Case Presentation, Management, Discussion and Sharing of Information on Dysphagia

1. 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

2. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” General Data: • F.D. 60 y.o Female • Sta. Ana, Manila.

3. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Chief Complaint Dysphagia

4. 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

5. 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

6. 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

7. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

8. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

9. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

10. 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.

11. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” PAST MEDICAL HISTORY: • S/P Ex- lap, Ectopic Pregancy, 1966

12. 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

13. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” PHYSICAL EXAMINATION:PHYSICAL EXAMINATION: • CARDIAC: Normal rate, regular rhythm, no murmur • ABDOMEN: Flabby, NABS, soft, no palpable mass • EXTREMITIES: Full and equal pulses, no deformities

14. 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

15. 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

16. 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

17. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Clinical Diagnosis

18. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” PARACLINICAL DIAGNOSTICPROCEDURE • Do I need a paraclinical diagnostic procedure? No.

19. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Pretreatment Diagnosis: Achalasia

20. 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

21. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Pre Treatment Options 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

22. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Treatment Plan • Surgical • What Approach? • Abdominal or Thoracic?

23. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Treatment Goal • Better exposure of gastro-esophageal junction

24. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Pre Treatment Options

25. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Treatment Plan • Abdominal Approach • Esophagomyotomy alone or Esophagomyotomy plus fundoplication?

26. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Treatment Goal • Reduce incidence of gastro -esophageal reflux

27. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Pre Treatment Options Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dorfundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004;240(3):405–412; discussion 412–415.

28. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Treatment Plan • Esophagomyotomy plus fundoplication

29. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Plan of Operation • Esophagomyotomy with fundoplication

30. 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

31. 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

32. 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

33. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Intraop- findings • Constricted LES • Marked dilatation of lower esophagus

34. 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

35. 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

36. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Operation Done: • Esophagomyotomy with posterior fundoplication

37. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Final Diagnosis Achalasia S/P Esophagomyotomy with Posterior Fundoplication

38. 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

39. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Sharing of Information

40. 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

41. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Signs & Symptoms • Vomiting • Progressive dysphagia • Weight loss

42. DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery” Theories • Neurogenic • Myogenic • Hormonal

43. 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.

44. 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

45. 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

46. 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”

47. 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

48. 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

49. 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

50. 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