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Bortolotti M. Problems with repairing gut sphincters malfunctions. World J Gastrointest Surg 2024; 16:2396-2408. [PMID: 39220086 PMCID: PMC11362937 DOI: 10.4240/wjgs.v16.i8.2396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 06/24/2024] [Accepted: 07/15/2024] [Indexed: 08/16/2024] Open
Abstract
Correcting a gut sphincter malfunction is a difficult problem. Because each sphincter has two opposite functions, that of closure and opening, repairing one there is a risk of damaging the other. Indeed, widening a narrow sphincter, such as lower esophageal sphincter (LES) and anal sphincter, may cause gastroesophageal reflux and fecal incontinence, respectively, whereas narrowing a wide sphincter, may cause a difficult transit. All the corrective treatments for difficult or retrograde transit concerning LES and anal sphincter with their unwanted consequences have been analyzed and discussed. To overcome the drawbacks of sphincter surgical repairs, researchers have devised devices capable of closing and opening the gut lumen, named artificial sphincters (ASs). Their function is based on various mechanisms, e.g., hydraulic, magnetic, mechanical etc, operating through many complicated components, such as plastic cuffs, balloons, micropumps, micromotors, connecting tubes and wires, electromechanical clamps, rechargeable batteries, magnetic devices, elastic bands, etc. Unfortunately, these structures may facilitate the onset of infections and induce a local fibrotic reaction, which may cause device malfunctioning, whereas the compression of the gut wall to occlude the lumen may give rise to ischemia with erosions and other lesions. Some ASs are already being used in clinical practice, despite their considerable limits, while others are still at the research stage. In view of the adverse events of the ASs mentioned above, we considered applying bioengineering methods to analyze and resolve biomechanical and biological interaction problems with the aim to conceive and build efficient and safe biomimetic ASs.
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Affiliation(s)
- Mauro Bortolotti
- Department of Internal Medicine and Gastroenterology, S Orsola-Malpighi Polyclinic, University of Bologna, Bologna 40138, Italy
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Delgado-Miguel C, Amarnath RP, Camps JI. Robotic-assisted vs. Laparoscopic Heller's Myotomy for Achalasia in Children. J Pediatr Surg 2024; 59:1072-1076. [PMID: 38016851 DOI: 10.1016/j.jpedsurg.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Robotic-assisted Heller-Dor procedure has been proposed as an alternative minimally invasive approach to traditional laparoscopy for the treatment of achalasia in children. Our aim is to compare the effectiveness, safety and associated costs between both procedures. METHODS A retrospective single center study was conducted among consecutive children operated for achalasia (Heller-Dor operation) between 2005 and 2021, who were divided into two groups according to the surgical approach: laparoscopic (LAP-group) or robotic (ROB-group). Demographics, clinical features, surgery time, length of hospital stay (LOS), postoperative complications, long-term outcomes and economic data were compared between both groups. RESULTS A total of 24 patients were included (12 in LAP-group; 12 in ROB-group), with no demographic or clinical differences between them. ROB-group patients presented lower intraoperative blood loss (23 ± 15 vs. 95 ± 15 ml; p < 0.001), shorter surgery time (178 ± 25 vs. 239 ± 55 min; p = 0.009) and shorter LOS, with a median of 2 days (Q1-Q3: 2-3) when compared to LAP-group (4 days [Q1-Q3:3-5]; p = 0.008). Three post-operative complications were reported, all in LAP-group (2 esophageal perforations and 1 esophageal tightness). After a median follow-up of 11 years, ROB-group patients presented fewer recurrences (0 vs 5; p = 0.039), less reintervention rate (0 % vs 41.7 %; p < 0.039) and lower associated economic costs (28,660$ vs. 60,360$; p < 0.001). CONCLUSION This is the first comparative study of robotic and laparoscopic treatment of achalasia in children. Initial outcomes of robotic-assisted Heller-Dor procedure suggests some intraoperative (less blood loss and surgical time) and postoperative advantages (fewer complications and reinterventions). However, long-term studies with larger numbers of patients are needed. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Carlos Delgado-Miguel
- Department of Pediatric Surgery, Prisma Health Children's Hospital, Columbia, SC, USA; Institute for Health Research IdiPAZ, La Paz University Hospital, Madrid, Spain.
| | | | - Juan I Camps
- Department of Pediatric Surgery, Prisma Health Children's Hospital, Columbia, SC, USA
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Abstract
BACKGROUND Laparoscopic Heller's cardiomyotomy (LHC) is the preferred treatment of achalasia. It improves dysphagia by dividing muscles of the lower oesophageal sphincter, but this intervention can result in debilitating gastro-oesophageal reflux symptoms in some patients. To prevent these reflux symptoms, most surgeons add a fundoplication to Heller's cardiomyotomy, but there is no consensus regarding this or the type of fundoplication which is best suited for the purpose. OBJECTIVES To assess how the addition of a fundoplication affects postoperative reflux and dysphagia in people undergoing LHC and compare the different types of fundoplications used in combination with LHC to determine which is better at controlling reflux without worsening the dysphagia. SEARCH METHODS We searched three databases (CENTRAL, MEDLINE and Embase) on 31 October 2021 and trial registers to identify all published and unpublished randomised controlled trials (RCTs) in any language, comparing different fundoplications used in combination with LHC to treat achalasia. We also included RCTs where LHC with a fundoplication is compared with LHC without any fundoplication. SELECTION CRITERIA We only included RCTs which recruited adult participants with achalasia undergoing LHC with minimal hiatal dissection. We excluded non-randomised studies or studies involving paediatric participants. We also excluded studies where the procedure was done by open surgery and where circumferential hiatal dissection of the oesophagus was carried out, unless it was necessary to reduce a hiatus hernia or to facilitate a Toupet or Nissen fundoplication. DATA COLLECTION AND ANALYSIS Two review authors independently identified studies to be included, assessed risk of bias using the Cochrane RoB 1 tool, and extracted the data. We calculated the risk ratio (RR) with 95% confidence interval (CI) using both fixed-effect and random-effect models with Review Manager (RevMan) software. MAIN RESULTS We included eight studies in this review, with a total of 571 participants with an average age of 45 years (range 33.5 to 50). LHC without any fundoplication was performed in 65 (11.3%) participants, 298 (52.1%) had Dor fundoplication, 81 (14.1%) had Toupet fundoplication, 72 (12.6%) had Nissen's fundoplication, and 55 (9.6%) participants had angle of His accentuation. Three studies with a total of 143 participants compared LHC + Dor to LHC without fundoplication. We found that the evidence is very uncertain as to whether the addition of a Dor fundoplication made any difference to the outcome of postoperative pathological acid reflux (RR 0.37, 95% CI 0.07 to 1.89; I2 = 56%; 2 studies, 97 participants; very low-certainty evidence) and uncertain for severe postoperative dysphagia (RR 3.00, 95% CI 0.34 to 26.33; I2 = 0%; 3 studies, 142 participants; low-certainty evidence). Three studies with 174 participants compared LHC + Dor to LHC + Toupet. The evidence suggests that there may be little to no difference in the outcomes of postoperative pathological acid reflux (RR 0.75, 95% CI 0.23 to 2.43; I2 = 60%; 3 studies, 105 participants; low-certainty evidence) and severe postoperative dysphagia (RR 0.78, 95% CI 0.19 to 3.15; I2 = 0%; 3 studies, 123 participants; low-certainty evidence) between the two interventions, but the certainty of the evidence is low. One study with 138 participants compared LHC + Dor to LHC + Nissen. Nissen fundoplication caused increased severe postoperative dysphagia (RR 0.19, 95% CI 0.04 to 0.83; 1 study, 138 participants; high-certainty evidence) when compared to Dor fundoplication. This study did not show a difference in postoperative pathological acid reflux (RR 4.72, 95% CI 0.23 to 96.59; 1 study, 138 participants; low-certainty evidence), but the certainty of evidence is low. One study with 110 participants compared LHC + Dor with LCH + angle of His accentuation, and reported that severe postoperative dysphagia was similar between the two interventions (RR 1.56, 95% CI 0.27 to 8.95; 1 study, 110 participants; moderate-certainty evidence), with moderate certainty of evidence. This study did not report on postoperative pathological acid reflux. AUTHORS' CONCLUSIONS When LHC was performed with minimal hiatal dissection, we were very uncertain whether the addition of a Dor fundoplication made a difference in controlling postoperative reflux, and we were uncertain if it increased the risk of severe postoperative dysphagia. There may be little to no difference in the outcomes of postoperative pathological acid reflux or severe dysphagia between Dor and Toupet fundoplications when used in combination with LHC, but the certainty of the evidence is low. Nissen (total) fundoplication used in combination with LHC for achalasia increased the risk of severe postoperative dysphagia. The angle of His accentuation and Dor fundoplication had a similar effect on severe postoperative dysphagia when combined with LHC, but their effect on postoperative pathological acid reflux was not reported.
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Affiliation(s)
- Sumit Midya
- Department of General Surgery, Frimley Park Hospital, Frimley, UK
| | - Debasish Ghosh
- Department of General Surgery, Royal Berkshire Hospital, Reading, UK
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Darwish MB, Logarajah SI, Nagatomo K, Jackson T, Benzie AL, McLaren PJ, Cho E, Osman H, Jeyarajah DR. To Wrap or Not to Wrap After Heller Myotomy. JSLS 2021; 25:JSLS.2021.00054. [PMID: 34803368 PMCID: PMC8580166 DOI: 10.4293/jsls.2021.00054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background and Objectives: The primary aim of this study is to assess the necessity of fundoplication for reflux in patients undergoing Heller myotomy for achalasia. The secondary aim is to assess the safety of the robotic approach to Heller myotomy. Methods: This is a single institution, retrospective analysis of 61 patients who underwent robotic Heller myotomy with or without fundoplication over a 4-year period (January 1, 2015 – December 31, 2019). Symptoms were evaluated using pre-operative and postoperative Eckardt scores at < 2 weeks (short-term) and 4 – 55 months (long-term) postoperatively. Incidence of gastroesophageal reflux and use of antacids postoperatively were assessed. Long-term patient satisfaction and quality of life (QOL) were assessed with a phone survey. Finally, the perioperative safety profile of robotic Heller myotomy was evaluated. Results: The long-term average Eckardt score in patients undergoing Heller myotomy without fundoplication was notably lower than in patients with a fundoplication (0.72 vs 2.44). Gastroesophageal reflux rates were lower in patient without a fundoplication (16.0% vs 33.3%). Additionally, dysphagia rates were lower in patients without a fundoplication (32.0% vs 44.4%). Only 34.8% (8/25) of patients without fundoplication continued use of antacids in the long-term. There were no mortalities and a 4.2% complication rate with two delayed leaks. Conclusion: Robotic Heller myotomy without fundoplication is safe and effective for achalasia. The rate of reflux symptoms and overall Eckardt scores were low postoperatively. Great patient satisfaction and QOL were observed in the long term. Our results suggest that fundoplication is unnecessary when performing Heller myotomy.
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Affiliation(s)
- Muhammad B Darwish
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | | | - Kei Nagatomo
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | - Terence Jackson
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | | | | | - Edward Cho
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | - Houssam Osman
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | - D Rohan Jeyarajah
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
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Midya S, Ghosh D, Mahmalat MW. Fundoplication in laparoscopic Heller's cardiomyotomy for achalasia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2019. [DOI: 10.1002/14651858.cd013386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sumit Midya
- Royal Berkshire Hospital; Department of General Surgery; Reading UK RG1 5AN
| | - Debasish Ghosh
- Royal Berkshire Hospital; Department of General Surgery; Reading UK RG1 5AN
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Pallabazzer G, Peluso C, de Bortoli N, Solito B, D'Imporzano S, Belluomini MA, Bellomini MG, Giusti P, Gianetri D, Santi S. Clinical and pathophysiological outcomes of the robotic-assisted Heller-Dor myotomy for achalasia: a single-center experience. J Robot Surg 2019; 14:331-335. [PMID: 31230265 DOI: 10.1007/s11701-019-00988-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/17/2019] [Indexed: 12/12/2022]
Abstract
Laparoscopic Heller myotomy and Dor fundoplication is considered a safe and effective treatment for achalasia. Robotic-assisted Heller-Dor procedure (RAHD) has emerged as an alternative approach due to improved visualization and fine motor control. The aim of this prospective study was to evaluate clinical, and functional results of RAHD. We evaluated a group of 66 patients with achalasia that underwent robotic-assisted Heller-Dor operation. Before treatment all patients underwent a diagnostic work-up such as upper endoscopy, esophageal barium swallow and high resolution manometry. The presence of postoperative gastroesophageal reflux disease was diagnosed by impedance and pH monitoring (MII-pH). Dysphagia improved in 92.4% of patients after treatment. Barium swallow series showed esophageal emptying in 100% of patients and a significant reduction of the esophageal diameter (p = 0.00235). Forty-five of 66 patients (68.2%) underwent upper endoscopy and 35 of 66 (53%) underwent MII-pH. Esophageal erosions were found in 4/45 (8,8%) and MII-pH showed abnormal results in 3/35 patients (8.6%). RAHD ensures a meticulous esophageal and gastric myotomy, allowing to visualize and divide each muscle fibers with a low rate of intraoperative and postoperative complications. resulting in turn in good clinical outcomes, radiological findings and functional results even if robotic tecnique definitely increases the surgical cost in the treatment of these functional esophageal disorders.
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Affiliation(s)
- G Pallabazzer
- Unit of Esophageal Surgery, Department of Surgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56124, Pisa, Italy.
| | - C Peluso
- Unit of Esophageal Surgery, Department of Surgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56124, Pisa, Italy
| | - N de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, AOUP, Pisa, Italy
| | - B Solito
- Unit of Esophageal Surgery, Department of Surgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56124, Pisa, Italy
| | - S D'Imporzano
- Unit of Esophageal Surgery, Department of Surgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56124, Pisa, Italy
| | - M A Belluomini
- Unit of Esophageal Surgery, Department of Surgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56124, Pisa, Italy
| | - M G Bellomini
- Unit of Esophageal Surgery, Department of Surgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56124, Pisa, Italy
| | - P Giusti
- Division of Radiology, Department of Radiology, Vascular and Interventional Radiology and Nuclear Medicine, AOUP, Pisa, Italy
| | - D Gianetri
- Unit of Esophageal Surgery, Department of Surgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56124, Pisa, Italy
| | - S Santi
- Unit of Esophageal Surgery, Department of Surgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Via Paradisa 2, 56124, Pisa, Italy
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Rebecchi F, Allaix ME, Schlottmann F, Patti MG, Morino M. Laparoscopic Heller Myotomy and Fundoplication: What Is the Evidence? Am Surg 2018. [DOI: 10.1177/000313481808400418] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
There is no agreement about the best type of fundoplication to add in patients undergoing laparoscopic Heller myotomy (LHM) for achalasia to reduce the risk of postoperative gastroesophageal reflux. This article reviews the current evidence about the outcomes in achalasia patients undergoing LHM with a partial anterior, a partial posterior, or a total fundoplication. We performed a review of the literature in PubMed/Medline electronic databases, which was evaluated according to the GRADE system. The results of the published randomized controlled trials show with a high level of evidence that the addition of a fundoplication reduces the risk of postoperative abnormal reflux, without impairing the food emptying of the esophagus. LHM with partial fundoplication is considered in most centers worldwide the standard of care for the treatment of patients with achalasia. The current evidence fails to show any significant difference between partial anterior and posterior fundoplication. In the absence of further large randomized controlled trial, the decision of performing an anterior or a posterior wrap is based on the surgeon's experience and preference. The addition of a partial fundoplication to LHM leads to a significantly lower rate of postoperative pathological reflux without impairing the esophageal emptying.
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Affiliation(s)
- Fabrizio Rebecchi
- Department of Surgical Sciences, University of Torino, Torino, Italy and
| | - Marco E. Allaix
- Department of Surgical Sciences, University of Torino, Torino, Italy and
| | - Francisco Schlottmann
- Department of Medicine and Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marco G. Patti
- Department of Medicine and Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Torino, Italy and
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Kummerow Broman K, Phillips SE, Faqih A, Kaiser J, Pierce RA, Poulose BK, Richards WO, Sharp KW, Holzman MD. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: long-term symptomatic follow-up of a prospective randomized controlled trial. Surg Endosc 2017; 32:1668-1674. [PMID: 29046957 DOI: 10.1007/s00464-017-5845-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/22/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Our prior randomized controlled trial of Heller myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term. METHODS We actively engaged participants from the prior randomized cohort, making up to six contact attempts per person using telephone, mail, and electronic messaging. We collected patient-reported measures of dysphagia and gastroesophageal reflux using the Dysphagia Score and the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) instrument. Patient-reported re-interventions for dysphagia were verified by obtaining longitudinal medical records. RESULTS Among living participants, 27/41 (66%) were contacted and all completed the follow-up study at a mean of 11.8 years postoperatively. Median Dysphagia Scores and GERD-HRQL scores were slightly worse for Heller than Heller plus Dor but were not statistically different (6 vs 3, p = 0.08 for dysphagia, 15 vs 13, p = 0.25 for reflux). Five patients in the Heller group and 6 in Heller plus Dor underwent re-intervention for dysphagia with most occurring more than five years postoperatively. One patient in each group underwent redo Heller myotomy and subsequent esophagectomy. Nearly all patients (96%) would undergo operation again. CONCLUSIONS Long-term patient-reported outcomes after Heller alone and Heller plus Dor for achalasia are comparable, providing support for either procedure.
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Affiliation(s)
- Kristy Kummerow Broman
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA. .,Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Nashville, TN, USA.
| | - Sharon E Phillips
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Adil Faqih
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Joan Kaiser
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Richard A Pierce
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Benjamin K Poulose
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - William O Richards
- Department of Surgery, University of South Alabama Health System, Mobile, AL, USA
| | - Kenneth W Sharp
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Michael D Holzman
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
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Allaix ME, Patti MG. Toward a Tailored Treatment of Achalasia: An Evidence-Based Approach. J Laparoendosc Adv Surg Tech A 2016; 26:256-63. [PMID: 27002740 DOI: 10.1089/lap.2016.0067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The treatment options in achalasia patients aim to improve symptoms by reducing the functional obstruction at the level of the gastroesophageal junction. Available treatment modalities are endoscopic botulinum toxin injection (EBTI), pneumatic dilatation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM). We provide an evidence-based review of current indications, limitations, and future perspectives of these options for the treatment of achalasia. METHODS The PubMed/Medline electronic databases and the Cochrane Library were searched. Quality of evidence was assessed according to the GRADE system. RESULTS Functional outcomes after EBTI are significantly worse than those after PD or LHM. LHM with partial fundoplication is associated with low complication rates and provides excellent long-term results with lower need for additional treatment of recurrent dysphagia than PD. POEM is a new promising treatment option with good short-term outcomes and low morbidity in experienced hands. CONCLUSIONS LHM should be considered the procedure of choice for the treatment of achalasia in patients who are fit for surgery. Large randomized controlled trials with long follow-up are needed to validate the role of POEM.
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Affiliation(s)
| | - Marco Giuseppe Patti
- 2 Department of Surgery and Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine , Chicago, Illinois
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Pandian TK, Naik ND, Fahy AS, Arghami A, Farley DR, Ishitani MB, Moir CR. Laparoscopic esophagomyotomy for achalasia in children: A review. World J Gastrointest Endosc 2016; 8:56-66. [PMID: 26839646 PMCID: PMC4724031 DOI: 10.4253/wjge.v8.i2.56] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/28/2015] [Accepted: 11/17/2015] [Indexed: 02/05/2023] Open
Abstract
Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy (LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multi-institutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term (> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care.
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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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Omura N, Yano F, Tsuboi K, Hoshino M, Yamamoto SR, Akimoto S, Ishibashi Y, Kashiwagi H, Yanaga K. Short-term surgical outcomes of reduced port surgery for esophageal achalasia. Surg Today 2015; 45:1139-43. [PMID: 25563589 DOI: 10.1007/s00595-014-1109-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 12/09/2014] [Indexed: 01/06/2023]
Abstract
PURPOSE To clarify the feasibility and utility of reduced port surgery (RPS) for achalasia. METHODS Between September 2005 and June 2013, 359 patients with esophageal achalasia, excluding cases of reoperation, underwent laparoscopic Heller myotomy and Dor fundoplication (LHD) according to our clinical pathway. Three-hundred and twenty-seven patients underwent LHD with five incisions (conventional approach), while the other 32 patients underwent RPS, including eight via SILS. The clinical data were collected in a prospective fashion and retrospectively reviewed. We selected 24 patients matched for gender, age and morphologic type with patients in the RPS group from among the 327 patients (C group). The surgical outcomes were compared between the C and RPS groups. RESULTS There were no significant differences between the two groups in the duration of symptoms, dysphagia score, chest pain score, shape of the distal esophagus and esophageal clearance. The operative time was significantly longer in the RPS group than in the C group (p < 0.001). There were no significant differences between the two groups in the length of postoperative hospital stay or rates of bleeding, mucosal injury of the esophagus and/or stomach and postoperative complications. The symptom scores significantly improved after surgery in both groups (p < 0.001). Furthermore, there were no significant differences between the C group and RPS group in terms of the postoperative symptom scores or satisfaction scores after surgery. CONCLUSIONS The surgical outcomes of RPS for achalasia are comparable to those obtained with the conventional method.
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Affiliation(s)
- Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan,
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Long-term outcome after laparoscopic myotomy for achalasia. J Thorac Cardiovasc Surg 2014; 147:730-6; Discussion 736-7. [DOI: 10.1016/j.jtcvs.2013.09.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 09/10/2013] [Accepted: 09/30/2013] [Indexed: 11/18/2022]
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The management of esophageal achalasia: from diagnosis to surgical treatment. Updates Surg 2013; 66:23-9. [PMID: 23817763 DOI: 10.1007/s13304-013-0224-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 06/21/2013] [Indexed: 02/07/2023]
Abstract
The goal of this review is to illustrate our approach to patients with achalasia in terms of preoperative evaluation and surgical technique. Indications, patient selection and management are herein discussed. Specifically, we illustrate the pathogenetic theories and diagnostic algorithm with current up-to-date techniques to diagnose achalasia and its manometric variants. Finally, we focus on the therapeutic approaches available today: medical and surgical. A special emphasis is given on the surgical treatment of achalasia and we provide the reader with a detailed description of our pre and postoperative management.
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Allaix ME, Patti MG. [New trends and concepts in diagnosis and treatment of achalasia]. Cir Esp 2013; 91:352-7. [PMID: 23558381 DOI: 10.1016/j.ciresp.2013.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 01/16/2013] [Indexed: 02/06/2023]
Abstract
The last 2 decades have witnessed a revolution in the treatment of esophageal achalasia. Nowadays, laparoscopic Heller myotomy with partial fundoplication is considered in most centers the primary treatment modality, while endoscopic treatment, i.e. pneumatic dilatation, is mainly reserved for the management of patients unfit for surgery or in case of surgical failure. Recently, a new approach to achalasia has been proposed: the peroral endoscopic myotomy (POEM), which combines the advantages of endoscopy and surgery. This article reviews the evolution of the diagnosis and treatment of esophageal achalasia during the last 20 years.
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Affiliation(s)
- Marco E Allaix
- Department of Surgery, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine, Chicago, Illinois, Estados Unidos
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Bello B, Herbella FA, Allaix ME, Patti MG. Impact of minimally invasive surgery on the treatment of benign esophageal disorders. World J Gastroenterol 2012; 18:6764-70. [PMID: 23239914 PMCID: PMC3520165 DOI: 10.3748/wjg.v18.i46.6764] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 05/26/2012] [Accepted: 07/18/2012] [Indexed: 02/06/2023] Open
Abstract
Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a change in the treatment algorithm of benign esophageal disorders. Today a laparoscopic operation is the treatment of choice for esophageal achalasia and for most patients with gastroesophageal reflux disease. Because the pathogenesis of achalasia is unknown, treatment is palliative and aims to improve esophageal emptying by decreasing the functional obstruction at the level of the gastro-esophageal junction. The refinement of minimally invasive techniques accompanied by large, multiple randomized control trials with long-term outcome has allowed the laparoscopic Heller myotomy and partial fundoplication to become the treatment of choice for achalasia compared to endoscopic procedures, including endoscopic botulinum toxin injection and pneumatic dilatation. Patients with suspected gastroesophageal reflux need to undergo a thorough preoperative workup. After establishing diagnosis, treatment for gastroesophageal reflux should be individualized to patient characteristics and a decision about an operation made jointly between surgeon and patient. The indications for surgery have changed in the last twenty years. In the past, surgery was often considered for patients who did not respond well to acid reducing medications. Today, the best candidate for surgery is the patient who has excellent control of symptoms with proton pump inhibitors. The minimally invasive approach to antireflux surgery has allowed surgeons to control reflux in a safe manner, with excellent long term outcomes. Like achalasia and gastroesophageal reflux, the treatment of patients with paraesophageal hernias has also seen a major evolution. The laparoscopic approach has been shown to be safe, and durable, with good relief of symptoms over the long-term. The most significant controversy with laparoscopic paraesophageal hernia repair is the optimal crural repair. This manuscript reviews the evolution of these techniques.
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Major complications of pneumatic dilation and Heller myotomy for achalasia: single-center experience and systematic review of the literature. Am J Gastroenterol 2012; 107:1817-25. [PMID: 23032978 PMCID: PMC3808165 DOI: 10.1038/ajg.2012.332] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) can be definitive therapies for achalasia; recent data suggest comparable efficacy. However, risk must also be considered. We reviewed the major complication rate of PD and LHM in a high-volume center and reviewed the corresponding literature. METHODS We reviewed 12 years of our institution's achalasia treatment experience. During this interval, a consistent technique of PD was used utilizing Rigiflex dilators. Medical records were reviewed for post-procedure complications. We administered a telephone survey and examined medical records to assess efficacy of treatment. We also performed a systematic review of the literature for comparable clinical data and examined 80 reports encompassing 12,494 LHM and PD procedures. RESULTS At our center, 463 achalasia patients underwent 567 PD or LHM procedures. In all, 78% of the PDs used a 30-mm Rigiflex dilator. In all, 157/184 (85%) patients underwent 1 or 2 PD without any subsequent treatment. There were seven clinically significant perforations; one from PD and six from LHM. There were no resultant deaths from these perforations; two deaths occurred within 30 days of LHM from unrelated causes. Complications and deaths post-PD were significantly fewer than those post-LHM (P=0.02). CONCLUSIONS Esophageal perforation from PD at our high-volume center was less common than often reported and lower than that associated with LHM. We conclude that, in the hands of experienced operators using conservative technique, PD has fewer major complications and deaths than LHM.
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The evolution of the treatment of esophageal achalasia: a look at the last two decades. Updates Surg 2012; 64:161-5. [PMID: 22847308 DOI: 10.1007/s13304-012-0169-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 07/17/2012] [Indexed: 01/01/2023]
Abstract
Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a revolution in the treatment of benign esophageal disorders, particularly for esophageal achalasia. This has brought a shift in the treatment algorithm of this disease, as today a laparoscopic Heller myotomy with partial fundoplication is considered the primary form of treatment in most Centers in North America. This article reviews the evolution of the treatment of esophageal achalasia during the last two decades, with particular stress on the key technical elements of this operation.
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Minimally invasive myotomy for the treatment of esophageal achalasia: evolution of the surgical procedure and the therapeutic algorithm. Surg Laparosc Endosc Percutan Tech 2012; 22:83-7. [PMID: 22487617 DOI: 10.1097/sle.0b013e318243368f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare disease of the esophagus, characterized by the absence of peristalsis in the esophageal body and incomplete relaxation of the lower esophageal sphincter, which may be hypertensive. The cause of this disease is unknown; therefore, the aim of the therapy is to improve esophageal emptying by eliminating the outflow resistance caused by the lower esophageal sphincter. This goal can be accomplished either by pneumatic dilatation or surgical myotomy, which are the only long-term effective therapies for achalasia. Historically, pneumatic dilatation was preferred over surgical myotomy because of the morbidity associated with a thoracotomy or a laparotomy. However, with the development of minimally invasive techniques, the surgical approach has gained widespread acceptance among patients and gastroenterologists and, consequently, the role of surgery has changed. The aim of this study was to review the changes occurred in the surgical treatment of achalasia over the last 2 decades; specifically, the development of minimally invasive techniques with the evolution from a thoracoscopic approach without an antireflux procedure to a laparoscopic myotomy with a partial fundoplication, the changes in the length of the myotomy, and the modification of the therapeutic algorithm.
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A comparative study of endoscopic full-thickness and partial-thickness myotomy using submucosal endoscopy with mucosal safety flap (SEMF) technique. Surg Endosc 2012; 26:1751-8. [PMID: 22258295 DOI: 10.1007/s00464-011-2105-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 11/26/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Esophageal myotomy using submucosal endoscopy with mucosal safety flap (SEMF) has been proposed as a new treatment of achalasia. In this technique, a partial-thickness myotomy (PTM) preserving the longitudinal outer esophageal muscular layer is advocated, which is different from the usual full-thickness myotomy (FTM) performed surgically. The aim of this study was to compare endoscopic FTM and PTM and analyze the outcomes of each method after a 4 week survival period. METHODS Twenty-four pigs were randomly assigned into group A (FTM, 12 animals) and group B (PTM) to undergo endoscopic myotomy. Lower esophageal sphincter (LES) pressure was assessed using pull-through manometry. For statistical analysis we compared the average esophageal sphincter pressure values at baseline, after 2 weeks, and after 4 weeks between groups A and B. The P value was set as <0.05 for significance. RESULTS Eighteen animals were included for statistical analysis. Mean (SD) LES pressures were similar between groups A and B (nine animals each) at baseline [group A = 23 (10.4) mmHg; group B = 20.7 (8.7) mmHg; P = 0.79], after 2 weeks [group A = 19 (7.7) mmHg; group B = 21.8 (8.4) mmHg; P = 0.79], and after 4 weeks [group A = 22.6 (10.2) mmHg; group B = 20.7 (9) mmHg; P = 0.82]. LES pressures were significantly reduced in three animals after 4 weeks: one animal (1%) in group A and two animals (2.5%) in group B. An extended myotomy (3 cm below the cardia) was achieved in three animals and was responsible for the significant drop in LES pressure seen in the two animals from group B. CONCLUSION Esophageal myotomy using SEMF is a feasible yet challenging procedure in pigs. Full-thickness myotomy does not seem to be superior to partial-thickness myotomy as demonstrated by pull-through manometry. Endoscopic esophageal myotomy results are greatly influenced by obtaining adequate myotomy extension into the gastric cardia.
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SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 2011; 26:296-311. [PMID: 22044977 DOI: 10.1007/s00464-011-2017-2] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/24/2011] [Indexed: 12/19/2022]
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Bello B, Herbella FA, Patti MG. Evolution of the minimally invasive treatment of esophageal achalasia. World J Surg 2011; 35:1442-6. [PMID: 21400015 DOI: 10.1007/s00268-011-1027-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Thanks to the advent of laparoscopic techniques, the last decade and a half have witnessed a radical change in the treatment of esophageal achalasia. Because of the high success rate of the laparoscopic Heller myotomy, surgery has now become in many centers the first modality of treatment for achalasia. This shift in the treatment algorithm reflects the fact that laparoscopic Heller myotomy with partial fundoplication outperforms nonsurgical approaches, such as balloon dilatation and intrasphincteric botulinum toxin injection.
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Affiliation(s)
- Brian Bello
- Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 South Maryland Avenue, MC 5031, Room G-201, Chicago, IL 60637, USA
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Bello B, Herbella FA, Patti MG. Evolution of the minimally invasive treatment of esophageal achalasia. World J Surg 2011. [PMID: 21400015 DOI: 10.1007/s00268-011-1027-5.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
Thanks to the advent of laparoscopic techniques, the last decade and a half have witnessed a radical change in the treatment of esophageal achalasia. Because of the high success rate of the laparoscopic Heller myotomy, surgery has now become in many centers the first modality of treatment for achalasia. This shift in the treatment algorithm reflects the fact that laparoscopic Heller myotomy with partial fundoplication outperforms nonsurgical approaches, such as balloon dilatation and intrasphincteric botulinum toxin injection.
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Affiliation(s)
- Brian Bello
- Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 South Maryland Avenue, MC 5031, Room G-201, Chicago, IL 60637, USA
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Laparoscopic myotomy or pneumatic dilatation for achalasia treatment? Open Med (Wars) 2011. [DOI: 10.2478/s11536-011-0072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
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Rawlings A, Soper NJ, Oelschlager B, Swanstrom L, Matthews BD, Pellegrini C, Pierce RA, Pryor A, Martin V, Frisella MM, Cassera M, Brunt LM. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc 2011; 26:18-26. [PMID: 21789646 DOI: 10.1007/s00464-011-1822-y] [Citation(s) in RCA: 180] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 06/22/2011] [Indexed: 01/02/2023]
Abstract
BACKGROUND The type of fundoplication that should be performed in conjunction with Heller myotomy for esophageal achalasia is controversial. We prospectively compared anterior fundoplication (Dor) with partial posterior fundoplication (Toupet) in patients undergoing laparoscopic Heller myotomy. METHODS A multicenter, prospective, randomized-controlled trial was initiated to compare Dor versus Toupet fundoplication after laparoscopic Heller myotomy. Outcome measures were symptomatic GERD scores (0-4, five-point Likert scale questionnaire) and 24-h pH testing at 6-12 months after surgery. Data are mean ± SD. Statistical analysis was by Mann-Whitney U test, Wilcoxon signed rank test, and Freidman's test. RESULTS Sixty of 85 originally enrolled and randomized patients who underwent 36 Dor and 24 Toupet fundoplications had follow-up data per protocol for analysis. Dor and Toupet groups were similar in age (46.8 vs. 51.7 years) and gender (52.8 vs. 62.5% male). pH studies at 6-12 months in 43 patients (72%: Dor n = 24 and Toupet n = 19) showed total DeMeester scores and % time pH < 4 were not significant between the two groups. Abnormal acid reflux was present in 10 of 24 Dor group patients (41.7%) and in 4 of 19 Toupet patients (21.0%) (p = 0.152). Dysphagia and regurgitation symptom scores improved significantly in both groups compared to preoperative scores. No significant differences in any esophageal symptoms were noted between the two groups preoperatively or at follow-up. SF-36 quality-of-life measures changed significantly from pre- to postoperative for five of ten domains in the Dor group and seven of ten in the Toupet patients (not significant between groups). CONCLUSION Laparoscopic Heller myotomy provides significant improvement in dysphagia and regurgitation symptoms in achalasia patients regardless of the type of partial fundoplication. Although a higher percentage of patients in the Dor group had abnormal 24-h pH test results compared to those of patients who underwent Toupet, the differences were not statistically significant.
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Affiliation(s)
- Arthur Rawlings
- Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave., Box 8109, St. Louis, MO 63110, USA
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Sánchez A, Rodríguez O, Nakhal E, Davila H, Valero R, Sánchez R, Pena R, Visconti MF. Robotic-assisted Heller myotomy versus laparoscopic Heller myotomy for the treatment of esophageal achalasia: a case–control study. J Robot Surg 2011; 6:213-6. [DOI: 10.1007/s11701-011-0294-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 06/16/2011] [Indexed: 10/18/2022]
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Fundoplication after laparoscopic Heller myotomy for esophageal achalasia: what type? J Gastrointest Surg 2010; 14:1453-8. [PMID: 20300876 DOI: 10.1007/s11605-010-1188-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Accepted: 02/23/2010] [Indexed: 01/31/2023]
Abstract
Because of the high success rate of minimally invasive surgery, a radical shift in the treatment algorithm of esophageal achalasia has occurred. Today, a laparoscopic Heller myotomy is the preferred treatment modality for achalasia. This remarkable change is due to the recognition by gastroenterologists and patients that a laparoscopic Heller myotomy gives better and more durable results than pneumatic dilatation and intrasphincteric injection of botulinum toxin injection, while it is associated to a short hospital stay and a fast recovery time. While there is agreement about the need of a fundoplication in conjunction to the myotomy, some questions still remain about the type of fundoplication: Should the fundoplication be total or partial, and in case a partial fundoplication is chosen, should it be anterior or posterior? The following review describes the data present in the literature in order to identify the best procedure that can achieve prevention or control of gastroesophageal reflux after a myotomy without impairing esophageal emptying.
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Yu L, Li J, Wang T, Zhang Y, Krasna MJ. Functional analysis of long-term outcome after Heller's myotomy for achalasia. Dis Esophagus 2010; 23:277-83. [PMID: 20002701 DOI: 10.1111/j.1442-2050.2009.01031.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Treatment of achalasia aims at reducing the pressure of the lower esophageal sphincter (LES) and palliate symptoms. Our objective in this study was to investigate functional changes of the esophagus after Heller myotomy and evaluate their influence on postoperative gastroesophageal reflux and esophageal morphologic changes. Between 1980 and 2003, 216 patients with achalasia underwent Heller myotomy, associated with anterior partial fundoplication (Dor fundoplication). Preoperative and long-term outcome data were collected from these patients at our hospital. The objective was to analyze esophageal functional results after Heller myotomy in the long term. Results were classified as excellent, good, fair, or poor, according to Vantrappen and Hellemans' modified classification. One-year, 2-year, 5-year, 10-year, and 20-year postoperative follow-up information was available in 100% of all patients, 91.7%, 85.1%, 60%, 52.6%, and 45.9%, respectively. There were no perioperative deaths. One year after the surgery, all patients had a significant reduction in symptoms of dysphagia and regurgitation. Five years, 10 years, 15 years, and 20 years after surgery, there were 77.2% of patients (142 in 184), 68.1%, 57.1%, and 54.5%, respectively, who were satisfied (excellent to good) with surgery. No esophageal peristalsis was demonstrated in patients during follow-up. Contractile waves in the body of the esophagus were simultaneous. The difference in the distal esophageal amplitude, the LES relaxation rate, and LES pressures in the anterior wall and/ or two sides was significant (P < 0.05) when compared before and after operation. However, there was no significant difference in the LES length and LES pressure in the posterior side. The change of direction of the LES pressure and the relaxation of LES correlate with long-term outcomes. Postoperative gastroesophageal reflux rates, including nocturnal reflux, increased with time. The percentage of patients whose esophageal diameter became normal or remained mildly increased with time in the first 10 years after surgery changed significantly. Myotomy is an effective way to palliate symptoms in patients with achalasia. Adequate myotomy can lead to reduction of LES pressure in two or three directions, which may facilitate esophageal emptying by gravity. Surgical intervention does not lead to the return of esophageal peristalsis. Functional damage of LES in patients with achalasia is irreversible.
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Affiliation(s)
- L Yu
- Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Bijing, China.
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Significance of limited hiatal dissection in surgery for achalasia. J Gastrointest Surg 2010; 14:587-93. [PMID: 20033338 DOI: 10.1007/s11605-009-1135-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 12/04/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION It is speculated that postoperative pathologic gastroesophageal reflux after Heller's myotomy can be diminished if the lateral and posterior phrenoesophageal attachments are left intact. The aim of this study was to evaluate the effectiveness of limited hiatal dissection in patients operated due to achalasia. METHODS Prospective, randomized, 3 years follow-up of 84 patients operated due to achalasia. In 26 patients, Heller-Dor with complete hiatal dissection was done (G1), limited hiatal dissection combined with myotomy and Dor's procedure was performed in 36 patients (G2), and with Heller's myotomy alone in 22 (G3). Stationary manometry and 24 h pH study were performed in regular postoperative intervals. RESULTS Postoperatively, higher median values of lower esophageal sphincter resting pressures were marked in G2 and G3, while patients in G1 were presented with higher median values of pH acid score (p < 0.001). Abnormal DeMeester score 3 years after surgery was present in 23.1% of patients in G1 and 8.5% and 9.1% in G2 and G3 accordingly. There was no statistical difference between the groups concerning postoperative dysphagia recurrence. CONCLUSION Indicating further long-term studies, 3 years after the operation limited hiatal dissection compared to complete obtains better reflux control in achalasia patients, regardless of Dor's fundoplication.
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Abstract
Achalasia is a primary motor disorder of the esophagus, in which esophageal emptying is impaired. Diagnosis of achalasia is based on clinical findings. The diagnosis is confirmed by radiographic, endoscopic, and manometric evaluations. Several treatments for achalasia have been introduced. We searched the PubMed Database for original articles and meta-analyses about achalasia to summarize the current knowledge regarding this disease, with particular focus on different procedures that are used for treatment of achalasia. We also report the Iranian experience of treatment of this disease, since it could be considered as a model for medium-resource countries. Myotomy, particularly laparoscopic myotomy with fundoplication, is the most effective treatment for achalasia. Compared to other treatments, however, the initial cost of myotomy is usually higher and the recovery period is longer. When performing myotomy is not indicated or not possible, graded pneumatic dilation with slow rate of balloon inflation seems to be an effective and safe initial alternative. Injection of botulinum toxin into the lower esophageal sphincter before pneumatic dilation may increase remission rates. However, this needs to be confirmed in further studies. Due to lack of adequate information regarding the role of expandable stents in the treatment of achalasia, insertion of stents does not currently seem to be a recommended treatment. In summary, laparoscopic myotomy can be considered as the procedure of choice for treatment of achalasia. Graded pneumatic dilation is an effective alternative when the performance of myotomy is not possible for any reason.
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Abstract
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.
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Vaziri K, Soper NJ. Laparoscopic Heller myotomy: technical aspects and operative pitfalls. J Gastrointest Surg 2008; 12:1586-91. [PMID: 18210187 DOI: 10.1007/s11605-008-0475-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Accepted: 01/07/2008] [Indexed: 01/31/2023]
Abstract
Achalasia is a rare motor disorder of the esophagus characterized by aperistalsis and impaired relaxation of the lower esophageal sphincter (LES). The etiology of this disease remains unknown. The current treatment is palliative and relies upon surgical disruption of the fibers of the LES. The technical aspects and operative pitfalls of laparoscopic Heller myotomy are described in this article.
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Affiliation(s)
- Khashayar Vaziri
- Department of Surgery, Northwestern University Feinberg School of Medicine, 201 E. Huron Street, Galter 10-105, Chicago, IL 60611, USA
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Tapper D, Morton C, Kraemer E, Villadolid D, Ross SB, Cowgill SM, Rosemurgy AS. Does Concomitant Anterior Fundoplication Promote Dysphagia after Laparoscopic Heller Myotomy? Am Surg 2008. [DOI: 10.1177/000313480807400710] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Concerns for gastroesophageal reflux after laparoscopic Heller myotomy for achalasia justify considerations of concomitant anterior fundoplication. This study was undertaken to determine if concomitant anterior fundoplication reduces symptoms of reflux after myotomy without promoting dysphagia. From 1992 to 2004, 182 patients underwent laparoscopic Heller myotomy without fundoplication. After a prospective randomized trial justified its concomitant application, anterior fundoplication was undertaken with laparoscopic Heller myotomy in 171 patients from 2004 to 2007. All patients have been prospectively followed. Pre and postoperatively, patients scored the frequency and severity of symptoms of achalasia (including dysphagia, choking, vomiting, regurgitation, chest pain, and heartburn) using a Likert Scale (0 = never/not bothersome to 10 = always/very bothersome). Before myotomy, symptoms of achalasia were frequent and severe for all patients. After myotomy, the frequency and severity of all symptoms of achalasia significantly decreased for all patients ( P < 0.001, Wilcoxon matched pairs test). Notably, relative to patients undergoing laparoscopic Heller myotomy alone, concomitant anterior fundoplication led to significantly less frequent and severe heartburn after myotomy ( P < 0.05, Mann-Whitney Test) and to less frequent and severe dysphagia and choking ( P < 0.05, Mann-Whitney Test). Laparoscopic Heller myotomy reduces the frequency and severity of symptoms of achalasia. Concomitant anterior fundoplication decreases the frequency and severity of heartburn and dysphagia after laparoscopic Heller myotomy. Concomitant anterior fundoplication promotes salutary relief in the frequency and severity of symptoms after myotomy and is warranted.
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Affiliation(s)
- Donovan Tapper
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Connor Morton
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Emily Kraemer
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Desiree Villadolid
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Sharona B. Ross
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Sarah M. Cowgill
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Alexander S. Rosemurgy
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
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Patti MG, Fisichella PM. Laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia. How I do it. J Gastrointest Surg 2008; 12:764-6. [PMID: 17957436 DOI: 10.1007/s11605-007-0368-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Accepted: 09/19/2007] [Indexed: 01/31/2023]
Abstract
The advent and the success of minimally invasive surgery have changed the treatment algorithm for esophageal achalasia. Today, a laparoscopic Heller myotomy and partial fundoplication is considered the treatment of choice for this disease. This article describes the technique of laparoscopic Heller myotomy and Dor fundoplication.
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Affiliation(s)
- Marco G Patti
- Department of Surgery, University of California San Francisco, 521 Parnassus Ave, Room C-341, San Francisco, CA 94143-0790, USA.
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Laparoscopic Heller myotomy for achalasia: a review of the controversies. Ann Thorac Surg 2008; 85:S743-6. [PMID: 18222208 DOI: 10.1016/j.athoracsur.2007.12.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2007] [Revised: 11/21/2007] [Accepted: 12/03/2007] [Indexed: 12/25/2022]
Abstract
Achalasia is a rare primary motility disorder of the esophagus with a United States prevalence of less than 0.001%. Laparoscopic modified Heller myotomy has become the standard of care for palliation of this incurable but benign disease. The role of a fundoplication with the myotomy continues to be controversial. This report summarizes the current laparoscopic management of achalasia with a review of the medical literature on the outcome of combining a fundoplication with a laparoscopic myotomy. The optimal length of myotomy as suggested in the literature is also summarized. To complete the goal, peer-reviewed publications were identified in PubMed by search terms achalasia, myotomy, fundoplication, Nissen, Dor, and Toupet.
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Rosen MJ, Novitsky YW, Cobb WS, Kercher KW, Heniford BT. Laparoscopic Heller myotomy for achalasia in 101 patients: can successful symptomatic outcomes be predicted? Surg Innov 2008; 14:177-83. [PMID: 17928616 DOI: 10.1177/1553350607307876] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We aimed to evaluate the clinical outcomes of patients undergoing laparoscopic esophageal myotomy for achalasia and identify the factors that might predict postoperative dysphagia or symptomatic reflux. A retrospective analysis of all patients undergoing laparoscopic Heller myotomy from January 1997 to June 2004 was performed. Postoperative frequency and severity of reflux, dysphagia, chest pain, and regurgitation were evaluated using a standardized telephone interview. Forty-eight males and 53 females, with an average age of 45 years, underwent laparoscopic Heller myotomy during the study period. Prior to presentation, 65% of patients had undergone pneumatic dilatation (52%) and/or Botox injection (28%). The mean lower esophageal sphincter pressure was 44 mmHg. A Toupet fundoplication was performed in 89 patients, and 12 patients had no fundoplication. There were no intraoperative complications and 10 minor postoperative complications. During an average follow-up of 34 months (range 2-90), 15% of patients had a weekly dysphagia, and 16% had subjective reflux. Only an older age predicted higher incidence of postoperative dysphagia. No factors were identified to predict postoperative symptomatic reflux. Eighty-one percent of patients rated their outcome as excellent, 14% good, 4% fair, and 1% poor. Ninety-nine percent of patients would choose surgery over other treatment options again. Laparoscopic anterior esophageal myotomy is a safe and effective treatment for achalasia. Improvement in dysphagia can be expected in more than 95% of patients. Younger patients tended to have better improvement of dysphagia. Predicting the patients at higher risk for postoperative reflux remains elusive at this time.
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Affiliation(s)
- Michael J Rosen
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina 28203, USA
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Tsiaoussis J, Pechlivanides G, Gouvas N, Athanasakis E, Zervakis N, Manitides A, Xynos E. Patterns of esophageal acid exposure after laparoscopic Heller's myotomy and Dor's fundoplication for esophageal achalasia. Surg Endosc 2007. [PMID: 18095027 DOI: 10.1007/s00464-007-9681-2.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Heller's myotomy for esophageal achalasia is associated with less esophageal acid gastroesophageal reflux when combined a Dor's fundoplication. The Aim of the study was to assess the incidence of postoperative esophageal acid exposure after laparoscopic Heller's myotomy and Dor's fundoplication (HM-DF). METHODS Seventy six patients (37 males) with esophageal achalasia were prospectively followed-up by clinical interview and laboratory tests before and after laparoscopic HM-DF. A symptom score was used for clinical assessment. Laboratory assessment included esophageal standard manometry, esophagogram and esophageal pH 24-hour monitoring before and 1- and 5-years after surgery. RESULTS Symptom score improved at 1-year after surgery (P < 0.001). Heartburn was only reported by 5 patients, dysphagia or/and regurgitation by 28 and substernal pain by 12. 91% of patients had satisfactory functional results. Pathological esophageal exposure to acid was seen in 21% of the cases. Pathological acid events showed the features of pseudoreflux in 66%t and those of true GER in 34%. Pathologically increased esophageal exposure to acid was more commonly detected in patients with a pseudodiverticulum (P = 0.001) and was related to the diameter of distal esophagus and symptom score (P < 0.001). There was no reduction in esophageal acid exposure after treatment with proton pump inhibitors in 16 patients. Neither the symptom score nor esophageal acid exposure at esophageal pH monitoring changed significantly at the 5-year follow-up in 35 patients. Esophageal configuration remained unchanged. CONCLUSIONS Increased esophageal exposure to acid after laparoscopic HM-DF for esophageal achalasia i) is detected in 21% of patients, and is rather the result of food stagnation than of true GER, ii) is more commonly seen in cases with pseudodiverticulum, iii) is related to the diameter of distal esophagus, iv) does not respond to antisecretory treatment and v) does not deteriorate by time.
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Affiliation(s)
- John Tsiaoussis
- Department of Surgery, Metropolitan Hospital of Athens, Athens, Greece.
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Tsiaoussis J, Pechlivanides G, Gouvas N, Athanasakis E, Zervakis N, Manitides A, Xynos E. Patterns of esophageal acid exposure after laparoscopic Heller's myotomy and Dor's fundoplication for esophageal achalasia. Surg Endosc 2007; 22:1493-9. [PMID: 18095027 DOI: 10.1007/s00464-007-9681-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Accepted: 10/10/2007] [Indexed: 12/15/2022]
Abstract
BACKGROUND Heller's myotomy for esophageal achalasia is associated with less esophageal acid gastroesophageal reflux when combined a Dor's fundoplication. The Aim of the study was to assess the incidence of postoperative esophageal acid exposure after laparoscopic Heller's myotomy and Dor's fundoplication (HM-DF). METHODS Seventy six patients (37 males) with esophageal achalasia were prospectively followed-up by clinical interview and laboratory tests before and after laparoscopic HM-DF. A symptom score was used for clinical assessment. Laboratory assessment included esophageal standard manometry, esophagogram and esophageal pH 24-hour monitoring before and 1- and 5-years after surgery. RESULTS Symptom score improved at 1-year after surgery (P < 0.001). Heartburn was only reported by 5 patients, dysphagia or/and regurgitation by 28 and substernal pain by 12. 91% of patients had satisfactory functional results. Pathological esophageal exposure to acid was seen in 21% of the cases. Pathological acid events showed the features of pseudoreflux in 66%t and those of true GER in 34%. Pathologically increased esophageal exposure to acid was more commonly detected in patients with a pseudodiverticulum (P = 0.001) and was related to the diameter of distal esophagus and symptom score (P < 0.001). There was no reduction in esophageal acid exposure after treatment with proton pump inhibitors in 16 patients. Neither the symptom score nor esophageal acid exposure at esophageal pH monitoring changed significantly at the 5-year follow-up in 35 patients. Esophageal configuration remained unchanged. CONCLUSIONS Increased esophageal exposure to acid after laparoscopic HM-DF for esophageal achalasia i) is detected in 21% of patients, and is rather the result of food stagnation than of true GER, ii) is more commonly seen in cases with pseudodiverticulum, iii) is related to the diameter of distal esophagus, iv) does not respond to antisecretory treatment and v) does not deteriorate by time.
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Affiliation(s)
- John Tsiaoussis
- Department of Surgery, Metropolitan Hospital of Athens, Athens, Greece.
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Youssef Y, Richards WO, Sharp K, Holzman M, Sekhar N, Kaiser J, Torquati A. Relief of dysphagia after laparoscopic Heller myotomy improves long-term quality of life. J Gastrointest Surg 2007; 11:309-13. [PMID: 17458603 DOI: 10.1007/s11605-006-0050-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVE Quality of life (QoL) is getting more attention in the medical literature. Treatment outcomes are now gauged by their effect on the QoL along with their direct effect on the diseases they are targeting. The aim of the study was to assess the impact of residual dysphagia on QoL after laparoscopic Heller myotomy for achalasia. METHODS QoL was evaluated using the short-form-36 (SF-36) and postoperative dysphagia was assessed using a dysphagia score. The score (range 0-10) was calculated by combining the frequency of dysphagia (0=never, 1 = < 1 day/wk, 2 = 1 day/wk, 3 = 2-3 days/wk, 4 = 4-6 days/wk, 5=daily) with the severity (0=none, 1=very mild, 2=mild, 3=moderate, 4=moderately severe, 5=severe). Patients were classified in the Nonresponder group when their dysphagia score was in the upper quartile. RESULTS Questionnaires were mailed to 110 patients. The overall response rate was 91% with 100 patients (54 female) returning the questionnaires. The average follow-up was 3.3 years. There was a significative inverse correlation between dysphagia score and mental component (P = 0.0001) and total SF-36 (P = 0.001) scores. According to their postoperative dysphagia scores, 77 patients were assigned to the Responder Group and 23 patients to the Nonresponder Group. The two groups were similar in terms of age, gender, rate of fundoplication, and length of follow-up. Mental component and total SF-36 scores were significantly (P < 0.05) higher in the Responder group. Successful relief of dysphagia after Heller myotomy was associated with health-related quality of life scores that were 13 higher in Vitality (P < 0.05), 11 points higher in mental health (P < 0.05), and 12 points higher in General Health (P < 0.05). Overall patient satisfaction with surgical outcome was 92%, with only eight patients not satisfied with the surgery. CONCLUSION Laparoscopic Heller myotomy offers excellent long-term relief of achalasia-related symptoms, namely dysphagia, and this was projected on a significant improvement in quality of life and patient satisfaction.
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Affiliation(s)
- Yassar Youssef
- Department of Surgery, Vanderbilt University School of Medicine, D-5203 MCN, Nashville, Tennessee 37232, USA
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Gholoum S, Feldman LS, Andrew CG, Bergman S, Demyttenaere S, Mayrand S, Stanbridge DD, Fried GM. Relationship between subjective and objective outcome measures after Heller myotomy and Dor fundoplication for achalasia. Surg Endosc 2005; 20:214-9. [PMID: 16333549 DOI: 10.1007/s00464-005-0213-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2005] [Accepted: 09/07/2005] [Indexed: 01/17/2023]
Abstract
BACKGROUND The purpose of this study is to assess how subjective evaluation (heartburn, dysphagia, quality of life, and satisfaction) correlates with objective data after Heller myotomy and Dor fundoplication for achalasia. METHODS A total of 53 consecutive patients with achalasia undergoing laparoscopic Heller myotomy and Dor fundoplication were studied prospectively. Subjective evaluation was done preop and postop using the Gastroesophageal Reflux Disease Health-Related Quality of Life instrument (GERD-HRQL; 0 = best, 45 = worse), 4-point dysphagia and heartburn scales (0 = best, 3 = worst), patient satisfaction scale (0 = very satisfied, 5 = incapacitated), and the SF-12 general health-related quality-of-life score. At 3 months postop, patients were asked to undergo objective evaluation with 24-h pH testing, manometry, and endoscopy. Data are expressed as median (interquartile range) and analyzed by Wilcoxon signed rank test or Mann-Whitney U test. RESULTS Forty-nine patients were more than 3 months postsurgery. Comparing preop to postop, improvements were found in dysphagia [3 (2-3) to 0 (0-1)], heartburn [1 (0-2) to 0 (0-1)], GERD-HRQL [13.5 (6.3-22.5) to 2 (0-5)], satisfaction [3 (3-4) to 1 (0-1)], and SF-12 mental component summary [46 (37-56) to 58 (50-59)] and physical component summary [46 (36-53) to 55 (48-56)] scores (p < 0.0001 for all). Thirty-eight patients (78%) agreed to undergo objective testing, and complete data were available for 32 (65%). Four of 32 patients (12.5%) had evidence of reflux based on 24-h pH testing. Of nine patients with GERD-HRQL >5, only two had positive pH test (22%). Of 23 patients with GERD-HRQL <5, two had positive pH test (7%). Of four tested patients with moderate to severe heartburn, two had an abnormal pH test. There was no significant relationship between GERD-HRQL score and pH test results. Lower esophageal sphincter pressure (LESP) decreased from 24 (16-35) to 13 mmHg (11-17) (p < 0.001). There was no relationship between dysphagia score and postop absolute LESP or a decrease in LESP after operation. CONCLUSIONS Laparoscopic Heller myotomy and Dor fundoplication is an effective treatment for achalasia. Subjective evaluation can document patient satisfaction and health-related quality of life but does not accurately reflect postop reflux. Twenty-four-hour pH study is required to accurately assess reflux disease.
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Affiliation(s)
- S Gholoum
- Steinberg-Bernstein Centre for Minimally Invasive Surgery, 1650 Cedar Avenue, Room L9.309, Montreal, Quebec, H3G 1A4, Canada
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