Efficacy and safety of cardiomyotomy in patients with achalasia after failure of pneumatic dilatation

Heller myotomy perforation: robotic visualization decreases perforation rate and revisional surgery is a perforation risk

Minimally invasive surgery (MIS) has improved surgical access to the foregut. While the benefits of MIS versus open surgery are well accepted, the relative benefits of laparoscopic versus robotic approaches continue to be debated. Procedure-specific comparisons are difficult to obtain for Heller myotomy, due to the relative rarity of the procedure in most practices. A retrospective review of prospectively collected perioperative data of a single surgical practice from 2001 to 2019 was conducted for the rate of perforation during Heller myotomy laparoscopically compared to robotically. From 2001 through February 2012, a laparoscopic approach was employed and from October 2008 to 2019, a robotic approach was employed. All perforations were recorded, as well as secondary outcomes of perforation location (gastric or esophageal), postoperative imaging for evidence of leak, length of stay, and complications. Chi-square and simple t test were employed for data analysis. During the 11 years of laparoscopic Heller myotomy, 14 cases resulted in 7 instances of perforation (50%). During the 11 years of robotic Heller myotomy, 45 cases resulted in 11 instances of perforation (24%) (p value = 0.06). All perforations in both groups were tiny, recognized, and repaired immediately. The length of stay (LOS) was longer in the laparoscopic perforation group (3.4 days) compared to the laparoscopic non-perforation group (1.2 days) (p value = 0.06). LOS for robotic was not significantly longer in the perforation group (2.8 days) compared to the robotic non-perforation group (1.5 days) (p value = 0.18). First time Heller myotomies showed a higher rate of perforation with laparoscopic (50%) vs robotic (14%) (p value = 0.009) approach. In subgroup analysis of revisional procedures, all ten were performed robotically (p value < 0.001) with a 60% perforation rate (p value = 0.001) and one associated, radiographically confirmed leak. Primary laparoscopic Heller myotomy related to more than four times the frequency of perforation than did primary robotic myotomy. We propose that the robotic platform provided the surgeon with superior ability to avoid perforation. Interestingly, the robotic group in this study dealt with more complex redo cases. In fact, reoperation in the area of the hiatus was a separate risk factor for perforation during robotic Heller myotomy. We recommend further prospective trials be done to better evaluate the benefits of robotic platform in regard to revisional foregut surgery.

Impact of preoperative balloon dilatation on outcomes of laparoscopic surgery in young patients with esophageal achalasia

BACKGROUND

Balloon dilatation is reportedly less effective for young patients with esophageal achalasia than for older patients. However, there is no consensus on the impact of prior balloon dilatation on outcomes of surgical treatment. This study investigated the significance of preoperative balloon dilatation on surgical outcomes in young patients with esophageal achalasia.

METHODS

Of patients aged less than 40 years who had undergone a laparoscopic Heller-Dor operation for esophageal achalasia, 201 with a postoperative follow-up period of at least 1 year were included. They were divided into two groups with and without a history of balloon dilatation, and compared preoperative pathological conditions and surgical outcomes.

RESULTS

This study included 100 men and 101 women with a median age of 31 years, of whom 158 patients without a history of pneumatic dilatation (79%, non-PD group) and 43 with a history of pneumatic dilatation (21%, PD group) The preoperative symptom scores for dysphagia and regurgitation were significantly higher in the non-PD group. Although no differences were observed in surgical outcomes or postoperative course, the esophageal clearance rates calculated on preoperative and postoperative timed barium esophagograms were lower in terms of both height and width of the barium column in the PD group than in the non-PD group. Subjectively, both groups expressed equally high satisfaction.

CONCLUSIONS

In patients aged less than 40 years with esophageal achalasia, although preoperative balloon dilatation did not affect subjective levels of satisfaction with surgery, postoperative improvement in esophageal clearance in the lower esophagus was inhibited.

Multiple good options are available for achalasia management

BACKGROUND

The aim of achalasia management is relieving functional obstruction at the esophagogastric junction. Pneumatic dilation (PD), Heller myotomy (HM), and Botox (BT) are available for this purpose. Many studies have compared efficacy of one treatment regimen to another however, many patients with achalasia undergo combinations of different procedures.

AIM

: The aim of this study was to follow-up achalasia patients treated at a tertiary referral center over a 10-year period and to compare patient satisfaction and symptoms in patients who were treated with either a single treatment (ST) versus multiple treatments (MT).

METHODS

A cohort of achalasia patients treated at the Medical University of South Carolina between 2002 and 2012 were identified, contacted by telephone, and completed a questionnaire about their treatments and symptoms. Symptomatic response was classified using the Eckardt score, and overall patient satisfaction was determined on a scale from 1 to 10. Data were analyzed using a paired Student t test.

RESULTS

Data were collected from 57 patients and 3 patients were excluded from the study because they had no prior interventions for achalasia. Demographic analysis of the patients revealed a mean age of 62.7 years (range, 24 to 89 y) with 45% males and 55% females. The average elapsed time since the last definitive treatment was 2.82 years. Twenty-eight patients had an ST performed and 26 patients underwent MT. The average number of different interventions in the MT group was 3 procedures/patient. There were no significant differences in overall patient satisfaction (ST, 7.5 vs. MT, 8; P=0.66) and the Eckardt scores between the 2 groups (ST, 3.39 vs. MT, 3.3; P=0.77).

CONCLUSIONS

MT options are available for management of achalasia. Improvement of clinical symptoms and overall patient satisfaction does not differ if the patient underwent an ST modality or a combination of different treatments.

Preoperative dilatation does not affect the surgical outcome of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia

BACKGROUND

Laparoscopic Heller myotomy and Dor fundoplication are now widely performed for achalasia. In patients who have had dilatation in the past, inflammation between the esophageal mucosal and muscular layers may make it difficult to perform myotomy.

PURPOSE

We investigated the effects of preoperative dilatation on the surgical outcomes.

METHOD

: One hundred and twelve patients were divided into 2 groups: 37 patients with a past history of preoperative dilatation and 75 patients who had no history of preoperative dilatation. The operating time, intraoperative blood loss, days required to resume postoperative oral intake, postoperative hospital stay, improvement in dysphagia, and incidence of postoperative esophagitis were compared.

RESULTS

The operating time, intraoperative blood loss, postoperative hospital stay, and improvement of dysphagia were no significant differences between these groups. Furthermore, there were no significant differences in the incidence of postoperative esophagitis.

CONCLUSIONS

The therapeutic outcome of laparoscopic Heller myotomy and Dor fundoplication is not affected by preoperative pneumatic dilatation.

Factors associated with postoperative symptoms after laparoscopic Heller myotomy

BACKGROUND

Our objective is to ascertain if preoperative and perioperative treatments affect the short- and long-term symptom frequency or symptom scores for dysphagia, regurgitation, and heartburn in patients with laparoscopic Heller myotomy for achalasia.

METHODS

From 1994 to 2008, 261 patients undergoing laparoscopic esophageal myotomy were enrolled prospectively. The diagnosis of classic achalasia was made on clinical history, barium swallow, endoscopy, and manometry. A validated symptom questionnaire and history was taken for each patient at the preoperative visit and at each postoperative visit.

RESULTS

In all, 261 patients had laparoscopic Heller myotomy during the study period. Preoperatively, 137 patients (62.3%) tried medications, 101 (38.7%) were treated with pneumatic dilation, and 29 (11.1%) were treated initially with at least one injection of botulinum toxin into the lower esophageal sphincter. In all, 134 patients (51.3%) received a Dor anterior fundoplication. On multivariate regression controlling for age and sex, preoperative dilation (p = 0.031), injection of botulinum toxin (p = 0.044), and a fundoplication (p = 0.005) were associated with significantly worse early postoperative dysphagia, with odds ratios of 2.11, 2.56, and 2.80, respectively; previous botulinum toxin injection was associated with worse late postoperative dysphagia (p = 0.001), regurgitation (p = 0.031), and heartburn (p = 0.049), with odds ratios of 5.24, 2.87, and 2.52, respectively. There was a trend for no fundoplication to be associated with late postoperative heartburn (p = 0.077) with an odds ratio of 1.80.

CONCLUSIONS

Many patients presenting for Heller myotomy have previously undergone a different form of treatment. Early postoperative dysphagia was affected by dilation, botulinum toxin injection, and fundoplication. Only botulinum toxin injection was associated with late symptoms.

Recurrent achalasia treated with Heller myotomy: A review of the literature

AIM: To evaluate the efficacy and safety of Heller myotomy (HM) for recurrent achalasia, performed after different methods of first-line treatment.

METHODS: We searched for studies published in PubMed from 1966 to March 2008 on treatment of recurrent achalasia with HM after failure with different methods of first-line treatment. The efficacy of HM was assessed by a pooled estimate of response rate with individual studies weighted proportionally to sample size.

RESULTS: Sixteen studies were eligible and included in the review. The results showed that HM has a better remission rate for recurrent achalasia after failure of HM [weighted mean (SD)] of 86.9% (21.8%) compared with 81.6% (23.8%) for pneumatic dilatation (PD). One study evaluated the efficacy of HM after failure of PD combined with botulinum toxin injection (83%). The most common complications were perforation and gastroesophageal reflux.

CONCLUSION: HM has the best efficacy in patients with recurrent achalasia who were treated with HM as first-line treatment. Future studies should focus on how to increase the success rate and decrease the complications of HM.

Laparoscopic esophageal myotomy for achalasia: factors affecting functional results

BACKGROUND

We reviewed our experience and analyzed factors affecting functional results after laparoscopic esophageal myotomy (LEM) for achalasia.

METHODS

From January 1996 through October 2003, the records of 211 patients (110 men and 101 women) who had LEM for achalasia were reviewed, and factors affecting morbidity and functional results were analyzed.

RESULTS

Median age was 47 years (range, 12 to 85). One hundred and twenty-five patients (59%) had prior esophageal dilatation and/or botulinum toxin injection and 19 (9%) had a prior myotomy. A partial fundoplication was performed in 198 patients (94%); posterior in 135 and anterior in 63. Median operative time was 208 minutes (range, 90 to 527). Intraoperative complications occurred in 37 patients (17.5%), and included mucosal perforation in 32, pneumothorax in 2, and retained needle, splenic capsular tear, and gastric short vessel bleeding in 1 each. Five patients (2%) required conversion to an open procedure. Postoperative complications occurred in 17 patients (8%) including 2 patients who required reoperation for leak. There were no perioperative deaths. Median hospitalization was 3 days (range, 1 to 48). Follow-up was complete in 167 patients (79%) and ranged from 1 to 70.5 months (median, 5.3). Functional results were classified as excellent in 105 patients (63%), good in 43 (26 %), and fair or poor in 19 (11%). Previous esophageal surgery for achalasia adversely affected functional results (p = 0.0139). Preoperative bougie dilatation (p = 0.9851), pneumatic dilatation (p = 0.8548), botulinum toxin injection (p = 0.1724), and the type of fundoplication (p = 0.5904) did not affect functional results. Preoperative bougie dilatation (p = 0.441), pneumatic dilatation (p = 0.1060), and botulinum toxin injection (p = 0.3938) did not affect the incidence of intraoperative perforation. As experience is gained, the incidence of intraoperative complications has decreased significantly (p = 0.0075).

CONCLUSIONS

Laparoscopic myotomy for achalasia is safe and effective in the majority of patients. The incidence of intraoperative complications decreases as experience is gained. Preoperative endoscopic treatment does not preclude successful surgical outcome. Excellent or good functional results are achieved in the majority of patients although previous surgical treatment adversely affects functional results.

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.

Long-term follow-up after pneumatic dilation for achalasia cardia: factors associated with treatment failure and recurrence

BACKGROUND

Though most patients with achalasia cardia (AC) respond to pneumatic dilation (PD), one-third experienced recurrence. Long-term follow-up studies on factors associated with various outcomes are scanty.

METHODS

In this retrospective study, 126 patients (36.5 +/- 14.6 yr, 76 male) with AC (diagnosed by esophagoscopy, barium esophagogram, and/or manometry) were followed up in person or through mail. The median dysphagia-free duration was calculated by Kaplan-Meier analysis. Factors associated with nonresponse and recurrence after PD were determined using univariate and multivariate analyses.

RESULTS

Symptoms were dysphagia (126, 100%), chest pain (21, 17%), regurgitation (61, 48%), weight loss (33, 26%), and pulmonary symptoms (23, 18%); 5 of 126 (4%) had megaesophagus (> or =7 cm). The mean lower esophageal sphincter (LES) pressure was 38.7 +/- 16.8 mmHg. One hundred and fifteen of 126 (91%) patients responded to PD (90 (71%) to first session); 25 of these had recurrence of dysphagia after 15 +/- 17 months. Post-PD chest pain requiring hospitalization occurred in 21 of 126 (17%; one had an esophageal perforation). Post-PD LES pressure, which was assessed in 48 of 126 patients, had decreased by >50% from baseline in 14 of 29 responders, 0 of 11 nonresponders (p= 0.004, chi(2) test), and 5 of 8 relapsers. The median dysphagia-free duration by Kaplan-Meier analysis was 60 months (SE 2.7, 95% CI 54.7-65.3). On univariate analysis, male gender, pulmonary symptoms (nocturnal coughing spell, history of respiratory infection), absence of chest pain, and failure to achieve a reduction in LES pressure >50% after PD were associated with poor outcome; whereas age, grade of dysphagia, regurgitation, megaesophagus, and LES pressure before PD were not. Male gender was associated with poor outcome by multivariate-analysis.

CONCLUSIONS

PD is an effective and safe treatment for AC. Post-PD LES pressure measurement may be helpful in assessing response. Male patients have poorer outcomes following PD.

Heller myotomy for failed pneumatic dilation in achalasia: how effective is it?

OBJECTIVES

This long-term prospective study describes the effect of myotomy in patients who fail to respond to repeated pneumatic dilations and compares their clinical course with that of patients responding to dilation therapy.

METHODS

Nineteen consecutive patients who had never reached a clinical remission after repeated pneumatic dilation underwent myotomy. Their clinical course was compared with that of patients who had reached a clinical remission after a single (n = 34) or multiple (n = 14) pneumatic dilation(s). Symptoms were graded with a previously described symptom score ranging from 0 to 12. Remission was defined as a score of 3 or less persisting for at least 6 months. Duration of remission was summarized using Kaplan Meier survival curves. Association between baseline factors and the need for surgery was evaluated using logistic regression.

RESULTS

Complete follow-up was obtained for 98.5% of the patients. The median duration of follow-up was similar in patients treated by myotomy (10.0 years), in patients reaching a clinical remission after a single dilation (10.6 years), but differed in patients undergoing repeated dilations (6.9 years). The 10-year remission rate was 77% (95% CI 53-100%) in patients undergoing myotomy, 72% (95% CI: 56-87%) in patients "successfully" treated with a single pneumatic dilation and 45% (95% CI: 16-73%) in patients undergoing several dilations. Among all baseline factors investigated, young age was associated with an increased need of surgery.

CONCLUSIONS

Myotomy is an effective treatment modality in patients with achalasia who have failed to respond to pneumatic dilation. Young patients may benefit from primary surgical therapy.

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.

Long-term outcome of esophageal myotomy for achalasia

AIM: Modified Heller’s myotomy is still the first choice for achalasia and the assessment of surgical outcomes is usually made based on the subjective sensation of patients. This study was to objectively assess the long-term outcomes of esophageal myotomy for achalasia using esophageal manometry, 24-hourour pH monitoring, esophageal scintigraphy and fiberoptic esophagoscopy.

METHODS: From February 1979 to October 2000, 176 patients with achalasia underwent modified Heller’s myotomy, including esophageal myotomy alone in 146 patients, myotomy in combination with Gallone or Dor antireflux procedure in 22 and 8 patients, respectively. Clinical score, pressure of the lower esophageal sphincter (LES), esophageal clearance rate and gastroesophageal reflux were determined before and 1 to 22 years after surgery.

RESULTS: After a median follow-up of 14 years, 84.5% of patients had a good or excellent relief of symptoms, and clinical scores as well as resting pressures of the esophageal body and LES were reduced compared with preoperative values (P < 0.001). However, there was no significant difference in DeMeester score between pre- and postoperative patients (P = 0.51). Esophageal transit was improved in postoperative patients, but still slower than that in normal controls. The incidence of gastroesophageal reflux in patients who underwent esophageal myotomy alone was 63.6% compared to 27.3% in those who underwent myotomy and antireflux procedure (P = 0.087). Three (1.7%) patients were complicated with esophageal cancer after surgery.

CONCLUSION: Esophageal myotomy for achalasia can reduce the resting pressures of the esophageal body and LES and improve esophageal transit and dysphagia. Myotomy in combination with antireflux procedure can prevent gastroesophageal reflux to a certain extent, but further randomized studies should be carried out to demonstrate its efficacy.

Selection and evaluation of three interventional procedures for achalasia based on long-term follow-up

AIM: To determine the best method out of the three types of interventional procedure for achalasia based on a long-term follow-up.

METHODS: The study cohort was comprised of 133 patients of achalasia. Among them, 60 patients were treated under fluoroscopy with pneumatic dilation (group A), 8 patients with permanent uncovered or antireflux covered metal stent dilation (group B), and 65 patients with temporary partially covered metal stent dilation (group C).

RESULTS: One hundred and thirty dilations were performed on the 60 patients of group A (mean 2.2 times per case). The mean diameter of the strictured cardia was 3.3 ± 2.1 mm before dilation and 10.6 ± 3.8 mm after dilation. The mean dysphagia score was 2.7 ± 1.4 before dilation and 0.9 ± 0.3 after dilation. Complications in group A were chest pain (n = 30), reflux (n = 16), and bleeding (n = 6). Thirty-six patients (60%) in group A exhibited dysphagia relapse during a 12-month follow-up, and 45 patients (90%) out of 50 exhibited dysphagia relapse during a 36-month follow-up. Five uncovered and 3 antireflux covered expandable metal stents were permanently placed in the 8 patients of group B. The mean diameter of the strictured cardia was 3.4 ± 1.9 mm before dilation and 19.5 ± 1.1 mm after dilation. The mean dysphagia score was 2.6 ± 1.3 before dilation and 0.4 ± 0.1 after dilation. Complications in group B were chest pain (n = 6), reflux (n = 5), bleeding (n = 3), and hyperplasia of granulation tissue (n = 3). Four patients (50%) in group B exhibited dysphagia relapse during a 12-month follow-up, and 2 case (66.7%) out of 3 patients exhibited dysphagia relapse during a 36-month follow-up. Sixty-five partially covered expandable metal stents were temporarily placed in the 65 patients of group C and withdrawn after 3-7 d via gastroscopy. The mean diameter of the strictured cardia was 3.3 ± 2.3 mm before dilation and 18.9 ± 3.5 mm after dilation. The mean dysphagia score was 2.4 ± 1.3 before dilation and 0.5 ± 0.2 after dilation. Complications in group C were chest pain (n = 26), reflux (n = 13), and bleeding (n = 8). 6 patients (9.2%) out of 65 exhibited dysphagia relapse during a 12-month follow-up, and 8 patients (14.5%) out of 55 exhibited dysphagia relapse during a 36-month follow-up. All the stents were inserted and withdrawn successfully. The follow-up in groups A-C lasted 12-96 months.

CONCLUSION: Temporary partially covered metal stent dilation is one of the best methods with interventional procedure for achalasia in terms of long-term follow-up.

Gastroesophageal reflux, quality of life, and satisfaction in patients with achalasia treated with open cardiomyotomy and partial fundoplication

BACKGROUND

Cardiomyotomy, often associated with an antireflux technique, is effective in the management of achalasia, although gastroesophageal reflux (GER) may occur after the procedure. Patient-centered measures, ie, health-related quality of life (HRQoL) and satisfaction, should be included in the evaluation of the patients.

METHODS

A study was made of the incidence of GER (symptoms, upper endoscopy and 24-hour pH monitoring), HRQoL (Short Form-36 Health Survey), and satisfaction after open-access cardiomyotomy and 180-degree anterior fundoplication in 28 consecutive patients, with a minimum postoperative follow-up of 12 months.

RESULTS

Mean age was 45 years (range 15 to 80) and 68% were female. In 8 subjects (all with heartburn) GER morbidity was present (4 with esophagitis and 4 with positive pH study), and 6 patients required proton pump inhibitors. Short Form-36 scores after surgery were similar to those found in the general population. Patient satisfaction was high and was more related to the absence of dysphagia than to the presence of GER symptoms.

CONCLUSIONS

Gastroesophageal reflux is relatively frequent after cardiomyotomy and partial fundoplication, although the efficacy of proton pump inhibitor treatment minimizes its clinical significance.

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.

Minimally invasive surgery for esophageal motility disorders

Laparoscopic Heller myotomy has emerged as an excellent primary treatment for patients with dysphagia secondary to achalasia. A laparoscopic rather than thoracoscopic approach has stood the test of time. An antireflux procedure combined with the myotomy is crucial to the maintenance of the antireflux barrier. Thoracoscopic long myotomy offers effective relief for spastic disorders of the esophagus. Endoscopic stapled diverticulotomy is a safe and effective procedure for Zenker's diverticulum and has potential advantages over the open approach.

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.

Laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children

BACKGROUND/PURPOSE

In the past, surgical treatment in achalasia usually has been reserved for patients whose dysphagia does not respond to pneumatic dilatation. The success of minimally invasive myotomy, however, has resulted in a shift in practice in adult patients, whereby laparoscopic surgery is becoming preferred as primary treatment by most gastroenterologists and surgeons. The aim of this study was to assess the efficacy of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children.

METHODS

Thirteen patients with esophageal achalasia (median age, 15 years; 6 boys and 7 girls; median duration of symptoms, 24 months) underwent laparoscopic Heller myotomy and Dor fundoplication between 1996 and 1999. Two patients had been treated previously by pneumatic dilatation, and 1 patient had received intrasphincteric Botulinum toxin injections.

RESULTS

Median duration of the operation was 130 minutes. The patients were fed after an average of 33 hours, and they all left the hospital within 2 days. At a median follow-up of 19 months, there was no residual dysphagia in any patient.

CONCLUSIONS

Laparoscopic Heller myotomy and Dor fundoplication were effective and safe for children with esophageal achalasia. Hospital stay and recovery time was short, and the functional results were excellent. These data support the notion that laparoscopic Heller myotomy should become the primary treatment of esophageal achalasia in children.

Esophageal motor disorders

Motor dysfunction is responsible for symptomatic illnesses both in the proximal skeletal muscle region and in the distal smooth muscle esophagus. Practical methods for diagnosing and treating oropharyngeal dysphagia continue to reach consensus. Achalasia, the most significant of the distal motor disorders, is of investigative interest because of the expanded armamentarium of treatment options. Minimally invasive surgical methods have taken an important foothold as a primary treatment of this disorder. Appreciation is growing for sensory dysfunction that accompanies distal motor disorders. Such dysfunction may help explain the observed discrepancies between symptoms and measurable motility abnormality.

Management of idiopathic achalasia: short-term and long-term outcomes

This article reviews current trends in management of esophageal achalasia, highlighting short-term outcome and cost comparisons of three treatments: botulinum toxin injection, pneumatic dilation, and laparoscopic myotomy. The quality of life resulting from these palliative treatments is also discussed, as are long-term outcomes.