Laparoscopic anterior esophageal myotomy and toupet fundoplication for achalasia.

Achalasia is an esophageal motility disorder characterized by the failure of lower esophageal sphincter relaxation and the absence of esophageal peristalsis. The purpose of this study was to evaluate the clinical outcomes of patients undergoing laparoscopic esophageal myotomy and Toupet fundoplication for achalasia. A 9-cm myotomy was performed in most cases extending 7 cm above and 2 cm below the gastroesophageal junction. Severity of dysphagia, heartburn, chest pain, and regurgitation was graded preoperatively and postoperatively using a five-point symptomatic scale (0-4). Patients also graded their outcomes as excellent, good, fair, or poor. Between December 1995 and November 2000 a total of 49 patients (23 male, 26 female) with a mean age of 44.3 years (range 23-71 years) were diagnosed with achalasia. Mean duration of symptoms was 40.2 months (range 4-240 months). Thirty-seven patients (76%) had had a previous nonsurgical intervention or combinations of nonsurgical interventions [pneumatic dilation (23), bougie dilation (five), and botulinum toxin (19)], and two patients had failed esophageal myotomies. Forty-five patients underwent laparoscopic esophageal myotomy and Toupet fundoplication. Two patients received laparoscopic esophageal myotomies without an antireflux procedure, and two were converted to open surgery. One patient presented 10 hours after a pneumatically induced perforation and underwent a successful laparoscopic esophageal myotomy and partial fundoplication. Mean operative time was 180.5 minutes (range 145-264 minutes). Mean length of stay was 1.98 days (range 1-18 days). There were five (10%) perioperative complications but no esophageal leaks. There was a significant difference (P < 0.05) between the preoperative and postoperative dysphagia, chest pain, and regurgitation symptom scores. All patients stated that they were improved postoperatively. Eighty-six per cent rated their outcome as excellent, 10 per cent as good, and 4 per cent as fair. Laparoscopic anterior esophageal myotomy and Toupet fundoplication effectively alleviates dysphagia, regurgitation, and chest pain accompanying achalasia and is associated with high patient satisfaction, a rapid hospital discharge, and few complications.

Lack of efficacy of ketorolac tromethamine for analgesia on patients undergoing colonoscopy.

Ketorolac tromethamine (KT) is a new non-narcotic parenteral analgesic which lacks the respiratory depressant and hypotensive side effects of narcotics. Our aim was to determine whether KT can reduce requirements for narcotics and narcotic side effects in colonoscopy. In a randomized, double-blind trial, either intravenous KT (n = 30) or placebo (n = 30) was administered as a preprocedure analgesic to male patients undergoing colonoscopy. Patients who had pain during colonoscopy received supplemental diazepam and meperidine as required to maintain comfort. KT treatment did not affect patient comfort. No significant difference in the dose of diazepam or meperidine required was noted between the study and the placebo group, and there was no difference in the number of patients who required supplemental narcotics. The incidences of hypotension or arterial oxygen desaturation were similar in the KT- and placebo-treated patients. Ten patients in the KT group and four patients in the placebo group reported discomfort at the site of injection. We conclude that intravenous ketorolac tromethamine is no better than placebo as an analgesic premedication in colonoscopy.