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Coss-Adame E, Furuzawa-Carballeda J, Perez-Ortiz AC, López-Ruiz A, Valdovinos MA, Sánchez-Gómez J, Peralta-Figueroa J, Olvera-Prado H, López-Verdugo F, Narváez-Chávez S, Santés-Jasso Ó, Aguilar-León D, Torres-Villalobos G. A Higher Manometric Esophageal Length to Height Ratio in Achalasia Explains the Lower Prevalence of Hiatal Hernia. J Neurogastroenterol Motil 2023; 29:501-512. [PMID: 37612234 PMCID: PMC10577459 DOI: 10.5056/jnm22139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/22/2022] [Accepted: 11/26/2022] [Indexed: 08/25/2023] Open
Abstract
Background/Aims The evidence suggests that a shorter esophageal length (EL) in gastroesophageal reflux disease (GERD) patients is associated with the presence of hiatal hernia (HH). However, there are no reports of this association in patients with achalasia. The aim is to (1) determine the prevalence of hiatal hernia in achalasia patients, (2) compare achalasia EL with GERD patients and healthy volunteers (HV), (3) measure achalasia manometric esophageal length to height (MELH) ratio, and (4) determine if there are differences in symptoms between patients with and without hiatal hernia. Methods This retrospective and cross-sectional study consist of 87 pre-surgical achalasia patients, 22 GERD patients, and 30 HV. High-resolution manometry (HRM), barium swallow, and upper endoscopy were performed to diagnose HH. The EL and MELH ratio were measured by HRM. Symptoms were assessed with Eckardt, Eating Assessment Tool, and GERD-health-related quality of life questionnaires. Results The HH in GERD's prevalence was 73% vs 3% in achalasia patients (P < 0.001). Achalasia patients had a longer esophagus and a higher MELH ratio than HV and GERD patients (P < 0.001). GERD patients had a lower MELH ratio than HV (P < 0.05). EAT-10 (P < 0.0001) and Eckardt (P < 0.05) scores were higher in achalasia without HH vs HH. Conclusions The prevalence of HH in achalasia is significantly lower than in GERD. The longer EL and the higher MELH ratio in achalasia could explain the lower prevalence of HH. Despite the low prevalence of HH in achalasia patients, the surgeon should be encouraged not to rule out HH since the risk of postoperative reflux may increase if this condition is not identified and corrected.
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Affiliation(s)
- Enrique Coss-Adame
- Departments of Gastroenterology, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | - Janette Furuzawa-Carballeda
- Departments of Experimental Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | | | - Ana López-Ruiz
- Departments of Experimental Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | - Miguel A Valdovinos
- Departments of Gastroenterology, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | - Josué Sánchez-Gómez
- Departments of Experimental Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | - José Peralta-Figueroa
- Departments of Experimental Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | - Héctor Olvera-Prado
- Departments of Experimental Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | - Fidel López-Verdugo
- Departments of Experimental Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | - Sofía Narváez-Chávez
- Departments of Experimental Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | - Óscar Santés-Jasso
- Departments of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | - Diana Aguilar-León
- Departments of Pathology, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
| | - Gonzalo Torres-Villalobos
- Departments of Experimental Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
- Departments of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, Mexico
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Noh JH, Jung HY. Role of Endoscopy in Motility Disorders of Upper Gastrointestinal Tract. J Neurogastroenterol Motil 2023; 29:7-19. [PMID: 36606432 PMCID: PMC9837547 DOI: 10.5056/jnm22170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023] Open
Abstract
Gastrointestinal motility disorders have a wide range of symptoms and affect patients' quality of life. With the advancement of endoscopy, the diagnostic and therapeutic roles of endoscopy in motility disorders is becoming more significant. Endoscopy is necessary to rule out possible organic diseases in patients with suspected motility disorders and provide significant clues for their diagnosis. Moreover, interventional endoscopy may be a primary or alternative treatment option for selected patients with motility disorders, and it is becoming a promising field as new therapeutic applications are developed and utilized for various motility disorders. This review may provide suitable indications for the use of endoscopy in diagnosing and treating motility disorders of the upper gastrointestinal tract.
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Affiliation(s)
- Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea,Correspondence: Hwoon-Yong Jung, MD, PhD, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea, Tel: +82-2-3010-3197, Fax: +82-2-476-0824, E-mail:
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Climaco K, Roubik D, Gorrell R. The differential for chest pain: when the most common cause is not the answer-a case of de novo esophageal bezoar. Surg Case Rep 2021; 7:245. [PMID: 34800192 PMCID: PMC8605939 DOI: 10.1186/s40792-021-01311-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background Having a broad differential and knowing how to manage the different possibilities in a patient with chest pain is important. Esophageal bezoars are rare entities and are even less common in patients without any recent hospitalizations, known achalasia, or nasogastric tubes. Despite their rarity, having it in one’s differential, and knowing how to manage it is important. Case presentation This case presents a patient with mega-esophagus secondary to an esophageal bezoar; and runs through the gamut of morbid chest pathophysiology, its differential, work-up, and management. The case is interesting in that the patient’s initial presentation brings to mind a bevy of feared chest issues to include myocardial infarction, dissection, pulmonary embolus, achalasia, and perforation. Conclusion This clinical case highlights more than just the rare diagnosis of esophageal bezoar. It also goes through initial resuscitation, key concerns, “can’t miss diagnoses”, and finally discusses the feared end state of an esophageal perforation.
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Affiliation(s)
- Kevin Climaco
- General Surgery Department, William Beaumont Army Medical Center, El Paso, TX, USA.
| | - Daniel Roubik
- General Surgery Department, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Robert Gorrell
- General Surgery Department, William Beaumont Army Medical Center, El Paso, TX, USA
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Long-term Outcomes of Laparoscopic Heller’s Cardiomyotomy in Achalasia Cardia With Megaesophagus. Surg Laparosc Endosc Percutan Tech 2021; 31:175-180. [PMID: 32890251 DOI: 10.1097/sle.0000000000000854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 07/28/2020] [Indexed: 11/27/2022]
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Abstract
Idiopathic achalasia is an esophageal motor disorder characterized by the loss of the lower esophageal sphincter ganglion, resulting in impaired lower esophageal relaxation and absence of esophageal peristalsis. Patients commonly present with progressive dysphagia accompanied by reflux, heartburn, retrosternal pain, and severe weight loss. Diagnosis is primarily based on the patient's chief complaints, barium esophagography, and the most recent high-resolution manometry. Endoscopic assessment and endoscopic ultrasonography also have significant value with regard to the exclusion of esophageal anatomical lesions, neoplastic diseases, and pseudoachalasia. However, as most patients with achalasia demonstrate a gradual onset, early diagnosis is difficult. Currently, treatment of idiopathic achalasia, including pneumatic dilation, stent placement, and surgical myotomy, is aimed at reducing lower esophageal sphincter pressure and relieving the symptoms of dysphagia. Peroral endoscopic myotomy has gradually become the mainstream treatment because it causes less trauma and has a rapid recovery rate. This article reviews the main methods of diagnosis and treatment of achalasia, with an emphasis on the potential of peroral endoscopic myotomy and the advancements of immunotherapy for achalasia.
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Qiu S, Chai N, Zhai Y, Wang X, Wang Y, Linghu E. Advanced achalasia: good candidate for peroral endoscopic myotomy. Dis Esophagus 2021; 34:5923116. [PMID: 33693695 DOI: 10.1093/dote/doaa097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) has been increasingly accepted as the first-line treatment of achalasia. However, laparoscopic Heller myotomy or esophagectomy still remains as the mainstay treatment for advanced achalasia featured with megaesophagus and/or sigmoid-shaped esophagus. Although the efficacy of POEM for advanced achalasia with sigmoid-shaped esophagus has been described, little is known about the role of POEM for patients with megaesophagus. The aim of our study is to evaluate the efficacy and safety of POEM for advanced achalasia with megaesophagus. Patients who received initial examinations and underwent POEM in our hospital from June 2013 to December 2018 were identified and data were retrospectively analyzed. The advanced achalasia was defined as megaesophagus with a diameter of ≥6 cm. The primary outcome was clinical success. The secondary outcomes were technical success and adverse events. A total of 112 patients (50 females, 44.6%) were included with a mean age of 44.8 years. The median symptom duration was 6.5 years (IQR:3.0-13.0 years). Modified POEM techniques were used in 27.7% (31/112) of patients. Technical success rate was 99.1% (112/113) per procedure. Clinical success was seen in 93.1% patients with median Eckardt score decreasing from 8.0 to 1.0 (P < 0.001) during a median 31.0 months of follow-up. The mean LES pressure decreased from 29.5 mmHg to 14.2 mmHg after POEM (P < 0.05). Procedure-related adverse events occurred in 8.9% patients. Reflux disease was observed postoperatively in 26.7% of patients. POEM is also indicated for patients with advanced achalasia with a favorable safety and efficacy.
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Affiliation(s)
- Shaotian Qiu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Ningli Chai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Yaqi Zhai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Xiangyao Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Yan Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Enqiang Linghu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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Santes O, Coss-Adame E, Valdovinos MA, Furuzawa-Carballeda J, Rodríguez-Garcés A, Peralta-Figueroa J, Narvaez-Chavez S, Olvera-Prado H, Clemente-Gutiérrez U, Torres-Villalobos G. Does laparoscopic reoperation yield symptomatic improvements similar to those of primary laparoscopic Heller myotomy in achalasia patients? Surg Endosc 2020; 35:4991-5000. [DOI: 10.1007/s00464-020-07978-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/14/2020] [Indexed: 01/06/2023]
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Felix VN, Murayama KM, Bonavina L, Park MI. Achalasia: what to do in the face of failures of Heller myotomy. Ann N Y Acad Sci 2020; 1481:236-246. [PMID: 32713020 DOI: 10.1111/nyas.14440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/07/2020] [Accepted: 06/25/2020] [Indexed: 12/21/2022]
Abstract
Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.
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Affiliation(s)
- Valter N Felix
- Nucleus of General and Specialized Surgery - São Paulo and Department of Gastroenterology - Surgical Division - São Paulo University, FMUSP, Sao Paulo, Brazil
| | - Kenric M Murayama
- Department of Surgery, John A. Burns School of Medicine, the University of Hawaii at Manoa, Honolulu, Hawaii
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, The University of Milan, San Donato Milanese, Italy
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Yoon HJ, Lee JE, Jung DH, Park JC, Youn YH, Park H. Morphologic Restoration After Peroral Endoscopic Myotomy in Sigmoid-type Achalasia. J Neurogastroenterol Motil 2020; 26:67-73. [PMID: 31869868 PMCID: PMC6955197 DOI: 10.5056/jnm19144] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/17/2019] [Accepted: 11/25/2019] [Indexed: 01/30/2023] Open
Abstract
Background/Aims Achalasia is a chronic, progressive motility disorder of the esophagus. The sigmoid-type achalasia is an advanced stage of achalasia characterized by severe dilatation and tortuous angulation of the esophageal body. Peroral endoscopic myotomy (POEM) has been reported to provide excellent clinical outcomes for achalasia, including the sigmoid type, but the restoration of esophageal morphology and function remain poorly described. The aim of our study is to investigate esophageal restoration after POEM for sigmoid-type achalasia. Methods From 98 patients with achalasia who underwent POEM in the Yonsei University Health System from 2013 to 2018, we recruited 13 patients with sigmoid-type achalasia (7 male; mean age 53.3 years) and assessed morphological and manometric changes in the esophagus. Results Clinical success (Eckardt score < 3) was achieved in all cases. After POEM, the average angle of esophageal tortuosity became more obtuse (91.5° vs 114.6°, P = 0.046), esophageal body diameter decreased (67.6 vs 49.8 mm, P = 0.002), and esophagogastric junction opening widened (6.4 vs 9.5 mm, P = 0.048). Patients whose esophageal tortuosity did not improve had longer durations of symptoms than patients with improvement (80.2 vs 636 months, P < 0.001). An absence of peristalsis was observed in all patients pre- and post-POEM. Conclusions POEM resulted in excellent clinical outcomes and morphologic improvement in sigmoid-type achalasia. These results suggest that the improvement of esophageal tortuosity through POEM reflects a reduced esophageal burden.
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Affiliation(s)
- Hong Jin Yoon
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeung Eun Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hoon Youn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyojin Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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10
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Per-oral endoscopic myotomy (POEM) for a sigmoid type of achalasia: short-term outcomes and changes in the esophageal angle. Surg Endosc 2019; 34:4124-4130. [PMID: 31605214 DOI: 10.1007/s00464-019-07180-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 09/30/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Per-oral endoscopic myotomy (POEM) is an endoscopic procedure whereby the esophageal muscle is incised in order to lower the lower esophageal sphincter (LES) pressure. Since the time it was first performed in 2008 and subsequently reported on in 2010 by Inoue et al., POEM has been shown to be safe and effective for straight type of achalasia. On the other hand, the efficacy of POEM had been controversial for patients with achalasia of the sigmoid type, in which a high LES pressure is accompanied by morphological changes, including dilation, acute angulation, and rotation. The aim of this study is to evaluate the safety and efficacy of POEM in patients with sigmoid type of achalasia. METHODS Between May 2015 and December 2017, 16 patients with a sigmoid type of achalasia underwent POEM in our institute. The POEM procedure was the same as that for the straight type of achalasia. The double-scope technique was used to check the distal end of the submucosal tunnel from the gastric side. The primary endpoint was improvement of Eckardt score at 2 months after POEM. The secondary endpoints comprised operating time, change in the esophageal angulation, and adverse events. RESULTS All patients underwent POEM without severe adverse events. The respective parameters before and after POEM significantly differed in terms of mean (SD) Eckardt score [4.9 (2.0) vs. 0.4 (0.6), p < 0.01], LES pressure [19.4 (10.2) vs. 9.2 (6.4), p < 0.01], and integrated relaxation pressure [17.6 (9.2) vs. 7.9 (5.5), p < 0.01]. The average operation time was 94.7 ± 31.4 min. The average esophageal angulation was 88.4° ± 23.1° before POEM and 109.5° ± 16.7° after POEM (p < 0.01). Four patients had postoperative complications that were treated conservatively. CONCLUSIONS POEM can improve both LES pressure and esophageal angulation in patients with sigmoid achalasia.
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Li L, Chai N, Linghu E, Li Z, Du C, Zhang W, Zou J, Xiong Y, Zhang X, Tang P. Safety and efficacy of using a short tunnel versus a standard tunnel for peroral endoscopic myotomy for Ling type IIc and III achalasia: a retrospective study. Surg Endosc 2018; 33:1394-1402. [PMID: 30187204 DOI: 10.1007/s00464-018-6414-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 08/31/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) for patients with Ling type IIc and III achalasia is associated with a high rate of adverse events. Decreasing the lengths of the tunnel and myotomy may be an effective method for reducing this rate. This study aimed to assess the safety and efficacy of using a short tunnel versus a standard tunnel for POEM. METHOD We conducted a retrospective study of 126 patients with Ling type IIc and III achalasia undergoing POEM from January 2013 to December 2016. These patients were divided into a short tunnel group (n = 63) and a standard tunnel group (n = 63). The clinical efficacy of the procedure, operative time, length of the tunnel, length of myotomy and rates of adverse events were analyzed. RESULTS The preoperative features were similar in both groups. No significant differences were found between the two groups in Eckardt score change, lower esophageal sphincter (LES) basal pressure or residual pressure after POEM (all p > 0.05). The mean lengths of the tunnel and myotomy were 7.6 cm and 4.8 cm, respectively, in the short tunnel group and 11.8 cm and 9.2 cm, respectively, in the standard tunnel group. The mean operative time of the short tunnel group was significantly shorter than that of the standard tunnel group (39.5 min vs. 48.2 min, respectively, p = 0.001). A significant difference was observed in the rates of procedure-related adverse events between the two groups (9.5% vs. 33.3%, p = 0.001). CONCLUSION The efficacy of the procedure was comparable between the two groups. However, the short tunnel significantly reduced the operation time and the rates of procedure-related adverse events.
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Affiliation(s)
- Longsong Li
- Department of Gastroenterology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Ningli Chai
- Department of Gastroenterology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Enqiang Linghu
- Department of Gastroenterology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Zhenjuan Li
- Department of Gastroenterology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Chen Du
- Department of Gastroenterology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Wengang Zhang
- Department of Gastroenterology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Jiale Zou
- Department of Gastroenterology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Ying Xiong
- Department of Gastroenterology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Xiaobin Zhang
- Department of Gastroenterology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Ping Tang
- Department of Gastroenterology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
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Abstract
Achalasia is a rare disease characterized by impaired lower esophageal sphincter relaxation loss and of peristalsis in the esophageal body. Endoscopic balloon dilation and laparoscopic surgical myotomy have been established as initial treatment modalities. Indications and outcomes of esophagectomy in the management of end-stage achalasia are less defined. A literature search was conducted to identify all reports on esophagectomy for end-stage achalasia between 1987 and 2017. MEDLINE, Embase, and Cochrane databases were consulted matching the terms “achalasia,” “end-stage achalasia,” “esophagectomy,” and “esophageal resection.” Seventeen articles met the inclusion criteria and 1422 patients were included in this narrative review. Most of the patients had previous multiple endoscopic and/or surgical treatments. Esophagectomy was performed through a transthoracic (74%) or a transhiatal (26%) approach. A thoracoscopic approach was used in a minority of patients and seemed to be safe and effective. In 95 per cent of patients, the stomach was used as an esophageal substitute. The mean postoperative morbidity rate was 27.1 per cent and the mortality rate 2.1 per cent. Symptom resolution was reported in 75 to 100 per cent of patients over a mean follow-up of 43 months. Only five series including 195 patients assessed the long-term follow-up (>5 years) after reconstruction with gastric or colon conduits, and the results seem similar. Esophagectomy for end-stage achalasia is safe and effective in tertiary referral centers. A thoracoscopic approach is a feasible and safe alternative to thoracotomy and may replace the transhiatal route in the future.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Stefano Siboni
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
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Abstract
Esophagectomy for benign disease is uncommonly used but it is an important option to consider in those patients who have lost function of this organ. Esophageal resection is, in fact considered as a last resort for benign disease, after multiple failed conservative treatments, when the primary disease is not amenable to other treatments and the esophagus has become non-functional leading to very poor quality of life. The indications for esophagectomy for benign diseases can be divided into three major categories: obstruction, perforation and dysmotility. The process leading to organ failure and the need for resection for each specific disease will be discussed in an attempt to provide guidance as to when an esophagectomy is appropriate.
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Affiliation(s)
- Jessica Mormando
- Division of Thoracic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Arianna Barbetta
- Division of Thoracic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniela Molena
- Division of Thoracic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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15
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Shestakov AL, Boyeva IA, Tskhovrebov AT, Tarasova IA, Petrosyan TV, Bezaltynnykh AA, Chernisheva EA, Strel'nikov IY. [Thoracoscopic subtotal esophageal resection for benign esophageal diseases]. Khirurgiia (Mosk) 2018:33-36. [PMID: 29992923 DOI: 10.17116/hirurgia2018733] [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] [Indexed: 06/08/2023]
Abstract
AIM To investigate the role of video-assisted subtotal esophageal resection in treatment of patients with benign esophageal diseases. MATERIAL AND METHODS Fifty-one patients with benign esophageal diseases have undergone subtotal esophageal resection in our department for the period 2010-2017. Thoracoscopic technique was applied in 25 cases, open approach - in 26 patients. Total surgery time, thoracoscopic stage duration, length of hospital-stay (LOS), ICU-stay, Clavien-Dindo morbidity rates with separate registration of respiratory complications, mortality have been considered. RESULTS Groups were similar in terms of age, gender, ASA status. Thoracoscopic stage duration gradually decreased from 175 to 65 min with average time of 102 (75; 123) min. Total surgery time was 390 (270; 495) min in group 1 and 465 (341; 561) min in the control group (р=0.035). Mean ICU-stay decreased up to 2 (1.25; 3.75) days compared with the control group (5 (3.92; 5.85) days, р<0.0001). Conversion rate was 8%. In the main group complications Clavien-Dindo grade 2 were detected in 10 (40%) patients compared with 20 (69%) cases in the control group (р=0.009). Respiratory complications occurred in 5 patients in group 1 and in 13 cases of the control group (р=0.039). Mortality was absent. CONCLUSION Thoracoscopic subtotal esophageal resection may be advisable alternative to open surgery for patients with benign esophageal diseases due to lower postoperative morbidity and earlier rehabilitation followed by improved outcomes.
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Affiliation(s)
- A L Shestakov
- Petrovsky Russian Research Center for Surgery, Moscow, Russia; Sechenov First Moscow State Medical University, Moscow, Russia
| | - I A Boyeva
- Petrovsky Russian Research Center for Surgery, Moscow, Russia
| | - A T Tskhovrebov
- Petrovsky Russian Research Center for Surgery, Moscow, Russia
| | - I A Tarasova
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - T V Petrosyan
- Petrovsky Russian Research Center for Surgery, Moscow, Russia
| | | | - Eh A Chernisheva
- Petrovsky Russian Research Center for Surgery, Moscow, Russia, Sechenov First Moscow State Medical University, Moscow, Russia
| | - I Yu Strel'nikov
- Petrovsky Russian Research Center for Surgery, Moscow, Russia, Sechenov First Moscow State Medical University, Moscow, Russia
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Familiari P, Greco S, Volkanovska A, Gigante G, Cali A, Boškoski I, Costamagna G. Achalasia: current treatment options. Expert Rev Gastroenterol Hepatol 2016; 9:1101-14. [PMID: 26186641 DOI: 10.1586/17474124.2015.1052407] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Achalasia is a rare esophageal motility disorder, characterized by impaired swallow-induced, lower esophageal sphincter (LES) relaxation and defective esophageal peristalsis. Unfortunately, there are no etiological therapies for achalasia. Patients present with dysphagia, chest pain and regurgitation of undigested food, often leading to weight loss. The currently available treatments have the common aim of relieving symptoms by decreasing the pressure of the LES. This can be achieved with some medications, by inhibiting the cholinergic innervation (botulinum toxin), by stretching (endoscopic dilation) or cutting (surgery) the LES. Recently, other therapeutic options, including per-oral endoscopic myotomy have been developed and are gaining international consensus. The authors report on the benefits and weaknesses of the different therapies and provide an updated approach to the management of achalasia.
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Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit - Gemelli University Hospital Università Cattolica del Sacro Cuore, Rome, Italy
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Neagoe R, Voidazan S, Szocs M, Sala DT, Bancu S, Mulhfay G. Outcomes after transhiatal esophagectomies in an eastern-European low-volume center. Balkan Med J 2015; 32:38-45. [PMID: 25759770 PMCID: PMC4342136 DOI: 10.5152/balkanmedj.2015.15514] [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: 06/13/2014] [Accepted: 10/27/2014] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The present study proposes to analyze the results obtained after transhiatal esophagectomies (THE), from the perspective of an Eastern European surgical center with low esophageal resection volume (LV). AIMS Our analysis, which to the authors' knowledge is the first of its kind in Romania, has the purpose of comparing our results with those obtained in higher or similar volume centers, in order to derive conclusions regarding the quality of therapeutic management for patients diagnosed with esophageal cancer in Romania. STUDY DESIGN Retrospective observational study. METHODS In total, 70 patients were included, in whom THE was performed during the period 1997-2013 by six senior surgeons. The majority of our patients had esophageal cancers (n=66; 94.3%); we also performed 4 THE procedures for benign conditions (n=3; 4.27%) and esophageal perforation (n=1; 1.42%). RESULTS The majority of cancer-group patients had T3/N+ tumors. The nodal involvement in the T2, T3 and T4 categories was 9.9%, 21.6% and 35.1%, respectively. Complications were identified in 45 patients (68.2%), with the majority being represented by pulmonary complications (16 patients; 24.3%) and cervical leaks (15 cases; 22.7%). In-hospital mortality was 9.09%. We found a one-year overall survival rate of 58.7% (95%CI: 51.7-65.7%), 27.2% at 2 years (95%CI: 21.2-36.2%) and 10.5% at 3 years (95%CI: 6.5-14.5%). The median survival rate was estimated to be 16 months. CONCLUSION Morbidity and in-hospital mortality after THE was performed in low-volume centers, despite being significantly higher than reported in HV centers, could be kept at reasonable rates. In our opinion, the measures which have the potential to raise the standard of care for patients diagnosed with esophageal cancer in Romania are represented by the standardization of therapeutic and diagnostic protocols for esophageal cancer and the centralization of these major oncologic interventions in surgical excellence centers.
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Affiliation(s)
- Radu Neagoe
- Second Department of General Surgery, Emergency Mureş County Hospital, University of Medicine and Pharmacy, Târgu Mureş, Romania
| | - Septimu Voidazan
- Department of Epidemiology, University of Medicine and Pharmacy, Târgu Mureş, Romania
| | - Mihaly Szocs
- Department of ENT Surgery, Emergency Mureş County Hospital, University of Medicine and Pharmacy, Târgu Mureş, Romania
| | - Daniela Tatiana Sala
- Second Department of General Surgery, Emergency Mureş County Hospital, University of Medicine and Pharmacy, Târgu Mureş, Romania
| | - Serban Bancu
- Second Department of General Surgery, Emergency Mureş County Hospital, University of Medicine and Pharmacy, Târgu Mureş, Romania
| | - Gheorghe Mulhfay
- Department of ENT Surgery, Emergency Mureş County Hospital, University of Medicine and Pharmacy, Târgu Mureş, Romania
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Peroral endoscopic myotomy for advanced achalasia with sigmoid-shaped esophagus: long-term outcomes from a prospective, single-center study. Surg Endosc 2014; 29:2841-50. [PMID: 25492452 DOI: 10.1007/s00464-014-4013-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 11/10/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND The sigmoid-shaped esophagus is considered to be the advanced stage of achalasia, in which the esophageal lumen is significantly dilated, swerved, and rotated. In consideration of the efficacy of peroral endoscopic myotomy (POEM) for early achalasia, it may also offer another option for the treatment of advanced achalasia with sigmoid-shaped esophagus. Our purpose was to evaluate the feasibility and long-term efficacy of POEM for patients with sigmoid-type achalasia. METHODS 32 consecutive patients with sigmoid-type achalasia (S1 type in 29 patients and S2 type in 3 patients) were prospectively included. Primary outcome was symptom relief during follow-up, defined as an Eckardt score ≤3. Secondary outcomes were procedure-related adverse events, the resting lower esophageal sphincter (LES) pressure, clinical reflux complications, and procedure-related parameters. RESULTS All cases received POEM successfully. The mean operation time was 63.7 min (range 22-130 min). No serious complications related to POEM were encountered. During a mean follow-up period of 30.0 months (range 24-44 months), treatment success was achieved e in 96.8% of cases (mean score pre- vs. post-treatment 7.8 vs. 1.4; P < 0.001). Mean LES pressure also decreased from a mean of 37.9 to 12.9 mmHg after POEM (P < 0.001). One patient experienced only partial symptom relief and additional balloon dilations were carried out to relief the symptoms twice. The overall clinical reflux complication rate of POEM for sigmoid-type achalasia was 25.8%. CONCLUSION The 2-year outcomes of POEM for advanced achalasia with sigmoid-shaped esophagus were excellent, resulting in long-term symptom relief in over 96% cases and without serious complications. The morphological changes of esophagus may make subsequent endoscopic tunneling more challenging and time-consuming, but do not prevent successful POEM.
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