Long-term symptom relief and patient satisfaction after Heller myotomy and Toupet fundoplication for achalasia

Per-oral endoscopic myotomy versus laparoscopic Heller's myotomy plus Dor fundoplication in patients with idiopathic achalasia: 5-year follow-up of a multicentre, randomised, open-label, non-inferiority trial

BACKGROUND

In this trial, we previously showed per-oral endoscopic myotomy (POEM) to be non-inferior to laparoscopic Heller's myotomy (LHM) plus Dor fundoplication in managing symptoms in patients with idiopathic achalasia 2 years post-procedure. However, post-procedural gastro-oesophageal reflux was more common after POEM at 2 years. Here we report 5-year follow-up data.

METHODS

This study is a multicentre, randomised, open-label, non-inferiority trial performed at eight centres in six European countries (Germany, Italy, Czech Republic, Sweden, the Netherlands, and Belgium). Patients with symptomatic primary achalasia were eligible for inclusion if they were older than 18 years and had an Eckardt symptom score higher than 3. Patients were randomly assigned (1:1; randomly permuted blocks of sizes 4, 8, or 12) to undergo either POEM or LHM plus Dor fundoplication. The primary endpoint was clinical success, defined by an Eckardt symptom score of 3 or less without the use of additional treatments, at 2 years, and was reported previously. Prespecified secondary endpoints at 5 years were clinical success; Eckardt symptom score; Gastrointestinal Quality of Life Index score; lower oesophageal sphincter function by high-resolution manometry; and parameters of post-procedural reflux (reflux oesophagitis according to the Los Angeles classification; pH-metry, and DeMeester clinical score). We hypothesised that POEM would be non-inferior (with a non-inferiority margin of -12·5 percentage points) to LHM plus Dor fundoplication with regards to clinical success. All analyses were performed on a modified intention-to-treat (mITT) population, which included all patients who underwent the assigned procedure. This study is registered with ClinicalTrials.gov (NCT01601678) and is complete.

FINDINGS

Between Dec 7, 2012, and Oct 9, 2015, 241 patients were randomly assigned (120 to POEM and 121 to LHM) and 221 had the assigned treatment (112 POEM and 109 LHM; mITT). 5-year follow up data were available for 90 (80%) patients in the POEM group and 87 (80%) patients in the LHM group. Clinical success rate at 5 years was 75·0% (95% CI 66·2 to 82·1) after POEM and 70·8% (61·7 to 78·5) after LHM (difference 4·2 percentage points [95% CI -7·4 to 15·7]). The mean Eckardt symptom score decreased from baseline to 5 years in both groups and the overall difference in mean scores was -0·29 (95% CI -0·62 to 0·05). Change in Gastrointestinal Quality of Life Index scores, as well as in integrated relaxation pressure on manometry, from baseline to 5 years, did not differ significantly between the groups. At 5 years, 26 (41%) of 63 patients after POEM and 18 (31%) of 58 patients after LHM had reflux oesophagitis (difference 10·2 percentage points [95% CI -7·0 to 26·8]). Significant oesophagitis (Los Angeles classification grade B, C, or D) was observed in nine (14%) of 63 patients after POEM and in four (7%) of 58 patients after LHM. pH-metry was performed in 81 (37%) of 221 patients, with higher mean acid exposure time for POEM (10·2% [95% CI 7·6 to 14·2]) than for LHM (5·5% [3·1 to 11·8]). Significantly more patients in the POEM than in the LHM group had abnormal acid exposure time at 5 years (>4·5%; 28 [62%] of 45 vs 11 [31%] of 36; difference 31·7 percentage points [95% CI 9·8 to 50·5]). The presence of reflux symptoms at 5 years was similar in both groups, with a mean DeMeester clinical score of 1·3 (95% CI 1·0 to 1·6) after POEM and 1·1 (0·9 to 1·4) after LHM. The complications of peptic stricture, Barrett's oesophagus, and oesophageal adenocarcinoma were not reported.

INTERPRETATION

Our long-term results support the role of POEM as a less invasive myotomy approach that is non-inferior to LHM in controlling symptoms of achalasia. Gastro-oesophageal reflux was common in both groups, but with a tendency towards higher rates in the POEM group. Thus, patients should be provided with the advantages and disadvantages of each approach in decision making.

FUNDING

European Clinical Research Infrastructure Network, Hamburgische Stiftung für Wissenschaften, Entwicklung und Kultur Helmut und Hannelore Greve, Dr med Carl-August Skröder Stiftung, Dr Gerhard Büchtemann Stiftung, Agnes-Graefe Stiftung, Georg und Jürgen Rickertsen Stiftung, Reinhard Frank Stiftung, Johann Max Böttcher Stiftung, Richard und Annemarie Wolf Stiftung, Olympus Europa, German Society for Gastroenterology and Metabolism and Olympus Europe Foundation, United European Gastroenterology Week, Olympus EuroNOTES Research Fund Program, Harvard Catalyst, the Harvard Clinical and Translational Science Center, and Harvard University and its affiliated academic health-care centres.

Long-term outcomes of treatment for achalasia: Laparoscopic Heller myotomy versus POEM

Achalasia is a rare esophageal motility disorder characterized by nonrelaxation of the lower esophageal sphincter. Laparoscopic Heller myotomy (LHM) is the gold standard treatment for achalasia. Peroral endoscopic myotomy (POEM), a less invasive treatment, is performed extensively, and the selection of the intervention method remains debatable to date. In addition to the availability of extensive studies on short-term outcomes, recent studies on the long-term outcomes of LHM and POEM have shown similar clinical success after 5 y of follow-up. However, gastroesophageal reflux disease (GERD) was more common in patients who had undergone POEM than in those who had undergone LHM. Moreover, existing studies have compared treatment outcomes in various disease states. Some studies have suggested that POEM is superior to LHM for patients with type III achalasia because POEM allows for a longer myotomy. Research on treatment for sigmoid types is currently in progress. However, the long-term results comparing LHD and POEM are insufficient, and the best treatment remains controversial. Further research is needed, and treatment options should be discussed with patients and tailored to their individual needs and pathologies.

Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality?

Peroral endoscopic myotomy (POEM) is an accepted treatment for achalasia cardia (AC), and results are comparable to those of laparoscopic Heller myotomy (LHM). In recent years, several reports have confirmed higher incidence of gastroesophageal reflux (GER) following POEM. This review evaluates the current evidence regarding post-POEM GER, critically examines the potential contributing factors responsible for GER, limitations of the current available functional testing, and precautions and preventive measures, and provides future directions for research. Factors conclusively contributing to increased post-POEM GER include injury to the sling fibers of the lower esophageal sphincter, length of gastric myotomy > 2 cm, and others. Historically, these same factors have been implicated for development of GER after surgical (laparoscopic) myotomy. Although less invasive, optimal technique of POEM may be important to control post-POEM GER. Most post-POEM GER occurs during the immediate post-POEM period, is mild, and is easily treatable using proton-pump inhibitors. GER incidence plateaus at 2 years and is comparable to that after LHM. Patients should therefore be prescribed proton-pump inhibitors for at least 2 years. Antireflux procedures (ARPs) are infrequently required in these patients as the incidence of refractory GER is low. Novel ARPs have been recently described and are currently under evaluation. Conclusive diagnosis of GER is a clinical challenge. Most patients are asymptomatic, and GER is diagnosed only on abnormal esophageal acid exposure (EAE). Studies have demonstrated that current measures to diagnose GER are inadequate, inaccurate, and cannot differentiate between true GER and abnormal EAE due to food fermentation in the distal esophagus. The Lyon Consensus criteria should be implemented for confirmation of diagnosis of GER. Finally, the review recommends an evidence-based clinical algorithm for evaluation and management of post-POEM GER and provides guidelines for future research in this field.

Long-term (17 years) subjective and objective evaluation of the durability of laparoscopic Heller esophagomyotomy in patients with achalasia of the esophagus (90% of follow-up): a real challenge to POEM

INTRODUCTION

Laparoscopic Heller Myotomy (LHM) with partial anterior or posterior fundoplication is the standard surgical procedure for treating achalasia patients. The results reported are mainly based on symptomatic evaluations and have less than 5 years of follow-up and none more than ten.

OBJECTIVE

To determine the late results of LHM, performing endoscopic, histologic, manometric, and functional studies in addition to clinical evaluations.

MATERIALS AND METHODS

Eighty-nine consecutive patients were included in a prospective study from 1993 to 2008. Inclusion criteria corresponded to achalasia patients with Types I to III (radiological evaluation). Exclusion criteria included patients with grade IV, patients with previous procedures (surgical or endoscopic), or giant hiatal hernia. They were submitted to a radiological evaluation, over two endoscopic procedures with biopsy samples, manometric assessments, and 24-h pH monitoring late after surgery.

RESULTS

There was no operative mortality nor postoperative complications. The average hospital stay was two days. Nine patients (10.1%) were lost from follow-up. The mean late follow-up was 17 years (10-26). Visick I and II (success) corresponded to 78.7% of patients and grades III-IV (failure) to 21.3%, mainly due to gastroesophageal reflux disease (GERD). Manometric evaluations showed a significant and permanent decrease in lower esophageal sphincter pressure (LESP). 24-h pH monitoring was normal among Visick I patients and showed pathologic acid reflux in patients with GERD. Two patients (2.5%) developed Barrett's esophagus. Squamous-cell carcinoma (SCC) appeared in three patients (3.7%).

CONCLUSION

LHM controlled symptoms in 79% of achalasia patients very late (17 years) after surgery. This was corroborated by endoscopic, manometric, and functional studies. GERD symptoms developed in 18.7% and SCC in 3.7% in previously asymptomatic patients. Endoscopic surveillance at regular intervals is recommended for all patients who have had surgery. These very long-term results are a real challenge to POEM endoscopic treatment. Unique Identifying Registration Number 3743.

Defining the Learning Curve of Laparoendoscopic Single-site Heller Myotomy

Initial outcomes suggest laparoendoscopic single-site (LESS) Heller myotomy with anterior fundoplication provides safe, efficacious, and cosmetically superior outcomes relative to conventional laparoscopy. This study was undertaken to define the learning curve of LESS Heller myotomy with anterior fundoplication. One hundred patients underwent LESS Heller myotomy with anterior fundoplication. Symptom frequency and severity were scored using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Symptom resolution, additional trocars, and complications were compared among patient quartiles. Median data are presented. Preoperative frequency/severity scores were: dysphagia = 10/8 and regurgitation = 8/7. Additional trocars were placed in 12 patients (10%), of whom all were in the first two quartiles. Esophagotomy/gastrotomy occurred in three patients. Postoperative complications occurred in 9 per cent. No conversions to “open” operations occurred. Length of stay was 1 day. Postoperative frequency/severity scores were: dysphagia = 2/0 and regurgitation = 0/0; scores were less than before myotomy ( P < 0.001). There were no apparent scars, except where additional trocars were placed. LESS Heller myotomy with anterior fundoplication well palliates symptoms of achalasia with no apparent scar. Placement of additional trocars only occurred early in the experience. For surgeons proficient with the conventional laparoscopic approach, the learning curve of LESS Heller myotomy with anterior fundoplication is short and safe, because proficiency is quickly attained.

Laparoscopic Heller myotomy and anterior Dor fundoplication for achalasia cardia in Malaysia: Clinical outcomes and satisfaction from four tertiary centers

BACKGROUND

To evaluate the clinical outcomes and satisfaction of patients following laparoscopic Heller myotomy for achalasia cardia in four tertiary centers.

METHODS

Fifty-five patients with achalasia cardia who underwent laparoscopic Heller myotomy between 2010 and 2019 were enrolled. The adverse events and clinical outcomes were analyzed. Overall patient satisfaction was also reviewed.

RESULTS

The mean operative time was 144.1 ± 38.33 min with no conversions to open surgery in this series. Intraoperative adverse events occurred in 7 (12.7%) patients including oesophageal mucosal perforation (n = 4), superficial liver injury (n = 1), minor bleeding from gastro-oesophageal fat pad (n = 1) & aspiration during induction requiring bronchoscopy (n = 1). Mean time to normal diet intake was 3.2 ± 2.20 days. Mean postoperative stay was 4.9 ± 4.30 days and majority of patients (n = 46; 83.6%) returned to normal daily activities within 2 weeks after surgery. The mean follow-up duration was 18.8 ± 13.56 months. Overall, clinical success (Eckardt ≤ 3) was achieved in all 55 (100%) patients, with significant improvements observed in all elements of the Eckardt score. Thirty-seven (67.3%) patients had complete resolution of dysphagia while the remaining 18 (32.7%) patients had some occasional dysphagia that was tolerable and did not require re-intervention. Nevertheless, all patients reported either very satisfied or satisfied and would recommend the procedure to another person.

CONCLUSIONS

Laparoscopic Heller myotomy and anterior Dor is both safe and effective as a definitive treatment for treating achalasia cardia. It does have a low rate of oesophageal perforation but overall has a high degree of patient satisfaction with minimal complications.

Therapeutic efficacy of laparoscopic Heller-Dor surgery for chest pain in patients with achalasia: a single institutional experience

BACKGROUND

Chest pain reduces the quality of life of patients with achalasia. Although laparoscopic Heller-Dor surgery (LHD) is a standard surgical treatment for achalasia, its therapeutic efficacy for chest pain is not clear. The present study evaluated the therapeutic efficacy of LHD for chest pain and tried to identify factors associated with the relief of chest pain.

METHODS

The study included 244 patients with preoperative chest pain who underwent LHD as the first surgical intervention. The questionnaire-based symptom frequency score was multiplied by the severity score, and the calculated metric was defined as the symptom score. The study population was stratified, by the change in the chest pain symptom score, into Complete Remission (CR), Partial Remission (PR), and No Remission (NR) groups, which were compared for patient background and surgical outcome. Multivariate analysis was also performed to determine factors associated with the relief of chest pain.

RESULTS

As for preoperative clinicopathological conditions, the CR subgroup was older (p = 0.0169) with fewer previous balloon dilatations (p = 0.009). Although no difference was detected in the surgical outcome, the NR group had higher postoperative symptom scores for both difficulty in swallowing and vomiting and a lower score for patient satisfaction with surgery (p = 0.0141). Multivariate analysis detected two factors associated with CR: disease duration over 60 months and less than two previous balloon dilatations.

CONCLUSIONS

LHD improved chest pain symptoms in 90% of patients with achalasia. The patients who achieved relief of chest pain were characterized by disease duration over 60 months and less than two previous balloon dilatations.

Laparoscopic Heller Myotomy for Achalasia: Experience from a Single Referral Tertiary Center

BACKGROUND

Achalasia is the most well known esophageal motility disorder. Laparoscopic Heller myotomy (LHM) is the most effective treatment for achalasia. The aim of this study was to review our results on LHM for achalasia.

METHODS

In this cross-sectional study all patients undergoing LHM between 2015 and 2017 were studied. The myotomy was followed by an anterior or posterior partial fundoplication. All patients were followed up for at least six months.

RESULTS

We conducted this prospective study on 36 consecutive patients who underwent LHM over 3 years. The mean age of the patients was 36.64 ± 13.47 years. 30 patients (83.3%) underwent Toupet and 6 patients (16.7%) received Dor fundoplication. 11 patients (30.6%) developed reflux after the procedure. According to the Eckardt Symptom Scoring (ESS), the symptoms improved in 74.2% of the patients and remained unchanged in 25.8% of the patients. Analysis of the ESS, indicated a significant change in regurgitation and retrosternal pain, dysphagia, and weight loss after the surgery (p = 0.001, p = 0.002, p = 0.046, and p = 0.001, respectively).

CONCLUSION

LHM with anterior or posterior partial fundoplication is safe and achieves a good outcome in the treatment of achalasia, especially in patients who have not responded to other methods while no serious complication was reported despite several prior endoscopic interventions.

Effect of Peroral Endoscopic Myotomy vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial

IMPORTANCE

Case series suggest favorable results of peroral endoscopic myotomy (POEM) for treatment of patients with achalasia. Data comparing POEM with pneumatic dilation, the standard treatment for patients with achalasia, are lacking.

OBJECTIVE

To compare the effects of POEM vs pneumatic dilation as initial treatment of treatment-naive patients with achalasia.

DESIGN, SETTING, AND PARTICIPANTS

This randomized multicenter clinical trial was conducted at 6 hospitals in the Netherlands, Germany, Italy, Hong Kong, and the United States. Adult patients with newly diagnosed achalasia and an Eckardt score greater than 3 who had not undergone previous treatment were included. The study was conducted between September 2012 and July 2015, the duration of follow-up was 2 years after the initial treatment, and the final date of follow-up was November 22, 2017.

INTERVENTIONS

Randomization to receive POEM (n = 67) or pneumatic dilation with a 30-mm and a 35-mm balloon (n = 66), with stratification according to hospital.

MAIN OUTCOMES AND MEASURES

The primary outcome was treatment success (defined as an Eckardt score ≤3 and the absence of severe complications or re-treatment) at the 2-year follow-up. A total of 14 secondary end points were examined among patients without treatment failure, including integrated relaxation pressure of the lower esophageal sphincter via high-resolution manometry, barium column height on timed barium esophagogram, and presence of reflux esophagitis.

RESULTS

Of the 133 randomized patients, 130 (mean age, 48.6 years; 73 [56%] men) underwent treatment (64 in the POEM group and 66 in the pneumatic dilation group) and 126 (95%) completed the study. The primary outcome of treatment success occurred in 58 of 63 patients (92%) in the POEM group vs 34 of 63 (54%) in the pneumatic dilation group, a difference of 38% ([95% CI, 22%-52%]; P < .001). Of the 14 prespecified secondary end points, no significant difference between groups was demonstrated in 10 end points. There was no significant between-group difference in median integrated relaxation pressure (9.9 mm Hg in the POEM group vs 12.6 mm Hg in the pneumatic dilation group; difference, 2.7 mm Hg [95% CI, -2.1 to 7.5]; P = .07) or median barium column height (2.3 cm in the POEM group vs 0 cm in the pneumatic dilation group; difference, 2.3 cm [95% CI, 1.0-3.6]; P = .05). Reflux esophagitis occurred more often in the POEM group than in the pneumatic dilation group (22 of 54 [41%] vs 2 of 29 [7%]; difference, 34% [95% CI, 12%-49%]; P = .002). Two serious adverse events, including 1 perforation, occurred after pneumatic dilation, while no serious adverse events occurred after POEM.

CONCLUSIONS AND RELEVANCE

Among treatment-naive patients with achalasia, treatment with POEM compared with pneumatic dilation resulted in a significantly higher treatment success rate at 2 years. These findings support consideration of POEM as an initial treatment option for patients with achalasia.

TRIAL REGISTRATION

Netherlands Trial Register number: NTR3593.

Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis

OBJECTIVE

To compare the outcome of per oral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia.

BACKGROUND

Over the last 2 decades, LHM has become the primary form of treatment in many centers. However, since the first description of POEM in 2010, this technique has widely disseminated, despite the absence of long-term results and randomized trials.

METHODS

A systematic Medline literature search of articles on LHM and POEM for the treatment of achalasia was performed. The main outcomes measured were improvement of dysphagia and posttreatment gastroesophageal reflux disease (GERD). Linear regression was used to model the effect of each procedure on the different outcomes.

RESULTS

Fifty-three studies reported data on LHM (5834 patients), and 21 articles examined POEM (1958 patients). Mean follow-up was significantly longer for studies of LHM (41.5 vs. 16.2 mo, P < 0.0001). Predicted probabilities for improvement in dysphagia at 12 months were 93.5% for POEM and 91.0% for LHM (P = 0.01), and at 24 months were 92.7% for POEM and 90.0% for LHM (P = 0.01). Patients undergoing POEM were more likely to develop GERD symptoms (OR 1.69, 95% CI 1.33-2.14, P < 0.0001), GERD evidenced by erosive esophagitis (OR 9.31, 95% CI 4.71-18.85, P < 0.0001), and GERD evidenced by pH monitoring (OR 4.30, 95% CI 2.96-6.27, P < 0.0001). On average, length of hospital stay was 1.03 days longer after POEM (P = 0.04).

CONCLUSIONS

Short-term results show that POEM is more effective than LHM in relieving dysphagia, but it is associated with a very high incidence of pathologic reflux.

Dissatisfaction after laparoscopic Heller myotomy: The truth is easy to swallow

BACKGROUND

Although laparoscopic Heller myotomy has been shown to well palliate symptoms of achalasia, we have observed a small subset of patients who are "Dissatisfied". This study was undertaken to identify the causes of their dissatisfaction.

STUDY DESIGN

Patients undergoing laparoscopic Heller myotomy from 1992 to 2015 were prospectively followed. Using a Likert scale, patients rated their symptom frequency/severity before and after the procedure. Patients graded their experience from "Very Satisfying" to "Very Unsatisfying."

RESULTS

647 patients underwent laparoscopic Heller myotomy. Fifty (8%) patients, median age 57 years and BMI 24 kg/m² reported dissatisfaction at follow-up subsequent to myotomy. "Dissatisfied" patients were more likely to have undergone prior abdominal operations (p = 0.01) or previous myotomies (p = 0.02). "Dissatisfied" patients had a greater incidence of diverticulectomy (p = 0.03) and had longer postoperative LOS (p = 0.01). Symptom frequency/severity persisted after myotomy for dissatisfied patients (p > 0.05).

CONCLUSION

Dissatisfaction after laparoscopic Heller myotomy is directly related to persistent/recurrent symptoms. Previous abdominal operations/myotomies, diverticulectomies, and longer LOS are predictors of dissatisfaction. With this understanding, we can identify patients who might be more prone to dissatisfaction.

Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years

BACKGROUND

The recently developed technique for peroral endoscopic myotomy (POEM) has been shown to be effective in several short-term studies. Longer term outcome data are largely non-existent.

OBJECTIVE

To systematically report clinical outcome with a minimum post-POEM follow-up of 2 years.

DESIGN

All patients treated consecutively by POEM for achalasia at three centres were retrospectively analysed, with a minimum follow-up of 2 years. The main outcome was the rate of POEM failures (Eckardt score >3) related to follow-up time.

RESULTS

Of 85 patients treated, five (5.9%) cases were excluded due to protocol violation or loss to follow-up; the remaining 80 patients (mean age 44.9 years, 54% men) were followed clinically for 29 months (range 24-41). Initial clinical response was observed in 77 cases (96.3%). Clinical recurrences (later failures) were seen in a further 14 cases (17.7%), accounting for a total failure rate of 21.5%. In a multivariate analysis, age and endoscopic reflux signs were independent predictors of treatment success. Of the 17 failures, eight were among the first 10 cases treated in the participating centres. Reflux-associated sequelae included one case of a severe reflux-associated stricture requiring dilatation, and two patients with minor transient Eckardt score elevations curable by proton pump inhibitor (PPI) treatment. Endoscopic signs of reflux oesophagitis, mostly Los Angeles grade A/B, were seen in 37.5% (37/72) at the 2-year control.

CONCLUSIONS

In this multicentre retrospective analysis, a high initial success rate of POEM is followed by a mid-term recurrence rate of 18%. Reflux oesophagitis, albeit mild, is frequent and should probably be treated by regular low-dose PPI therapy.

TRIAL REGISTRATION NUMBER

NCT 01405417 (UKE study).

Management of primary achalasia: The role of endoscopy

Achalasia is an oesophageal motor disorder which leads to the functional obstruction of the lower oesophageal sphincter (LES) and is currently incurable. The main objective of all existing therapies is to achieve a reduction in the obstruction of the distal oesophagus in order to improve oesophageal transit, relieve the symptomatology, and prevent long-term complications. The most common treatments used are pneumatic dilation (PD) and laparoscopic Heller myotomy, which involves partial fundoplication with comparable short-term success rates. The most economic non-surgical therapy is PD, with botulinum toxin injections reserved for patients with a higher surgical risk for whom the former treatment option is unsuitable. A new technology is peroral endoscopic myotomy, postulated as a possible non-invasive alternative to surgical myotomy. Other endoluminal treatments subject to research more recently include injecting ethanolamine into the LES and using a temporary self-expanding metallic stent. At present, there is not enough evidence permitting a routine recommendation of any of these three novel methods. Patients must undergo follow-up after treatment to guarantee that their symptoms are under control and to prevent complications. Most experts are in favour of some form of endoscopic follow-up, however no established guidelines exist in this respect. The prognosis for patients with achalasia is good, although a recurrence after treatment using any method requires new treatment.

National outcomes of laparoscopic Heller myotomy: operative complications and risk factors for adverse events

INTRODUCTION

Laparoscopic Heller myotomy (LHM) has supplanted an open approach due to decreased operative morbidity. Our goal was to quantify the incidence of peri-operative complications and identify risk factors for adverse outcomes in LHM.

METHODS

All LHM were queried from 2005 to 2011 from the National Surgical Quality Improvement Program database. Adverse outcomes were identified, and univariate and stepwise logistic regression (MVR) was then performed to quantify association.

RESULTS

There were 1,237 LHM in the study period. Patient averages were: age 51.9 ± 16.8 years, BMI 27.3 ± 6.6 kg/m(2), Charlson comorbidity index (CCI) 0.2 ± 0.6. 15.3 % had >10 % body mass loss in the preoperative 6 months. During surgery, 10.2 % underwent concomitant EGD, and mean operative time was 141.6 ± 63.4 min. There were 7(0.06 %) wound complications, 22(1.8 %) general complications, and 30(2.4 %) major complications. Average length of stay (LOS) was 2.8 ± 5.5 days. The rate of readmission and reoperation were 3.1 and 2.3 %, respectively, and there were 4(0.03 %) deaths. General and major complications were associated with alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times (p < 0.05); however, these factors did not remain significant on MVR (p > 0.05). Operative time was found to be significantly longer by 35.3 min for inpatients, 43.1 min in functionally dependent patients, 50.0 min in preoperative septic patients, and 17.2 min with concomitant EGD (p < 0.01 for all). LOS was found to be longer by 1.9 days for inpatients, 1.8 days in ASA category ≥3, and 1.2 days per one point increase in CCI (p < 0.001 for all).

CONCLUSION

LHM is being performed nationally with a low incidence of operative complications and mortality. General and major complications following LHM are associated with patient alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times. Additionally, independent predictors of longer operative time and LOS were identified.

Peroral endoscopic myotomy for achalasia

BACKGROUND

Treatment of achalasia is complicated by symptom recurrence and a significant risk for severe complications. Endoscopic myotomy was developed in the search for a highly efficacious treatment with lower risks. Since its introduction in 2010, several centers have adopted the technique and published excellent short-term results of open label series. Randomized trials with long-term endpoint comparing per-oral endoscopic myotomy (POEM) with the established treatments such as balloon dilation and surgical myotomy are now warranted, before POEM can be regarded as the routine clinical care for achalasia patients.

PURPOSE

This review describes the development, technical aspects, efficacy, and complications of POEM.

Current status in the treatment options for esophageal achalasia

Recent advances in the treatment of achalasia include the use of high-resolution manometry to predict the outcome of patients and the introduction of peroral endoscopic myotomy (POEM). The first multicenter randomized, controlled, 2-year follow-up study conducted by the European Achalasia Trial group indicated that laparoscopic Heller myotomy (LHM) was not superior to pneumatic dilations (PD). Publications on the long-term success of laparoscopic surgery continue to emerge. In addition, laparoscopic single-site surgery is applicable to advanced laparoscopic operations such as LHM and anterior fundoplication. The optimal treatment option is an ongoing matter of debate. In this review, we provide an update of the current progress in the treatment of esophageal achalasia. Unless new conclusive data prove otherwise, LHM is considered the most durable treatment for achalasia at the expense of increased reflux-associated complications. However, PD is the first choice for non-surgical treatment and is more cost-effective. Repeated PD according to an “on-demand” strategy based on symptom recurrence can achieve long-term remission. Decision making should be based on clinical evidence that identifies a subcategory of patients who would benefit from specific treatment options. POEM has shown promise but its long-term efficacy and safety need to be assessed further.

Temporary endoscopic metallic stent for idiopathic esophageal achalasia

Idiopathic achalasia is a motor disorder of the esophagus of unknown etiology caused by loss of motor neurons determining an altered motility. It may determine severe symptoms such as progressive dysphagia, regurgitations, and pulmonary aspirations. Many therapeutic options may be offered to patients with achalasia, from surgery to endoscopic treatments such as pneumatic dilation, botulinum injection, peroral endoscopic myotomy, or endoscopic stenting. Recently, temporary placement of a stent was proposed by Cheng as therapy for achalasia disorders, whereas no Western authors have dealt with it up to date. The present study reports our preliminary experience in 7 patients with achalasia treated with a temporary stent. Partially covered self-expanding metallic stents (Micro-Tech, Nanjin, China) 80 mm long and 30 mm wide were placed under fluoroscopic control and removed after 6 days. Clinical follow-up was scheduled to check endoscopic success, symptoms release, and complications. The placement and the removal of the stents were obtained in all patients without complications. Mean clinical follow-up was 19 months. Five out of 7 patients referred total symptoms release and 2 experienced significant improvement of dysphagia. The procedure was not time consuming and was safe; no mild or severe complications were registered. In conclusion, our results may suggest a possible safe and effective endoscopic alternative treatment in patients with achalasia; however, further larger studies are necessary to confirm these promising, but very preliminary, data.