1
|
Patti MG, Herbella FA. Laparoscopic heller myotomy versus peroral endoscopic myotomy for the treatment of achalasia. Curr Opin Gastroenterol 2024; 40:314-318. [PMID: 38661336 DOI: 10.1097/mog.0000000000001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW To compare different therapeutic modalities and determine their role in the treatment of esophageal achalasia. RECENT FINDINGS The last 3 decades have seen a significant improvement in the diagnosis and treatment of esophageal achalasia. Conventional manometry has been replaced by high-resolution manometry, which has determined a more precise classification of achalasia in three subtypes, with important treatment implications. Therapy, while still palliative, has evolved tremendously. While pneumatic dilatation was for a long time the main choice of treatment, this approach slowly changed at the beginning of the nineties when minimally invasive surgery was adopted, initially thoracoscopically and then laparoscopically with the addition of partial fundoplication. And in 2010, the first report of a new endoscopic technique - peroral endoscopic myotomy (POEM) - was published, revamping the interest in the endoscopic treatment of achalasia. SUMMARY This review focuses particularly on the comparison of POEM and laparoscopic Heller myotomy (LHM) with partial fundoplication as primary treatment modality for esophageal achalasia. Based on the available data, we believe that LHM with partial fundoplication should be the primary treatment modality in most patients. POEM should be selected when surgical expertise is not available, for type III achalasia, for the treatment of recurrent symptoms, and for patients who had prior abdominal operations that would make LHM challenging and unsafe.
Collapse
Affiliation(s)
- Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
| | | |
Collapse
|
2
|
Blaustein M, Sillcox R, Wright AS, Tatum R, Yates R, Bryant MK, Oelschlager BK. Laparoscopic Heller myotomy with Toupet fundoplication: revisiting GERD in treated achalasia. Surg Endosc 2024; 38:1283-1288. [PMID: 38102398 DOI: 10.1007/s00464-023-10643-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/03/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION With the advent of the laparoscopic era in the 1990s, laparoscopic Heller myotomy replaced pneumatic dilation as the first-line treatment for achalasia. An advantage of this approach was the addition of a fundoplication to reduce gastroesophageal reflux disease (GERD). More recently, Peroral Endoscopic Myotomy has competed for first-line therapy, but the postoperative GERD may be a weakness. This study leverages our experience to characterize GERD following LHM with Toupet fundoplication (LHM+T ) so that other treatments can be appropriately compared. METHODS A single-institution retrospective review of adult patients with achalasia who underwent LHM+T from January 2012 to April 2022 was performed. We obtained routine 6-month postoperative pH studies and patient symptom questionnaires. Differences in questionnaires and reflux symptoms in relation to pH study were explored via Kruskal-Wallis test or chi-square tests. RESULTS Of 170 patients who underwent LHM+T , 51 (30%) had postoperative pH testing and clinical symptoms evaluation. Eleven (22%) had an abnormal pH study; however, upon manual review, 5 of these (45.5%) demonstrated low-frequency, long-duration reflux events, suggesting poor esophageal clearance of gastric refluxate and 6/11 (54.5%) had typical reflux episodes. Of the cohort, 7 (15.6%) patients reported GERD symptoms. The median [IQR] severity was 1/10 [0, 3] and median [IQR] frequency was 0.5/4 [0, 1]. Patients with abnormal pH reported more GERD symptoms than patients with a normal pH study (3/6, 50% vs 5/39, 12.8%, p = 0.033). Those with a poor esophageal clearance pattern (n = 5) reported no concurrent GERD symptoms. CONCLUSION The incidence of GERD burden after LHM+T is relatively low; however, the nuances relevant to accurate diagnosis in treated achalasia patients must be considered. Symptom correlation to abnormal pH study is unreliable making objective postoperative testing important. Furthermore, manual review of abnormal pH studies is necessary to distinguish GERD from poor esophageal clearance.
Collapse
Affiliation(s)
- Megan Blaustein
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Rachel Sillcox
- Department of Surgery, University of Washington, Seattle, WA, USA.
- , Washington, USA.
| | - Andrew S Wright
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Roger Tatum
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Robert Yates
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Mary Kate Bryant
- Department of Surgery, University of Washington, Seattle, WA, USA
| | | |
Collapse
|
3
|
Tustumi F, Szachnowicz S, Andreollo NA, Seguro FCBDC, Bianchi ET, Duarte AF, Nasi A, Sallum RAA. MANAGEMENT OF SYMPTOMS RECURRENCE AFTER MYOTOMY FOR ACHALASIA. A PRACTICAL APPROACH. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1780. [PMID: 38088726 PMCID: PMC10712922 DOI: 10.1590/0102-672020230062e1780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Achalasia is an esophageal motility disorder, and myotomy is one of the most used treatment techniques. However, symptom persistence or recurrence occurs in 9 to 20% of cases. AIMS This study aims to provide a practical approach for managing the recurrence or persistence of achalasia symptoms after myotomy. METHODS A critical review was performed to gather evidence for a rational approach for managing the recurrence or persistence of achalasia symptoms after myotomy. RESULTS To properly manage an achalasia patient with significant symptoms after myotomy, such as dysphagia, regurgitation, thoracic pain, and weight loss, it is necessary to classify symptoms, stratify severity, perform appropriate tests, and define a treatment strategy. A systematic differential diagnosis workup is essential to cover the main etiologies of symptoms recurrence or persistence after myotomy. Upper digestive endoscopy and dynamic digital radiography are the main tests that can be applied for investigation. The treatment options include endoscopic dilation, peroral endoscopic myotomy, redo surgery, and esophagectomy, and the decision should be based on the patient's individual characteristics. CONCLUSIONS A good clinical evaluation and the use of proper tests jointly with a rational assessment, are essential for the management of symptoms recurrence or persistence after achalasia myotomy.
Collapse
Affiliation(s)
- Francisco Tustumi
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Sérgio Szachnowicz
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | | | | | - Edno Tales Bianchi
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | - André Fonseca Duarte
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Ary Nasi
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | | |
Collapse
|
4
|
Forero-Vásquez BN, Yopasa-Romero JJ. Diagnóstico y manejo actual de la acalasia. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.2187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introducción. La acalasia es un trastorno motor del esófago poco común, de etiología no clara, caracterizado por la pérdida de relajación del esfínter esofágico inferior, pérdida del peristaltismo normal, regurgitación y disfagia.
Métodos. Se realizó una revisión narrativa de la literatura en revistas científicas y bases de datos en español e inglés, con el fin de presentar información actualizada en lo referente al diagnóstico y tratamiento de esta patología.
Resultado. Se presenta la actualización de los criterios de los trastornos motores esofágicos según la clasificación de Chicago (CCv4.0) para el diagnóstico de acalasia y sus subtipos de acuerdo con los nuevos criterios, así como los tratamientos actuales.
Conclusión. La acalasia es un trastorno esofágico multimodal, con manifestaciones de predominio gastrointestinal, por lo que su diagnóstico y abordaje terapéutico oportuno es esencial para mejorar la calidad de vida de los pacientes.
Collapse
|
5
|
Gallyamov EA, Erin SA, Gololobov GY, Burmistrov AI, Chicherina MA, Rikunova AA. [Features and results of minimally invasive treatment of recurrent achalasia]. Khirurgiia (Mosk) 2022:16-22. [PMID: 35289544 DOI: 10.17116/hirurgia202203116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the early and long-term postoperative outcomes in patients with recurrent achalasia, as well as the main features of surgical treatment. MATERIAL AND METHODS There were 7 patients (4 men and 3 women) with recurrent achalasia. Mean age of patients was 42.3±13.5 years, body mass index - 22.7±3.3 kg/m2. Physiological status ASA grade 1-3 was observed in all patients. Concomitant diseases were diagnosed in 5 (71.4%) cases. Six (85.7%) patients underwent laparoscopic Heller cardiomyotomy with Dor fundoplication. Peroral endoscopic myotomy (POEM) was performed in 1 (14.3%) patient. Mean preoperative Eckardt score was 10.7±1.4 points, mean GERD-HRQL score - 42.7±6.4 points. According to preoperative radiography, 5 (71.4%) patients had achalasia stage III, 2 (28.6%) ones - stage IV. RESULTS All patients underwent laparoscopic Heller esophagocardiomyotomy with anterior Dor fundoplication and posterior partial fundoplication with posterior cruroraphy. Intraoperative complications (perforation of esophageal mucosa) occurred in 3 (42.9%) patients. Mean surgery time was 130±56 min, mean blood loss - 37 ml (35-205 ml), mean hospital-stay - 11.3±7.7 days. Postoperative complications Clavien-Dindo grade 3-4 were detected in 1 (14.3%) patient. One patient was diagnosed with bilateral pneumonia (SARS-Cov-2 infection) in 4 postoperative days. Median postoperative follow-up period was 22 months. Mean BMI in 6 months after surgery was 25.3±3.1 kg/m2, mean Eckardt score - 2.1±0.7 points, mean GERD-HRQL score - 3.3±0.9 points. CONCLUSION Our data confirm the effectiveness and safety of the modified laparoscopic Heller procedure with Dor fundoplication as the main method for recurrent achalasia.
Collapse
Affiliation(s)
- E A Gallyamov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - S A Erin
- Spasokukotsky Moscow City Clinical Hospital, Moscow, Russia
| | - G Yu Gololobov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A I Burmistrov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - M A Chicherina
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A A Rikunova
- Sechenov First Moscow State Medical University, Moscow, Russia
| |
Collapse
|
6
|
Milito P, Siboni S, Lovece A, Andreatta E, Asti E, Bonavina L. Revisional Therapy for Recurrent Symptoms After Heller Myotomy for Achalasia. J Gastrointest Surg 2022; 26:64-69. [PMID: 34341888 PMCID: PMC8760227 DOI: 10.1007/s11605-021-05098-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/17/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE Symptom recurrence after initial surgical management of esophageal achalasia occurs in 10-25% of patients. The aim of this study was to analyze safety and efficacy of revisional therapy after failed Heller myotomy (HM). METHODS A retrospective review of a prospective database was performed searching for patients with recurrent symptoms after primary surgical therapy for achalasia. Patients with previously failed HM were considered for the final analysis. The Foregut questionnaire, and the Atkinson and Eckardt scales were used to assess severity of symptoms. Objective investigations routinely included upper gastrointestinal endoscopy and barium swallow study. Redo treatments consisted of endoscopic pneumatic dilation (PD), laparoscopic HM, hybrid Ivor Lewis esophagectomy, or stapled cardioplasty. A yearly clinical and endoscopic follow-up was scheduled in all patients. RESULTS Over a 20-year period, 26 patients with a median age of 66 years (IQR 19.5) underwent revisional therapy after failed HM for achalasia at a tertiary-care university hospital. The median time after index procedure was 10 years (IQR 21). Revisional therapy consisted of endoscopic pneumatic dilation (n=13), laparoscopic HM and fundoplication (n=10), esophagectomy (n=2), and stapled cardioplasty and fundoplication (n=1). Nine (34.6%) of these patients required further endoscopic or surgical treatments. There was no mortality, and the overall complication rate was 7.7%. At a median follow-up of 42 months (range 10-149), a significant decrease of dysphagia, regurgitation, chest pain, respiratory symptoms, and median Eckardt score (p<0.05) was noted. CONCLUSION In specialized and multidisciplinary centers, revisional therapy for achalasia is feasible, safe, and effective.
Collapse
Affiliation(s)
- Pamela Milito
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Stefano Siboni
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Andrea Lovece
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Erika Andreatta
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy ,Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Piazza Malan 1, 20097 San Donato Milanese (Milano), Italy
| |
Collapse
|
7
|
Idrissa S, Oumarou A, Mahmoudi A, Elmadi A, Khattala K, Bouabdallah Y. Diagnosis and surgical management of children with oesophageal achalasia: A 10-year single-centre experience in Morocco. Afr J Paediatr Surg 2021; 18:155-159. [PMID: 34341200 PMCID: PMC8362917 DOI: 10.4103/ajps.ajps_46_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Achalasia is a primary oesophageal motility disorder with unknown aetiology. The aim of this study was to evaluate our 10-year experience in the diagnostic process and surgical management of oesophageal achalasia (OA) in children. METHODS A retrospective review of all children (age: 0-15 years) treated for achalasia at the department of paediatric surgery from 2007 to 2016 was conducted. The demographics, presenting symptoms, associated diseases, diagnostic process, outcomes and complications were analysed. RESULTS Fourteen patients were identified, with a mean age of 5.2 years. There were eight female and six male patients. The most common symptom was chronic vomiting, in all patients (100%), followed by weight loss in 10 (71.4%), cough in 6 (42.9%), dysphagia in 5 (35.7%) and chest pain in 3 (21.4%). The mean duration of symptoms until diagnosis was 36.3 ± 29.1 months. Three patients underwent an open Heller myotomy (HM) and 11 laparoscopic HM (LHM) including three conversions. The reasons for conversion were mucosal perforation in two cases and liver bleeding in one patient. The mean operating time and the average length of postoperative stay in the patients of LHM group were, respectively, 2.0 ± 0.7 h and 4 ± 1.5 days. The mean follow-up was 43.2 months. CONCLUSION : The diagnosis of OA in children is based on clinical arguments and especially on the barium oesophagram findings. Laparoscopic myotomy is the most effective surgical approach in children.
Collapse
Affiliation(s)
- Salahoudine Idrissa
- Department of Pediatric Surgery, University Hospital of Hassan II, University of Sidi Mohamed Ben Abdellah, Fez, Morocco
| | - A Oumarou
- Department of Pediatric Surgery, University Hospital of Hassan II, University of Sidi Mohamed Ben Abdellah, Fez, Morocco
| | - Abdelhalim Mahmoudi
- Department of Pediatric Surgery, University Hospital of Hassan II, University of Sidi Mohamed Ben Abdellah, Fez, Morocco
| | - Aziz Elmadi
- Department of Pediatric Surgery, University Hospital of Hassan II, University of Sidi Mohamed Ben Abdellah, Fez, Morocco
| | - Khalid Khattala
- Department of Pediatric Surgery, University Hospital of Hassan II, University of Sidi Mohamed Ben Abdellah, Fez, Morocco
| | - Youssef Bouabdallah
- Department of Pediatric Surgery, University Hospital of Hassan II, University of Sidi Mohamed Ben Abdellah, Fez, Morocco
| |
Collapse
|
8
|
Sanaka MR, Garg R, Chadalavada P, Thota PN, Gabbard S, Parikh MP, Khoudari G, Murthy S, Raja S. Peroral Endoscopic Myotomy Is Safe and Highly Effective Treatment for Advanced Achalasia With Sigmoid Esophagus. J Clin Gastroenterol 2021; 55:505-511. [PMID: 32649445 DOI: 10.1097/mcg.0000000000001388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/02/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS In advanced achalasia patients with sigmoid esophagus, peroral endoscopic myotomy (POEM) might be technically challenging and its outcomes are not well known in western population. Hence, our study aims were to assess and compare the safety and efficacy of POEM in achalasia patients with and without sigmoid esophagus. MATERIALS AND METHODS Medical records of achalasia patients who had POEM at our institution between April 2014 and December 2019 were reviewed. Patients who underwent work-up comprising timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with 2-month post-POEM esophageal pH study, TBE and HREM were included in the final analysis. Patients were categorized as either sigmoid or no sigmoid esophagus based on the morphology of esophagus on TBE as per Japan Esophageal Society guidelines. Treatment success was defined as reduction of post-POEM Eckardt score to ≤3. RESULTS A total of 168 patients (sigmoid esophagus=20; no sigmoid esophagus=148) were included. Esophageal width on TBE at 1 minute was significantly higher in sigmoid esophagus group compared with no sigmoid esophagus group (4.9 vs. 3.0 cm, P<0.001). Procedural outcomes and complications were similar in both groups. At 2-month follow-up, both groups had significant improvement in Eckardt scores, TBE, and HREM parameters. Treatment success was high and similar in both sigmoid and no sigmoid groups (94.4% vs. 93.2%, P=0.84). The rates of gastroesophageal reflux disease were also similar in both groups. CONCLUSIONS Our study findings suggest that POEM is safe and highly effective treatment for achalasia patients with sigmoid esophagus similar to those without sigmoid esophagus in western population. POEM should be considered as the treatment of choice in advanced achalasia with sigmoid esophagus.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Sudish Murthy
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
| | - Siva Raja
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
9
|
Felix VN, Murayama KM, Bonavina L, Park MI. Achalasia: what to do in the face of failures of Heller myotomy. Ann N Y Acad Sci 2020; 1481:236-246. [PMID: 32713020 DOI: 10.1111/nyas.14440] [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] [Received: 04/03/2020] [Revised: 06/07/2020] [Accepted: 06/25/2020] [Indexed: 12/21/2022]
Abstract
Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.
Collapse
Affiliation(s)
- Valter N Felix
- Nucleus of General and Specialized Surgery - São Paulo and Department of Gastroenterology - Surgical Division - São Paulo University, FMUSP, Sao Paulo, Brazil
| | - Kenric M Murayama
- Department of Surgery, John A. Burns School of Medicine, the University of Hawaii at Manoa, Honolulu, Hawaii
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, The University of Milan, San Donato Milanese, Italy
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| |
Collapse
|
10
|
Costa LCDAS, Braga JGR, Tercioti Junior V, Coelho Neto JDES, Ferrer JAP, Lopes LR, Andreollo NA. Surgical treatment of relapsed megaesophagus. ACTA ACUST UNITED AC 2020; 47:e20202444. [PMID: 32520130 DOI: 10.1590/0100-6991e-20202444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/29/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE to analyze the surgical treatment of patients with recurrent megaesophagus followed at the esophageal-stomach-duodenal outpatient clinic of the Hospital de Clínicas - UNICAMP. METHODS a retrospective study, from 2011 to 2017, with 26 patients with Chagas or idiopathic megaesophagus, surgically treated, and who recurred with dysphagia. Clinical, endoscopic and radiographic aspects were assessed and correlated with the performed surgical procedures. RESULTS 50% had dysphagia for liquids, 69% regurgitation, 65.3% heartburn, 69.2% weight loss and 69.2% had Chagas disease. In addition, 38.4% had megaesophagus stage 1 and 2 and 61.5% stage 3 and 4. Regarding the reoperations, 53% of them underwent Heller-Pinotti surgery by laparoscopy, Serra-Dória in 30.7% and esophageal mucosectomy in 7.9%. In 72% of the reoperations there were no postoperative complications, and 80% of the patients had a good outcome, with reduction or elimination of dysphagia. Among the reoperated patients undergoing the laparoscopic Heller-Pinotti technique, three reported little improvement of dysphagia in the postoperative period and among those who underwent Serra-Dória surgery, 100% had no dysphagia. It was observed that, when the time between the first procedure and the reoperation was longer, the better the surgical result was, with statistical significant decreased dysphagia (p=0.0013, p<0.05). CONCLUSIONS there was a preference to perform laparoscopic re-miotomy and, as a second option, Serra-Dória surgery, for patients with recurrent megaesophagus. Esophagectomy or esophageal mucosectomy were reserved for more severe patients.
Collapse
Affiliation(s)
| | | | - Valdir Tercioti Junior
- - Faculty of Medical Sciences / UNICAMP, Department of Surgery - Campinas - São Paulo - Brazil
| | | | | | - Luiz Roberto Lopes
- - Faculty of Medical Sciences / UNICAMP, Department of Surgery - Campinas - São Paulo - Brazil
| | - Nelson Adami Andreollo
- - Faculty of Medical Sciences / UNICAMP, Department of Surgery - Campinas - São Paulo - Brazil
| |
Collapse
|
11
|
Peroral endoscopic myectomy: a novel thought to reduce recurrence after previous failed myotomy. VideoGIE 2020; 5:196-198. [PMID: 32426567 PMCID: PMC7222027 DOI: 10.1016/j.vgie.2020.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
12
|
Smith KE, Saad AR, Hanna JP, Tran T, Jacobs J, Richter JE, Velanovich V. Revisional Surgery in Patients with Recurrent Dysphagia after Heller Myotomy. J Gastrointest Surg 2020; 24:991-999. [PMID: 31147973 DOI: 10.1007/s11605-019-04264-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/06/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recurrent/persistent symptoms of achalasia occur in 10-20% of individuals after Heller myotomy. The causes and treatment outcomes are ambiguous. Our aim is to assess the causes and outcomes of a multidisciplinary approach to this patient population. METHODS All patients undergoing revisional operations after a Heller myotomy were reviewed retrospectively. DATA COLLECTED demographics, date of initial Heller myotomy, preoperative evaluation, etiology of recurrent symptoms, date of revisional operation, and surgical outcomes. RESULTS A total of 34 patients underwent 37 revisional operations. Operations were tailored based on preoperative multidisciplinary evaluation. Causes of symptoms: periesophageal/perihiatal fibrosis 11 (27%), obstructing fundoplication 11 (27%), incomplete myotomy 8 (20%), progression of disease 9 (22%), and epiphrenic diverticulum 1 (2%). Operations performed: reversal/no creation of fundoplication with or without re-do myotomy 22 (59%), revision/creation of fundoplication with or without myotomy 6 (16%), and esophagectomy 9 (24%). Ten patients in the 37 operations (27%) developed postoperative complications. Of 33 patients for 36 operations with follow-up, 25 patient-operations (69%) resulted in resolution or improved dysphagia. Although there was variation in symptomatic improvement by cause and operation type, none reached statistical significance. CONCLUSION There are several causes of dysphagia after Heller myotomy and a thoughtful evaluation is required. Complication rates are higher than first-time operations. Symptomatic improvement occurs in the majority of cases, but a significant minority will have persistent dysphagia. Although an individualized approach to dysphagia after Heller myotomy may improve symptoms and passage of food, the perception of dysphagia may persist in patients.
Collapse
Affiliation(s)
- Kaylee E Smith
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Adham R Saad
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.,The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA
| | - John P Hanna
- Division of Surgical Research, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Thanh Tran
- Division of Surgical Research, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - John Jacobs
- The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida, Tampa, FL, USA
| | - Joel E Richter
- The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA. .,The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the efficacy, morbidity and side-effects of innovative management strategies for achalasia that include high-resolution manometry (HRM), pneumatic dilatation, laparoscopic Heller's myotomy (LHM), injection of botulinum toxin into the lower esophageal sphincter and peroral endoscopic myotomy (POEM). RECENT FINDINGS HRM has enabled identification of achalasia subtypes that have important prognostic implications. Pneumatic dilatation is a commonly-used and cost-effective method of treating achalasia but has shown poor longevity of symptom relief compared with other modalities and carries a risk of esophageal perforation. LHM is often the preferred, most effective treatment modality, however new studies may show that outcomes are equivalent or even inferior to POEM. Botulinum toxin injection of the lower esophageal sphincter has a waning and short duration of efficacy and is used primarily for patients unsuitable for more definitive invasive procedures. POEM is considered the most effective treatment for type III achalasia but carries a high risk of iatrogenic gastroesophageal reflux disease that might predispose to the development of Barrett's esophagus. SUMMARY HRM and POEM are two major innovations in the management of achalasia developed over the past decade. There are now three major management options for patients with achalasia, namely pneumatic dilatation, LHM and POEM. Treatment selection should be tailored to the patient's individual esophageal physiology, physical fitness and dominant symptoms.
Collapse
|
14
|
Triantafyllou T, Theodoropoulos C, Georgiou G, Kalles V, Chrysikos D, Filis K, Zografos G, Theodorou D. Long-term outcome of myotomy and fundoplication based on intraoperative real-time high-resolution manometry in achalasia patients. Ann Gastroenterol 2018; 32:46-51. [PMID: 30598591 PMCID: PMC6302195 DOI: 10.20524/aog.2018.0326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/16/2018] [Indexed: 12/29/2022] Open
Abstract
Background Current treatment options for achalasia of the esophagus predominantly consist of endoscopic myotomy or laparoscopic myotomy combined with a partial fundoplication. The intraoperative use of conventional manometry has previously been proposed with various results. The aim of the present study was to introduce the use of high-resolution manometry (HRM) during surgical treatment for achalasia and to assess the long-term outcome of this technique. Methods We enrolled achalasia patients within the time period November 2013 to July 2016 who underwent HRM and evaluation of Eckardt scores (ES) before and after tailored laparoscopic myotomy and fundoplication with intraoperative recording using HRM. Results Twenty patients were classified as having achalasia type I (20%), type II (55%), or type III (25%). During surgery, 9 myotomies were extended and 13 fundoplications were modified according to HRM findings. Mean resting (16.1 vs. 41.9 mmHg) and residual (9 vs. 28.7 mmHg) pressures of the lower esophageal sphincter and ES (0.7 vs. 6.9) were significantly eliminated postoperatively over a mean follow-up time of 17.7 months. Conclusions The use of intraoperative HRM gives us the advantage of simultaneous real-time estimation of intraluminal pressures of the esophagus and the ability to identify the exact points that produce pressure during laparoscopy. Consequently, it may be the key to the tailoring of the Heller-Dor technique and improving the outcomes for achalasia patients.
Collapse
Affiliation(s)
- Tania Triantafyllou
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Charalampos Theodoropoulos
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Georgia Georgiou
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Vasileios Kalles
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Demosthenis Chrysikos
- General and Oncologic Hospital of Kifissia "Agii Anargiri" (Demosthenis Chrysikos), Athens, Greece
| | - Konstantinos Filis
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Georgios Zografos
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Dimitrios Theodorou
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Fernandez-Ananin S, Fernández AF, Balagué C, Sacoto D, Targarona EM. What to do when Heller's myotomy fails? Pneumatic dilatation, laparoscopic remyotomy or peroral endoscopic myotomy: A systematic review. J Minim Access Surg 2018; 14:177-184. [PMID: 29319024 PMCID: PMC6001296 DOI: 10.4103/jmas.jmas_94_17] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/14/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Surgical treatment of achalasia fails in 10%-20% of patients. The most frequent responsible cause is the performance of an incomplete myotomy at primary surgery. The treatment when the failure happens is not well defined. In this study, we review and evaluate the possible treatments to be carried out when surgical myotomy fails. We define its benefits and results, with the purpose of defining a therapeutic algorithm. MATERIALS AND METHODS The systematic review was performed following the guidelines established by the Meta-analysis of Observational Studies in Epidemiology statement. We searched several electronic databases (MEDLINE, PubMED, EMBASE and Cochrane) from January 1991 to March 2017, with the keywords 'recurrent achalasia' 'POEM remyotomy', 'esophagomyotomy failure', 'Heller myotomy failure', 'myotomy failure', 'pneumatic balloon dilatation achalasia' and combinations between them, 'redo Heller', 'redo myotomy', 'reoperative Heller'. RESULTS A total of 61 observational studies related to the treatment of patients with failure of Heller's myotomy were initially found. Finally, 37 articles were included in our study that provided data on 289 patients. Of these 289 patients, diagnosed of failed Heller's myotomy, 87 were treated with pneumatic dilatation (PD), 166 underwent surgical revision and finally 36 were treated with POEM. No randomised controlled trial was identified. CONCLUSIONS The three therapeutic options analysed in this review are effective and safe in the treatment of patients with achalasia with failure of surgical myotomy. The best results can be achieved following an algorithm similar to the one proposed here, where each procedure must be performed by well-experienced team in the selected modality.
Collapse
Affiliation(s)
- Sonia Fernandez-Ananin
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Arnulfo F. Fernández
- Department of General and Digestive Surgery, Centro Laparoscópico Dr. Ballesta, Hospital Quirón Teknon, Barcelona, Spain
| | - Carmen Balagué
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - David Sacoto
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Eduardo Maria Targarona
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| |
Collapse
|
17
|
Management of recurrent symptoms after per-oral endoscopic myotomy in achalasia. Gastrointest Endosc 2018; 87:95-101. [PMID: 28478028 DOI: 10.1016/j.gie.2017.04.036] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 04/22/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) has been rapidly gaining ground as a treatment for achalasia. Although POEM is a safe and effective treatment, a subset of patients has persistent or recurrent symptoms after POEM. This study aimed to examine the efficacy of different retreatments after failed POEM. METHODS POEM was performed on 441 patients with achalasia at 3 tertiary-care hospitals between 2010 and 2015. A review of prospectively collected data was conducted. All patients with achalasia with significant persistent or recurrent symptoms within 3 years after POEM, defined as an Eckardt symptom score >3, were included. RESULTS Forty-three of 441 patients (9.8%) had persistent or recurrent symptoms after POEM, of which 34 (8%) received 1 or more retreatments. Retreatment with laparoscopic Heller myotomy and retreatment with POEM showed a modest efficacy of 45% and 63%, respectively, whereas pneumatic dilatation showed a poor efficacy of only 0% to 20%, depending on the size of the balloon. Male patients were more likely to have retreatment failure than female patients (P = .038). CONCLUSIONS In patients with achalasia with persistent or recurrent symptoms after failed POEM, retreatment with laparoscopic Heller myotomy or retreatment with POEM has a higher efficacy than retreatment with pneumatic dilatations. Failure of retreatment occurred more often in male patients.
Collapse
|
18
|
Zilberstein B, Franciss MY, Genovesi A, Volpe P, Domene CE, Barchi LC. Pioneer Robotic Serra-Doria Operation for Recurrent Achalasia After Heller's Cardiomyotomy: A "New Quondam" Procedure. J Laparoendosc Adv Surg Tech A 2017; 27:524-528. [PMID: 28355101 DOI: 10.1089/lap.2017.0076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Recurrence of achalasia may occur in 10%-20% of cases operated by Heller's cardiomyotomy. Most of these patients will require further surgery to relieve symptoms. Major technical difficulties can be found in these reoperations. CASE REPORT A 50-year-old female patient with relapsed idiopathic achalasia after Heller's technique was treated with an unusual procedure, for the first time in the literature, by minimally invasive access with robotic assistance. CONCLUSIONS The Serra-Doria operation allows preserving the esophagus and alleviating dysphagic symptoms with low rates of postoperative complications. The use of robotic technology is perfectly feasible and allows minimally invasive access in complex cases and reoperations.
Collapse
Affiliation(s)
- Bruno Zilberstein
- 1 Department of Digestive Surgery, Gasstromed Institute , São Paulo, Brazil
| | | | - Aletheia Genovesi
- 1 Department of Digestive Surgery, Gasstromed Institute , São Paulo, Brazil
| | - Paula Volpe
- 2 Department of Digestive Surgery, Hospital Nove de Julho , São Paulo, Brazil
| | | | | |
Collapse
|
19
|
POEM vs Laparoscopic Heller Myotomy and Fundoplication: Which Is Now the Gold Standard for Treatment of Achalasia? J Gastrointest Surg 2017; 21:207-214. [PMID: 27844266 DOI: 10.1007/s11605-016-3310-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/13/2016] [Indexed: 01/31/2023]
|