| 1. |
- Andersson, Mats, 1954, et al.
(författare)
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Evaluation of the response to treatment in patients with idiopathic achalasia by the timed barium esophagogram: results from a randomized clinical trial.
- 2009
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Ingår i: Diseases of the Esophagus. - : Oxford University Press (OUP). - 1442-2050 .- 1120-8694. ; 22:3, s. 264-73
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Tidskriftsartikel (refereegranskat)abstract
- To choose which treatment would be most effective for the individual patient with newly diagnosed achalasia is difficult for the tending physician. A diagnostic tool that would allow prediction of the symptomatic and functional response after treatment for achalasia is therefore needed. The timed barium esophagogram (TBE) is a method that allows objective assessment of esophageal emptying, but the value of TBE in the clinical management of achalasia remains to be clarified. The aim of this study was first, to assess the ability of TBE to predict symptoms and treatment failure during post-treatment follow-up. Second, to determine whether esophageal emptying as assessed by TBE differs after treatment with pneumatic dilatation or laparoscopic myotomy. Fifty-one patients with newly diagnosed achalasia were prospectively randomized to pneumatic dilatation (n = 26) or laparoscopic myotomy (n = 25). Evaluation with TBE was performed before (n = 46) and after treatment (n = 43). The median interval between treatment and post-treatment TBE was 6 months, and the median follow-up time after the post-treatment TBE was 18 months. Following therapeutic intervention, TBE parameters did not differ significantly between treatment groups. However, significant correlations were found between the height of the barium column at 1 min and the symptom scores at the end of follow up for 'dysphagia for liquids' (P < 0.05, rho = 0.47), 'chest pain' (P < 0.05, rho = 0.42), and the 'Watson dysphagia score' (P < 0.05, rho = 0.46). Patients with less than 50% improvement in this TBE-parameter (height at 1 min) post-treatment had a 40% risk of treatment failure during follow-up. In summary, pneumatic balloon dilatation and laparoscopic myotomy similarly affected esophageal function as assessed by TBE-emptying. Lack of improvement in barium-column height post-treatment was associated with an increased risk of treatment failure which should motivate close surveillance in order to detect symptomatic recurrence at an early stage.
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| 2. |
- Andersson, Mats, 1954, et al.
(författare)
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MRI combined with MR cholangiopancreatography versus helical CT in the evaluation of patients with suspected periampullary tumors: a prospective comparative study
- 2005
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Ingår i: Acta Radiol. - : SAGE Publications. - 0284-1851. ; 46:1, s. 16-27
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: To establish the diagnostic accuracy of MRI including MR cholangiopancreatography (MRCP) compared with helical CT in the differentiation of malignant and benign lesions in the periampullary region. MATERIAL AND METHODS: Fifty-one patients (27 M, 24 F, mean age 66 years, range 39-86 years) with obstructive jaundice and sonographic evidence of intra- and extrahepatic bile duct dilatation (n=31) or suspicion of periampullary tumor, based on previously performed ultrasound and/or CT examination (n=20), were studied. MRI with MRCP and helical CT were reviewed blindly under standardized conditions. Lesion status (differentiation of malignant versus benign) was rated on a 5-point diagnostic confidence scale. Reference standards for comparison were findings at surgery or laparoscopy and/ or the clinical outcome. The predictive value of imaging findings was determined with multivariate logistic regression analysis. RESULTS: The areas under the receiver operating characteristic curve were 0.96 for MRI with MRCP and 0.81 for CT (P <0.05). Multivariate analysis of eight imaging variables at MRI indicated that a stricture with malignant characteristics at MRCP was the best predictor of malignancy. CONCLUSION: MRI with MRCP was significantly more accurate than CT in differentiating between malignant and benign lesions in patients with suspected periampullary tumors, mainly due to the information obtained on the MRCP images of the biliary and pancreatic duct anatomy.
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| 3. |
- Casselbrant, Anna, 1970, et al.
(författare)
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The muscular expression of RAS in patients with achalasia.
- 2015
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Ingår i: Journal of the renin-angiotensin-aldosterone system : JRAAS. - : Hindawi Limited. - 1752-8976 .- 1470-3203. ; 16:3, s. 578-586
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Tidskriftsartikel (refereegranskat)abstract
- Angiotensin II (AngII) elicits smooth muscle contractions via activation of AngII type 1 receptor (AT1R) in the intestinal wall and in sphincter regions in several species. Achalasia is a rare swallowing disorder and is characterized by a loss of the wave-like contraction that forces food through the oesophagus and a failure of the lower oesophageal sphincter to relax during swallowing.Aims and methods:The present study was undertaken to elucidate expression and distribution of a local renin-angiotensin system (RAS) in the muscular layer of distal normal human oesophagus as well as in patients with achalasia using western blot analysis, immunohistochemistry and polymerase chain reaction (PCR).
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| 4. |
- Hyltander, Anders, 1954, et al.
(författare)
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Supportive nutrition on recovery of metabolism, nutritional state, health-related quality of life, and exercise capacity after major surgery: a randomized study
- 2005
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Ingår i: Clinical gastroenterology and hepatology. - 1542-3565. ; 3:5, s. 466-74
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND & AIMS: The aim of this study was to investigate whether specialized supportive enteral and parenteral feeding have superior effects compared to oral nutrition on recovery during long-term postoperative treatment of cancer patients with preoperative weight loss and reduced maximum exercise capacity. METHODS: One hundred twenty-six patients referred for resection of the esophagus (n = 48), stomach (n = 28), or pancreas (n = 50) were considered to be included before operation. Included patients (n = 80) received supportive enteral or parenteral nutrition postoperatively at home corresponding to 1000 kcal/d until the patients did not wish to continue with artificial nutrition for any reason. Patients randomized to oral nutrition only served as control subjects. Caloric intake, body composition (dual-energy x-ray absorptiometry), and respiratory gas exchanges at rest and during exercise were measured including health-related quality of life. RESULTS: Survival and hospital stay did not differ among the groups, whereas overall complications were higher on artificial nutrition (P < .05). Changes in resting energy expenditure and biochemical tests did not differ during follow-up among the groups. Body weight and whole body fat declined similarly over time in all groups (P < .005), whereas lean body mass was unchanged during follow-up compared to preoperative values. Maximum exercise capacity and maximum oxygen consumption were normalized within 6 months postoperatively in all groups. There was no difference in recovery of food intake among the groups. Parenteral feeding was associated with the highest rate of nutrition-related complications, whereas enteral feeding reduced quality of life most extensively. CONCLUSION: After major surgery, specialized supportive enteral and parenteral nutrition are not superior to oral nutrition only when guided by a dietitian.
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| 6. |
- Kostic, Srdjan, 1958, et al.
(författare)
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Health economic evaluation of therapeutic strategies in patients with idiopathic achalasia: results of a randomized trial comparing pneumatic dilatation with laparoscopic cardiomyotomy
- 2007
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Ingår i: Surgical endoscopy. - 1432-2218 .- 0930-2794. ; 21:7, s. 1184-9
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: We have prospectively collected information concerning the costs incurred during the management of patients allocated to either forceful dilatation or to an immediate laparoscopic operation because of newly diagnosed achalasia. METHODS: Fifty-one patients with newly diagnosed achalasia were randomized to either pneumatic dilatation to a diameter of 30-40 mm or to a laparoscopic myotomy to which was added a posterior partial fundoplication. Follow-ups were scheduled at 1, 3, 6, and 12 months after inclusion. At each follow-up visit a study nurse interviewed the patients regarding symptoms and their quality of life (QoL) and a health economic questionnaire was completed. In the latter questionnaire, patients were asked to report the presence and character of contacts with the healthcare system since the last visit. RESULTS: In the dilatation group six patients (23%), including the patient who was operated on because of perforation, were classified as failures during the first 12 months of follow-up compared to one (4%) in the myotomy group (p = 0.047). Five of those classified as failures in the dilatation group subsequently had a surgical myotomy and the sixth patient was treated with repeated dilatations. The patient classified as failure in the myotomy group was treated with endoscopic dilatation. The initial treatment cost and the total costs were significantly higher for laparoscopic myotomy compared to a pneumatic dilatation-based strategy (p = 0.0002 and p = 0.0019, respectively). When the total costs were subdivided into the different resources used, we found that the single largest cost item for pneumatic dilatation was that for hospital stay and that for laparoscopic myotomy was the actual operative treatment (operating room time). The cost-effectiveness analysis, relating to the actual treatment failures, revealed that the cost to avoid one treatment failure (incremental cost-effectiveness ratio) amounted to 9239 euros. CONCLUSION: The current prospective, controlled clinical trial shows that despite a higher level of clinical efficacy of laparoscopic myotomy to prevent treatment failure in newly diagnosed achalasia, the cost effectiveness of pneumatic dilatation is superior, at least when a reasonable time horizon is applied.
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| 7. |
- Kostic, Srdjan, 1958, et al.
(författare)
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Leakage testing at the time of surgical oesophageal myotomy
- 2004
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Ingår i: Digestive surgery. - : S. Karger AG. - 0253-4886 .- 1421-9883. ; 21:3, s. 223-6
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Surgical myotomy is a well-established and validated method to treat severe gastro-oesophageal motor disorders such as achalasia. The benign character of these diseases further substantiates the importance of operating with greatest possible safety margins. We presently report our experiences with the use of perioperative leakage testing. MATERIALS AND METHODS: Thirty-seven consecutive patients are reported of whom 30 had a laparoscopic, 3 a thoracoscopic and 4 an open operation. The indications for an operation were in 3 patients oesophageal spasm, in 30 patients newly diagnosed achalasia and 4 patients had an open reoperation due to a previous incomplete myotomy plus epiphrenic diverticulum. Thirty patients had a perioperative endoscopy with gas insufflation and a leakage test, whereas the others did not. RESULTS: A previously unrecognised oesophageal mucosal tear was discovered during the test and repaired in 4 of the 30 tested cases whereafter everyone had an uneventful postoperative recovery. Among the remaining 7 untested patients, 3 developed clinical signs of leakage of whom 1 had an immediate reoperation. The postoperative courses were in all those prolonged and complicated. CONCLUSION: Perioperative use of endoscopy at the time of completion of the surgical myotomy is a useful tool to document leakage. Thereby the safety profile of the operation can be further enhanced.
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| 8. |
- Kostic, Srdjan, 1958, et al.
(författare)
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Pneumatic dilatation or laparoscopic cardiomyotomy in the management of newly diagnosed idiopathic achalasia. Results of a randomized controlled trial
- 2007
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Ingår i: World journal of surgery. - : Springer Science and Business Media LLC. - 0364-2313 .- 1432-2323. ; 31:3, s. 470-8
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The most effective therapeutic strategy in newly diagnosed achalasia is yet to be established. Therefore we designed a study in which pneumatic dilatation was compared to laparoscopic cardiomyotomy to which was added a partial posterior fundoplication. PATIENTS AND RESULTS: A series of 51 patients (24 males, mean age 44 years) were randomly allocated to the therapeutic modalities (dilatation = 26, surgery = 25). All patients were followed for at least 12 months, and during that period the pneumatic dilatations strategy had significantly more treatment failures (P = 0.04). Only minor differences emerged between the study groups when symptoms, dysphagia scorings, and quality-of-life assessments were evaluated 12 months after initiation of therapy. CONCLUSIONS: Laparoscopic myotomy was found to be superior to an endoscopic balloon dilatation strategy in the treatment of achalasia when studied during the first 12 months after treatment.
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| 9. |
- Kostic, Srdjan, 1958, et al.
(författare)
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Timed barium esophagogram in the assessment of patients with achalasia: reproducibility and observer variation
- 2005
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Ingår i: Diseases of the esophagus. - 1120-8694. ; 18:2, s. 96-103
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Tidskriftsartikel (refereegranskat)abstract
- SUMMARY. The timed barium esophagogram (TBE) is a further development of the barium swallow, introducing functional and dynamic dimensions to the assessment. The purpose of our study was to assess the day to day variability of TBE parameters when scored in healthy subjects, in untreated and in previously treated patients with confirmed diagnoses of achalasia and to assess the intra- and interobserver agreement. After fasting, the subjects drank 250 mL of low-density barium sulfate suspension. Radiographs of the esophagus were exposed at 1, 2 and 5 min after the start of the barium ingestion. The heights and widths of the barium column and changes in these parameters over time (esophageal emptying) were assessed. Each subject was re-tested after a median time interval of 8 days. Healthy individuals emptied their esophagi effectively and promptly with no significant amount of contrast remaining in the lumen after 2 min. In the achalasia patients all TBE variables differed profoundly compared to the controls. There was an excellent intra- and interobserver agreement for all measured variables. The reproducibility of the static TBE variables from day-to-day was good, but not so for the functional assessment of esophageal emptying, having a correlation coefficient of only 0.50. The usefulness of TBE as a clinical and research tool in achalasia patients requires further evaluation.
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| 10. |
- Persson, Jan, 1962, et al.
(författare)
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Treatment of Achalasia with Laparoscopic Myotomy or Pneumatic Dilatation: Long-Term Results of a Prospective, Randomized Study
- 2015
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Ingår i: World Journal of Surgery. - : Springer Science and Business Media LLC. - 0364-2313 .- 1432-2323. ; 39:3, s. 713-720
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Tidskriftsartikel (refereegranskat)abstract
- Abstract BACKGROUND: This study compares the long-term results of pneumatic dilatations versus laparoscopic myotomy using treatment failure as the primary outcome. The frequency and degree of dysphagia, the effects on quality of life (QoL), and health economy were also examined. METHODS: Fifty-three patients with achalasia were randomized to laparoscopic myotomy with a posterior partial fundoplication [laparoscopic myotomy (LM) n = 25] or repetitive pneumatic dilatation [pneumatic dilatation (PD) n = 28]. The median observation period was 81.5 months (range 12-131). RESULTS: At the minimal follow-up of 5 years, ten patients (36 %) in the dilatation group and two patients (8 %) in the myotomy group, including two patients lost to follow-up (one in each arm), were classified as failures (p = 0.016). The cumulative incidence of treatment failures was analyzed by survival statistics. Taking the entire follow-up period into account, a significant difference was observed in favor of the LM strategy (p = 0.02). Although both treatments resulted in significant improvements in dysphagia scores, LM was significantly favored over PD after 1 and 3 years, but not after 5 years. Health-related QoL assessed by the personal general well being score was higher in the LM group after 3 years, but the difference was not fully statistically significant at 5 years. Direct medical costs during the entire follow-up period were in median $13,421 for LM as compared to $5,558 for PD (p = 0.001). CONCLUSIONS: This long-term follow-up of a randomized clinical study shows that LM is superior to repetitive PD treatment of newly diagnosed achalasia, albeit that this surgical strategy is burdened by high initial direct medical costs. www.ClinicalTrials.gov NCT 02086669.
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