Surgical treatment of achalasia: a retrospective comparative study

Heller myotomy for achalasia. From the open to the laparoscopic approach

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.

Diffusely infiltrative squamous cell carcinoma of the esophagus presenting as a case with diagnostic difficulty

We report a rare case of diffusely infiltrative squamous cell carcinoma of the esophagus. The patient, a 68-year-old man, was admitted to our hospital for investigation of dysphagia. Esophagography and upper gastrointestinal endoscopy revealed esophageal stenosis and gastric cancer. As a biopsy from the esophagus revealed no sign of malignancy, he underwent only distal gastrectomy. After 3 months, the stenosis became worse. Again, biopsy from a gastrointestinal endoscopy showed no malignancy, but endobronchial ultrasound-guided transbronchial needle aspiration revealed squamous cell carcinoma of the esophagus. Despite various treatments, the patient died of disease progression 20 months after its onset. Autopsy revealed diffusely infiltrative squamous cell carcinoma of the esophagus, which is a rare malignancy with few case reports documented.

Achalasia--if surgical treatment fails: analysis of remedial surgery

INTRODUCTION

Heller myotomy leads to good-excellent long-term results in 90% of patients with achalasia and thereby has evolved to the "first-line" therapy. Failure of surgical treatment, however, remains an urgent problem which has been discussed controversially recently.

MATERIALS AND METHODS

A systematic review of the literature was performed to analyze the long-term results of failures after Heller's operation with emphasis on treatment by remedial myotomy.

DISCUSSION

Other reinterventions and their causes after failure of surgical treatment in patients with achalasia are discussed.

Laparoscopic Heller myotomy and Dor fundoplication combined with laparoscopic diverticular introversion suturing for achalasia complicated by epiphrenic diverticulum: report of a case

A 41-year-old woman was admitted due to dysphagia and weight loss of 6 kg. An upper gastrointestinal radiographic contrast study demonstrated an S-shaped lower esophagus with a peak transverse diameter of 65 mm. Moreover, an epiphrenic diverticulum was also detected in the lower part of the esophagus (50 x 40 mm). The measurement of intraesophageal pressure showed a lower esophageal sphincter pressure of 80 mmHg and a lower esophageal sphincter length of 31 mm. Esophageal clearance assessment via a timed barium esophagogram demonstrated impaired contrast clearance, with a rate of 26% at 5 min. A laparoscopic Heller myotomy, Dor fundoplication, and diverticular introversion suturing were performed. The postoperative course was uneventful and the patient was discharged on day 4. At the 2-year follow-up, no dysphagia was present. This is the first report of a laparoscopic diverticuloplasty using an introversion buried suture with a Heller myotomy and Dor fundoplication for achalasia complicated by an epiphrenic diverticulum.

Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis

BACKGROUND

Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes mostly come from cohort studies.

OBJECTIVE

To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia.

METHODS

A systematic electronic Medline literature search of articles on esophageal achalasia. Treatment options reviewed included EBTI, EBD, and surgical myotomy using open and minimally invasive techniques. Main outcome measures were frequency of symptom relief, prevalence of post-treatment gastroesophageal reflux (GER), and complications. Outcome probability was estimated using weighted averages of the sample prevalence in each study, with weights equal to the number of patients. Outcomes, within or across studies, were compared using meta-analysis and meta-regression, respectively.

RESULTS

A total of 105 articles reporting on 7855 patients were selected, tabulated and reviewed. Symptom relief after EBD was better than after EBTI (68.2% vs. 40.6%; OR 3.4; 95% CI, 1.2-9.8; P = 0.02), and the need for additional therapy was greater for patients receiving EBTI (46.6% vs. 25%; OR, 2.6; 95% CI, 1.05-6.5; P = 0.04). Laparoscopic myotomy, when combined with an antireflux procedure, provided better symptom relief (90%) than all endoscopic and other surgical approaches and a low complication rate (6.3%). The incidence of postoperative GER was lower when a fundoplication was added to a laparoscopic myotomy (31.5% without a fundoplication vs. 8.8% with; OR, 6.3; 95% CI, 2.0-19.4; P = 0.003).

CONCLUSIONS

EBD is superior to EBTI. Laparoscopic myotomy with fundoplication was the most effective surgical technique and can be considered the operative procedure of choice.

Very long-term objective evaluation of heller myotomy plus posterior partial fundoplication in patients with achalasia of the cardia

OBJECTIVE

To present the objectively assessed very long-term results of a prospective study of 149 patients with achalasia of the cardia who underwent Heller myotomy and posterior partial fundoplication.

SUMMARY BACKGROUND DATA

Very few studies evaluate objectively the very long-term results to analyze whether the effectiveness of Heller myotomy is maintained with the passing of time.

METHODS

The study group consisted of 149 patients who underwent a Heller myotomy plus a posterior partial fundoplication through a laparotomy. The median follow-up was 6 years (range, 1-27 years). Follow-up period was over 10 years in 53 patients and over 15 in 36. Clinical, radiologic, endoscopic, manometric, and pHmetric evaluations were performed postoperatively.

RESULTS

Satisfactory results were higher than 90% up to 5 years. From that time on results gradually decreased to a 75% rate after 15 years (P < 0.001) due to either heartburn or dysphagia. Both the esophageal diameter and the mean resting pressure of the lower esophageal sphincter decreased postoperatively with no significant changes during follow-up. Esophagitis appeared in 11% of the patients (47% of them being asymptomatic) and 24-hour pH monitoring showed pathologic rates of acid reflux in 14% of patients, 58% of them being asymptomatic. Both esophagitis and pathologic rates of reflux appeared in >40% of the patients late in the follow-up.

CONCLUSION

Results after Heller myotomy plus posterior partial fundoplication deteriorate with time, although we achieved a 75% of satisfactory results after >15 years of follow-up. Our study highlights the importance of life long follow-up and the objective assessment of the results.

Therapeutic effects of a laparoscopic Heller myotomy and Dor fundoplication on the chest pain associated with achalasia

PURPOSE

The therapeutic effects of a laparoscopic Heller myotomy and Dor fundoplication (LHD) on the chest pain associated with achalasia were investigated.

METHODS

Sixty-six patients who were diagnosed to have achalasia underwent LHD. The degree of dilatation was assessed based on the maximum horizontal diameter of the esophagus (Grades I-III). The type of dilatation was assessed based on the shape of the distal esophagus, namely, spindle type (Sp), flask type (Fk), and sigmoid type (Sig). The degree of improvement was classified into three grades as follows: A (complete disappearance), B (partial response), and C (unchanged).

RESULTS

Chest pain improved (A or B) in 22 patients (92%). The statistical results revealed that the improvement of postoperative A or B was significantly better in patients with Sp than in those with Fk or Sig (P = 0.0213). In addition, the results revealed that the improvement of postoperative A or B was significantly better in patients with grade I and grade II than in those with grade III (P = 0.004).

CONCLUSION

LHD is an effective therapeutic technique for the treatment of chest pain associated with achalasia. These results suggest that both the morphological type and esophageal dilatation are useful predictors for the improvement of chest pain after surgical therapy.

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

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.

Heller's esophagomyotomy with or without a 360 degrees floppy Nissen fundoplication for achalasia. Long-term results from a prospective randomized study

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.

Gastroesophageal reflux, quality of life, and satisfaction in patients with achalasia treated with open cardiomyotomy and partial fundoplication

BACKGROUND

Cardiomyotomy, often associated with an antireflux technique, is effective in the management of achalasia, although gastroesophageal reflux (GER) may occur after the procedure. Patient-centered measures, ie, health-related quality of life (HRQoL) and satisfaction, should be included in the evaluation of the patients.

METHODS

A study was made of the incidence of GER (symptoms, upper endoscopy and 24-hour pH monitoring), HRQoL (Short Form-36 Health Survey), and satisfaction after open-access cardiomyotomy and 180-degree anterior fundoplication in 28 consecutive patients, with a minimum postoperative follow-up of 12 months.

RESULTS

Mean age was 45 years (range 15 to 80) and 68% were female. In 8 subjects (all with heartburn) GER morbidity was present (4 with esophagitis and 4 with positive pH study), and 6 patients required proton pump inhibitors. Short Form-36 scores after surgery were similar to those found in the general population. Patient satisfaction was high and was more related to the absence of dysphagia than to the presence of GER symptoms.

CONCLUSIONS

Gastroesophageal reflux is relatively frequent after cardiomyotomy and partial fundoplication, although the efficacy of proton pump inhibitor treatment minimizes its clinical significance.

Long-term effects of myotomy and partial fundoplication for esophageal achalasia

Controversy persists in the surgical approach to treat esophageal achalasia. This investigation reports the long-term effects of esophageal myotomy and partial fundoplication in treating this disorder. From 1984 to 1998, 32 patients with achalasia underwent myotomy and partial fundoplication (Belsey Mark IV) using a left thoracotomy. The median follow up is 7.2 years. Assessments include clinical evaluation, esophagogram, radionuclide transit, manometry, 24-h pH, and endoscopy. There is no complication and no mortality. Preoperative assessment was compared with that in 0-3, 3-7, and 7-16 postoperative years. Clinically, the prevalence of dysphagia was decreased from 100% to 6%, 12%, and 13%, respectively (P < 0.001). Heartburn remains unchanged (P > 0.25). On radiology, the prevalence of barium stasis was decreased from 97% to 44%, 48%, and 47%, respectively (P=0.001), whereas a pseudo-diverticulum was observed in two-thirds of patients after operation (P=0.001). Percent radionuclide stasis at 2 min was measured as 70%, 17%, 20%, and 20%, respectively (P=0.001). Manometrically, lower esophageal sphincter (LES) gradient was decreased from 29 to 10, 9, and 9 mmHg, respectively (P=0.001). LES relaxation was improved from 41% preoperatively to 100% postoperatively at each postoperative period (P < 0.001). An abnormal acid exposure was observed in four patients after the operation. Endoscopy documented mucosal damage in three patients (P > 0.25). In conclusion, on long-term follow up, myotomy and partial fundoplication for achalasia relieve obstructive symptoms and improve esophageal emptying, and reduce LES gradient and improve LES relaxation. Acid reflux is recorded in 13% of patients and esophageal mucosal damage is identified in 11% of the patient population. A longer myotomy not covered by the fundoplication results in pseudodiverticulum formation and increased esophageal retention.

Selective application of fundoplication during laparoscopic heller myotomy ensures favorable outcomes

We propose that selective fundoplication during laparoscopic Heller myotomy achieves optimal outcomes. Fundoplication was applied selectively in 21 of 100 patients undergoing laparoscopic Heller myotomy with hiatus hernia, patulous esophageal hiatus, or intraoperative perforation. Dysphagia and heartburn incidence and severity in patients undergoing myotomy with or without fundoplication were compared before and after myotomy. Median follow-up was 19 months and was similar for both groups. Preoperative symptoms were similar for both groups of patients and showed significant improvement following myotomy with or without fundoplication. As well, there were no significant differences in postoperative dysphagia (26% vs. 14%), dysphagia score (1.1 +/- 1.4 vs. 0.8 +/- 1.3), heartburn (21% vs. 27%), or heartburn score (0.9 +/- 1.5 vs. 1.4 +/- 1.6). Overall improvement was seen in 86% of patients undergoing myotomy with fundoplication and in 97% without fundoplication (P = 0.06). Selective application of fundoplication during laparoscopic Heller myotomy promotes optimal outcomes.

Minimally invasive surgery for esophageal motility disorders

Laparoscopic Heller myotomy has emerged as an excellent primary treatment for patients with dysphagia secondary to achalasia. A laparoscopic rather than thoracoscopic approach has stood the test of time. An antireflux procedure combined with the myotomy is crucial to the maintenance of the antireflux barrier. Thoracoscopic long myotomy offers effective relief for spastic disorders of the esophagus. Endoscopic stapled diverticulotomy is a safe and effective procedure for Zenker's diverticulum and has potential advantages over the open approach.

Esophageal carcinoma showing a long stricture due to prominent lymphatic permeation: report of a case

Some esophageal diseases such as carcinoma, esophagitis, and collagen diseases have often been reported to show a diffusely thickened esophageal wall in the roentogenogram findings. In the current report, a preoperative upper gastrointestinal series and an endoscopic examination showed a diffusely infiltrative type carcinoma, but other examinations did not suggest any diseases such as esophagitis or collagen diseases which might cause a thickening of the esophageal wall or a constriction of the esophagus. A postoperative histological examination revealed the primary carcinoma to remain only within the mucosal layer, while a large degree of lymphatic vessel permeation reached the adventitia over a wide area. An extraordinary degree of lymphatic permeation spread through the esophageal wall, and stromal fibrosis developed as a result of such lymphatic permeation. These histological phenomena might thus have led to the macroscopic appearance of infiltrative type esophageal carcinoma.

Tailored surgery for esophageal body diverticula

OBJECTIVE

The aim of our study was to identify the presence of associated functional disorders (dysmotility or gastro-esophageal reflux, GER), to select patients who need surgery and to plan a tailored surgical treatment in patients affected by esophageal body diverticula.

METHODS

We report on 51 consecutive patients with esophageal body diverticula, observed at our department, who underwent a thorough functional evaluation by means of radiology, endoscopy and manometry; 24 h pH-monitoring was performed in 11 patients who complained of symptoms of GER. The treatment of choice was planned in each patient on the basis of the following elements: the need of diverticulum excision and correction of esophageal body dismotility, LES dysfunction or GER.

RESULTS

An esophageal motor dysfunction was detected in 73% (37 patients) of our total cases with an impaired LES function in 53% (27 patients); GER was identified in nine out the 11 patients submitted for 24 h pH-monitoring. On the overall series, we observed dysmotility or GER in 49/51 patients (96%). Sixteen patients did not require surgical treatment and eight patients refused it; 27 patients underwent tailored surgery. The overall complication rate was 11% (two esophageal fistulae, one acute coronary disease) with 7% mortality rate (one septic shock from esophageal leakage and one myocardial infarction). At follow up (average 47 months; range 6-103 months) 92% satisfactory results (Visick I and II) and only 8% of poor results were observed in our series. None of 13 patients who underwent conservative management had major complications at mean follow-up of 64 months.

CONCLUSIONS

Based upon our experience, we believe that any case of diverticulum of the esophageal body deserves a complete physiopathological evaluation because an underlying functional disorder is associated in most cases. The evidence that the diverticulum per se can be considered as the ultimate phenomenon of an underlying functional disease determined the need for a tailored surgery, planning treatment of the functional disorder as the primary goal, not necessarily associated with a diverticulectomy. In our experience a tailored surgical treatment provided best results.

Current therapies for achalasia: comparison and efficacy

Achalasia is a primary esophageal motor disorder of unknown etiology producing complaints of dysphagia, regurgitation, and chest pain. The current treatments for achalasia involve the reduction of lower esophageal sphincter (LES) pressure resulting in improved esophageal emptying. Calcium channel blockers and nitrates, once used as initial treatment strategy for early achalasia, are now only used in patients who are not candidates for pneumatic dilation or surgery and those not responding to botulinum toxin injections. By virtue of the more rigid balloons, the current pneumatic dilators are more effective and have better efficacy than the older more compliant balloons. The graded approach to pneumatic dilation using the Rigiflex balloons (3.0, 3.5, and 4.0 cm) are now the most commonly used nonsurgical means of treating patients with achalasia, resulting in symptom improvement in up to 90% of patients. Surgical myotomy, once with high morbidity and long hospital stay, can now be performed laparoscopically with similar efficacy to the open surgical approach (94% vs. 84%, respectively), reduced morbidity, and hospitalization time. Given the advances in both balloon dilation and laparoscopic myotomy, most patients with achalasia can now choose between these two equally efficacious treatment options. Botulinum toxin injection of the LES should be reserved for patients who cannot undergo balloon dilation and are not surgical candidates.

Laparoscopic extramucosal myectomy with anterior fundoplication (Dor) for esophageal achalasia using intraoperative manometry

Laparoscopic extramucosal myectomy with anterior fundoplication according to the Dor technique was performed on a 24-year-old-woman. Intraoperative inflation of a pneumatic balloon made the operative procedures such as extended submucosal dissection quite easy. Intraoperative gastrofiberscopy was useful for confirming that the remaining mucosal layer was not injured after completion of myectomy. Intraoperative manometry confirmed a complete decompression of the high-pressure zone in the lower esophageal sphincter. Complete relief of the symptoms has been recognized for 6 months after operation without any medication. It is considered that these laparoscopic procedures including intraoperative inflation of a pneumatic balloon, gastrofiberscopy, and intraoperative manometry can be used as a standard operation for esophageal achalasia.