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Do my capstone logistics baytown write for me average age menstruation starts looking for someone to type my dissertation conclusion on high school students due tomorrow bill Richards who's going to talk to us about reoperation for failed Heller myotomy bill thank you for coming were interested in what you're going to have to say okay thank you very much I'm going to take a little bit different tact and tell you about some of the thoughts that I have before I even approach someone to do a redo Heller myotomy can I have my sides seem to be advancing here I have nothing to disclose except that I'm extremely biased towards laparoscopic eller plus door fundoplication with intraoperative endoscopic evaluation so achalasia has two motility problems you have a non relaxing hypertensive le s non relaxing hypertensive le s so you have a functional obstruction at the bottom of the esophagus and you have a peristalsis with the Heller myotomy all we're doing is reducing le s pressure we're doing nothing for the a peristalsis so one thing is to think about how why what patients do we get good results with Heller myotomy well if you look at our studies if you have a higher preoperative le s pressure in other words if you have more le s pressure more obstruction doing a hell of my outta me reducing pressure gives better results another way to look at it if you look at the post op le s pressure if you get the post-op ileus pressure below 18 we have much less dysphasia if it's greater than 18 it's much greater so doing a longer myotomy is the thing to do the other thing that you can say is if the change in le s pressure in other words the change difference between the pre-op and the post-op pressure is greater then you have less dysphasia okay how to lower le s pressure intra-operative endoscopy is critical and you have to extend it on to the stomach which means you have to tease it out and it's rather tedious and anc's provoking I really do think that the endoscopic appearance and doing the video endoscopy at the same time is critical either have one of your other surgeons in the department do the procedure because I find that the guest neurologists just tire of the back and forth and they want to do the in and out and they will not stay for you to do an adequate Hillary myotomy okay experience improves the results this is our first hundred procedures and you can see 83% had response our second hundred procedures eighty-seven percent so experience does matter the Safa deal acid exposure symptoms don't correlate with acid exposure you also we have to think about reduce Delhi s pressure but also reduced esophageal clearance is a major major pathophysiology of why these patients develop severe reflux so again we're creating a defective lower esophageal sphincter when we're doing the Heller myotomy certainly if you have a hiatal hernia you've got to repair that this is a typical post Heller upright reflux even still you can see that in some of these you can see here in the distal port my laser is not working in the distal port you still have prolonged reflux there I think clearance of acid is critical to think about when you're looking at patients with reflux this is a post Heller recumbent reflux and you can see that the reflux eight stays in the esophagus and the distal esophagus and just stays there the esophagus is not able to clear it so one of the things to tell your patience is put them on ppis and everything else this is our technique of the door fundoplication I think it's more than just a one or two stitch fundoplication you want to accentuate the angle of his-- you want to place your door fundoplication to cover the entire myotomy Jerry freed told me earlier today that he scenes several pseudo diverticulum occur above the door fundoplication if you just do a very short door fundoplication we do try to do a long door fundoplication during that and cover the exact thing this is from our paper several years ago in which we randomize patients to Heller versus Heller + door and it's wanted to point out that the Heller plus door had a significantly very substantial rate reduced rate of oesophageal acid exposure the Heller post or only nine point one percent of the patients had pathologic reflux versus forty seven percent in their Heller alone so concluding just for this part the door fundoplication really does significantly reduce post-op GERD but you have to do it so that you accentuate the angle of his-- cover the entire myotomy relief of dysphasia is similar in both techniques Heller + door is our preferred treatment so what do you got you've got a patient with post-op symptoms after Heller myotomy well number one these patients have really screwy symptoms so regurgitation might mean that you've got pour le s pressure reduction it may mean that they have very poor clearance so you got to do your barium swallow you gotta do endoscopy you got to repeat the manometry and you have to do pH you got to do all of these because you got to get objective evidence of what the hell's going on okay the barium swallow of all those is the most helpful it tells you whether or not you've got diverticula diverticulum a dilation of the esophagus if you have the typical classic Sigma weight esophagus you've got that big esophagus you're not going to do anything by doing repeat myotomy you're going to look at the length of narrowing in the presence or absence of a hiatal hernia manometry basically the way I look at it if you've got an Elias pressure greater than 18 millimeters mercury it's worthwhile to redo the my enemy if it's less than 18 it's not going to be worthwhile if you've got an el es greater than 35 you're going to have a really good result one of the essential things is if these patients have obstruction at the el es no amount of fasting is going to clear that so I put them on a liquid diet preoperatively I notify anesthesia whether or not make sense or not to do a rapid sequence intubation I'm not here to debate that but medically legally tell your anesthesiologist of your concern prepare for it and prepare the patient ok here's the video of we're doing a redo Heller it's much more likely that you're going to get into a perforation this is video that we put together a couple years ago with Brandon Williams again I I really think that the simultaneous video endoscopy is critical to determine the extent of your myotomy and to gauge whether or not you've got a perforation here we're doing the procedure you've got to be really patient doing these procedures here I think we're just a little bit too vigorous trying to get this off here and we can easily see is there any way we can speed this up a little bit there you can easily see the little hole here I use 50 monofilament to absorbable suture here to sew this up I've tended to use a running suture in this particular instance we're using some interrupted sutures that tend to work pretty well I tend not to use the braided sutures even though I use braided sutures virtually every place else this mucosa is oftentimes just so friable you want the monofilament so it goes easily through the tissues really want to get down to the point where we're going to test this because I think this is a critical testing testing testing yield some you know some sort of funny results and again one of the critical things too that you want to make sure once you've got a in Tarata me here in the proximal esophagus you want to make sure that your myotomy extends down because it's critical not to have high intra-assay fidel pressure okay so now we're going to do our testing and lo and behold you see the bubbles coming up you didn't see that before so I'm here to say that i really think that intra-operative endoscopy is key let me end it there and thank saz's for the privilege of presenting this afternoon next up is dr. Joe friedberg and he's going to be talking about the worker's copic management of postoperative chylothorax Joe bus 599 assignment 4 capstone project online Yeshiva College, Washington Heights, Manhattan.