Achalasia: current evaluation and therapy

Anesthesia for Per-oral endoscopic myotomy (POEM) – not so poetic!

Peroral endoscopic myotomy (POEM) is a promising natural orifice transluminal endoscopic procedure for the treatment of esophageal motility disorders, with similar effectiveness as of Heller myotomy. It is performed under general anesthesia in endoscopy suite. Creation of submucosal tunnel in the esophageal wall is a key component. The continuous insufflation of CO₂ inadvertently tracks into surrounding tissues and leads to capno mediastinum, capno thorax, capno peritoneum, and subcutaneous emphysema. Thus, the challenges, for an anesthesiologist are not only providing remote location anesthesia, increased risk of aspiration during induction, but also early detection of these complications and specific emergency management. Though a therapeutic innovation, POEM remains an interdisciplinary challenge with no specific anesthesia care algorithms and evidence-based recommendations. The purpose of this review is to outline the anesthesia and periprocedural practices based on existing evidence.

Change in body composition in patients with achalasia before and after peroral endoscopic myotomy

BACKGROUND AND AIM

Patients with achalasia experience weight loss because of dysphagia caused by impaired relaxation of the lower esophageal sphincter. This study aimed to use dual bioelectrical impedance analysis (BIA) to determine the change in bodyweight and body composition in patients with achalasia before and after peroral endoscopic myotomy (POEM).

METHODS

Patients with achalasia who underwent POEM from 2013 to 2018 (n = 72) were retrospectively analyzed for change in bodyweight before and after 3 months. Additionally, change in body composition was prospectively investigated in the final 10 of 72 patients using non-radiation dual BIA.

RESULTS

Twenty patients (27.8%) were underweight (body mass index < 18.5) before undergoing POEM. No clinical parameters were identified to be associated with the underweight condition before POEM and be predictive of an increase in bodyweight after POEM. Low visceral fat volume observed on dual BIA correlated closely with the result obtained using computed tomography (Pearson correlation coefficient: r = 0.850, P < 0.01). Patients with achalasia had a statistically significant increase in visceral (P < 0.01) and subcutaneous fat volumes (P < 0.01) after POEM. Skeletal muscle mass index slightly increased (P = 0.02), although the value after POEM was still low. No blood biomarkers were indicators for low bodyweight or low visceral fat volume.

CONCLUSIONS

Dual BIA is an effective non-invasive tool to evaluate the change in body composition of underweight patients with achalasia. Skeletal muscle volume was not enough after POEM, although a rapid increase in the intra-abdominal fat volume was observed. Additional studies are warranted to understand the pathological implications.

Anesthesia for peroral endoscopic myotomy in Japan

PURPOSE OF REVIEW

Peroral endoscopic myotomy (POEM) was developed in Japan as a less invasive treatment for esophageal achalasia requiring general anesthesia under positive pressure ventilation. In 2018, the Japan Gastroenterological Endoscopy Society published the first guidelines describing the standard care for POEM. Based on these guidelines, we discuss the typical approach to anesthesia during POEM for the management of esophageal achalasia in Japan.

RECENT FINDINGS

Prior cleansing of the esophagus is essential to prevent both aspiration during induction of anesthesia and contamination of the mediastinum and thoracic/abdominal cavity by esophageal remnants after endoscopic resection of the esophageal mucosa. Although rare, adverse events related to intraoperative carbon dioxide insufflation occur. These are treated through percutaneous needle decompression and insertion of a chest drainage tube for pneumoperitoneum and pneumothorax, respectively. Caution should be exercised regarding the development of subcutaneous emphysema and its involvement in airway obstruction.

SUMMARY

Prevention of aspiration pneumonia and adverse events related to the insufflation of carbon dioxide is essential in the management of esophageal achalasia through POEM. Close cooperation between gastrointestinal endoscopic surgeons and anesthesiologists is indispensable in POEM.

The course of achalasia one to four decades after initial treatment

BACKGROUND

Most follow-up studies of achalasia are limited to <5 years.

AIM

To study the long-term efficacy of pneumatic dilation (PD) and myotomy in achalasia at least 10 years after treatment.

METHODS

We performed a retrospective cohort study of achalasia patients with >10 years follow-up after initial myotomy or pneumatic dilation. Symptom recurrence which required repeat dilation or surgery was compared between pneumatic dilation and myotomy.

RESULTS

One hundred and fifty patients (112 myotomy, 38 pneumatic dilation) of similar characteristics were studied. The mean duration of follow-up after initial treatment was 17.5 ± 7.2 years (10-40 years). Symptoms recurrence rate was 60.7% (100% pneumatic dilation patients vs. 47.3% myotomy), hazard ratio 0.24 demonstrating a lower need for repeat dilation or surgery with myotomy than pneumatic dilation (P = 0.008). All pneumatic dilation patients underwent myotomy in 4 ± 4 (0-16 years). Forty of 53 myotomy patients had symptom recurrence prompting further treatment: 16 pneumatic dilation, 11 myotomy and 13 both. The mean time to repeat procedure was 6.9 years (0-40). The myotomy group required fewer dilations and/or surgeries than the pneumatic dilation group (1.6 vs. 3.6, P < 0.001). 13 patients (10.1%) progressed to end-stage achalasia (five myotomy, eight pneumatic dilation) over 40 years. At last follow-up, 57/62 (92%) patients had absent or mild dysphagia, 53/62 (85%) patients had regurgitation less than once per week and 37 (60.7%) had heartburn episodes <1/week similar for pneumatic dilation and myotomy (P = 0.27).

CONCLUSION

Although the majority of patients treated for achalasia do well after decades of treatment, most patients may need a series of endoscopic and/or surgical procedures to maintain effective symptom control.

A prospective analysis of GERD after POEM on anterior myotomy

Background

Peroral endoscopic myotomy (POEM) is an emerging, minimally invasive procedure capable of overcoming limitations of achalasia treatments, but gastroesophageal reflux disease (GERD) after POEM is of concern and its risk factors have not been evaluated. This prospective study examined GERD and the association of POEM with reflux esophagitis.

Methods

Achalasia patients were recruited from a single center. The pre- and postoperative assessments included Eckardt scores, manometry, endoscopy, and pH monitoring.

Results

Between September 2011 and November 2014, 105 patients underwent POEM; 70 patients were followed up 3 months after POEM. Postoperatively, significant reductions were observed in lower esophageal sphincter (LES) pressure [from 40.0 ± 22.8 to 20.7 ± 14.0 mmHg (P < 0.05)], LES residual pressure [from 22.1 ± 13.3 to 11.4 ± 6.6 mmHg (P < 0.05)], and Eckardt scores [from 5.7 ± 2.5 to 0.7 ± 0.8 (P < 0.05)]. Symptomatic GERD and moderate reflux esophagitis developed in 5 and 11 patients (grade B, n = 8; grade C, n = 3), respectively, and were well controlled with proton pump inhibitors. Univariate logistic regression analysis revealed integrated relaxation pressure was a predictor of ≥grade B reflux esophagitis. No POEM factors were found to be associated with reflux esophagitis.

Conclusion

POEM is effective and safe in treating achalasia, with no occurrence of clinically significant refractory GERD. Myotomy during POEM, especially of the gastric side, was not associated with ≥grade B (requiring medical intervention) reflux esophagitis. Extended gastric myotomy (2–3 cm) during POEM is recommended to improve outcomes.

Safety and efficacy of the modified peroral endoscopic myotomy with shorter myotomy for achalasia patients: a prospective study

Peroral endoscopic myotomy (POEM) has been developed as a minimally invasive endoscopic treatment for achalasia for years. However, the optimal length of submucosal tunnel and myotomy of muscle bundles during procedure of POEM has not yet been determined, so we aim to assess safety and efficacy of modified POEM with shorter myotomy of muscle bundles in achalasia patients. Consecutive achalasia patients had been performed modified POEM with shorter myotomy, and assessed by symptoms, high-resolution manometry, and barium swallow examinations before and 3 months after POEM for safety and efficacy evaluation. Modified POEM with shorter submucosal tunnel (mean length 6.8 cm) and endoscopic myotomy of muscle bundles (total mean length 5.4 cm) were completed in 46 consecutive achalasia patients. During the 3-month follow up in all cases, significant improvement of symptoms (a significant drop in the Eckardt score 8.4 ± 3.2 vs. 2.7 ± 1.9; P < 0.001), decreased lower esophageal sphincter pressure (39.4 ± 10.1 vs. 24.4 ± 9.1 mmHg; P < 0.001) and integrated relaxation pressure (38.6 ± 10.4 vs. 25.7 ± 9.6 mmHg; P < 0.01), and a drop in height of esophagus barium-contrast column (5.4 ± 3.1 vs. 2.6 ± 1.8 cm; P < 0.001) were observed. The frequencies of adverse events were lower in those under endotracheal anesthesia and CO2 insufflations compared with intravenous anesthesia and air insufflations. Only three patients were found to have gastroesophageal reflux disease on follow up. Modified POEM with shorter myotomy under endotracheal anesthesia and CO2 insufflations shows its good safety and excellent short-term efficacy in the treatment of achalasia. But further studies are warranted to assess the long-term efficacy.

Efficacy of pneumatic dilatation in Saudi achalasia patients

BACKGROUND/AIMS

Pneumatic dilatation (PD) is one of the effective treatments of achalasia. The aim of this study was to evaluate the efficacy of pneumatic dilation and patient satisfaction in Saudi achalasia patients.

PATIENTS AND METHODS

We have retrospectively recruited patients with confirmed achalasia, who underwent at least one dilatation session from January 1990 to January 2010 at a single tertiary center. Symptoms, including weight loss, dysphagia, retrosternal pain, and regurgitation, were assessed with the use of the Eckardt score (which ranges from 0 to 12, with higher scores indicating more pronounced symptoms). All patients were called and asked about their Eckardt score in addition to their satisfaction score post the dilatation procedure. The primary outcome was therapeutic success (Eckardt score≤3) and patient satisfaction at the time of their calls. The secondary outcomes included the need for retreatment and the rate of complications.

RESULTS

A total of 29 patients were included, with a mean age of 40.30 (95% CI: 36.1-44.6) and 55.2% of them were males. The mean of the pre-dilatation Eckardt score was 8.3 (95% CI: 7.2-9.4), which dropped to 2.59 (95% CI: 1.7-3.5) after PD (P<0.01) with a clinical remission of 76.7% after the first dilatation and a total failure in two patients (7%) after the third dilatation. The mean number of dilatations was 1.3 (95% CI: 1.1-1.5) where 50.7% required one dilatation, 19.2% required two dilatations, and 30.1% required three dilatations. The mean of the symptoms-free period was 53.4 months (SD 52.7, range 1-180) with symptoms recurring in 35% of patients within 2 years. The mean of post-PD patient satisfaction was 7.45 (95% CI: 6.2-8.7). Perforation, which was treated conservatively, occurred in one patient (3.5%), whereas bleeding occurred in two patients (7%). Age or gender was not found to be a predictor of Eckardt score improvement on multivariate linear regression analysis.

CONCLUSION

PD is an efficacious procedure in Saudi achalasia patients with a very good overall patient satisfaction with 53.4 months of symptoms-free period after a successful dilatation.

Anesthetic management of peroral endoscopic myotomy for esophageal achalasia: a retrospective case series

Peroral endoscopic myotomy (POEM) is a newly developed, less invasive treatment for esophageal achalasia that requires general anesthesia under positive pressure ventilation. In this retrospective case series, we describe the anesthetic management of 28 consecutive patients who underwent POEM for esophageal achalasia. Anesthesia was maintained with sevoflurane and remifentanil under positive pressure ventilation through a tracheal tube. Retained contents in the esophagus were evacuated just before anesthesia induction to prevent regurgitation into the trachea. The POEM procedure was performed using an orally inserted flexible fiberscope. Elevation of end-tidal carbon dioxide after initiating esophageal carbon dioxide insufflation was observed in all patients and was treated by minute adjustments to the ventilation volume. Scopolamine butylbromide-induced tachycardia in one patient was treated with landiolol hydrochloride, which is a short-acting beta 1-selective blocker. Minor subcutaneous emphysema around the neck was observed in one patient. POEM was successfully completed, and tracheas were extubated immediately after the procedure in all patients. Our findings suggest that prevention of aspiration pneumonia during anesthesia induction, preparation for carbon dioxide insufflation-related complications, and treatment of scopolamine butylbromide-induced tachycardia play important roles in safe anesthesia management of POEM for esophageal achalasia.

Comparison of the Heller-Toupet procedure with the Heller-Dor procedure in patients who underwent laparoscopic surgery for achalasia

PURPOSE

We compared the outcomes of Toupet fundoplication with those of Dor fundoplication in patients with achalasia who underwent laparoscopic Heller myotomy.

METHODS

Seventy-two patients with achalasia and dysphagia underwent laparoscopic Heller myotomy with fundoplication performed by a single surgeon. Heller-Toupet fundoplication (HT) was performed in 30 patients, and Heller-Dor fundoplication (HD) was done in 42. The symptoms and esophageal function were retrospectively assessed in both groups.

RESULTS

The dysphagia scores significantly decreased after both the HT and HD procedures, and did not differ significantly between them. The incidence of reflux symptoms was significantly higher after HT (26.7%) than after HD (7.1%). The lower esophageal sphincter (LES) resting pressure significantly decreased after both HT and HD. Upon endoscopic examination, the incidence of reflux esophagitis was significantly higher after HT (38.5%) than after HD (8.8%). During esophageal pH monitoring, the fraction time at pH <4 was similar in the patients who underwent HT and HD.

CONCLUSIONS

Laparoscopic Heller myotomy provided significant improvements in the dysphagia symptoms of achalasia patients, regardless of the type of fundoplication. The incidences of reflux symptoms and reflux esophagitis were higher after HT than after HD. However, the results of pH monitoring did not differ between the procedures.

Recent trends in the management of achalasia

Radical treatment for achalasia is currently unavailable. At present, most palliative procedures are designed improve the passage of food through the gastroesophageal junction and thereby alleviate symptoms. Drug therapy is of limited, transient effectiveness. Pneumatic dilation (PD) is considered superior to endoscopic botulinum toxin injection (EBTI). The mainstay of surgical treatment for achalasia is laparoscopic Heller myotomy (LHM) with fundoplication, currently considered superior to PD. Per oral endoscopic myotomy (POEM), a "state-of-the-art" procedure for minimally invasive surgery, holds great promise for the future management of achalasia. Definitive conclusions regarding the benefits and risks of currently available treatments for achalasia must await the accumulation of evidence from well-designed clinical trials.

Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia

BACKGROUND

Many experts consider laparoscopic Heller's myotomy (LHM) to be superior to pneumatic dilation for the treatment of achalasia, and LHM is increasingly considered to be the treatment of choice for this disorder.

METHODS

We randomly assigned patients with newly diagnosed achalasia to pneumatic dilation or LHM with Dor's fundoplication. Symptoms, including weight loss, dysphagia, retrosternal pain, and regurgitation, were assessed with the use of the Eckardt score (which ranges from 0 to 12, with higher scores indicating more pronounced symptoms). The primary outcome was therapeutic success (a drop in the Eckardt score to ≤3) at the yearly follow-up assessment. The secondary outcomes included the need for retreatment, pressure at the lower esophageal sphincter, esophageal emptying on a timed barium esophagogram, quality of life, and the rate of complications.

RESULTS

A total of 201 patients were randomly assigned to pneumatic dilation (95 patients) or LHM (106). The mean follow-up time was 43 months (95% confidence interval [CI], 40 to 47). In an intention-to-treat analysis, there was no significant difference between the two groups in the primary outcome; the rate of therapeutic success with pneumatic dilation was 90% after 1 year of follow-up and 86% after 2 years, as compared with a rate with LHM of 93% after 1 year and 90% after 2 years (P=0.46). After 2 years of follow-up, there was no significant between-group difference in the pressure at the lower esophageal sphincter (LHM, 10 mm Hg [95% CI, 8.7 to 12]; pneumatic dilation, 12 mm Hg [95% CI, 9.7 to 14]; P=0.27); esophageal emptying, as assessed by the height of barium-contrast column (LHM, 1.9 cm [95% CI, 0 to 6.8]; pneumatic dilation, 3.7 cm [95% CI, 0 to 8.8]; P=0.21); or quality of life. Similar results were obtained in the per-protocol analysis. Perforation of the esophagus occurred in 4% of the patients during pneumatic dilation, whereas mucosal tears occurred in 12% during LHM. Abnormal exposure to esophageal acid was observed in 15% and 23% of the patients in the pneumatic-dilation and LHM groups, respectively (P=0.28).

CONCLUSIONS

After 2 years of follow-up, LHM, as compared with pneumatic dilation, was not associated with superior rates of therapeutic success. (European Achalasia Trial Netherlands Trial Register number, NTR37, and Current Controlled Trials number, ISRCTN56304564.).

Achalasia

Achalasia is a rare motor disorder of the oesophagus, characterised by the absence of peristalsis and impaired swallow-induced relaxation. These motor abnormalities result in stasis of ingested food in the oesophagus, leading to clinical symptoms, such as dysphagia, regurgitation of food, retrosternal pain and weight loss. Although it is well demonstrated that loss of myenteric oesophageal neurons is the underlying problem, it still remains unclear why these neurons are preferentially attacked and destroyed by the immune system. This limited insight into pathophysiology explains the fact that treatment is limited to interventions aimed at reducing the pressure of the lower oesophageal sphincter. The most successful therapies are clearly pneumatic dilatation and Heller myotomy with short-term success rates of 70-90%, declining to 50-65% after more than 15 years. The challenge for the coming years will undoubtedly be to get more insight into the underlying disease mechanisms and to develop a treatment to restore function.

Management of achalasia with transabdominal esophagocardiomyotomy and partial posterior fundoplication

In this article we present our experience in the management of achalasia. From May 1988 through August 2005, 71 patients with achalasia underwent transabdominal esophagocardiomyotomy and partial posterior fundoplication. Barium swallow, manometry, and 24-h pH studies were performed in all patients preoperatively. Manometry and 24-h pH monitoring were only carried out in 58 patients at the third post-operative week and in 43 patients during follow-up, even though 52 patients were included in the follow-up. There were no operative deaths or complications. All the 71 patients were able to eat semifluid or solid food without dysphagia and heartburn at discharge. Esophageal barium studies showed that the maximum esophageal diameter decreased 2.2 cm and the minimum gastroesophageal junction diameter increased 8.4 mm after operation. Manometry examination in 58 patients revealed that the lower esophageal sphincter resting pressure decreased 15.0 mmHg in the wake of the procedure. Twenty-four hour pH monitoring demonstrated that reflux events were within the normal post-operative range. Fifty-five of the 58 patients had normal DeMeester scores. Among the patients with a mean 90-month follow-up, 49 patients had normal intake of food without reflux, the remaining three had mild dysphagia without requiring treatment. All the patients resumed their preoperative work and social activities. The manometry and 24-h pH studies in the 43 patients showed there were no significant changes between the third post-operative week and during follow-up. Transabdominal esophagocardiomyotomy and posterior partial fundoplication are able to relieve the functional outflow obstruction of the lower esophageal sphincter, obviate the rehealing of the myotomy edge and prevent gastroesophageal reflux in patients who have undergone myotomy alone.

Laparoscopic Heller myotomy with Toupet fundoplication for achalasia straightens the esophagus and relieves dysphagia

BACKGROUND

A standard procedure for the treatment of achalasia remains to be established. We assessed the usefulness of a laparoscopic Heller myotomy with a Toupet fundoplication (LHT).

METHODS

LHT was performed in 30 patients (12 men, 18 women; mean age, 41.8 y) who had esophageal achalasia with severe dysphagia. Caution was exercised when the esophagus was pulled downward and straightened. Symptoms and esophageal function were evaluated before and after surgery.

RESULTS

The esophagus was straightened surgically in 22 (88%) of 25 patients with esophageal curvature on preoperative esophagography. The dysphagia score decreased to 1.7 +/- 1.2 (mean +/- SD) points from a preoperative value of 10. The lower esophageal sphincter pressure decreased significantly. Two patients (7%) had esophageal diverticula as postoperative sequelae. Pathologic acid reflex was noted in 3 patients (12%).

CONCLUSIONS

LHT is a useful procedure for straightening the esophagus, reducing lower esophageal sphincter pressure, and relieving dysphagia in patients with achalasia.

Transthoracic Heller Myotomy for Esophageal Achalasia: Analysis of Long-Term Results

BACKGROUND

Swallowing deteriorates over time in some patients after transthoracic esophagomyotomy for achalasia. The causes of decline are poorly understood.

METHODS

We report a retrospective analysis of transthoracic esophagomyotomy for achalasia. Symptom relief, patient satisfaction, and late intervention were determined during short- and long-term follow-up. Predictors of long-term outcome were identified by logistic regression.

RESULTS

From 1962 to 1999, 64 patients underwent transthoracic esophagomyotomy. Five patients had repeat myotomy. Sigmoid esophagus was present in 12 (18%). Fundoplication was absent in 50 patients (myotomy only) and added in 15 (myotomy plus fundoplication). Follow-up was complete in 86% (56 of 65); mean follow-up was 154 months. Thirty-one patients (48%) were followed for more than 10 years. Short-term results were good to excellent in 91% (51 of 56) and long-term in 63% (33 of 52; p < 0.0005). Late peptic stricture occurred in 4 patients (myotomy only, 2 of 38 [5%]; myotomy plus fundoplication, 2 of 14 [14%]). Fewer patients had reflux symptoms after fundoplication (myotomy only, 16 of 38 [42%]; myotomy plus fundoplication, 4 of 14 [29%]), whereas late dysphagia was not reduced (myotomy only, 13 of 38 [34%]; myotomy plus fundoplication, 5 of 14 [36%]). Two patients after myotomy plus fundoplication and 1 after myotomy only had esophagectomy. Early recurrence of symptoms predicted late poor outcome (p < 0.001), whereas sigmoid esophagus, fundoplication, or early postoperative reflux did not.

CONCLUSIONS

Early good results after esophagomyotomy for achalasia deteriorate over time. Recurring dysphagia early after operation predicts late failure, while sigmoid esophagus does not. Fundoplication reduces reflux symptoms, but not late poor results. These data should be considered in the evaluation of newer, minimally invasive procedures.

Laparoscopic Heller myotomy for classic achalasia: results of our initial series of 20 patients

BACKGROUND

The aim of this study was to review our results in the surgical management of achalasia by laparoscopic esophageal cardiomyotomy and partial fundoplication.

METHODS

The patient population was comprised of a consecutive series of 20 patients with classic achalasia who underwent laparoscopic cardiomyotomy and partial fundoplication. Clinical, radiological, and physiological characteristics were analyzed prospectively, with an emphasis on the outcome and complications.

RESULTS

There were 12 women and eight men; their mean age was 37 years. Four intraoperative complications occurred-two mucosal perforations that were resolved laparoscopically and two cases of pneumothorax. The median hospital stay was 4 days (range, 2-14) and the median time to start oral feeding was 3 days (range, 1-7). After a median follow-up of 14 months (range, 2-83), 16 patients were asymptomatic and four had mild heartburn and/or dysphagia. All patients gained weight (median, 8.0 kg; range, 1-23). We observed a median postoperative decrease in esophageal diameter of 1.6 cm (range, 0.2-2.9). Fifteen patients were subjected to physiological esophageal studies; the results showed that power esophageal sphincter pressure had decreased from 32 (range, 15-60) to 12 mmHg (range, 6-25). The median DeMeester score was 14.5 (range, 0.9-194). The median esophageal acid exposure was 3% (range 0-34.6).

CONCLUSIONS

Our initial experience with the laparoscopic management of classic achalasia yielded satisfactory clinical, radiological, and physiological results.

Objective analysis of gastroesophageal reflux after laparoscopic heller myotomy: an anti-reflux procedure is required

BACKGROUND

Controversy exists over the necessity of performing a concurrent antireflux procedure with a Heller myotomy. We therefore sought to objectively analyze gastroesophageal reflux following laparoscopic Heller myotomy where an antireflux procedure was not performed.

METHODS

A prospective database of 66 cases of laparoscopic Heller myotomy performed between November 1996 and June 2002 was reviewed. Previous, concurrent, or subsequent fundoplication was performed in 12 patients; therefore 54 patients without antireflux procedures were available for analysis. Follow-up included symptomatic assessment in 50 patients (93%). Heartburn was assessed on a four-point scale with clinical significance defined as >2 episodes/week. Objective testing, including endoscopy, esophagogram, manometry, and 24-h pH monitoring, was offered to all patients. Objective evidence of reflux was defined as the composite endpoint of positive 24-h pH monitoring or esophagitis on endoscopy.

RESULTS

Significant heartburn was reported in 15 of 50 patients (30%). Positive 24-h pH recordings were seen in 11 of 22 patients tested while esophagitis was seen in 13 of 21 patients tested, resulting in objective evidence of reflux in 18 of 30 patients tested (60%). Of these 18 patients, seven did not have significant heartburn. All 12 patients without objective reflux did not have significant heartburn. Therefore, of the 30 patients with objective testing, seven (23%) had objective reflux without subjective heartburn (silent reflux).

CONCLUSION

Objective analysis reveals an unacceptable rate of gastroesophageal reflux in laparoscopic Heller myotomy without an antireflux procedure. We therefore recommend performing a concurrent antireflux procedure.

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

Heller's esophagomyotomy relieves dysphagia but does not restore esophageal peristalsis. The myotomy may induce reflux and the addition of a 360 degrees fundoplication may be hazardous with regard to the remaining aperistaltic esophagus. The aim of this prospectively randomized clinical trial was to compare the outcome for patients with uncomplicated achalasia who underwent an anterior Heller's esophagomyotomy (H group) with or without an additional floppy Nissen fundoplication (H + N group). Between 1984 and 1995, 20 patients were prospectively randomized to one or other of the performed operations, 10 patients per group. Esophagitis including Barrett's esophagus (n = 2) was seen under medical treatment, in 6 of 9 in the H group but none in the H + N group. No patient in the H + N group required postoperative continuous acid-reducing drugs. Twenty-four-hour esophageal pH-studies in median 3.4 years after surgery showed pathological reflux expressed as a percentage of time below pH 4 of 13.1% in the H group compared to 0.15% (P < 0.001) in H + N group. One patient with recurrent dysphagia in the H + N group later had an esophagectomy. The remaining patients reported significant improvement of dysphagia without symptoms of reflux at 8.0 years follow-up. Heller's esophagomyotomy eliminates dysphagia, but can induce advanced reflux that requires medical treatment. The addition of a 360 degrees fundoplication eliminates reflux without adding dysphagia in the majority of patients and can be recommended for most patients with uncomplicated achalasia.

Intrasphincteric botulinum toxin injection in the treatment of chagasic achalasia

According to the WHO, 16-18 million people in Central and South America are infected by Trypanosoma cruzi. Chagasic achalasia affects between 7.1% and 10.6% of the population. The aim of this study was to evaluate the effects of Botox injections in the clinical response and esophageal function of patients with dysphagia due to chagasic achalasia. In total, 24 symptomatic patients with chagasic achalasia were randomly chosen to receive Botulinum Toxin (BT) or saline injected by endoscopy in the lower esophageal sphincter (LES). Patients were monitored with a clinical score of dysphagia and an objective assessment (esophagograms, scintillography, manometry, and nutritional assessment) for a period of 6 months. Clinical improvement of dysphagia was statistically significant (P < 0.001) in patients receiving BT when compared with the placebo. There was no significant difference in the placebo group regarding clinical score, LES basal pressure and esophageal emptying time. Esophageal emptying time in the toxin group was significantly lower than in the placebo (P=0.04) after 90 days. There were non-significant increases in esophageal emptying of 25.36% and 17.39%, respectively, at 90 and 180 days, in the BT group (P=0.266). Gender, age, and baseline LES pressure did not influence the response to BT. Our data strongly suggests that intrasphincteric injection of BT in LES is clinically effective in the treatment of chagasic achalasia.

Achalasia: a comprehensive review

Achalasia is a rare neurologic deficit of the esophagus, producing a syndrome of impaired relaxation of the lower esophageal sphincter and decreased motility of the esophageal body for which the cause is unknown. The resultant chronic esophageal stasis produces discomforting symptoms that can be managed with medication, chemical paralysis of the lower esophageal sphincter, mechanical dilation, or surgical esophagomyotomy. Chemical paralysis by injection of the esophagus with botulinum toxin and dilation with an inflatable balloon offers good short-term relief of symptoms; however, the best long-term results are produced by surgery, and advancing minimally invasive techniques continually reduce the morbidity of these operations. The type of surgical procedure, the necessity for fundoplication, and the order of treatment continue to be unresolved issues, but prospective evaluation with objective followup should allow us to provide the optimal treatment regimen to our patients.

Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change

BACKGROUND

Twenty years ago an average of 1.5 Heller myotomies were performed per year in our hospital, mostly for patients whose dysphagia did not improve following balloon dilatation or whose esophagus had been perforated during a balloon dilatation. Ten years ago we started using minimally invasive surgery to treat this disease.

STUDY DESIGN

This study measures the impact of minimally invasive surgery with regard to the following: the number of patients referred for treatment; the number of patients who came to surgery without previous treatment; and the results of surgical treatment. Between 1991 and 2001, 149 patients had minimally invasive surgery for achalasia: 25 patients (17%) had thoracoscopic Heller myotomy and 124 (84%) had laparoscopic Heller myotomy and Dor fundoplication. Of the 149 patients, 79 patients (53%) had previous treatment (56 patients [71%], balloon dilatation; 7 patients [9%], botulinum toxin injection; 16 patients [20%], both) and 70 patients (43%) had none of these treatments. Mean postoperative followup was 59 +/- 36 months. Patients were divided into two groups: group A, operated on between 1991 and 1995; and group B, operated on between 1996 and 2001.

RESULTS

In the past decade, the number of patients referred for surgery has increased substantially--group A, 48; group B, 101; an increasing proportion of patients were referred for surgery without previous treatment--group A, 38%; group B, 51%; and the outcomes of the operation progressively improved--group A, 87%; group B, 95%.

CONCLUSIONS

These data show that the high success rate of laparoscopic Heller myotomy for achalasia has brought a shift in practice; surgery has become the preferred treatment of most gastroenterologists and other referring physicians. This has followed documentation that laparoscopic treatment outperforms balloon dilatation and botulinum toxin injection.

100 consecutive minimally invasive Heller myotomies: lessons learned

OBJECTIVE

To evaluate the authors' first 100 patients treated for achalasia by a minimally invasive approach.

METHODS

Between November 1992 and February 2001, the authors performed 95 laparoscopic and 5 thoracoscopic Heller myotomies in 100 patients (age 49.5 +/- 1.5 years) with manometrically confirmed achalasia. Before presentation, 51 patients had previous dilation, 23 had been treated with botulinum toxin (Botox), and 4 had undergone prior myotomy. Laparoscopic myotomy was performed by incising the distal 4 to 6 cm of esophageal musculature and extended 1 to 2 cm onto the cardia under endoscopic guidance. Fifteen patients underwent antireflux procedures.

RESULTS

There were eight intraoperative perforations and only four conversions to open surgery. Follow-up is 10.8 +/- 1 months; 75% of the patients have been followed up for at least 14 months. Outcomes assessed by patient questionnaires revealed satisfactory relief of dysphagia in 93 patients and "poor" relief in 7 patients. Postoperative heartburn symptoms were reported as "moderate to severe" in 14 patients and "none or mild" in 86 patients. Fourteen patients required postoperative procedures for continued symptoms of dysphagia after myotomy. Esophageal manometry studies revealed a decrease in lower esophageal sphincter pressure (LESP) from 37 +/- 1 mm Hg to 14 +/- 1 mm Hg. Patients with a decrease in LESP of more than 18 mm Hg and whose absolute postoperative LESP was 18 or less were more likely to have relief of dysphagia after surgery. Thirty-one patients who underwent Heller alone were studied with a 24-hour esophageal pH probe and had a median Johnson-DeMeester score of 10 (normal <22.0). Mean esophageal acid exposure time was 3 +/- 0.6% (normal 4.2%). Symptoms did not correlate with esophageal acid exposure.

CONCLUSIONS

The results after minimally invasive treatment for achalasia are equivalent to historical outcomes with open techniques. Satisfactory outcomes occurred in 93% of patients. Patients whose postoperative LESP was less than 18 mm Hg reported the fewest symptoms. After myotomy, patients rarely have abnormal esophageal acid exposure, and the addition of an antireflux procedure is not required.

Late results on the surgical treatment of Chagasic megaesophagus with the Thal-Hatafuku procedure

BACKGROUND

Chagas' disease has a wide distribution in Central and South America. It is endemic in 21 countries, with 16 to 18 million persons infected and 100 million at risk. Surgical treatment of achalasia from Chagas' disease is the first choice in advanced stages. The aim of this study was to analyze the late clinical followup of 50 patients operated on for Chagas megaesophagus with the Thal-Harafuku procedure.

STUDY DESIGN

During the period of January 1966 to January 1993, 50 patients suffering from advanced achalasia from Chagas' disease were submitted to the Thal-Hatafuku procedure. The patients answered a questionnaire concerning the most relevant postoperative symptoms. The Thal-Hatafuku procedure was performed as the first surgical option (46 patients), and on reoperations because of failure of other surgical techniques (4 patients).

RESULTS

The mean followup was 63.11 months for the 44 patients with longterm followup. Postoperative complications included surgical site infection (3 of 50 patients), urinary infections (3 of 50 patients), atelectasis (2 of 50 patients), pleural effusion (2 of 50 patients), and deep venous thrombosis (1 of 50 patients). The main symptoms found in the postoperative period were dysphagia (20 of 44 patients), heartburn (11 of 44 patients), vomiting (13 of 44 patients), and retrosternal pain (6 of 44 patients). Eleven patients of the 44 remained asymptomatic at the end of the followup period. Outcomes were analyzed according to the modified Visick classification. Visick classes I and II represented 25% and 27.3%, respectively. Eighteen patients (40.9%) were classified as Visick III.

CONCLUSION

We conclude that the Thal-Hatafuku operation is a therapeutic option that should be considered in the treatment of achalasia of the esophagus secondary to Chagas' disease, in advanced cases.

The use of endoscopy in patients with gastrointestinal motility problems

Gastrointestinal motility disorders are a commonly encountered problem. Although some are associated with organic alterations, others are defined by their symptoms, and no anatomic or histologic organic changes are to be found. In most cases, the etiology is completely unclear. Endoscopy, with the option of obtaining biopsies for histopathologic evaluation, plays the most important role in the diagnostic workup, as it can exclude such lesions as tumors, ulcers, inflammatory processes, and diverticula and it helps to define the grade and extent of motility-associated diseases (e.g., GERD). Furthermore, endoscopic interventional procedures offer sufficient treatment of several motility-related disorders (e.g., achalasia, GERD, its associated diseases, secondary constipation).

Evaluation of minimally invasive approaches to achalasia in children

BACKGROUND

Achalasia is an uncommon disease in children, but when present can result in severe disabling symptoms often requiring surgical intervention. This report describes the authors' experience with thoracoscopic (TH) and later laparoscopic Heller (LH) myotomy for definitive treatment of this disease.

METHODS

Nine patients with achalasia were referred for surgical therapy. Ages ranged from 5 to 17 years and weight from 23 to 78 kg. All had undergone at least one dilatation with recurrence of symptoms. The first 4 were treated by TH and the last five by LH. The 5 LH procedures also included a partial fundoplication.

RESULTS

All procedures were completed successfully using minimally invasive techniques. Operating times averaged 95 minutes for TH and 62 minutes for LH. One patient undergoing TH had a small esophageal perforation repaired primarily. The other 3 TH patients were started on clear liquids within 1 day and discharged on day 2. One patient had recurrent symptoms at 6 months and underwent a LH for an incomplete TH. All 5 LH patients were discharged on postoperative day 1. One had an esophageal perforation 4 days after operation requiring laparoscopic repair. Seven of 9 patients are asymptomatic. Studies of pH levels in 2 asymptomatic TH patients show mild gastroesophageal reflux (GER).

CONCLUSIONS

Minimally invasive Heller myotomy is a safe and effective procedure in children. TH results in a slightly longer operating time and hospital stay and, without a partial fundoplication, also may be associated with a higher incidence of silent GER. From these results, we prefer LH with a Dor fundoplication for treatment of achalasia in children.

Evaluation of the use of botulinum toxin in children with achalasia

BACKGROUND

Achalasia is rare in children. Recently, injection of botulinum toxin into the lower esophageal sphincter has been studied as an alternative to esophageal pneumatic dilatation or surgical myotomy as treatment for achalasia. In the current study, the effects of botulinum toxin were investigated in the largest known series of children with achalasia.

METHODS

Treatment for achalasia was assessed in 23 pediatric patients who received botulinum toxin from June 1995 through November 1998. Those who continued to receive botulinum toxin and did not subsequently undergo pneumatic dilatation or surgery were considered repeat responders. Results were compared with those of published studies evaluating the use of botulinum toxin in adults with achalasia.

RESULTS

Nineteen patients initially responded to botulinum toxin. Mean duration of effect was 4.2 months +/- 4.0 (SD). At the end of the study period, three were repeat responders, three experienced dysphagia but did not receive pneumatic dilatation or surgery, three underwent pneumatic dilatation, eight underwent surgery, three underwent pneumatic dilatation with subsequent surgery, and three awaited surgery. Meta-analysis shows that, in the current study group, the data point expressing time of follow-up evaluation versus percentage of patients needing one injection session without additional procedures (botulinum toxin injection, pneumatic dilatation, or surgery) falls within the curve for those in studies on adult patients receiving botulinum toxin for achalasia.

CONCLUSIONS

Botulinum toxin effectively initiates the resolution of symptoms associated with achalasia in children. However, one half of patients are expected to need an additional procedure approximately 7 months after one injection session. The authors recommend that botulinum toxin be used only for children with achalasia who are poor candidates for either pneumatic dilatation or surgery.

Video-assisted surgical management of achalasia of the esophagus

PURPOSE

Video-assisted surgical approaches to esophageal achalasia continue to be explored by many surgeons involved in the management of this motor disorder. We report our experience with thoracoscopic and laparoscopic esophagomyotomy to more clearly define the efficacy and safety of these approaches.

PATIENTS

Over 73 months, 58 patients with achalasia underwent thoracoscopic myotomy (n = 19) alone or laparoscopic myotomy (n = 39) with partial fundoplication (anterior = 15; posterior = 24). Mean age was 47.2 years and average length of symptoms was 60 months. Primary symptoms were as follows: dysphagia, 100%; pulmonary abnormalities, 22%; weight loss; 47%, and pain, 45%. Mean esophageal diameter was 6 cm and tortuosity was present in 16% (9/58) of patients. Prior management consisted of dilation (n = 47), botulinum toxin injection (n = 8), and prior myotomy (n = 1).

METHODS

In the operating room all patients underwent endoscopic examination and evacuation of retained esophageal contents. The esophagomyotomy was extended 4 cm superiorly and inferiorly to 1 cm beyond the lower esophageal sphincter. Thoracoscopic and laparoscopic procedures were completed in all patients without conversion to an open operation. Mean operative time was 183 minutes (+/-58.1) and hospital stay averaged 2.3 days (+/-0.8). There was no operative mortality. The 1 operative complication was a perforation that was identified during the operation and repaired thoracoscopically.

RESULTS

Symptoms improved in 97% of patients. Mean dysphagia scores (range 0-10) decreased from 9.8 +/- 1.6 before the operation to 2.0 +/- 1.5 after the operation (P <.001) at a mean follow-up of 6 months. Postoperative reflux symptoms developed in 5% (1/19) of the thoracoscopy group and 8% (4/39) of the laparoscopy group. Nine patients have persistent or recurrent dysphagia (16%). Seven patients have successfully undergone Savary dilation, and 2 required esophagectomy to manage recalcitrant dysphagia.

CONCLUSION

At this intermediate term analysis, video-assisted approaches for management of achalasia are a reasonable alternative to extended medical therapy or open operations.

Treatment of achalasia: recent advances in surgery

Achalasia is an uncommon motility disorder of the esophagus with an uncertain etiology. Considerable debate exists regarding the most effective treatment for long-term relief of symptoms. For decades, pneumatic dilatation has been the primary treatment option, and surgery was reserved for patients who required repeated dilations or for those who were not willing to undergo the risk of perforation associated with dilatation. Recently botulinum toxin injection of the lower esophageal sphincter has been shown to provide substantial short-term relief from dysphagia; however, its effect only lasts for a short period of time. Recently, minimally invasive surgical techniques have been developed to perform a Heller myotomy effectively with an antireflux procedure. This has become a primary treatment option for many patients. We present a review of the outcome of different therapeutic options of achalasia with a special focus on laparoscopic procedures.

Thoracoscopic Hellers myotomy for oesophageal achalasia

Surgical myotomy is the mainstay of treatment for oesophageal achalasia. Minimally invasive surgical techniques, if feasible, reduce patient morbidity and mortality. In this study we review our experience of thoracoscopic Heller's myotomy. Thoracoscopic myotomy was undertaken in 9 patients (male = 3; female = 6, mean age = 37). All patients presented with dysphagia of 1 to 8 yr duration. Diagnosis was based on barium swallow and manometry. Two patients had previous dilatations and 1 had a transabdominal myotomy. All patients had a 5 port thoracoscopic technique. Thoracoscopic Heller's myotomy was completed in 8 out of 9 patients. In 1 patient extensive oesophagitis and peri-oesophagitis precluded both a thoracoscopic and an open myotomy, and oesophagectomy was subsequently performed. The mean duration of surgery was 142 min. Completion of myotomy and mucosal integrity was confirmed by intraoperative gastroscopy. All patients had an uneventful post-operative recovery. The mean hospital stay was 4 days. All patients are now asymptomatic, with documented weight gain. No patients have reflux oesophagitis symptoms. Our preliminary experience would suggest that thoracoscopic Heller's myotomy is a safe alternative to open surgery, with satisfactory results and reduced hospital stay.

Laparoscopic esophagomyotomy without an antireflux procedure for the treatment of achalasia

Various gastroenteric surgical procedures have been attempted laparoscopically. Laparoscopic esophagomyotomy (LE) with or without fundoplication, performed for achalasia, has gained popularity. In our clinic, LE (Heller's myotomy) was performed on six patients with achalasia. All patients underwent barium esophagography, endoscopy, and esophageal manometry for diagnosis. Extramucosal myotomy was started 6 cm above the cardioesophageal junction on the left anterolateral aspect of the esophagus and continued 1 cm below this area. Endoscopic control of the distal esophageal mucosa and the stomach was carried out under direct laparoscopic visualization following the completion of myotomy during the operation. LE was completed without complication in five patients. In one patient (16%), mucosal perforation occurred after myotomy during endoscopic control and was repaired with endostitches. There were no postoperative complications. The average hospital stay was 3 days. Three of the six patients agreed to 24-h pH monitoring, the results of which showed no evidence of reflux. All patients were completely symptom free in the postoperative period. The average preoperative lower esophageal sphincter pressure was 44 mm Hg, whereas in the early postoperative period and 6 months later, it was 11 mm Hg. There was no dysphagia or reflux esophagitis during the follow-up period (range 12 to 24 months). LE is associated with low morbidity and a high success rate, comparable with an open procedure, and can be done without an antireflux procedure.

Importance of preoperative and postoperative pH monitoring in patients with esophageal achalasia

Gastroesophageal reflux (GER) can develop in patients with esophageal achalasia either before treatment or following pneumatic dilatation or Heller myotomy. In this study we assessed the value of pre- and postoperative pH monitoring in identifying GER in patients with esophageal achalasia. Ambulatory pH monitoring was performed preoperatively in 40 patients with achalasia (18 untreated patients and 22 patients after pneumatic dilatation), 27 (68%) of whom complained of heartburn in addition to dysphagia (group A), and postoperatively in 18 of 51 patients who underwent a thoracoscopic (n=30) or laparoscopic (n=21) Heller myotomy (group B). The DeMeester reflux score was abnormal in 14 patients in group A, 13 of whom had been treated previously by pneumatic dilatation. Two types of pH tracings were seen: (1) GER in eight patients (7 of whom had undergone dilatation) and (2) pseudo-GER in six patients (all 6 of whom had undergone dilatation). Therefore 7 (32%) of 22 patients had abnormal GER after pneumatic dilatation. Postoperatively (group B) seven patients had abnormal GER (6 after thoracoscopic and 1 after laparoscopic myotomy). Six of the seven patients were asymptomatic. These findings show that (1) approximately one third of patients treated by pneumatic dilatation had GER; (2) symptoms were an unreliable index of the presence of abnormal GER, so pH monitoring must be performed in order to make this diagnosis; and (3) the preoperative detection of GER in patients with achalasia is important because it influences the choice of operation.

Surgical management of achalasia

Although achalasia is not a common illness in the United States and Europe, there continues to be a need for surgical therapy for treatment. Laparoscopic Heller myotomy and partial fundoplication has, for the most part, replaced open surgery (abdominal or thoracic) as the surgical treatment of choice. In order to perform this procedure well, one must select patients carefully, evaluate them fully, and adhere to the technical principles required to achieve consistently good results.

Laparoscopic esophageal myotomy and anterior partial fundoplication for the treatment of achalasia

BACKGROUND

The purpose of this study was to determine the initial results of laparoscopic esophageal myotomy and anterior fundoplication in the treatment of 26 patients with achalasia.

METHODS

Operative time, complications, and length of hospitalization were recorded for each patient. Postoperative outcomes were assessed by a standardized patient questionnaire, 24-hour esophageal pH studies, and esophageal transit studies.

RESULTS

Twenty-six consecutive patients with class IV dysphagia underwent a laparoscopic esophageal myotomy and anterior partial fundoplication, with a single incidence of intraoperative esophageal perforation. The mean operative time was 3.5 hours. The median length of hospitalization was 5 days. Of the 21 patients for whom follow-up was available (median follow-up, 4 months), 19 (90%) were satisfied and 2 (10%) were somewhat satisfied with their surgery. After operation, 14 of the 21 patients (67%) reported no dysphagia (class I), whereas 6 (28%) had class II dysphagia (less than once per week) and only 1 (5%) had class III dysphagia (greater than once per week). Liquid-phase esophageal transit studies (n = 14) revealed a significant improvement in esophageal clearance in the supine position from 18% before operation to 44% after operation (p = 0.006). Distal esophageal acid exposure was normal in 6 of 7 patients.

CONCLUSIONS

These early results suggest that laparoscopic esophageal myotomy and anterior partial fundoplication provides efficacious treatment of achalasia.

Laparoscopic Heller myotomy and fundoplication for achalasia

OBJECTIVE

The goal of this study was to review the authors' results with laparoscopic cardiomyotomy and partial fundoplication for achalasia.

SUMMARY BACKGROUND DATA

Pneumatic dilatation and botulinum toxin (BOTOX) injection of the lower esophageal sphincter largely have replaced cardiomyotomy for treatment of achalasia. After a brief experience with a thoracoscopic approach, the authors elected to perform cardiomyotomy laparoscopically, in combination with a partial fundoplication (anterior or posterior).

PATIENTS AND METHODS

Forty patients were treated between July 1992 and November 1996. Thirty patients had previous therapy of achalasia, 21 with pneumatic dilation, 1 with BOTOX, 6 with balloon and BOTOX, and 2 with transthoracic cardiomyotomy. Three patients had previous laparoscopic fundoplication for gastroesophageal reflux. Symptom scores (0 = none to 4 = disabling) were obtained before surgery and after surgery. Barium swallows and esophagogastroduodenoscopy were performed in all patients. Esophageal motility study was performed in 36 patients. Laparoscopic Heller myotomy and fundoplication was performed through five upper abdominal trocars. A 7-cm myotomy extended 6 cm above the GE junction and 1 cm below the GE junction. A posterior fundoplication was performed in 32 patients, anterior fundoplication in 7 patients, and no fundoplication in 1 patient. Statistical inference was performed with a Wilcoxon signed rank test.

RESULTS

Mean operative duration was 199 +/- 36.2 minutes. Mean hospital stay was 2.75 days (range, 1-13 days). Dysphagia was alleviated in all but four patients (90%), and regurgitation in all but two patients (95%) (p < 0.001). Chest pain and heartburn improved significantly (p < 0.01) as well. Intraoperative complications included mucosal laceration in six patients and hypercarbia in one. Postoperative pneumonia developed in two patients, and one patient had moderate hemorrhage from an esophageal ulcer 2 weeks after surgery.

CONCLUSIONS

Laparoscopic cardiomyotomy and fundoplication appears to provide definitive treatment of achalasia with rapid rehabilitation and few complications.

Minimally invasive surgery of the esophagus and stomach

BACKGROUND

Minimally invasive surgery has assumed an ever-expanding role in gastrointestinal surgery since the introduction of laparoscopic cholecystectomy. This review describes some of the more common minimally invasive procedures of the esophagus and stomach, with particular attention to technique.

DATA SOURCES

A literature review of minimally invasive surgery of the esophagus and stomach was conducted.

CONCLUSIONS

Laparoscopic (and thoracoscopic) approaches for gastroesophageal reflux disease appear to have excellent operative and short-term follow-up results. Long-term follow-up data, however, remain unobtainable for several more years. Limited reports of esophageal cardiomyotomy, paraesophageal hernia repair, and gastric surgery for peptic ulcer disease performed through a minimally invasive approach are encouraging. Experience with resection of esophageal and gastric neoplasia is limited to a few specialized centers. Results should be scrutinized and compared with open operation before proclaiming the benefits of a minimally invasive approach.