

Current status in the treatment options for esophageal achalasia

PubMed Central

Chuah, Seng-Kee; Chiu, Chien-Hua; Tai, Wei-Chen; Lee, Jyong-Hong; Lu, Hung-I; Changchien, Chi-Sin; Tseng, Ping-Huei; Wu, Keng-Liang

2013-01-01

Recent advances in the treatment of achalasia include the use of high-resolution manometry to predict the outcome of patients and the introduction of peroral endoscopic myotomy (POEM). The first multicenter randomized, controlled, 2-year follow-up study conducted by the European Achalasia Trial group indicated that laparoscopic Heller myotomy (LHM) was not superior to pneumatic dilations (PD). Publications on the long-term success of laparoscopic surgery continue to emerge. In addition, laparoscopic single-site surgery is applicable to advanced laparoscopic operations such as LHM and anterior fundoplication. The optimal treatment option is an ongoing matter of debate. In this review, we provide an update of the current progress in the treatment of esophageal achalasia. Unless new conclusive data prove otherwise, LHM is considered the most durable treatment for achalasia at the expense of increased reflux-associated complications. However, PD is the first choice for non-surgical treatment and is more cost-effective. Repeated PD according to an “on-demand” strategy based on symptom recurrence can achieve long-term remission. Decision making should be based on clinical evidence that identifies a subcategory of patients who would benefit from specific treatment options. POEM has shown promise but its long-term efficacy and safety need to be assessed further. PMID:24023484

Disease-specific health-related quality of life in patients with esophageal achalasia before and after therapy.

PubMed

Garrigues, V; Ortiz, V; Casanova, C; Bujanda, L; Moreno-Osset, E; Rodríguez-Téllez, M; Montserrat, A; Brotons, A; Fort, E; Ponce, J

2010-07-01

To evaluate disease-specific health-related quality of life (HRQoL) in patients with symptomatic esophageal achalasia before and after therapy. Symptoms and disease-specific HRQoL were evaluated before and 3 months after therapy. Therapy selection, either dilatation or myotomy, depended exclusively on the opinion of the physician on charge of the patient. Symptom severity was graded from 0 to 3, using a scoring system. A disease-specific questionnaire for achalasia developed and validated in Spanish language with 18 items and four subscales (AE-18) was used to evaluate HRQoL. Changes after therapy in HRQoL and its association with clinical improvement were analyzed. Sixty-five patients were prospectively included in eight hospitals in Spain. Of them, 47 were treated with dilatation, and 18 with laparoscopic Heller myotomy. After therapy, AE-18 global and subscales scores improved significantly. Changes in HRQoL were associated with improvement in symptoms. An important improvement in symptoms (>or=50%) was needed to obtain a minimal clinically important improvement (>or=20%) in HRQoL. Disease-specific HRQoL improves in patients with symptomatic achalasia after therapy with dilatation or myotomy. The degree of improvement of HRQoL depends on the degree of improvement of esophageal symptoms.

Current status in the treatment options for esophageal achalasia.

PubMed

Chuah, Seng-Kee; Chiu, Chien-Hua; Tai, Wei-Chen; Lee, Jyong-Hong; Lu, Hung-I; Changchien, Chi-Sin; Tseng, Ping-Huei; Wu, Keng-Liang

2013-09-07

Recent advances in the treatment of achalasia include the use of high-resolution manometry to predict the outcome of patients and the introduction of peroral endoscopic myotomy (POEM). The first multicenter randomized, controlled, 2-year follow-up study conducted by the European Achalasia Trial group indicated that laparoscopic Heller myotomy (LHM) was not superior to pneumatic dilations (PD). Publications on the long-term success of laparoscopic surgery continue to emerge. In addition, laparoscopic single-site surgery is applicable to advanced laparoscopic operations such as LHM and anterior fundoplication. The optimal treatment option is an ongoing matter of debate. In this review, we provide an update of the current progress in the treatment of esophageal achalasia. Unless new conclusive data prove otherwise, LHM is considered the most durable treatment for achalasia at the expense of increased reflux-associated complications. However, PD is the first choice for non-surgical treatment and is more cost-effective. Repeated PD according to an "on-demand" strategy based on symptom recurrence can achieve long-term remission. Decision making should be based on clinical evidence that identifies a subcategory of patients who would benefit from specific treatment options. POEM has shown promise but its long-term efficacy and safety need to be assessed further.

Treatments for achalasia in 2017: how to choose among them.

PubMed

Kahrilas, Peter J; Pandolfino, John E

2017-07-01

To review recent advances in achalasia diagnostics and therapeutics. The cardinal feature of achalasia, impaired lower esophageal sphincter (LES) relaxation, can occur in association with varied patterns of esophageal contractility. The Chicago Classification distinguishes among these as follows: without contractility (type I), with panesophageal pressurization (type II), with premature (spastic) distal esophageal contractions (type III), or even with preserved peristalsis [esophagogastric junction (EGJ) outlet obstruction]. Physiological testing also reveals achalasia-like syndromes that also benefit from achalasia therapies. Coincident with this has been the development of peroral endoscopic myotomy (POEM), an endoscopic technique for performing an esophageal myotomy. Hence, the option now exists to either selectively ablate the LES (pneumatic dilation, laparoscopic Heller myotomy, or POEM) or to ablate the sphincter and create a myotomy along some or the entire adjacent smooth muscle esophagus (POEM). Each achalasia syndrome has unique treatment considerations; type II achalasia responds well to all therapies, whereas type III responds best to POEM. Emerging data support the concept that optimal management of achalasia is phenotype-specific, guided by high-resolution manometry, and, in some instance, functional luminal imaging probe studies. This opinion article reviews the varied characteristic and treatment considerations of achalasia syndromes as currently understood.

Clinical Practice Update: The Use of Per-Oral Endoscopic Myotomy in Achalasia: Expert Review and Best Practice Advice From the AGA Institute.

PubMed

Kahrilas, Peter J; Katzka, David; Richter, Joel E

2017-11-01

The purpose of this review is to describe a place for per-oral endoscopic myotomy (POEM) among the currently available robust treatments for achalasia. The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations: 1) in determining the need for achalasia therapy, patient-specific parameters (Chicago Classification subtype, comorbidities, early vs late disease, primary or secondary causes) should be considered along with published efficacy data; 2) given the complexity of this procedure, POEM should be performed by experienced physicians in high-volume centers because an estimated 20-40 procedures are needed to achieve competence; 3) if the expertise is available, POEM should be considered as primary therapy for type III achalasia; 4) if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes; and 5) post-POEM patients should be considered high risk to develop reflux esophagitis and advised of the management considerations (potential indefinite proton pump inhibitor therapy and/or surveillance endoscopy) of this before undergoing the procedure. Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.

On-the-fly ab initio semiclassical dynamics: Emission spectra of oligothiophenes

NASA Astrophysics Data System (ADS)

Wehrle, Marius; Sulc, Miroslav; Vanicek, Jiri

2014-03-01

We employ the thawed Gaussian approximation (TGA) [E. J. Heller, J. Chem. Phys. 62, 1544 (1975)] within an on-the-fly ab initio (OTF-AI) scheme to calculate the vibrationally resolved emission spectra of oligothiophenes up to five rings. OTF-AI-TGA is efficient enough to treat all vibrational degrees of freedom on an equal footing even in case of 5-oligothiophene (105 vibrational degrees of freedom), thus obviating the need for the crude global harmonic approximation, popular for large system. The experimental emission spectra have been almost perfectly reproduced. In order to provide a deeper insight into the associated physical and chemical processes, we present a systematic approach to assess the importance and to analyze the mutual coupling of individual vibrational degrees of freedom during the dynamics. This allows us to explain the changes in the vibrational line shapes of the oligothiophenes with increasing number of rings. Furthermore, we observe the dynamical interplay between quinoid and aromatic characters of individual rings in the oligothiophene chain during the dynamics and confirm that the quinoid character prevails in the center of the chain. This research was supported by the Swiss NSF Grant No. 200021_124936/1 and NCCR Molecular Ultrafast Science & Technology (MUST), and by the EPFL.

Region 9 - Social Vulnerability Index

EPA Pesticide Factsheets

The Social Vulnerability Index is derived from the 2000 US Census data. The fields included are percent minority, median household income, age (under 18 and over 64), population without a high school diploma, linguistically isolated households, and single female head of households with own children under 18 (single moms). The data is at the block group level. Each field for each block group is assigned an index score of 0-3, based on whether the value of that dataset falls in the top quartile (score=3), second quartile (score=2), third quartile (score=1), or bottom quartile (score=0). The scores for each field are then added together to assign a comprehensive score to each block group (0-21). The highest scores are block groups that have the highest percentage of sensitive populations (highest percent minority, lowest per capita income, highest percent of population under 18 and over 64, highest percentage of population without a high school degree, highest percent of linguistically isolated households, and highest percent of single female head of households). Zoe Heller of the US EPA Region 9's Communities and Ecosystems Division, is responsible for the design and development of the Social Vulnerability Index data set.

Arizona - Social Vulnerability Index

EPA Pesticide Factsheets

The Social Vulnerability Index is derived from the 2000 US Census data. The fields included are percent minority, median household income, age (under 18 and over 64), population without a high school diploma, linguistically isolated households, and single female head of households with own children under 18 (single moms). The data is at the block group level. Each field for each block group is assigned an index score of 0-3, based on whether the value of that dataset falls in the top quartile (score=3), second quartile (score=2), third quartile (score=1), or bottom quartile (score=0). The scores for each field are then added together to assign a comprehensive score to each block group (0-21). The highest scores are block groups that have the highest percentage of sensitive populations (highest percent minority, lowest per capita income, highest percent of population under 18 and over 64, highest percentage of population without a high school degree, highest percent of linguistically isolated households, and highest percent of single female head of households). Zoe Heller of the US EPA Region 9's Communities and Ecosystems Division, is responsible for the design and development of the Social Vulnerability Index data set.

Insights on the genus Acronymolpus Samuelson with new synonymies and exclusion of Stethotes Baly from the fauna of New Caledonia (Coleoptera, Chrysomelidae, Eumolpinae).

PubMed

Gómez-Zurita, Jesús

2017-01-01

In this work, several taxonomic problems affecting the recently erected genus Acronymolpus Samuelson, 2015, endemic to New Caledonia, are addressed. Two of the three New Caledonian species described in Stethotes Baly are transferred to Acronymolpus and their priority is recognized over the names proposed in the revision of this genus. Moreover, different forms of Acronymolpus always found in sympatry, one reddish and larger, and the other black and smaller, were each given species status in that revision, but they are recognized here as the females and males, respectively, of the same species. The taxonomic summary of these discoveries is: (i) A. bertiae (Jolivet, Verma & Mille, 2007), comb. n. = A. meteorus Samuelson, 2015, syn. n. , and A. turbo Samuelson, 2015, syn. n. ; and (ii) A. jourdani (Jolivet, Verma & Mille, 2013), comb. n. = A. gressitti Samuelson, 2015, syn. n. , and A. joliveti Samuelson, 2015, syn. n. New distribution data and the male genitalia and the spermatheca of the two valid species of Acronymolpus are described for the first time with reference to taxonomically important characters. Finally, the last New Caledonian species described in Stethotes is recognized here as a member of the endemic genus Taophila Heller: T. mandjeliae (Jolivet, Verma & Mille, 2010), comb. n.

Computation of the influence of scanning probe microscope (SPM) on quantum dot eigenstates and 2DEG potential

NASA Astrophysics Data System (ADS)

Stopa, Michael

2005-03-01

We calculate the electronic structure of GaAs-AlGaAs two-dimensional electron gas (2DEG) devices, such as quantum dots and quantum point contacts (QPCs) in the presence of a tip of a scanning probe microscope at some distance above the surface. The calculation employs standard density functional theory with exchange and correlation treated in the local density approximation. The position and voltage on the tip are varied and the conditions for depletion of the 2DEG are shown to compare favorably to experiment [1]. We show that the size of the depletion region created (by a negative tip voltage) is unexpectedly small due to focusing of the potential lines by the higher dielectric. We study the interaction of the tip with an isolated quantum dot that contains one or two electrons. The raster pattern of the difference between single particle energies reveals that the tip distorts the shape of the confining potential and suggests that excited state properties, if they can be measured experimentally, can contribute to the resolution of spatial information. [1] M.A. Topinka, R.M. Westervelt, E.J. Heller, ``http://meso.deas.harvard.edu/papers/Topinka, PT 56 12 (2003)'' (Imaging Electron Flow), Physics Today 56, 12 (2003).

Bayesian Hierarchical Grouping: perceptual grouping as mixture estimation

PubMed Central

Froyen, Vicky; Feldman, Jacob; Singh, Manish

2015-01-01

We propose a novel framework for perceptual grouping based on the idea of mixture models, called Bayesian Hierarchical Grouping (BHG). In BHG we assume that the configuration of image elements is generated by a mixture of distinct objects, each of which generates image elements according to some generative assumptions. Grouping, in this framework, means estimating the number and the parameters of the mixture components that generated the image, including estimating which image elements are “owned” by which objects. We present a tractable implementation of the framework, based on the hierarchical clustering approach of Heller and Ghahramani (2005). We illustrate it with examples drawn from a number of classical perceptual grouping problems, including dot clustering, contour integration, and part decomposition. Our approach yields an intuitive hierarchical representation of image elements, giving an explicit decomposition of the image into mixture components, along with estimates of the probability of various candidate decompositions. We show that BHG accounts well for a diverse range of empirical data drawn from the literature. Because BHG provides a principled quantification of the plausibility of grouping interpretations over a wide range of grouping problems, we argue that it provides an appealing unifying account of the elusive Gestalt notion of Prägnanz. PMID:26322548

Implications of nonadventitious rhizome spread on reproduction, inbreeding, and conservation for a rare grassland legume.

PubMed

Severns, Paul M; Liston, Aaron; Wilson, Mark V

2011-01-01

Small population size, genetic diversity, and spatial patterns of vegetative spread are important aspects to consider when managing populations of rare clonal plant species. We used 5 variable nuclear simple sequence repeat nDNA loci to determine the extent of genet rhizome spread, examine the possibility of very small population sizes, and project how Bombus spp. (bumblebee) foraging may impact selfing (through geitonogamy) for a threatened lupine (Lupinus oreganus Heller) that sprawls through nonadventitious rhizomes. Genotyping identified 1 genet (27 × 13 m) that dominated about 30% of a study site, whereas 15 genets spread a maximum average distance of about 5.5 m (range 1.6 -27.1 m) and appeared to be well integrated with intervening genets. We found unexpectedly high genotype diversity, no evidence of a recent genetic bottleneck, and 5 of 6 patches had mean fixation index values that were near Hardy-Weinberg Equilibrium expectations. If the median maximum Bombus foraging distance observed in lupine patches (1.2 m) occurred within genotyped populations, a typical foraging flight would have >80% chance of occurring between different genets. Our study demonstrates that inferences associated with clonality, small population size, and inbreeding depression should be directly evaluated for rare vegetatively spreading plants.

Data analyses and perspectives on laparoscopic surgery for esophageal achalasia.

PubMed

Tsuboi, Kazuto; Omura, Nobuo; Yano, Fumiaki; Hoshino, Masato; Yamamoto, Se-Ryung; Akimoto, Shunsuke; Masuda, Takahiro; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2015-10-14

In general, the treatment methods for esophageal achalasia are largely classified into four groups, including drug therapy using nitrite or a calcium channel blocker, botulinum toxin injection, endoscopic therapy such as endoscopic balloon dilation, and surgery. Various studies have suggested that the most effective treatment of esophageal achalasia is surgical therapy. The basic concept of this surgical therapy has not changed since Heller proposed esophageal myotomy for the purpose of resolution of lower esophageal obstruction for the first time in 1913, but the most common approach has changed from open-chest surgery to laparoscopic surgery. Currently, the laparoscopic surgery has been the procedure of choice for the treatment of esophageal achalasia. During the process of the transition from open-chest surgery to laparotomy, to thoracoscopic surgery, and to laparoscopic surgery, the necessity of combining antireflux surgery has been recognized. There is some debate as to which type of antireflux surgery should be selected. The Toupet fundoplication may be the most effective in prevention of postoperative antireflux, but many medical institutions have selected the Dor fundoplication which covers the mucosal surface exposed by myotomy. Recently, a new endoscopic approach, peroral endoscopic myotomy (POEM), has received attention. Future studies should examine the long-term outcomes and whether POEM becomes the gold standard for the treatment of esophageal achalasia.

Management of primary achalasia: The role of endoscopy

PubMed Central

Luján-Sanchis, Marisol; Suárez-Callol, Patricia; Monzó-Gallego, Ana; Bort-Pérez, Inmaculada; Plana-Campos, Lydia; Ferrer-Barceló, Luis; Sanchis-Artero, Laura; Llinares-Lloret, María; Tuset-Ruiz, Juan Antonio; Sempere-Garcia-Argüelles, Javier; Canelles-Gamir, Pilar; Medina-Chuliá, Enrique

2015-01-01

Achalasia is an oesophageal motor disorder which leads to the functional obstruction of the lower oesophageal sphincter (LES) and is currently incurable. The main objective of all existing therapies is to achieve a reduction in the obstruction of the distal oesophagus in order to improve oesophageal transit, relieve the symptomatology, and prevent long-term complications. The most common treatments used are pneumatic dilation (PD) and laparoscopic Heller myotomy, which involves partial fundoplication with comparable short-term success rates. The most economic non-surgical therapy is PD, with botulinum toxin injections reserved for patients with a higher surgical risk for whom the former treatment option is unsuitable. A new technology is peroral endoscopic myotomy, postulated as a possible non-invasive alternative to surgical myotomy. Other endoluminal treatments subject to research more recently include injecting ethanolamine into the LES and using a temporary self-expanding metallic stent. At present, there is not enough evidence permitting a routine recommendation of any of these three novel methods. Patients must undergo follow-up after treatment to guarantee that their symptoms are under control and to prevent complications. Most experts are in favour of some form of endoscopic follow-up, however no established guidelines exist in this respect. The prognosis for patients with achalasia is good, although a recurrence after treatment using any method requires new treatment. PMID:26078828

Quantum Corral Wave-function Engineering

NASA Astrophysics Data System (ADS)

Correa, Alfredo; Reboredo, Fernando; Balseiro, Carlos

2005-03-01

We present a theoretical method for the design and optimization of quantum corrals[1] with specific electronic properties. Taking advantage that spins are subject to a RKKY interaction that is directly controlled by the scattering of the quantum corral, we design corral structures that reproduce spin Hamiltonians with coupling constants determined a priori[2]. We solve exactly the bi-dimensional scattering problem for each corral configuration within the s-wave approximation[3] and subsequently the geometry of the quantum corral is optimized by means of simulated annealing[4] and genetic algorithms[5]. We demonstrate the possibility of automatic design of structures with complicated target electronic properties[6]. This work was performed under the auspices of the US Department of Energy by the University of California at the LLNL under contract no W-7405-Eng-48. [1] M. F. Crommie, C. P. Lutz and D. M. Eigler, Nature 403, 512 (2000) [2] D. P. DiVincenzo et al., Nature 408, 339 (2000) [3] G. A. Fiete and E. J. Heller, Rev. Mod. Phys. 75, 933 (2003) [4] M. R. A. T. N. Metropolis et al., J. Chem. Phys. 1087 (1953) [5] E. Aarts and J. K. Lenstra, eds. Local search in combinatorial problems (Princeton University Press, 1997) [6] A. A. Correa, F. Reboredo and C. Balseiro, Phys. Rev. B (in press).

Data analyses and perspectives on laparoscopic surgery for esophageal achalasia

PubMed Central

Tsuboi, Kazuto; Omura, Nobuo; Yano, Fumiaki; Hoshino, Masato; Yamamoto, Se-Ryung; Akimoto, Shunsuke; Masuda, Takahiro; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2015-01-01

In general, the treatment methods for esophageal achalasia are largely classified into four groups, including drug therapy using nitrite or a calcium channel blocker, botulinum toxin injection, endoscopic therapy such as endoscopic balloon dilation, and surgery. Various studies have suggested that the most effective treatment of esophageal achalasia is surgical therapy. The basic concept of this surgical therapy has not changed since Heller proposed esophageal myotomy for the purpose of resolution of lower esophageal obstruction for the first time in 1913, but the most common approach has changed from open-chest surgery to laparoscopic surgery. Currently, the laparoscopic surgery has been the procedure of choice for the treatment of esophageal achalasia. During the process of the transition from open-chest surgery to laparotomy, to thoracoscopic surgery, and to laparoscopic surgery, the necessity of combining antireflux surgery has been recognized. There is some debate as to which type of antireflux surgery should be selected. The Toupet fundoplication may be the most effective in prevention of postoperative antireflux, but many medical institutions have selected the Dor fundoplication which covers the mucosal surface exposed by myotomy. Recently, a new endoscopic approach, peroral endoscopic myotomy (POEM), has received attention. Future studies should examine the long-term outcomes and whether POEM becomes the gold standard for the treatment of esophageal achalasia. PMID:26478674

Application of robotics in general surgery: initial experience.

PubMed

Nguyen, Ninh T; Hinojosa, Marcelo W; Finley, David; Stevens, Melinda; Paya, Mahbod

2004-10-01

Robotic surgery was recently approved for clinical use in general abdominal surgery. The aim of this study was to review our experience with the da Vinci surgical system during laparoscopic general surgical procedures. Eighteen patients underwent robotically assisted laparoscopic abdominal surgery between June 2002 and March 2003. Main outcome measures were operative time, room setup time, robotic arm-positioning and surgical time, blood loss, conversion to laparoscopy, length of stay, and morbidity. The types of robotically assisted laparoscopic procedures were excision of gastric leiomyoma (n = 1), Heller myotomy (n = 1), cholecystectomy (n = 2), gastric banding (n = 2), Nissen fundoplication (n = 4), and gastric bypass (n = 8). The mean room setup time was 63 +/- 14 minutes, and the mean robotic arm-positioning time was 16 +/- 7 minutes. Conversion to laparoscopy occurred in two (11%) of 18 cases because of equipment difficulty (n = 1) and technical difficulty (n = 1). Estimated blood loss was 91 +/- 71 mL. The mean operative time was 156 +/- 42 minutes, and the robotic operative time was 27% of the total operative time. The mean length of hospital stay was 2.2 +/- 1.5 days. There was one postoperative wound infection and one anastomotic stricture. Robotically assisted laparoscopic abdominal surgery is feasible and safe; however, the theoretical advantages of the da Vinci surgical system were not clinically apparent.

Outcomes of esophagectomy for esophageal achalasia in the United States.

PubMed

Molena, Daniela; Mungo, Benedetto; Stem, Miloslawa; Feinberg, Richard L; Lidor, Anne O

2014-02-01

While the outcomes after Heller myotomy have been extensively reported, little is known about patients with esophageal achalasia who are treated with esophagectomy. This was a retrospective analysis using the Nationwide Inpatient Sample over an 11-year period (2000-2010). Patients admitted with a primary diagnosis of achalasia who underwent esophagectomy (group 1) were compared to patients with esophageal cancer who underwent esophagectomy (group 2) during the same time period. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay, postoperative complications, and total hospital charges. A propensity-matched analysis was conducted comparing the same outcomes between group 1 and well-matched controls in group 2. Nine hundred sixty-three patients with achalasia and 18,003 patients with esophageal cancer underwent esophagectomy. The propensity matched analysis showed a trend toward a higher mortality in group 2 (7.8 vs. 2.9 %, p = 0.08). Postoperative length of stay and complications were similar in both groups. Total hospital charges were higher for the achalasia group ($115,087 vs. $99, 654.2, p = 0.006). This is the largest study to date examining outcomes after esophagectomy in patients with achalasia. Based on our findings, esophagectomy can be considered a safe option, and surgeons should not be hindered by a perceived notion of prohibitive operative risk in this patient population.

Diagnosis and Treatment Strategy of Achalasia Subtypes and Esophagogastric Junction Outflow Obstruction Based on High-Resolution Manometry.

PubMed

Ihara, Eikichi; Muta, Kazumasa; Fukaura, Keita; Nakamura, Kazuhiko

2017-01-01

Based on Chicago Classification version 3.0, the disorders of esophagogastric junction outflow obstruction (EGJOO) include achalasia (types I, II and III) and EGJOO. Although no curative treatments are currently available for the treatment of the disorders of EGJOO, medical treatments, endoscopic pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and per-oral endoscopic myotomy (POEM) are usually the sought-after modes of treatment. Since the etiology and pathogenesis might vary depending on the types of EGJOO disorders, treatment strategies should be considered based on those subtypes. Based on the accumulated evidences, the treatment strategies of our institution are as follows: effects of medical treatments on achalasia are limited. Either PD or LHM/POEM can be considered a first-line in achalasia type I, according to the patient's wish. PD and POEM can be considered first-line in achalasia types II and III, respectively. Conversely, In EGJOO, medical treatments including drugs like acotiamide and/or diltiazem can be tested as a first-line, and PD and POEM will be considered second and third-line treatments, respectively. Key Messages: The classification of subtypes based on high-resolution manometry will help us consider which treatment option can be selected as a first-line treatment depending upon the subtypes of disorders of EGJOO. Acotiamide has the potential to cure patients with EGJOO. © 2016 S. Karger AG, Basel.

Laparoscopic Transhiatal Treatment of Large Epiphrenic Esophageal Diverticulum

PubMed Central

Casella, Giovanni; Recchia, Carlo Luigi; Bianchi, Ermanno; Lomartire, Nazzareno

2008-01-01

Background: Epiphrenic diverticulum is an uncommon disorder of the distal third of the esophagus. We report the case of a 73-year-old woman with a large symptomatic esophageal epiphrenic diverticulum, diffuse nonspecific esophageal dysmotility, and a hiatal hernia. Methods: Surgery was indicated by the patient's symptoms, the size of the diverticulum (maximum diameter 10 cm), and the associated esophageal motor disorder. Preoperative study included barium swallow, upper gastrointestinal endoscopy, and esophageal manometry. A laparoscopic transhiatal diverticulectomy associated with a Heller myotomy, hiatoplasty, and a Dor's fundoplication was carried out. The overall operative time was 230 minutes. Results: No intraoperative complications occurred. Gastrografin swallow performed on postoperative day 4 did not show any signs of leakage from the staple line. The postoperative hospital stay was 5 days. The patient was readmitted 10 days after discharge complaining of fever and chest pain. A new Gastrografin swallow demonstrated a small leak from the staple line successfully treated with 3 weeks of total enteral nutrition. Conclusion: The laparoscopic approach to epiphrenic diverticulum is feasible. Postoperative Gastrografin swallow is not 100% sensitive in detecting small suture-line leaks if a preexisting esophageal motility disorder is present. In case of late postoperative fever and pleural effusion, a suture-line leak should be suspected. Conservative management of the small suture-line leak should be considered as an effective therapeutic option. PMID:18402751

Independent component processes underlying emotions during natural music listening.

PubMed

Rogenmoser, Lars; Zollinger, Nina; Elmer, Stefan; Jäncke, Lutz

2016-09-01

The aim of this study was to investigate the brain processes underlying emotions during natural music listening. To address this, we recorded high-density electroencephalography (EEG) from 22 subjects while presenting a set of individually matched whole musical excerpts varying in valence and arousal. Independent component analysis was applied to decompose the EEG data into functionally distinct brain processes. A k-means cluster analysis calculated on the basis of a combination of spatial (scalp topography and dipole location mapped onto the Montreal Neurological Institute brain template) and functional (spectra) characteristics revealed 10 clusters referring to brain areas typically involved in music and emotion processing, namely in the proximity of thalamic-limbic and orbitofrontal regions as well as at frontal, fronto-parietal, parietal, parieto-occipital, temporo-occipital and occipital areas. This analysis revealed that arousal was associated with a suppression of power in the alpha frequency range. On the other hand, valence was associated with an increase in theta frequency power in response to excerpts inducing happiness compared to sadness. These findings are partly compatible with the model proposed by Heller, arguing that the frontal lobe is involved in modulating valenced experiences (the left frontal hemisphere for positive emotions) whereas the right parieto-temporal region contributes to the emotional arousal. © The Author (2016). Published by Oxford University Press. For Permissions, please email: journals.permissions@oup.com.

Peroral endoscopic myotomy: procedural complications and pain management for the perioperative clinician

PubMed Central

Misra, Lopa; Fukami, Norio; Nikolic, Katarina; Trentman, Terrence L

2017-01-01

Achalasia refers to the lack of smooth muscle relaxation of the distal esophagus. Although nonsurgical treatments such as pneumatic dilatation of the distal esophagus and botulinum toxin injections have been performed, these procedures have limited duration. Similarly, surgical treatment with Heller myotomy is associated with complications. At our institution, we perform the peroral endoscopic myotomy (POEM) in qualified patients. Briefly, POEM involves endoscopic creation of a mid-esophageal submucosal bleb, creation of a submucosal tunnel with the endoscope, and then a distal myotomy, resulting in relaxation of the distal esophagus. The aim of our study is to document perioperative pain and associated pain management for our initial patients undergoing POEM and to review the literature for perioperative complications of this procedure. Therefore, anesthetic and pain management for our initial eleven patients undergoing POEM were reviewed. Patient demographics, pre-POEM pain medication history, perioperative pain medication requirements, and post-POEM pain scores were examined. We found post-POEM pain was usually in the mild–moderate range; a combination of medications was effective (opioids, nonsteroidal anti-inflammatory drugs, acetaminophen). Our literature search revealed a wide frequency range of complications such as pneumoperitoneum and subcutaneous emphysema, with rare serious events such as capnopericardium leading to cardiac arrest. In conclusion, our experience with POEM suggests pain and can be managed adequately with a combination of medications; the procedure appears to be safe and reasonable to perform in an outpatient endoscopy unit. PMID:28260955

Incidence, reasons, and risk factors for readmission after surgery for benign distal esophageal disease.

PubMed

Poupore, Amy K; Stem, Miloslawa; Molena, Daniela; Lidor, Anne O

2016-09-01

Our aim was to ascertain the incidence of, reasons for, and risk factors associated with hospital readmission after an operation for benign distal esophageal disease. Using the American College of Surgeons National Surgical Quality Improvement Program database (2012-2014), patients with a primary diagnosis of gastroesophageal reflux disease, paraesophageal hiatal hernia, or achalasia who underwent fundoplication, paraesophageal hernia repair, or Heller myotomy were identified. The primary outcome was hospital readmission. Multivariable logistic regression analysis was used to identify risk factors associated with hospital readmission. Of the 14,478 patients included in this study, 801 (5.5%) were readmitted at a median of 11 days (interquartile range 6-17) postprocedure. Intolerance of oral intake (21.8%), respiratory complications (11.6%), abdominal pain (6.0%), and venous thromboembolic events (4.7%) were some of the most common reasons for readmission. Open operative approach (odds ratio 1.34, 95% confidence interval 1.05-1.71), chronic steroid use (odds ratio 1.48, 95% confidence interval 1.10-2.00), emergency admission (odds ratio 1.50, 95% confidence interval 1.01-2.21), and predischarge complication (odds ratio 1.91, 95% confidence interval 1.42-2.59) were associated most strongly with hospital readmission. Implementing standardized perioperative strategies, such as nutritional counseling, early ambulation, intensive pulmonary toilet, and deep vein thrombosis prophylaxis, may help decrease the number of preventable readmissions and enhance the overall quality of care in this patient population. Copyright © 2016 Elsevier Inc. All rights reserved.

Laparoscopic cardiomyotomy in the treatment of esophageal achalasia.

PubMed

Radovanovic, N; Feussner, H; Stein, H; Siewert, J R

2000-01-01

Tu evaluate the usefulness of the laparoscopic approach as the standard procedure in the surgical treatment of achalasia. Among different competing options of the treatment of esophageal achalasia, extramucosal myotomy of the lower esophageal sphincter--usually combined with anterior fundoplasty--is the most effective but also the most invasive approach. Minimally invasive performance of this operation reduces invasivity and should make the operative treatment a more attractive alternative to other procedures, such as pneumatic dilatation or botox injection. From 1991 till 1997, 27 patients underwent laparoscopic Heller Dor operation (16 males, 11 females, mean age 37 years). Diagnosis was established in all of them by an esophagogram and esophageal manometry. The main symptom was dysphagia in all of the patients. No mortality was observed in this series. There were no conversions to laparotomy. The single intraoperative complication was one case of iatrogenic mucosal laceration. Post operative complications were found in one case of wound infection, and two cases of pneumomedistinum. After a mean follow-up of 33 months (3-77), all patients are without dysphagia and without pathological gastroesophageal reflux. The mean value of residual LES pressure could be reduced from 21 +/- 6.4 mmHg to 7.44 +/- 2.7 mmHg. Laparoscopic cardiomyotomy is at lesat as safe, in terms of morbidity and mortality, as open surgery and similarily effective in alleviating dysphagia. Short hospitalisation and convalascent periods have provided an attractive alternative to repeated dilations for many patients.

Robot-assisted general surgery.

PubMed

Hazey, Jeffrey W; Melvin, W Scott

2004-06-01

With the initiation of laparoscopic techniques in general surgery, we have seen a significant expansion of minimally invasive techniques in the last 16 years. More recently, robotic-assisted laparoscopy has moved into the general surgeon's armamentarium to address some of the shortcomings of laparoscopic surgery. AESOP (Computer Motion, Goleta, CA) addressed the issue of visualization as a robotic camera holder. With the introduction of the ZEUS robotic surgical system (Computer Motion), the ability to remotely operate laparoscopic instruments became a reality. US Food and Drug Administration approval in July 2000 of the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) further defined the ability of a robotic-assist device to address limitations in laparoscopy. This includes a significant improvement in instrument dexterity, dampening of natural hand tremors, three-dimensional visualization, ergonomics, and camera stability. As experience with robotic technology increased and its applications to advanced laparoscopic procedures have become more understood, more procedures have been performed with robotic assistance. Numerous studies have shown equivalent or improved patient outcomes when robotic-assist devices are used. Initially, robotic-assisted laparoscopic cholecystectomy was deemed safe, and now robotics has been shown to be safe in foregut procedures, including Nissen fundoplication, Heller myotomy, gastric banding procedures, and Roux-en-Y gastric bypass. These techniques have been extrapolated to solid-organ procedures (splenectomy, adrenalectomy, and pancreatic surgery) as well as robotic-assisted laparoscopic colectomy. In this chapter, we review the evolution of robotic technology and its applications in general surgical procedures.

Confirmatory factor analysis applied to the Force Concept Inventory

NASA Astrophysics Data System (ADS)

Eaton, Philip; Willoughby, Shannon D.

2018-06-01

In 1995, Huffman and Heller used exploratory factor analysis to draw into question the factors of the Force Concept Inventory (FCI). Since then several papers have been published examining the factors of the FCI on larger sets of student responses and understandable factors were extracted as a result. However, none of these proposed factor models have been verified to not be unique to their original sample through the use of independent sets of data. This paper seeks to confirm the factor models proposed by Scott et al. in 2012, and Hestenes et al. in 1992, as well as another expert model proposed within this study through the use of confirmatory factor analysis (CFA) and a sample of 20 822 postinstruction student responses to the FCI. Upon application of CFA using the full sample, all three models were found to fit the data with acceptable global fit statistics. However, when CFA was performed using these models on smaller sample sizes the models proposed by Scott et al. and Eaton and Willoughby were found to be far more stable than the model proposed by Hestenes et al. The goodness of fit of these models to the data suggests that the FCI can be scored on factors that are not unique to a single class. These scores could then be used to comment on how instruction methods effect the performance of students along a single factor and more in-depth analyses of curriculum changes may be possible as a result.

Treatment of esophageal achalasia in children: Today and tomorrow.

PubMed

Caldaro, Tamara; Familiari, Pietro; Romeo, Erminia Francesca; Gigante, Giovanni; Marchese, Michele; Contini, Anna Chiara Iolanda; Federici di Abriola, Giovanni; Cucchiara, Salvatore; De Angelis, Paola; Torroni, Filippo; Dall'Oglio, Luigi; Costamagna, Guido

2015-05-01

Esophageal achalasia (EA) is a rare esophageal motility disorder in children. Laparoscopic Heller myotomy (LHM) represents the treatment of choice in young patients. Peroral endoscopic myotomy (POEM) is becoming an alternative to LHM. The aim of this study is to evaluate the effectiveness, safety, and outcomes of POEM vs LHM in treatment of children with EA. Data of pediatric patients with EA, who underwent LHM and POEM from February 2009 to December 2013 in two centers, were collected. Eighteen patients (9 male, mean age: 11.6 years; range: 2-17 years) were included. Nine patients (6 male, mean age: 10.7 years; range: 2-16 years) underwent LHM, and the other 9 (3 males, mean age: 12.2 years; range: 6-17 years) underwent POEM procedure. Mean operation time was shorter in POEM group compared with LHM group (62/149 minutes). Myotomy was longer in POEM group than in LHM group (11/7 cm). One major complication occurred after LHM (esophageal perforation). No clinical and manometric differences were observed between LHM and POEM in follow-up. The incidence of iatrogenic gastroesophageal reflux disease was low (1 patient in both groups). Results of a midterm follow-up show that LHM and POEM are safe and effective treatments also in children. Besides, POEM is a mini-invasive technique with an inferior execution timing compared to LHM. A skilled endoscopic team is mandatory to perform this procedure. Copyright © 2015 Elsevier Inc. All rights reserved.

Short-term surgical outcomes of reduced port surgery for esophageal achalasia.

PubMed

Omura, Nobuo; Yano, Fumiaki; Tsuboi, Kazuto; Hoshino, Masato; Yamamoto, Se Ryung; Akimoto, Shunsuke; Ishibashi, Yoshio; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2015-09-01

To clarify the feasibility and utility of reduced port surgery (RPS) for achalasia. Between September 2005 and June 2013, 359 patients with esophageal achalasia, excluding cases of reoperation, underwent laparoscopic Heller myotomy and Dor fundoplication (LHD) according to our clinical pathway. Three-hundred and twenty-seven patients underwent LHD with five incisions (conventional approach), while the other 32 patients underwent RPS, including eight via SILS. The clinical data were collected in a prospective fashion and retrospectively reviewed. We selected 24 patients matched for gender, age and morphologic type with patients in the RPS group from among the 327 patients (C group). The surgical outcomes were compared between the C and RPS groups. There were no significant differences between the two groups in the duration of symptoms, dysphagia score, chest pain score, shape of the distal esophagus and esophageal clearance. The operative time was significantly longer in the RPS group than in the C group (p < 0.001). There were no significant differences between the two groups in the length of postoperative hospital stay or rates of bleeding, mucosal injury of the esophagus and/or stomach and postoperative complications. The symptom scores significantly improved after surgery in both groups (p < 0.001). Furthermore, there were no significant differences between the C group and RPS group in terms of the postoperative symptom scores or satisfaction scores after surgery. The surgical outcomes of RPS for achalasia are comparable to those obtained with the conventional method.

Thoracoplasty-Current View on Indication and Technique.

PubMed

Kuhtin, Oleg; Veith, Marina; Alghanem, Mohammed; Martel, Ivan; Giller, Dmitrii; Haas, Viktor; Lampl, Ludwig

2018-05-17

Thoracoplasty was invented for removing cavities between thoracic wall and remnant lung or mediastinum. It was initially used in cases of tuberculosis or unspecific infections, while currently it is used mainly for space problems after lobectomy/pneumonectomy.This article presents an overview of the historical and current techniques of this surgical procedure.Nowadays, thoracoplasty is rarely performed due to the low incidence of diseases for which this method is necessary. Therefore, this method has even been discredited. Furthermore, certain technical aspects of the thoracoplasty are not very well known because of the infrequent application of this procedure.Unfortunately, a look into the literature of thoracoplasty is not always usefull due to the biased views of advocates of different techniques such as Schede's thoracoplasty, Heller's Jalousie-Plastik, Alexander's extramusculoperiosteal thoracoplasty, Bjork's osteoplastic thoracoplasty, etc.Not to forget, there has always been a lack of research on the relevance and on the several techniques of thoracoplasty.The point is precise indication and correct execution of thoracoplasty as a final therapeutic option, which allows a safe and definitive solution of the space problem even in complex cases, without creating serious functional and cosmetic impairment for the patient.The main types of thoracoplasty are described in this article. Although the core principle of this operation remains unchanged, modern techniques are often cosmetically more considerable and less destructive, compared with techniques that were used in the past. Georg Thieme Verlag KG Stuttgart · New York.

Outcomes of operations for benign foregut disease in elderly patients: a National Surgical Quality Improvement Program database analysis.

PubMed

Molena, Daniela; Mungo, Benedetto; Stem, Miloslawa; Feinberg, Richard L; Lidor, Anne O

2014-08-01

The development of minimally invasive operative techniques and improvement in postoperative care has made surgery a viable option to a greater number of elderly patients. Our objective was to evaluate the outcomes of laparoscopic and open foregut operation in relation to the patient age. Patients who underwent gastric fundoplication, paraesophageal hernia repair, and Heller myotomy were identified via the National Surgical Quality Improvement Program (NSQIP) database (2005-2011). Patient characteristics and outcomes were compared between five age groups (group I: ≤65 years, II: 65-69 years; III: 70-74 years; IV: 75-79 years; and V: ≥80 years). Multivariable logistic regression analysis was used to predict the impact of age and operative approach on the studied outcomes. A total of 19,388 patients were identified. Advanced age was associated with increased rate of 30-day mortality, overall morbidity, serious morbidity, and extended length of stay, regardless of the operative approach. After we adjusted for other variables, advanced age was associated with increased odds of 30-day mortality compared with patients <65 years (III: odds ratio 2.70, 95% confidence interval 1.34-5.44, P = .01; IV: 2.80, 1.35-5.81, P = .01; V: 6.12, 3.41-10.99, P < .001). Surgery for benign foregut disease in elderly patients carries a burden of mortality and morbidity that needs to be acknowledged. Copyright © 2014 Mosby, Inc. All rights reserved.

Navigating the pathway to robotic competency in general thoracic surgery.

PubMed

Seder, Christopher W; Cassivi, Stephen D; Wigle, Dennis A

2013-01-01

Although robotic technology has addressed many of the limitations of traditional videoscopic surgery, robotic surgery has not gained widespread acceptance in the general thoracic community. We report our initial robotic surgery experience and propose a structured, competency-based pathway for the development of robotic skills. Between December 2008 and February 2012, a total of 79 robot-assisted pulmonary, mediastinal, benign esophageal, or diaphragmatic procedures were performed. Data on patient characteristics and perioperative outcomes were retrospectively collected and analyzed. During the study period, one surgeon and three residents participated in a triphasic, competency-based pathway designed to teach robotic skills. The pathway consisted of individual preclinical learning followed by mentored preclinical exercises and progressive clinical responsibility. The robot-assisted procedures performed included lung resection (n = 38), mediastinal mass resection (n = 19), hiatal or paraesophageal hernia repair (n = 12), and Heller myotomy (n = 7), among others (n = 3). There were no perioperative mortalities, with a 20% complication rate and a 3% readmission rate. Conversion to a thoracoscopic or open approach was required in eight pulmonary resections to facilitate dissection (six) or to control hemorrhage (two). Fewer major perioperative complications were observed in the later half of the experience. All residents who participated in the thoracic surgery robotic pathway perform robot-assisted procedures as part of their clinical practice. Robot-assisted thoracic surgery can be safely learned when skill acquisition is guided by a structured, competency-based pathway.

Geologic map and database of the Roseburg 30' x 60' quadrangle, Douglas and Coos counties, Oregon

USGS Publications Warehouse

Wells, Ray E.; Jayko, A.S.; Niem, A.R.; Black, G.; Wiley, T.; Baldwin, E.; Molenaar, K.M.; Wheeler, K.L.; DuRoss, C.B.; Givler, R.W.

2001-01-01

The Roseburg 30' x 60' Quadrangle covers the southeastern margin of the Oregon Coast Range and its tectonic boundary with Mesozoic terranes of the Klamath Mountains (see figures 1 and 2 in pamphlet, also shown on map sheet). The geologic framework of the Roseburg area was established by the pioneering work of Diller (1898), Wells and Peck, (1961) and Ewart Baldwin (1974) and his students (see figure 3 in pamphlet, also shown on map sheet). Baldwin and his students focussed on the history of the Eocene Tyee basin, where the sediments lap across the tectonic boundary with the Mesozoic terranes and record the accretion of the Coast Range basement to the continent. Others have examined the sedimentary fill of the Tyee basin in detail, recognizing the deep marine turbidite facies of the Tyee Formation (Snavely and others, 1964) and proposing several models for the Eocene evolution of the forearc basin (Heller and Ryberg, 1983; Chan and Dott, 1983; Heller and Dickinson, 1985; Molenaar, 1985; see Ryu and others, 1992 for a comprehensive summary). Along the eastern margin of the quadrangle, both the Tyee basin and the Klamath terranes are overlain by Eocene volcanic rocks of the Western Cascade arc (Walker and MacLeod, 1991). The thick Eocene sedimentary sequence of the Tyee basin has significant oil and gas potential (Armentrout and Suek, 1985; Gautier and others, 1993; Ryu and others, 1996). Although 13 deep test wells have been drilled in the Roseburg quadrangle (see figure 2 and table 1 in pamphlet, also shown on map sheet), exploration to date has been hampered by an incomplete understanding of the basin�s tectonic setting and evolution. In response, the Oregon Department of Geology and Mineral Industries (DOGAMI) initiated a five year assessment of the oil and gas potential of the Tyee basin. This map is a product of a cooperative effort by the U. S. Geological Survey, Oregon State University, and DOGAMI to systematically map the sedimentary facies and structure

Comparison of direct DNA strand breaks induced by low energy electrons with different inelastic cross sections

NASA Astrophysics Data System (ADS)

Li, Jun-Li; Li, Chun-Yan; Qiu, Rui; Yan, Cong-Chong; Xie, Wen-Zhang; Zeng, Zhi; Tung, Chuan-Jong

2013-09-01

In order to study the influence of inelastic cross sections on the simulation of direct DNA strand breaks induced by low energy electrons, six different sets of inelastic cross section data were calculated and loaded into the Geant4-DNA code to calculate the DNA strand break yields under the same conditions. The six sets of the inelastic cross sections were calculated by applying the dielectric function method of Emfietzoglou's optical-data treatments, with two different optical datasets and three different dispersion models, using the same Born corrections. Results show that the inelastic cross sections have a notable influence on the direct DNA strand break yields. The yields simulated with the inelastic cross sections based on Hayashi's optical data are greater than those based on Heller's optical data. The discrepancies are about 30-45% for the single strand break yields and 45-80% for the double strand break yields. Among the yields simulated with cross sections of the three different dispersion models, generally the greatest are those of the extended-Drude dispersion model, the second are those of the extended-oscillator-Drude dispersion model, and the last are those of the Ashley's δ-oscillator dispersion model. For the single strand break yields, the differences between the first two are very little and the differences between the last two are about 6-57%. For the double strand break yields, the biggest difference between the first two can be about 90% and the differences between the last two are about 17-70%.

Identification of Hepatozoon erhardovae Krampitz, 1964 from bank voles (Myodes glareolus) and fleas in Southern Hungary.

PubMed

Rigó, Krisztina; Majoros, Gábor; Szekeres, Sándor; Molnár, Imola; Jablonszky, Mónika; Majláthová, Viktória; Majláth, Igor; Földvári, Gábor

2016-06-01

In order to investigate the prevalence and life cycle of apicomplexan parasites, small mammals were live-trapped with modified Sherman traps in Southern Hungary between 2010 and 2012. Altogether, 528 rodents (Apodemus flavicollis Melchior, 1834, Apodemus agrarius Pallas, 1771, Myodes glareolus Schreber, 1780, Microtus agrestis Linnaeus, 1761, Mus musculus Linnaeus, 1758 and Micromys minutus Pallas, 1771) were collected and four shrews (Sorex spp.) were by-catched. Captured animals belonging to non-protected species were euthanized, and spleen samples were preserved for histological and molecular analyses. During the examination of spleen smears, Hepatozoon parasites were observed in eight out of 48 bank voles (M. glareolus). DNA was isolated from altogether 221 spleen samples, and 18S rDNA was amplified using two different PCR protocols. The eight bank vole samples were positive with PCR, but none of the other M. glareolus spleen samples or any of the tissue samples from other species were found to be infected. Sequenced amplicons were very similar to Hepatozoon spp. detected in M. glareolus in Spain and Poland. Ectoparasites were collected from the small mammal carcasses and from the vegetation. Hepatozoon DNA was not found in the 181 ticks removed from the small mammals or in the 162 ticks collected with flagging, but was detected in all three flea species (4/43 Megabothris turbidus Rothschild, 1909, 3/10 Ctenophthalmus assimilis Taschenberg, 1880 and 7/78 Ctenophthalmus agyrtes Heller, 1896). Based on gamont morphology, vertebrate and arthropod host species and DNA sequences, the parasites in our study can be identified as Hepatozoon erhardovae.

In vivo experience with peroral endoscopic myotomy: An essential activity for developing the technique in humans.

PubMed

Peñaloza-Ramírez, A; Suárez-Correa, J; Báez-Blanco, J; Sabogal-Gómez, C; Kuan-Casas, H; Sánchez-Pignalosa, C; Aponte-Ordóñez, P

Achalasia is the most widely studied esophageal motility disorder. No treatment has achieved completely satisfactory results. The laparoscopic Heller esophagomyotomy is currently the most accepted technique. With the advent of minimally invasive surgery, the appearance of peroral endoscopic myotomy (POEM) has promising results. The primary aim of our study was to perform peroral endoscopic esophagomyotomy in animal experimentation models to perfect the technique and later apply it to humans. The secondary aims were to evaluate the intraoperative and postoperative complications and to describe the anatomopathologic findings. An experimental study was conducted on 8 live porcine models that were followed for 30 days to identify postoperative complications. Necropsy was then performed to evaluate the histopathologic findings. The international requirements and regulations for animal experimentation were met. The technique was carried out in all the models. There was one intraoperative death. Pneumothorax was observed in 50% of the units in experimentation and subcutaneous cervical emphysema in 75%, with no significant clinical repercussions. Histologic muscle layer (myotomy) involvement was above the gastroesophageal junction in 87% of the cases and below it in 25%. Peroral endoscopic esophagomyotomy is a feasible, albeit complex, procedure that requires advanced training, and thus should be performed in highly specialized centers. Specific skills in advanced therapeutic endoscopic procedures of this type must continue to be developed through continuing education (ideally in in vivo models), to then be performed on humans. Copyright © 2017 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. All rights reserved.

Update on the endoscopic treatments for achalasia

PubMed Central

Uppal, Dushant S; Wang, Andrew Y

2016-01-01

Achalasia is the most common primary motility disorder of the esophagus and presents as dysphagia to solids and liquids. It is characterized by impaired deglutitive relaxation of the lower esophageal sphincter. High-resolution manometry allows for definitive diagnosis and classification of achalasia, with type II being the most responsive to therapy. Since no cure for achalasia exists, early diagnosis and treatment of the disease is critical to prevent end-stage disease. The central tenant of diagnosis is to first rule out mechanical obstruction due to stricture or malignancy, which is often accomplished by endoscopic and fluoroscopic examination. Therapeutic options include pneumatic dilation (PD), surgical myotomy, and endoscopic injection of botulinum toxin injection. Heller myotomy and PD are more efficacious than pharmacologic therapies and should be considered first-line treatment options. Per oral endoscopic myotomy (POEM) is a minimally-invasive endoscopic therapy that might be as effective as surgical myotomy when performed by a trained and experienced endoscopist, although long-term data are lacking. Overall, therapy should be individualized to each patient’s clinical situation and based upon his or her risk tolerance, operative candidacy, and life expectancy. In instances of therapeutic failure or symptom recurrence re-treatment is possible and can include PD or POEM of the wall opposite the site of prior myotomy. Patients undergoing therapy for achalasia require counseling, as the goal of therapy is to improve swallowing and prevent late manifestations of the disease rather than to restore normal swallowing, which is unfortunately impossible. PMID:27818585

Therapeutic Outcome of Achalasia Based on High-Resolution Manometry: A Korean Multicenter Study.

PubMed

Lee, Hyuk; Chung, Hyunsoo; Lee, Tae Hee; Hong, Kyoung Sup; Youn, Young Hoon; Park, Jung Ho; Park, Hyung Seok; Park, Hyojin

2017-09-11

Because achalasia subtype is associated with therapeutic response, it is possible that regional differences in subtype distribution could lead to differences in therapeutic outcomes. We aimed to evaluate and compare high-resolution manometry (HRM) profiles among the different subtypes of achalasia and to elucidate predictive factors associated with treatment outcomes. Patients who were diagnosed with achalasia using HRM at 4 Korean university hospitals were retrospectively identified and analyzed. Sixty-four patients with untreated achalasia were divided into 3 subtypes using the Chicago classification system. Clinical characteristics, manometric features, and treatment outcomes were compared. Among 64 patients diagnosed with achalasia, 31 patients were classified as type I, 27 as type II, and 6 as type III. Regarding HRM parameters, there were statistically significant differences in basal lower esophageal sphincter pressure, 4-second-integrated relaxation pressure, residual upper esophageal sphincter pressure, body amplitude, and maximal intrabolus pressure between subtypes. Regarding therapeutic outcome, type II patients (overall success rate of 80.0%) were more likely to respond than type I (55.2%) or type III (33.2%) patients. Multivariate analysis demonstrated that achalasia subtype (type I vs. III, P = 0.072; type II vs. III, P = 0.005), therapeutic modality (dilation vs. pharmacologic, P = 0.013; laparoscopic Heller's myotomy vs. pharmacologic, P = 0.006), and HRM-measured esophageal length (<27.5 vs. ≥27.5 cm, P = 0.014) are independent predictive factors for therapeutic failure. Patients with type II achalasia had better treatment outcomes than patients with other achalasia subtypes. Achalasia subtype, therapeutic modality, and esophageal length are independent predictive factors of therapeutic outcome.

Biofuel cells for biomedical applications: colonizing the animal kingdom.

PubMed

Falk, Magnus; Narváez Villarrubia, Claudia W; Babanova, Sofia; Atanassov, Plamen; Shleev, Sergey

2013-07-22

Interdisciplinary research has combined the efforts of many scientists and engineers to gain an understanding of biotic and abiotic electrochemical processes, materials properties, biomedical, and engineering approaches for the development of alternative power-generating and/or energy-harvesting devices, aiming to solve health-related issues and to improve the quality of human life. This review intends to recapitulate the principles of biofuel cell development and the progress over the years, thanks to the contribution of cross-disciplinary researchers that have combined knowledge and innovative ideas to the field. The emergence of biofuel cells, as a response to the demand of electrical power devices that can operate under physiological conditions, are reviewed. Implantable biofuel cells operating inside living organisms have been envisioned for over fifty years, but few reports of implanted devices have existed up until very recently. The very first report of an implanted biofuel cell (implanted in a grape) was published only in 2003 by Adam Heller and his coworkers. This work was a result of earlier scientific efforts of this group to "wire" enzymes to the electrode surface. The last couple of years have, however, seen a multitude of biofuel cells being implanted and operating in different living organisms, including mammals. Herein, the evolution of the biofuel concept, the understanding and employment of catalyst and biocatalyst processes to mimic biological processes, are explored. These potentially green technology biodevices are designed to be applied for biomedical applications to power nano- and microelectronic devices, drug delivery systems, biosensors, and many more. Copyright © 2013 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

A partnership in like-minded thinking-generating hopefulness in persons with cancer.

PubMed

Ayers, Tressie A Dutchyn

2007-03-01

A conceptual model of a partnership in 'like-minded thinking' consists of the following components: a relationship, a shared goal with mutual agreement to work toward that goal, and reciprocal encouragement between two people. A like-minded alliance is a relationship that offers support while at the same time encourages hope and establishes a reciprocating emotional attitude of hopefulness. The discussion focuses on the principles of such a model that is designed primarily as a lay intervention for anyone who has a close friend with cancer and who wants to assist the friend in maintaining a hopeful attitude in the face of illness. While this model is not directed at healthcare professionals it may be transferable into psychosocial interventions to assist persons toward sustaining hopefulness in the context of the cancer trajectory. Much has been written in the literature about how hopelessness spawns despair for individuals who have cancer and in those near the end of life; it may even create a desire for hastened death (Breitbart W., Heller K.S.: 2003, 'Reframing Hope: Meaning-Centered Care for Patients Near the End of Life'. Journal of Palliative Medicine 6, 979-988; Jones J.M., Huggins M.A., Rydall A.C., Rodin G.M.: 2003, 'Symptomatic distress, hopelessness, and the desire for hastened death in hospitalized cancer patients', Journal of Psychosomatic Research 55, 411-418). Therefore, the aim of this paper is to explore how like-minded thinking for a person with cancer and his or her support person provides a framework for a personal shared worldview that is hope-based, meaningful and coherent.

Oversight hearings on P. L. 93-577, ERDA Plan and Program. Hearings before the Subcommittee on Energy Research, Development and Demonstration of the Committee on Science and Technology, U. S. House of Representatives, Ninety-Fourth Congress, Second Session

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

1976-01-01

The purpose of the hearings was to examine the comprehensive plan and program for dealing with energy that ERDA submitted to Congress on June 30, 1975. Included as an appendix to these hearings is the October 1975 report of the Office of Technology Assessment (OTA) entitled, ''An Analysis of the ERDA Plan and Program'' (for abstract of this report, see EAPA 2:79). Testifying on Jan. 22 was the director of OTA, Emilio Q. Daddario, and chairmen of various task groups that assisted in the ERDA analysis, namely: Dr. John Gibbons, Conservation; Dr. Paul Craig, Overview Panel; Dr. Alvin Weinberg, Nuclear;more » Dr. Stanford S. Penner, Environmental and Health; and Dr. Jerry Grey, Solar; also present, and participating in the question and answer portion was Lionel Johns, head of the energy projects and programs in OTA. Testifying at the Jan. 23 hearings were experts presenting environmental, scientific, and engineering viewpoints, namely: Dr. Donald McDonald, director of the environmental studies program at Dartmouth College; Dr. Reginald Vachon, Auburn University, representing the American Society of Mechanical Engineers; and Dr. Thomas Lee, General Electric Co., representing the Inst. of Electrical and Electronics Engineers. The final hearings on Jan. 29 included the testimony of Dr. Robert W. Fri, Deputy Administrator, ERDA, and that of each of five assistant administrators: Dr. John Teem, Solar, Geothermal, and Advanced Energy Systems; Dr. Austin Heller, Conservation; Dr. Richard W. Roberts, Nuclear Energy; Dr. Roger W. A. LeGassie, Planning and Analysis; and Dr. James Liverman, Environment and Safety. (LMT)« less

Multidisciplinary Approach to Esophageal Achalasia: A Single Center Experience.

PubMed

Schlottmann, Francisco; Andolfi, Ciro; Kavitt, Robert T; Konda, Vani J A; Patti, Marco G

2017-04-01

The treatment of achalasia is palliative. Pneumatic dilatation (PD) or laparoscopic Heller myotomy (LHM) just eliminates the outflow obstruction allowing easier emptying of the esophagus. The aim of this study was to evaluate the results of a multidisciplinary approach to esophageal achalasia. A consecutive series of patients with achalasia treated by a multidisciplinary esophageal team consisting of radiologists, gastroenterologists, and surgeons in a quaternary care center between May 2008 and April 2015 were analyzed. A total of 147 patients with achalasia underwent LHM and partial fundoplication. Sixty-two patients (42%) had been treated preoperatively with PD and/or botulinum toxin (BT). The preoperative Eckardt score (ES) was 6.4 ± 2. At a median follow-up of 22 months, 128 patients (87%) did well and required no further treatment (ES 0.1). The remaining 19 patients (13%) had recurrence of symptoms and required further treatment: 12 were treated with PD and improved (ES 0.7); 4 were treated with PD and BT and improved (ES 1.3); 3 failed PD. These 3 patients had been treated with multiple sessions of PD and BT before the myotomy. Overall, 144 patients (98%) did well with laparoscopic (87%) or laparoscopic and endoscopic treatment (11%). The results of this study show that (a) LHM is an effective treatment modality, (b) PD improved symptoms in the majority of patients with recurrent dysphagia after myotomy and (c) multiple preoperative endoscopic treatments seem to affect outcomes of LHM. Patients with achalasia should be treated in a quaternary care center by a multidisciplinary team.

Lipid and protein accumulation in developing seeds of three lupine species: Lupinus luteus L., Lupinus albus L., and Lupinus mutabilis Sweet.

PubMed

Borek, Slawomir; Pukacka, Stanisława; Michalski, Krzysztof; Ratajczak, Lech

2009-01-01

A comparative study was carried out on the dynamics of lipid accumulation in developing seeds of three lupine species. Lupine seeds differ in lipid content; yellow lupine (Lupinus luteus L.) seeds contain about 6%, white lupine (Lupinus albus L.) 7-14%, and Andean lupine (Lupinus mutabilis Sweet) about 20% of lipids by dry mass. Cotyledons from developing seeds were isolated and cultured in vitro for 96 h on Heller medium with 60 mM sucrose (+S) or without sucrose (-S). Each medium was additionally enriched with 35 mM asparagine or 35 mM NaNO3. Asparagine caused an increase in protein accumulation and simultaneously decreased the lipid content, but nitrate increased accumulation of both protein and lipid. Experiments with [1-14C]acetate and [2-14C]acetate showed that the decrease in lipid accumulation in developing lupine seeds resulted from exhaustion of lipid precursors rather than from degradation or modification of the enzymatic apparatus. The carbon atom from the C-1 position of acetate was liberated mainly as CO2, whereas the carbon atom from the C-2 position was preferentially used in anabolic pathways. The dominant phospholipid in the investigated lupine seed storage organs was phosphatidylcholine. The main fatty acid in yellow lupine cotyledons was linoleic acid, in white lupine it was oleic acid, and in Andean lupine it was both linoleic and oleic acids. The relationship between stimulation of lipid and protein accumulation by nitrate in developing lupine cotyledons and enhanced carbon flux through glycolysis caused by the inorganic nitrogen form is discussed.

Generalization of the coherent-state path integrals and systematic derivation of semiclassical propagators

DOE Office of Scientific and Technical Information (OSTI.GOV)

Koda, Shin-ichi; Takatsuka, Kazuo

The coherent path integral is generalized such that the identity operator represented in a complete (actually overcomplete) set of the coherent states with the ''time-variable'' exponents are inserted between two consecutive short-time propagators. Since such a complete set of any given exponent can constitute the identity operator, the exponent may be varied from time to time without loss of generality as long as it is set common to all the Gaussians. However, a finite truncation of the coherent state expansion should result in different values of the propagator depending on the choice of the exponents. Furthermore, approximation methodology to treatmore » with the exact propagator can also depend on this choice, and thereby many different semiclassical propagators may emerge from these combinations. Indeed, we show that the well-known semiclassical propagators such as those of Van Vleck, Herman-Kluk, Heller's thawed Gaussian, and many others can be derived in a systematic manner, which enables one to comprehend these semiclassical propagators from a unified point of view. We are particularly interested in our generalized form of the Herman-Kluk propagator, since the relative accuracy of this propagator has been well established by Kay, and since, nevertheless, its derivation was not necessarily clear. Thus our generalized Herman-Kluk propagator replaces the classical Hamiltonian with a Gaussian averaged quantum Hamiltonian, generating non-Newtonian trajectories. We perform a numerical test to assess the quality of such a family of generalized Herman-Kluk propagators and find that the original Herman-Kluk gives an accurate result. The reason why this has come about is also discussed.« less

Achalasia: Outcome in children.

PubMed

Meyer, Anell; Catto-Smith, Anthony; Crameri, Joe; Simpson, Di; Alex, George; Hardikar, Winita; Cameron, Donald; Oliver, Mark

2017-02-01

Oesophageal achalasia is well-recognized but relatively rare in children, occasionally appearing as the "triple A" syndrome (with adrenal insufficiency and alacrima). Treatment modalities, as in adult practice, are not curative, often needing further interventions and spurring the search for better management. The outcome for syndromic variants is unknown. We sought to define the efficacy of treatments for children with achalasia with and without triple A syndrome. We conducted a retrospective analysis of presentation and outcomes for 42 children with achalasia presenting over three decades to a major pediatric referral center. Long term impact of the diagnosis was assessed by questionnaire. We identified 42 children including six with triple A syndrome. The median overall age at diagnosis was 10.8 years and median follow-up 1593 days. Initial Heller myotomy in 17 required further interventions in 11 (65%), while initial treatment with botulinum toxin (n = 20) was ultimately followed by myotomy in 17 (85%). Ten out of 35 patients who underwent myotomy required a repeat myotomy (29%). Patients with triple A syndrome developed symptoms earlier, but had delayed diagnosis, were more underweight at diagnosis and at last follow up. Questionnaire results suggested a significant long term deleterious impact on the quality of life of children and their families. Many children with achalasia relapse after initial treatment, undergoing multiple, different procedures, despite which symptoms persist and impact on quality of life. Symptoms develop earlier in patients with triple A syndrome, but the diagnosis is delayed and this has substantial nutritional impact. © 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Valuing innovative endoscopic techniques: per-oral endoscopic myotomy for the management of achalasia.

PubMed

Shah, Eric D; Chang, Andrew C; Law, Ryan

2018-04-20

Unclear reimbursement for new and innovative endoscopic procedures can limit adoption in clinical practice despite effectiveness in clinical trials. The aim of this study was to determine maximum cost-effective reimbursement for per-oral endoscopic myotomy (POEM) in treating achalasia. We constructed a decision analytic model assessing POEM versus laparoscopic Heller myotomy with Dor fundoplication (LHM) in managing achalasia from a payer perspective over a 1-year time horizon. Reimbursement data were derived from 2017 Medicare data. Responder rates were based on clinically meaningful improvement in validated Eckardt scores. Validated health utility values were assigned to terminal health states based on data previously derived with a standard gamble technique. Contemporary willingness-to-pay (WTP) levels per quality-adjusted life year (QALY) were used to estimate maximum reimbursement for POEM using threshold analysis. Effectiveness of POEM and LHM was similar at one year of follow-up (0.91 QALY). Maximum cost-effective reimbursement for POEM was $1,200.07 to $1,389.85 (33.4-38.7 total 2017 RVUs). This compares to contemporary total reimbursement of 10-15 total RVU for advanced endoscopic procedures. The model was most sensitive to the probability of GERD after procedure. The rate of conversion to open laparotomy due to perforation or bleeding was infrequent in published clinical practice experience, thus did not significantly affect reimbursement. POEM is an example of an innovative and potentially disruptive endoscopic technique offering greater cost-effective value and similar outcomes to the established surgical standard at contemporary reimbursement levels. Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.

Transmission of live laparoscopic surgery over the Internet2.

PubMed

Damore, L J; Johnson, J A; Dixon, R S; Iverson, M A; Ellison, E C; Melvin, W S

1999-11-01

Video broadcasting of surgical procedures is an important tool for education, training, and consultation. Current video conferencing systems are expensive and time-consuming and require preplanning. Real-time Internet video is known for its poor quality and relies on the equipment and the speed of the connection. The Internet2, a new high-speed (up to 2,048 Mbps), large bandwidth data network presently connects more than 100 universities and corporations. We have successfully used the Internet2 to broadcast the first real-time, high-quality audio/video program from a live laparoscopic operation to distant points. Video output of the laparoscopic camera and audio from a wireless microphone were broadcast to distant sites using a proprietary, PC-based implementation of H.320 video conferencing over a TCP/IP network connected to the Internet2. The receiving sites participated in two-way, real-time video and audio communications and graded the quality of the signal they received. On August 25, 1998, a laparoscopic Nissen fundoplication was transmitted to Internet2 stations in Colorado, Pennsylvania, and to an Internet station in New York. On September 28 and 29, 1998, we broadcast laparoscopic operations throughout both days to the Internet2 Fall Conference in San Francisco, California. Most recently, on February 24, 1999, we transmitted a laparoscopic Heller myotomy to the Abilene Network Launch Event in Washington, DC. The Internet2 is currently able to provide the bandwidth needed for a turn-key video conferencing system with high-resolution, real-time transmission. The system could be used for a variety of teaching and educational programs for experienced surgeons, residents, and medical students.

Prediction of new brain metastases after radiosurgery: validation and analysis of performance of a multi-institutional nomogram.

PubMed

Ayala-Peacock, Diandra N; Attia, Albert; Braunstein, Steve E; Ahluwalia, Manmeet S; Hepel, Jaroslaw; Chung, Caroline; Contessa, Joseph; McTyre, Emory; Peiffer, Ann M; Lucas, John T; Isom, Scott; Pajewski, Nicholas M; Kotecha, Rupesh; Stavas, Mark J; Page, Brandi R; Kleinberg, Lawrence; Shen, Colette; Taylor, Robert B; Onyeuku, Nasarachi E; Hyde, Andrew T; Gorovets, Daniel; Chao, Samuel T; Corso, Christopher; Ruiz, Jimmy; Watabe, Kounosuke; Tatter, Stephen B; Zadeh, Gelareh; Chiang, Veronica L S; Fiveash, John B; Chan, Michael D

2017-11-01

Stereotactic radiosurgery (SRS) without whole brain radiotherapy (WBRT) for brain metastases can avoid WBRT toxicities, but with risk of subsequent distant brain failure (DBF). Sole use of number of metastases to triage patients may be an unrefined method. Data on 1354 patients treated with SRS monotherapy from 2000 to 2013 for new brain metastases was collected across eight academic centers. The cohort was divided into training and validation datasets and a prognostic model was developed for time to DBF. We then evaluated the discrimination and calibration of the model within the validation dataset, and confirmed its performance with an independent contemporary cohort. Number of metastases (≥8, HR 3.53 p = 0.0001), minimum margin dose (HR 1.07 p = 0.0033), and melanoma histology (HR 1.45, p = 0.0187) were associated with DBF. A prognostic index derived from the training dataset exhibited ability to discriminate patients' DBF risk within the validation dataset (c-index = 0.631) and Heller's explained relative risk (HERR) = 0.173 (SE = 0.048). Absolute number of metastases was evaluated for its ability to predict DBF in the derivation and validation datasets, and was inferior to the nomogram. A nomogram high-risk threshold yielding a 2.1-fold increased need for early WBRT was identified. Nomogram values also correlated to number of brain metastases at time of failure (r = 0.38, p < 0.0001). We present a multi-institutionally validated prognostic model and nomogram to predict risk of DBF and guide risk-stratification of patients who are appropriate candidates for radiosurgery versus upfront WBRT.

New records of Caligidae (Copepoda, Siphonostomatoida) from the Philippines.

PubMed

Maran, Balu Alagar Venmathi; Cruz-Lacierda, Erlinda R; Ohtsuka, Susumu; Nagasawa, Kazuya

2016-10-11

Parasitic copepods, especially sea lice (Caligidae) are causing economic problems in both aquaculture and to wild fishes around the world, but their study in at least some of the southeastern Asian countries, is still scanty. Here we provide new information on the distribution of 11 known species of parasitic copepods collected from 11 marine fish hosts from Iloilo, central part of the Philippines. Two species of the genus Anuretes Heller, 1865 and nine species of the genus Caligus Müller, 1785 were found to infest these hosts, i.e. Anuretes branchialis Rangnekar, 1953 from Platax orbicularis (Forsskål, 1775); A. plectorhynchi Yamaguti, 1936 from P. orbicularis and Plectorhinchus pictus (Tortonese, 1936); Caligus absens Ho, Lin et Chen, 2000 from Priacanthus macracanthus Cuvier in Cuvier & Valenciennes, 1829; C. asymmetricus Kabata, 1965 and C. coryphaenae (Steenstrup & Lütken, 1861) from Auxis thazard (Lacepède, 1800); C. bonito Wilson, 1905 from Coryphaena hippurus Linnaeus, 1758; C. cordyla Pillai, 1963 from Megalaspis cordyla (Linnaeus, 1758); C. cornutus Heegaard, 1962 from Sphyraena jello Cuvier in Cuvier & Valenciennes, 1829; C. epinepheli Yamaguti, 1936 from Scomberoides commersonnianus Lacepède, 1801; C. kanagurta Pillai, 1961 from Decapterus kurroides Bleeker, 1855, D. macarellus (Cuvier in Cuvier & Valenciennes, 1833) and C. hippurus; and C. rotundigenitalis Yü, 1933 from Scatophagus argus (Linnaeus, 1766). Attachment sites included the gill filaments and the body surface. Prevalence and mean intensity of caligids are provided in addition to an update on the checklist of caligids of the Philippines. Although reports on caligids in the Philippines are few, the published records indicate that sea lice are widely distributed throughout the archipelago.

Lipid and protein accumulation in developing seeds of three lupine species: Lupinus luteus L., Lupinus albus L., and Lupinus mutabilis Sweet

PubMed Central

Borek, Sławomir; Pukacka, Stanisława; Michalski, Krzysztof; Ratajczak, Lech

2009-01-01

A comparative study was carried out on the dynamics of lipid accumulation in developing seeds of three lupine species. Lupine seeds differ in lipid content; yellow lupine (Lupinus luteus L.) seeds contain about 6%, white lupine (Lupinus albus L.) 7–14%, and Andean lupine (Lupinus mutabilis Sweet) about 20% of lipids by dry mass. Cotyledons from developing seeds were isolated and cultured in vitro for 96 h on Heller medium with 60 mM sucrose (+S) or without sucrose (–S). Each medium was additionally enriched with 35 mM asparagine or 35 mM NaNO3. Asparagine caused an increase in protein accumulation and simultaneously decreased the lipid content, but nitrate increased accumulation of both protein and lipid. Experiments with [1-14C]acetate and [2-14C]acetate showed that the decrease in lipid accumulation in developing lupine seeds resulted from exhaustion of lipid precursors rather than from degradation or modification of the enzymatic apparatus. The carbon atom from the C-1 position of acetate was liberated mainly as CO2, whereas the carbon atom from the C-2 position was preferentially used in anabolic pathways. The dominant phospholipid in the investigated lupine seed storage organs was phosphatidylcholine. The main fatty acid in yellow lupine cotyledons was linoleic acid, in white lupine it was oleic acid, and in Andean lupine it was both linoleic and oleic acids. The relationship between stimulation of lipid and protein accumulation by nitrate in developing lupine cotyledons and enhanced carbon flux through glycolysis caused by the inorganic nitrogen form is discussed. PMID:19635747

Fleas (Siphonaptera) in the Nests of Dormice (Gliridae: Rodentia) in Lithuania.

PubMed

Lipatova, I; Stanko, M; Paulauskas, A; Spakovaite, S; Gedminas, V

2015-05-01

Negative effects of flea (Siphonaptera) parasitism on the host may be expressed in different ways. The aim of this study was to assess distribution of the flea fauna in nests of dormice in Lithuania. Nests of Glis glis (L.), Dryomys nitedula (Pallas), and Muscardinus avellanarius (L.) were collected from nest boxes in 2012 and 2013. Fleas were collected from nests in the laboratory and put into plastic tubes with 70% ethanol. Flea species were identified using morphological keys. From 400 nest boxes, 112 nests of dormice were collected from eight sites from mixed forests of central Lithuania. Twenty-three nests of G. glis were collected from nest boxes, with 16 of them containing 286 fleas belonging to four species: Ceratophyllus sciurorum (Schrank) (259), C. gallinae (Schrank) (23), Hystrichopsylla talpae (Curtis) (3), and Megabothris turbidus (Rothschild) (1). Fourteen nests of M. avellanarius were collected from nest boxes, 4 of which contained 224 fleas belonging to two species: C. sciurorum (221) and C. gallinae (3). Twenty-four nests of D. nitedula were collected from nest boxes, including 17 containing 207 fleas belonging to two species: C. sciurorum (205) and C. gallinae (2). Fifty-one nests of undetermined dormice species also were collected from nest boxes, 12 of them contained 395 fleas belonging to three species: C. sciurorum (374), Ctenophthalmus agyrtes (Heller) (19), and Ctenophthalmus assimilis (Taschenberg) (2). C. sciurorum was a predominant species in the nests of dormice. The occurrence of C. gallinae was documented in Lithuania for the first time. © The Authors 2015. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Instituto Nacional de Enfermedades Neoplásicas: past and present.

PubMed

Pinillos, L

1990-01-01

The Instituto Nacional de Enfermedades Neoplásicas was established by the government of Peru as an institution for the treatment of cancer patients in 1939; it has existed under different names until the current title was adopted in 1952. Between 1980 and 1987, attendance increased by 70% and a new and larger facility came into use at the beginning of 1988. This institution has national responsibility for cancer prevention, detection, treatment, education, and research and is currently organizing satellite treatment centers in other parts of the country. More than 80% of the medical staff has been trained in the institute's residency program, the majority of whom received additional postgraduate training in the United States and Europe; 90% of the medical staff hold academic appointments in medical schools. In 1952 the Institute became the first hospital in Peru with a formal postgraduate training system for various medical disciplines, including surgical oncology and medical oncology. So far we have trained about 500 surgical oncologists who are working in all parts of Peru. The Maes-Heller Institute for Cancer Research forms part of the National Cancer Institute complex. Research will be directed mainly toward new diagnostic and therapeutic approaches, multidisciplinary tumor therapy, and large-scale cancer screening. The Institute focuses on early detection and prevention of cancer and is active in breast self-examination education and antismoking campaigns. It enjoys community support evidenced in the women's organization, Adainen, involved in fundraising; 460 women volunteers give at least 4 hr service per week to the Institute. The Institute has grown from 9,000 patients seen per year in its early days to 215,000 attendances in 1986.

An audit of combined multichannel intraluminal impedance manometry in the assessment of dysphagia.

PubMed

Burgess, Nicholas G; Wyeth, John W

2011-04-01

Multichannel Intraluminal Impedance (MII) Monitoring is a method of examining oesophageal bolus transit without the need for radiation. In combination with oesophageal manometry it allows correlation of bolus transit with peristaltic activity. The clinical application of impedance manometry is still being refined. This audit looked to examine whether impedance manometry had advantages over standard manometry in assessment of patients with dysphagia. 41 patients with the presenting symptom of dysphagia were assessed by combined MII and oesophageal manometry at a Wellington Hospital between February 2008 and December 2009. Each underwent manometry and MII using standardised techniques. Achalasia was diagnosed in 23 patients (56.1%), Ineffective oesophageal motility (IEM) in 5 patients (12.2%), Diffuse oesophageal Spasm (DES) in 7 patients (17.1%), and Nutcracker oesophagus in 2 patients (4.9%). 4 patients had normal manometry studies (9.8%). All patients with achalasia, IEM, and DES had abnormal bolus transit. All patients with normal manometry had abnormal bolus transit. Both patients with nutcracker oesophagus had normal bolus transit. 4 patients with achalasia had undergone previous Hellers myotomy. Two of these patients (50.0%) now had normal LES relaxation pressures, but all four still had abnormal oesophageal peristalsis and abnormal bolus transit. Multichannel Intraluminal Impedance manometry has advantages over standard manometry in characterising the physiological abnormalities associated with dysphagia. Patients in this study had severe defects including achalasia where bolus transit was invariably poor meaning little further information was gained. Extension of this study to include a wider group of patients with dysphagia may yield different results. © 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.

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

PubMed

Kumagai, Koshi; Kjellin, Ann; Tsai, Jon A; Thorell, Anders; Granqvist, Staffan; Lundell, Lars; Håkanson, Bengt

2014-01-01

The 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. Patients 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. Forty-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. A 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. ClinicalTrials.gov Identifier: NCT01933373. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

The Spectrum of Surgical Remediation of Transoral Incisionless Fundoplication-Related Failures.

PubMed

Puri, Ruchir; Smith, C Daniel; Bowers, Steven P

2018-05-16

To evaluate outcomes of surgical remediation for symptomatic or anatomic failure after a transoral incisionless fundoplication (TIF). This retrospective study was performed on 11 patients who underwent a remedial operation following TIF failure between June 2011 and September 2016 at the Mayo Clinic in Florida for persistent foregut symptoms. Upper gastrointestinal workup characterized 1 patient as having normal post-TIF anatomy and 10 as having anatomic failure. Ambulatory pH testing was performed in 7 patients and was abnormal in all. All patients underwent a laparoscopic takedown of the prior endoscopic fundoplication and removal of all accessible polypropylene T-fasteners. All patients had esophageal salvage and have not required a reoperation. Anatomical findings included hiatal hernia (7), esophageal diverticulum (2), hiatal mesh erosion of esophagus (1), long-segment esophageal stricture (1), and normal anatomy (1). Remedial operations included laparoscopic explant of fasteners in all patients with conversion to fundoplication (7), resection/imbrication of esophageal diverticulum (2), Heller myotomy (1), and mesh explant and complex esophageal repair (1). Mean operative time was 177 minutes and median length of stay 3 days (range 2-13 days). At mean follow-up of 10.7 months (range 1-42 months), 7 patients had persistent complaints. Esophagogastroduodenoscopy was repeated in these 7 patients and was normal (n = 3), mild stenosis requiring dilation (n = 2), Los Angeles grade B esophagitis (n = 1), and Barrett's esophagus (n = 1). Anatomic distortion of the distal esophagus after TIF can be significant, making subsequent operations complex. After remedial surgery, few patients will continue to have troublesome symptoms such as dysphagia.

A multicenter international registry of redo per-oral endoscopic myotomy (POEM) after failed POEM.

PubMed

Tyberg, Amy; Seewald, Stefan; Sharaiha, Reem Z; Martinez, Guadalupe; Desai, Amit P; Kumta, Nikhil A; Lambroza, Arnon; Sethi, Amrita; Reavis, Kevin M; DeRoche, Ketisha; Gaidhane, Monica; Talbot, Michael; Saxena, Payal; Zamarripa, Felipe; Barret, Maximilien; Eleftheriadis, Nicholas; Balassone, Valerio; Inoue, Haruhiro; Kahaleh, Michel

2017-06-01

Per-oral endoscopic myotomy (POEM) has become an accepted treatment for patients with achalasia. Despite its excellent efficacy rate of greater than 80%, a small percentage of patients remain symptomatic after the procedure. Limited data exist as to the best management for recurrence of symptoms after POEM. We present the first international, multicenter experience on the efficacy and safety of a repeat POEM in the management of achalasia. Patients who underwent a redo POEM from 15 centers in 9 countries were included in a dedicated registry. Technical success was defined as successful completion of a second myotomy. Clinical success was defined as an Eckardt score of less than or equal to 3 after the second myotomy. Adverse events including anesthesia-related, operative, and postoperative adverse events were recorded. Forty-six patients were included in the study. The average age was 49.3 ± 16.78 years. Twenty (45%) patients were male. The mean pre-redo-POEM Eckardt score was 4.3 ± 2.48. Technical success was achieved in 46 (100%) patients. Clinical success was achieved in 41 patients (85%). The average post-POEM Eckardt score was 1.64 ± 1.67, with a significant difference of 2.58 (P < .00001). Eight patients (17%) had adverse events consisting of procedural bleeding, all managed endoscopically. There were no deaths. No POEMs were aborted or required surgical conversion or assistance. For patients with persistent symptoms after POEM, repeat POEM appears to be an efficacious and safe technique. Further randomized trials comparing redo POEM versus Heller should be considered. (Clinical trial registration number: NCT02162589.). Copyright © 2017 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.

Per-oral Endoscopic Myotomy (POEM) After the Learning Curve: Durable Long-term Results With a Low Complication Rate.

PubMed

Hungness, Eric S; Sternbach, Joel M; Teitelbaum, Ezra N; Kahrilas, Peter J; Pandolfino, John E; Soper, Nathaniel J

2016-09-01

We aimed to report long-term outcomes for patients undergoing per-oral endoscopic myotomy (POEM) after our initial 15-case learning curve. POEM has become an established, natural-orifice surgical approach for treating esophageal motility disorders. To date, published outcomes and comparative-effectiveness studies have included patients from the early POEM experience. Consecutive patients undergoing POEM after our initial 15 cases, with a minimum of 1-year postoperative follow-up, were included. Treatment success was defined as an Eckardt score ≤3 without reintervention. Gastroesophageal reflux was defined by abnormal pH-testing or reflux esophagitis >Los Angeles grade A. Between January 2012 and March 2015, 115 patients underwent POEM at a single, high-volume center. Operative time was 101 ± 29 minutes, with 95% (109/115) of patients discharged on postoperative day 1. Clavien-Dindo grade III complications occurred in 2.7%, one of which required diagnostic laparoscopy to rule out Veress needle injury to the gall bladder. The rate of grade I complications was 15.2%. At an average of 2.4 years post-POEM (range 12-52 months), the overall success rate was 92%. Objective evidence of reflux was present in 40% for all patients and 33% for patients with a body mass index <35 kg/m and no hiatal hernia. POEM performed by experienced surgeons provided durable symptomatic relief in 94% of patients with nonspastic achalasia and 90% of patients with type 3 achalasia/spastic esophageal motility disorders, with a low rate of complications. The rate of gastroesophageal reflux was comparable with prior studies of both POEM and laparoscopic Heller myotomy.

Impacts of lithological discontinuities on the vertical distribution of dissolved trace elements in stratified soils

NASA Astrophysics Data System (ADS)

Reiss, Martin; Chifflard, Peter

2016-04-01

research at the point and hillslope scale in a small forested catchment (0.24 square kilometer) in Central-Germany called "Krofdorfer Forst". The study area is totally covered by beech forest and characterized as a typically sloped terrain of the mid-latitudes with periglacial cover beds. The catchment is devoid of any riparian zone and is characterized by steep hillslopes that issue directly into the receiving creek. At the point scale the impacts of LDs on the depth distribution of metals (Cr, Mn, Fe, Ni, Cu, Zn, Ar, Se, Cd, Pb) and alkaline earths (Na, Mg, K, Ca) were investigated. Soil water samples were captured at several soil profiles along a hillslope (upper, middle, foot slope) by soil solution access tubes which are installed in different depths depending on the LDs ranging from 10 cm to 110 cm. Soil water samples were taken since October 2012 in an irregular interval. In a complementary effort the temporal variability of the same geochemical parameters mentioned above were investigated in a high temporal resolution in the catchment runoff by using an automatic water sampler. All water samples were filtered and analyzed by using an ICP-MS. First results show that especially manganese is a very suitable element to identify chemical depth functions in soil pore water at the point scale. For this element the LDs act as geochemical barrier. Further elements have to be considered under different aspects since their depth distribution depends not on the lithological discontinuities. At the catchment scale the temporal variability of manganese concentration during different rainfall-runoff events can be used to detect sources of subsurface stormflow. References Reiss, M. & Chifflard, P. (2014): Short Report: Identifying sources of subsurface flow - A theoretical framework assessing the hydrological implications of lithological discontinuities. In: Open Journal of Modern Hydrology 4(3):91-94 Moldenhauer, K.-M., Heller, K., Chifflard, P., Hübner, R. & Kleber, A. (2013

The natural history of achalasia: Evidence of a continuum-"The evolutive pattern theory".

PubMed

Salvador, Renato; Voltarel, Guerrino; Savarino, Edoardo; Capovilla, Giovanni; Pesenti, Elisa; Perazzolo, Anna; Nicoletti, Loredana; Costantini, Andrea; Merigliano, Stefano; Costantini, Mario

2018-04-01

It is currently unclear if the three manometric patterns of esophageal achalasia represent distinct entities or part of a disease continuum. The study's aims were: a) to test the hypothesis that the three patterns represent different stages in the evolution of achalasia; b) to investigate whether manometric patterns change after Laparoscopic-Heller-Dor (LHD). We assessed the patients diagnosed with achalasia who underwent LHD as their first treatment from 1992 to 2016. Their symptoms were scored using a detailed questionnaire for dysphagia, food-regurgitation, and chest pain. Barium-swallow, endoscopy, and esophageal-manometry were performed before and 6 months after surgery. The study population consisted of 511 patients (M:F=283:228). Patients' demographic and clinical data showed that those with pattern III had a shorter history of symptoms, a higher incidence of chest pain, and a less dilated gullet (p<0.001). All patients with a sigmoid-shaped mega-esophagus had pattern I achalasia. One patient with a diagnosis of pattern III achalasia developed pattern II at a follow-up manometry before surgery. At a median follow-up of 30 months (IQR 12-56), the outcome of surgery was positive in 479 patients (91.7%). All patients with pattern I preoperatively had the same pattern after LHD, whereas more than 50% of patients with pattern III before treatment showed pattern I or II after surgery. This study supports the hypothesis/theory that the different manometric patterns represent different stages in the evolution of the disease-where pattern III is the earliest stage, pattern II an intermediate stage, and pattern I the final stage. Copyright © 2017 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection

PubMed Central

Eleftheriadis, Nikolas; Inoue, Haruhiro; Ikeda, Haruo; Onimaru, Manabu; Maselli, Roberta; Santi, Grace

2016-01-01

Peroral endoscopic myotomy (POEM) is an innovative, minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy (LHM), not only for all types of esophageal achalasia [classical (I), vigorous (II), spastic (III), Chicago Classification], but also for advanced sigmoid type achalasia (S1 and S2), failed LHM, or other esophageal motility disorders (diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction (EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection (POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors (submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives. PMID

[Laparoscopic approach in large hiatal hernia--particular considerations].

PubMed

Munteanu, R; Copăescu, C; Iosifescu, R; Timişescu, Lucia; Dragomirescu, C

2003-01-01

Large hiatal hernia are associated with permanent or intermittent protrusion of more than 1/3 of the stomach into the chest, single or in associated with other organs, a hiatal defect greater than 5 cm and various complications related to the morphological and physiological modifications. While the laparoscopic approach in small hiatal hernia and gastro-esophageal reflux disease is a standard procedure in large hiatal hernia persists a number of questions and controversies. Between 1995 and 2002 a number of 23 patients with large hiatal hernia (9 men, 14 women), mean age 65.8 years (range 49 to 77) underwent laparoscopic surgery. The majority of the patients had complications of the disease (dysphagia, severe esophagitis, anemia, respiratory and cardiac failure). In 16 cases was a sliding hernia (one recurrent after open procedure), in 2 paraesophageal and in 5 a mixed hernia (two "upside-down" type). In 7 cases we perform, in the same operation, cholecystectomy for gallbladder stones and in one cases Heller myotomy for achalasia. In all cases the repairs was performed by using interrupted stitches to approximate the crurae, but in three of them (recurrent and upside down hernia) we consider necessary to repair with a polypropylene mesh (10 x 5 cm) with a "keyhole" for the esophagus. In these particular cases we do not perform a antireflux procedure, in others 20 cases a short floppy Nissen was done. During the operation one patient developed a left pneumothorax and required pleural drainage. Postoperatively one patient had dysphagia treated by pneumatic dilatation and another die 3 weeks after the surgery because severe respiratory and cardiac failure. Laparoscopic approach is a feasible and effective procedure with good postoperatively results, but required good skills in mininvasive technique.

Transoral endoscopic esophageal myotomy based on esophageal function testing in a survival porcine model.

PubMed

Perretta, Silvana; Dallemagne, Bernard; Donatelli, Gianfranco; Diemunsch, Pierre; Marescaux, Jacques

2011-01-01

The most effective treatment of achalasia is Heller myotomy. To explore a submucosal endoscopic myotomy technique tailored on esophageal physiology testing and to compare it with the open technique. Prospective acute and survival comparative study in pigs (n = 12; 35 kg). University animal research center. Eight acute-4 open and 4 endoscopic-myotomies followed by 4 survival endoscopic procedures. Preoperative and postoperative manometry; esophagogastric junction (EGJ) distensibility before and after selective division of muscular fibers at the EGJ and after the myotomy was prolonged to a standard length by using the EndoFLIP Functional Lumen Imaging Probe (Crospon, Galway, Ireland). All procedures were successful, with no intraoperative and postoperative complications. In the survival group, the animals recovered promptly from surgery. Postoperative manometry demonstrated a 50% drop in mean lower esophageal sphincter pressure (LESp) in the endoscopic group (mean preoperative LESp, 22.2 ± 3.3 mm Hg; mean postoperative LESp, 11.34 ± 2.7 mm Hg; P < .005) and a 69% loss in the open procedure group (mean preoperative LESp, 24.2 ± 3.2 mm Hg; mean postoperative LESp, 7.4 ± 4 mm Hg; P < .005). The EndoFLIP monitoring did not show any distensibility difference between the 2 techniques, with the main improvement occurring when the clasp circular fibers were taken. Healthy animal model; small sample. Endoscopic submucosal esophageal myotomy is feasible and safe. The lack of a significant difference in EGJ distensibility between the open and endoscopic procedure is very appealing. Were it to be perfected in a human population, this endoscopic approach could suggest a new strategy in the treatment of selected achalasia patients. Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.

Conceptual physics differences by pedagogy and gender: Questioning the deficit model

NASA Astrophysics Data System (ADS)

Majors, Twanelle Deann Walker

The differences in physics performance between males and females have been studied extensively (Blue & Heller, 2003; Coletta, 2015; Madsen, McKagan, & Sayre 2013; McCullough, 2002, 2004, 2011; Pollock, Finkelstein, & Kost, 2007; Zohar & Sela, 2003). The purpose of this study was to look at the ways teaching methods and assessment choices have fabricated a gender gap. Deficit ways of thinking have further marginalized women by renegotiating prior acts of power that initiated and perpetuated marginalization. Outside of the deficit model, the blame for the underperformance of females has been attributed to discourses of power as well as less-than-critical ways of evaluating learning and schooling. Students in introductory algebra-based physics courses from 2008-2014 at Tennessee Technological University were self-enrolled in PHYS2010 sections that were taught using either a traditional or constructivist, interactive-engagement Learner-centered Environment for Algebra-based Physics (LEAP) pedagogy. Propensity scoring on all feasible and relevant independent variables was used to adjust for the probability of students choosing either LEAP or traditional sections. The Force Concept Inventory (FCI) and Gender Force Concept Inventory (GFCI) were used as the measures to gauge students' performance on physics concepts. The results showed that there were no differences in the FCI or GFCI performance of males and females. Results also showed that when accounting for pretest performance and the likelihood of choosing a LEAP section, LEAP pedagogy accounted for roughly 30% of performance differences. Not only was this true on the average, it was true for both genders. This meant that the main effect of LEAP pedagogy was even stronger and more generalizable. Gender did not moderate pedagogy, indicating that a pedagogy gap focus was more appropriate for evaluating physics learners.

Predictors of short term treatment outcome in patients with achalasia following endoscopic or surgical therapy.

PubMed

Gheorghe, Cristian; Bancila, Ion; Tutuian, Radu; Iacob, Razvan; Tomulescu, Victor

2012-01-01

Pneumatic balloon dilation and surgical myotomy are the most effective treatments for achalasia. While there is controversy which method is best, the aim of the current study was to identify predictors of symptom recurrence after endoscopic or surgical therapy. Patients undergoing pneumatic balloon dilatation (30mm) or laparoscopic Heller myotomy with Dor fundoplication were included in the study. Analyzed parameters include total symptom score (sum of 0-5 point intensity for dysphagia, regurgitation and chest pain), width and height of esophageal column at 2 and 5 minutes after oral barium ingestion, lower esophageal sphincter (LES) length, resting (LESP) and residual pressure (LESRP) before and 3 months after intervention. Patients with symptoms score <3 at the 3-month follow-up visit were considered asymptomatic. Twenty-one patients underwent pneumatic dilation (14) or laparoscopic myotomy (7). Total symptom score improved (p<0.01) from pre- (7.2±2.7) to post-intervention (1.7±2.6). Eleven (85.8%) patients in the endoscopic group vs. 7 (100%) patients in the surgical group were symptom-free 3 months after intervention. Therapies improved LESP (24.4±8.2mmHg pre- vs. 15.4±10.3mmHg post-therapy; p=0.003) and mean LESRP (7.9±4.3mmHg pre- vs. 5.3±6.7mmHg post-therapy; p=0.03). Univariate linear regression analysis identified barium contrast column width >5cm at 2 minutes (p=0.04), LES length <2cm (p=0.003) and LESRP >10mmHg (p=0.02) as predictors for persistent symptoms. While >85% of achalasia patients responded well to 30mm pneumatic balloon dilation, patients with elevated LES pressure, short LES and wide esophagus should be considered as primary surgical candidates.

Regular Cycles of Forward and Backward Signal Propagation in Prefrontal Cortex and in Consciousness

PubMed Central

Werbos, Paul J.; Davis, Joshua J. J.

2016-01-01

This paper addresses two fundamental questions: (1) Is it possible to develop mathematical neural network models which can explain and replicate the way in which higher-order capabilities like intelligence, consciousness, optimization, and prediction emerge from the process of learning (Werbos, 1994, 2016a; National Science Foundation, 2008)? and (2) How can we use and test such models in a practical way, to track, to analyze and to model high-frequency (≥ 500 hz) many-channel data from recording the brain, just as econometrics sometimes uses models grounded in the theory of efficient markets to track real-world time-series data (Werbos, 1990)? This paper first reviews some of the prior work addressing question (1), and then reports new work performed in MATLAB analyzing spike-sorted and burst-sorted data on the prefrontal cortex from the Buzsaki lab (Fujisawa et al., 2008, 2015) which is consistent with a regular clock cycle of about 153.4 ms and with regular alternation between a forward pass of network calculations and a backwards pass, as in the general form of the backpropagation algorithm which one of us first developed in the period 1968–1974 (Werbos, 1994, 2006; Anderson and Rosenfeld, 1998). In business and finance, it is well known that adjustments for cycles of the year are essential to accurate prediction of time-series data (Box and Jenkins, 1970); in a similar way, methods for identifying and using regular clock cycles offer large new opportunities in neural time-series analysis. This paper demonstrates a few initial footprints on the large “continent” of this type of neural time-series analysis, and discusses a few of the many further possibilities opened up by this new approach to “decoding” the neural code (Heller et al., 1995). PMID:27965547

Some shallow-water hydroids (Cnidaria: Hydrozoa) from the central east coast of Florida, USA.

PubMed

Calder, Dale R

2013-01-01

This paper gives a systematic account of 67 species, referable to 22 families and 40 genera, identified in a small collection of hydroids from the central Atlantic coast of Florida between Melbourne and Palm Beach. The fauna mostly comprises an assemblage of tropical western Atlantic species ranging northwards along the southeastern coast of the United States. One new species, Lafoea intorta, is described. Applying Reversal of Precedence provisions in zoological nomenclature, the widely-used generic name Halopteris Allman, 1877 is designated as valid and as a nomen protectum, while its virtually unused senior synonym Halicornaria Hincks, 1865 (not Halicornaria Allman, 1874) is reduced to a nomen oblitum. The genus Pasya Stechow, 1922 is resurrected for the hydroid generally known as Dynamena quadridentata (Ellis & Solander, 1786). Laomedea tottoni Leloup, 1935 is shown to be a junior objective synonym of Clytia fragilis Congdon, 1907, which in turn is a junior subjective synonym of Clytia linearis (Thornely, 1900). Obelia oxydentata Stechow, 1914 is recognized as distinct from O. bidentata Clark, 1875. Hincksella brevitheca Galea, 2009, first described from Cuba, is reported for only the second time; records of the species are added here from Grand Cayman Island and the Caribbean coast of Panama as well as from the Atlantic coast of Florida. Also reported for the second time is Antennella incerta Galea, 2010, previ-ously known only from Guadeloupe in the Caribbean Sea. The true Halopteris diaphana (Heller, 1868), known from the Mediterranean Sea and from Brazil, is reported for the first time from the western North Atlantic. Earlier records of the species in the region are based on misidentifications of H. alternata (Nutting, 1900). Male gonothecae of Halecium calderi Galea, 2010 are reported and illustrated for the first time.

Effects of laparoscopic myotomy on the esophageal motility pattern of esophageal achalasia as measured by high-resolution manometry.

PubMed

Salvador, Renato; Savarino, Edoardo; Pesenti, Elisa; Spadotto, Lorenzo; Voltarel, Guerrino; Capovilla, Giovanni; Cavallin, Francesco; Nicoletti, Loredana; Valmasoni, Michele; Ruol, Alberto; Merigliano, Stefano; Costantini, Mario

2017-09-01

Esophageal achalasia can be classified on the grounds of three distinct manometric patterns that correlate well with final outcome after laparoscopic Heller-Dor myotomy (LHM). No analytical data are available, however, on the postoperative picture and its possible correlation with final outcome. The aims of this study were: (a) to investigate whether manometric patterns change after LHM for achalasia; (b) to ascertain whether postoperative patterns and/or changes can predict final outcome; and (c) to test the hypothesis that the three known patterns represent different stages in the evolution of the disease. During the study period, we prospectively enlisted 206 consecutive achalasia patients who were assessed using high-resolution manometry (HRM) before undergoing LHM. Symptoms were scored using a detailed questionnaire. Barium swallow, endoscopy and HRM were performed, before and again 6 months after surgery. Preoperative HRM revealed the three known patterns with statistically different esophageal diameters (pattern I having the largest), and patients with pattern I had the highest symptom scores. The surgical treatment failed in 10 cases (4.9%). The only predictor of final outcome was the preoperative manometric pattern (p = 0.01). All patients with pattern I preoperatively had the same pattern afterward, whereas nearly 50% of patients with pattern III before LHM had patterns I or II after surgery. There were no cases showing the opposite trend. Neither a change of manometric pattern after surgery nor a patient's postoperative pattern was a predictor of final outcome, whereas preoperative pattern confirmed its prognostic significance. The three manometric patterns distinguishable in achalasia may represent different stages in the disease's evolution, pattern III and pattern I coinciding with the early and final stages of the disease, respectively.

Regular Cycles of Forward and Backward Signal Propagation in Prefrontal Cortex and in Consciousness.

PubMed

Werbos, Paul J; Davis, Joshua J J

2016-01-01

This paper addresses two fundamental questions: (1) Is it possible to develop mathematical neural network models which can explain and replicate the way in which higher-order capabilities like intelligence, consciousness, optimization, and prediction emerge from the process of learning (Werbos, 1994, 2016a; National Science Foundation, 2008)? and (2) How can we use and test such models in a practical way, to track, to analyze and to model high-frequency (≥ 500 hz) many-channel data from recording the brain, just as econometrics sometimes uses models grounded in the theory of efficient markets to track real-world time-series data (Werbos, 1990)? This paper first reviews some of the prior work addressing question (1), and then reports new work performed in MATLAB analyzing spike-sorted and burst-sorted data on the prefrontal cortex from the Buzsaki lab (Fujisawa et al., 2008, 2015) which is consistent with a regular clock cycle of about 153.4 ms and with regular alternation between a forward pass of network calculations and a backwards pass, as in the general form of the backpropagation algorithm which one of us first developed in the period 1968-1974 (Werbos, 1994, 2006; Anderson and Rosenfeld, 1998). In business and finance, it is well known that adjustments for cycles of the year are essential to accurate prediction of time-series data (Box and Jenkins, 1970); in a similar way, methods for identifying and using regular clock cycles offer large new opportunities in neural time-series analysis. This paper demonstrates a few initial footprints on the large "continent" of this type of neural time-series analysis, and discusses a few of the many further possibilities opened up by this new approach to "decoding" the neural code (Heller et al., 1995).

Utilization and outcome of laparoscopic versus robotic general and bariatric surgical procedures at Academic Medical Centers.

PubMed

Villamere, James; Gebhart, Alana; Vu, Stephen; Nguyen, Ninh T

2015-07-01

Robotic-assisted general and bariatric surgery is gaining popularity among surgeons. The aim of this study was to analyze the utilization and outcome of laparoscopic versus robotic-assisted laparoscopic techniques for common elective general and bariatric surgical procedures performed at Academic Medical Centers. We analyzed data from University HealthSystem Consortium clinical database from October 2010 to February 2014 for all patients who underwent laparoscopic versus robotic techniques for eight common elective general and bariatric surgical procedures: gastric bypass, sleeve gastrectomy, gastric band, antireflux surgery, Heller myotomy (HM), cholecystectomy (LC), colectomy, rectal resection (RR). Utilization and outcome measures including demographics, in-hospital mortality, major complications, 30-day readmission, length of stay (LOS), and costs were compared between techniques. 96,694 laparoscopic and robotic procedures were analyzed. Utilization of the robotic approach was the highest for RR (21.4%), followed by HM (9.1%). There was no significant difference in in-hospital mortality or major complications between laparoscopic versus robotic techniques for all procedures. Only two procedures had improved outcome associated with the robotic approach: robotic HM and robotic LC had a shorter LOS compared to the laparoscopic approach (2.8 ± 3.6 vs. 2.3 ± 2.1; respectively, p < 0.05 for HM and 2.9 ± 2.4 vs. 2.3 ± 1.7; respectively, p < 0.05 for LC). Costs were significantly higher (21%) in the robotic group for all procedures. A subset analysis of patients with minor/moderate severity of illness showed similar results. This national analysis of academic centers showed a low utilization of robotic-assisted laparoscopic elective general and bariatric surgical procedures with the highest utilization for rectal resection. Compared to conventional laparoscopy, there were no observed clinical benefits associated with the robotic approach, but there was a

User Acceptance of Computerized Cognitive Behavioral Therapy for Depression: Systematic Review.

PubMed

Rost, Theresia; Stein, Janine; Löbner, Margrit; Kersting, Anette; Luck-Sikorski, Claudia; Riedel-Heller, Steffi G

2017-09-13

Computerized cognitive behavioral therapy (cCBT) has been proven to be effective in depression care. Moreover, cCBT packages are becoming increasingly popular. A central aspect concerning the take-up and success of any treatment is its user acceptance. The aim of this study was to update and expand on earlier work on user acceptance of cCBT for depression. This paper systematically reviewed quantitative and qualitative studies regarding the user acceptance of cCBT for depression. The initial search was conducted in January 2016 and involved the following databases: Web of Science, PubMed, the Cochrane Library, and PsycINFO. Studies were retained if they described the explicit examination of the user acceptance, experiences, or satisfaction related to a cCBT intervention, if they reported depression as a primary outcome, and if they were published in German or English from July 2007 onward. A total of 1736 studies were identified, of which 29 studies were eligible for review. User acceptance was operationalized and analyzed very heterogeneously. Eight studies reported a very high level of acceptance, 17 indicated a high level of acceptance, and one study showed a moderate level of acceptance. Two qualitative studies considered the positive and negative aspects concerning the user acceptance of cCBT. However, a substantial proportion of reviewed studies revealed several methodical shortcomings. In general, people experience cCBT for depression as predominantly positive, which supports the potential role of these innovative treatments. However, methodological challenges do exist in terms of defining user acceptance, clear operationalization of concepts, and measurement. ©Theresia Rost, Janine Stein, Margrit Löbner, Anette Kersting, Claudia Luck-Sikorski, Steffi G Riedel-Heller. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 13.09.2017.

OXALOACETATE DECARBOXYLATION AND OXALOACETATE-CARBON DIOXIDE EXCHANGE IN ACETOBACTER XYLINUM

PubMed Central

Benziman, Moshe; Heller, N.

1964-01-01

Benziman, Moshe (The Hebrew University of Jerusalem, Jerusalem, Israel), and N. Heller. Oxaloacetate decarboxylation and oxaloacetate-carbon dioxide exchange in Acetobacter xylinum. J. Bacteriol. 88:1678–1687. 1964.—Extracts of Acetobacter xylinum, prepared by sonic treatment, were shown to catalyze the decarboxylation of oxaloacetate (OAA) to pyruvate and CO2, and the exchange of C14-carbon dioxide into the β-carboxyl of OAA. Fractionation of the extracts with ammonium sulfate resulted in a 10-fold increase of the specific activity of the enzyme system catalyzing the CO2 exchange and OAA decarboxylation reactions. The purified preparation catalyzed the exchange of pyruvate-3-C14 into OAA. Similar pH curves with a pH optimum of 5.6 were obtained for the CO2 exchange and OAA decarboxylation reactions. Both reactions require the presence of Mn2+ or Mg2+ ions. OAA decarboxylation was more strongly inhibited than the exchange of CO2 by dialysis or metal-chelating agents. Avidin did not inhibit either reaction. Adenosine triphosphate (ATP), adenosine diphosphate (ADP), guanosine triphosphate (GTP), guanosine diphosphate (GDP), pyrophosphate, or inorganic phosphate did not promote OAA decarboxylation and the CO2-exchange reaction catalyzed by the purified preparation. The purified preparation failed to catalyze the carboxylation of phosphoenolpyruvate in the presence of GDP, ADP, or inorganic phosphate, and that of pyruvate in the presence of ATP or GTP, even when supplemented with an OAA-trapping system. A scheme for OAA decarboxylation which could account for the observed exchange reactions and for the failure to obtain net fixation of CO2 is proposed. The relation between the exchange reaction and the synthesis of cellulose from pyruvate by A. xylinum is discussed. PMID:14240957

Deployment technique that takes advantage of the characteristics of Enterprise VRD2: an in vitro study.

PubMed

Chihara, Hideo; Ishii, Akira; Kikuchi, Takayuki; Ikeda, Hiroyuki; Arai, Daisuke; Miyamoto, Susumu

2017-10-01

Enterprise VRD, a stent frequently used to assist coil embolization of cerebral aneurysms, has been upgraded to reduce the risk of incomplete stent apposition (ISA), a known risk factor for thromboembolic complications. To compare the performances of Enterprise VRD and Enterprise VRD2 in curved vessels, and to investigate a deployment method that takes advantage of the features of Enterprise VRD2 to achieve better vessel wall apposition. A silicone vascular model connected to a temperature-adjustable perfusion circuit was used. First, Enterprise VRD and Enterprise VRD2 were deployed under fluoroscopy and then ISA was evaluated as the stent cross-sectional area ratio at the curved segment of the vessel. For the measurements, each stent was deployed in vessels with different angles of curvature. Second, the incidence of ISA after insertion of Enterprise VRD2 by the 'pushing over outer curve technique', in which stents are deployed along the outer curve of vessels with continuous wire advancement, was compared with 'Heller's push and pull technique'. For all stents, the cross-sectional area ratio decreased with acute curvature of the vessel. Comparisons of the two stents showed that Enterprise VRD2 was better than Enterprise VRD in maintaining a greater cross-sectional area ratio in curved vessels. In addition, kinking with an acute curvature was also minimized with Enterprise VRD2. Furthermore, ISA was reduced using our technique with Enterprise VRD2. Enterprise VRD2 is superior to Enterprise VRD in reducing ISA in curved vessels and can alter ISA according to the deployment technique used. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Developing and validating a novel metabolic tumor volume risk stratification system for supplementing non-small cell lung cancer staging.

PubMed

Pu, Yonglin; Zhang, James X; Liu, Haiyan; Appelbaum, Daniel; Meng, Jianfeng; Penney, Bill C

2018-06-07

We hypothesized that whole-body metabolic tumor volume (MTVwb) could be used to supplement non-small cell lung cancer (NSCLC) staging due to its independent prognostic value. The goal of this study was to develop and validate a novel MTVwb risk stratification system to supplement NSCLC staging. We performed an IRB-approved retrospective review of 935 patients with NSCLC and FDG-avid tumor divided into modeling and validation cohorts based on the type of PET/CT scanner used for imaging. In addition, sensitivity analysis was conducted by dividing the patient population into two randomized cohorts. Cox regression and Kaplan-Meier survival analyses were performed to determine the prognostic value of the MTVwb risk stratification system. The cut-off values (10.0, 53.4 and 155.0 mL) between the MTVwb quartiles of the modeling cohort were applied to both the modeling and validation cohorts to determine each patient's MTVwb risk stratum. The survival analyses showed that a lower MTVwb risk stratum was associated with better overall survival (all p < 0.01), independent of TNM stage together with other clinical prognostic factors, and the discriminatory power of the MTVwb risk stratification system, as measured by Gönen and Heller's concordance index, was not significantly different from that of TNM stage in both cohorts. Also, the prognostic value of the MTVwb risk stratum was robust in the two randomized cohorts. The discordance rate between the MTVwb risk stratum and TNM stage or substage was 45.1% in the modeling cohort and 50.3% in the validation cohort. This study developed and validated a novel MTVwb risk stratification system, which has prognostic value independent of the TNM stage and other clinical prognostic factors in NSCLC, suggesting that it could be used for further NSCLC pretreatment assessment and for refining treatment decisions in individual patients.

Description of a new species of Petrolisthes in the Indo-West Pacific with a redefinition of P.hastatus Stimpson, 1858 and resurrection of P.inermis (Heller, 1862) (Crustacea, Anomura, Porcellanidae).

PubMed

Werding, Bernd; Hiller, Alexandra

2015-01-01

The porcellanid crab Petrolistheshastatus Stimpson, 1858, has been traditionally viewed as a highly variable species with a wide distribution in the West Pacific. For more than a century there has been taxonomic confusion of this species with morphologically similar taxa, some of which were synonymized with Stimpson's taxon. We redefine Petrolistheshastatus, resurrect Petrolisthesinermis as a valid species, discuss the status of Petrolisthestenkatei De Man, 1893, and describe a new species as Petrolistheselegantissimus from Indonesia.

A Self-Paced Online Module for Teachers Using Climate Change as a Context for Bringing Sustainability Education to the Classroom

NASA Astrophysics Data System (ADS)

Metzger, E. P.; Santone, S.; Smith, G.; Cordero, E.

2013-12-01

Sustainability education is an approach to learning that builds knowledge, skills, and values needed to create lasting economic prosperity, environmental health, and social justice. In collaboration with Creative Change Educational Solutions (http://www.creativechange.net/) and with funding from the Clarence E. Heller Charitable Foundation and NASA, scientists and science educators at San José State University (SJSU) are developing an online 'Introduction for Sustainability' course for middle and high school educators. The module will introduce sustainability as a context for learning, highlight connections to climate change science and solutions, and provide strategies for linking the environmental, economic and social dimensions of climate destabilization to fundamental sustainability concepts. This self-paced course will be piloted during the 2013-2014 academic year. Upon completion, participants will receive inexpensive university credit ( $50/unit) from SJSU. Course goals are to demonstrate the applicability of sustainability themes across disciplines; increase learners' knowledge about the causes and impacts of climate change and related sustainability challenges; and support learners in integrating course content and methods into their classroom teaching. Course activities combine: 1) reading selections and questions; 2) online discussion; 3) digital media (short videos and tutorials); and 4) journal entries and other written assignments, including consideration of how course content aligns with the Common Core and Next Generation Science Standards. The module is divided into five sections: 1) Defining What Matters - What Do We All Need for a Fulfilling Life?; 2) The Commons and Ecosystem Services; 3) Causes and Impacts of Climate Change; 4) Individual and Collective Actions to Mitigate Its Effects; and 5) Integrating Sustainability into the Curriculum. Initial recruitment for the course will take place among participants in workshops offered by the Bay

A single center 26-year experience with treatment of esophageal achalasia: is there an optimal method?

PubMed

Pastor, Aimee C; Mills, Jessica; Marcon, Margaret A; Himidan, Sharifa; Kim, Peter C W

2009-07-01

Treatment modalities for achalasia are evolving and remain controversial. Herein, we report the relative efficacy and outcomes after dilatation or myotomy in children with achalasia. A retrospective analysis of all children treated for achalasia at a tertiary center from 1981 to 2007 was performed (n = 40). Demographics, presenting symptoms, perioperative parameters, and outcomes were analyzed using t tests and chi(2) statistics. Thirty patients were initially treated by esophageal dilatation (ED), whereas 10 were treated by laparoscopic or open Heller myotomy (HM). Both groups were similar with respect to age (10.6 vs 12.4 years; P = .19). There were 18 males and 12 females in the ED group, compared to 5 males and 5 females in the HM group (P = .72). Mean duration of symptoms before diagnosis, including dysphagia, vomiting, food sticking, chest pain, and weight loss, was 15.9 months for ED and 10.7 months for HM (P = .41). Mean time from diagnosis to initial intervention was 76 days in ED vs 86 days in HM (P = .78). Subsequent interventions by myotomy or both dilatation and myotomy were required in 9 (30%) of 30 patients in the ED group and 2 (20%) of 10 patients in the HM group (P = .70). A clear transition from open to laparoscopic approach occurred between 1995 and 2001. Mean operating times were comparable (186.3 vs 156.0 minutes; P = .48). Of 14 laparoscopic myotomies, 11 (79%) had fundoplication, and 2 (18%) of the 11 were converted to open procedure. Intraoperative mucosal perforation rates were similar between open and laparoscopic groups (17% vs 18%). At follow-up, 32% of ED patients vs 43% HM had complete symptom relief (mean follow-up duration, 75.2 months; SD, 196.5). Both dilatation and myotomy are effective immediate treatment of achalasia. A clear transition to and preference for laparoscopic approach has occurred in the treatment of achalasia in children.

Assessment of the expression and role of the α1-nAChR subunit in efferent cholinergic function during the development of the mammalian cochlea.

PubMed

Roux, Isabelle; Wu, Jingjing Sherry; McIntosh, J Michael; Glowatzki, Elisabeth

2016-08-01

Hair cell (HC) activity in the mammalian cochlea is modulated by cholinergic efferent inputs from the brainstem. These inhibitory inputs are mediated by calcium-permeable nicotinic acetylcholine receptors (nAChRs) containing α9- and α10-subunits and by subsequent activation of calcium-dependent potassium channels. Intriguingly, mRNAs of α1- and γ-nAChRs, subunits of the "muscle-type" nAChR have also been found in developing HCs (Cai T, Jen HI, Kang H, Klisch TJ, Zoghbi HY, Groves AK. J Neurosci 35: 5870-5883, 2015; Scheffer D, Sage C, Plazas PV, Huang M, Wedemeyer C, Zhang DS, Chen ZY, Elgoyhen AB, Corey DP, Pingault V. J Neurochem 103: 2651-2664, 2007; Sinkkonen ST, Chai R, Jan TA, Hartman BH, Laske RD, Gahlen F, Sinkkonen W, Cheng AG, Oshima K, Heller S. Sci Rep 1: 26, 2011) prompting proposals that another type of nAChR is present and may be critical during early synaptic development. Mouse genetics, histochemistry, pharmacology, and whole cell recording approaches were combined to test the role of α1-nAChR subunit in HC efferent synapse formation and cholinergic function. The onset of α1-mRNA expression in mouse HCs was found to coincide with the onset of the ACh response and efferent synaptic function. However, in mouse inner hair cells (IHCs) no response to the muscle-type nAChR agonists (±)-anatoxin A, (±)-epibatidine, (-)-nicotine, or 1,1-dimethyl-4-phenylpiperazinium iodide (DMPP) was detected, arguing against the presence of an independent functional α1-containing muscle-type nAChR in IHCs. In α1-deficient mice, no obvious change of IHC efferent innervation was detected at embryonic day 18, contrary to the hyperinnervation observed at the neuromuscular junction. Additionally, ACh response and efferent synaptic activity were detectable in α1-deficient IHCs, suggesting that α1 is not necessary for assembly and membrane targeting of nAChRs or for efferent synapse formation in IHCs.

Mucosal perforation during laparoscopic surgery for achalasia: impact of preoperative pneumatic balloon dilation.

PubMed

Souma, Yoshihito; Nakajima, Kiyokazu; Taniguchi, Eiji; Takahashi, Tsuyoshi; Kurokawa, Yukinori; Yamasaki, Makoto; Miyazaki, Yasuhiro; Makino, Tomoki; Hamada, Tetsuhiro; Yasuda, Jun; Yumiba, Takeyoshi; Ohashi, Shuichi; Takiguchi, Shuji; Mori, Masaki; Doki, Yuichiro

2017-03-01

Controversy remains whether preoperative pneumatic balloon dilation (PBD) influences the surgical outcome of laparoscopic esophagocardiomyotomy in patients with esophageal achalasia. The aim of this study was to evaluate whether preoperative PBD represents a risk factor for surgical complications and affects the symptomatic and/or functional outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD). A retrospective chart review was conducted on a prospectively compiled surgical database of 103 consecutive patients with esophageal achalasia who underwent LHD from November 1994 to September 2014. The following data were compared between the patients with preoperative PBD (PBD group; n = 26) and without PBD (non-PBD group; n = 77): (1) patients' demographics: age, gender, body mass index, duration of symptoms, maximum transverse diameter of esophagus; (2) operative findings: operating time, blood loss, intraoperative complications; (3) postoperative course: complications, clinical symptoms, postoperative treatment; and (4) esophageal functional tests: preoperative and postoperative manometric data and postoperative profile of 24-h esophageal pH monitoring. (1) No significant differences were observed in the patients' demographics. (2) Operative findings were similar between the two groups; however, the incidence of mucosal perforation was significantly higher in the PBD group (n = 8; 30.7 %) compared to the non-PBD group (n = 6; 7.7 %) (p = 0.005). (3) Postoperative complications were not encountered in either group. The differences were not significant for postoperative clinical symptoms, the incidence of gastroesophageal reflux disease, or necessity of postoperative treatments. (4) Lower esophageal sphincter pressure was effectively reduced in both groups, and no differences were observed in manometric data or 24-h pH monitoring profiles between the two groups. Multivariate logistic regression analysis showed that preoperative PBD and the

The European Micropaleontological Reference Centre in Kraków

NASA Astrophysics Data System (ADS)

Kaminski, Michael; Waskowska, Anna; Bebenek, Slawomir; Pilarz, Monika

2016-04-01

We are pleased to announce the establishment of the European Micropaleontological Reference Centre, housed in the offices of Micropress Europe at the AGH University of Science & Technology in Krakow, Poland. The new European Micropaleontological Reference Centre is an initiative of the Grzybowski Foundation and Micropress Europe. The centre is designed to serve the micropaleontological community by providing a permanent repository or "museum" for published microfossil collections. The centre houses a growing collection of microfossils picked into faunal slides, as well as a well-stocked library of micropaleontological books, journals, and reprints. We have the only up-to-date paper copy of the Ellis & Messina Catalogue of Foraminifera in Central Europe. Currently, the slide collections include: - Type slides of benthic foraminifera from Poland (the collection of I. Heller from the Polish oil company GEONAFTA), - Carboniferous foraminifera from Germany and Poland (collections of G. Eickhoff and Z. Alexandrowicz), - IODP sites in the Arctic, Atlantic, and Indian Oceans (collections of M. Kaminski, E. Setoyama, A. Holborn), - Exploration wells in the Boreal seas: North Sea, Norwegian Sea, Western Barents Sea, Labrador Sea, Bering Sea, Spitsbergen, Western Siberia (collections of M. Kaminski, J. Nagy, T. Van Den Akker, V. Podobina, and others), - Paratethyan Foraminifera (collections of E. Luczkowska, C. Beldean, F. Szekely), - Mesozoic-Paleogene Foraminifera from Gubbio, Italy (collections of M. Kaminski, C. Cetean, and students) and the Polish Carpathians (collection of A. Waskowska), - Caribbean (collection of M. Kaminski, R. Preece), West Africa (collection of R. Preece, S. Kender, C. Cetean), - We have a separate collection of type specimens of species (paratypes). Slides are housed in cabinet drawers together with the relevant publication. Researchers are welcome to visit the offices of Micropress Europe to view the archived microfossil collections. The center

Assessment of the expression and role of the α1-nAChR subunit in efferent cholinergic function during the development of the mammalian cochlea

PubMed Central

Wu (武靜靜), Jingjing Sherry; McIntosh, J. Michael; Glowatzki, Elisabeth

2016-01-01

Hair cell (HC) activity in the mammalian cochlea is modulated by cholinergic efferent inputs from the brainstem. These inhibitory inputs are mediated by calcium-permeable nicotinic acetylcholine receptors (nAChRs) containing α9- and α10-subunits and by subsequent activation of calcium-dependent potassium channels. Intriguingly, mRNAs of α1- and γ-nAChRs, subunits of the “muscle-type” nAChR have also been found in developing HCs (Cai T, Jen HI, Kang H, Klisch TJ, Zoghbi HY, Groves AK. J Neurosci 35: 5870–5883, 2015; Scheffer D, Sage C, Plazas PV, Huang M, Wedemeyer C, Zhang DS, Chen ZY, Elgoyhen AB, Corey DP, Pingault V. J Neurochem 103: 2651–2664, 2007; Sinkkonen ST, Chai R, Jan TA, Hartman BH, Laske RD, Gahlen F, Sinkkonen W, Cheng AG, Oshima K, Heller S. Sci Rep 1: 26, 2011) prompting proposals that another type of nAChR is present and may be critical during early synaptic development. Mouse genetics, histochemistry, pharmacology, and whole cell recording approaches were combined to test the role of α1-nAChR subunit in HC efferent synapse formation and cholinergic function. The onset of α1-mRNA expression in mouse HCs was found to coincide with the onset of the ACh response and efferent synaptic function. However, in mouse inner hair cells (IHCs) no response to the muscle-type nAChR agonists (±)-anatoxin A, (±)-epibatidine, (−)-nicotine, or 1,1-dimethyl-4-phenylpiperazinium iodide (DMPP) was detected, arguing against the presence of an independent functional α1-containing muscle-type nAChR in IHCs. In α1-deficient mice, no obvious change of IHC efferent innervation was detected at embryonic day 18, contrary to the hyperinnervation observed at the neuromuscular junction. Additionally, ACh response and efferent synaptic activity were detectable in α1-deficient IHCs, suggesting that α1 is not necessary for assembly and membrane targeting of nAChRs or for efferent synapse formation in IHCs. PMID:27098031

Gender differences in both the pathology and surgical outcome of patients with esophageal achalasia.

PubMed

Tsuboi, Kazuto; Omura, Nobuo; Yano, Fumiaki; Hoshino, Masato; Yamamoto, Se-Ryung; Akimoto, Shusuke; Masuda, Takahiro; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2016-12-01

Esophageal achalasia is a relatively rare disease that occurs usually in middle-aged patients. The laparoscopic Heller-Dor (LHD) procedure is the gold-standard surgical treatment for esophageal achalasia. There are many studies on the pathology and surgical outcome of esophageal achalasia from various perspectives, but there are no studies on gender differences in both the pathology and surgical outcome. This study aimed to evaluate gender differences in the surgical outcome with the LHD procedure and in the pathology of esophageal achalasia patients. The study included 474 LHD-treated patients who were postoperatively followed up for 6 months or more. The patients were divided into 2 groups by gender, to compare the preoperative pathology, surgical outcome, symptom scores before and after LHD, symptom score improvement frequency, and patient satisfaction with the surgery. The study population consisted of 248 male and 226 female, having a mean age of 45.1 years. There were no gender differences in the preoperative pathology, but a significantly lower BMI (p < 0.0001) and a smaller esophageal dilation (p = 0.0061) were observed in the female group. The frequency and severity of chest pain before the surgery were significantly higher in the female group (p = 0.0117 and p = 0.0103, respectively), and the improvement in both the frequency and severity of chest pain was significantly higher in the female group (p = 0.0005 and p = 0.003, respectively). No differences were identified in the surgical outcomes and postoperative course. The patient satisfaction with the surgery was high in both groups and comparable (p = 0.6863). The female patients with esophageal achalasia were characterized by low BMI, less esophageal dilation, and increased frequency and severity of chest pain. LHD improved the chest pain in the female patients, whereas the surgical outcome and satisfaction with the surgery were excellent regardless of gender.

POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment options in the management of achalasia.

PubMed

Miller, Heidi J; Neupane, Ruel; Fayezizadeh, Mojtaba; Majumder, Arnab; Marks, Jeffrey M

2017-04-01

Achalasia is a rare motility disorder of the esophagus. Treatment is palliative with the goal of symptom remission and slowing the progression of the disease. Treatment options include per oral endoscopic myotomy (POEM), laparoscopic Heller myotomy (LM) and endoscopic treatments such as pneumatic dilation (PD) and botulinum toxin type A injections (BI). We evaluate the economics and cost-effectiveness of treating achalasia. We performed cost analysis for POEM, LM, PD and BI at our institution from 2011 to 2015. Cost of LM was set to 1, and other procedures are presented as percentage change. Cost-effectiveness was calculated based on cost, number of interventions required for optimal results for dilations and injections and efficacy reported in the current literature. Incremental cost-effectiveness ratio was calculated by a cost-utility analysis using quality-adjusted life year gained, defined as a symptom-free year in a patient with achalasia. Average number of interventions required was 2.3 dilations or two injections for efficacies of 80 and 61 %, respectively. POEM cost 1.058 times the cost of LM, and PD and BI cost 0.559 and 0.448 times the cost of LM. Annual cost per cure over a period of 4 years for POEM, and LM were consistently equivalent, trending the same as PD although this has a lower initial cost. The cost per cure of BI remains stable over 3 years and then doubles. The cost-effectiveness of POEM and LM is equivalent. Myotomy, either surgical or endoscopic, is more cost-effective than BI due to high failure rates of the economical intervention. When treatment is being considered BI should be utilized in patients with less than 2-year life expectancy. Pneumatic dilations are cost-effective and are an acceptable approach to treatment of achalasia, although myotomy has a lower relapse rate and is cost-effective compared to PD after 2 years.

Sub-50 fs excited state dynamics of 6-chloroguanine upon deep ultraviolet excitation.

PubMed

Mondal, Sayan; Puranik, Mrinalini

2016-05-18

The photophysical properties of natural nucleobases and their respective nucleotides are ascribed to the sub-picosecond lifetime of their first singlet states in the UV-B region (260-350 nm). Electronic transitions of the ππ* type, which are stronger than those in the UV-B region, lie at the red edge of the UV-C range (100-260 nm) in all isolated nucleobases. The lowest energetic excited states in the UV-B region of nucleobases have been investigated using a plethora of experimental and theoretical methods in gas and solution phases. The sub-picosecond lifetime of these molecules is not a general attribute of all nucleobases but specific to the five primary nucleobases and a few xanthine and methylated derivatives. To determine the overall UV photostability, we aim to understand the effect of more energetic photons lying in the UV-C region on nucleobases. To determine the UV-C initiated photophysics of a nucleobase system, we chose a halogen substituted purine, 6-chloroguanine (6-ClG), that we had investigated previously using resonance Raman spectroscopy. We have performed quantitative measurements of the resonance Raman cross-section across the Bb absorption band (210-230 nm) and constructed the Raman excitation profiles. We modeled the excitation profiles using Lee and Heller's time-dependent theory of resonance Raman intensities to extract the initial excited state dynamics of 6-ClG within 30-50 fs after photoexcitation. We found that imidazole and pyrimidine rings of 6-ClG undergo expansion and contraction, respectively, following photoexcitation to the Bb state. The amount of distortions of the excited state structure from that of the ground state structure is reflected by the total internal reorganization energy that is determined at 112 cm(-1). The contribution of the inertial component of the solvent response towards the total reorganization energy was obtained at 1220 cm(-1). In addition, our simulation also yields an instantaneous response of the first

Review and evaluation of performance measures for survival prediction models in external validation settings.

PubMed

Rahman, M Shafiqur; Ambler, Gareth; Choodari-Oskooei, Babak; Omar, Rumana Z

2017-04-18

When developing a prediction model for survival data it is essential to validate its performance in external validation settings using appropriate performance measures. Although a number of such measures have been proposed, there is only limited guidance regarding their use in the context of model validation. This paper reviewed and evaluated a wide range of performance measures to provide some guidelines for their use in practice. An extensive simulation study based on two clinical datasets was conducted to investigate the performance of the measures in external validation settings. Measures were selected from categories that assess the overall performance, discrimination and calibration of a survival prediction model. Some of these have been modified to allow their use with validation data, and a case study is provided to describe how these measures can be estimated in practice. The measures were evaluated with respect to their robustness to censoring and ease of interpretation. All measures are implemented, or are straightforward to implement, in statistical software. Most of the performance measures were reasonably robust to moderate levels of censoring. One exception was Harrell's concordance measure which tended to increase as censoring increased. We recommend that Uno's concordance measure is used to quantify concordance when there are moderate levels of censoring. Alternatively, Gönen and Heller's measure could be considered, especially if censoring is very high, but we suggest that the prediction model is re-calibrated first. We also recommend that Royston's D is routinely reported to assess discrimination since it has an appealing interpretation. The calibration slope is useful for both internal and external validation settings and recommended to report routinely. Our recommendation would be to use any of the predictive accuracy measures and provide the corresponding predictive accuracy curves. In addition, we recommend to investigate the characteristics

Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis.

PubMed

Patel, K; Abbassi-Ghadi, N; Markar, S; Kumar, S; Jethwa, P; Zaninotto, G

2016-10-01

Peroral endoscopic myotomy (POEM) is a novel approach to performing esophageal myotomy for the treatment of achalasia. This review aims to assess subjective and objective metrics of achalasia treatment efficacy, perioperative adverse events and the incidence of postoperative gastroesophageal reflux disease in patients treated with POEM. Secondary aims include a pooled analysis comparison of the clinical outcomes and procedural safety of POEM versus laparoscopic Heller's myotomy (LHM). A systematic review of the literature, up to and including January 15, 2015, was conducted for studies reporting POEM outcomes. Studies comparing POEM to LHM were also included for the purpose of pooled analysis. Outcomes from 1122 POEM patients, from 22 studies, are reported in this systematic review. Minor operative adverse events included capno/pneumo-peritoneum (30.6%), capno/pneumo-thorax (11.0%) and subcutaneous emphysema (31.6%). Major operative adverse events included mediastinal leak (0.3%), postoperative bleeding (1.1%) and a single mortality (0.09%). There was an improvement in lower esophageal sphincter pressure and timed barium esophagram column height of 66% and 80% post-POEM, respectively. Symptom improvement was demonstrated with a pre- and post-POEM Eckardt score ± standard deviation of 6.8 ± 1.0 and 1.2 ± 0.6, respectively. Pre- and post-POEM endoscopy showed esophagitis in 0% and 19% of patients, respectively. The median (interquartile range) points scored for study quality was 15 (14-16) out of total of 32. Pooled analysis of three comparative studies between LHM and POEM showed similar results for adverse events, perforation rate, operative time and a nonsignificant trend toward a reduced length of hospital stay in the POEM group. In conclusion, POEM is a safe and effective treatment for achalasia, showing significant improvements in objective metrics and achalasia-related symptoms. Randomized comparative studies of LHM and POEM are required to determine the

Manifestations of the 15.11.2006 Kuril Tsunami Consequences on the Central Kuril Islands: the Reconstruction Events of the Destruction of Soil and Coastal Vegetation.

NASA Astrophysics Data System (ADS)

Levin, B.; Kopanina, A.; Ivelskaya, T.; Sasorova, E.

2007-12-01

The investigation of the Central Kuril Islands (Simushir, Urup, Ketoy) coast was performance by the field survey for the Institute of Marine Geology and Geophysics FEB RAS (Yuzhno-Sakhalinsk) on the vessel "Iskatel-4" to be able find different deposits of the devastating tsunami waves influence on soil and vegetation. There were average run-up heights and inundation areas (tsunami flooding zones): h=6-9 m and 40-60 m (Ketoy); h=7-19 m and 80-300 m (Simushir). The field observation showed destruction of the soil layer. The estimation of water stream velocity for the hydraulic destruction of rocks enabled to receive velocity average mean for the water stream during tsunami dynamic inundation which may be in interval of velocities near 30 -50 m/sec. Field observations of coastal plants in tsunami inundation zones on Urup, Simushir and Ketoy Islands enabled us to recognize the character of destructive influence of tsunami waves to plant structure and essential signs of micro-phytocenoses for ecotopes at different distances from the coastline. Various plant species and vital morphes were found to indicate different reaction on sea waves. The investigation results showed that selected plant species demonstrate the strong response to tsunami wave inundation. We found that the most sensitive species to mechanical and physical- chemical tsunami impact are: Pinus pumila (Pall.) Regel and Phyllodoce aleutica (Spreng.) A. Heller. The character of plant damage shows in breaking of skeletal axes, infringement of root systems, and leaf dying. These findings allow us to use the species as effective indicators of tsunami flooding zone and estimation of tsunami run-up heights. Fulfilled analyzes let us to reconstruct possible events when tsunami hits to coast with specific shore morphology. The wave front at the slightly sloping coast (from coastline to first terrace) is characterized by uniform growth of water level when water moves away soil material (no more 2-3 cm) and micro

Efficacy of peroral endoscopic myotomy compared with other invasive treatment options for the different esophageal motor disorders.

PubMed

Estremera-Arévalo, Fermín; Albéniz, Eduardo; Rullán, María; Areste, Irene; Iglesias, Rosa; Vila, Juan José

2017-08-01

Peroral endoscopic myotomy (POEM) has been performed since 2008 on more than 5,000 patients. It has proven to be highly effective in the treatment of achalasia and has shown promising outcomes for other esophageal motility spastic disorders. A literature review of the efficacy of POEM compared to the previous invasive treatments for different esophageal motility disorders was performed. The application in the pediatric and elderly populations and its role as a rescue therapy after other procedures are also outlined. Short-term outcomes are similar to laparoscopic Heller myotomy (LHM) and pneumatic endoscopic dilation (PD) (clinical success > 90%) for achalasia subtypes I and II. Mid-term outcomes are comparable to LHM and overcome the results obtained after PD (> 90% vs ~50%). With regard to type III achalasia, POEM efficacy is 98% compared to 80.8% for LHM and the PD success remains at 40%. With regard to spastic esophageal disorders (SED), POEM has an effectiveness of 88% and 70% for distal esophageal spasm (DES) and jackhammer esophagus (JE) respectively. A response of 95% in patients with sigmoid esophagus has been reported. POEM has been performed in pediatric and elderly populations and has obtained a higher efficacy than PD in pediatric series (100% vs 33%) without greater adverse events. Previous treatments do not seem to hinder POEM results with excellent response rates, including 97% in post LHM and 100% in a re-POEM series. Final considerations: POEM has shown excellent short and mid-term results for all subtypes of achalasia but long-term results are not yet available. The promising results in SED may make POEM the first-line treatment for SED. A high-safety profile and efficacy have been shown in elderly and pediatric populations. Previous treatments do not seem to diminish the success rate of POEM. Core tip: POEM has emerged as an efficient treatment option for all subtypes of achalasia and other scenarios (including previous treatments and elderly

Is laparoscopic reoperation for failed antireflux surgery feasible?

PubMed

Floch, N R; Hinder, R A; Klingler, P J; Branton, S A; Seelig, M H; Bammer, T; Filipi, C J

1999-07-01

Laparoscopic techniques can be used to treat patients whose antireflux surgery has failed. Case series. Two academic medical centers. Forty-six consecutive patients, of whom 21 were male and 25 were female (mean age, 55.6 years; range, 15-80 years). Previous antireflux procedures were laparoscopic (21 patients), laparotomy (21 patients), thoracotomy (3 patients), and thoracoscopy (1 patient). The cause of failure, operative and postoperative morbidity, and the level of follow-up satisfaction were determined for all patients. The causes of failure were hiatal herniation (31 patients [67%]), fundoplication breakdown (20 patients [43%]), fundoplication slippage (9 patients [20%]), tight fundoplication (5 patients [11%]), misdiagnosed achalasia (2 patients [4%]), and displaced Angelchik prosthesis (2 patients [4%]). Twenty-two patients (48%) had more than 1 cause. Laparoscopic reoperative procedures were Nissen fundoplication (n = 22), Toupet fundoplication (n = 13), paraesophageal hernia repair (n = 4), Dor procedure (n = 2), Angelchik prosthesis removal (n = 2), Heller myotomy (n = 2), and the takedown of a wrap (n = 1). In addition, 18 patients required crural repair and 13 required paraesophageal hernia repair. The mean +/- SEM duration of surgery was 3.5+/-1.1 hours. Operative complications were fundus tear (n = 8), significant bleeding (n = 4), bougie perforation (n = 1), small bowel enterotomy (n = 1), and tension pneumothorax (n = 1). The conversion rate (from laparoscopic to an open procedure) was 20% overall (9 patients) but 0% in the last 10 patients. Mortality was 0%. The mean +/- SEM hospital stay was 2.3+/-0.9 days for operations completed laparoscopically. Follow-up was possible in 35 patients (76%) at 17.2+/-11.8 months. The well-being score (1 best; 10, worst) was 8.6+/-2.1 before and 2.9+/-2.4 after surgery (P<.001). Thirty-one (89%) of 35 patients were satisfied with their decision to have reoperation. Antireflux surgery failures are most commonly

PREFACE: The 395th Wilhelm and Else Heraeus Seminar: `Time-dependent phenomena in Quantum Mechanics'

NASA Astrophysics Data System (ADS)

Kleber, Manfred; Kramer, Tobias

2008-03-01

The 395th Wilhelm and Else Heraeus Seminar: `Time-dependent phenomena in Quantum Mechanics' took place at the Heinrich Fabri Institute in Blaubeuren, Germany, 12-16 September 2007. The conference covered a wide range of topics connected with time-dependent phenomena in quantum mechanical systems. The 20 invited talks and 15 short talks with posters at the workshop covered the historical debate between Schrödinger, Dirac and Pauli about the role of time in Quantum Mechanics (the debate was carried out sometimes in footnotes) up to the almost direct observation of electron dynamics on the attosecond time-scale. Semiclassical methods, time-delay, monodromy, variational principles and quasi-resonances are just some of the themes which are discussed in more detail in the papers. Time-dependent methods also shed new light on energy-dependent systems, where the detour of studying the time-evolution of a quantum states allows one to solve previously intractable problems. Additional information is available at the conference webpage http://www.quantumdynamics.de The organizer would like to thank all speakers, contributors, session chairs and referees for their efforts in making the conference a success. We also gratefully acknowledge the generous financial support from the Wilhelm and Else Heraeus Foundation for the conference and the production of this special volume of Journal of Physics: Conference Series. Manfred Kleber Physik Department T30, Technische Universität München, 85747 Garching, Germany mkleber@ph.tum.de Tobias Kramer Institut I: Theoretische Physik, Universität Regensburg, 93040 Regensburg, Germany tobias.kramer@physik.uni-regensburg.de Guest Editors Front row (from left): W Schleich, E J Heller, J B Delos, H Friedrich, K Richter, M Kleber, P Kramer, M Man'ko, A del Campo, V Man'ko, M Efremov, A Ruiz, M O Scully Middle row: A Zamora, R Aganoglu, T Kramer, J

Bottles to trees: Plastic beverage bottles as an alternative nursery growing container for reforestation in developing countries.

PubMed

Khurram, Safiullah; Burney, Owen T; Morrissey, Robert C; Jacobs, Douglass F

2017-01-01

Reforestation is needed globally to help restore degraded sites, combat desertification, protect watersheds, and provide forest products. This involves planting forest tree seedlings grown in local nurseries, but technologies to produce quality seedlings are lacking in developing countries. Modern nursery containers used to propagate seedlings have internal-surface barriers (ribs or ridges) or side-slits to prevent root spiraling. These are cost prohibitive or unavailable in developing countries and so polybags (plastic bags) are more commonly used, despite their tendency to produce seedlings with deformed root systems that have less potential to establish on field sites. Discarded plastic bottles, which are readily available worldwide, may be a feasible alternative for seedling propagation. We conducted two experiments to assess the potential of repurposed plastic beverage bottles to grow quality trees: 1) Container Comparison-to evaluate Arizona walnut (Juglans major [Toor.] Heller) and Afghan pine (Pinus eldarica Medw.) seedling root and shoot development in two plastic bottle types compared to modern nursery containers and polybags, and 2) Bottle Modification-to examine the effects of root spiraling prevention techniques (side-slits, internal-ridges, and control) and container opacity (green, black, and clear) on Afghan pine seedling morphological attributes. Nursery growth and first-year seedling field performance were evaluated for both experiments. In experiment one, seedlings of both species had fewer spiraled roots in bottle containers compared to polybags. Arizona walnut had more fibrous root systems in polybags, while Afghan pine root system fibrosity was greatest in bottle containers. First-year field performance of both species was not affected by container type. In experiment two, less spiraled roots occurred in containers with air-slits and interior-ridges compared to the control. The effects of container opacity on seedling morphology were

Bottles to trees: Plastic beverage bottles as an alternative nursery growing container for reforestation in developing countries

PubMed Central

Khurram, Safiullah; Burney, Owen T.; Morrissey, Robert C.

2017-01-01

Reforestation is needed globally to help restore degraded sites, combat desertification, protect watersheds, and provide forest products. This involves planting forest tree seedlings grown in local nurseries, but technologies to produce quality seedlings are lacking in developing countries. Modern nursery containers used to propagate seedlings have internal-surface barriers (ribs or ridges) or side-slits to prevent root spiraling. These are cost prohibitive or unavailable in developing countries and so polybags (plastic bags) are more commonly used, despite their tendency to produce seedlings with deformed root systems that have less potential to establish on field sites. Discarded plastic bottles, which are readily available worldwide, may be a feasible alternative for seedling propagation. We conducted two experiments to assess the potential of repurposed plastic beverage bottles to grow quality trees: 1) Container Comparison–to evaluate Arizona walnut (Juglans major [Toor.] Heller) and Afghan pine (Pinus eldarica Medw.) seedling root and shoot development in two plastic bottle types compared to modern nursery containers and polybags, and 2) Bottle Modification–to examine the effects of root spiraling prevention techniques (side-slits, internal-ridges, and control) and container opacity (green, black, and clear) on Afghan pine seedling morphological attributes. Nursery growth and first-year seedling field performance were evaluated for both experiments. In experiment one, seedlings of both species had fewer spiraled roots in bottle containers compared to polybags. Arizona walnut had more fibrous root systems in polybags, while Afghan pine root system fibrosity was greatest in bottle containers. First-year field performance of both species was not affected by container type. In experiment two, less spiraled roots occurred in containers with air-slits and interior-ridges compared to the control. The effects of container opacity on seedling morphology were

Separating the Contribution of Glucocorticoids and Wakefulness to the Molecular and Electrophysiological Correlates of Sleep Homeostasis

PubMed Central

Mongrain, Valérie; Hernandez, Susana A.; Pradervand, Sylvain; Dorsaz, Stéphane; Curie, Thomas; Hagiwara, Grace; Gip, Phung; Heller, H. Craig; Franken, Paul

2010-01-01

V; Hernandez SA; Pradervand S; Dorsaz S; Curie T; Hagiwara G; Gip P; Heller HC; Franken P. Separating the contribution of glucocorticoids and wakefulness to the molecular and electrophysiological correlates of sleep homeostasis. SLEEP 2010;33(9):1147-1157. PMID:20857860

[Pneumatic dilation in the treatment of achalasia].

PubMed

Ruiz Cuesta, Patricia; Hervás Molina, Antonio José; Jurado García, Juan; Pleguezuelo Navarro, María; García Sánchez, Valle; Casáis Juanena, Luis L; Gálvez Calderón, Carmen; Naranjo Rodríguez, Antonio

2013-10-01

Pneumatic dilation and surgical myotomy are currently the procedures of choice to treat achalasia. The selection of one or other treatment depends on the experience of each center and patient preferences. To review the experience of pneumatic dilation in patients with achalasia in our center. We included all patients with a clinical, endoscopic and manometric diagnosis compatible with achalasia who underwent pneumatic dilation in a 19-year period. All dilations were routinely performed with a Rigiflex(®) balloon, usually at pressures of 250, 250 and 300mm Hg in three inflations of one minute, each separated by one minute. The success of the dilation was assessed on the basis of the patient's symptoms, the number of sessions, the need for surgery, and the presence of complications. A total of 171 patients were included, 53.2% men and 46.8% women, with a mean age of 51.53±17.78 years (16-87 years), from June 1993 to October 2012. A 35-mm balloon was used in 157 patients, a 30-mm balloon in 9 patients and a 40-mm balloon in 7 patients. A single dilation session was required in 108 patients, two sessions were required in 56 patients, with a mean time between the first and second sessions of 25.23±43.25 months (1-215 months), and 3 sessions were required in 7 patients with a mean time between the second and third sessions of 6.86±5.33 months (1-15 months). Outcome after dilation was successful in 81% of the patients. Of the 140 responders, 121 had complete response (complete disappearance of symptoms without recurrence) and 19 partial response (initial disappearance of symptoms with subsequent reappearance). Surgery (Heller myotomy) was required in 15.8% of the patients. Perforation occurred in 4 of the 171 patients as a complication of the technique; these perforations were satisfactorily resolved, two by conservative treatment and two by surgery. There was no mortality associated with the technique or its complications. In our series, pneumatic dilation had a

"Wish You Were Here": Examining Characteristics, Outcomes, and Statistical Solutions for Missing Cases in Web-Based Psychotherapeutic Trials.

PubMed

Karin, Eyal; Dear, Blake F; Heller, Gillian Z; Crane, Monique F; Titov, Nickolai

2018-04-19

likelihood and jointly predict lesser clinical improvement. Under such circumstances, individuals with potentially worst off treatment outcomes can become concealed, and failure to adjust for this can lead to substantial clinical measurement bias. Together, this preliminary research suggests that missing cases in Web-based psychotherapeutic interventions may not occur as random events and can be systematically predicted. Critically, at the same time, missing cases may experience outcomes that are distinct and important for a complete understanding of the treatment effect. ©Eyal Karin, Blake F Dear, Gillian Z Heller, Monique F Crane, Nickolai Titov. Originally published in JMIR Mental Health (http://mental.jmir.org), 19.04.2018.

The California Alliance for Sustainability: A Collaborative Pilot Project to Build Regional Advocacy and Leadership for Sustainability Education

NASA Astrophysics Data System (ADS)

Metzger, E. P.; Smith, G.; Cordero, E. C.; Santone, S.

2012-12-01

For Education for Sustainability (Efs) to have the presence in the K-12 curriculum that it arguably should, considerable obstacles must be overcome. Barriers include the role of high-stakes testing in marginalizing science and social studies and the lack of environmental and sustainability content in teacher education programs. The California Alliance for Sustainability (CASE), a collaborative 18-month project funded by the Clarence E. Heller Charitable Foundation, unites San José State University (SJSU) and Creative Change Educational Solutions (CCES) (http://www.creativechange.net/) to investigate and address potential barriers to Efs in San Francisco Bay area schools and regional teacher education programs and to document best practices for integrating sustainability into teachers' existing standards-based teaching. The overarching goal of the CASE project is to create a regional infrastructure of K-12 teachers and pre-service teacher educators who use EfS as a context for educational innovation and transformation, thus supplying a focused first step for investigating how Efs can be more broadly implemented in California's classrooms. This presentation will showcase the efforts of a pilot group of classroom teachers and teacher educators to bring EfS to their teaching. In summer 2012, the CASE Project provided 16 in-service teachers and 5 pre-service teacher education faculty from SJSU and California State University East Bay with a three-day professional development workshop. Practicing teachers and teacher educators experienced joint instruction in the content and pedagogy of sustainability though investigation of topics (e.g., Sustainable Communities, Ecological Footprint Analysis, Climate Change, Resource Use, Food Systems and Life Cycle Analysis) that offer broad connections to California standards in science and other disciplines. Sustainability concepts were also discussed as an engaging context for addressing the emerging Common Core and Next Generation

Efficacy of peroral endoscopic myotomy vs other achalasia treatments in improving esophageal function.

PubMed

Sanaka, Madhusudhan R; Hayat, Umar; Thota, Prashanthi N; Jegadeesan, Ramprasad; Ray, Monica; Gabbard, Scott L; Wadhwa, Neha; Lopez, Rocio; Baker, Mark E; Murthy, Sudish; Raja, Siva

2016-05-28

To assess and compare the esophageal function after peroral endoscopic myotomy (POEM) vs other conventional treatments in achalasia. Chart review of all achalasia patients who underwent POEM, laparoscopic Heller myotomy (LHM) or pneumatic dilation (PD) at our institution between January 2012 and March 2015 was performed. Patient demographics, type of achalasia, prior treatments, pre- and post-treatment timed barium swallow (TBE) and high-resolution esophageal manometry (HREM) findings were compared between the three treatment groups. Patients who had both pre- and 2 mo post-treatment TBE or HREM were included in the final analysis. TBE parameters compared were barium column height, width and volume of barium remaining at 1 and 5 min. HREM parameters compared were basal lower esophageal sphincter (LES) pressures and LES-integrated relaxation pressures (IRP). Data are presented as mean ± SD, median [25(th), 75(th) percentiles] or frequency (percent). Analysis of variance, Kruskal-Wallis test, Pearsons χ(2) test and Fishers Exact tests were used for analysis. A total of 200 achalasia patients were included of which 36 underwent POEM, 22 underwent PD and 142 underwent LHM. POEM patients were older (55.4 ± 16.8 years vs 46.5 ± 15.7 years, P = 0.013) and had higher BMI than LHM (29.1 ± 5.9 kg/m(2) vs 26 ± 5.1 kg/m(2), P = 0.012). More number of patients in POEM and PD groups had undergone prior treatments compared to LHM group (72.2% vs 68.2% vs 44.3% respectively, P = 0.003). At 2 mo post-treatment, all TBE parameters including barium column height, width and volume remaining at 1 and 5 min improved significantly in all three treatment groups (P = 0.01 to P < 0.001) except the column height at 1 min in PD group (P = 0.11) . At 2 mo post-treatment, there was significant improvement in basal LES pressure and LES-IRP in both LHM (40.5 mmHg vs 14.5 mmHg and 24 mmHg vs 7.1 mmHg respectively, P < 0.001) and POEM groups (38.7 mmHg vs 11.4 mmHg and 23.6 mmHg vs 6.6 mm

Efficacy of peroral endoscopic myotomy vs other achalasia treatments in improving esophageal function

PubMed Central

Sanaka, Madhusudhan R; Hayat, Umar; Thota, Prashanthi N; Jegadeesan, Ramprasad; Ray, Monica; Gabbard, Scott L; Wadhwa, Neha; Lopez, Rocio; Baker, Mark E; Murthy, Sudish; Raja, Siva

2016-01-01

AIM: To assess and compare the esophageal function after peroral endoscopic myotomy (POEM) vs other conventional treatments in achalasia. METHODS: Chart review of all achalasia patients who underwent POEM, laparoscopic Heller myotomy (LHM) or pneumatic dilation (PD) at our institution between January 2012 and March 2015 was performed. Patient demographics, type of achalasia, prior treatments, pre- and post-treatment timed barium swallow (TBE) and high-resolution esophageal manometry (HREM) findings were compared between the three treatment groups. Patients who had both pre- and 2 mo post-treatment TBE or HREM were included in the final analysis. TBE parameters compared were barium column height, width and volume of barium remaining at 1 and 5 min. HREM parameters compared were basal lower esophageal sphincter (LES) pressures and LES-integrated relaxation pressures (IRP). Data are presented as mean ± SD, median [25th, 75th percentiles] or frequency (percent). Analysis of variance, Kruskal-Wallis test, Pearsons χ2 test and Fishers Exact tests were used for analysis. RESULTS: A total of 200 achalasia patients were included of which 36 underwent POEM, 22 underwent PD and 142 underwent LHM. POEM patients were older (55.4 ± 16.8 years vs 46.5 ± 15.7 years, P = 0.013) and had higher BMI than LHM (29.1 ± 5.9 kg/m2 vs 26 ± 5.1 kg/m2, P = 0.012). More number of patients in POEM and PD groups had undergone prior treatments compared to LHM group (72.2% vs 68.2% vs 44.3% respectively, P = 0.003). At 2 mo post-treatment, all TBE parameters including barium column height, width and volume remaining at 1 and 5 min improved significantly in all three treatment groups (P = 0.01 to P < 0.001) except the column height at 1 min in PD group (P = 0.11) . At 2 mo post-treatment, there was significant improvement in basal LES pressure and LES-IRP in both LHM (40.5 mmHg vs 14.5 mmHg and 24 mmHg vs 7.1 mmHg respectively, P < 0.001) and POEM groups (38.7 mmHg vs 11.4 mmHg and 23.6 mm

Petrology and Eruptive Styles of Central WA Teanaway Basalt: Uplift and Bimodal Volcanism in Subsiding Eocene Basin

NASA Astrophysics Data System (ADS)

Ivener, D.; Tepper, J. H.

2013-12-01

The 47 Ma Teanaway Basalt (TB) is a bimodal unit that erupted in Central Washington during the poorly-understood Challis Event. The TB consists of over 2500 meters of subaerial mafic flows, hyaloclastite, rhyolite domes, and tuff. In order to better understand the origin and tectonic setting of the TB, we have studied three localities that encompass the geographic extent of the unit: Easton Ridge (ER), Teanaway River Middle Fork (MF), and Liberty Ridge (LR). The TB lies stratigraphically between two thick arkosic sedimentary units (Swauk and Roslyn Formations) that are thought to have accumulated in a rapidly subsiding basin (Tabor et al., 1990). The gently-dipping, 380 meter thick, MF section is comprised of subaerial flows interbedded with hyaloclastite layers; no pillows were observed. These observations suggest that the TB erupted in shallow water and that the rate of subsidence was approximately equal to the rate of construction. In addition, the absence of arkosic interbeds within the MF section suggests that the sediment supply to the basin was interrupted during TB eruptions and/or that the basin was a highland during this period. Based on tectonic reconstructions (Heller et al., 1987), which place the Kula-Farallon Ridge in this area during the Eocene, we suggest that uplift during TB magmatism is a result of ridge subduction. Furthermore, the evidence of extensional dikes at a convergent margin can be accounted for by the subduction of a spreading ridge. Mafic TB lavas are moderately evolved (45.2 - 63.1 wt. % SiO2, Mg # = 0.13-0.48). These rocks are aphanitic to very fine-grained with sparse phenocrysts of plagioclase. These flows are commonly either massive or display spectacular columnar jointing and range in thickness from less than two feet to almost 150 feet (Clayton, 1973). They show extensive compositional overlap with dikes in the underlying Swauk Formation although the dikes tend to be slightly more primitive. These data support interpretation

Preface

USGS Publications Warehouse

Horton, J. Wright; Chapman, Martin C.; Green, Russell A.

2015-01-01

This book grew out of a topical session on “Central Virginia Earthquakes of 2011: Geology, Geophysics, and Significance for Seismic Hazards in Eastern North America” at the 2012 The Geological Society of America (GSA) Annual Meeting in Charlotte, North Carolina (USA). It also benefitted from related sessions at other meetings. The goal of this volume, The 2011 Mineral, Virginia, Earthquake, and Its Significance for Seismic Hazards in Eastern North America, is to bring together as much information as possible on lessons learned from this rare event. Chapters encompass a wide range of geoscience, engineering, and related studies of this earthquake and its effects from the epicentral area in central Virginia to Washington, D.C., and beyond. The intended audience is a broad spectrum of geoscientists, engineers, and decision makers interested in understanding earthquakes and seismic hazards in eastern North America and other intraplate settings. Chapters by Berti et al. (21), Chapman (2), Costain (8), Davenport et al. (15), Green et al. (9), Heller and Carter (10), Horton et al. (14), Hughes et al. (19), Powars et al. (23), Pratt et al. (16), Roeloffs et al. (7), Shah et al. (17), Stephenson et al. (3), Walsh et al. (18), and Wells et al. (12) are expansions of presentations at the 2012 GSA meeting. The volume also contains chapters from recent studies that were not presented at the GSA meeting, including those by Bobyarchick (22), Burton et al. (20), Dreiling and Mooney (5), Li et al. (11), McNamara et al. (4), Pollitz and Mooney (6), and Shahidi et al. (13). Following an overview and synthesis by the volume editors (1), chapters are arranged under the topical headings “Seismology and Regional Effects,” “Earthquake Damage, Geotechnical, and Engineering Investigations,” “Aftershocks, Geophysical Imaging, and Modeling,” “Geologic Investigations—Epicentral Area,” and “Geologic Investigations— Central Virginia Seismic Zone and Nearby Faults

Esophageal cancer screening in achalasia: is there a consensus?

PubMed

Ravi, K; Geno, D M; Katzka, D A

2015-04-01

Achalasia is an important but relatively uncommon disorder. While highly effective therapeutic options exist, esophageal cancer remains a long-term potential complication. The risk of esophageal cancer in achalasia remains unclear, with current guidelines recommending against routine endoscopic screening. However, given limited data and conflicting opinion, it is unknown whether consensus regarding screening practices in achalasia among experts exists. A 10-question survey to assess screening practices in achalasia was created and distributed to 28 experts in the area of achalasia. Experts were identified based on publications and meeting presentations in the field. Survey responses were received from 17 of 28 (61%) experts. Wide geographic distribution was seen among respondents, with eight (47%) from Europe or Australia, seven (41%) from the United States, and two (12%) from Asia. Screening for esophageal cancer was inconsistent, with nine (53%) experts endorsing the practice and eight (47%) not. Screening practices did not differ among geographic regions. No consensus regarding the risk for esophageal cancer in achalasia was seen, with three experts reporting no increased risk compared with the general population, eight experts a lifetime risk of 0.1-0.5%, three experts a 0.5-1% risk, two experts a 1-2% risk, and one expert a 3-5% risk. However, these differences in perception of risk did not influence screening practices. Upper endoscopy was utilized among all experts who endorsed screening. However, practices still varied with screening commencing at or within 1 year of diagnosis in two practices compared with 5 and 10 years in three respective practices each. Surveillance intervals also varied, performed every 2 years in four practices, every 3 years in four practices, and every 5 years in one practice. Practice variation in the management of achalasia itself was also seen, with initial treatment with Heller myotomy endorsed by eight experts, pneumatic

Clackamas/Hood River Habitat Enhancement Program, 1987 Annual Report.

DOE Office of Scientific and Technical Information (OSTI.GOV)

MacDonald, Ken; Cain, Thomas C.; Heller, David A.

1988-03-01

a variety of species and age group: of salmon and trout can rear. It also results in the sorting of gravel, rubble, and boulders being transported downstream, creating high quality spawning and rearing habitats, and food producing areas. In 1987, a total of 11.0 miles of stream were treated; 334 log structures (Including: ''deflector'', ''digger'', ''sill'', and ''cover'' logs) and 141 boulder structures (including: single boulder placement, ''berms'', ''alcoves'', and ''clusters'') were completed to meet habitat improvement objectives. In addition to these direct habitat improvement activities, BPA and the Forest Service financed a number of project and program assessment activities that have improved the efficiency and effectiveness of the Forest's fisheries management program. Notable findings relate to the durability of habitat improvement structures, the associated changes in physical habitat, and biological response to the improvement activities. A discussion of the 1987 habitat monitoring and evaluation program results can be found in the supplemental document, Appendix: Monitoring and Evaluation of Mt. Hood National Forest Stream Habitat Improvement and Rehabilitation Projects: 1987 Annual Report (Forsgren, Heller, and Ober, 1988).« less

The study of the geomagnetic excursions and the relative intensities from Chinese loess 10Be over the past 130 ka

NASA Astrophysics Data System (ADS)

Zhou, W.; Xian, F.; Beck, J.; An, Z.; Wu, Z.; Liu, M.; Chen, M.; Priller, A.; Kutschera, W.; Jull, A. T.; Yu, H.; Song, S.; Cheng, P.; Kong, X.

2009-12-01

., 34, L17306. 4. Shen, C. D., J. Beer, T. S. Liu, H. Oeschger, G. Bonani, M. Suter, and W.Wolfli (1992), 10Be in Chinese loess, Earth Planet. Sci. Lett., 109(1-2), 169-177. 5. Gu, Z. Y., D. Lal, T. S. Liu, J. Southon, M. W. Caffee, Z. T. Guo, and M. Y.Chen (1996), Five million year 10Be record in Chinese loess and red-clay: climate and weathering relationships, Earth Planet. Sci. Lett., 144(1-2), 273-287. 6. Beer, J., C. D. Shen, F. Heller ,T.S. Liu, G. Bonani, B. Dittrich, M. Suter, and P.W. Kubik (1993), 10Be and magnetic susceptibility in Chinese Loess, Geophys. Res. Lett., 20(1), 57-60 7. Channell, J. E. T.(2006), Late Brunhes polarity excursions (Mono Lake, Laschamp, Iceland Basin and Pringle Falls) recorded at ODP Site 919 (Irminger Basin), Earth Planet. Sci. Lett., 244(1-2), 378-393.

Smart plants, smart models? On adaptive responses in vegetation-soil systems

NASA Astrophysics Data System (ADS)

van der Ploeg, Martine; Teuling, Ryan; van Dam, Nicole; de Rooij, Gerrit

2015-04-01

functional type. Assigning plant functional types does not allow for local plant adaptation to be reflected in the model parameters, nor does it allow for correlations that might exist between root parameters and soil type. [1] Seibert, J. 2000. Multi-criteria calibration of a conceptual runoff model using a genetic algorithm. Hydrology and Earth System Sciences 4(2): 215-224. [2] Van der Ploeg, M.J., H.P.A. Gooren, G. Bakker, C.W. Hoogendam, C. Huiskes, L.K. Koopal, H. Kruidhof and G.H. de Rooij. 2010. Polymer tensiometers with ceramic cones: performance in drying soils and comparison with water-filled tensiometers and time domain reflectometry. Hydrol. Earth Syst. Sci. 14: 1787-1799, doi: 10.5194/hess-14-1787-2010. [3] McClintock B. The significance of responses of the genome to challenge. Science 1984; 226: 792-801 [4] Ries G, Heller W, Puchta H, Sandermann H, Seldlitz HK, Hohn B. Elevated UV-B radiation reduces genome stability in plants. Nature 2000; 406: 98-101 [5] Lucht JM, Mauch-Mani B, Steiner H-Y, Metraux J-P, Ryals, J, Hohn B. Pathogen stress increases somatic recombination frequency in Arabidopsis. Nature Genet. 2002; 30: 311-314 [6] Kovalchuk I, Kovalchuk O, Kalck V., Boyko V, Filkowski J, Heinlein M, Hohn B. Pathogen-induced systemic plant signal triggers DNA rearrangements. Nature 2003; 423: 760-762 [7] Cullis C A. Mechanisms and control of rapid genomic changes in flax. Ann. Bot. (Lond.) 2005; 95: 201-206

Quantum Chaos

NASA Astrophysics Data System (ADS)

Casati, Giulio; Chirikov, Boris

2006-11-01

in two-electron atoms R. Blümel and W. P. Reinhardt; Part III. Semiclassical Approximations: 20. Semiclassical theory of spectral rigidity M. V. Berry; 21. Semiclassical structure of trace formulas R. G. Littlejohn; 22. h-Expansion for quantum trace formulas P. Gaspard; 23. Pinball scattering B. Eckhardt, G. Russberg, P. Cvitanovic, P. E. Rosenqvist and P. Scherer; 24. Logarithm breaking time in quantum chaos G. P. Berman and G. M. Zaslavsky; 25. Semiclassical propagation: how long can it last? M. A. Sepulveda, S. Tomsovic and E. J. Heller; 26. The quantized Baker's transformation N. L. Balazs and A. Voros; 27. Classical structures in the quantized baker transformation M. Saraceno; 28. Quantum nodal points as fingerprints of classical chaos P. Leboeuf and A. Voros; 29. Chaology of action billiards A. M. Ozorio de Almeida and M. A. M. de Aguiar; Part IV. Level Statistics and Random Matrix Theory: 30. Characterization of chaotic quantum spectra and universality of level fluctuation laws O. Bohigas, M. J. Giannono, and C. Schmit; 31. Quantum chaos, localization and band random matrices F. M. Izrailev; 32. Structural invariance in channel space: a step toward understanding chaotic scattering in quantum mechanics T. H. Seligman; 33. Spectral properties of a Fermi accelerating disk R. Badrinarayanan and J. J. José; 34. Spectral properties of systems with dynamical localization T. Dittrich and U. Smilansky; 35. Unbound quantum diffusion and fractal spectra T. Geisel, R. Ketzmerick and G. Petschel; 36. Microwave studies in irregularly shaped billiards H.-J. Stöckmann, J. Stein and M. Kollman; Index.

Quantum Chaos

NASA Astrophysics Data System (ADS)

Casati, Giulio; Chirikov, Boris

1995-04-01

in two-electron atoms R. Blümel and W. P. Reinhardt; Part III. Semiclassical Approximations: 20. Semiclassical theory of spectral rigidity M. V. Berry; 21. Semiclassical structure of trace formulas R. G. Littlejohn; 22. h-Expansion for quantum trace formulas P. Gaspard; 23. Pinball scattering B. Eckhardt, G. Russberg, P. Cvitanovic, P. E. Rosenqvist and P. Scherer; 24. Logarithm breaking time in quantum chaos G. P. Berman and G. M. Zaslavsky; 25. Semiclassical propagation: how long can it last? M. A. Sepulveda, S. Tomsovic and E. J. Heller; 26. The quantized Baker's transformation N. L. Balazs and A. Voros; 27. Classical structures in the quantized baker transformation M. Saraceno; 28. Quantum nodal points as fingerprints of classical chaos P. Leboeuf and A. Voros; 29. Chaology of action billiards A. M. Ozorio de Almeida and M. A. M. de Aguiar; Part IV. Level Statistics and Random Matrix Theory: 30. Characterization of chaotic quantum spectra and universality of level fluctuation laws O. Bohigas, M. J. Giannono, and C. Schmit; 31. Quantum chaos, localization and band random matrices F. M. Izrailev; 32. Structural invariance in channel space: a step toward understanding chaotic scattering in quantum mechanics T. H. Seligman; 33. Spectral properties of a Fermi accelerating disk R. Badrinarayanan and J. J. José; 34. Spectral properties of systems with dynamical localization T. Dittrich and U. Smilansky; 35. Unbound quantum diffusion and fractal spectra T. Geisel, R. Ketzmerick and G. Petschel; 36. Microwave studies in irregularly shaped billiards H.-J. Stöckmann, J. Stein and M. Kollman; Index.

Plant adaptive behaviour in hydrological models (Invited)

NASA Astrophysics Data System (ADS)

van der Ploeg, M. J.; Teuling, R.

2013-12-01

-224. [2] McClintock B. The significance of responses of the genome to challenge. Science 1984; 226: 792-801 [3] Ries G, Heller W, Puchta H, Sandermann H, Seldlitz HK, Hohn B. Elevated UV-B radiation reduces genome stability in plants. Nature 2000; 406: 98-101 [4] Lucht JM, Mauch-Mani B, Steiner H-Y, Metraux J-P, Ryals, J, Hohn B. Pathogen stress increases somatic recombination frequency in Arabidopsis. Nature Genet. 2002; 30: 311-314 [5] Kovalchuk I, Kovalchuk O, Kalck V., Boyko V, Filkowski J, Heinlein M, Hohn B. Pathogen-induced systemic plant signal triggers DNA rearrangements. Nature 2003; 423: 760-762 [6] Cullis C A. Mechanisms and control of rapid genomic changes in flax. Ann. Bot. (Lond.) 2005; 95: 201-206 [7] de Rosnay, P. and J. Polcher. 1998. Modelling root water uptake in a complex land surface scheme coupled to a GCM. Hydrology and Earth System Sciences 2: 239-255. [8] Feddes, R.A., H. Hoff, M. Bruen, T. Dawson, P. de Rosnay, P. Dirmeyer, R.B. Jackson, P. Kabat, A. Kleidon, A. Lilly, and A.J. Pitman. 2001. Modeling root water uptake in hydrological and climate models. Bulletin of the American Meteorological Society 82: 2797-2809. [9] Jung, M., M. Reichstein, P. Ciais, S.I. Seneviratne, J. Sheffield et al. 2010. Recent decline in the global land evaporation trend due to limited moisture supply. Nature 476: 951-954, doi:10.1038/nature09396.

Electron Paramagnetic Resonance: Elementary Theory and Practical Applications, Second Edition (John A. Weil and James R. Bolton)

NASA Astrophysics Data System (ADS)

Williams, Ffrancon

2009-01-01

-orbital (MO) theory for estimating the spin distribution in π-type organic radicals, reference is only made to the 1968 INDO program although it was supplanted in the 1990s by more accurate DFT (density functional theory) methods (9) . Moreover, in suggestions for further reading on the relations between hyperfine splittings and spin densities, the preponderance of the references are to works in the 1960s except for the 1993 Atherton book (10) and the 2003 text by Gerson and Hüber (3) . Appendix 9A on the use of Hückel MO calculations in π-electron systems is retained, but in Section 9.2 on π-type organic radicals there is no mention of the cases of symmetry-enhanced and symmetry-forbidden hyperconjugation in cyclic systems. Such effects are exemplified by the β-hydrogen couplings in the cyclohexadienyl and cyclobutenyl radicals where the symmetry of the SOMO is the determining factor and the usual McConnell-Heller equation (11) for the proportionality between the α-carbon spin density and -hydrogen hyperfine coupling does not apply ( 12, 13 ). In fact, these EPR results that depend on the amplitude of the wave function provide a direct illustration of the operation of the superposition principle in quantum mechanics ( 14 ). The above omissions bring to mind that at least one major area of EPR applications is not covered here in any depth. This pertains to work carried out over the last four decades in the field of physical organic chemistry. There are, for example, no references to the extensive studies of G. A. Russell, K. U. Ingold, and J. K. Kochi that have contributed greatly to our detailed understanding of both the structure and the kinetic transformations of organic radicals. Another field that is completely neglected is that of radical cations derived from saturated molecules, despite a considerable level of activity during the 1980s and 1990s as represented particularly by the innovative work of M. Iwasaki on alkanes and of L. B. Knight, Jr. on water, methane

List of Participants

NASA Astrophysics Data System (ADS)

2007-11-01

Heller Jagiellonian University, Krakow Samuli Hemming University of Iceland Yasuaki Hikida DESY, Hamburg Christian Hillmann Max-Planck-Institut für Gravitationsphysik, Potsdam Stephan Hoehne Max-Planck-Institut für Physik, München Gabriele Honecker CERN, Geneva Carlos Hoyos University of Wales, Swansea Mechthild Huebscher Consejo Superior de Investigaciones Cientificas, Madrid Matthias Ihl University of Texas at Austin Emiliano Imeroni University of Wales, Swansea Nikos Irges University of Crete Negru Iulian University of Craiova Matthias Kaminski Ludwig-Maximilians-Universität, München Stefanos Katmadas Universiteit Utrecht Shoichi Kawamoto Oxford University Christoph Keller Eidgenössische Technische Hochschule, Zürich Arjan Keurentjes Vrije Universiteit, Brussel Sadi Khodaee Institute for Advanced Studies in Basic Sciences (IASBS), Zanjan, Iran Michael Kiermaier Massachusetts Institute of Technology, Cambridge, MA Elias Kiritsis Centre de Physique Théorique, École Polytechnique, Palaiseau and University of Crete Ingo KirschEidgenössische Technische Hochschule, Zürich Johanna Knapp CERN, Geneva Paul Koerber Max-Planck-Institut für Physik, München Simon Koers Max-Planck-Institut für Physik, München Anatoly Konechny Heriot-Watt University, Edinburgh Peter Koroteev Institute for Theoretical and Experimental Physics (ITEP), Moscow Daniel KreflLudwig-Maximilians-Universität and Max-Planck-Institut für Physik, München Chethan KrishnanUniversité Libre de Bruxelles Stanislav Kuperstein Université Libre de Bruxelles Alberto Lerda Università del Piemonte Orientale, Alessandria Roman Linares Universidad Autonoma Metropolitana, Iztapalapa, México Maria A Lledo Universidad de Valencia Dieter Luest Ludwig-Maximilians-Universität and Max-Planck-Institut für Physik, München Joseph Lykken Fermi National Accelerator Laboratory (Fermilab), Batavia, IL Carlo Maccaferri Vrije Universiteit, Brussel Oscar Macia Universidad de Valencia Tristan Maillard Centre de

Quantitative Analysis of Piezoelectric and Seismoelectric Anomalies in Subsurface Geophysics

NASA Astrophysics Data System (ADS)

Eppelbaum, Lev

2017-04-01

, M.D., Smeulders, D.M.J., Slob, E.C. and Heller, H.K.J., 2011. Seismoelectric interface response: Experimental results and forward model. Geophysics, 76, No. 4, p. N29-N36.