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Arcerito M, Jamal MM, Perez MG, Kaur H, Sundahl A, Moon JT. Esophageal Achalasia: From Laparoscopic to Robotic Heller Myotomy and Dor Fundoplication. JSLS 2022; 26:JSLS.2022.00027. [PMID: 35967962 PMCID: PMC9355798 DOI: 10.4293/jsls.2022.00027] [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: 11/22/2022] Open
Abstract
Objective: Laparoscopic Heller myotomy and Dor fundoplication has become the gold standard in treating esophageal achalasia and robotic surgical platform represents its natural evolution. The objective of our study was to assess durable long-term clinical outcomes in our cohort. Methods and Procedures: Between June 1, 1999 and June 30, 2019, 111 patients underwent minimally invasive treatment for achalasia (96 laparoscopically and 15 robotically). Fifty-two were males. Mean age was 49 years (20 – 96). Esophageal manometry confirmed the diagnosis. Fifty patients underwent pH monitoring study, with pathologic reflux in 18. Preoperative esophageal dilation was performed in 76 patients and 21 patients received botulin injection. Dysphagia was universally present, and mean duration was 96 months (5 – 480). Results: Median operative time was 144 minutes (90 – 200). One patient required conversion to open approach. Four mucosal perforations occurred in the laparoscopic group and were repaired intraoperatively. Seven patients underwent completion esophageal myotomy and added Dor fundoplication. Upper gastrointestinal series was performed before discharge. Median hospital stay was 39 hours (24 – 312). Median follow up was 157 months (6 – 240), and dysphagia was resolved in 94% of patients. Seven patients required postoperative esophageal dilation. Conclusions: Minimally invasive Heller myotomy and Dor fundoplication are feasible. The operation is challenging, but excellent results hinge on the operative techniques and experience. The high dexterity, three-dimensional view, and the ergonomic movements of robotic surgery allow application of all the technical elements, achieving the best durable outcome for the patient. Robotic surgery is the natural evolution of minimally invasive treatment of esophageal achalasia.
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Affiliation(s)
- Massimo Arcerito
- Division of Surgical Oncology and Minimally Invasive Surgery Riverside Medical Clinic Inc. Department of Surgery/Corona Regional Medical Center, Department of Surgery/Riverside Community Hospital, Temescal Valley, California
| | - M Mazen Jamal
- Oceana Gastroenterology Associates, Corona, California
| | - Martin G Perez
- Division of Surgical Oncology and Minimally Invasive Surgery, Riverside Medical Clinic Inc, Department of Surgery / Corona Regional Medical Center, Department of Surgery / Riverside Community Hospital, Riverside, California
| | - Harpreet Kaur
- Hemet Global Medical Center - KPC Health, Hemet, California
| | - Andrew Sundahl
- Department of Surgery / Riverside Community Hospital, Riverside, California
| | - John T Moon
- Department of General Surgery and Minimally Invasive Surgery, University of Maryland Shore Medical Center at Easton, Easton, Maryland
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Andrási L, Ábrahám S, Simonka Z, Paszt A, Erdős M, Rovó L, Rosztóczy A, Ollé G, Lázár G. [Minimally invasive surgery for motility disorders of the oesophagus]. Magy Seb 2022; 75:121-132. [PMID: 35895537 DOI: 10.1556/1046.2022.20006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 01/06/2023]
Abstract
Introduction and aims. We present our experience with minimally invasive surgery for pharyngoesophageal (Zenker) diverticulums, epiphrenic diverticulums and achalasia cardiae focusing on the perioperative features and patients’ quality of life. Patients and methods. Between 1 January 2003 and 31 December 2020, patients were selected with a symptom-causing Zenker diverticulum, epiphrenic diverticulum and achalasia cardiae. In 17 cases, transoral stapler diverticulostomy, in 23 cases transcervical diverticulectomy and cricomyotomy were done because of Zenker diverticulum, in 14 cases, laparoscopic transhiatal surgery was performed because of epiphrenic diverticula, while in 63 cases, laparoscopic Heller–Dor operation were carried out because of achalasia cardiae. Perioperative results, the quality of life outcomes of various surgeries were evaluated in mid- and long-term. Results/conclusions. The surgeries were performed with minimal blood loss, zero mortality and low morbidity. According to our result, the two different surgical approaches in the therapy of Zenker’s diverticulum, the laparoscopic Heller–Dor procedure applied in the management of epiphrenic diverticulas and achalasia cardiae are safe and effective operations. In the long term, the symptom control in patients after minimally invasive surgeries is sufficient and only a small percentage of the patients may require additional medication therapy and/or reintervention due to persistent complaints.
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Affiliation(s)
- László Andrási
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Szabolcs Ábrahám
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Zsolt Simonka
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Attila Paszt
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Márton Erdős
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - László Rovó
- 2 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Fül-Orr-Gégészeti és Fej-Nyaksebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Rovó László)
| | - András Rosztóczy
- 3 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lengyel Csaba)
| | - Georgina Ollé
- 3 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lengyel Csaba)
| | - György Lázár
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
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3
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Andrási L, Paszt A, Simonka Z, Ábrahám S, Erdős M, Rosztóczy A, Ollé G, Lázár G. Surgical Treatment of Esophageal Achalasia in the Era of Minimally Invasive Surgery. JSLS 2021; 25:JSLS.2020.00099. [PMID: 33879995 PMCID: PMC8035823 DOI: 10.4293/jsls.2020.00099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Introduction: We have analyzed the short- and long-term results of various surgical therapies for achalasia, especially changes in postoperative esophageal function. Patients and Methods: Between January 1, 2008 and December 31, 2017, 54 patients with esophageal achalasia were treated in our institution. Patients scheduled for surgery underwent a comprehensive gastroenterological assessment pre- and post-surgery. Forty-eight of the elective cases involved a laparoscopic cardiomyotomy with Dor’s semifundoplication, while two cases entailed an esophageal resection with an intrathoracic gastric replacement for end-stage achalasia. Torek’s operation was performed on two patients for iatrogenic esophageal perforation, and two others underwent primary suture repair with Heller–Dor surgery as an emergency procedure. The results of the different surgical treatments, as well as changes in the patients’ pre- and post-operative complaints were evaluated. Results: No intra-operative complications were observed, and no mortalities resulted. During the 12 to 24-month follow-up period, recurrent dysphagia was observed mostly in the spastic group (TIII: 33%; diffuse esophageal spasm: 60%), while its occurrence in the TI type did not change significantly (14.5%–20.8%). As a result of the follow-up of more than two years, good symptom control was achieved in 93.7% of the patients, with only four patients (8.3%) developing postoperative reflux. Conclusions: The laparoscopic Heller–Dor procedure provides satisfactory long-term results with low morbidity. In emergency and advanced cases, traditional surgical procedures are still the recommended therapy.
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Affiliation(s)
- László Andrási
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Attila Paszt
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Zsolt Simonka
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Szabolcs Ábrahám
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Márton Erdős
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - András Rosztóczy
- 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Georgina Ollé
- 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - György Lázár
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
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4
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Nurczyk K, Patti MG. Surgical management of achalasia. Ann Gastroenterol Surg 2020; 4:343-351. [PMID: 32724877 PMCID: PMC7382425 DOI: 10.1002/ags3.12344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/03/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022] Open
Abstract
Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.
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Affiliation(s)
- Kamil Nurczyk
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- 2nd Department of General and Gastrointestinal Surgery, and Surgical Oncology of the Alimentary TractMedical University of LublinLublinPoland
| | - Marco G. Patti
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
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5
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Schizas D, Kapsampelis P, Tsilimigras DI, Kanavidis P, Moris D, Papanikolaou IS, Karamanolis GP, Theodorou D, Liakakos T. The 100 most cited manuscripts in esophageal motility disorders: a bibliometric analysis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:310. [PMID: 31475180 DOI: 10.21037/atm.2019.06.34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background The use of bibliometrics can help us identify the most impactful articles on a topic or scientific discipline and their influence on clinical practice. We aimed to identify the 100 most cited articles covering esophageal motility disorders and examine their key characteristics. Methods The Web of Science database was utilized to perform the search, using predefined search terms. The returned dataset was filtered to include full manuscripts written in the English language. After screening, we identified the 100 most cited articles and analyzed them for title, year of publication, names of authors, institution, country of the first author, number of citations and citation rate. Results The initial search returned 29,521 results. The top 100 articles received a total of 20,688 citations. The most cited paper was by Inoue et al. (665 citations) who first described peroral endoscopic myotomy (POEM) for treating achalasia. The article with the highest citation rate was the third version of the Chicago Classification system, written by Kahrilas and colleagues. Gastroenterology published most papers on the list (n=32) and accrued the highest number of citations (6,675 citations). Peter Kahrilas was the most cited author (3,650 citations) and, along with Joel Richter, authored the highest number of manuscripts (n=14). Most articles were produced in the USA (n=66) between the years 1991 and 2000 (n=32). Conclusions By analyzing the most influential articles, this work is a reference on the articles that shaped our understanding of esophageal motility disorders, thus serving as a guide for future research.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Panagiotis Kapsampelis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Diamantis I Tsilimigras
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Prodromos Kanavidis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine and Research Institute, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Georgios P Karamanolis
- Gastroenterology Unit, Second Department of Surgery, National and Kapodistrian University of Athens, Aretaieio University Hospital, Athens, Greece
| | - Dimitrios Theodorou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - Theodore Liakakos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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6
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Bonifácio P, de Moura DTH, Bernardo WM, de Moura ETH, Farias GFA, Neto ACM, Lordello M, Korkischko N, Sallum R, de Moura EGH. Pneumatic dilation versus laparoscopic Heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials. Dis Esophagus 2019; 32:5149492. [PMID: 30380036 DOI: 10.1093/dote/doy105] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Achalasia is a primary esophageal motor disorder with a variety of causes. It is most common in Central and South America, where Chagas disease is endemic. In addition to the infectious etiology, achalasia can be idiopathic, autoimmune, or drug induced. It is an incurable, progressive condition that destroys the intramural nerve plexus, causing aperistalsis of the esophageal body and impaired relaxation of the lower esophageal sphincter. The literature on the treatment of achalasia comparing pneumatic dilation (PD) and laparoscopic Heller's myotomy (LHM) shows conflicting results. Therefore, a systemic review and meta-analysis are needed. A systematic review and meta-analysis of randomized controlled trials of PD and LHM, based on the preferred reporting items for systematic reviews and meta-analyses recommendations, was presented. The primary outcome was symptom remission based on the Eckardt score. Secondary outcomes were lower esophageal sphincter pressure (LESP), gastroesophageal reflux (GER), and perforation. A total of four studies were included in this analysis. The total number of patients was 404. Posttreatment symptom remission rates did not differ significantly between LHM and PD at 2 years (RD = 0.03, 95% CI [-0.05, 0.12], P = 0.62), or 5 years (RD = 0.13, 95% CI [-0.12, 0.39], P = 0.32). The posttreatment perforation rate was lower for LHM (RD = 0.04, 95% CI [-0.08, -0.01], P = 0.03). There was no significant difference in terms of LESP or GER. For the treatment of esophageal achalasia, LHM and PD were found to be similar in terms of their long-term efficacy, as well as in terms of the posttreatment GER rates. However, the perforation rate appears to be lower when LHM is employed.
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Affiliation(s)
- P Bonifácio
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - D T H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - W M Bernardo
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - E T H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - G F A Farias
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - A C M Neto
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - M Lordello
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - N Korkischko
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - R Sallum
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - E G H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
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Banki F, Weaver M, Roife D, Kaushik C, Khanna A, Ochoa K, Miller CC. Laparoscopic Reoperative Antireflux Surgery Is More Cost-Effective than Open Approach. J Am Coll Surg 2017; 225:235-242. [DOI: 10.1016/j.jamcollsurg.2017.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 12/26/2016] [Accepted: 03/20/2017] [Indexed: 12/01/2022]
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8
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Allaix ME, Patti MG. Toward a Tailored Treatment of Achalasia: An Evidence-Based Approach. J Laparoendosc Adv Surg Tech A 2016; 26:256-63. [PMID: 27002740 DOI: 10.1089/lap.2016.0067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The treatment options in achalasia patients aim to improve symptoms by reducing the functional obstruction at the level of the gastroesophageal junction. Available treatment modalities are endoscopic botulinum toxin injection (EBTI), pneumatic dilatation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM). We provide an evidence-based review of current indications, limitations, and future perspectives of these options for the treatment of achalasia. METHODS The PubMed/Medline electronic databases and the Cochrane Library were searched. Quality of evidence was assessed according to the GRADE system. RESULTS Functional outcomes after EBTI are significantly worse than those after PD or LHM. LHM with partial fundoplication is associated with low complication rates and provides excellent long-term results with lower need for additional treatment of recurrent dysphagia than PD. POEM is a new promising treatment option with good short-term outcomes and low morbidity in experienced hands. CONCLUSIONS LHM should be considered the procedure of choice for the treatment of achalasia in patients who are fit for surgery. Large randomized controlled trials with long follow-up are needed to validate the role of POEM.
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Affiliation(s)
| | - Marco Giuseppe Patti
- 2 Department of Surgery and Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine , Chicago, Illinois
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9
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Fukuda S, Nakajima K, Miyazaki Y, Takahashi T, Makino T, Kurokawa Y, Yamasaki M, Miyata H, Takiguchi S, Mori M, Doki Y. Laparoscopic surgery for esophageal achalasia: Multiport vs single-incision approach. Asian J Endosc Surg 2016; 9:14-20. [PMID: 26315292 DOI: 10.1111/ases.12226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 07/14/2015] [Accepted: 07/27/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION SILS can potentially improve aesthetic outcomes without adversely affecting treatment outcomes, but these outcomes are uncertain in laparoscopic Heller-Dor surgery. We determined if the degree of patient satisfaction with aesthetic outcomes progressed with the equivalent treatment outcomes after the introduction of a single-incision approach to laparoscopic Heller-Dor surgery. METHODS We retrospectively reviewed 20 consecutive esophageal achalasia patients (multiport approach, n = 10; single-incision approach, n = 10) and assessed the treatment outcomes and patient satisfaction with the aesthetic outcomes. RESULTS In the single-incision approach, thin supportive devices were routinely used to gain exposure to the esophageal hiatus. No statistically significant differences in the operating time (210.2 ± 28.8 vs 223.5 ± 46.3 min; P = 0.4503) or blood loss (14.0 ± 31.7 vs 16.0 ± 17.8 mL; P = 0.8637) were detected between the multiport and single-incision approaches. We experienced no intraoperative complications. Mild dysphagia, which resolved spontaneously, was noted postoperatively in one patient treated with the multiport approach. The reduction rate of the maximum lower esophageal sphincter pressure was 25.1 ± 34.4% for the multiport approach and 21.8 ± 19.2% for the single-incision approach (P = 0.8266). Patient satisfaction with aesthetic outcomes was greater for the single-incision approach than for the multiport approach. CONCLUSION When single-incision laparoscopic Heller-Dor surgery was performed adequately and combined with the use of thin supportive devices, patient satisfaction with the aesthetic outcomes was higher and treatment outcomes were equivalent to those of the multiport approach.
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Affiliation(s)
- Shuichi Fukuda
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kiyokazu Nakajima
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.,Division of Next Generation Endoscopic Intervention, Global Center for Medical Engineering and Informatics, Osaka University, Osaka, Japan
| | - Yasuhiro Miyazaki
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsuyoshi Takahashi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tomoki Makino
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yukinori Kurokawa
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Makoto Yamasaki
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Miyata
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shuji Takiguchi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Abstract
The last three decades have witnessed a progressive evolution in the surgical treatment of esophageal achalasia, with a shift from open to a minimally invasive Heller myotomy. The laparoscopic approach is currently the standard of care with better short-term outcomes and similar long-term functional results when compared to open surgery. More recently, the laparoscopic single-site approach and the use of the robot have been proposed to further improve the surgical outcome in achalasia patients.
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Kitagawa Y, Idani H, Inoue H, Udagawa H, Uyama I, Osugi H, Katada N, Takeuchi H, Akutsu Y, Asami S, Ishikawa K, Okamura A, Ono T, Kato F, Kawabata T, Suda K, Takesue T, Tanaka T, Tsutsui M, Hosoda K, Matsuda S, Matsuda T, Mani M, Miyazaki T. Gastroenterological surgery: esophagus. Asian J Endosc Surg 2015; 8:114-24. [PMID: 25913582 DOI: 10.1111/ases.12185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/10/2014] [Indexed: 01/25/2023]
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12
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Simic´ A, Skrobić O, Veličković D, Ražnatović Z, Šaranović Đ, Šljukić V, Jovanović S, Ivanović N, Peško P. Minimally invasive surgery for benign esophageal disorders: first 200 cases. Eur Surg 2015. [DOI: 10.1007/s10353-015-0296-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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13
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The outcome of laparoscopic surgery with and without short gastric vessel division for achalasia. Int Surg 2014; 99:846-50. [PMID: 25437598 DOI: 10.9738/intsurg-d-13-00177.1] [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] Open
Abstract
Short gastric vessel division (SGVD) has been performed as a part of fundoplication for achalasia. However, whether or not SGVD is necessary is still unknown. Forty-six patients with achalasia who underwent a laparoscopic surgery with or without SGVD were analyzed. A questionnaire was administered to assess the postoperative improvement. Regarding improvement of dysphagia and postoperative reflux, there were no significant differences between SGVD (+) group and SGVD (-) group (P = 0.588 and P = 0.686, respectively). Nineteen patients (95%) in the SGVD (+) group and 24 (92%) in the SGVD (-) group answered that the surgery was satisfactory (P = 0.756). In the SGVD (+) group, the pre- and postsurgical body weight increase was +7.3%. In the SGVD (-) group, it was 8.2%. There was no significant difference of body weight increase between the 2 groups (P = 0.354). SGVD is not always required in laparoscopic surgery for achalasia.
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14
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From Heller to POEM (1914-2014): a 100-year history of surgery for Achalasia. J Gastrointest Surg 2014; 18:1870-5. [PMID: 24878993 DOI: 10.1007/s11605-014-2547-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 05/15/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND The year 2014 marks the 100th anniversary of Dr. Heller's description of the surgical treatment of patients with achalasia with a cardiomyotomy. This 100-year-old operation, which is today performed laparoscopically with the addition of a partial fundoplication, is considered the treatment of choice for patients with achalasia. PURPOSE Our goals are to revisit the accounts from the beginning of the twentieth century in which surgeons tried to identify the pathophysiology of achalasia and proposed several operative techniques and to follow the evolution of the surgical treatment until modern days.
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Falkenback D, Lehane CW, Lord RVN. Robot-assisted gastrectomy and oesophagectomy for cancer. ANZ J Surg 2014; 84:712-21. [PMID: 24730691 DOI: 10.1111/ans.12591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Robot-assisted surgery is a technically feasible alternative to open and laparoscopic surgery, which is being more frequently used in general surgery. We undertook this review to investigate whether robotic assistance provides a significant benefit for oesophagogastric cancer surgery. METHODS Electronic databases were searched for original English-language publications for robotic-assisted gastrectomy and oesophagectomy between January 1990 and October 2013. RESULTS Sixty-one publications were included. Thirty-five included gastrectomy, 31 included oesophagectomy and five included both operations. Several publications suggest that robot-assisted subtotal gastrectomy can be as safe and effective as an open or laparoscopic procedure, with equal outcomes with regard to the number of lymph nodes resected, overall morbidity and perioperative mortality, and length of hospital stay. Robotic assistance is associated with longer operation times but also with less blood loss in some reports. A significant benefit for robotic assistance has not been shown for the more extensive operations of oesophagectomy or total gastrectomy with D2-lymphadenectomy. There are very few oncologic data regarding local recurrence or long-term survival for any of the robotic operations. CONCLUSIONS No significant differences in morbidity, mortality or number of lymph node harvested have been shown between robot-assisted and laparoscopic gastrectomy or oesophagectomy. Robotic surgery, with its relatively short learning curve, may facilitate reproducible minimally invasive surgery in this field but operation times are reportedly longer and cost differences remain unclear. Randomized trials with oncologic outcomes and cost comparisons are needed.
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Affiliation(s)
- Dan Falkenback
- Department of Surgery, St. Vincent's Hospital and University of Notre Dame School of Medicine, Sydney, New South Wales, Australia; Department of Surgery, Lund University and Lund University Hospital (Skane University Hospital), Lund, Sweden
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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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Katada N, Sakuramoto S, Yamashita K, Shibata T, Moriya H, Kikuchi S, Watanabe M. Recent trends in the management of achalasia. Ann Thorac Cardiovasc Surg 2013; 18:420-8. [PMID: 23099422 DOI: 10.5761/atcs.ra.12.01949] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Radical treatment for achalasia is currently unavailable. At present, most palliative procedures are designed improve the passage of food through the gastroesophageal junction and thereby alleviate symptoms. Drug therapy is of limited, transient effectiveness. Pneumatic dilation (PD) is considered superior to endoscopic botulinum toxin injection (EBTI). The mainstay of surgical treatment for achalasia is laparoscopic Heller myotomy (LHM) with fundoplication, currently considered superior to PD. Per oral endoscopic myotomy (POEM), a "state-of-the-art" procedure for minimally invasive surgery, holds great promise for the future management of achalasia. Definitive conclusions regarding the benefits and risks of currently available treatments for achalasia must await the accumulation of evidence from well-designed clinical trials.
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Affiliation(s)
- Natsuya Katada
- Department of Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan.
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Abbes L, Leconte M, Coriat R, Dousset B, Chaussade S, Gaudric M. [Achalasia: role of endoscopic therapy and surgery]. Presse Med 2012; 42:814-8. [PMID: 22959337 DOI: 10.1016/j.lpm.2012.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 06/28/2012] [Indexed: 11/17/2022] Open
Abstract
Pneumatic dilation of achalasia has a same medium-term efficacy than surgery and is commonly proposed as the first-line treatment. Intra-sphincteric injection of botulinum toxin is reserved for elderly patients with serious comorbidities. Per-endoscopic myotomy is possible but needs to be evaluated by further studies. Laparoscopic Heller's myotomy in first intension is reserved for young patients less than 40 years. Results of Heller's myotomy are not modified by prior endoscopic treatment or by mega-esophagus. Better surgery results are shown in recent and severe achalasia.
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Affiliation(s)
- Leila Abbes
- CHU Cochin Port Royal, université Sorbonne Paris V, faculté de médecine, service de gastroentérologie, 75014 Paris, France
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Yuan Y, Zeng XX, Zhao YF. Pneumodilation versus laparoscopic Heller's myotomy for achalasia. N Engl J Med 2011; 365:467; author reply 467-8. [PMID: 21812682 DOI: 10.1056/nejmc1106642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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20
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Novais PA, Lemme EMO. 24-h pH monitoring patterns and clinical response after achalasia treatment with pneumatic dilation or laparoscopic Heller myotomy. Aliment Pharmacol Ther 2010; 32:1257-65. [PMID: 20955445 DOI: 10.1111/j.1365-2036.2010.04461.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The most effective treatment for achalasia is pneumatic dilation or myotomy. The best option is still controversial and incidence of complications could help choosing. Gastro-oesophageal reflux (GER) is the most frequent complication after treatment for achalasia. The 24-h pH monitoring (24-h pH) is the best method to evaluate true GER. AIM To analyse the 24-h pH patterns after treatment, correlating with therapeutic success. METHODS Untreated patients with achalasia were randomized to pneumatic dilation or laparoscopic Heller myotomy with fundoplication (LHM+Fp) and evaluated with clinical/manometric results and 24-h pH. RESULTS Ninety-four patients were analysed pre-treatment and 85 post-treatment. Clinical success was 73.8% in pneumatic dilation group and 88.3% in LHM+Fp group (P = 0.08). The incidence of GER was 31% in pneumatic dilation, and 4.7% in LHM+Fp (P = 0.001). The occurrence of hypotensive lower oesophageal sphincter (LES) was 53.3% in patients who developed GER and 28.6% in patients with 24-h pH suggesting fermentation (P = 0.019). The rates of dysphagia resolution in patients with 24-h pH of GER and fermentation were respectively 86.7% and 85.7% (P = 0.89). CONCLUSIONS True GER 24-h pH is more frequent after pneumatic dilation for achalasia, and it is associated with a hypotensive LES. A 24-h pH suggestive of fermentation or true GER is not associated with worse clinical/manometric results.
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Affiliation(s)
- P A Novais
- Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Brazil.
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21
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Reynoso JF, Tiwari MM, Tsang AW, Oleynikov D. Does illness severity matter? A comparison of laparoscopic esophagomyotomy with fundoplication and esophageal dilation for achalasia. Surg Endosc 2010; 25:1466-71. [PMID: 20976492 DOI: 10.1007/s00464-010-1415-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Accepted: 09/03/2010] [Indexed: 01/25/2023]
Abstract
INTRODUCTION There is scarce evidence regarding optimal treatment options for achalasia in patients with varying illness severity risk. The objective of this study was to evaluate and compare outcomes with laparoscopic esophagomyotomy with fundoplication (LM) and esophageal dilation (ED) for hospitalized patients with different illness severity. METHODS The University HealthSystem Consortium (UHC) is an alliance of more than 100 academic medical centers and nearly 200 affiliate hospitals. UHC's Clinical Data Base/Resource Manager (CDB/RM) allows member hospitals to compare patient-level risk-adjusted outcomes for performance improvement purposes. The CDB/RM was queried for patients with achalasia who underwent LM (n=1,390) or ED (n=492) during a 3-year period between 2006 and 2008. RESULTS Overall esophageal perforation rates were significantly higher for ED (0.4% LM vs. 2.4% ED; p<0.001). Patients undergoing LM with minor/moderate illness severity showed higher morbidity (9.42% LM vs. 5.15% ED; p<0.05). However, LM patients in this illness severity group showed significantly lower 30-day readmission rate (0.38% LM vs. 7.32% ED; p<0.001) and length of stay (2.23±1.78 LM vs. 4.88±4.42 days ED; p<0.001), but comparable cost ($9,539 LM vs. $8990 ED; p>0.05). In the major/extreme illness severity group mortality was comparable (1.37% LM vs. 2.44% ED; p>0.05). Overall morbidity was significantly greater in LM (50.48% LM vs. 19.57% ED; p<0.001). However, the length of stay was significantly increased in the ED group (8.96±7.86 LM vs. 11.72±11.05 days ED; p=0.04). CONCLUSION In hospitalized patients with minor/moderate illness severity, laparoscopic myotomy for achalasia showed comparable or better outcomes than ED. For major/extreme illness severity, dilation showed comparable or better profile for hospitalized achalasia patients. These results highlight the importance and impact of illness severity on outcomes of achalasia patients.
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Affiliation(s)
- Jason F Reynoso
- Department of Surgery, University of Nebraska, University of Nebraska Medical Center, Omaha, NE, USA.
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Tratamiento quirúrgico de la acalasia: ¿mejor que las dilataciones? GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:653-61. [DOI: 10.1016/j.gastrohep.2009.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 02/13/2009] [Indexed: 01/22/2023]
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Adikibi BT, MacKinlay GA, Munro FD, Khan LR, Gillett PM. Intraoperative Upper GI Endoscopy Ensures an Adequate Laparoscopic Heller's Myotomy. J Laparoendosc Adv Surg Tech A 2009; 19:687-9. [PMID: 19694563 DOI: 10.1089/lap.2008.0156] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Boma T. Adikibi
- Department of Pediatric Surgery, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Gordon A. MacKinlay
- Department of Pediatric Surgery, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Fraser D. Munro
- Department of Pediatric Surgery, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Lucy R. Khan
- Department of Pediatric Surgery, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Peter M. Gillett
- Department of Pediatric Surgery, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
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Abstract
Achalasia is a rare motor disorder of the oesophagus. As its etiology and pathogenesis are still unclear, the treatment nowadays is focused on relief of symptoms. At present, treatment options for achalasia include pharmacotherapy, endoscopic botulinum toxin injection, endoscopic dilation, endoscopic microwave therapy and surgery therapy. In this article, we will review the recent advances in the treatment of achalasia.
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Laparoscopic esophagomyotomy for achalasia: how I do it. J Gastrointest Surg 2009; 13:542-9. [PMID: 18594931 DOI: 10.1007/s11605-008-0574-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Accepted: 06/04/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The pathophysiology, diagnosis, and treatment options for achalasia are briefly discussed, followed by a description of the minimally invasive surgical approaches to this disease, as practiced by the authors. SUMMARY Laparoscopic myotomy is performed routinely at our institution in the lithotomy position under endoscopic control. The techniques for performing the myotomy, the use of fundoplication, and the adaptation of this approach to use the surgical robot are described. Laparoscopic esophagomyotomy has been highly effective, durable, safe, and widely accepted by patients. There is less data about the robotic approach, but increased degrees of freedom afforded by articulation in the instruments promises finer control and possibly lower perforation rates.
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Abstract
BACKGROUND Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes mostly come from cohort studies. OBJECTIVE To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia. METHODS A systematic electronic Medline literature search of articles on esophageal achalasia. Treatment options reviewed included EBTI, EBD, and surgical myotomy using open and minimally invasive techniques. Main outcome measures were frequency of symptom relief, prevalence of post-treatment gastroesophageal reflux (GER), and complications. Outcome probability was estimated using weighted averages of the sample prevalence in each study, with weights equal to the number of patients. Outcomes, within or across studies, were compared using meta-analysis and meta-regression, respectively. RESULTS A total of 105 articles reporting on 7855 patients were selected, tabulated and reviewed. Symptom relief after EBD was better than after EBTI (68.2% vs. 40.6%; OR 3.4; 95% CI, 1.2-9.8; P = 0.02), and the need for additional therapy was greater for patients receiving EBTI (46.6% vs. 25%; OR, 2.6; 95% CI, 1.05-6.5; P = 0.04). Laparoscopic myotomy, when combined with an antireflux procedure, provided better symptom relief (90%) than all endoscopic and other surgical approaches and a low complication rate (6.3%). The incidence of postoperative GER was lower when a fundoplication was added to a laparoscopic myotomy (31.5% without a fundoplication vs. 8.8% with; OR, 6.3; 95% CI, 2.0-19.4; P = 0.003). CONCLUSIONS EBD is superior to EBTI. Laparoscopic myotomy with fundoplication was the most effective surgical technique and can be considered the operative procedure of choice.
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Agrawal S, Super P. Laparoscopic Heller Myotomy for Achalasia: Changing Trend Toward “True” Day-Case Procedure. J Laparoendosc Adv Surg Tech A 2008; 18:785-8. [DOI: 10.1089/lap.2008.0057] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sanjay Agrawal
- Department of General and Upper GI Surgery, Birmingham Heartlands Hospital, Birmingham, United Kingdom
| | - Paul Super
- Department of General and Upper GI Surgery, Birmingham Heartlands Hospital, Birmingham, United Kingdom
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Tsuboi K, Omura N, Yano F, Kashiwagi H, Yanaga K. Results after laparoscopic Heller-Dor operation for esophageal achalasia in 100 consecutive patients. Dis Esophagus 2008; 22:169-76. [PMID: 19018850 DOI: 10.1111/j.1442-2050.2008.00891.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The laparoscopic Heller-Dor operation has been the procedure of choice for the treatment of achalasia. However, because the incidence of achalasia is low, reports on the outcome of surgical treatment for achalasia are limited. In this study, the therapeutic results after laparoscopic Heller-Dor operation for achalasia at a single university hospital were evaluated. Between August 1994 and July 2006, 100 consecutive patients underwent laparoscopic Heller-Dor operation. The therapeutic results after laparoscopic Heller-Dor operation were assessed based on complications, operation time, blood loss, postoperative hospital stay, and the standardized questionnaire for satisfaction by telephone or outpatient clinic interview. With respect to perioperative complications, lower esophageal mucosal perforation occurred in 14 patients, but all of them could be suture-obliterated laparoscopically. One patient was converted to laparotomy because of uncontrolled bleeding from the short gastric artery. The mean operative time was 169 minutes, and the mean perioperative blood loss was 22 mL. The median postoperative hospital stay was 7 days. Reflux esophagitis, which was seen in five patients, was treated successfully with a proton pump inhibitor. According to the standardized questionnaire for satisfaction, 77 patients rated their recovery as 'excellent', 17 as 'good', 4 as 'fair', and 2 as 'poor'; thus, the overall success rate was 94%. There were no significant differences in surgical outcomes by morphologic type and severity of esophageal dilatation; however, the success rate deteriorated significantly with progression of the morphologic type. Laparoscopic Heller-Dor operation is a safe and effective surgical treatment for achalasia.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan.
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Leconte M, Douard R, Gaudric M, Dousset B. [Surgical management of primary esophageal motility disorders]. JOURNAL DE CHIRURGIE 2008; 145:428-436. [PMID: 19106862 DOI: 10.1016/s0021-7697(08)74651-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Primary esophageal motility disorders are rare, the most common diagnoses being achalasia and diffuse esophageal spasm. Treatment aims to alleviate symptoms and may be medical, endoscopic, or surgical. Achalasia is most commonly treated by pneumatic dilatation or by laparoscopic Heller cardiomyotomy. Pneumatic dilatation is effective in 60-80% of cases, but functional results deteriorate over time. Surgical treatment is indicated when endoscopic dilatation is contraindicated or has failed. Functional results after cardiomyotomy are satisfactory in 90% of cases and results appear to be stable over time. The need for an associated antireflux procedure and the type of fundoplication remain controversial. For diffuse esophageal spasm, extended esophageal myotomy has yielded satisfactory functional results, but surgical treatment should be reserved for selected patients with severe symptoms.
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Affiliation(s)
- M Leconte
- Service de chirurgie digestive et endocrinienne, hôpital Cochin - Paris.
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31
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Minimally-Invasive Esophagomyotomy in 200 Consecutive Patients: Factors Influencing Postoperative Outcomes. Ann Thorac Surg 2008; 85:1729-34. [PMID: 18442574 DOI: 10.1016/j.athoracsur.2007.11.017] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 11/05/2007] [Accepted: 11/06/2007] [Indexed: 01/10/2023]
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Pneumatic Balloon Dilation Therapy Is as Effective as Esophagomyotomy for Achalasia. Dysphagia 2008; 23:155-60. [DOI: 10.1007/s00455-007-9115-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2007] [Accepted: 07/03/2007] [Indexed: 01/09/2023]
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Esophagus Benign Diseases of the Esophagus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kawasaki N, Suzuki Y, Omura N, Tsuboi K, Matsumoto A, Kashiwagi H, Yanaga K. Achalasia Complicated by Multiple Intramucosal Carcinomas: Report of a Case. Surg Today 2007; 37:897-900. [PMID: 17879043 DOI: 10.1007/s00595-007-3505-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2006] [Accepted: 02/21/2007] [Indexed: 12/13/2022]
Abstract
A 56-year-old woman underwent a laparoscopic Heller-Dor operation for esophageal achalasia in June 2002. As dysphagia became exacerbated and the oral intake became extremely poor, an esophagectomy was thus considered to be indicated. In September 2005, a transhiatal esophagectomy was performed, and the esophagus was reconstructed using a gastric tube through the posterior mediastinum. The patient developed pneumonia postoperatively, but responded to conservative therapy and was discharged in good health 30 days after surgery. A histopathological analysis demonstrated degeneration and a loss of gangliocytes throughout the esophagus as well as the presence of seven intramucosal cancers. The main cause of dysphagia was due to a marked flexion of the upper esophagus. Even though we identified a precancerous state, we believe that surgery was an appropriate option in this case.
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Affiliation(s)
- Naruo Kawasaki
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo 105-8461, Japan
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Ferulano GP, Dilillo S, D'Ambra M, Lionetti R, Brunaccino R, Fico D, Pelaggi D. Short and long term results of the laparoscopic Heller-Dor myotomy. The influence of age and previous conservative therapies. Surg Endosc 2007; 21:2017-23. [PMID: 17705085 DOI: 10.1007/s00464-007-9506-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Revised: 03/12/2007] [Accepted: 03/24/2007] [Indexed: 02/07/2023]
Abstract
AIMS To evaluate the long-term outcome and quality of life (QoL) data, and to assess the potential influence of age and different conservative procedures on laparoscopic surgery. BACKGROUND Current therapies for achalasia can palliate dysphagia, but other symptoms may persist, making it difficult to quantify and compare. To understand if they could influence results, we analyzed short- and long-term results and correlated them to age and previous conservative treatments using a specific QoL test. METHODS Functional examinations (endoscopy, 24-hr pH manometry, upper GI X-rays) and the gastrointestinal quality of life index (GIQLI) were used before and after a laparoscopic Heller-Dor myotomy. Data were analyzed by the Mann-Whitney U test, Wilcoxon signed rank test, and Spearman's rho coefficient for bivariate correlations (p < 0.05). RESULTS From January 1996 to January 2004, 31 consecutive patients out of 35 diagnosed with achalasia, in clinical stages I-III, were operated on by laparoscopy . Two groups were identified using the break point of 70 years of age, (20 younger and 15 older) and two subgroups according to the conservative therapy performed (20, none; 15, some). Patients underwent a clinical manometry evaluation at six and 12 months, and then yearly, and pH-metry at six, 24, and 60 months. In 78% of patients dysphagia disappeared and the incidence of reflux was 13%. Age and previous treatments did not influence surgical outcome. Patients completed a GIQLI questionnaire before surgery, six months after surgery, and then yearly (for five years). The median preoperative GIQLI score was 78 (range 38-109) out of a theoretical maximum score of 144. At a median follow-up of 49 months (range 24-72 months), the score had significantly improved to 115 (range 71-140). There was no significant statistical difference between the groups. CONCLUSIONS Laparoscopic Heller-Dor myotomy is an effective palliation for achalasia; the long-term outcome is not significantly affected by preoperative conservative treatments or by the age of the patients. The GIQLI questionnaire is a reliable instrument to compare the impact of achalasia symptoms on health-related QoL before and after surgery.
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Abstract
Achalasia is a rare motor disorder of the oesophagus, characterised by the absence of peristalsis and impaired swallow-induced relaxation. These motor abnormalities result in stasis of ingested food in the oesophagus, leading to clinical symptoms, such as dysphagia, regurgitation of food, retrosternal pain and weight loss. Although it is well demonstrated that loss of myenteric oesophageal neurons is the underlying problem, it still remains unclear why these neurons are preferentially attacked and destroyed by the immune system. This limited insight into pathophysiology explains the fact that treatment is limited to interventions aimed at reducing the pressure of the lower oesophageal sphincter. The most successful therapies are clearly pneumatic dilatation and Heller myotomy with short-term success rates of 70-90%, declining to 50-65% after more than 15 years. The challenge for the coming years will undoubtedly be to get more insight into the underlying disease mechanisms and to develop a treatment to restore function.
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Affiliation(s)
- G E E Boeckxstaens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Diamantis T, Pikoulis E, Felekouras E, Tsigris C, Arvelakis A, Karavokyros I, Bastounis E. Laparoscopic esophagomyotomy for achalasia without a complementary antireflux procedure. J Laparoendosc Adv Surg Tech A 2007; 16:345-9. [PMID: 16968179 DOI: 10.1089/lap.2006.16.345] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Achalasia is a progressive motility disorder of the esophagus, without a definitive cure. The principal method of palliation is myotomy of the distal esophagus. We analyzed the 5-year experience at our institution with laparoscopic Heller myotomy without an antireflux procedure to determine its results, particularly regarding postoperative gastroesophageal reflux. MATERIALS AND METHODS Thirty-three patients, mean age 43 years (range, 29-62 years) with clinical, manometric, x-ray, and endoscopic proof of achalasia were operated on and followed up for 24 months. Prior to being referred to surgery they had all undergone at least one pneumatic balloon dilation. The operative technique was a 7-cm myotomy that included the lower esophageal sphincter but did not exceed 5 mm of the gastric cardia. Follow-up consisted of clinical observation, cineesophagography, and 24-hour pHmetry. RESULTS All patients reported satisfactory to excellent results regarding dysphagia and no heartburn two years after the operation. The 24-hour pHmetry and the radiographic investigation showed no evidence of gastroesophageal reflux. CONCLUSION It seems that the risk of gastroesophageal reflux is very low when the cardiomyotomy does not exceed the length of 5 mm. Our results are in accordance with other observational studies as well as larger cohort and meta-analysis studies. Prospective randomized studies are needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.
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Lake JM, Wong RKH. Review article: the management of achalasia - a comparison of different treatment modalities. Aliment Pharmacol Ther 2006; 24:909-18. [PMID: 16948803 DOI: 10.1111/j.1365-2036.2006.03079.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Achalasia is an uncommon primary oesophageal motor disorder with an unknown aetiology. Therapeutic options for achalasia are aimed at decreasing the lower oesophageal sphincter pressure, improving the oesophageal empting, and most importantly, relieving the symptoms of achalasia. Modalities for treatment include pharmacologic, endoscopic, pneumatic dilatation and surgical. The decision of which modality to use involves the consideration of multiple clinical and economic factors. AIM To review the management strategies currently available for achalasia. METHODS A Medline search identified the original articles and reviews the published in the English language literature between 1966 and 2006. RESULTS The results reveal that pharmacotherapy, injection of botulinum toxin, pneumatic dilatation and minimally invasive surgical oesophagomyotomy are variably effective at controlling the symptoms of achalasia but that each modality has specific strengths and weaknesses which make them each suitable in certain populations. Overall, pharmacologic therapy results in the shortest lived, least durable response followed by botulinum toxin injection, pneumatic dilatation and surgery, respectively. CONCLUSION The optimal treatment for achalasia remains an area of controversy given our lack of complete understanding about the pathophysiology of the disease as well as the high numbers of clinical relapse after treatment. Further research focusing on optimal dosing of botulinum toxin injection and optimal timing of repeated graduated pneumatic dilatations could add to our knowledge regarding long-term therapy.
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Affiliation(s)
- J M Lake
- Department of Medicine, Walter Reed Army Medical Center, Gastroenterology Service, Uniformed Services University of the Health Sciences, Washington, DC 20307, USA
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Katada N, Sakuramoto S, Kobayashi N, Futawatari N, Kuroyama S, Kikuchi S, Watanabe M. Laparoscopic Heller myotomy with Toupet fundoplication for achalasia straightens the esophagus and relieves dysphagia. Am J Surg 2006; 192:1-8. [PMID: 16769266 DOI: 10.1016/j.amjsurg.2006.01.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2005] [Revised: 01/15/2006] [Accepted: 01/15/2006] [Indexed: 12/29/2022]
Abstract
BACKGROUND A standard procedure for the treatment of achalasia remains to be established. We assessed the usefulness of a laparoscopic Heller myotomy with a Toupet fundoplication (LHT). METHODS LHT was performed in 30 patients (12 men, 18 women; mean age, 41.8 y) who had esophageal achalasia with severe dysphagia. Caution was exercised when the esophagus was pulled downward and straightened. Symptoms and esophageal function were evaluated before and after surgery. RESULTS The esophagus was straightened surgically in 22 (88%) of 25 patients with esophageal curvature on preoperative esophagography. The dysphagia score decreased to 1.7 +/- 1.2 (mean +/- SD) points from a preoperative value of 10. The lower esophageal sphincter pressure decreased significantly. Two patients (7%) had esophageal diverticula as postoperative sequelae. Pathologic acid reflex was noted in 3 patients (12%). CONCLUSIONS LHT is a useful procedure for straightening the esophagus, reducing lower esophageal sphincter pressure, and relieving dysphagia in patients with achalasia.
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Affiliation(s)
- Natsuya Katada
- Department of Surgery, School of Medicine, Kitasato University 2-1-1, Asamizodai, Sagamihara, Kanagawa 228-8520, Japan.
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Abstract
In 1987 Mouret performed the first laparoscopic cholecystectomy, starting a revolution in surgery. For paediatricians it is difficult to appreciate the magnitude of what has occurred in this short period. The development of minimal access techniques represents the most significant change in surgical practice since the introduction of aseptic technique or safe anaesthesia. As with many innovations, rapid change, technical language, and the evangelism of pioneers has left confusion in its wake.
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Affiliation(s)
- B Jaffray
- Department of Clinical Medical Sciences, University of Newcastle upon Tyne, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK.
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Campo SMA, Balsamo G, Zullo A, Hassan C, Morini S. Management of idiopathic achalasia: drugs, balloon or knife? Expert Opin Ther Pat 2005. [DOI: 10.1517/13543776.14.3.367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Tello E, de la Garza L, Valdovinos MA, Tielve M, Valdovinos F, Herrera MF. Laparoscopic Heller myotomy for classic achalasia: results of our initial series of 20 patients. Surg Endosc 2005; 19:338-41. [PMID: 15645330 DOI: 10.1007/s00464-003-8285-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2003] [Accepted: 07/29/2004] [Indexed: 01/24/2023]
Abstract
BACKGROUND The aim of this study was to review our results in the surgical management of achalasia by laparoscopic esophageal cardiomyotomy and partial fundoplication. METHODS The patient population was comprised of a consecutive series of 20 patients with classic achalasia who underwent laparoscopic cardiomyotomy and partial fundoplication. Clinical, radiological, and physiological characteristics were analyzed prospectively, with an emphasis on the outcome and complications. RESULTS There were 12 women and eight men; their mean age was 37 years. Four intraoperative complications occurred-two mucosal perforations that were resolved laparoscopically and two cases of pneumothorax. The median hospital stay was 4 days (range, 2-14) and the median time to start oral feeding was 3 days (range, 1-7). After a median follow-up of 14 months (range, 2-83), 16 patients were asymptomatic and four had mild heartburn and/or dysphagia. All patients gained weight (median, 8.0 kg; range, 1-23). We observed a median postoperative decrease in esophageal diameter of 1.6 cm (range, 0.2-2.9). Fifteen patients were subjected to physiological esophageal studies; the results showed that power esophageal sphincter pressure had decreased from 32 (range, 15-60) to 12 mmHg (range, 6-25). The median DeMeester score was 14.5 (range, 0.9-194). The median esophageal acid exposure was 3% (range 0-34.6). CONCLUSIONS Our initial experience with the laparoscopic management of classic achalasia yielded satisfactory clinical, radiological, and physiological results.
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Affiliation(s)
- E Tello
- Department of Surgery, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Tlalpan 14000, Mexico
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Affiliation(s)
- William O Richards
- Department of Surgery, Vanderbilt University Medical School, Nashville, Tennessee, USA
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Abstract
OBJECTIVE We sought to assess the long-term outcome of Heller myotomy and anterior fundoplication in patients with achalasic sigmoid esophagus. METHODS Fourteen patients with achalasia and sigmoid esophagus (median age, 42.5 years) operated on by the same surgeon through a laparotomy (n = 8) or laparoscopic approach (n = 6) between 1985 and 2000 were evaluated. According to a 4-grade classification (1, no symptoms; 4, persistent symptoms), both dysphagia and regurgitation had a median score of 4.0. Five patients complained of respiratory symptoms. Six patients had undergone previous pneumatic dilation. Preoperative and postoperative workup included an esophagogram, esophagoscopy, manometry, and health-related quality-of-life assessment with the Short-Form 36-item questionnaire. RESULTS Median follow-up was 85 months. At 24 months, esophageal width decreased by 10 mm (P =.003), and the change correlated inversely with the age of the patients (R = -0.61; P =.02). Lower esophageal sphincter pressure decreased by 17 mm Hg (P =.001), and both dysphagia and regurgitation scores decreased to 1.0 (P <.003). Comparison with the results of 37 patients with earlier-stage achalasia showed no difference in changes of esophageal width, lower esophageal sphincter pressure, dysphagia score, and regurgitation score. Quality-of-life Short-Form 36-item questionnaire domains, including general health, social functioning, and vitality, improved significantly. Overall results were classified as excellent or good in 10 patients and as satisfactory and unsatisfactory in 2 patients each. No patient required esophagectomy or had esophageal carcinoma. CONCLUSIONS In this study Heller myotomy proved effective in improving subjective, objective, and quality-of-life outcome measures in patients with achalasic sigmoid esophagus and should be considered as the first-choice treatment for this severe condition.
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Douard R, Gaudric M, Chaussade S, Couturier D, Houssin D, Dousset B. Functional results after laparoscopic Heller myotomy for achalasia: A comparative study to open surgery. Surgery 2004; 136:16-24. [PMID: 15232534 DOI: 10.1016/j.surg.2004.01.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prospective studies comparing laparoscopic to open Heller myotomy for esophageal achalasia are lacking. The aim of this study was to compare functional outcome after laparoscopic and open Heller myotomy for esophageal achalasia. METHODS Eighty-two patients who underwent Heller-Dor myotomy for achalasia, via laparoscopy (n=52) or open surgery (n=30) were recorded prospectively (1993-2002). Median follow-up was 51 (12-111) months. Perioperative functional data were assessed via dysphagia and overall clinical (dysphagia, chest pain, regurgitation, gastroesophageal reflux) scores. RESULTS In laparoscopy patients, the operative time was longer (145 [95-290] vs 120 [70-230] minutes, P <.0001); the postoperative hospital stay and feeding resumption time was shorter (4 [2-25] vs 7.5 [5-18] days, P <.0001 and 2 [1-15] vs 4 [1-14] days, P <.0001). Three mucosal tears necessitated conversion to open surgery (6%). The rates of " excellent" or " satisfactory" results after laparoscopic and open surgery were 92% (n=48/52) versus 93% (n=28/30), and 83% (n=43/52) versus 83% (n=25/30) on overall clinical score. In both groups, the overall clinical score indicated significant improvement during 12-month follow-up. The laparoscopy and open surgery symptomatic gastroesophageal reflux rates were 10% and 7%, respectively. CONCLUSIONS Laparoscopic Heller myotomy favorably compares with open surgery regarding dysphagia relief and gastroesophageal reflux rate. Overall clinical score indicates gradual improvement in patient functional status during 12-month follow-up.
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Affiliation(s)
- Richard Douard
- Department of Surgery, Cochin University Hospital, Paris, France
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Valezi AC, Mali Júnior J, Marson AC, Brito EMD, Souza JCLD. Tratamento do megaesôfago chagásico grau II por laparoscopia: experiência em 12 casos. Rev Col Bras Cir 2004. [DOI: 10.1590/s0100-69912004000300002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar os resultados da cardiomiotomia com fundoplicatura parcial por vídeolaparoscopia (Heller-Dor) no tratamento de 12 pacientes portadores de megaesôfago grau II. MÉTODO: Foram analisados prospectivamente 12 pacientes com megaesôfago não avançado (grau II segundo classificação de Ferreira - Santos ), submetidos a cardiomiotomia à Heller por laparoscopia associado à confecção de vávula anti-refluxo ( fundoplicatura à Dor ), no Hospital Universitário da Universidade Estadual de Londrina, no período de Janeiro de 1999 a Dezembro de 2001. RESULTADOS: Não houve necessidade de conversão para laparotomia em nenhum caso. A pressão média do esfincter inferior do esôfago ( EIE ) no pré-operatório foi de 39,1 mmHg (normal de 15 a 30 mm Hg), e no pós-operatório (seis meses) de 12,5 mmHg. Em relação à sintomatologia pós-operatória, nove dos 12 pacientes ficaram assintomáticos, sendo que três pacientes apresentaram disfagia, sialorréia e pirose, respectivamente. Ocorreram três complicações intra-operatórias: dois casos de perfuração gástrica e um de perfuração esofágica. Não houve mortalidade no intra ou pós-operatório. CONCLUSÕES: Podemos concluir, baseado neste estudo, que a cardiomiotomia a Heller associada à fundoplicatura a Dor por vídeo-laparoscopia, após seis meses de acompanhamento, mostrou-se eficaz no tratamento do megaesôfago grau II.
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Abstract
Achalasia is a condition of unknown etiology. It represents a motor disorder of the esophagus characterized by absent or incomplete relaxation of the lower esophageal sphincter upon swallowing and by non-propulsive swallow-induced contraction waves or amotility of the esophageal body. Dysphagia and regurgitation of ingesta are the most frequent symptoms. Medical treatment, i.e. by calcium-channel blockers and nitric oxide donors, may be tried in patients with mild dysphagia or in elderly patients but rarely yields adequate symptom relief. Mechanical dilatation of the achalasic sphincter may be performed as an initial treatment option. Intrasphincteric injections of botulinum toxin seemed to be a promising alternative, but it has become obvious that, in most cases, repeated applications of the toxin are required to maintain patients symptom-free. Myotomy of the achalasic sphincter with or without fundoplication to prevent gastroesophageal reflux, is employed mainly in patients in whom dilatations have failed, but since the introduction of minimally invasive surgery, myotomy has become the primary treatment at many centers. This article aims to provide an overview of the development of the conservative and surgical treatment of achalasia.
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Affiliation(s)
- Enrico P Cosentini
- Klinische Abteilung für Allgemeinchirurgie, Universitätsklinik für Chirurgie, Wien, Osterreich.
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Bloomston M, Durkin A, Boyce HW, Johnson M, Rosemurgy AS. Early results of laparoscopic Heller myotomy do not necessarily predict long-term outcome. Am J Surg 2004; 187:403-7. [PMID: 15006571 DOI: 10.1016/j.amjsurg.2003.12.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2003] [Revised: 08/11/2003] [Indexed: 11/23/2022]
Abstract
BACKGROUND We sought to evaluate how patients' symptoms evolve after laparoscopic Heller myotomy. METHODS Before and after laparoscopic Heller myotomy, 88 patients graded dysphagia and heartburn on a Likert scale (0 = none; 5 = severe). Patients graded outcomes as excellent, good, fair, or poor. Outcomes were compared in the same patients at 1 and 3 years of follow-up. RESULTS At early follow-up (10.6 +/- 7.8 months) significant reductions were noted in dysphagia (11% versus 100%), dysphagia scores (0.6 +/- 1.1 versus 4.7 +/- 0.7), heartburn (31% versus 72%), and heartburn scores (1.2 +/- 1.6 versus 2.7 +/- 1.9). By late follow-up (37.6 months +/- 18.0) these values increased (47%, 1.9 +/- 1.7, 48%, 1.8 +/- 1.5, respectively) but remained significantly reduced compared with before operation. Excellent/good outcomes at early and late follow-up were 89% and 85%, respectively (P = not significant). CONCLUSIONS Laparoscopic Heller myotomy is highly effective at palliating the symptoms of achalasia. With time, symptoms may recur owing to esophageal dysmotility, mandating continued surveillance.
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Affiliation(s)
- Mark Bloomston
- Department of Surgery, University of South Florida, P.O. Box 1289, Room F-145, Tampa, FL 33601, USA.
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Kesler KA, Tarvin SE, Brooks JA, Rieger KM, Lehman GA, Brown JW. Thoracoscopy-assisted Heller myotomy for the treatment of achalasia: results of a minimally invasive technique. Ann Thorac Surg 2004; 77:385-91; discussion 391-2. [PMID: 14759402 DOI: 10.1016/j.athoracsur.2003.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Several surgical methods have been described to treat achalasia with a recent trend toward utilizing minimally invasive techniques to perform a myotomy. Since 1998 our institution has utilized a minimally invasive thoracoscopy-assisted technique (ThAM) that allows a myotomy to be performed under direct visualization. METHODS From 1992 to 2002, 57 patients underwent transthoracic Heller myotomy at our institution. Thirty-eight patients (67%) who underwent ThAM were reviewed and compared with 19 (33%) who previously underwent myotomy through a standard open left thoracotomy (OM). RESULTS There were no operative deaths in the ThAM group (n = 38) and 4 patients (11%) experienced minor morbidity. Four ThAM patients required conversion to open thoracotomy and 2 were lost to follow-up. Of the remaining 32 patients, 29 have improved postoperative dysphagia scores after a mean follow-up of 17 months. Only 4 patients have required further endoscopic or surgical intervention. Compared with the OM group, ThAM patients experienced significantly shorter average surgery time (97 versus 139 minutes), less blood loss (80 versus 155 mL), less postoperative narcotic requirement (8 versus 20 days), and shorter recovery to normal activity (20 versus 73 days). CONCLUSIONS Thoracoscopy-assisted myotomy results in excellent relief of dysphagia in the short term and would be expected to have long-term results similar to OM. Shorter operating and recovery times as compared with OM without the need for an antireflux procedure makes ThAM an attractive minimally invasive technique.
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Affiliation(s)
- Kenneth A Kesler
- Department of Surgery, Thoracic Division, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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