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Mittal S, Kumar A, Gunjan D, Netam RK, Anil AK, Suhani S, Joshi M, Bhattacharjee HK, Sharma R, Parshad R. Long-term outcomes of laparoscopic Heller's myotomy with angle of His accentuation in patients of achalasia cardia. Surg Endosc 2024; 38:659-670. [PMID: 38012444 DOI: 10.1007/s00464-023-10571-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Laparoscopic Heller's myotomy (LHM) is an established treatment for achalasia cardia. Anti-reflux procedures (ARP) are recommended with LHM to reduce the post-operative reflux though the optimal anti-reflux procedure is still debatable. This study reports on the long-term outcomes of LHM with Angle-of-His accentuation (AOH) in patients of achalasia cardia. METHODS One hundred thirty-six patients of achalasia cardia undergoing LHM with AOH between January 2010 to October 2021 with a minimum follow-up of one year were evaluated for symptomatic outcomes using Eckardt score (ES), DeMeester heartburn (DMH) score and achalasia disease specific quality of life (A-DsQoL) questionnaire. Upper gastrointestinal endoscopy, high resolution manometry (HRM) and timed barium esophagogram (TBE) were performed when feasible and rates of esophagitis and improvement in HRM and TBE parameters evaluated. Time dependent rates of success were calculated with respect to improvement in ES and dysphagia-, regurgitation- and heartburn-free survival using Kaplan-Meier analysis. RESULTS At a median follow-up of 65.5 months, the overall success (ES ≤ 3) was 94.1%. There was statistically significant improvement in ES, heartburn score and A-DsQoL score (p < 0.00001, p = 0.002 and p < 0.00001). Significant heartburn (score ≥ 2) was seen in 12.5% subjects with 9.5% patients reporting frequent PPI use (> 3 days per week). LA-B and above esophagitis was seen in 12.7%. HRM and TBE parameters also showed a significant improvement as compared to pre-operative values (IRP: p < 0.0001, column height: p < 0.0001, column width: p = 0.0002). Kaplan-Meier analysis showed dysphagia, regurgitation, and heartburn free survival of 75%, 96.2% and 72.3% respectively at 10 years. CONCLUSIONS LHM with AOH gives a lasting relief of symptoms in patients of achalasia cardia with heartburn rates similar to that reported in studies using Dor's or Toupet's fundoplication with LHM. Hence, LHM with AOH may be a preferred choice in patients of achalasia cardia given the simplicity of the procedure.
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Affiliation(s)
- Sonali Mittal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Ritesh Kumar Netam
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Abhijith K Anil
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Suhani Suhani
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Joshi
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanga K Bhattacharjee
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Rajinder Parshad
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 419, 4th Floor, Surgery Block, New Delhi, 110029, India.
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Nita AF, Chanpong A, Nikaki K, Rybak A, Thapar N, Borrelli O. Recent advances in the treatment of gastrointestinal motility disorders in children. Expert Rev Gastroenterol Hepatol 2023; 17:1285-1300. [PMID: 38096022 DOI: 10.1080/17474124.2023.2295495] [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: 04/12/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Pediatric gastrointestinal motility disorders represent some of the most challenging clinical conditions with largely undefined pathogenetic pathways and therefore limited therapeutic options. Herein, we provide an overview of the recent advances in treatment options for these disorders and their clinical impact. AREAS COVERED PubMed and Medline databases were searched for relevant articles related to the treatment of achalasia, esophageal atresia, gastroparesis, PIPO and constipation published between 2017 and 2022. In this article, we review and summarize recent advances in management of gastrointestinal motility disorders in children with a particular focus on emerging therapies as well as novel diagnostic modalities that help guide their application or develop new, more targeted treatments. EXPERT OPINION Gastrointestinal motility disorders represent one of the most challenging conundrums in pediatric age and despite significant advances in investigative tools, the palette of treatment options remain limited. Overall, while pharmacological options have failed to bring a curative solution, recent advances in minimal invasive therapeutic and diagnostic techniques have emerged as potential keys to symptom and quality of life improvement, such as ENDOFLIP, POEM, cine-MRI, fecal microbiota transplantation.
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Affiliation(s)
- Andreia Florina Nita
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Atchariya Chanpong
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Division of Gastroenterology and Hepatology, Department of Paediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
| | - Kornilia Nikaki
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Anna Rybak
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
| | - Osvaldo Borrelli
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
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Kumar N, Gadgade BD, Shivapur AA, Radhakrishna V, Vasudev RB. Evaluation and Management of Achalasia Cardia in Children: A Retrospective Observational Study. J Indian Assoc Pediatr Surg 2023; 28:369-374. [PMID: 37842218 PMCID: PMC10569275 DOI: 10.4103/jiaps.jiaps_175_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/24/2023] [Accepted: 03/06/2023] [Indexed: 10/17/2023] Open
Abstract
Background Achalasia cardia is a neuromuscular disorder of unknown etiology characterized by aperistalsis of the body of the esophagus and failure of relaxation of the lower esophageal sphincter. The diagnosis of achalasia cardia is delayed due to the rarity and the ability to mimic other common conditions in children. Hence, a study was conducted to evaluate the clinical presentation and the management of achalasia cardia in children. Materials and Methods A retrospective observational study was conducted in the department of pediatric surgery at a tertiary center. The children with achalasia cardia who presented between January 2014 and December 2021 were included. Results A total of 12 patients were treated for achalasia cardia during the study period. All children presented with recurrent episodes of vomiting, whereas dysphagia was seen in six (50%) children. Eighty-three percent of the children presented with a history of weight loss, whereas failure to thrive was seen in nine (75%) children. Five (42%) children were managed as gastroesophageal reflux disease (GERD) for more than a year before presenting to us. Three (25%) children underwent open cardiomyotomy with Thal fundoplication and the rest nine (75%) underwent laparoscopic cardiomyotomy. All are thriving well. Conclusion Achalasia is an important differential diagnosis in children with suspected GERD. The most common symptom of achalasia cardia is vomiting followed by dysphagia. Weight loss and failure to thrive are important presenting features in children with achalasia which are uncommon in adults. Cardiomyotomy without fundoplication is safe and effective to treat achalasia cardia in children without having any extra complications.
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Affiliation(s)
- Nitin Kumar
- Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Bahubali Deepak Gadgade
- Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Achyuth Ananth Shivapur
- Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Veerabhadra Radhakrishna
- Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Raghunath Bangalore Vasudev
- Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
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Tassi V, Lugaresi M, Pilotti V, Bassi F, Daddi N, D'Ovidio F, Leiva-Juarez MM, Mattioli S. Outcomes of Heller Myotomy for Esophageal Achalasia: Lessons From a 48-Year Prospective Experience With 4 Different Techniques. Ann Surg 2023; 278:e27-e34. [PMID: 36082979 DOI: 10.1097/sla.0000000000005677] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide information on long-term outcomes of Heller myotomy for esophageal achalasia with or without an antireflux fundoplication. BACKGROUND Since the adoption of the Heller myotomy, surgeons have modified the original technique in order to balance the cure of dysphagia and the consequent cardial incontinence. METHODS Totally, 470 patients underwent primary Heller myotomy between 1955 and 2020. A long abdominal myotomy (AM) was performed in 83 patients, the Ellis limited transthoracic myotomy (TM) in 30, the laparotomic Heller-Dor (L-HD) in 202, the videolaparoscopic Heller-Dor (VL-HD) in 155. The HD was performed under intraoperative manometric assessment. Starting on 1973 these patients underwent a prospective follow-up program of timed lifelong clinical, radiological, endoscopic evaluations. RESULTS Median follow-up time was 23.06 years [interquantile range (IQR): 15.04-32.06] for AM, 29.22 years (IQR: 13.46-40.17) for TM, 14.85 years (IQR: 11.05-21.56) for L-HD and 7.51 years (IQR: 3.25-9.60) for VL-HD. In AM, relapse of dysphagia occurred in 25/71 (35.21%), in TM in 11/30 (36.66%), in LH-D in 10/201 (4.97%), in VL-HD in 3/155 (1.93%). Erosive-ulcerative esophagitis was diagnosed for AM in 28.16%, for TM in 30%, for L-HD in 8.45%, for VL-HD in 2.58%. Overall, the outcome was satisfactory in 52.11% for AM, 41.9% for TM, 89.05% for L-HD, 96.12% for VL-HD. CONCLUSIONS The Dor fundoplication drastically reduces postmyotomy gastroesophageal reflux. The Heller-Dor operation is a competitive option for the cure of esophageal achalasia if this operation is performed according to the rules of surgical physiology learned by means of intraoperative manometry.
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Affiliation(s)
| | - Marialuisa Lugaresi
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola
- Alma Mater Studiorum, University of Bologna, Bologna
| | | | | | - Niccolò Daddi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Frank D'Ovidio
- Division of Cardiac, Department of Surgery, Vascular, and Thoracic Surgery, New York Presbyterian Columbia University Medical Center, New York, NY
| | - Miguel M Leiva-Juarez
- Division of Cardiac, Department of Surgery, Vascular, and Thoracic Surgery, New York Presbyterian Columbia University Medical Center, New York, NY
| | - Sandro Mattioli
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola
- Alma Mater Studiorum, University of Bologna, Bologna
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Zambetti BR, Murphy WG, Craner D, Wong DL, Pettigrew BD, Webb DL, Voeller GR, Stoikes NFN. Laparoscopic Heller Myotomy With EGD and Balloon Dilation: A Durable Solution for Achalasia. Am Surg 2022:31348221101473. [PMID: 35544037 DOI: 10.1177/00031348221101473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Laparoscopic Heller myotomy (LHM) and esophageal balloon dilation (BD) are the two mainstays of achalasia treatment-this study examines the outcomes when they are performed simultaneously without fundoplication. METHODS All patients undergoing LHM&BD were reviewed for demographic and procedural data, and to see if additional procedures for achalasia had been performed. Patients were surveyed using the Eckardt score and the GERD quality-of-life score (GERD-HRQL) to assess the durability of repair. RESULTS From 2013-2020, 66 patients underwent LHM&BD. There were no esophageal perforations and a median LOS of 1 day. Seven patients have required additional operations or procedures at median 4-years follow up. 31 patients (47%) responded to the survey. The average Eckardt score was 2.9 (goal<4) with mean GERD-HRQL of 14.4 (goal<25). CONCLUSIONS LHM&BD allows for a safe, durable repair of achalasia. Reflux symptoms are manageable with PPI without fundoplication and the re-intervention rate similar to published values.
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Affiliation(s)
- Benjamin R Zambetti
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - William G Murphy
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Domenic Craner
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Denise L Wong
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Benjamin D Pettigrew
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - David L Webb
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guy R Voeller
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nathaniel F N Stoikes
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
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Tsuboi K, Yano F, Omura N, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Sakashita Y, Fukushima N, Kashiwagi H. Risk factors for the occurrence of peptic esophagitis following laparoscopic Heller-Dor surgery for esophageal achalasia. Dis Esophagus 2022; 35:6325812. [PMID: 34296268 DOI: 10.1093/dote/doab050] [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: 03/13/2021] [Revised: 05/17/2021] [Accepted: 07/04/2021] [Indexed: 12/11/2022]
Abstract
Peptic esophagitis can occur as a complication of laparoscopic Heller-Dor surgery (LHD) among patients with esophageal achalasia. The goal of this study was to identify the characteristics of patients who have developed peptic esophagitis following LHD surgery along with the risk factors associated with the occurrence of peptic esophagitis. Among the 447 cases consisting of esophageal achalasia patients who underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not peptic esophagitis occurred following surgery. We also attempted to use univariate and multivariate analyses to identify the risk factors for peptic esophagitis occurring following surgery. Esophagitis following surgery was confirmed in 67 cases (15.0%). With respect to the patient backgrounds for cases in which peptic esophagitis had occurred, a significantly higher number were male patients, with a significantly high occurrence of mucosal perforation during surgery in terms of surgical outcomes, along with a high occurrence of esophageal hiatal hernias in terms of postoperative course (P = 0.045, 0.041, and 0.022, respectively). However, there were no significant differences in terms of age, BMI, disease duration, preoperative symptoms, esophageal manometric findings, esophageal barium findings, and esophageal clearance. A multivariate analysis indicated independent risk factors for the occurrence of peptic esophagitis following LHD as being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias. Peptic esophagitis occurred following LHD in 15% of cases. Independent risk factors for the occurrence of peptic esophagitis following LHD included being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias following surgery.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Fuji City General Hospital, Shizuoka, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.,Department of Surgery, Nishisaitama-Chuo National Hospital, Saitama, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Se-Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Orlandini MF, Serafim MCA, Datrino LN, Tavares G, Tristão LS, Dos Santos CL, Bernardo WM, Tustumi F. Myotomy in sigmoid megaesophagus: is it applicable? A systematic review and meta-analysis. Dis Esophagus 2021; 34:6342447. [PMID: 34355243 DOI: 10.1093/dote/doab053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/02/2021] [Accepted: 07/18/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Achalasia may evolve to sigmoid megaesophagus in 10-15% of patients and is usually treated with esophagectomy, which has high morbi-mortality. Many surgeons debate the applicability of the Heller myotomy for treating sigmoid megaesophagus. This study intents to analyze the effectiveness of myotomy for treating patients with sigmoid megaesophagus. METHODS A systematic review and meta-analysis was conducted in PubMed, Cochrane, Lilacs and Embase alongside manual search of references. The inclusion criteria were clinical trials, cohort, case-series; patients with sigmoid megaesophagus and esophageal diameter ≥ 6 cm; and patients undergoing primary myotomy. The exclusion criteria were reviews, case reports, cross-sectional studies, editorials, letters, congress abstracts, full-text unavailability; previous surgical treatment for achalasia; and pediatric or animal model studies. No restrictions on language and date of publication, and no filters were applied. Subgroups analyses were performed to assess the laparoscopic myotomy perioperative outcomes. Besides, subgroup analyses were performed to assess the long-term outcomes of the studies with a follow-up time > 24 months. To verify heterogeneity, the I2 test was used. The random effects were applied, and the fixed model was evaluated as sensitivity analysis. To assess risk of bias and certainty of evidence, the tools ROBINS-I and GRADE were used, respectively. Registration number: CRD42020199667. RESULTS Sixteen articles were selected, encompassing 350 patients. The mean age ranged from 36 to 61 years old, and the mean follow-up ranged from 16 to 109 months. Complications rate was 0.08 (CI: 0.040-0.153; P = 0.01). Need for retreatment rate was 0.128 (CI: 0.031-0.409; P = 0.01). The probability of good or excellent outcomes after myotomy was 0.762 (CI: 0.703-0.812; P < 0.01). Postoperative mortality rate was 0.008 (CI: 0.004-0.015; P < 0.01). CONCLUSION Surgical myotomy is an option for avoiding esophagectomy in achalasia, with a low morbi-mortality rate and good results. It is effective for most patients and only a minority will demand retreatment.
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Affiliation(s)
| | | | | | - Guilherme Tavares
- Department of Evidence-Based Medicine, Centro Universitário Lusíada, Santos, Brazil
| | | | | | - Wanderley Marques Bernardo
- Department of Evidence-Based Medicine, Centro Universitário Lusíada, Santos, Brazil.,Department of Evidence-Based Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Francisco Tustumi
- Department of Evidence-Based Medicine, Centro Universitário Lusíada, Santos, Brazil.,Department of Evidence-Based Medicine, Universidade de São Paulo, São Paulo, Brazil.,Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Sanaka MR, Garg R, Chadalavada P, Thota PN, Gabbard S, Parikh MP, Khoudari G, Murthy S, Raja S. Peroral Endoscopic Myotomy Is Safe and Highly Effective Treatment for Advanced Achalasia With Sigmoid Esophagus. J Clin Gastroenterol 2021; 55:505-511. [PMID: 32649445 DOI: 10.1097/mcg.0000000000001388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/02/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS In advanced achalasia patients with sigmoid esophagus, peroral endoscopic myotomy (POEM) might be technically challenging and its outcomes are not well known in western population. Hence, our study aims were to assess and compare the safety and efficacy of POEM in achalasia patients with and without sigmoid esophagus. MATERIALS AND METHODS Medical records of achalasia patients who had POEM at our institution between April 2014 and December 2019 were reviewed. Patients who underwent work-up comprising timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with 2-month post-POEM esophageal pH study, TBE and HREM were included in the final analysis. Patients were categorized as either sigmoid or no sigmoid esophagus based on the morphology of esophagus on TBE as per Japan Esophageal Society guidelines. Treatment success was defined as reduction of post-POEM Eckardt score to ≤3. RESULTS A total of 168 patients (sigmoid esophagus=20; no sigmoid esophagus=148) were included. Esophageal width on TBE at 1 minute was significantly higher in sigmoid esophagus group compared with no sigmoid esophagus group (4.9 vs. 3.0 cm, P<0.001). Procedural outcomes and complications were similar in both groups. At 2-month follow-up, both groups had significant improvement in Eckardt scores, TBE, and HREM parameters. Treatment success was high and similar in both sigmoid and no sigmoid groups (94.4% vs. 93.2%, P=0.84). The rates of gastroesophageal reflux disease were also similar in both groups. CONCLUSIONS Our study findings suggest that POEM is safe and highly effective treatment for achalasia patients with sigmoid esophagus similar to those without sigmoid esophagus in western population. POEM should be considered as the treatment of choice in advanced achalasia with sigmoid esophagus.
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Affiliation(s)
| | | | | | | | | | | | | | - Sudish Murthy
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
| | - Siva Raja
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
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Mattioli S, Tassi V. CONTROVERSIES ON THE TREATMENT OF ESOPHAGEAL ACHALASIA. Ann Thorac Surg 2021; 113:1757-1758. [PMID: 34058165 DOI: 10.1016/j.athoracsur.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Sandro Mattioli
- Division of Thoracic Surgery Maria Cecilia Hospital (RA) and Alma Mater Studiorum University of Bologna Via Massarenti 9 Bologna, 40138 Italy
| | - Valentina Tassi
- Division of Thoracic Surgery Maria Cecilia Hospital (RA) and Alma Mater Studiorum University of Bologna Via Massarenti 9 Bologna, 40138 Italy
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10
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Risk of Squamous Cell Carcinoma and Adenocarcinoma of the Esophagus in Patients With Achalasia: A Long-Term Prospective Cohort Study in Italy. Am J Gastroenterol 2021; 116:289-295. [PMID: 33009050 DOI: 10.14309/ajg.0000000000000955] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/24/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Epidemiological studies assessing relative risk and incidence rate of esophageal cancer in patients with achalasia are scarce. We performed a long-term prospective cohort study to evaluate the risk of both squamous cell carcinoma and adenocarcinoma of the esophagus in these patients. METHODS Between 1973 and 2018, patients with primary achalasia were followed by the same protocol including upper endoscopy with esophageal biopsies. Standardized incidence ratios (SIRs) with 95% confidence interval (CI) were used to estimate the relative risk of esophageal cancer in patients with achalasia compared with the sex- and age-matched general population. RESULTS A cohort of 566 patients with achalasia (46% men, mean age at diagnosis: 48.1 years) was followed for a mean of 15.5 years since the diagnosis of achalasia. Overall, 20 patients (15 men) developed esophageal cancer: 15 squamous cell carcinoma and 5 adenocarcinoma. The risk of esophageal cancer was significantly greater than the general population (SIR 104.2, 95% CI 63.7-161), and this for both squamous cell carcinoma (SIR 126.9, 95% CI 71.0-209.3) and adenocarcinoma (SIR 110.2, 95% CI 35.8-257.2). The excess risk was higher in men than women. Annual incidence rate of esophageal cancer was only 0.24% and was higher for squamous cell carcinoma (0.18%) than adenocarcinoma (0.06%). DISCUSSION Patients with achalasia have an excess risk of developing both squamous cell carcinoma and adenocarcinoma of the esophagus; however, this prospective cohort study confirms that the annual incidence of esophageal cancer is rather low. These findings may have implications for endoscopic surveillance of patients with achalasia.
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Tassi V, Lugaresi M, Mattioli B, Daddi N, Pilotti V, Ferruzzi L, Longaroni M, Mattioli S. Quality of Life After Operation for End-Stage Achalasia: Pull-Down Heller-Dor Versus Esophagectomy. Ann Thorac Surg 2021; 113:271-278. [PMID: 33515542 DOI: 10.1016/j.athoracsur.2020.12.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Therapy for end-stage achalasia is debated, and data on long-term functional results of myotomy and esophagectomy are lacking. We compared quality of life and objective outcomes after pull-down Heller-Dor and esophagectomy. METHODS The study included 32 patients, aged 57 years (interquartile range [IQR], 49-70 years), who underwent the Heller-Dor operation with verticalization of the distal esophagus in case of first instance treatment or failed surgery caused by insufficient myotomy, and 16 patients, aged 58 years (IQR, 49-67 years; P = .806), who underwent esophagectomy after failed surgery for other causes. Data were extracted from a database designed for prospective clinical research. Postoperative dysphagia, reflux symptoms, and endoscopic esophagitis were graded by semiquantitative scales. Quality of life was assessed with the 36-Item Short Form Health Survey questionnaire. RESULTS The median follow-up period was 68 months (IQR, 40.43-94.48 months) after pull-down Heller-Dor and 61 months (IQR 43.72-181.43 months) after esophagectomy (P = .598). No statistically significant differences were observed for dysphagia (P = .948), reflux symptoms (P = .186), or esophagitis (P = .253). No statistically significant differences were observed in the domains physical functioning (P = .092), bodily pain (P = .075) or general health (P = .453). Significant differences were observed in favor of pull-down Heller-Dor for the domains role physical (100 vs 100, P = .043), role emotional (100 vs 0, P = .002), vitality (90 vs 55, P< .001), mental health (92 vs 68, P = .002), and social functioning (100 v s75, P = .011). CONCLUSIONS The pull-down Heller-Dor achieved objective results similar to those of esophagectomy with a better quality of life. This technique may be the first choice for end-stage achalasia in patients with null or low risk for cancer or after recurrent dysphagia caused by insufficient myotomy.
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Affiliation(s)
- Valentina Tassi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | | | | | - Niccolò Daddi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Vladimiro Pilotti
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
| | - Luca Ferruzzi
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
| | | | - Sandro Mattioli
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy.
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12
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Bruenderman EH, Bhutiani N, Martin RCG, Fox MP, van Berkel VH, Block SB, Kehdy FJ. Intraoperative Esophagogastroduodenoscopy During Heller Myotomy: Evaluating Guidelines. World J Surg 2020; 45:808-814. [PMID: 33230586 DOI: 10.1007/s00268-020-05870-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND National guidelines suggest routine intraoperative esophagogastroduodenoscopy (EGD) during laparoscopic Heller myotomy (LHM) to assess for mucosal perforation and myotomy adequacy, but the utility of this is unknown. This study aimed to evaluate the effect of intraoperative EGD on outcomes after LHM. METHODS Patients who underwent LHM in a single center were retrospectively identified. Outcomes were compared between patients who did and did not undergo intraoperative EGD. RESULTS Sixty-one patients were reviewed: 46 (75%) underwent intraoperative EGD and 15 (25%) did not. Mucosal perforations occurred in 2 (4%) of the EGD group and 3 (20%) of the non-EGD group (p = 0.06). All perforations, regardless of EGD use, were recognized laparoscopically. There were no postoperative leaks. Failed myotomy occurred in 5 (11%) who underwent EGD and 1 (7%) who did not (p = 0.64). CONCLUSIONS Because EGD does not appear to improve outcomes after LHM, we emphasize its selective, rather than routine, use.
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Affiliation(s)
- Elizabeth H Bruenderman
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Neal Bhutiani
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Robert C G Martin
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY, United States of America
| | - Matthew P Fox
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, United States of America
| | - Victor H van Berkel
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, United States of America
| | - Stacy B Block
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Farid J Kehdy
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America.
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13
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Pantanali CAR, Herbella FAM, Henry MA, Mattos Farah JF, Patti MG. Laparoscopic Heller Myotomy and Fundoplication in Patients with Chagas’ Disease Achalasia and Massively Dilated Esophagus. Am Surg 2020. [DOI: 10.1177/000313481307900133] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Laparoscopic Heller myotomy and fundoplication is considered today the treatment of choice for achalasia. The optimal treatment for end-stage achalasia with esophageal dilation is still controversial. This multicenter and retrospective study aims to evaluate the outcome of laparoscopic Heller myotomy in patients with a massively dilated esophagus. Eleven patients (mean age, 56 years; 6 men) with massively dilated esophagus (esophageal diameter greater than 10 cm) underwent a laparoscopic Heller myotomy and anterior fundoplication between 2000 and 2009 at three different institutions. Preoperative workup included upper endoscopy, esophagram, and esophageal manometry in all patients. Average follow-up was 31.5 months (range, 3 to 60 months). Two patients (18%) had severe dysphagia, four patients (36%) had mild and occasional dysphagia to solid food, and five patients (45%) were asymptomatic. All patients gained or kept body weight, except for the two patients with severe dysphagia. Of the two patients with severe dysphagia, one underwent esophageal dilatation and the other a laparoscopic esophagectomy. They are both doing well. Heller myotomy relieves dysphagia in the majority of patients even when the esophagus is massively dilated.
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Affiliation(s)
- Carlos A. R. Pantanali
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, SP, Brazil; the
| | - Fernando A. M. Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, SP, Brazil; the
| | - Maria A. Henry
- Department of Surgery and Orthopedics, State University of São Paulo, Botucatu, SP, Brazil
| | - Jose Francisco Mattos Farah
- Department of Surgery, Hospital do Servidor Público Estadual de São Paulo Francisco Morato de Oliveira, São Paulo, SP, Brazil
| | - Marco G. Patti
- Department of Surgery, University of Chicago, Chicago, Illinois
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14
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Tassi V, Lugaresi M, Mattioli B, Fortunato F, Zagari RM, Daddi N, Bassi F, Pilotti V, Mattioli S. Incidence and risk factors for the development of epidermoid carcinoma in oesophageal achalasia†. Eur J Cardiothorac Surg 2018; 55:956-963. [DOI: 10.1093/ejcts/ezy401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 10/07/2018] [Accepted: 10/23/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Valentina Tassi
- PhD Course in Cardio-Nephro-Thoracic Sciences, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Marialuisa Lugaresi
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Benedetta Mattioli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Francesca Fortunato
- Department of Statistical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Rocco Maurizio Zagari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Niccolò Daddi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Francesco Bassi
- Division of Radiology, Policlinico Sant’Orsola-Malpighi, Bologna, Italy
- Division of Radiology, Maria Cecilia Hospital, Cotignola, Italy
| | - Vladimiro Pilotti
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
| | - Sandro Mattioli
- PhD Course in Cardio-Nephro-Thoracic Sciences, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
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15
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Angle of His Accentuation Is a Viable Alternative to Dor Fundoplication as an Adjunct to Laparoscopic Heller Cardiomyotomy: Results of a Randomized Clinical Study. Dig Dis Sci 2018; 63:2395-2404. [PMID: 29796913 DOI: 10.1007/s10620-018-5130-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 05/18/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND There is no consensus regarding the type of anti-reflux procedure to be used as an adjunct to laparoscopic Heller cardiomyotomy (LHCM). The aim of this study was to compare Angle of His accentuation (AOH) with Dor Fundoplication (Dor) as an adjunct to LHCM. METHODS A total of 110 patients with achalasia cardia presenting for LHCM from March 2010 to July 2015 were randomized to Dor and AOH. Symptom severity, achalasia-specific quality of life (ASQOL), new onset heartburn, and patient satisfaction were assessed using standardized scores preoperatively, at 3, 6 months, and then yearly. The primary outcome was relief of esophageal symptoms while secondary outcomes were new onset heartburn and ASQOL. RESULTS Both groups were comparable with respect to the baseline demographic characteristics. There was no conversion to open and no mortality in either group. Median operative time was 128 min in AOH and 144 min in Dor group (p < 0.01). Mean follow-up was 36 months and was available in 98% patients. There was significant improvement in esophageal symptoms in both groups with no statistically significant difference between the two groups (p > 0.05). There was no difference in cumulative symptom scores between the two groups over the period of follow-up. New onset heartburn was seen in 11% in AOH and 9% in Dor group. Mean ASQOL score improved in both groups with no difference between the two groups (p = 0.83). Patient satisfaction was similar in both groups. CONCLUSION AOH is similar to Dor as an adjunct to LHCM in safety and efficacy and can be performed in shorter time. CLINICAL REGISTRATION NUMBER CTRI: REF/2014/06/007146.
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16
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Zaninotto G, Bennett C, Boeckxstaens G, Costantini M, Ferguson MK, Pandolfino JE, Patti MG, Ribeiro U, Richter J, Swanstrom L, Tack J, Triadafilopoulos G, Markar SR, Salvador R, Faccio L, Andreollo NA, Cecconello I, Costamagna G, da Rocha JRM, Hungness ES, Fisichella PM, Fuchs KH, Gockel I, Gurski R, Gyawali CP, Herbella FAM, Holloway RH, Hongo M, Jobe BA, Kahrilas PJ, Katzka DA, Dua KS, Liu D, Moonen A, Nasi A, Pasricha PJ, Penagini R, Perretta S, Sallum RAA, Sarnelli G, Savarino E, Schlottmann F, Sifrim D, Soper N, Tatum RP, Vaezi MF, van Herwaarden-Lindeboom M, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Gittens S, Pontillo C, Vermigli S, Inama D, Low DE. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31:5087687. [PMID: 30169645 DOI: 10.1093/dote/doy071] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Affiliation(s)
- G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Ireland
| | - G Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M Costantini
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - M K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J E Pandolfino
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - U Ribeiro
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - J Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - L Swanstrom
- Institute of Image-Guided Surgery, Strasbourg, France; Interventional Endoscopy and Foregut Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - J Tack
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - G Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Stanford University, Stanford, California, USA
| | - S R Markar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - R Salvador
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - L Faccio
- Division of Surgery, Padova University Hospital, Padova, Italy
| | - N A Andreollo
- Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
| | - I Cecconello
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - G Costamagna
- Digestive Endoscopy Unit, A. Gemelli Hospital, Catholic University, Rome, Italy
| | - J R M da Rocha
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - E S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Frankfurt, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - R Gurski
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - F A M Herbella
- Department of Surgery, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - M Hongo
- Department of Medicine, Kurokawa Hospital, Taiwa, Kurokawa, Miyagi, Japan
| | - B A Jobe
- Esophageal and Lung Institute, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - P J Kahrilas
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - D Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - A Moonen
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - A Nasi
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; Università degli Studi, Milan, Italy
| | - S Perretta
- Institute for Image Guided Surgery IHU-Strasbourg, Strasbourg, France
| | - R A A Sallum
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - G Sarnelli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - E Savarino
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - D Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Soper
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - R P Tatum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - M F Vaezi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M F Vela
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - D I Watson
- Department of Surgery, Flinders University, Adelaide, Australia
| | - F Zerbib
- Department of Gastroenterology, University of Bordeaux, Bordeaux, France
| | - S Gittens
- ECD Solutions, Atlanta, Georgia, USA
| | - C Pontillo
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - S Vermigli
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D Inama
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D E Low
- Department of Thoracic Surgery Virginia Mason Medical Center, Seattle, Washington, USA
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17
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Abstract
Achalasia is a rare neurogenic motility disorder of the esophagus, occurring in approximately 0.11 cases per 100,000 children. The combination of problems (aperistalsis, hypertensive lower esophageal sphincter (LES), and lack of receptive LES relaxation) results in patients having symptoms of progressive dysphagia, weight loss, and regurgitation. Treatment modalities have evolved over the past few decades from balloon dilation and botulinum toxin injection to laparoscopic Heller myotomy and endoscopic myotomy. Most data on achalasia management is extrapolated to children from adult experience. This article describes understanding of the pathogenesis and discusses newer therapeutic techniques as well as controversies in management.
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Affiliation(s)
- Saleem Islam
- Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100119, Gainesville, Florida 32610.
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18
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Ilczyszyn A, Hamaoui K, Cartwright J, Botha A. Intraoperative distensibility measurement during laparoscopic Heller's myotomy for achalasia may reduce the myotomy length without compromising patient outcome. Dis Esophagus 2016; 29:455-62. [PMID: 25765569 DOI: 10.1111/dote.12343] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Our study aimed to assess whether intraoperative esophagogastric junction (EGJ) distensibility measurement using the EndoFLIP EF325 catheter (Crospon Ltd., Galway, Ireland) could potentially be used to guide laparoscopic Heller's myotomy (LHM), potentially modifying the operation outcome and comparing this clinically to our previous technique of gastroscopic assessment. Following a full diagnostic assessment with manometry and endoscopy patients with achalasia were divided into two groups. A retrospective cohort of patients operated on between 2007 and 2010 had a gastroscopy-guided LHM (G-LHM) with a standardized myotomy of 8 cm on the esophagus and 3 cm on the stomach. From 2010, patients were prospectively studied with an EndoFLIP-guided LHM (E-LHM). The length of the myotomy was dictated by intraoperative distensibility monitoring of the EGJ. All patients with achalasia recorded Urbach quality of life scoring preoperatively and 6 months postoperatively. A further group of normal laparoscopic control patients (E-LC) without any esophageal pathology also underwent intraoperative EGJ distensibility monitoring. Thirty-eight patients took part, 15 in the E-LC group, 8 in G-LHM group and 15 in the E-LHM group. We revealed that patients with achalasia in the E-LHM group had a significantly smaller EGJ cross-sectional area and distensibility than the E-LC group. Myotomy and fundoplication increased the distensibility of the EGJ to a value greater than normal control patients. Patients in the G-LHM group had a standard myotomy of 11 cm; patients in the E-LHM group had a variable length myotomy of 6 cm (IQR 5.0-6.0). In both G-LHM and E-LHM groups, there was a significant improvement in patient's quality of life with no significant difference between the groups. Our study has shown that the EndoFLIP system was effective at measuring distensibility changes during LHM. LHM significantly increases the distensibility of the EGJ and also significantly improves patient symptoms. E-LHM may reduce the overall myotomy length, and this does not appear to compromise the clinical outcome.
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Affiliation(s)
- A Ilczyszyn
- Department of Upper GI Surgery, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - K Hamaoui
- Department of Surgery, Imperial College London, London, UK
| | - J Cartwright
- Department of Upper GI Surgery, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - A Botha
- Department of Upper GI Surgery, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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19
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Intraoperative Assessment of Esophagogastric Junction Distensibility During Laparoscopic Heller Myotomy. Surg Laparosc Endosc Percutan Tech 2016; 26:137-40. [DOI: 10.1097/sle.0000000000000245] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hong D, Pescarus R, Khan R, Ambrosini L, Anvari M, Cadeddu M. Early clinical experience with the POEM procedure for achalasia. Can J Surg 2016; 58:389-93. [PMID: 26574830 DOI: 10.1503/cjs.017214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Per oral endoscopic myotomy (POEM) is a viable alternative to standard Heller myotomy for surgical treatment of achalasia. Outcomes from the United States, Europe and Asia have been reported. We sought to report data after the initiation of POEM in a Canadian centre. METHODS We enrolled patients with achalasia in a research ethics board-approved pilot study. Surgeons learned the POEM procedure in a systematic manner that included visiting experts in POEM, practice in an animal laboratory and mentoring from POEM experts. Preoperative evaluation included manometry, 24-hour pH, barium swallow, endoscopy and Eckhardt Symptom Score. All patients underwent gastrograffin swallow on postoperative day 1. Patients were re-evaluated using the Eckhardt score on postoperative day 14. RESULTS Ten patients underwent POEM. Seven patients had previous endoscopic treatments: 6 had balloon dilatation and 1 had botulinum toxin injection. Mean preoperative Eckhardt score was 8.1 ± 2.4. Mean preoperative lower esophageal sphincter resting and residual pressure was 32.3 ± 9.2 and 20.8 ± 5.3, respectively. Mean duration of surgery was 141.3 ± 43.7 minutes. Mean length of hospital stay was 1 day. No major perioperative complications occurred. On postoperative day 14, the mean Eckhardt score was 1 ± 1.2. CONCLUSION Our approach to POEM introduction was systematic and deliberate. The procedure is safe, feasible and has good perioperative outcomes. Our early results are consistent with current literature.
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Affiliation(s)
- Dennis Hong
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Radu Pescarus
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Rana Khan
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Luciano Ambrosini
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Mehran Anvari
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Margherita Cadeddu
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
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21
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Familiari P, Greco S, Gigante G, Calì A, Boškoski I, Onder G, Perri V, Costamagna G. Gastroesophageal reflux disease after peroral endoscopic myotomy: Analysis of clinical, procedural and functional factors, associated with gastroesophageal reflux disease and esophagitis. Dig Endosc 2016; 28:33-41. [PMID: 26173511 DOI: 10.1111/den.12511] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 06/16/2015] [Accepted: 07/08/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Peroral endoscopic myotomy (POEM) does not include any antireflux procedure, resulting in a certain risk of iatrogenic gastroesophageal reflux disease (GERD). The aim of the present study was to evaluate the incidence of iatrogenic GERD after POEM and identify preoperative, perioperative and postoperative factors associated with GERD. METHODS All patients treated at a single center who had a complete GERD evaluation after POEM were included in the study. Demographics, preoperative and follow-up data, results of functional studies and procedural data were collected and analyzed. RESULTS A total of 103 patients (mean age 46.6 years, 47 males) were included. Postoperative altered esophageal acid exposure was attested in 52 patients (50.5%). A total of 19 patients (18.4%) had heartburn and 21 had esophagitis (20.4%). Overall, a clinically relevant GERD (altered esophageal acid exposure, associated with heartburn and/or esophagitis) was diagnosed in 30 patients (29.1%). Correlation between the severity of esophageal acid exposure with heartburn and esophagitis after POEM was found. Patients with heartburn had a lower postoperative 4-second integrated relaxation pressure compared to patients without symptoms (7.6 ± 3.8 mmHg vs 10.01 ± 4.4 mmHg, p<0.05). No correlations were identified with patient sex, age, postoperative body mass index, esophageal shape (sigmoid vs non sigmoid), lower esophageal sphincter pressure, length of myotomy, previous therapies and type of achalasia at high-resolution manometry. CONCLUSIONS Preoperative, perioperative or postoperative factors minimally correlated with GERD after POEM. Clinically relevant GERD was identified in less than one-third of patients, but all patients were well controlled with medical therapy.
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Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Santi Greco
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Gigante
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Calì
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Graziano Onder
- Department of Geriatrics, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
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Ngamruengphong S, von Rahden BHA, Filser J, Tyberg A, Desai A, Sharaiha RZ, Lambroza A, Kumbhari V, El Zein M, Abdelgelil A, Besharati S, Clarke JO, Stein EM, Kalloo AN, Kahaleh M, Khashab MA. Intraoperative measurement of esophagogastric junction cross-sectional area by impedance planimetry correlates with clinical outcomes of peroral endoscopic myotomy for achalasia: a multicenter study. Surg Endosc 2015; 30:2886-94. [PMID: 26487227 DOI: 10.1007/s00464-015-4574-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 09/19/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has been introduced as an endoscopic alternative to surgical myotomy. The endoluminal functional lumen imaging probe (endoFLIP) evaluates esophagogastric junction (EGJ) distensibility based on cross-sectional area and pressure in response to volume distension. The aim of this study was to evaluate whether there is a correlation between endoFLIP measurements during POEM and postoperative clinical outcomes in terms of symptom relief and development of post-procedure reflux. METHODS We conducted a retrospective review of achalasia patients who underwent POEM and intraoperative endoFLIP at three tertiary centers. Patients were divided into two groups based on clinical response measured by Eckardt score (ES): good response (ES < 3) or poor response (ES ≥ 3). Post-procedure reflux was defined as the presence of esophagitis and/or abnormal pH study. EGJ diameter, cross-sectional area, and distensibility measured by endoFLIP were compared. RESULTS Of the 63 treated patients, 50 had good and 13 had poor clinical response. The intraoperative final EGJ cross-sectional area was significantly higher in the good-response group versus poor-response group; median (interquartile range): 89.0 (78.5-106.7) versus 72.4 (48.8-80.0) mm(2) [p = 0.01]. The final EGJ cross-sectional area was also significantly higher in patients who had reflux esophagitis after POEM: 99.5 (91.2-103.7) versus 79.3 (57.1-94.2) mm(2) [p = 0.02]. CONCLUSION Intraoperative EGJ cross-sectional area during POEM for achalasia correlated with clinical response and post-procedure reflux. Impedance planimetry is a potentially important tool to guide the extent and adequacy of myotomy during POEM.
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Affiliation(s)
| | | | - Jörg Filser
- Department of General Surgery, University Hospital Wurzburg, Würzburg, Germany
| | - Amy Tyberg
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Amit Desai
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Arnon Lambroza
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mohamad El Zein
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ahmed Abdelgelil
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sepideh Besharati
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - John O Clarke
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ellen M Stein
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Anthony N Kalloo
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA.
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1800 Orleans Street, Zayed Bldg, Suite 7125B, Baltimore, MD, 21287, USA.
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Luján-Sanchis M, Suárez-Callol P, Monzó-Gallego A, Bort-Pérez I, Plana-Campos L, Ferrer-Barceló L, Sanchis-Artero L, Llinares-Lloret M, Tuset-Ruiz JA, Sempere-Garcia-Argüelles J, Canelles-Gamir P, Medina-Chuliá E. Management of primary achalasia: The role of endoscopy. World J Gastrointest Endosc 2015; 7:593-605. [PMID: 26078828 PMCID: PMC4461934 DOI: 10.4253/wjge.v7.i6.593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 11/13/2014] [Accepted: 02/11/2015] [Indexed: 02/05/2023] Open
Abstract
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.
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24
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Minami H, Inoue H, Isomoto H, Urabe S, Nakao K. Clinical application of endoscopic ultrasonography for esophageal achalasia. Dig Endosc 2015; 27 Suppl 1:11-6. [PMID: 25573637 DOI: 10.1111/den.12432] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/06/2015] [Indexed: 01/05/2023]
Abstract
Endoscopic ultrasonography (EUS) has been widely used for evaluating the nature of diseases of various organs. The possibility of applying EUS for esophageal motility diseases has not been well discussed despite its versatility. At present, peroral endoscopic myotomy (POEM) for esophageal achalasia and related diseases has brought new attention to esophageal diseases because POEM provides a more direct approach to the inner structures of the esophageal wall. In the present study, we discuss the clinical utility of EUS in evaluating and treating esophageal motility diseases such as esophageal achalasia and related diseases.
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Affiliation(s)
- Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
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25
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Herbella FAM, Patti MG. Laparoscopic Heller Myotomy and Fundoplication in Patients with End-Stage Achalasia. World J Surg 2015; 39:1631-3. [DOI: 10.1007/s00268-014-2940-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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26
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Omura N, Yano F, Tsuboi K, Hoshino M, Yamamoto SR, Akimoto S, Ishibashi Y, Kashiwagi H, Yanaga K. Short-term surgical outcomes of reduced port surgery for esophageal achalasia. Surg Today 2015; 45:1139-43. [PMID: 25563589 DOI: 10.1007/s00595-014-1109-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 12/09/2014] [Indexed: 01/06/2023]
Abstract
PURPOSE To clarify the feasibility and utility of reduced port surgery (RPS) for achalasia. METHODS Between September 2005 and June 2013, 359 patients with esophageal achalasia, excluding cases of reoperation, underwent laparoscopic Heller myotomy and Dor fundoplication (LHD) according to our clinical pathway. Three-hundred and twenty-seven patients underwent LHD with five incisions (conventional approach), while the other 32 patients underwent RPS, including eight via SILS. The clinical data were collected in a prospective fashion and retrospectively reviewed. We selected 24 patients matched for gender, age and morphologic type with patients in the RPS group from among the 327 patients (C group). The surgical outcomes were compared between the C and RPS groups. RESULTS There were no significant differences between the two groups in the duration of symptoms, dysphagia score, chest pain score, shape of the distal esophagus and esophageal clearance. The operative time was significantly longer in the RPS group than in the C group (p < 0.001). There were no significant differences between the two groups in the length of postoperative hospital stay or rates of bleeding, mucosal injury of the esophagus and/or stomach and postoperative complications. The symptom scores significantly improved after surgery in both groups (p < 0.001). Furthermore, there were no significant differences between the C group and RPS group in terms of the postoperative symptom scores or satisfaction scores after surgery. CONCLUSIONS The surgical outcomes of RPS for achalasia are comparable to those obtained with the conventional method.
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Affiliation(s)
- Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan,
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27
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Teitelbaum EN, Soper NJ, Pandolfino JE, Kahrilas PJ, Hirano I, Boris L, Nicodème F, Lin Z, Hungness ES. Esophagogastric junction distensibility measurements during Heller myotomy and POEM for achalasia predict postoperative symptomatic outcomes. Surg Endosc 2014; 29:522-8. [PMID: 25055891 DOI: 10.1007/s00464-014-3733-1] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 07/07/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND The functional lumen imaging probe (FLIP) is a novel diagnostic tool that can be used to measure esophagogastric junction (EGJ) distensibility. In this study, we performed intraoperative FLIP measurements during laparoscopic Heller myotomy (LHM) and peroral esophageal myotomy (POEM) for treatment of achalasia and evaluated the relationship between EGJ distensibility and postoperative symptoms. METHODS Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by distensive pressure) was measured with FLIP at two time points during LHM and POEM: (1) at baseline after induction of anesthesia, and (2) after operation completion. RESULTS Measurements were performed in 20 patients undergoing LHM and 36 undergoing POEM. Both operations resulted in an increase in DI, although this increase was larger with POEM (7 ± 3.1 vs. 5.1 ± 3.4 mm(2)/mmHg, p < .05). The two patients (both LHM) with the smallest increases in DI (1 and 1.6 mm(2)/mmHg) both had persistent symptoms postoperatively and, overall, LHM patients with larger increases in DI had lower postoperative Eckardt scores. In the POEM group, there was no correlation between change in DI and symptoms; however, all POEM patients experienced an increase in DI of >3 mm(2)/mmHg. When all patients were divided into thirds based on final DI, none in the lowest DI group (<6 mm(2)/mmHg) had symptoms suggestive of reflux (i.e., GerdQ score >7), as compared with 20 % in the middle third (6-9 mm(2)/mmHg) and 36 % in the highest third (>9 mm(2)/mmHg). Patients within an "ideal" final DI range (4.5-8.5 mm(2)/mmHg) had optimal symptomatic outcomes (i.e., Eckardt ≤ 1 and GerdQ ≤ 7) in 88 % of cases, compared with 47 % in those with a final DI above or below that range (p < .05). CONCLUSIONS Intraoperative EGJ distensibility measurements with FLIP were predictive of postoperative symptomatic outcomes. These results provide initial evidence that FLIP has the potential to act as a useful calibration tool during operations for achalasia.
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Affiliation(s)
- Ezra N Teitelbaum
- Department of Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 650, Chicago, IL, 60611, USA,
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28
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Issaka A, Kara HV, Eldem B, Batirel HF. Left-sided thoracoscopy in the prone position for surgery of distal esophageal benign pathologies. SAGE Open Med Case Rep 2014; 2:2050313X14521393. [PMID: 27489640 PMCID: PMC4857372 DOI: 10.1177/2050313x14521393] [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] [Indexed: 11/23/2022] Open
Abstract
Exposure of the distal esophagus can be achieved by a wide variety of surgical approaches. The standard procedure is mostly by laparoscopy. In cases where laparoscopy is relatively contraindicated, thoracoscopy is preferred. In this case, exposure of the distal esophagus from the aorta, heart and lung is technically challenging using thoracoscopy in the right lateral decubitus position. Surgery in the prone position for esophageal cancer has been successfully described in previous literature. We present our experience with left-sided thoracoscopy in the prone position in three patients with benign distal esophageal pathologies. This approach provided a much better exposure of the distal esophagus and enabled a successful surgery to be done in all patients with less manipulation of the lung.
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Affiliation(s)
- Adamu Issaka
- Marmara University Faculty of Medicine, Department of Thoracic Surgery, The Ministry of Health of Turkey - Marmara University Hospital, Istanbul, Turkey
| | - Hasan Volkan Kara
- Marmara University Faculty of Medicine, Department of Thoracic Surgery, The Ministry of Health of Turkey - Marmara University Hospital, Istanbul, Turkey
| | - Barkin Eldem
- Marmara University Faculty of Medicine, Department of Thoracic Surgery, The Ministry of Health of Turkey - Marmara University Hospital, Istanbul, Turkey
| | - Hasan F Batirel
- Marmara University Faculty of Medicine, Department of Thoracic Surgery, The Ministry of Health of Turkey - Marmara University Hospital, Istanbul, Turkey
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29
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Teitelbaum EN, Boris L, Arafat FO, Nicodème F, Lin Z, Kahrilas PJ, Pandolfino JE, Soper NJ, Hungness ES. Comparison of esophagogastric junction distensibility changes during POEM and Heller myotomy using intraoperative FLIP. Surg Endosc 2013; 27:4547-55. [PMID: 24043641 DOI: 10.1007/s00464-013-3121-2] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 07/17/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a novel endoscopic surgical procedure for the treatment of achalasia. The comparative effects of POEM and laparoscopic Heller myotomy (LHM) on esophagogastric junction (EGJ) physiology are unknown. A novel measurement catheter, the functional lumen imaging probe (FLIP), allows for intraoperative evaluation of EGJ compliance by measuring luminal geometry and pressure during volume-controlled distensions. METHODS Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by pressure) was measured with FLIP intraoperatively in patients undergoing LHM and POEM. Separate measurements were taken after each operative step. During LHM, measurements were performed after: (1) induction of anesthesia, (2) insufflation of pneumoperitoneum, (3) hiatal dissection and esophageal mobilization, (4) myotomy, (5) partial fundoplication, and (6) deinsufflation. During POEM, they were performed after: (1) induction of anesthesia, (2) submucosal tunnel creation, and (3) myotomy. RESULTS Eleven LHM and 14 POEM patients underwent intraoperative FLIP. Baseline DI was similar between groups. LHM resulted in an overall increase in mean DI (pre 1.4 vs. post 7.6 mm(2)/mmHg, using a 40-ml distension volume; p < 0.001). Insufflation of pneumoperitoneum and hiatal dissection did not affect DI. Myotomy caused an increase in DI. Partial fundoplication (6 Toupet, 5 Dor) caused a decrease in DI, and deinsufflation caused an increase in DI. POEM also resulted in an overall increase in mean DI (pre 1.4 vs. post 7.9 mm(2)/mmHg; p < 0.001). Measured individually, both submucosal tunnel creation and myotomy caused increases in DI. When overall changes were compared, there were no differences in the amount of DI increase between LHM and POEM. CONCLUSIONS POEM and LHM result in a similar improvement in EGJ distensibility intraoperatively. Further study is needed to correlate intraoperative FLIP measurements with postoperative symptomatic and physiologic outcomes.
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Affiliation(s)
- Ezra N Teitelbaum
- Department of Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 650, Chicago, IL, 60611, USA,
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30
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Müller M, Eckardt AJ, Wehrmann T. Endoscopic approach to achalasia. World J Gastrointest Endosc 2013; 5:379-390. [PMID: 23951393 PMCID: PMC3742703 DOI: 10.4253/wjge.v5.i8.379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 05/10/2013] [Indexed: 02/05/2023] Open
Abstract
Achalasia is a primary esophageal motor disorder. The etiology is still unknown and therefore all treatment options are strictly palliative with the intention to weaken the lower esophageal sphincter (LES). Current established endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection. Both treatment approaches have an excellent symptomatic short term effect, and lead to a reduction of LES pressure. However, the long term success of botulinum toxin (BT) injection is poor with symptom recurrence in more than 50% of the patients after 12 mo and in nearly 100% of the patients after 24 mo, which commonly requires repeat injections. In contrast, after a single PD 40%-60% of the patients remain asymptomatic for ≥ 10 years. Repeated on demand PD might become necessary and long term remission can be achieved with this approach in up to 90% of these patients. The main positive predictors for a symptomatic response to PD are an age > 40 years, a LES-pressure reduction to < 15 mmHg and/or an improved radiological esophageal clearance post-PD. However PD has a significant risk for esophageal perforation, which occurs in about 2%-3% of cases. In randomized, controlled studies BT injection was inferior to PD and surgical cardiomyotomy, whereas the efficacy of PD, in patients > 40 years, was nearly equivalent to surgery. A new promising technique might be peroral endoscopic myotomy, although long term results are needed and practicability as well as safety issues must be considered. Treatment with a temporary self expanding stent has been reported with favorable outcomes, but the data are all from one study group and must be confirmed by others before definite recommendations can be made. In addition to its use as a therapeutic tool, endoscopy also plays an important role in the diagnosis and surveillance of patients with achalasia.
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31
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AGRUSA A, ROMANO G, BONVENTRE S, SALAMONE G, COCORULLO G, GULOTTA G. Laparoscopic treatment for esophageal achalasia: experience at a single center. G Chir 2013; 34:220-3. [PMID: 24091178 PMCID: PMC3915613 DOI: 10.11138/gchir/2013.34.7.220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Achalasia is a not frequent esophageal disorder characterized by the absence of esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter (LES). Its cause is unknown. The aim of treatment is to improve the symptoms. We report the results of the treatment of this condition achieved in one center. PATIENTS AND METHODS We conducted a retrospective study of patients with esophageal achalasia. In the period 2010-2012 we observed 64 patients, of whom 19 were referred for medical treatment. Three of the remaining patients underwent botulinum toxin injection, 17 underwent multiple endoscopic dilation procedures and 25 underwent laparoscopic surgery. RESULTS There were no complications in the group undergoing endoscopic therapy, but symptom remission was only temporary. Patients undergoing surgery showed a significant improvement in symptoms and no recurrence throughout the follow-up period, that is still ongoing (3 years). There were no major complications in any case and no morbidity or mortality. CONCLUSIONS Surgical treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor fundoplication gives the best and longest-lasting results in suitably selected patients. The extension of the myotomy and reduction in LES pressure are the most important parameters to achieve a good result.
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Affiliation(s)
- A. AGRUSA
- Department of General and Emergency Surgery and Organ Transplantation, University Hospital “P. Giaccone”, Palermo, Italy (Director: Prof. G. Gulotta)
| | - G. ROMANO
- Department of General and Emergency Surgery and Organ Transplantation, University Hospital “P. Giaccone”, Palermo, Italy (Director: Prof. G. Gulotta)
| | - S. BONVENTRE
- Department of General and Emergency Surgery and Organ Transplantation, University Hospital “P. Giaccone”, Palermo, Italy (Director: Prof. G. Gulotta)
| | - G. SALAMONE
- Department of General and Emergency Surgery and Organ Transplantation, University Hospital “P. Giaccone”, Palermo, Italy (Director: Prof. G. Gulotta)
| | - G. COCORULLO
- Department of General and Emergency Surgery and Organ Transplantation, University Hospital “P. Giaccone”, Palermo, Italy (Director: Prof. G. Gulotta)
| | - G. GULOTTA
- Department of General and Emergency Surgery and Organ Transplantation, University Hospital “P. Giaccone”, Palermo, Italy (Director: Prof. G. Gulotta)
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32
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Comparison of the Heller-Toupet procedure with the Heller-Dor procedure in patients who underwent laparoscopic surgery for achalasia. Surg Today 2013; 44:732-9. [PMID: 23793852 DOI: 10.1007/s00595-013-0640-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 04/30/2013] [Indexed: 01/01/2023]
Abstract
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.
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Major complications of pneumatic dilation and Heller myotomy for achalasia: single-center experience and systematic review of the literature. Am J Gastroenterol 2012; 107:1817-25. [PMID: 23032978 PMCID: PMC3808165 DOI: 10.1038/ajg.2012.332] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) can be definitive therapies for achalasia; recent data suggest comparable efficacy. However, risk must also be considered. We reviewed the major complication rate of PD and LHM in a high-volume center and reviewed the corresponding literature. METHODS We reviewed 12 years of our institution's achalasia treatment experience. During this interval, a consistent technique of PD was used utilizing Rigiflex dilators. Medical records were reviewed for post-procedure complications. We administered a telephone survey and examined medical records to assess efficacy of treatment. We also performed a systematic review of the literature for comparable clinical data and examined 80 reports encompassing 12,494 LHM and PD procedures. RESULTS At our center, 463 achalasia patients underwent 567 PD or LHM procedures. In all, 78% of the PDs used a 30-mm Rigiflex dilator. In all, 157/184 (85%) patients underwent 1 or 2 PD without any subsequent treatment. There were seven clinically significant perforations; one from PD and six from LHM. There were no resultant deaths from these perforations; two deaths occurred within 30 days of LHM from unrelated causes. Complications and deaths post-PD were significantly fewer than those post-LHM (P=0.02). CONCLUSIONS Esophageal perforation from PD at our high-volume center was less common than often reported and lower than that associated with LHM. We conclude that, in the hands of experienced operators using conservative technique, PD has fewer major complications and deaths than LHM.
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Pontone S, Urciuoli P, Pontone P, Custureri F. Dor against toupet fundoplication after heller myotomy. Laparoscopic technical improvements and endoscopic support. J Gastrointest Surg 2011; 15:2119-20. [PMID: 21720927 DOI: 10.1007/s11605-011-1603-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 06/20/2011] [Indexed: 01/31/2023]
Affiliation(s)
- Stefano Pontone
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy.
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Abstract
Controversy exists with regard to the optimal treatment for achalasia and whether surveillance for early recognition of late complications is indicated. Currently, surgical myotomy and pneumatic dilation are the most effective treatments for patients with idiopathic achalasia, and a multicenter, randomized, international trial has confirmed similar efficacy of these treatments, at least in the short term. Clinical predictors of outcome, patient preferences and local expertise should be considered when making a decision on the most appropriate treatment option. Owing to a lack of long-term benefit, endoscopic botulinum toxin injection and medical therapies are reserved for patients of advanced age and those with clinically significant comorbidites. The value of new endoscopic, radiologic or surgical treatments, such as peroral endoscopic myotomy, esophageal stenting and robotic-assisted myotomy has not been fully established. Finally, long-term follow-up data in patients with achalasia support the notion that surveillance strategies might be beneficial after a disease duration of more than 10-15 years.
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Affiliation(s)
- Alexander J Eckardt
- Department of Gastroenterology, Deutsche Klinik für Diagnostik, Aukammallee 33, 65191 Wiesbaden, Germany
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