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Samarasam I, Joel RK, Pulimood AB. Gastroesophageal reflux following per-oral endoscopic myotomy: Can we improve outcomes? World J Gastroenterol 2024; 30:2834-2838. [PMID: 38947293 PMCID: PMC11212718 DOI: 10.3748/wjg.v30.i22.2834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/30/2024] [Accepted: 05/20/2024] [Indexed: 06/05/2024] Open
Abstract
This editorial is an analysis the review article by Nabi et al recently published in this journal. Achalasia Cardia is a disease whose pathophysiology is still unclear. It is known that there is inflammation of unknown aetiology leading to loss of ganglion cells in the muscularis propria. The end result is lower oesophageal sphincter spasm, loss of receptive relaxation, decreased oesophageal peristalsis, all leading on to varying degrees of dysphagia. The treatment of this condition is palliative in nature, performed by myotomy of the lower oesophagus either surgically or endoscopically. Gastroesophageal reflux disease (GERD) has been associated with the myotomy performed, particularly with the Peroral Endoscopic Myotomy (POEM) procedure. Nabi et al have provided an excellent overview of the latest developments in predicting, preventing, evaluating, and managing GERD subsequent to POEM. Based on this theme, this review article explores the concept of using histology of the oesophageal muscle layer, to grade the disease and thereby help tailoring the length/type of myotomy performed during the POEM procedure. In the future, will a histology based algorithm available preoperatively, help modify the POEM procedure, thereby decreasing the incidence of GERD associated with POEM?
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Affiliation(s)
- Inian Samarasam
- Department of Surgery, Upper Gastrointestinal Surgery Unit, Christian Medical College & Hospital, Vellore 632004, Tamilnadu, India
| | - Raj Kumar Joel
- Department of Cardiothoracic Surgery, Christian Medical College & Hospital, Vellore 632004, Tamilnadu, India
| | - Anna B Pulimood
- Department of Gastrointestinal Sciences, Christian Medical College and Hospital, Vellore 632004, Tamil Nadu, India
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Howk AA, Clifton MS, Garza JM, Durham MM. Impedance planimetry (EndoFLIP) assisted laparoscopic esophagomyotomy in pediatric population. J Pediatr Surg 2022; 57:1000-1004. [PMID: 35659759 DOI: 10.1016/j.jpedsurg.2022.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/12/2022] [Accepted: 05/05/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Functional lumen imaging probe (EndoFLIP) is a diagnostic technology that assesses esophageal cross-sectional area via impedance planimetry during controlled volumetric distention. The purpose of this study is to evaluate the utility of EndoFLIP intraoperatively during laparoscopic esophagomyotomy. METHODS We performed a retrospective cohort study reviewing all patients undergoing EndoFLIP assisted laparoscopic esophagomyotomy for achalasia between January and December 2021 (n = 10). Twenty-two patients with achalasia that underwent traditional laparoscopic esophagomyotomy between July 2014 and September 2019 served as a comparison. Primary outcome evaluated was resolution of symptoms at discharge. Secondary outcomes included change in distensibility index (DI), operative time, length of stay, time to regular diet, and reinterventions. RESULTS All patients managed with EndoFLIP assistance had resolution of dysphagia and postprandial vomiting following intervention. Mean change in DI was 5.32 mm2/mmHg with a myotomy length of 3.6 cm. Operative time was shorter in the EndoFLIP cohort (97 min versus 185 min, p = <0.001). Study patients did not undergo an antireflux operation. There was no difference in length of stay or time to soft diet between groups. All patients were discharged on postoperative day 1 tolerating a mechanical soft diet. No acid suppressive medications were prescribed during the observation period. One patient required dilation for recurrent symptoms and one required reoperation for mucosal leak. CONCLUSION EndoFLIP assisted laparoscopic esophagomyotomy results in similar short-term outcomes to traditional surgical technique. EndoFLIP allows for focused myotomy length and a shorter operative time. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Amy A Howk
- Emory-Children's Pediatric Institute, Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States.
| | - Matthew S Clifton
- Emory-Children's Pediatric Institute, Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Jose M Garza
- Neurogastroenterology and Motility Program, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Megan M Durham
- Emory-Children's Pediatric Institute, Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
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Bapaye A, Gandhi A, Bapaye J. Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality? JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0041-1740489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AbstractPeroral endoscopic myotomy (POEM) is an accepted treatment for achalasia cardia (AC), and results are comparable to those of laparoscopic Heller myotomy (LHM). In recent years, several reports have confirmed higher incidence of gastroesophageal reflux (GER) following POEM. This review evaluates the current evidence regarding post-POEM GER, critically examines the potential contributing factors responsible for GER, limitations of the current available functional testing, and precautions and preventive measures, and provides future directions for research. Factors conclusively contributing to increased post-POEM GER include injury to the sling fibers of the lower esophageal sphincter, length of gastric myotomy > 2 cm, and others. Historically, these same factors have been implicated for development of GER after surgical (laparoscopic) myotomy. Although less invasive, optimal technique of POEM may be important to control post-POEM GER. Most post-POEM GER occurs during the immediate post-POEM period, is mild, and is easily treatable using proton-pump inhibitors. GER incidence plateaus at 2 years and is comparable to that after LHM. Patients should therefore be prescribed proton-pump inhibitors for at least 2 years. Antireflux procedures (ARPs) are infrequently required in these patients as the incidence of refractory GER is low. Novel ARPs have been recently described and are currently under evaluation. Conclusive diagnosis of GER is a clinical challenge. Most patients are asymptomatic, and GER is diagnosed only on abnormal esophageal acid exposure (EAE). Studies have demonstrated that current measures to diagnose GER are inadequate, inaccurate, and cannot differentiate between true GER and abnormal EAE due to food fermentation in the distal esophagus. The Lyon Consensus criteria should be implemented for confirmation of diagnosis of GER. Finally, the review recommends an evidence-based clinical algorithm for evaluation and management of post-POEM GER and provides guidelines for future research in this field.
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Affiliation(s)
- Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Ashish Gandhi
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Jay Bapaye
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
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Fajardo RA, Petrov RV, Bakhos CT, Abbas AE. Endoscopic and Surgical Treatments for Achalasia: Who to Treat and How? Gastroenterol Clin North Am 2020; 49:481-498. [PMID: 32718566 PMCID: PMC7387747 DOI: 10.1016/j.gtc.2020.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Achalasia is a progressive neurodegenerative disorder characterized by failure of relaxation of the lower esophageal sphincter (LES) and altered motility of the esophagus. The traditional, highly effective, surgical approach to relieve obstruction at the LES includes cardiomyotomy. Fundoplication is added to decrease risk of postoperative reflux. Per oral endoscopic myotomy is a new endoscopic procedure that allows division of the LES via transoral route. It has several advantages including less invasiveness, cosmesis, and tailored approach to the length on the myotomy. However, it is associated with increased rate of post-procedural reflux. Various endoscopic interventions are used to address this problem.
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Affiliation(s)
- Romulo A. Fajardo
- Department of General Surgery, Temple University Hospital, Philadelphia, PA, USA, 3401 N Broad St, C-401, Philadelphia, PA 19140
| | - Roman V. Petrov
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
| | - Charles T. Bakhos
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
| | - Abbas E. Abbas
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
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Duggan EM, Nurko S, Smithers CJ, Rodriguez L, Fox VL, Fishman SJ. Thoracoscopic esophagomyotomy for achalasia in the pediatric population: A retrospective cohort study. J Pediatr Surg 2019; 54:572-576. [PMID: 30121126 DOI: 10.1016/j.jpedsurg.2018.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/13/2018] [Accepted: 07/21/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND/PURPOSE Achalasia is an extremely rare disease in children (0.1 per 100,000 individuals). Standard treatments for this include pneumatic dilation and esophagomyotomy. Minimally invasive esophagomyotomies have increasingly been used owing to improved postoperative pain and length of stay. We describe our experience with thoracoscopic esophagomyotomy in this population. METHODS This is a retrospective cohort study of all patients at our institution who underwent thoracoscopic esophagomyotomy for achalasia from 1995 to 2016. We used endoscopic guidance during all procedures. No fundoplication was performed. RESULTS Thirty-one patients were included in this study. Thirteen patients underwent pneumatic dilations prior to their operation with a median of 3 dilations. Two patients had a mucosal injury during the case. There were no conversions to an open procedure. Median length of stay was 2 days. After the procedure, 97% of patients had initial symptom relief. Eight patients (26%) required postoperative pneumatic dilations for recurrent symptoms; there was a greater chance of this (OR 8.5) if they had a preoperative dilation. No patients required a fundoplication for reflux postoperatively. CONCLUSIONS Thoracoscopic esophagomyotomy is a safe and effective procedure for achalasia in the pediatric population. It should be considered as an alternative to the laparoscopic approach for these patients. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Eileen M Duggan
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA.
| | - Samuel Nurko
- Division of Gastroenterology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA.
| | - Charles J Smithers
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA.
| | - Leonel Rodriguez
- Division of Gastroenterology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA.
| | - Victor L Fox
- Division of Gastroenterology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA.
| | - Steven J Fishman
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA.
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Zaninotto G, Bennett C, Boeckxstaens G, Costantini M, Ferguson MK, Pandolfino JE, Patti MG, Ribeiro U, Richter J, Swanstrom L, Tack J, Triadafilopoulos G, Markar SR, Salvador R, Faccio L, Andreollo NA, Cecconello I, Costamagna G, da Rocha JRM, Hungness ES, Fisichella PM, Fuchs KH, Gockel I, Gurski R, Gyawali CP, Herbella FAM, Holloway RH, Hongo M, Jobe BA, Kahrilas PJ, Katzka DA, Dua KS, Liu D, Moonen A, Nasi A, Pasricha PJ, Penagini R, Perretta S, Sallum RAA, Sarnelli G, Savarino E, Schlottmann F, Sifrim D, Soper N, Tatum RP, Vaezi MF, van Herwaarden-Lindeboom M, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Gittens S, Pontillo C, Vermigli S, Inama D, Low DE. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31:5087687. [PMID: 30169645 DOI: 10.1093/dote/doy071] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Affiliation(s)
- G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Ireland
| | - G Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M Costantini
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - M K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J E Pandolfino
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - U Ribeiro
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - J Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - L Swanstrom
- Institute of Image-Guided Surgery, Strasbourg, France; Interventional Endoscopy and Foregut Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - J Tack
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - G Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Stanford University, Stanford, California, USA
| | - S R Markar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - R Salvador
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - L Faccio
- Division of Surgery, Padova University Hospital, Padova, Italy
| | - N A Andreollo
- Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
| | - I Cecconello
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - G Costamagna
- Digestive Endoscopy Unit, A. Gemelli Hospital, Catholic University, Rome, Italy
| | - J R M da Rocha
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - E S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Frankfurt, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - R Gurski
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - F A M Herbella
- Department of Surgery, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - M Hongo
- Department of Medicine, Kurokawa Hospital, Taiwa, Kurokawa, Miyagi, Japan
| | - B A Jobe
- Esophageal and Lung Institute, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - P J Kahrilas
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - D Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - A Moonen
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - A Nasi
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; Università degli Studi, Milan, Italy
| | - S Perretta
- Institute for Image Guided Surgery IHU-Strasbourg, Strasbourg, France
| | - R A A Sallum
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - G Sarnelli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - E Savarino
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - D Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Soper
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - R P Tatum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - M F Vaezi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M F Vela
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - D I Watson
- Department of Surgery, Flinders University, Adelaide, Australia
| | - F Zerbib
- Department of Gastroenterology, University of Bordeaux, Bordeaux, France
| | - S Gittens
- ECD Solutions, Atlanta, Georgia, USA
| | - C Pontillo
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - S Vermigli
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D Inama
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D E Low
- Department of Thoracic Surgery Virginia Mason Medical Center, Seattle, Washington, USA
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DeHaan RK, Frelich MJ, Gould JC. Limited Hiatal Dissection Without Fundoplication Results in Comparable Symptomatic Outcomes to Laparoscopic Heller Myotomy with Anterior Fundoplication. J Laparoendosc Adv Surg Tech A 2016; 26:506-10. [PMID: 26919162 DOI: 10.1089/lap.2015.0523] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Previous randomized controlled trials have demonstrated that partial fundoplication following Heller myotomy results in less pathologic acid exposure to the esophagus when compared to myotomy without fundoplication. Recent studies have questioned the necessity of a fundoplication, especially when a limited hiatal dissection (LHD) is performed and the angle of His is preserved. MATERIALS AND METHODS This is a retrospective review of prospectively maintained data. All patients underwent primary Heller myotomy for achalasia over a 30-month period. In select patients, an LHD was performed anteriorly. Symptomatic outcomes were assessed up to 2 years postoperation using the Achalasia Severity Questionnaire (ASQ), Gastrointestinal Quality of Life Index (GIQLI), and Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL). RESULTS A total of 31 patients underwent Heller myotomy during the study interval. The majority of patients underwent Heller myotomy with full hiatal dissection (FHD) (21, 68%). Intraoperative mucosal perforations occurred in 3 (14%) patients undergoing FHD. Patient demographics, surgery details, and baseline symptomatic outcomes did not differ significantly preoperatively. At greater than 1 year postoperation, there was no significant difference between the groups for ASQ, GERD-HRQL, and GIGLI (P = .76, .78, and .33, respectively). CONCLUSIONS Heller myotomy with LHD and no fundoplication and Heller myotomy with FHD and partial fundoplication result in similar GERD-related quality of life outcomes. Further studies (including pH studies) are necessary to determine if fundoplication is a necessary step in selected patients in whom an LHD is possible.
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Affiliation(s)
- Reece K DeHaan
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - Matthew J Frelich
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - Jon C Gould
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin , Milwaukee, Wisconsin
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Abstract
The last three decades have witnessed a progressive evolution in the surgical treatment of esophageal achalasia, with a shift from open to a minimally invasive Heller myotomy. The laparoscopic approach is currently the standard of care with better short-term outcomes and similar long-term functional results when compared to open surgery. More recently, the laparoscopic single-site approach and the use of the robot have been proposed to further improve the surgical outcome in achalasia patients.
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Affiliation(s)
- Nelson Adami Andreoll
- Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SAo Paulo, Brazil
| | - Luiz Roberto Lope
- Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SAo Paulo, Brazil
| | - Osvaldo Malafai
- Faculdade Evangelica do Parana, Universidade Federal do Parana, Brazil
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Weiner R. Ernst Heller und die Myotomie. Chirurg 2014. [DOI: 10.1007/s00104-014-2752-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Revisional surgery after heller myotomy for treatment of achalasia: a comparative analysis focusing on operative approach. Indian J Surg 2012; 74:309-13. [PMID: 23904720 DOI: 10.1007/s12262-011-0402-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 12/22/2011] [Indexed: 10/14/2022] Open
Abstract
Surgical myotomy is the gold standard in therapy for achalasia, but treatment failures occur and require revisional surgery. A MEDLINE search of peer-reviewed articles published in English from 1970 to December 2008 was performed using the following terms: esophageal achalasia, Heller myotomy, and revisional surgery. Thirty-three articles satisfied our inclusion criteria. A total of 12,727 patients, with mean age of 43.3 years (males 46% and females 50%), underwent Heller myotomy (open 94.8% and laparoscopic 5.2%). Revisional surgery was performed in 6.19%. Procedures performed included revision of the original myotomy or creation of a new myotomy with or without an antireflux procedure or esophagectomy. Reasons for reoperation were incomplete myotomy (51.8%), onset of reflux (34%), megaesophagus (16.2%), and esophageal carcinoma (3.04%). Systematic review of the literature for revisional surgery following Heller myotomy revealed a 6.19% rate of reoperation with a low mortality rate.
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Lopes LR, Braga NDS, Oliveira GCD, Coelho Neto JDS, Camargo MA, Andreollo NA. Results of the surgical treatment of non-advanced megaesophagus using Heller-Pinotti's surgery: Laparotomy vs. Laparoscopy. Clinics (Sao Paulo) 2011; 66:41-6. [PMID: 21437434 PMCID: PMC3044574 DOI: 10.1590/s1807-59322011000100008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 09/02/2010] [Accepted: 10/04/2010] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Dysphagia is the important symptom in achalasia, and surgery is the most common treatment. The Heller-Pinotti technique is the method preferred by Brazilian surgeons. For many years, this technique was performed by laparotomy, and now the laparoscopic method has been introduced. The objective was to evaluate the immediate and long-term results of patients submitted to surgery by either laparotomy or laparoscopy. MATERIALS AND METHODS A total of 67 patients submitted to surgery between 1994 and 2001 with at least 5 years of follow-up were evaluated retrospectively and divided into two groups: laparotomy (41 patients) and laparoscopy (26 patients). Chagas was the etiology in 76.12% of cases. Dysphagia was evaluated according to the classification defined by Saeed et al. RESULTS There were no cases of conversion to open surgery. The mean duration of hospitalization was 3.32 days for laparotomy and 2.54 days for laparoscopy (p < 0.05). An improvement in dysphagia occurred with both groups reporting good or excellent results (laparotomy: 73.17% and laparoscopy: 73.08%). Mean duration of follow-up was 8 years. CONCLUSIONS There was no difference between the two groups with respect to relief from dysphagia, thereby confirming the safety and effectiveness of the Heller-Pinotti technique, which can be performed by laparotomy or laparoscopy, depending on the surgeon's experience.
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Affiliation(s)
- Luiz Roberto Lopes
- Department of Surgery, University of Campinas, Campinas, São Paulo, Brazil.
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Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results. Ann Surg 2009; 248:1023-30. [PMID: 19092347 DOI: 10.1097/sla.0b013e318190a776] [Citation(s) in RCA: 156] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To compare in a prospective, randomized trial the long-term results of laparoscopic Heller myotomy plus Dor fundoplication versus laparoscopic Heller myotomy plus floppy-Nissen for achalasia. SUMMARY BACKGROUND DATA Anterior fundoplication is usually performed after Heller myotomy to control GER; however, the incidence of postoperative GER ranges between 10% and 30%. Total fundoplication may aid in reducing GER rates. METHODS From December 1993 to September 2002, 153 patients with achalasia underwent Heller laparoscopic myotomy plus antireflux fundoplication. Of these, 9 were excluded from the study. The remaining 144 patients were randomly assigned to 2 treatment groups: Heller laparoscopic myotomy plus anterior fundoplication (Dor procedure) or Heller laparoscopic myotomy plus total fundoplication (floppy-Nissen procedure). The primary end point was incidence of clinical and instrumental GER after a minimum of 60 months follow-up. The secondary end point was recurrence of dysphagia. Follow-up clinical assessments were performed at 1, 3, 12, and 60 months using a modified DeMeester Symptom Scoring System (MDSS). Esophageal manometry and 24-hour pH monitoring were performed at 3, 12, and 60 months postoperative. RESULTS Of the 144 patients originally included in the study, 138 were available for long-term analysis: 71 (51%) underwent antireflux fundoplication plus a Dor procedure (H + D group) and 67 (49%) antireflux fundoplication plus a Nissen procedure (H + N group). No mortality was observed. The mean follow-up period was 125 months. No statistically significant differences in clinical (5.6% vs. 0%) or instrumental GER (2.8% vs. 0%) were found between the 2 groups; however, a statistically significant difference in dysphagia rates was noted (2.8% vs. 15%; P < 0.001). CONCLUSIONS Although both techniques achieved long-term GER control, the recurrence rate of dysphagia was significantly higher among the patients who underwent Nissen fundoplication. This evidence supports the use of Dor fundoplication as the preferred method to re-establish GER control in patients undergoing laparoscopic Heller myotomy.
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Leconte M, Douard R, Gaudric M, Dousset B. [Surgical management of primary esophageal motility disorders]. JOURNAL DE CHIRURGIE 2008; 145:428-436. [PMID: 19106862 DOI: 10.1016/s0021-7697(08)74651-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Primary esophageal motility disorders are rare, the most common diagnoses being achalasia and diffuse esophageal spasm. Treatment aims to alleviate symptoms and may be medical, endoscopic, or surgical. Achalasia is most commonly treated by pneumatic dilatation or by laparoscopic Heller cardiomyotomy. Pneumatic dilatation is effective in 60-80% of cases, but functional results deteriorate over time. Surgical treatment is indicated when endoscopic dilatation is contraindicated or has failed. Functional results after cardiomyotomy are satisfactory in 90% of cases and results appear to be stable over time. The need for an associated antireflux procedure and the type of fundoplication remain controversial. For diffuse esophageal spasm, extended esophageal myotomy has yielded satisfactory functional results, but surgical treatment should be reserved for selected patients with severe symptoms.
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Affiliation(s)
- M Leconte
- Service de chirurgie digestive et endocrinienne, hôpital Cochin - Paris.
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16
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Abstract
Cardiomyotomy is now usually performed using a minimally invasive approach. A consecutive series of 18 patients with an intention to treat thoracoscopically were followed by the same number of patients treated laparoscopically. Both groups have been followed prospectively for a minimum of 2 years. The groups were well matched for age, symptom duration, preoperative lower esophageal sphincter pressure, and number having undergone balloon dilatation. There was one conversion from a thoracoscopic to a laparoscopic approach so that, for the purpose of analysis, there are 17 in the thoracoscopic group and 19 in the laparoscopic group. There was no difference in the average operating time, rate of conversion to open operation, mucosal breaches, or length of hospitalization. Nor was there any difference in dysphagia symptoms, with 14/17 having a satisfactory result after thoracoscopic myotomy and 18/19 after laparoscopic myotomy. Frequency of reflux symptoms was similar and, although mild reflux was common, only two patients required treatment with a proton pump blocker. In the treatment of achalasia, thoracoscopic and laparoscopic myotomy without fundoplication are equally effective in relieving dysphagia and have a similar safety profile.
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Affiliation(s)
- R Cade
- St Vincent's Hospital and Box Hill Hospital, Melbourne, Australia
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Pneumatic Balloon Dilation Therapy Is as Effective as Esophagomyotomy for Achalasia. Dysphagia 2008; 23:155-60. [DOI: 10.1007/s00455-007-9115-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2007] [Accepted: 07/03/2007] [Indexed: 01/09/2023]
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Zhu ZJ, Chen LQ, Duranceau A. Long-term Result of Total versus Partial Fundoplication after Esophagomyotomy for Primary Esophageal Motor Disorders. World J Surg 2008; 32:401-7. [DOI: 10.1007/s00268-007-9385-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Kostic S, Kjellin A, Ruth M, Lönroth H, Johnsson E, Andersson M, Lundell L. Pneumatic dilatation or laparoscopic cardiomyotomy in the management of newly diagnosed idiopathic achalasia. Results of a randomized controlled trial. World J Surg 2007; 31:470-8. [PMID: 17308851 DOI: 10.1007/s00268-006-0600-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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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Affiliation(s)
- S Kostic
- Department of General Surgery, Borås Central Hospital, Brämhultsvägen 53, S-501 82, Borås, Sweden.
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Diamantis T, Pikoulis E, Felekouras E, Tsigris C, Arvelakis A, Karavokyros I, Bastounis E. Laparoscopic esophagomyotomy for achalasia without a complementary antireflux procedure. J Laparoendosc Adv Surg Tech A 2007; 16:345-9. [PMID: 16968179 DOI: 10.1089/lap.2006.16.345] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Achalasia is a progressive motility disorder of the esophagus, without a definitive cure. The principal method of palliation is myotomy of the distal esophagus. We analyzed the 5-year experience at our institution with laparoscopic Heller myotomy without an antireflux procedure to determine its results, particularly regarding postoperative gastroesophageal reflux. MATERIALS AND METHODS Thirty-three patients, mean age 43 years (range, 29-62 years) with clinical, manometric, x-ray, and endoscopic proof of achalasia were operated on and followed up for 24 months. Prior to being referred to surgery they had all undergone at least one pneumatic balloon dilation. The operative technique was a 7-cm myotomy that included the lower esophageal sphincter but did not exceed 5 mm of the gastric cardia. Follow-up consisted of clinical observation, cineesophagography, and 24-hour pHmetry. RESULTS All patients reported satisfactory to excellent results regarding dysphagia and no heartburn two years after the operation. The 24-hour pHmetry and the radiographic investigation showed no evidence of gastroesophageal reflux. CONCLUSION It seems that the risk of gastroesophageal reflux is very low when the cardiomyotomy does not exceed the length of 5 mm. Our results are in accordance with other observational studies as well as larger cohort and meta-analysis studies. Prospective randomized studies are needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.
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Aquino JLBD, Said MM, Fernandes PR. Avaliação tardia da mucosectomia esofágica com conservação da túnica muscular em pacientes com megaesôfago avançado. Rev Col Bras Cir 2007. [DOI: 10.1590/s0100-69912007000100004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Estudar retrospectivamente, por meio de uma avaliação tardia, a técnica de mucosectomia esofágica em pacientes com megaesôfago avançado. MÉTODO: Foram estudados 50 pacientes portadores de megaesôfago avançado submetidos à mucosectomia esofágica com conservação da túnica muscular no período de janeiro de 1991 a dezembro de 1997. Em todos os pacientes foi realizada avaliação tardia entre 6 e 15 anos de pós-operatório. A idade variou de 30 a 69 anos, com média de 53,5 anos, com predominância do sexo masculino em 32 pacientes (64%). Em todos os doentes, o estudo se fez em relação à avaliação clínica no que concerne à qualidade da deglutição, à presença ou não de regurgitação, a alterações no hábito intestinal, à evolução ponderal, à satisfação com a cirurgia e ao retorno à atividade normal. Também foi realizada a avaliação morfológica e funcional pelo estudo radiológico contrastado, pela endoscopia digestiva alta e pela tomografia computadorizada de tórax. Na avaliação clínica, morfológica e funcional foi realizada uma avaliação global representada pela somatória dos valores numéricos decorrentes da análise de cada um dos parâmetros, sendo o resultado final considerado bom, ótimo e regular e mau de acordo com o total dos pontos obtidos. RESULTADOS: Na avaliação clínica global, 44 pacientes (88%) apresentaram classificação entre ótima e boa, e o restante regular para mau. Na avaliação radiológica global, ótima e boa estiveram presentes em 47 pacientes (94%) e regular e mau no restante. Na avaliação endoscópica global, 45 pacientes (90%) obtiveram resultados ótimos para bons, e o restante regular para mau. Em relação à tomografia computadorizada de tórax, a avaliação global foi realizada em 31 pacientes sendo considerada ótima e boa em todos os pacientes. CONCLUSÃO: A avaliação tardia do pós-operatório evidenciou que a maioria dos pacientes apresentou avaliação boa e ótima, tanto na avaliação clínica como na morfológica e funcional.
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Csendes A, Braghetto I, Burdiles P, Korn O, Csendes P, Henríquez A. Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months. Ann Surg 2006; 243:196-203. [PMID: 16432352 PMCID: PMC1448918 DOI: 10.1097/01.sla.0000197469.12632.e0] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Laparoscopic esophagomyotomy is the preferred approach to patients with achalasia of the esophagus, However, there are very few long-term follow-up studies (>10 years) in these patients. OBJECTIVE To perform a very late subjective and objective follow-up in a group of 67 patients submitted to esophagomyotomy plus a partial antireflux surgery (Dor's technique). MATERIAL AND METHODS In a prospective study that lasted 30 years, 67 patients submitted to surgery were divided into 3 groups: group I followed for 80 to 119 months (15 patients); group II, with follow-up of 120 to 239 months (35 patients); and group III, with follow-up more than 240 months (17 patients). They were submitted to clinical questionnaire, endoscopic evaluation, histologic analysis, radiologic studies, manometric determinations, and 24-hour pH studies late after surgery. RESULTS Three patients developed a squamous cell esophageal carcinoma 5, 7, and 15 years after surgery. At the late follow-up, Visick III and IV were seen in 7%, 23%, and 35%, according to the length of follow-up of each group. Endoscopic examination revealed a progressive nonsignificant deterioration of esophageal mucosa, histologic analysis distal to squamous-columnar junction showed a significant decrease of fundic mucosa in patients of group III, with increase of intestinal metaplasia, although not significant time. Lower esophageal sphincter showed a significant decrease of resting pressure 1 year after surgery, which remained similar at the late control. There was no return to peristaltic activity. Acid reflux measured by 24-hour pH studies revealed a progressive increase, and the follow-up was longer. Nine patients developed Barrett esophagus: 6 of them a short-segment and 3 a long-segment Barrett esophagus. Final clinical results in all 67 patients demonstrated excellent or good results in 73% of the cases, development of epidermoid carcinoma in 4.5%, and failures in 22.4% of the patients, mainly due to reflux esophagitis. Incomplete myotomy was seen in only 1 case. CONCLUSION In patients with achalasia submitted to esophagomyotomy and Dor's antireflux procedure, there is a progressive clinical deterioration of initially good results if a very long follow-up is performed (23 years after surgery), mainly due to an increase in pathologic acid reflux disease and the development of short- or long-segment Barrett esophagus.
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Affiliation(s)
- Attila Csendes
- Department of Surgery, University Hospital, Santiago, Chile.
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Leeuwenburgh I, Haringsma J, Van Dekken H, Scholten P, Siersema PD, Kuipers EJ. Long-term risk of oesophagitis, Barrett's oesophagus and oesophageal cancer in achalasia patients. Scand J Gastroenterol 2006:7-10. [PMID: 16782616 DOI: 10.1080/00365520600664201] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Achalasia is a motility disorder of the oesophagus of unknown origin in which loss of relaxation of the lower oesophageal sphincter (LOS) and aperistalsis in the distal oesophagus leads to functional oesophageal obstruction. The treatment is symptomatic, aimed at lowering of the LOS pressure, and may be accompanied by various side effects, including gastro-oesophageal reflux, a risk factor for oesophagitis and its complications. Stasis and fermentation can also lead to inflammation of the oesophageal mucosa, giving rise to hyperplasia of the epithelium, multifocal dysplasia and in some patients eventually squamous cell carcinoma. Unfortunately, the sensitivity and specificity of endoscopical inspection to assess inflammation or dysplasia of the oesophageal lining is low, such that biopsy sampling is necessary for accurate assessment. Although it is generally accepted that achalasia is a pre-malignant disorder, the reported increased risk of patients with achalasia developing a squamous cell carcinoma varies from 0 to 140 times that of the normal population. In addition, achalasia may predispose to Barrett's metaplasia and oesophageal adenocarcinoma, which have been described in case reports after myotomy. Surveillance endoscopy with tissue sampling to detect pre-neoplastic lesions has been recommended, even though this can be very difficult due to mucosal adherence of food as well as hyperplastic changes of the mucosa. In the event of moderate to severe inflammation and/or persisting stasis of food despite adequate LOS pressure-lowering therapy, the surveillance interval should be shortened and performed after a 3-day liquid diet. The exact technique and time intervals still need to be established, however.
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Affiliation(s)
- Ivonne Leeuwenburgh
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre Rotterdam, The Netherlands.
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Gupta R, Sample C, Bamehriz F, Birch D, Anvari M. Long-term outcomes of laparoscopic heller cardiomyotomy without an anti-reflux procedure. Surg Laparosc Endosc Percutan Tech 2005; 15:129-32. [PMID: 15956895 DOI: 10.1097/01.sle.0000166987.82227.f5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Certain technical features of laparoscopic Heller cardiomyotomy (LHM) remain controversial, including the extent of the myotomy and the indication for an antireflux procedure. We completed a retrospective chart review of all patients who underwent LHM for achalasia at 1 tertiary care institution to review our institutional experience with LHM without an antireflux procedure. Forty patients underwent a LHM performed by 2 surgeons, 65% of whom had previous medical management (Botox: 12 patients, LES dilatation: 14). The operating time was significantly increased in patients with Botox injections (98.3 vs. 71.1 minutes, P = 0.005). There were 3 intraoperative complications (mucosal injury in 3 patients, 2 had Botox injections). Postoperative evaluation demonstrated a mean dysphagia score of 0.2, a mean heartburn score of 3.2, and a mean LES pressure of 6.32 mm Hg. Thirty-two patients are maintained on acid-suppressing medications with good control of reflux symptoms. LHM without an antireflux procedure achieves excellent clinical outcomes in most patients with achalasia regardless of previous medical management. Previous medical management may present a greater technical challenge and may place patients at increased risk of mucosal injury.
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Affiliation(s)
- R Gupta
- Centre for Minimal Access Surgery, St. Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada
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Rossetti G, Brusciano L, Amato G, Maffettone V, Napolitano V, Russo G, Izzo D, Russo F, Pizza F, Del Genio G, Del Genio A. A total fundoplication is not an obstacle to esophageal emptying after heller myotomy for achalasia: results of a long-term follow up. Ann Surg 2005; 241:614-21. [PMID: 15798463 PMCID: PMC1357065 DOI: 10.1097/01.sla.0000157271.69192.96] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the role and efficacy of a total 360 degrees wrap, Nissen-Rossetti fundoplication, after esophagogastromyotomy in the treatment of esophageal achalasia. SUMMARY BACKGROUND DATA Surgery actually achieves the best results in the treatment of esophageal achalasia; the options vary from a short extramucosal esophagomyotomy to an extended esophagogastromyotomy with an associated partial fundoplication to restore the main antireflux barrier. A total 360 degrees fundoplication is generally regarded as an obstacle to esophageal emptying. MATERIALS AND METHODS Since 1992 to November 2003, a total of 195 patients (91 males, 104 females), mean age 45.2 years (range, 12-79 years), underwent laparoscopic treatment of esophageal achalasia. Intervention consisted of Heller myotomy and Nissen-Rossetti fundoplication with intraoperative endoscopy and manometry. RESULTS In 3 patients (1.5%), a conversion to laparotomy was necessary. Mean operative time was 75 +/- 15 minutes. No mortality was observed. Overall major morbidity rate was 2.1%. Mean postoperative hospital stay was 3.6 +/- 1.1 days (range, 1-12 days). At a mean clinical follow up of 83.2 +/- 7 months (range, 3-141 months) on 182 patients (93.3%), an excellent or good outcome was observed in 167 patients (91.8%) (dysphagia DeMeester score 0-1). No improvement of dysphagia was observed in 4 patients (2.2%). Gastroesophageal pathologic reflux was absent in all the patients. CONCLUSIONS Laparoscopic Nissen-Rossetti fundoplication after Heller myotomy is a safe and effective treatment of esophageal achalasia with excellent results in terms of dysphagia resolution, providing total protection from the onset of gastroesophageal reflux.
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Affiliation(s)
- Gianluca Rossetti
- I Division of General and Gastrointestinal Surgery, Second University of Naples, Naples, Italy.
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Costantini M, Zaninotto G, Guirroli E, Rizzetto C, Portale G, Ruol A, Nicoletti L, Ancona E. The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up. Surg Endosc 2005; 19:345-51. [PMID: 15645326 DOI: 10.1007/s00464-004-8941-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2004] [Accepted: 08/25/2004] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to investigate the long-term clinical outcome of the laparoscopic Heller Dor procedure for esophageal achalasia. METHODS A total of 71 consecutive patients with a minimum 6 year follow-up were evaluated. These patients were seen at 1 and 6 months after the operation (at which time barium swallow, endoscopy, manometry, and pH monitoring were performed), and annually thereafter. A dedicated symptom score, that combined severity and frequency of symptoms was used. RESULTS The median symptom score decreased from 22 (range, 9-29) preoperatively to 4 (range, 0-16) at last follow-up, (p < 0.01). During the follow-up period, 13 patients suffered symptom recurrence; seven of them (54%) had already been diagnosed at the 1-year follow-up. All of these patients were treated with complementary pneumatic dilations. Overall, at a minimum of 6- years after the operation, 81.7% of the patients were satisfied with the treatment and were able to eat normally. CONCLUSIONS The long-term outcome of laparoscopic surgical treatment of esophageal achalasia is only slightly affected by the length of the follow-up and most of the symptomatic failures occur in the early period after the operation.
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Affiliation(s)
- M Costantini
- Department of Medical and Surgical Sciences, Clinical Chirurgica III, School of Medicine, University of Padua, via Giustiniani, 35128, Padua, Italy.
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Avtan L, Avci C, Guvenc H, Igci A, Ozmen V. Laparoscopic myotomy for oesophageal achalasia--adding an antireflux procedure is not always necessary. Int J Clin Pract 2005; 59:35-8. [PMID: 15707462 DOI: 10.1111/j.1742-1241.2004.00368.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Laparoscopy is the access of choice for functional surgery of the gastroesophageal junction, and oesophagocardiomyotomy, as the conventional surgical treatment of achalasia, is one of the favourable indications for laparoscopic surgery. Laparoscopic anterior myotomy technique is highly effective and secure for relieving dysphagia with minimal risk of gastroesophageal reflux. Fifteen patients with the diagnosis of achalasia were treated with laparoscopic anterior face oesophagocardiomyotomy without a concomitant antireflux procedure. There was not any perioperative complication and no procedure was converted to open operation. Oesophageal cineradiography, manometry and 24-h pH monitoring were repeated postoperatively. Manometry showed a significant reduction of the resting tone (48-34.4 to 18-3.2 mmHg), and patients were free of symptoms for reflux and dysphagia at the follow-up between 8 and 96 (median 42) months. Only one patient needed pneumatic dilation, 1 year after the operation for mild dysphagia, and one patient had moderate reflux, which was managed by medication. Thanks to minimal invasive technique of laparoscopic surgery and intraoperative endoscopy, oesophagocardiomyotomy can safely be performed in a length needed without dividing lateral and posterior phrenoesophageal ligamentous attachments. Consequently, adding an antireflux procedure routinely is not necessary. We advocate laparoscopic anterior oesophagocardiomyotomy alone as the first-line treatment for achalasia.
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Affiliation(s)
- L Avtan
- Department of Surgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey.
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Azevedo JLMC, Kozu FO, Azevedo O, Paiva VC, Silva CEPD, Simões MDJ. Cicatrização da miotomia de Heller por acesso videolaparoscópico com e sem fundocardioplastia de dor associada, em porcos. Rev Col Bras Cir 2004. [DOI: 10.1590/s0100-69912004000600003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Comparar a cicatrização da miotomia esofagiana laparoscópica associada ou não à fundocardioplastia de Dor. MÉTODO: Foram utilizados 18 porcos, em três grupos de seis animais. No grupo A foi realizada miotomia esofagiana. No grupo B associou-se plicatura gástrica à miotomia. O grupo C foi sem miotomia. No 21º dia pós-operatório houve moldagem do lume para obter índices de estenose (IE) na região da miotomia (RM) e na transição esôfago-gástrica (I'E'). Foram também estudados aspectos macro e microscópicos. RESULTADOS: Duração maior (t de Student) no grupo B (93,6 minutos) que no A (45 minutos). Considerando- se o IE dos grupos A e B, não houve estenose e eles se equivaleram - Mann-Withney (-11.1% no grupo A e -12.7% no grupo B). O I'E' foi sempre maior que o IE - Wilcoxon (18% versus -11,1% no grupo A e 37,7 % versus -12.7% no grupo B). O I'E' do grupo B (37,7%) foi o maior entre os grupos (Kruskal-Wallis): A: 18%; C: 15,5%. Houve regularidade macroscópica da região da miotomia do grupo A e deformidades com inflamação aguda persistente e granulomas no B. No grupo A houve epitelização mesotelial e no B a superfície cruenta permaneceu granulada. Na RM do grupo B, leucócitos (22 versus 8,6 do A) e vasos (18,7 versus 9,7 da A) foram mais numerosos. A fibrose foi mais profusa no grupo B (25,85 fibras versus 15,6 no A). CONCLUSÕES: A plicatura gástrica sobre a miotomia esofagiana propicia cicatrização menos adequada e é mais demorada que a miotomia isolada.
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Burpee SE, Mamazza J, Schlachta CM, Bendavid Y, Klein L, Moloo H, Poulin EC. Objective analysis of gastroesophageal reflux after laparoscopic heller myotomy: an anti-reflux procedure is required. Surg Endosc 2004; 19:9-14. [PMID: 15531966 DOI: 10.1007/s00464-004-8932-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2004] [Accepted: 06/30/2004] [Indexed: 01/27/2023]
Abstract
BACKGROUND Controversy exists over the necessity of performing a concurrent antireflux procedure with a Heller myotomy. We therefore sought to objectively analyze gastroesophageal reflux following laparoscopic Heller myotomy where an antireflux procedure was not performed. METHODS A prospective database of 66 cases of laparoscopic Heller myotomy performed between November 1996 and June 2002 was reviewed. Previous, concurrent, or subsequent fundoplication was performed in 12 patients; therefore 54 patients without antireflux procedures were available for analysis. Follow-up included symptomatic assessment in 50 patients (93%). Heartburn was assessed on a four-point scale with clinical significance defined as >2 episodes/week. Objective testing, including endoscopy, esophagogram, manometry, and 24-h pH monitoring, was offered to all patients. Objective evidence of reflux was defined as the composite endpoint of positive 24-h pH monitoring or esophagitis on endoscopy. RESULTS Significant heartburn was reported in 15 of 50 patients (30%). Positive 24-h pH recordings were seen in 11 of 22 patients tested while esophagitis was seen in 13 of 21 patients tested, resulting in objective evidence of reflux in 18 of 30 patients tested (60%). Of these 18 patients, seven did not have significant heartburn. All 12 patients without objective reflux did not have significant heartburn. Therefore, of the 30 patients with objective testing, seven (23%) had objective reflux without subjective heartburn (silent reflux). CONCLUSION Objective analysis reveals an unacceptable rate of gastroesophageal reflux in laparoscopic Heller myotomy without an antireflux procedure. We therefore recommend performing a concurrent antireflux procedure.
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Affiliation(s)
- S E Burpee
- The Centre for Minimally Invasive Surgery, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
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Douard R, Gaudric M, Chaussade S, Couturier D, Houssin D, Dousset B. Functional results after laparoscopic Heller myotomy for achalasia: A comparative study to open surgery. Surgery 2004; 136:16-24. [PMID: 15232534 DOI: 10.1016/j.surg.2004.01.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prospective studies comparing laparoscopic to open Heller myotomy for esophageal achalasia are lacking. The aim of this study was to compare functional outcome after laparoscopic and open Heller myotomy for esophageal achalasia. METHODS Eighty-two patients who underwent Heller-Dor myotomy for achalasia, via laparoscopy (n=52) or open surgery (n=30) were recorded prospectively (1993-2002). Median follow-up was 51 (12-111) months. Perioperative functional data were assessed via dysphagia and overall clinical (dysphagia, chest pain, regurgitation, gastroesophageal reflux) scores. RESULTS In laparoscopy patients, the operative time was longer (145 [95-290] vs 120 [70-230] minutes, P <.0001); the postoperative hospital stay and feeding resumption time was shorter (4 [2-25] vs 7.5 [5-18] days, P <.0001 and 2 [1-15] vs 4 [1-14] days, P <.0001). Three mucosal tears necessitated conversion to open surgery (6%). The rates of " excellent" or " satisfactory" results after laparoscopic and open surgery were 92% (n=48/52) versus 93% (n=28/30), and 83% (n=43/52) versus 83% (n=25/30) on overall clinical score. In both groups, the overall clinical score indicated significant improvement during 12-month follow-up. The laparoscopy and open surgery symptomatic gastroesophageal reflux rates were 10% and 7%, respectively. CONCLUSIONS Laparoscopic Heller myotomy favorably compares with open surgery regarding dysphagia relief and gastroesophageal reflux rate. Overall clinical score indicates gradual improvement in patient functional status during 12-month follow-up.
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Affiliation(s)
- Richard Douard
- Department of Surgery, Cochin University Hospital, Paris, France
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31
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Abstract
Eponyms are frequently used in the surgery in homage to remarkable surgeons, specially creators of new surgical techniques and instruments. Sometimes, however, the right person is not revered or the name persists, but the author's technique has been changed over time and the original procedure is lost. Eponyms of the 10 most famous procedures in esophageal surgery are revisited. Names like Lortat-Jacob, Toupet, Dor, Heller, Nissen, Ivor Lewis, Collis, Merendino, Hill, and Belsey, are reviewed, analyzing the man behind the name, the original technique and its modifications.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, Esophagus Division, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil.
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32
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Abstract
Achalasia is a condition of unknown etiology. It represents a motor disorder of the esophagus characterized by absent or incomplete relaxation of the lower esophageal sphincter upon swallowing and by non-propulsive swallow-induced contraction waves or amotility of the esophageal body. Dysphagia and regurgitation of ingesta are the most frequent symptoms. Medical treatment, i.e. by calcium-channel blockers and nitric oxide donors, may be tried in patients with mild dysphagia or in elderly patients but rarely yields adequate symptom relief. Mechanical dilatation of the achalasic sphincter may be performed as an initial treatment option. Intrasphincteric injections of botulinum toxin seemed to be a promising alternative, but it has become obvious that, in most cases, repeated applications of the toxin are required to maintain patients symptom-free. Myotomy of the achalasic sphincter with or without fundoplication to prevent gastroesophageal reflux, is employed mainly in patients in whom dilatations have failed, but since the introduction of minimally invasive surgery, myotomy has become the primary treatment at many centers. This article aims to provide an overview of the development of the conservative and surgical treatment of achalasia.
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Affiliation(s)
- Enrico P Cosentini
- Klinische Abteilung für Allgemeinchirurgie, Universitätsklinik für Chirurgie, Wien, Osterreich.
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Kesler KA, Tarvin SE, Brooks JA, Rieger KM, Lehman GA, Brown JW. Thoracoscopy-assisted Heller myotomy for the treatment of achalasia: results of a minimally invasive technique. Ann Thorac Surg 2004; 77:385-91; discussion 391-2. [PMID: 14759402 DOI: 10.1016/j.athoracsur.2003.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Several surgical methods have been described to treat achalasia with a recent trend toward utilizing minimally invasive techniques to perform a myotomy. Since 1998 our institution has utilized a minimally invasive thoracoscopy-assisted technique (ThAM) that allows a myotomy to be performed under direct visualization. METHODS From 1992 to 2002, 57 patients underwent transthoracic Heller myotomy at our institution. Thirty-eight patients (67%) who underwent ThAM were reviewed and compared with 19 (33%) who previously underwent myotomy through a standard open left thoracotomy (OM). RESULTS There were no operative deaths in the ThAM group (n = 38) and 4 patients (11%) experienced minor morbidity. Four ThAM patients required conversion to open thoracotomy and 2 were lost to follow-up. Of the remaining 32 patients, 29 have improved postoperative dysphagia scores after a mean follow-up of 17 months. Only 4 patients have required further endoscopic or surgical intervention. Compared with the OM group, ThAM patients experienced significantly shorter average surgery time (97 versus 139 minutes), less blood loss (80 versus 155 mL), less postoperative narcotic requirement (8 versus 20 days), and shorter recovery to normal activity (20 versus 73 days). CONCLUSIONS Thoracoscopy-assisted myotomy results in excellent relief of dysphagia in the short term and would be expected to have long-term results similar to OM. Shorter operating and recovery times as compared with OM without the need for an antireflux procedure makes ThAM an attractive minimally invasive technique.
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Affiliation(s)
- Kenneth A Kesler
- Department of Surgery, Thoracic Division, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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Frantzides CT, Moore RE, Carlson MA, Madan AK, Zografakis JG, Keshavarzian A, Smith C. Minimally invasive surgery for achalasia: a 10-year experience. J Gastrointest Surg 2004; 8:18-23. [PMID: 14746831 DOI: 10.1016/j.gassur.2003.09.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Minimally invasive esophagomyotomy for achalasia has become the preferred surgical treatment; the employment of a concomitant fundoplication with the myotomy is controversial. Here we report a retrospective analysis of 53 patients with achalasia treated with laparoscopic Heller myotomy; fundoplication was used in all patients except one, and 48 of the fundoplications were complete (floppy Nissen). There were no deaths or reoperations, and minor complications occurred in three patients. Good-to-excellent long-term results were obtained in 92% of the subjects (median follow-up 3 years). Two cases (4%) of persistent postoperative dysphagia were documented, one of which was treated with dilatation. Postoperative reflux occurred in five patients, four of whom did not receive a complete fundoplication; these patients were well controlled with medical therapy. We suggest that esophageal achalasia may be successfully treated with laparoscopic Heller myotomy and floppy Nissen fundoplication with an acceptable rate of postoperative dysphagia.
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Falkenback D, Johansson J, Oberg S, Kjellin A, Wenner J, Zilling T, Johnsson F, Von Holstein CS, Walther B. Heller's esophagomyotomy with or without a 360 degrees floppy Nissen fundoplication for achalasia. Long-term results from a prospective randomized study. Dis Esophagus 2003; 16:284-90. [PMID: 14641290 DOI: 10.1111/j.1442-2050.2003.00348.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heller's esophagomyotomy relieves dysphagia but does not restore esophageal peristalsis. The myotomy may induce reflux and the addition of a 360 degrees fundoplication may be hazardous with regard to the remaining aperistaltic esophagus. The aim of this prospectively randomized clinical trial was to compare the outcome for patients with uncomplicated achalasia who underwent an anterior Heller's esophagomyotomy (H group) with or without an additional floppy Nissen fundoplication (H + N group). Between 1984 and 1995, 20 patients were prospectively randomized to one or other of the performed operations, 10 patients per group. Esophagitis including Barrett's esophagus (n = 2) was seen under medical treatment, in 6 of 9 in the H group but none in the H + N group. No patient in the H + N group required postoperative continuous acid-reducing drugs. Twenty-four-hour esophageal pH-studies in median 3.4 years after surgery showed pathological reflux expressed as a percentage of time below pH 4 of 13.1% in the H group compared to 0.15% (P < 0.001) in H + N group. One patient with recurrent dysphagia in the H + N group later had an esophagectomy. The remaining patients reported significant improvement of dysphagia without symptoms of reflux at 8.0 years follow-up. Heller's esophagomyotomy eliminates dysphagia, but can induce advanced reflux that requires medical treatment. The addition of a 360 degrees fundoplication eliminates reflux without adding dysphagia in the majority of patients and can be recommended for most patients with uncomplicated achalasia.
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Affiliation(s)
- D Falkenback
- Department of Surgery, Business Area Elective Surgery, Helsingborg Hospital Inc., Helsingborg, Sweden.
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36
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Abstract
Achalasia is a rare neurologic deficit of the esophagus, producing a syndrome of impaired relaxation of the lower esophageal sphincter and decreased motility of the esophageal body for which the cause is unknown. The resultant chronic esophageal stasis produces discomforting symptoms that can be managed with medication, chemical paralysis of the lower esophageal sphincter, mechanical dilation, or surgical esophagomyotomy. Chemical paralysis by injection of the esophagus with botulinum toxin and dilation with an inflatable balloon offers good short-term relief of symptoms; however, the best long-term results are produced by surgery, and advancing minimally invasive techniques continually reduce the morbidity of these operations. The type of surgical procedure, the necessity for fundoplication, and the order of treatment continue to be unresolved issues, but prospective evaluation with objective followup should allow us to provide the optimal treatment regimen to our patients.
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Affiliation(s)
- Shawn D St Peter
- Department of General Surgery, Mayo Clinic Scottsdale, Arizona, USA
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37
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Gastrointestinal quality of life before and after laparoscopic heller myotomy with partial posterior fundoplication. Ann Surg 2003. [PMID: 12454513 DOI: 10.1097/01.sla.0000036270.41686.b1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess the outcome of laparoscopic Heller myotomy for achalasia using a specific quality of life (QoL) instrument for gastrointestinal disorders. SUMMARY BACKGROUND DATA Current therapies for achalasia do not restore normal esophageal motility but aim at palliating dysphagia. However, many other symptoms may persist that cannot be assessed objectively by currently available symptom scores. Although generic QoL instruments have shown improvement in QoL after myotomy, disease-specific QoL instruments may be more responsive to change and therefore more reliable for comparing outcomes of therapeutic options for achalasia. METHODS The Gastrointestinal Quality of Life Index (GIQLI) was studied before and after laparoscopic Heller myotomy associated with posterior partial fundoplication. RESULTS Starting in January 1991, 73 consecutive patients were operated on laparoscopically for various clinical stages of achalasia. Since 1996, 40 patients completed a GIQLI questionnaire both preoperatively and after a minimum postoperative follow-up of 1 year. Median preoperative GIQLI score was 84 (range 34-129) out of a theoretical maximum score of 144. At a median follow-up of 31 months (range 12-54), the score had significantly improved to 119 (range 77-143), close to the range for the normal French population. Not only items assessing gastrointestinal symptoms but also the domains of physical, social, and emotional function were significantly improved. The most marked improvements were achieved in patients with the lowest preoperative scores. CONCLUSIONS The GIQLI allows us to objectify the impact of achalasia symptoms on health-related QoL. At medium-term follow-up, laparoscopic Heller myotomy, performed either as primary treatment or after endoscopic dilation, significantly improves most health-related QoL aspects. Short of randomized comparisons between the different therapeutic options available for achalasia, reported series could be made more comparable if validated QoL instruments specific for gastrointestinal disorders were used routinely for outcome evaluation.
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Decker G, Borie F, Bouamrirene D, Veyrac M, Guillon F, Fingerhut A, Millat B. Gastrointestinal quality of life before and after laparoscopic heller myotomy with partial posterior fundoplication. Ann Surg 2002; 236:750-8; discussion 758. [PMID: 12454513 PMCID: PMC1422641 DOI: 10.1097/00000658-200212000-00007] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To assess the outcome of laparoscopic Heller myotomy for achalasia using a specific quality of life (QoL) instrument for gastrointestinal disorders. SUMMARY BACKGROUND DATA Current therapies for achalasia do not restore normal esophageal motility but aim at palliating dysphagia. However, many other symptoms may persist that cannot be assessed objectively by currently available symptom scores. Although generic QoL instruments have shown improvement in QoL after myotomy, disease-specific QoL instruments may be more responsive to change and therefore more reliable for comparing outcomes of therapeutic options for achalasia. METHODS The Gastrointestinal Quality of Life Index (GIQLI) was studied before and after laparoscopic Heller myotomy associated with posterior partial fundoplication. RESULTS Starting in January 1991, 73 consecutive patients were operated on laparoscopically for various clinical stages of achalasia. Since 1996, 40 patients completed a GIQLI questionnaire both preoperatively and after a minimum postoperative follow-up of 1 year. Median preoperative GIQLI score was 84 (range 34-129) out of a theoretical maximum score of 144. At a median follow-up of 31 months (range 12-54), the score had significantly improved to 119 (range 77-143), close to the range for the normal French population. Not only items assessing gastrointestinal symptoms but also the domains of physical, social, and emotional function were significantly improved. The most marked improvements were achieved in patients with the lowest preoperative scores. CONCLUSIONS The GIQLI allows us to objectify the impact of achalasia symptoms on health-related QoL. At medium-term follow-up, laparoscopic Heller myotomy, performed either as primary treatment or after endoscopic dilation, significantly improves most health-related QoL aspects. Short of randomized comparisons between the different therapeutic options available for achalasia, reported series could be made more comparable if validated QoL instruments specific for gastrointestinal disorders were used routinely for outcome evaluation.
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Affiliation(s)
- Georges Decker
- Department of Visceral Surgery A, Hôpital Saint-Eloi, University Hospital Center Montpellier, Montpellier, France
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Zaninotto G, Costantini M, Molena D, Portale G, Costantino M, Nicoletti L, Ancona E. Minimally invasive surgery for esophageal achalasia. J Laparoendosc Adv Surg Tech A 2001; 11:351-9. [PMID: 11814125 DOI: 10.1089/10926420152761860] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Esophageal achalasia is characterized by loss of peristaltic activity and failure of relaxation of the lower esophageal sphincter (LES). The characteristic dysphagia may be alleviated by surgery, dilations, or botulinum toxin injections. Video-endoscopic surgery is used increasingly. PATIENTS AND METHODS This paper reports our experience with 142 consecutive achalasia patients treated by laparoscopic Heller myotomy and Dor antireflux fundoplication and followed for a median 26 months. RESULTS Overall, the actuarial lifetable analysis showed a 90% probability of a patient's being symptom free over a 5-year period. Radiologic assessment showed a significant reduction in esophageal diameter and manometry a significant reduction in the resting tone and residual pressure of the LES. Twenty-four-hour pH monitoring showed postoperative reflux in 6.7% of patients. Persistent dysphagia or chest pain (i.e., failure of treatment) were reported by 15 patients (10.6%): 14 of them were subsequently treated with multiple pneumatic dilations, which were successful in 12 cases. CONCLUSION Laparoscopic Heller myotomy with Dor fundoplication is a feasible and effective treatment for achalasia, with an actuarial success rate of 90% at 5 years. With additional dilation, a 98% success rate can be achieved.
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Affiliation(s)
- G Zaninotto
- Department of Medical and Surgical Sciences, Clinica Chirurgica IV, University of Padua, School of Medicine, Italy.
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Lehman MB, Clark SB, Ormsby AH, Rice TW, Richter JE, Goldblum JR. Squamous mucosal alterations in esophagectomy specimens from patients with end-stage achalasia. Am J Surg Pathol 2001; 25:1413-8. [PMID: 11684958 DOI: 10.1097/00000478-200111000-00009] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Achalasia is an esophageal motor disorder in which the primary morphologic changes are found in the myenteric plexus. However, a number of secondary alterations are characteristically found in esophagectomy specimens, including the mucosa. In addition, these patients are at increased risk of developing esophageal squamous cell carcinoma. We studied the squamous mucosal alterations in 35 esophagectomy specimens from patients with end-stage achalasia and compared them with those found in the squamous mucosa near the esophagogastric junction from pediatric autopsies (</=18 years) from patients with no known esophageal disease. A representative block was immunostained for p53 (DO7), CD3, and CD20. p53 immunoreactivity was graded as follows: 0 = no staining; 1+ = rare basal cell staining; 2+ = extensive basal cell staining; 3+ = suprabasilar staining. Intraepithelial lymphocyte counts were performed by counting five high power fields (HPF) and calculating an average/HPF. Ages of achalasia patients at esophagectomy ranged from 21 to 78 years (mean 56 years), including 20 men and 15 women. Disease duration ranged from 1 to 44 years (mean 17 years). In all cases the squamous mucosa from achalasia patients was markedly hyperplastic with papillomatosis and basal cell hyperplasia. p53 staining in the squamous mucosa from achalasia patients was significantly more common than in controls (32 of 35 [91%] vs 1 of 17 [6%]; p <0.05). In all achalasia cases CD3+ cells far outnumbered CD20+ cells. There was a significantly greater number of CD3+ cells in achalasia cases (range 32-239/HPF; mean 107/HPF) compared with controls (range 0.8-12/HPF; mean 6/HPF) (p <0.05). In conclusion, the squamous mucosa in esophagectomy specimens from patients with end-stage achalasia shows significant alterations including marked squamous hyperplasia, an increased frequency of p53 immunoreactivity, and increased numbers of CD3+ cells when compared with controls. These changes may be related to the increased risk of squamous cell carcinoma in these patients.
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Affiliation(s)
- M B Lehman
- Center for Swallowing and Esophageal Disorders and the Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Maher JW, Conklin J, Heitshusen DS. Thoracoscopic esophagomyotomy for achalasia: preoperative patterns of acid reflux and long-term follow-up. Surgery 2001; 130:570-6; discussion 576-7. [PMID: 11602886 DOI: 10.1067/msy.2001.116681] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The best technique for surgical esophagomyotomy to treat achalasia remains contentious. The controversies include the best approach (thoracoscopic or laparoscopic) and the need for an antireflux procedure. Postoperative pH studies have suggested pathologic gastroesophageal reflux (GER) in many cases; however, control studies of reflux patterns are scarce. This study presents pH studies before esophagomyotomy as well as long-term follow-up of patients undergoing esophagomyotomy. METHODS Forty-nine patients underwent esophagomyotomy (45 thoracoscopically, 4 laparoscopically) for achalasia. Before treatment, 24-hour pH studies were conducted for 38 patients with achalasia. The patients were evaluated postoperatively for dysphagia and reflux. Results were classified as excellent, good, fair, or poor. RESULTS The findings of the pretreatment pH studies were abnormal in 15 patients (39%). Twelve patients (32%) had GER either with esophageal fermentation (6 patients [16%]) or without fermentation (6 patients [16%]). Eight percent had esophageal fermentation alone. There was no correlation between GER and previous pneumatic dilatation. Twenty-three patients (60%) had normal pH scores; of these, 24% had esophageal fermentation, whereas 29% had neither reflux nor fermentation. Operative results were excellent in 70% of patients, good in 10%, and fair in 20%. All patients considered their conditions improved. Four patients required a subsequent operation because of dysphagia (n = 3) or reflux (n = 1), and their original procedures were classified as failures. Their current status is fair (n = 2), good (n = 1), and excellent (n = 1). GER was documented before the original operation in 3 of the 4 patients in whom the procedure failed. Fifteen patients were eligible for 5-year follow-up. Their results are excellent or good (n = 11) (73%) and fair (n = 4) (27%). CONCLUSIONS A high percentage of patients with achalasia exhibit pathologic GER before surgical therapy and seem to be at higher risk for failed surgical treatment. Thoracoscopic esophagomyotomy resulted in improvement in 92% of patients, and long-term follow-up indicates that these results are durable.
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Affiliation(s)
- J W Maher
- Department of Surgery, University of Iowa College of Medicine, Iowa City, Iowa, USA
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Abstract
Cardiomyotomy is now usually performed using a minimally invasive approach. A consecutive series of 18 patients with an intention to treat thoracoscopically were followed by the same number of patients treated laparoscopically. Both groups have been followed prospectively for a minimum of 2 years. The groups were well matched for age, symptom duration, preoperative lower esophageal sphincter pressure, and number having undergone balloon dilatation. There was one conversion from a thoracoscopic to a laparoscopic approach so that, for the purpose of analysis, there are 17 in the thoracoscopic group and 19 in the laparoscopic group. There was no difference in the average operating time, rate of conversion to open operation, mucosal breaches, or length of hospitalization. Nor was there any difference in dysphagia symptoms, with 14/17 having a satisfactory result after thoracoscopic myotomy and 18/19 after laparoscopic myotomy. Frequency of reflux symptoms was similar and, although mild reflux was common, only two patients required treatment with a proton pump blocker. In the treatment of achalasia, thoracoscopic and laparoscopic myotomy without fundoplication are equally effective in relieving dysphagia and have a similar safety profile.
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Affiliation(s)
- R Cade
- St Vincent's Hospital and Box Hill Hospital, Melbourne, Australia
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Abstract
Achalasia is characterized by the absence of peristalsis in the distal two thirds of the esophagus, failure of receptive relaxation of the lower esophageal sphincter, and dysphagia to both solids and liquids. Diagnosis is confirmed by barium swallow, esophageal manometry, and flexible endoscopy. Treatment is based primarily on disruption of the lower esophageal sphincter, which can be achieved by forceful dilation of surgical esophagomyotomy. Esophagomyotomy produces relief of symptoms in more than 90% of patients.
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Affiliation(s)
- J W Maher
- Department of Surgery, University of Iowa Health Care, Iowa City 52242, USA
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Donahue PE, Teresi M, Patel S, Schlesinger PK. Laparoscopic myotomy in achalasia: intraoperative evidence for myotomy of the gastric cardia. Dis Esophagus 2000; 12:30-6. [PMID: 10941858 DOI: 10.1046/j.1442-2050.1999.00003.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The myotomy performed for achalasia of the esophagus should divide all of the constricting, diseased muscular elements that obstruct the esophagogastric junction (EGJ). Whether the disease process includes proximal gastric as well as esophageal components is as yet unclear, but anatomic evidence complemented by clinical data suggest that the disease process does not end at the evanescent and poorly defined EGJ. Clinical reports from enthusiastic proponents of a particular operative approach for achalasia have not been illuminating in this regard, because all patients are improved to some degree post-operatively, and there are no objective parametric standards for the evaluation of swallowing function. This study reports a series of patients in whom endoscopic viewing was used to judge the adequacy of myotomy after 'esophageal' myotomy. The question posed by this study was, 'Does esophageal myotomy remove all constricting elements at the gastroesophageal junction?' Laparoscopic myotomy was performed in 48 patients with a diagnosis of achalasia; these patients are the most recent in a total cohort of 72 patients operated upon for achalasia during the past 20 years. Myotomy was begun on the esophagus, and extended to the esophagogastric junction; anatomic landmarks, including the appearance of submucosal veins, guided the initial dissection. Intraoperative endoscopy was then performed to determine whether there was residual constriction of the channel between the esophagus and stomach; if so, myotomy was extended onto the gastric cardia until visual evidence of obstruction had disappeared. All patients had either Toupet fundoplication or Dor fundoplication after myotomy. There were obvious constricting elements distal to the gastroesophageal junction in 90% of the patients. These patients required extension of the myotomy onto the stomach for an average of 15 mm. All but one patient had improved swallowing post-operatively. Eight patients required 'stretch' of the distal esophagus/cardia within the first year post-operatively; one patient was reoperated for fibrous scar obstruction of the distal esophagus. Esophageal myotomy limited to the esophageal muscle does not remove all constricting elements at the gastroesophageal junction; as a result, the extended myotomy must be complemented by an antireflux procedure during operations for achalasia.
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Affiliation(s)
- P E Donahue
- Department of Surgery, Cook County Hospital, University of Illinois at Chicago, 60612, USA
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Zaninotto G, Costantini M, Molena D, Buin F, Carta A, Nicoletti L, Ancona E. Treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor partial anterior fundoplication: prospective evaluation of 100 consecutive patients. J Gastrointest Surg 2000; 4:282-9. [PMID: 10769091 DOI: 10.1016/s1091-255x(00)80077-3] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In this article we report our experience in 100 consecutive achalasia patients who were treated with laparoscopic Heller myotomy and Dor antireflux fundoplication, with particular regard to the technical problems encountered, the learning curve, and the long-term follow-up. The operation was completed laparoscopically in 94 patients, with a median operative duration of 150 minutes, and a continuous steady reduction in the operating time from the first patients to the last. In six patients the operation was completed through "open" access. Postoperative complications were recorded in six cases. Follow-up was completed in all 100 patients, with a median follow-up of 24 months. Overall, actuarial life-table analysis showed a probability of 90% that patients would be symptom free over a 5-year period. Radiologic assessment showed a significant reduction in the esophageal diameter, and manometry showed a significant reduction in the lower esophageal sphincter resting pressure and residual pressure. Twenty-four-hour pH monitoring showed postoperative reflux in 6.9% of the patients. Persistent dysphagia or chest pain was reported by eight patients, which constituted treatment failures. Seven of these eight patients were eventually treated with multiple pneumatic dilatations, which were successful in six cases. It was concluded that laparoscopic Heller myotomy with Dor fundoplication is a feasible and effective treatment for achalasia, with an actuarial success rate of 90% at 5 years.
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Affiliation(s)
- G Zaninotto
- Department of Medical and Surgical Sciences (Clinica Chirurgica IV), University of Padua School of Medicine, Italy.
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Shai SE, Chen CY, Hsu CP, Hsia JY, Yang SS. Transthoracic oesophagomyotomy in the treatment of achalasia--a 15-year experience. SCAND CARDIOVASC J 2000; 33:333-6. [PMID: 10622544 DOI: 10.1080/14017439950141380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Oesophageal achalasia was treated with modified Heller's oesophagomyotomy in 51 patients (19 males, 32 females) via thoracotomy in 47 cases and thoracoscopy in 4 cases. A Belsey Mark IV antireflux procedure was added to transthoracic oesophagomyotomy in two cases, because of extended cardiomyotomy. There were no hospital deaths. The overall improvement rate was 93.5%, with excellent results in 80.6%. Postoperative follow-up averaged 7.4 years. In all four cases of thoracoscopic oesophagomyotomy, simultaneous oesophagoscopy was performed to facilitate the procedure. One patient required repeat surgery 2 months later because of inadequate myotomy. Thirty-one patients, including three with severe gastro-oesophageal reflux, received long-term medication. Barrett's oesophagus developed in two of the 31 patients (6.5%) 4.7 and 7.6 years, respectively, after myotomy and squamous cell carcinoma was diagnosed in a 44-year-old woman 2.2 years postoperatively. The study suggests that transthoracic oesophagomyotomy without antireflux procedure can provide excellent long-term relief of dysphagia in oesophageal achalasia and carries a low risk of serious postoperative complications.
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Affiliation(s)
- S E Shai
- Department of Surgery, Taichung Veterans' General Hospital, Taiwan, ROC.
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Wiechmann RJ, Ferguson MK, Naunheim KS, Hazelrigg SR, Mack MJ, Aronoff RJ, Weyant RJ, Santucci T, Macherey R, Landreneau RJ. Video-assisted surgical management of achalasia of the esophagus. J Thorac Cardiovasc Surg 1999; 118:916-23. [PMID: 10534698 DOI: 10.1016/s0022-5223(99)70062-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Video-assisted surgical approaches to esophageal achalasia continue to be explored by many surgeons involved in the management of this motor disorder. We report our experience with thoracoscopic and laparoscopic esophagomyotomy to more clearly define the efficacy and safety of these approaches. PATIENTS Over 73 months, 58 patients with achalasia underwent thoracoscopic myotomy (n = 19) alone or laparoscopic myotomy (n = 39) with partial fundoplication (anterior = 15; posterior = 24). Mean age was 47.2 years and average length of symptoms was 60 months. Primary symptoms were as follows: dysphagia, 100%; pulmonary abnormalities, 22%; weight loss; 47%, and pain, 45%. Mean esophageal diameter was 6 cm and tortuosity was present in 16% (9/58) of patients. Prior management consisted of dilation (n = 47), botulinum toxin injection (n = 8), and prior myotomy (n = 1). METHODS In the operating room all patients underwent endoscopic examination and evacuation of retained esophageal contents. The esophagomyotomy was extended 4 cm superiorly and inferiorly to 1 cm beyond the lower esophageal sphincter. Thoracoscopic and laparoscopic procedures were completed in all patients without conversion to an open operation. Mean operative time was 183 minutes (+/-58.1) and hospital stay averaged 2.3 days (+/-0.8). There was no operative mortality. The 1 operative complication was a perforation that was identified during the operation and repaired thoracoscopically. RESULTS Symptoms improved in 97% of patients. Mean dysphagia scores (range 0-10) decreased from 9.8 +/- 1.6 before the operation to 2.0 +/- 1.5 after the operation (P <.001) at a mean follow-up of 6 months. Postoperative reflux symptoms developed in 5% (1/19) of the thoracoscopy group and 8% (4/39) of the laparoscopy group. Nine patients have persistent or recurrent dysphagia (16%). Seven patients have successfully undergone Savary dilation, and 2 required esophagectomy to manage recalcitrant dysphagia. CONCLUSION At this intermediate term analysis, video-assisted approaches for management of achalasia are a reasonable alternative to extended medical therapy or open operations.
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Affiliation(s)
- R J Wiechmann
- Allegheny University Hospitals, Allegheny General, Pittsburgh, PA 15212-4772, USA
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Vanderpool D, Westmoreland MV, Fetner E. Achalasia: Willis or Heller? Proc (Bayl Univ Med Cent) 1999. [DOI: 10.1080/08998280.1999.11930180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- David Vanderpool
- From the Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | | | - Eric Fetner
- From the Department of Surgery, Baylor University Medical Center, Dallas, Texas
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Abstract
The Nissen fundoplication, and in particular the laparoscopic Nissen fundoplication, has received widespread acceptance as the most definitive therapy for gastroesophageal reflux disease. There remains, however, certain patients who do better with a less aggressive surgical augmentation of the lower esophageal sphincter. Partial fundoplications originated in the early 1960s as an alternative procedure to the Nissen, which was associated with moderately high rates of postoperative side effects. These "more physiologic" procedures have proved successful in the treatment of reflux disease in patients with poor or no esophageal motility. In particular, the use of partial fundoplications in association with Heller's myotomy for achalasia has been demonstrated to be well tolerated and to reduce the risk of late dysphasia resulting from uncontrolled gastroesophageal reflux (GER). The use of partial fundoplications in GER patients with normal motility, however, has been less successful. High recurrence rates are documented by many centers with the main cause appearing to be related to a less competent neo-lower esophageal sphincter and a higher rate of wrap herniation. This has led to the current practice of a "tailored approach" to reflux disease, in which all patients receive a thorough preoperative physiologic evaluation to determine the best antireflux procedure for the individual. This is generally a Nissen repair for those with normal motility and either an extrashort "floppy" Nissen or a partial wrap for those with impaired peristalsis.
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Affiliation(s)
- L L Swanstrom
- Department of Surgery, Oregon Health Sciences University, Portland, USA
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Abstract
Surgical myotomy is the mainstay of treatment for oesophageal achalasia. Minimally invasive surgical techniques, if feasible, reduce patient morbidity and mortality. In this study we review our experience of thoracoscopic Heller's myotomy. Thoracoscopic myotomy was undertaken in 9 patients (male = 3; female = 6, mean age = 37). All patients presented with dysphagia of 1 to 8 yr duration. Diagnosis was based on barium swallow and manometry. Two patients had previous dilatations and 1 had a transabdominal myotomy. All patients had a 5 port thoracoscopic technique. Thoracoscopic Heller's myotomy was completed in 8 out of 9 patients. In 1 patient extensive oesophagitis and peri-oesophagitis precluded both a thoracoscopic and an open myotomy, and oesophagectomy was subsequently performed. The mean duration of surgery was 142 min. Completion of myotomy and mucosal integrity was confirmed by intraoperative gastroscopy. All patients had an uneventful post-operative recovery. The mean hospital stay was 4 days. All patients are now asymptomatic, with documented weight gain. No patients have reflux oesophagitis symptoms. Our preliminary experience would suggest that thoracoscopic Heller's myotomy is a safe alternative to open surgery, with satisfactory results and reduced hospital stay.
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Affiliation(s)
- S Rea
- Department of Surgery, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9
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