Successful treatment of esophageal achalasia with laparoscopic Heller myotomy and Toupet fundoplication

Laparoscopic versus robotic-assisted Heller myotomy for the treatment of achalasia: A systematic review with meta-analysis

BACKGROUND

Robotic-assisted laparoscopic Heller myotomy has been proposed as an alternative minimally invasive approach to traditional laparoscopy for the treatment of achalasia. This systematic review aims to compare the safety and post-operative outcomes of the two procedures.

METHODS

Systematic literature search was performed in MEDLINE through Ovid, Scopus and Cochrane to identify clinical trials and retrospective analyses. Outcome measures used for meta-analysis included operative time, estimated blood loss, length of stay, 30-day readmission, intraoperative oesophageal perforation, conversion, mortality, morbidity, symptom relief beyond 1 year, re-intervention for recurrent symptoms and gastroesophageal reflux during follow-up rates.

RESULTS

Seven studies were selected with a total of 3214 patients. The only factor to be statistically different is intraoperative oesophageal perforation rate, which is lower in robotic-assisted Heller myotomy compared to laparoscopic (odds ratio = 0.1139; 95% confidence interval [0.0334, 0.3887]; p = 0.0005).

CONCLUSIONS

The results suggest a robotic approach is associated with improved patient safety.

Peroral endoscopic myotomy (POEM) for achalasia

Achalasia is an uncommon disorder that results from the degeneration of ganglion cells of the myenteric plexus in the lower esophageal wall. It is manifested by a loss of peristalsis in the lower part of the esophagus and failure of the lower esophageal sphincter (LES) to relax. Peroral endoscopic myotomy (POEM) is a minimally invasive intervention that aims to treat achalasia. It is regarded as the endoscopic equivalent of Heller myotomy. POEM is a form of natural orifice transluminal endoscopic surgery that is completed by creating a submucosal tunnel in the lower part of esophagus to reach the inner circular muscle bundles of the LES to perform myotomy, while preserving the outer longitudinal muscle bundles. The result is decreased resting pressure of the LES, facilitating the passage of ingested material. POEM was initially introduced to treat achalasia by targeting the LES. POEM has expanded to include gastric POEM (G-POEM), myotomy of the pyloric sphincter to treat gastroparesis, and per rectal endoscopic myotomy to treat adult Hirschsprung's disease.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

GERD after per-oral endoscopic myotomy as compared with Heller's myotomy with fundoplication: a systematic review with meta-analysis

BACKGROUND AND AIMS

Per-oral endoscopic myotomy (POEM) represents a less invasive alternative to conventional laparoscopic Heller's myotomy (LHM) for patients with achalasia. It cannot be excluded, however, that the lack of fundoplication after POEM may result in a higher incidence of reflux disease, as compared with LHM. The aim of our study was to conduct a systematic review of prospective studies reporting the incidence of reflux disease developed after POEM and LHM.

METHODS

A literature search with electronic databases was performed (up to February 2017) to identify full articles on the incidence of gastroesophageal reflux symptoms and endoscopic monitoring and pH monitoring findings after POEM and LHM (with fundoplication). Proportions and rates were pooled by means of random or fixed-effects models, according to the level of heterogeneity between studies.

RESULTS

After we applied the selection criteria, 17 and 28 studies, including 1542 and 2581 participants who underwent POEM and LHM, respectively, were included. The pooled rate of postprocedural symptoms was 19.0% (95% confidence interval [CI], 15.7%-22.8%) after POEM and 8.8% (95% CI, 5.3%-14.1%) after LHM, respectively. The pooled rate estimate of abnormal acid exposure at pH monitoring was 39.0% (95% CI, 24.5%-55.8%) after POEM and 16.8% (95% CI, 10.2%-26.4%) after LHM, respectively. The rate of esophagitis after POEM was 29.4% (95% CI, 18.5%-43.3%) after POEM and 7.6% (95% CI, 4.1%-13.7%) after LHM. At meta-regression, heterogeneity was explained partly by the POEM approach and study population.

CONCLUSION

The incidence of reflux disease appears to be significantly more frequent after POEM than after LHM with fundoplication. Monitoring pH and ensuring appropriate treatment after POEM should be considered in order to prevent long-term reflux-related adverse events.

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Identification of risk factors for mucosal injury during laparoscopic Heller myotomy for achalasia

BACKGROUND

Mucosal injury during myotomy is the most frequent complication seen with the Heller-Dor procedure for achalasia. The present study aimed to examine risk factors for such mucosal injury during this procedure.

METHODS

This was a retrospective analysis of patients who underwent the laparoscopic Heller-Dor procedure for achalasia at a single facility. Variables for evaluation included patient characteristics, preoperative pathophysiological findings, and surgeon's operative experience. Logistic regression was used to identify risk factors. We also examined surgical outcomes and the degree of patient satisfaction in relation to intraoperative mucosal injury.

RESULTS

Four hundred thirty-five patients satisfied study criteria. Intraoperative mucosal injury occurred in 67 patients (15.4%). In univariate analysis, mucosal injury was significantly associated with the patient age ≥60 years, disease history ≥10 years, prior history of cardiac diseases, preoperative esophageal transverse diameter ≥80 mm, and surgeon's operative experience with fewer than five cases. In multivariate analysis involving these factors, the following variables were identified as risk factors: age ≥60 years, esophageal transverse diameter ≥80 mm, and surgeon's operative experience with fewer than five cases. The mucosal injury group had significant extension of the operative time and increased blood loss. However, there were no significant differences between the two groups in the incidence of reflux esophagitis or the degree of symptom alleviation postoperatively.

CONCLUSION

The fragile esophagus caused by advanced patient age and/or dilatation were risk factor for mucosal injury during laparoscopic Heller-Dor procedure. And novice surgeon was also identified as an isolated risk factor for mucosal injury.

Long-term outcome following pneumatic dilatation as initial therapy for idiopathic achalasia: an 18-year single-centre experience

BACKGROUND

Relapse after treatment for idiopathic achalasia is common and long-term outcome data are limited.

AIM

To determine the cumulative relapse rate and long-term outcome after pneumatic dilatation (PD) for achalasia in a tertiary referral centre.

METHODS

A retrospective study of 301 patients with achalasia treated with PD as first-line therapy. Short-term outcome was measured at 12 months. Long-term outcome was assessed in those who were in remission at 12 months by cumulative relapse rate and cross-sectional analysis of long-term remission rate regardless of any interval therapy, using a validated achalasia-specific questionnaire.

RESULTS

Eighty-two percent of patients were in remission 12 months following initial PD. Relapse rates thereafter were 18% by 2 years; 41% by 5 years and 60% by 10 years. Whilst 43% patients underwent additional treatments [PD (29%), myotomy (11%) or botulinum toxin (3%)] beyond 12 months, 32% of those who had not received interval therapy had relapsed at cross-sectional analysis. After a mean follow-up of 9.3 years, regardless of nature, timing or frequency of any interval therapy, 71% (79/111) patients were in remission. The perforation rate from PD was 2%. Chest pain had a poor predictive value (24%) for perforation.

CONCLUSIONS

Long-term relapse is common following pneumatic dilatation. While on-demand pneumatic dilatation for relapse yields a good response, one-third of relapsers neither seek medical attention nor receive interval therapy. Close follow-up with timely repeat dilatation is necessary for a good long-term outcome. Given the poor predictive value of chest pain for perforation, routine gastrografin swallow is recommended postdilatation.

Impact of minimally invasive surgery on the treatment of benign esophageal disorders

Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a change in the treatment algorithm of benign esophageal disorders. Today a laparoscopic operation is the treatment of choice for esophageal achalasia and for most patients with gastroesophageal reflux disease. Because the pathogenesis of achalasia is unknown, treatment is palliative and aims to improve esophageal emptying by decreasing the functional obstruction at the level of the gastro-esophageal junction. The refinement of minimally invasive techniques accompanied by large, multiple randomized control trials with long-term outcome has allowed the laparoscopic Heller myotomy and partial fundoplication to become the treatment of choice for achalasia compared to endoscopic procedures, including endoscopic botulinum toxin injection and pneumatic dilatation. Patients with suspected gastroesophageal reflux need to undergo a thorough preoperative workup. After establishing diagnosis, treatment for gastroesophageal reflux should be individualized to patient characteristics and a decision about an operation made jointly between surgeon and patient. The indications for surgery have changed in the last twenty years. In the past, surgery was often considered for patients who did not respond well to acid reducing medications. Today, the best candidate for surgery is the patient who has excellent control of symptoms with proton pump inhibitors. The minimally invasive approach to antireflux surgery has allowed surgeons to control reflux in a safe manner, with excellent long term outcomes. Like achalasia and gastroesophageal reflux, the treatment of patients with paraesophageal hernias has also seen a major evolution. The laparoscopic approach has been shown to be safe, and durable, with good relief of symptoms over the long-term. The most significant controversy with laparoscopic paraesophageal hernia repair is the optimal crural repair. This manuscript reviews the evolution of these techniques.

[Achalasia: role of endoscopic therapy and surgery]

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.

Evolution of the minimally invasive treatment of esophageal achalasia

Thanks to the advent of laparoscopic techniques, the last decade and a half have witnessed a radical change in the treatment of esophageal achalasia. Because of the high success rate of the laparoscopic Heller myotomy, surgery has now become in many centers the first modality of treatment for achalasia. This shift in the treatment algorithm reflects the fact that laparoscopic Heller myotomy with partial fundoplication outperforms nonsurgical approaches, such as balloon dilatation and intrasphincteric botulinum toxin injection.

Evolution of the minimally invasive treatment of esophageal achalasia

Thanks to the advent of laparoscopic techniques, the last decade and a half have witnessed a radical change in the treatment of esophageal achalasia. Because of the high success rate of the laparoscopic Heller myotomy, surgery has now become in many centers the first modality of treatment for achalasia. This shift in the treatment algorithm reflects the fact that laparoscopic Heller myotomy with partial fundoplication outperforms nonsurgical approaches, such as balloon dilatation and intrasphincteric botulinum toxin injection.

Does illness severity matter? A comparison of laparoscopic esophagomyotomy with fundoplication and esophageal dilation for achalasia

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.

Fundoplication after laparoscopic Heller myotomy for esophageal achalasia: what type?

Because of the high success rate of minimally invasive surgery, a radical shift in the treatment algorithm of esophageal achalasia has occurred. Today, a laparoscopic Heller myotomy is the preferred treatment modality for achalasia. This remarkable change is due to the recognition by gastroenterologists and patients that a laparoscopic Heller myotomy gives better and more durable results than pneumatic dilatation and intrasphincteric injection of botulinum toxin injection, while it is associated to a short hospital stay and a fast recovery time. While there is agreement about the need of a fundoplication in conjunction to the myotomy, some questions still remain about the type of fundoplication: Should the fundoplication be total or partial, and in case a partial fundoplication is chosen, should it be anterior or posterior? The following review describes the data present in the literature in order to identify the best procedure that can achieve prevention or control of gastroesophageal reflux after a myotomy without impairing esophageal emptying.

Laparoscopic esophagomyotomy for achalasia: how I do it

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.

Prevention of post-operative leak following laparoscopic Heller myotomy

PURPOSE

Laparoscopic Heller myotomy is the preferred treatment for achalasia. Post-operative leaks cause significant morbidity and impair functional outcome. This study assesses the efficacy of intra-operative leak testing on post-operative leak rate.

METHODS

A retrospective analysis of 106 consecutive patients undergoing laparoscopic Heller myotomy by a single surgeon between November 2001 and August 2006 was undertaken. Intra-operative leak testing was performed in all patients. Variables associated with intra-operative mucosotomy were assessed by univariate analysis and logistic regression modeling.

RESULTS

Intra-operative mucosotomy occurred in 25% of patients. All mucosotomies were repaired primarily and tested with methylene-blue-stained saline. Dor fundoplication was performed in 74% of the patients. There were no post-operative leaks and patients were started on diet day of surgery. Mean LOS was 1.4(+/-0.7) days. Logistic regression modeling demonstrated that prior myotomy was associated with a statistically significant increase in the rate of mucosotomy (p = 0.033), while previous botox injection (p = 0.193), pneumatic dilation (p = 0.599) or concomitant hiatal hernia (p = 0.874) were not significantly associated with mucosotomy.

CONCLUSION

Laparoscopic Heller myotomy for the treatment of achalasia is a safe procedure. Intra-operative leak testing minimizes the risk of post-operative leaks and expedites post-operative management. Prior endoscopic treatment does not impair operative results.

Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis

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.

[Surgical management of primary esophageal motility disorders]

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic re-operation for failed Heller myotomy

Laparoscopic Heller myotomy for achalasia has a 10-20% failure rate and may require re-operation to control persistent or recurrent symptoms. We report follow-up of 15 patients who underwent laparoscopic re-operation for failed Heller myotomy. Between 1993 and 2004, 15 patients underwent laparoscopic re-operation for failed Heller myotomy at our center. The mean duration between procedures was 23 months. Follow-up was completed at a mean duration of 30 months in 14 patients (93%) via a telephone questionnaire. Our overall failure rate for primary surgery (n = 106) was 5.6%. The mechanisms of failure were incomplete myotomy (33%), myotomy fibrosis (27%), fundoplication disruption (13%), too tight fundoplication (7%) and a combination of myotomy fibrosis and incomplete myotomy (20%). Significant symptom improvement was observed with postoperative symptom resolution seen in 71% of patients with dysphagia, 89% for regurgitation, 58% for heartburn and 40% for chest pain. Fifty percent reported excellent results and 79% would recommend the procedure to a friend. Subsequent dilations were performed in four patients (29%). Two patients required conversion to open surgery (13%). Three patients (20%) failed the re-operation and required further revisional surgery. Complications included intraoperative perforation in three (none of which resulted in postoperative morbidity) and a pneumothorax in one patient. Prior endoscopic therapies (pneumatic dilation or Botulinum toxin) were not associated with poor results. Laparoscopic re-operation for failed Heller myotomy is feasible and results are encouraging.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Technique and follow-up of minimally invasive Heller myotomy for achalasia

BACKGROUND

Laparoscopic Heller myotomy has been proven effective. Reliable predictive factors for outcome and the true benefit of the da Vinci robotic system, however, remain unknown.

METHODS

Seventy patients underwent laparoscopic Heller myotomy. The number of intraoperative perforations and the symptom-predictive value of postoperative esophagogram width measurement at the gastroesophageal junction were analyzed.

RESULTS

The overall complication rate was 11%. Four patients experienced intraoperative perforation during the laparoscopic technique. No perforations were experienced with the da Vinci robotic system (n = 19). Of the total, 82% of patients had resolution of dysphagia, 91% of regurgitation, 91% of heartburn and 82% of chest pain. Immediate postoperative esophagogram gastroesophageal junction width demonstrated a positive predictive trend from 0 to 10 mm for dysphagia.

CONCLUSION

Laparoscopic Heller myotomy is an effective treatment for achalasia. Immediate postoperative esophagogram gastroesophageal junction width measurement as a predictor for symptom resolution requires further study.

A total fundoplication is not an obstacle to esophageal emptying after heller myotomy for achalasia: results of a long-term follow up

OBJECTIVE

The aim of this study was to evaluate the role and efficacy of a total 360 degrees wrap, Nissen-Rossetti fundoplication, after esophagogastromyotomy in the treatment of esophageal achalasia.

SUMMARY BACKGROUND DATA

Surgery actually achieves the best results in the treatment of esophageal achalasia; the options vary from a short extramucosal esophagomyotomy to an extended esophagogastromyotomy with an associated partial fundoplication to restore the main antireflux barrier. A total 360 degrees fundoplication is generally regarded as an obstacle to esophageal emptying.

MATERIALS AND METHODS

Since 1992 to November 2003, a total of 195 patients (91 males, 104 females), mean age 45.2 years (range, 12-79 years), underwent laparoscopic treatment of esophageal achalasia. Intervention consisted of Heller myotomy and Nissen-Rossetti fundoplication with intraoperative endoscopy and manometry.

RESULTS

In 3 patients (1.5%), a conversion to laparotomy was necessary. Mean operative time was 75 +/- 15 minutes. No mortality was observed. Overall major morbidity rate was 2.1%. Mean postoperative hospital stay was 3.6 +/- 1.1 days (range, 1-12 days). At a mean clinical follow up of 83.2 +/- 7 months (range, 3-141 months) on 182 patients (93.3%), an excellent or good outcome was observed in 167 patients (91.8%) (dysphagia DeMeester score 0-1). No improvement of dysphagia was observed in 4 patients (2.2%). Gastroesophageal pathologic reflux was absent in all the patients.

CONCLUSIONS

Laparoscopic Nissen-Rossetti fundoplication after Heller myotomy is a safe and effective treatment of esophageal achalasia with excellent results in terms of dysphagia resolution, providing total protection from the onset of gastroesophageal reflux.

Esophageal dilation / dilators

Esophageal dilation is the treatment of choice for most patients with esophageal dysphagia (functional and mechanical). Multiple forms of esophageal dilators are available. Mechanical dilators (guidewire/nonguidewire assisted) are the major forms of dilators used. Balloon dilator use has increased but they offer only a marginal advantage over traditional mechanical dilators at a greatly increased cost (2 degrees to single use). Comparative trials are biased in favor of balloon dilators, but balloon dilators are not indicated for empiric dilation for dysphagia. Empiric dilation for solid food dysphagia is still controversial. Dilation is rarely associated with complications and is rarely contraindicated unless previous dilation attempts have been unsuccessful. Special circumstances such as caustic strictures, radiation stricture, and dysphagia associated with eosinophilic esophagitis should engender cautious dilation. Attention to detail about placement of guidewires and stricture type are still critical for safety. Predilation barium studies are not needed in all patients but should be employed if the endoscope is not able to pass the stricture and stricture length and angulation are unknown. Intralesional steroids and proton pump inhibitor therapy are important adjuvant treatments for resistant strictures and reflux associated strictures. Balloon dilation for achalasia is still a viable alternative, but it is likely to decrease in usage with the advent of more widespread laparoscopic myotomy.

Long-term outcome of pneumatic dilation in the treatment of achalasia

OBJECTIVE

Achalasia is a well-defined esophageal motor disorder for which pneumatic dilation is an established therapeutic method. Even though it has been used for several years, there are limited data on the long-term outcomes of patients treated with this procedure. Hence, we aimed to evaluate the long-term efficacy of pneumatic dilation to control the symptoms of achalasia.

METHODS

The medical records of all patients treated in our unit for achalasia with pneumatic dilation were reviewed. We identified the long-term result of the initial procedure, the date of the first dilation, and the time interval between dilation and retreatment.

RESULTS

Of 260 patients who were treated with pneumatic dilation, 153 (67 men, 86 women) were followed up for more than 5 yr. The mean follow-up period was 11.09 +/- 3.91 yr, and the success rate of the dilation was 75.8%. Among these patients, 35 (19 men, 16 women) had follow-up periods of more than 15 yr. The mean follow-up time of those patients was 16.56 +/- 1.09 yr, and the success rate was 51.4%. Kaplan-Meier survival analysis showed that, overall, 50% of patients develop recurring symptoms after 10.92 yr.

CONCLUSIONS

Although 51.4% of patients continued to be in clinical remission more than 15 yr after the initial pneumatic dilation, the long-term success rate of pneumatic dilation seems to drop progressively with time.

Functional results after laparoscopic Heller myotomy for achalasia: A comparative study to open surgery

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.

Laparoscopic esophagomyotomy for achalasia: does anterior hemifundoplication affect clinical outcome?

OBJECTIVE

To determine whether the addition of anterior hemifundoplication to laparoscopic esophagomyotomy for achalasia yields better clinical outcomes than laparoscopic esophagomyotomy alone.

SUMMARY BACKGROUND DATA

Although hemifundoplication may prevent gastroesophageal reflux after esophagomyotomy for achalasia, it may also lead to persistent dysphagia in these patients with esophageal aperistalsis.

METHODS

This is a retrospective study of 51 consecutive patients (mean age 47.5 +/- 12.6 years) who had laparoscopic esophagomyotomy for achalasia by our group between August 1995 and January 2001. In 29 patients (57%) an anterior hemifundoplication was added to the esophagomyotomy. In 22 patients (43%), no wrap was added. Patients scored (0 = none; 1 = mild; 2 = moderate; 3 = severe) symptom severity (dysphagia, regurgitation, heartburn, chest pain) preoperatively and postoperatively. Weight gain, use of gastrointestinal (GI) medication, tolerance to food, and patient satisfaction were also assessed.

RESULTS

Mean patient follow-up was 33 months, and there were no operative deaths. Four patients were converted to open operation (8%). The wrap and no wrap groups were similar in terms of esophageal dilation, preoperative symptom severity and duration (5.7 +/- 7.1 versus 6.1 +/- 7.0 years), and preoperative weight loss (18 +/- 15 versus 20 +/- 20 pounds). Both groups had similar improvement in symptom grade postoperatively and equivalent satisfaction rates (86%). Postoperative weight gain, GI medication use, and food intolerance was also similar. Postoperatively, patients in the wrap group did not have higher dysphagia scores or lower heartburn scores than the no wrap group.

CONCLUSION

The addition of anterior hemifundoplication to esophagomyotomy for achalasia does not improve or worsen clinical results.

Laparoscopic Heller myotomy and fundoplication: findings and predictive value of early postoperative radiographic studies

BACKGROUND

We describe the findings on esophagography, the frequency and appearance of leaks after laparoscopic Heller myotomy and fundoplication, and the utility of early postoperative studies for predicting clinical outcome.

METHODS

Our study group consisted of 40 patients who underwent laparoscopic Heller myotomy and fundoplication in whom radiographic studies were performed during the early postoperative period. The radiographic reports and images were reviewed to determine the esophageal diameter, visualization or nonvisualization of the wrap, and the presence or absence of a leak. The esophageal diameter subsequently was correlated with the clinical findings to determine whether this was a useful parameter for predicting clinical outcome.

RESULTS

Two patients (5%) had small, sealed-off leaks on radiographic studies, and four (10%) had pseudo-leaks resulting from trapping of contrast material alongside the fundoplication wrap. Twelve (60%) of 20 patients with a dilated esophagus had esophageal symptoms on short-term follow-up versus three (15%) of 20 with a normal-caliber esophagus (p = 0.008), and five (56%) of nine patients with a dilated esophagus had symptoms on long-term follow-up versus six (43%) of 14 with a normal-caliber esophagus (p = 0.68).

CONCLUSION

Radiographic studies are useful for showing leaks after laparoscopic Heller myotomy and fundoplication, but radiologists should differentiate true leaks from trapping of contrast material alongside the fundoplication wrap. The caliber of the esophagus on early postoperative studies is also a useful parameter for predicting short-term clinical outcome in these patients.

Tratamento do megaesôfago chagásico grau II por laparoscopia: experiência em 12 casos

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.

Preoperative lower esophageal sphincter pressure affects outcome of laparoscopic esophageal myotomy for achalasia

The primary aim of this study was to identify factors that influence outcome of the surgical treatment of achalasia. A secondary aim was to compare outcomes after laparoscopic Heller myotomy and partial fundoplication using either a Dor or Toupet hemifundoplication. Between 1994 and 2002, a total of 78 patients underwent laparoscopic Heller myotomy and partial fundoplication. Preoperative investigations included esophageal manometry, a videoesophogram, and upper gastrointestinal endoscopy with biopsy. In 64 patients (35 males and 29 females), telephone contact was possible at a median 24 months (IQR 14-34). A Dor fundoplication was performed in 41 patients and a Toupet fundoplication in 23. Symptoms were assessed prior to surgery and at follow-up by an independent physician using standardized definitions to grade the severity of dysphagia, regurgitation, and chest pain. To assess outcome, dysphagia was categorized as persistent or resolved. Persistent was defined as dysphagia that occurred on a weekly or daily basis. Resolved was defined as dysphagia that occurred occasionally or not at all. At follow-up, patients were asked to make a personal evaluation of their outcome as to whether (1) their swallowing was improved by the procedure, (2) they were satisfied with the outcome, and (3) they would undergo surgery again under the same circumstances. There was a significant improvement in dysphagia and regurgitation scores after surgery (P<0.05). The scores for chest pain/heartburn remained unchanged. By physician assessment, dysphagia was resolved in 49 patients (77%) and persisted in 15 (33%). By patient assessment, 62 patients (97%) reported an improvement in the symptom of dysphagia, and 60 (94%) stated that they were satisfied with their improvement and would undergo surgery if they had to make the choice again. On univariate analysis, patients who had resolution of their dysphagia had a significantly higher resting lower esophageal sphincter (LES) pressure prior to myotomy (P=0.01) and on multivariate analysis only a high resting LES pressure prior to surgery was a predictor of resolution of dysphagia (P=0.015). Outcome comparison of patients with Dor and Toupet fundoplications showed no significant differences in physician assessment of postoperative symptom scores and resolution of dysphagia, patient assessment of outcome, or postoperative use of proton pump inhibitors. Ninety-four percent of patients are satisfied with their surgical myotomy for achalasia. By physician assessment dysphagia was resolved in 77% of patients. A high LES resting pressure before surgery predicted resolution of dysphagia.

Minimally invasive surgery for achalasia: a 10-year experience

Minimally invasive esophagomyotomy for achalasia has become the preferred surgical treatment; the employment of a concomitant fundoplication with the myotomy is controversial. Here we report a retrospective analysis of 53 patients with achalasia treated with laparoscopic Heller myotomy; fundoplication was used in all patients except one, and 48 of the fundoplications were complete (floppy Nissen). There were no deaths or reoperations, and minor complications occurred in three patients. Good-to-excellent long-term results were obtained in 92% of the subjects (median follow-up 3 years). Two cases (4%) of persistent postoperative dysphagia were documented, one of which was treated with dilatation. Postoperative reflux occurred in five patients, four of whom did not receive a complete fundoplication; these patients were well controlled with medical therapy. We suggest that esophageal achalasia may be successfully treated with laparoscopic Heller myotomy and floppy Nissen fundoplication with an acceptable rate of postoperative dysphagia.

Balloon dilation-assisted laparoscopic heller myotomy and Dor fundoplication

Two methods are currently used in the treatment of achalasia: endoscopic balloon dilation and surgical Heller myotomy. Laparoscopy has come into use in achalasia surgery, and good outcomes have been achieved. This study included 11 patients (mean age, 30.7 years). Balloon dilation-assisted laparoscopic Heller myotomy and Dor fundoplication were performed in all patients. A 36-F orogastric tube was placed under visualization. The balloon of the tube was placed in the esophagogastric junction. After laparoscopic cardiomyotomy, the balloon was removed and Dor fundoplication was performed. The mean operative time was 90 minutes. The patients were discharged on the second and third postoperative days (mean [standard deviation], 3 +/- 0.46). One month after the operation, the patients were tested with barium swallowing, and no complications or recurrences were observed. Laparoscopic distal esophagomyotomy combined with partial fundoplication may be the surgical approach of choice in achalasia because it is safer, provides good to excellent relief of symptoms and excellent cosmetic results, involves a shorter hospital stay, and is easy to execute. Balloon dilation makes myotomy easier because it separates the muscle fibers. Placing and insufflation of the balloon become safer because the entire procedure is executed under visualization; thus, excessive dilation is avoided.

Laparoscopic gastrointestinal surgery

In the short time since LC was first performed in humans, minimal-access surgical techniques have been applied to the full spectrum of surgical therapy of gastrointestinal diseases. For many gastrointestinal diseases, [figure: see text] laparoscopy seems to offer advantages over traditional open surgery. The long-term results of laparoscopic surgery for cancer await the results of prospective clinical trials currently underway and caution is urged when laparoscopic curative resection is performed. On the horizon are significant improvements in technology that should lead to further applications and advances in laparoscopic gastrointestinal surgery.

Selective application of fundoplication during laparoscopic heller myotomy ensures favorable outcomes

We propose that selective fundoplication during laparoscopic Heller myotomy achieves optimal outcomes. Fundoplication was applied selectively in 21 of 100 patients undergoing laparoscopic Heller myotomy with hiatus hernia, patulous esophageal hiatus, or intraoperative perforation. Dysphagia and heartburn incidence and severity in patients undergoing myotomy with or without fundoplication were compared before and after myotomy. Median follow-up was 19 months and was similar for both groups. Preoperative symptoms were similar for both groups of patients and showed significant improvement following myotomy with or without fundoplication. As well, there were no significant differences in postoperative dysphagia (26% vs. 14%), dysphagia score (1.1 +/- 1.4 vs. 0.8 +/- 1.3), heartburn (21% vs. 27%), or heartburn score (0.9 +/- 1.5 vs. 1.4 +/- 1.6). Overall improvement was seen in 86% of patients undergoing myotomy with fundoplication and in 97% without fundoplication (P = 0.06). Selective application of fundoplication during laparoscopic Heller myotomy promotes optimal outcomes.

100 consecutive minimally invasive Heller myotomies: lessons learned

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Redo laparoscopic surgery for achalasia

BACKGROUND

Operative treatment of achalasia can fail in 10% to 15% of patients. No information is available on the outcome of laparoscopic reoperation for achalasia.

METHODS

Data from patients undergoing redo surgery for achalasia were prospectively collected. The data were analyzed, and a questionnaire was sent to all the patients.

RESULTS

Eight patients underwent redo procedures at our institution between 1994 and 1998. The reasons for failure of the initial operations were incomplete myotomy (n = 5), incorrect diagnosis (n = 2), and new onset of reflux symptoms (n = 1). All the redo procedures were performed laparoscopically. All the patients except one had excellent or good results. The average symptom severity score for dysphagia, regurgitation, chest pain, cough, and heartburn all improved after redo procedures. The average quality of life score improved from poor to good.

CONCLUSIONS

Laparoscopic reoperation for achalasia is safe and feasible. It results in symptom improvement for most patients. Surgeon experience and recognition of the cause for failure of the original operation are most important in predicting the outcome.

Minimally invasive surgery for esophageal achalasia

BACKGROUND

Esophageal achalasia is characterized by loss of peristaltic activity and failure of relaxation of the lower esophageal sphincter (LES). The characteristic dysphagia may be alleviated by surgery, dilations, or botulinum toxin injections. Video-endoscopic surgery is used increasingly.

PATIENTS AND METHODS

This paper reports our experience with 142 consecutive achalasia patients treated by laparoscopic Heller myotomy and Dor antireflux fundoplication and followed for a median 26 months.

RESULTS

Overall, the actuarial lifetable analysis showed a 90% probability of a patient's being symptom free over a 5-year period. Radiologic assessment showed a significant reduction in esophageal diameter and manometry a significant reduction in the resting tone and residual pressure of the LES. Twenty-four-hour pH monitoring showed postoperative reflux in 6.7% of patients. Persistent dysphagia or chest pain (i.e., failure of treatment) were reported by 15 patients (10.6%): 14 of them were subsequently treated with multiple pneumatic dilations, which were successful in 12 cases.

CONCLUSION

Laparoscopic Heller myotomy with Dor fundoplication is a feasible and effective treatment for achalasia, with an actuarial success rate of 90% at 5 years. With additional dilation, a 98% success rate can be achieved.

Laparoscopic and thoracoscopic esophagomyotomy for children with achalasia

BACKGROUND

Minimally invasive esophagomyotomy, consisting of a laparoscopic or thoracoscopic approach, has become a preferred surgical treatment for adults with achalasia. This multicenter study reports on the clinical status of children who have undergone minimally invasive esophagomyotomy for achalasia.

METHODS

Symptomatology for achalasia was assessed in 22 pediatric patients who underwent minimally invasive esophagomyotomy for achalasia between 1995 and 2000. All patients were evaluated for duration of hospitalization, postoperative resumption of feeds, postoperative complications, and symptomatic relief. Participants were assigned pre-and postoperative symptom severity scores ranging from 0 (no symptoms) to 3 (severe).

RESULTS

The median age of the 10 females and 12 males at time of surgery was 11.3 years +/- 3.4 (standard deviation). Transabdominal laparoscopic esophagomyotomy with fundoplication was performed in 18 patients, and thoracoscopic esophagomyotomy without fundoplication was performed in 4. Two patients required conversion from transabdominal laparoscopic esophagomyotomy to open esophagomyotomy because of intraoperative esophageal perforation. The mean duration of postsurgical follow-up was 17 +/- 16 (standard deviation) months (range, 1-54 months). Mean duration of hospitalization (days +/- standard error or mean) was less for transabdominal laparoscopic esophagomyotomy than for converted open esophagomyotomy (2.7 +/- 0.3 vs. 9.0 +/- 3.0 days; P < 0.05) or for thoracoscopic esophagomyotomy (4.8 +/- 1.7 days; P = not significant). Mean time to resumption of soft feedings (days +/- standard error or mean) occurred sooner after transabdominal laparoscopic esophagomyotomy than after converted open esophagomyotomy (2.0 +/- 0.2 vs. 5.5 +/- 0.5 days; P < 0.001) or after thoracoscopic esophagomyotomy (4.0 +/- 1.3 days; P = not significant). Patients experienced significant pre-to postoperative improvement in mean severity score with regard to dysphagia (2.6 vs. 0.4; P < 0.001) and regurgitation (1.7 vs. 0.2; P < 0.001).

CONCLUSIONS

Minimally invasive esophagomyotomy can provide excellent symptomatic relief from dysphagia and regurgitation for children with achalasia.

Intraoperative manometry to assess the esophagogastric junction during laparoscopic fundoplication and myotomy

SUMMARY

Surgery for gastroesophageal reflux disease and achalasia is performed to alleviate symptoms by improving esophagogastric junction (EGJ) function. Intraoperative manometry was used to evaluate the pressure-length characteristics of the reconstructed EGJ during laparoscopic Nissen fundoplication and laparoscopic Heller myotomy. Intraoperative manometry was performed in 37 consecutive patients undergoing laparoscopic Nissen fundoplication (n = 22) or laparoscopic Heller myotomy (n = 15). Measurements were taken before surgery, after creation of the pneumoperitoneum, after completion of the myotomy in achalasia, and after creation of the fundoplication. Tracings were analyzed for pressure, length, and the integrated pressure-length relation (area under the curve [AUC]). Statistical comparison was made using paired t tests; intraoperative EGJ measurements did not correlate well with preoperative values for either pressure or length. Laparoscopic Nissen fundoplication significantly increased pressure, length, and AUC of the EGJ compared with prefundoplication values. Laparoscopic Heller myotomy significantly decreased EGJ pressure, length, and AUC. Creation of a Toupet fundoplication after myotomy did not significantly increase pressure, length, and AUC of the EGJ compared with postmyotomy values. Intraoperative manometry identified 2 of 15 achalasia patients (13%) with persistent areas of high pressure after initial myotomy that were corrected by extending the myotomy. Intraoperative manometry identifies mechanical changes created during EGJ surgery and may be a useful adjunct to improve outcomes of laparoscopic Nissen fundoplication and laparoscopic Heller myotomy.

Longterm results of esophageal myotomy for achalasia

BACKGROUND

Achalasia is a progressive, noncurable, motor disorder of the esophagus. Myotomy of the distal esophagus is the principal method of providing palliation. A major controversy is the necessity for a complementary antireflux procedure.

STUDY DESIGN

Forty-two patients were studied by clinical history manometrically, roentgenographically, and endoscopically. Transabdominal Heller myotomy is the preferred approach. Nine patients had Nissen fundoplication and parietal cell vagotomy (group 1), and 16 had posterior gastropexy and parietal cell vagotomy (group II). Initially 16 of 17 patients underwent transthoracic Heller myotomy without fundoplication (group III). Twenty-five patients were followed a mean of 10 years (range 5 to 26 years).

RESULTS

One postoperative death was from adult respiratory distress. Results in group I were excellent in five, good in three, and fair in one. The patient with a fair result developed a diverticulum at the myotomy site and significant reflux at 9 years. Results in group II patients were excellent in 2, good in 11, there was 1 operative death, and no followup in 1. Of the 17 patients in group III, 3 had resection of an esophageal diverticulum, and 3 had closure of esophageal perforation caused by pneumatic dilatation. Results in the 13 patients followed were excellent in 6, good in 5, and poor in 2.

CONCLUSIONS

There is no statistical difference in results by chi-square analysis between transthoracic Heller myotomy without fundoplication and transabdominal Heller myotomy with parietal cell vagotomy and Nissen fundoplication or posterior gastropexy.

Functional outcome after Heller myotomy and fundoplication for achalasia

This study aims to provide longitudinal prospective data on symptomatic outcome following Heller myotomy with fundoplication and to examine variables that might predict a poor outcome. Patients were prospectively followed by means of a biannual mailed questionnaire that assessed symptoms, satisfaction with the procedure, medication, and need for further intervention. Patients were classified as achieving a good or poor outcome based on predetermined criteria. Duration of clinical remission was determined using Kaplan-Meier curves. Between 1992 and 1999, 62 patients with at least 12 months' follow-up were categorized as having either a good outcome (41 patients) or a poor outcome (21 patients). The cumulative probability of a good outcome at 7 years was 37%. Dysphagia significantly increased over the follow-up period despite initial resolution. Patient variables (age, sex, symptom duration, esophageal dilatation, manometric findings) and operative factors (myotomy length, wrap type, case number mucosal perforation, primary therapy) were not demonstrated to influence outcome at 3 years. A comparison of Nissen fundoplication with partial fundoplication suggested increased dysphagia and chest pain in the Nissen group. Despite initial symptomatic relief, patients with achalasia suffer a progressive decline with recurrent dysphagia and regurgitation. The type of fundoplication used may contribute to these poor results.

Achalasia: the case for primary laparoscopic treatment

Laparoscopic Heller myotomy offers the best-known surgical therapy for esophageal achalasia. Nevertheless, this procedure continues to compete with alternative endoscopic treatment and is often considered only as a secondary resort. In this study, the authors performed a review of the results of laparoscopic Heller myotomy and an evaluation of the impact of previous endoscopic treatment regarding perioperative complications and late results. Twenty-seven patients with achalasia confirmed by a manometry examination underwent a primary laparoscopic Heller myotomy (group 1, n = 14) or experienced endoscopic treatment failure (group 2, n = 13). A dysphagia score (0-4) was obtained before and after surgery. Clinical course was reviewed at 2 months and then every 6 months after surgery. In December 1999, patients answered a questionnaire regarding surgery satisfaction, postoperative reflux, and dysphagia for statistical analysis. There were no deaths. Mean hospital stay was 5.6 days. Three perforations occurred in group 2 (25%) versus one in group 1 (6%) (not statistically significant). At a mean 27-month follow-up, the dysphagia score was significantly (P < 0.001) improved in both groups but more significantly in group 1 versus group 2 (not statistically significant). Only one patient in group 2 reported heartburn. All patients in group 1 (100%) were satisfied with surgery as opposed to 10 of 13 patients (75%) in group 2 (P < 0.10). Primary laparoscopic Heller myotomy appears to be the treatment of choice for achalasia. Previous endoscopic treatment increases intraoperative complications and may affect long-term results.

Achalasia

The optimal treatment of achalasia includes several options and presents a challenge for most gastroenterologists. There are numerous patient variables that must be assessed including age, degree of symptoms, duration of disease, desires of each patient, and related comorbidities. Treatment includes both medical and surgical options, with medical therapy further subclassified into pharmacologic and pneumatic dilation. Pneumatic dilations with a polyethylene dilator (sizes of 3.0, 3.5, and 4.0 cm) and laparoscopic myotomy represent the most common forms of therapy. A graduated increase in dilator size, based on symptomatic response, minimizes complications and is successful in more than 90% of patients. Further dilations or adjustment of pharmacologic therapy should be based on symptoms, weight gain, and a timed barium meal. Referral for myotomy should be considered for patients who do not respond to medical therapy or individuals that do not desire pneumatic dilations. Most patients responding to botulinum toxin (Botox; Allergan, Irvine, CA) injections will require repeat treatment at 3- to 6-month intervals. Due to cost constraints, Botox therapy should be reserved for patients who are at an increased risk from possible complications of a dilation or surgery, or those with less than 2 years of life expectancy. The most cost-effective course of therapy per patient cured over a 5-year period is pneumatic dilation, then Botox, and finally laparoscopic myotomy.

Laparoscopic Heller myotomy for achalasia

BACKGROUND

Laparoscopic Heller myotomy provides similar results to open Heller myotomy for the treatment of oesophageal achalasia with the advantage of quicker recovery. The present series examines the evolution of operative technique, postoperative outcome and the effect of the 'learning curve' in a group of 70 consecutive patients.

METHODS

Between 1992 and 1999, details of all patients undergoing oesophagogastric myotomy for achalasia were prospectively entered on a database. Patients were followed with a biannual postal symptom questionnaire and scores were obtained for dysphagia, heartburn, regurgitation and chest pain. Comparison between preoperative and postoperative symptom scores, and case number and operative complications was made using Fisher's exact test or Mann-Whitney U-test where appropriate.

RESULTS

The indication for surgery was as a primary procedure in 20 cases; after failed endoscopic treatment in 48 cases; and after a 'failed' fundoplication in two cases. Myotomy was combined with a 360 degrees fundoplication in 57 patients and with an anterior fundoplication in 13 patients. Mucosal perforation occurred intraoperatively in 11 cases. Conversion to an open procedure was required in seven patients. Seven patients required a second operation. At a mean follow up of 2.9 years, symptom scores were significantly improved from preoperative values for dysphagia, regurgitation and chest pain (P < 0.001). There was no increase in the postoperative score for heartburn. The 'learning curve' contributed significantly to the length of the procedure, and the need for reoperation.

CONCLUSIONS

Laparoscopic Heller myotomy is a technically challenging procedure that provides good early palliation of the symptoms associated with achalasia.