DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Case Presentation, Management,
Discussion and Sharing of Information
on Dysphagia
Jonathan R. Malabanan, M.D.
Surgery Resident
OMMC
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
General Data:
• F.D. 60 y.o Female
• Sta. Ana, Manila.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Chief Complaint
Dysphagia
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
History of Present Illness:
• 9 months PTA→ (+) dysphagia to solids
(+) Chest pain
(+) normal ECG
• 5 months PTA→ (+) weight loss
(+) dysphagia to liquids and
solids
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• 2 wks PTA →(+) feeling of
regurgitation
(+) progression of above
conditions
consulted at private Hospital
→(+) normal CXR
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
→Esophagogram
(+) Dilated esophagus with non
passage of barium into the
stomach.
→EGD:
Tight contraction of G.E jxn
scope inserted up to D2
no mucosal irregularity
no mass
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
→Advised to undergo
surgery and consulted our hospital due to
financial constraint.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
PAST MEDICAL HISTORY:
• S/P Ex- lap, Ectopic Pregancy, 1966
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
PHYSICAL EXAMINATION:
• GEN SURVEY:
Conscious,coherent,oriented
BP=120/80 CR=80 RR=21 T=36.5
• HEENT: Pink conjunctivae, anicteric
sclerae, no cervical
lymphadenopathies
• CHEST: SCE, clear breath sounds
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
PHYSICAL EXAMINATION:
“Towards Patient Safety in Surgery”
PHYSICAL EXAMINATION:
• CARDIAC: Normal rate, regular rhythm,
no murmur
• ABDOMEN: Flabby, NABS, soft, no
palpable mass
• EXTREMITIES: Full and equal pulses, no
deformities
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Salient Features:
• 60 y.o Female
• (+) Progressive dysphagia
• (+) non cardiac chest pain
• (+) weight loss
• (+) Feeling of regurgitation
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Salient Features:
• (+) Esophagogram Findings:
dilated esophagus with non passage of
barium into the stomach
• (+) EGD: Tight contraction of G.E junction,
scope inserted up to D2, no mucosal
irregularity, no mass
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Algorithm
Progressive dysphagia
Barium swallow
Dilated esophagus, non passage of barium
Achalasia Tumor Stricture
Endoscopy:
• no intraluminal mass
• tight GE junction
• no mucosal irregularity
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Clinical Diagnosis
DIAGNOSIS CERTAINTY TREATMENT
PRIMARY Achalasia 95% Surgical
Medical
Mechanical
SECONDARY Stricture 5% Surgical
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
PARACLINICAL DIAGNOSTIC
PROCEDURE
• Do I need a paraclinical diagnostic
procedure?
No.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Pretreatment Diagnosis:
Achalasia
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Goals of Treatment
1. Complete resolution of functional distal
esophageal obstruction
2. Better long term improvement and
prevent complication
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Pre Treatment Options
BENEFIT RISK COST AVAILABI
LITY
Mechanical SR:40-78% -Perforation P20-30 thou Not available
(Pneumatic RR:20-50% (5 (3-15%)
Dilation) yrs) -Scarring
Surgical SR:95% -Perforation P30-40 thou Available
(myotomy) (1%)
-Hemorrhage
Medical Short duration -Hemorrhage P20-30 thou Botox:
(Botox, ISDN, of effect -Scarring Not available
Nifedipine) SR
(botox):38%
DAVID VANDERPOOL, MD, MATTHEW V. WESTMORELAND, MD, AND ERIC FETNER, MD.
Achalasia: Willis or Heller? Department of Surgery, Baylor University Medical Center,
Dallas, Texas. 1999;12:227-2
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Treatment Plan
• Surgical
• What Approach?
• Abdominal or Thoracic?
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Treatment Goal
• Better exposure of gastro-esophageal
junction
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Pre Treatment Options
BENEFIT RISK COST AVAILABILI
TY
Thoracic Inadequate Perforation P40 thou Available
exposure of mediastinitis
Gastro- CTT
esophageal
junction
Abdominal better access Perforation P30 thou Available
to gastro-
esophageal
jxn
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Treatment Plan
• Abdominal Approach
• Esophagomyotomy alone or
Esophagomyotomy plus fundoplication?
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Treatment Goal
• Reduce incidence of gastro -esophageal
reflux
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Pre Treatment Options
BENEFIT RISK COST AVAILABILI
TY
Esophagomyo Same incidence Perforation P30 thou Available
tomy alone of Hemorrhage
gastroesophage
al reflux
Esophagomyo Reduce Perforation P30 thou Available
tomy plus incidence of Hemorrhage
fundoplication gastro -
esophageal
reflux
By nine fold
Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy
with Dor fundoplication for achalasia: a prospective randomized double-blind clinical
trial. Ann Surg 2004;240(3):405–412; discussion 412–415.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Treatment Plan
• Esophagomyotomy plus fundoplication
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Plan of Operation
• Esophagomyotomy with fundoplication
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
PREOPERATIVE PREPARATION
• 1. Informed Consent
• 2. Psychosocial Support
• 3. Optimize Patient’s Physical Health
• 4. Screening For Other Medical Problem
• 5. Prepare Materials For OR
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Operative Maneuvers
• Patient supine under GA
• Asepsis antisepsis
• Sterile drapes placed
• Subxiphoid midline incision carried down
to the peritoneum
• Liver inspected, stomach identified
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Operative Maneuvers
• Left triangular ligament and falciform
ligament cut
• Liver deflected laterally exposing the
esophagus.
• Esophagus gently encircled with the index
finger
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Intraop- findings
• Constricted LES
• Marked dilatation of
lower esophagus
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Operative Maneuvers
Left vagus nerve deflected
out of area of dissection
Myotomy performed
extending distally over
the stomach 2 cm below
the GE junction and 5 cm
proximally
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Operative Maneuvers
Note of dilatation of
the LES area post
myotomy
-Posterior fundoplication
carried out
-Hemostasis
-OS and instrument
checked
-Layer by layer closure
-Dry sterile dressing
placed
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Operation Done:
• Esophagomyotomy with posterior
fundoplication
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Final Diagnosis
Achalasia
S/P Esophagomyotomy with Posterior
Fundoplication
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Post op Management:
• Maintained on NPO
• Adequate analgesia given
• Antibiotics continued (24 hrs)
• Adequate pulmonary support
• Chest physiotherapy
• Monitoring of early complications
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Sharing of Information
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Achalasia
-disorder of lower esophagogastric motility
due to failure of the lower esophageal
sphincter to relax with swallowing.
-Incidence of 1 in 100,000 per year
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Signs & Symptoms
• Vomiting
• Progressive dysphagia
• Weight loss
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Theories
• Neurogenic
• Myogenic
• Hormonal
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Pathogenesis
• Neurogenic/Myogenic Theory:
• Degeneration of ganglion cells in the
myenteric plexus and loss of nerves
innervating the smooth muscle cells of the
lower esophageal sphincter.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Pathogenesis
• Hormonal cause:
• Reduced VIP( Vasoactive Intestinal
Polypeptide) major inhibitory released at
the intramural postganglionic neurons of
the lower esophageal sphincter
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Diagnostics
• CXR:
widened mediastinum
esophageal air fluid level
or absence of gastric air
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Diagnostics
• Barium Swallow:
- esophageal dilatation with tapering at
the esophageal junction “birds beak
deformity”
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Diagnostics
• Manometry:
• Characteristic Findings
1. hypertensive lower esophageal sphincter
resting pressure
2. absence of peristalsis
3. incomplete or abnormal LES relaxation
4. elevated intraesophageal pressure
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Diagnostics
• Endoscopy:
• assess the presence of:
– inflammation
– mucosal irregularity
– or tumors in the esophagus
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Treatment
• Medical
– early stage of disease
– patients who are high risk for surgery
• Isosorbide dinitrate
– 5-10mg
– reduces LES pressure 66% for 90 min
• Nifedipine
– 10-20mg
– reduces LES 30-40% for >1 hour
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Treatment
• Botulinum toxin A (Botox)
– 80μg injected in 4 aliquots LES
– potent inhibitor of achetylcholine released
from nerve endings
– decreasing unopposed LES stimulation
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Treatment
• Mechanical
pneumatic dilation
• Surgery
myotomy
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
References:
• DAVID VANDERPOOL, MD, MATTHEW V. WESTMORELAND, MD, AND ERIC
FETNER, MD. Achalasia: Willis or Heller? Department of Surgery, Baylor
University Medical Center, Dallas, Texas. 1999;12:227-230
• Jedediah A. Kaufman, M.D., Dave R. Lal, M.D. and Brant K. Oelschlager,
M.D. Surgical treatment for achalasia. GI Motility online (2006)
doi:10.1038/gimo53
Published 16 May 2006
• Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller
myotomy with Dor fundoplication for achalasia: a prospective randomized
double-blind clinical trial. Ann Surg 2004;240(3):405–412; discussion 412–
415.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCQ
1. The following are Theories in the
pathophysiology of achalasia except?
a. Myogenic
b. Neurogenic
c. Immunologic
d. Hormonal
e. NOTA
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCQ
1. The following are Theories in the
pathophysiology of achalasia except?
a. Myogenic
b. Neurogenic
c. Immunologic
d. Hormonal
e. NOTA
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCQ
2. The following are characteristic
manometric findings in Achalasia except?
a. increased lower esophageal sphincter
b. absence of peristalsis
c. widened mediastinum
d. incomplete or abnormal LES relaxation
e. elevated intraesophageal pressure
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCQ
2. The following are characteristic
manometric findings in Achalasia except?
a. increased lower esophageal sphincter
b. absence of peristalsis
c. widened mediastinum
d. incomplete or abnormal LES relaxation
e. elevated intraesophageal pressure
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCQ
3. Act as a potent inhibitor of achetylcholine
release from nerve endings thereby
decreasing unopposed LES stimulation?
a. Isosorbide dinitrate
b. Atropine Sulfate
c. Nifedipine
d. Metoprolol
e. Botox
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCQ
3. Act as a potent inhibitor of achetylcholine
release from nerve endings thereby
decreasing unopposed LES stimulation?
a. Isosorbide dinitrate
b. Atropine Sulfate
c. Nifedipine
d. Metoprolol
e. Botox
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCR
Direction: Write
“A” if 1, 2, and 3 are valid statements.
“B” if only 1 and 3 are valid statements.
“C” if only 2 and 4 are valid statements.
“D” if only 4 is a valid statement.
“E” if all are valid statements.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCR
4. All of the following are involve in the
treatment for Achalasia except?
1. Isosorbide dinitrate
2. Atropine Sulfate
3. Nifedipine
4. Metoprolol
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCR
C.4. All of the following are involve in the
treatment for Achalasia except?
1. Isosorbide dinitrate
2. Atropine Sulfate
3. Nifedipine
4. Metoprolol
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCR
5. Achalasia can be described by which of
the following?
1. It is failure or lack of relaxation of the
LES.
2. Dysphagia, regurgitation and nocturnal
asthma are included in the classic triad
3. A barium esophagogram may
demonstrate birds beak configuration at
the GE junction.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCR
5. Achalasia can be described by which of
the following?
4. T. cruzi that causes Chaga’s disease
destroys Auerbach’s plexus only in the
esophagus resulting in failure of LES to
relax
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCR
B. 5. Achalasia can be described by which
of the following?
1. It is failure or lack of relaxation of the
LES.
2. Dysphagia, regurgitation and nocturnal
asthma are included in the classic triad
3. A barium esophagogram may
demonstrate birds beak configuration at
the GE junction.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
MCR
5. Achalasia can be described by which of
the following?
4. T. cruzi that causes Chaga’s disease
destroys Auerbach’s plexus only in the
esophagus resulting in failure of LES to
relax
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Thank You!
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Journal Appraisal
Heller Myotomy Versus Heller Myotomy With
Dor Fundoplication for Achalasia: A
Prospective Randomized Double-Blind
Clinical Trial
William O. Richards, MD,* Alfonso Torquati, MD, MSCI,* Michael D. Holzman, MD,
MPH,* Leena Khaitan, MD, MPH,* Daniel Byrne, MS,† Rami Lutfi, MD,* and Kenneth
W. Sharp, MD*
Departments of Surgery and †Medicine and Biostatistics, Vanderbilt University,
Medical School, Nashville, Tennessee.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Objective:
– We sought to determine the impact of
the addition of Dor fundoplication on the
incidence of postoperative
gastroesophageal reflux (GER) after
Heller myotomy.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Summary Background Data:
– Based only on case series, many
surgeons believe that an antireflux
procedure should be added to the Heller
myotomy. However, no prospective
randomized data support this approach.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Patients and Methods:
• In this prospective, randomized, double-
blind, institutional review board-approved
clinical trial, patients with achalasia were
assigned to undergo Heller myotomy or
Heller myotomy plus Dor fundoplication.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Patients and Methods:
• Patients were studied via 24-hour pH
study and manometry at 6 months
postoperatively. Pathologic GER was
defined as distal esophageal time acid
exposure time greater than 4.2% per 24-
hour period. The outcome variables were
analyzed on an intention-to-treat basis.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Results:
• Forty-three patients were enrolled. There
were no differences in the baseline
characteristics between study groups.
Pathologic GER Incidence
Heller myotomy 47.6% 10/21
Heller myotomy plus Dor 9.1% 2/22
fundoplication
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Results:
• Heller plus Dor was associated with a
significant reduction in the risk of GER
(relative risk 0.11; 95% confidence interval
0.02–0.59; P = 0.01).
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Results:
• Median distal esophageal acid exposure time
was lower in the Heller plus Dor (0.4%; range,
0–16.7) compared with the Heller group
(4.9%; range, 0.1–43.6; P = 0.001).
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Results:
• No significant difference in surgical
outcome between the 2 techniques with
respect to postoperative lower-esophageal
sphincter pressure or postoperative
dysphagia score was observed.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Conclusions:
• Heller Myotomy plus Dor Fundoplication
was superior to Heller myotomy alone in
regard to the incidence of postoperative
GER.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Clinical Question:
• In Achalasia patients, should Heller
Myotomy plus Dor Fundoplication be done
to decrease the incidence of postoperative
GER?
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Tentative Answer
• Yes. In Achalasia patients, Heller
Myotomy plus Dor Fundoplication should
be done to decrease the incidence of
postoperative GER.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Are the results of the study
valid?
Primary Guides:
1. Was the assignment of patients to
treatment randomized?
Yes.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Are the results of the study
valid?
Primary Guides:
2. Were all patients who entered the trial
properly accounted for and attributed at its
conclusion?
Yes.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Are the results of the study
valid?
Secondary Guides:
3. Were patients, their clinicians, and study
personnel "blind" to treatment?
Yes
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Are the results of the study
valid?
Secondary Guides:
4. Were the groups similar at the start of the
trial?
Yes.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
Are the results of the study
valid?
Secondary Guides:
5. Aside from the experimental intervention,
were the groups treated equally?
Yes.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
• Conclusion
In Achalasia patients, Heller Myotomy
plus Dor Fundoplication should be done to
decrease the incidence of postoperative
GER.
DEPARTMENT OF SURGERY
OSPITAL NG MAYNILA MEDICAL CENTER
“Towards Patient Safety in Surgery”
God bless