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Montalva L, Farha E, Hervieux E, Ali L, Rousseau V, Schmitt F, Guinot A, Sassi N, Grosos C, Arnaud AP, Scalabre A, Dubois R, Bonnard A. Complications after Heller myotomy in children: a national multicenter study on the impact of prior endoscopic dilatation and identification of risk factors. Surg Endosc 2024; 38:3602-3608. [PMID: 38769183 DOI: 10.1007/s00464-024-10884-x] [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: 02/08/2024] [Accepted: 04/28/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Although esophageal achalasia has been historically treated by Heller myotomy, endoscopic esophageal dilatations are nowadays often the first-line treatment in children. The aim was to assess whether performing an endoscopic dilatation before a Heller myotomy is associated with higher risks of esophageal perforation in children. METHODS A retrospective multicentric study was performed, including children that underwent a Heller myotomy (2000-2022, 10 centers). Two groups were compared based on the history of previous dilatation before myotomy. Outcomes esophageal perforation (intra-operative or secondary) and post-operative complications requiring surgery (Clavien-Dindo III). Statistics Comparisons using contingency tables or Kruskal-Wallis when appropriate. Statistical significance: p-value < 0.05. RESULTS A Heller myotomy was performed in 77 children (median age: 11.8 years), with prior endoscopic dilatation in 53% (n = 41). A laparoscopic approach was used in 90%, with associated fundoplication in 95%. Esophageal perforation occurred in 19% of children (n = 15), including 12 patients with intra-operative mucosal tear and 3 with post-operative complications related to an unnoticed esophageal perforation. Previous endoscopic dilatation did not increase the risk of esophageal perforation (22% vs 17%, OR: 1.4, 95%CI: 0.43-4.69). Post-operative complications occurred in 8% (n = 6), with similar rates regardless of prior endoscopic dilatation. Intra-operative mucosal tear was the only risk factor for post-operative complications, increasing the risk of complications from 5 to 25% (OR: 6.89, 95%CI: 1.38-31.87). CONCLUSIONS Prior endoscopic dilatations did not increase the risk of esophageal perforation or postoperative complications of Heller myotomy in this cohort of children with achalasia. Mucosal tear was identified as a risk factor for post-operative complications.
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Affiliation(s)
- Louise Montalva
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France.
- Paris-Cité University, Paris, France.
| | - Elie Farha
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
| | - Erik Hervieux
- Department of Pediatric Surgery, Armand Trousseau University Hospital, Paris, France
| | - Liza Ali
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
- Paris-Cité University, Paris, France
| | - Véronique Rousseau
- Department of Pediatric Surgery, AP-HP, Necker-Enfants Malades, Paris, France
| | - Françoise Schmitt
- Department of Pediatric Surgery, Angers University Hospital, Angers, France
| | - Audrey Guinot
- Department of Pediatric Surgery, Hôtel-Dieu University Hospital, Nantes, France
| | - Nizar Sassi
- Department of Pediatric Surgery, Strasbourg University Hospital, Strasbourg, France
| | - Céline Grosos
- Department of Pediatric Surgery, Limoges University Hospital, Limoges, France
| | - Alexis P Arnaud
- Department of Pediatric Surgery, Rennes University Hospital, University of Rennes, Rennes, France
| | - Aurélien Scalabre
- Department of Pediatric Surgery, University Hospital, Saint-Etienne, France
| | - Remi Dubois
- Department of Pediatric Surgery, Hospices Civils de Lyon, Hôpital Femme Mère Enfant University Hospital, Bron, France
| | - Arnaud Bonnard
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
- Paris-Cité University, Paris, France
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Chadu Junior JB, Oliveira JAD, Faion AG, Zilberstein B. SHORT AND LONG-TERM RESULTS OF LAPAROSCOPIC ESOPHAGOCARDIOMYOTOMY WITH FUNDOPLICATION (HELLER-PINOTTI SURGERY) IN THE TREATMENT OF NON-ADVANCED ACHALASIA (MEGAESOPHAGUS). ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 37:e1803. [PMID: 38896699 PMCID: PMC11182623 DOI: 10.1590/0102-6720202400010e1803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 02/01/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Videolaparoscopic esophagocardiomyotomy with fundoplication has been a widely used technique for the treatment of achalasia. This study analyzes the safety and effectiveness of the technique in the treatment of non-advanced achalasia (megaesophagus) in a Brazilian federal university public hospital. AIMS To evaluate the short- and long-term results of videolaparoscopic treatment of non-advanced megaesophagus in a public university hospital in Brazil, employing the esophagocardiomyotomy technique with fundoplication. METHODS The medical records of 44 patients who underwent surgical treatment for non-advanced achalasia at the Clinical Hospital of Federal University of Uberlândia (UFU-MG), Minas Gerais, from January 2001 to July 2021 were analyzed. The following data were evaluated: gender, age, etiology, radiological classification of Rezende-Alves and Ferreira-Santos, immediate and late complications (mean follow-up of 31.4 months), need or not for conversion to open access, postoperative reflux, performance or not of endoscopic esophageal dilation in the preoperative period, postoperative mortality, frequency of pre and postoperative symptoms (persistent dysphagia, regurgitation, heartburn, vomiting, odynophagia, and weight loss), surgery time, hospital stay, duration of dysphagia, pre and postoperative weight, and Eckardt score. RESULTS Among the analyzed patients, 23 (52.3%) were male, and 21 (47.7%) were female, with a mean age of 50.8 years. No early complications were recorded and there were 27.2% cases of late gastroesophageal reflux. Postoperative weight gain was 81.8% and the success rate of surgery according to the Eckardt score was 84.1%. CONCLUSIONS Esophagocardiomyotomy with fundoplication is an effective and safe technique for the treatment of non-advanced achalasia.
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Affiliation(s)
- João Bosco Chadu Junior
- Universidade Federal de Uberlândia, Digestive Surgery Unit - Uberlândia (MG), Brazil
- Faculdade São Leopoldo Mandic, Minimally Invasive Surgery, Master of Medical Sciences - Campinas (SP), Brazil
| | | | - Adilson Gomes Faion
- Universidade Federal de Uberlândia, Digestive Surgery Unit - Uberlândia (MG), Brazil
| | - Bruno Zilberstein
- Faculdade São Leopoldo Mandic, Minimally Invasive Surgery, Master of Medical Sciences - Campinas (SP), Brazil
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Correlation between our symptom-based scoring system and the Eckardt score for assessing patients with esophageal achalasia. Surg Today 2022; 52:1680-1687. [PMID: 35438368 DOI: 10.1007/s00595-022-02503-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/10/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE The Eckardt score (ES) is a famous scoring system used for assessing achalasia patients. We studied the correlation between our scoring system and the ES and examined the relationship between each score and the pathophysiology of achalasia. METHODS The subjects were 143 patients with diagnosed achalasia. We assessed the frequency and degree of dysphagia, regurgitation (vomiting), and chest pain on a 5-point scale from 0 to 4, with the product of the frequency and degree score defined as each symptom score (0-16). The sum of the three symptom scores was the Total Symptom Score (TSS). We then studied the correlation between the TSS and the ES, including whether these scores reflected the pathophysiology. RESULTS The median scores were 20 for TSS and 6 for the ES, indicating a high correlation between the two scores (r = 0.7280, p < 0.0001). A relationship was found between the morphologic type and both scores (TSS: p = 0.002, ES: p = 0.0036). On creating a receiver operating characteristic (ROC) curve for the Straight type and each score, the AUC was 0.6740 for TSS and 0.6628 for ES. CONCLUSIONS A high positive correlation was found between the TSS and the ES. Both scoring systems reflected the morphologic type well, demonstrating that the TSS was a scoring system comparable to the ES.
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Fiume I, Molena D. Robotic esophagomyotomy for achalasia: technical note and review of the literature. Minerva Surg 2021; 77:157-170. [PMID: 34693674 DOI: 10.23736/s2724-5691.21.08979-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The treatment of achalasia has undergone continuous evolution with the advancement of technology. Since the beginning of the new millennium, the employment of robotics has led to technical facilitation with the execution of the myotomy and consequently to improvement of outcomes and decrease perioperative morbidity. EVIDENCE ACQUISITION We provide a detailed description of the surgical procedure and the perioperative management together with a literature search of Electronic PubMed/Medline database and Cochrane Library. English written studies on robotic assisted myotomy (case reports, reviews, single arm and comparative studies) were included. EVIDENCE SYNTHESIS Between 2001 and 2020, 10 case reports, 13 single arm studies, 10 comparative studies, 2 meta-analysis, 11 reviews and 2 technical notes on robotic assisted esophagomyotomy for achalasia were published. CONCLUSIONS As reported by the studies available in the literature and evaluated in this manuscript, robotic assisted cardiomyotomy seems not only feasible but also a safer operation compared with traditional laparoscopic Heller myotomy, due to a significant lower incidence of intraoperative esophageal perforation. Also if large and randomized controlled studies are advocated, robotic assisted esophagocardiomyotomy might be considered superior to laparoscopic Heller myotomy that, until now, is mostly considered the gold standard in the surgical treatment of achalasia.
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Affiliation(s)
- Irene Fiume
- Department of General, Oncologic and Vascular Surgery, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy -
| | - Daniela Molena
- Esophageal Surgery Program, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Redo laparoscopic Heller myotomy and Dor fundoplication versus rescue peroral endoscopic myotomy for esophageal achalasia after failed Heller myotomy: a single-institution experience. Surg Today 2021; 52:401-407. [PMID: 34535816 DOI: 10.1007/s00595-021-02376-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/06/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To compare the surgical outcomes of redo laparoscopic Heller-Dor procedure and rescue peroral endoscopic myotomy for patients with failed Heller myotomy. METHODS We identified patients who had undergone redo laparoscopic Heller-Dor procedure or rescue peroral endoscopic myotomy from August 1996 to September 2019 and assessed the patients' characteristics, timed barium swallow results, symptom scores before/after surgery, surgical outcomes, and postoperative outcomes. RESULTS Eleven patients underwent redo laparoscopic Heller-Dor procedure, and 14 underwent rescue peroral endoscopic myotomy. Blood loss (p = 0.001) and intraoperative complications rate (p = 0.003) were lower and the operative time (p > 0.001) and observation period (p = 0.009) shorter in patients who underwent rescue peroral endoscopic myotomy than in patients who underwent redo laparoscopic Heller-Dor procedure. Patients who underwent rescue peroral endoscopic myotomy had a higher rate of postoperative reflux esophagitis (p = 0.033) than those who underwent redo laparoscopic Heller-Dor procedure. After the interventions, the dysphagia symptoms were improved for both groups. Furthermore, both groups expressed satisfaction with their respective procedures. CONCLUSIONS Rescue peroral endoscopic myotomy was associated with better surgical outcomes than redo laparoscopic Heller-Dor for patients with failed Heller myotomy. However, rescue peroral endoscopic myotomy had higher rates of postoperative reflux esophagitis.
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Tsuboi K, Yano F, Omura N, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Sakashita Y, Fukushima N, Ikegami T. Effects of the preoperative IRP values on the pathophysiology of patients with esophageal achalasia and on the treatment outcome of laparoscopic Heller-Dor surgery. Langenbecks Arch Surg 2021; 406:1037-1044. [PMID: 33604819 DOI: 10.1007/s00423-021-02130-y] [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: 12/27/2020] [Accepted: 02/09/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE One diagnostic criterion of esophageal achalasia is that the integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) is at least 15 mmHg. Moreover, while the standard surgical treatment for esophageal achalasia is laparoscopic Heller-Dor surgery (LHD), there have been insufficient investigations concerning the surgical outcomes from the perspective of the preoperative IRP value. METHODS We split 121 cases in which LHD was performed as an initial treatment on patients with esophageal achalasia, into two categories according to the IRP median value, and performed a comparative investigation of the surgical outcomes with regard to the preoperative pathophysiology and symptoms. RESULTS The IRP median value was 29.6 mmHg. The high IRP group consisted of younger individuals and low BMI (p = 0.004 and p = 0.0273, respectively), and the percentage of Chicago classification Type II and III was high (p = 0.029) and the regurgitation score in the preoperative symptoms was high (p = 0.0043). However, no differences in the surgical outcomes were confirmed. CONCLUSION In patients with esophageal achalasia, the degree of the preoperative IRP value affects the age, BMI, preoperative LESP, and preoperative regurgitation symptoms. However, there were no effects on the surgical outcomes, with the surgical outcomes being satisfactory, regardless of the IRP value.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Fuji City General Hospital, 50, Takashima-cho, Fuji, Shizuoka, 416-0951, Japan.
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
- Department of Surgery, Nishisaitama-Chuo National Hospital, Saitama, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Se-Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Tsuboi K, Yano F, Omura N, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Sakashita Y, Ikegami T. Factors affecting the treatment outcomes of laparoscopic fundoplication for erosive reflux esophagitis: findings of esophageal pathological function tests. Surg Today 2021; 51:1568-1576. [PMID: 33491102 DOI: 10.1007/s00595-021-02226-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/03/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE To identify the factors that affect laparoscopic fundoplication (LF) treatment efficacy in patients with erosive gastroesophageal reflux disease (e-GERD) esophagitis, based on the findings of multichannel intraluminal impedance pH (MII-pH) and high-resolution manometry (HRM). METHODS The subjects were 102 patients with e-GERD diagnosed by endoscopy, who underwent LF as the initial surgery. To analyze the findings of MII-pH and HRM, the patients were divided into two groups: a cured group (CR), comprised of patients whose esophagitis was cured postoperatively; and a recurrence group (RE), comprised of patients who suffered recurrent esophagitis. RESULTS There were 96 patients in the CR group and 6 in the RE group. MII-pH indicated that the acid reflux time, the longest reflux time, and the number of refluxes longer than 5 min, were significantly higher in the RE group than in the CR group (p = 0.0028, p = 0.0008, p = 0.012, respectively). The HRM indicated that only the distal contractile integral (DCI) was significantly lower in the RE group (p = 0.0109). CONCLUSION The results of this study indicate that esophageal clearance may affect the treatment outcome of LF. Based on the findings of MII-pH, the longest reflux time and the number of refluxes longer than 5 min were important factors influencing the therapeutic effect, whereas based on the HRM, the DCI value was most important.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Fuji City General Hospital, 50, Takashima-cho, Fuji, Shizuoka, 416-0951, Japan. .,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, Nishisaitama-Chuo National Hospital, Saitama, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Se-Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Tsuboi K, Yano F, Omura N, Hoshino M, Akimoto S, Masuda T, Sakashita Y, Fukushima N, Ikegami T. The evaluation of the dilation-degree classification of esophageal achalasia patients from the viewpoint of esophageal clearance. Surg Today 2021; 51:962-970. [PMID: 33387027 DOI: 10.1007/s00595-020-02193-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/04/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To examine whether or not we could propose a more appropriate dilation-degree classification suitable for the pathological condition of patients with esophageal achalasia. METHODS In accordance with the current dilation-degree classification, the maximum dilated diameter was measured based on the esophageal barium swallow. The relationship between the pathophysiology and dilation-degree classification was examined. Furthermore, the current dilatation-degree classification from the viewpoint of esophageal clearance was evaluated to examine whether or not a more appropriate dilatation-degree classification could be proposed. RESULTS Because the clearance ratio tended to decrease at a maximum expansion diameter of 80 mm, when the maximum dilated diameter was divided into units of 10 mm, they were classified into two groups, with 80 mm as the boundary. As a result, the illness period was significantly prolonged (p = 0.0045) and the frequency of sigmoid type was high (p < 0.001) for lengths of ≥ 80 mm. With regard to the esophageal clearance rate, the clearance rate was significantly decreased in patients with a diameter of ≥ 80 mm at 5 min after taking barium (p = 0.0229). CONCLUSIONS From the viewpoint of esophageal clearance, classification into 2 groups with a boundary of 80 mm may reflect the pathological condition.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Fuji City General Hospital, 50, Takashima-cho, Fuji, Shizuoka, 417-8567, Japan. .,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, Nishi-Saitama Chuo National Hospital, Saitama, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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