Thoracoscopic esophagomyotomy for achalasia: preoperative patterns of acid reflux and long-term follow-up

Defining "true acid reflux" after peroral endoscopic myotomy for achalasia: a prospective cohort study

BACKGROUND AND AIMS

The symptoms of reflux in achalasia patients undergoing peroral endoscopic myotomy (POEM) are believed to result from gastroesophageal reflux, and the current treatment primarily focuses on acid suppression. Nevertheless, other factors such as nonreflux acidification caused by fermentation or stasis might play a role. This study aimed to identify patients with "true acid reflux" who actually require acid suppression and fundoplication.

METHODS

In this prospective large cohort study, the primary objective was to assess the incidence and risk factors for true acid reflux in achalasia patients undergoing POEM. Acid reflux with normal and delayed clearance defined true acid reflux, whereas other patterns were labeled as nonreflux acidification patterns on manual analysis of pH tracings. These findings were corroborated with a symptom questionnaire, esophagogastroscopy, esophageal manometry, and timed barium esophagogram at 3 months after the POEM procedure.

RESULTS

Fifty-four achalasia patients aged 18 to 80 years (mean age, 41.1 ± 12.8 years; 59.3% men; 90.7% with type II achalasia) underwent POEM, which resulted in a significant mean Eckardt score improvement (6.7 to 1.6, P < .05). True acid reflux was noted in 29.6% of patients as compared with 64.8% on automated analysis. Acid fermentation was the predominant acidification pattern seen in 42.7% of patients. On multivariable logistic regression analysis, increasing age (odds ratio, 1.12; 95% confidence interval, 1.02-1.27; P = .04) and preprocedural integrated relaxation pressure (IRP; odds ratio, 1.13; 95% confidence interval, 1.04-1.30; P = .02) were significantly associated with true acid reflux in patients after undergoing POEM.

CONCLUSIONS

A manual review of pH tracings helps to identify true acid reflux in patients with achalasia after undergoing POEM. Preprocedural IRP can be a predictive factor in determining patients at risk for this outcome. (Clinical trial registration number: NCT04951739.).

Attitudes on Prophylactic Antibiotic Use in Dermatologic Surgery: A Survey Study of American College of Mohs Surgery Members

BACKGROUND

Antibiotic prescriptions associated with dermatologic surgical visits are increasing and prescribing practices vary among surgeons.

OBJECTIVE

To describe dermatologic surgeons' attitudes and practices regarding prophylactic antibiotic use for surgical site infection (SSI), to compare current prescribing practices to those of a 2012 survey, and to determine surgeons' interest in clinical trial data on the utility of prophylactic antibiotics.

MATERIALS AND METHODS

This was a cross-sectional online survey of the American College of Mohs Surgery (ACMS) members. Survey items were adapted from a 2012 survey of ACMS members.

RESULTS

The survey was initiated by 101 ACMS members. 75.25% (76/101) of surgeons reported routinely prescribing prophylactic antibiotics to reduce SSI risk. The use of prophylactic antibiotics varied with clinical scenario. Most providers (84.21%, 64/76) prescribe postoperative antibiotics, with an average course of 6.56 days. 40.21% (39/97) of respondents were uncertain if prophylaxis prevents SSI, and up to 90.63% (87/96) indicated interest in clinical trial data evaluating the efficacy of oral antibiotics for SSI prevention.

CONCLUSION

Dermatologic surgeons continue to report varied attitudes and practices for SSI prophylaxis. Evidence from clinical trials is desired by surgeons to guide clinical practice.

Gastroesophageal reflux disease after peroral endoscopic myotomy: lest we forget what we already know

After the performance of the first peroral endoscopic myotomy (POEM) in 2008, POEM has now spread worldwide and has arguably become a first-line treatment option for achalasia. Recently, there is increasing debate regarding post-POEM gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD). The reported incidences of GERD vary widely, owing to the variability in the definitions used. The literature regarding GERD and achalasia patients with a focus on 24-hour pH testing, esophageal acid exposure, and fermentation and the definitions of GERD used in the POEM literature are examined. 24-hour pH testing in achalasia patients may be abnormal due to fermentation both pre- and post-treatment. It is vital that POEM operators ensure that fermentation is recognized during 24-hour pH testing and excluded in the analysis of acid exposure time (AET) used in the diagnosis of GERD. In untreated achalasia, 24-hour pH testing may suggest abnormal AET in over a third of patients. However, most abnormal AETs in untreated achalasia patients are due to fermentation rather than GER. In treated achalasia, up to half of the patients with abnormal AET may be attributable to fermentation. To have a candid discussion and appropriately address the questions surrounding post-POEM GERD, consistent definitions need to be applied. We suggest the recent definition of GERD from the Lyon Consensus to be utilized when diagnosing GERD in post-POEM patients. Further studies are required in establishing ideal parameters for 24-hour pH testing in achalasia patients.

Postoperative Gastroesophageal Reflux After Laparoscopic Heller-Dor for Achalasia: True Incidence with an Objective Evaluation

INTRODUCTION

The most common complication after laparoscopic Heller-Dor (LHD) is gastroesophageal reflux disease (GERD). The present study aimed (a) to analyze the true incidence of postoperative reflux by objectively assessing a large group of LHD patients and (b) to see whether the presence of typical GERD symptoms correlates with the real incidence of postoperative reflux.

METHODS

After LHD, patients were assessed by means of a symptom score, endoscopy, esophageal manometry, and 24-h pH monitoring. Patients were assigned to three groups: those did not accept to perform 24-h pH monitoring (group NP); those with normal postoperative pH findings (group A); and those with pathological postoperative acid exposure (group B).

RESULTS

Four hundred sixty-three of the 806 LHD patients agreed to undergo follow-up 24-h pH monitoring. Normal pH findings were seen in 423 patients (group A, 91.4 %), while 40 (8.6 %) had a pathological acid exposure (group B). The median symptom scores were similar: 3.0 (IQR 0-8) in group A and 6.0 (IQR 0-10) in group B (p = 0.29). At endoscopy, the percentage of esophagitis was also similar (11 % in group A, 19 % in group B; p = 0.28).

CONCLUSIONS

This study demonstrated that, after LHD was performed by experienced surgeons, the true incidence of postoperative GERD is very low. The incidence of this possible complication should be assessed by pH monitoring because endoscopic findings and symptoms may be misleading.

Data analyses and perspectives on laparoscopic surgery for esophageal achalasia

In general, the treatment methods for esophageal achalasia are largely classified into four groups, including drug therapy using nitrite or a calcium channel blocker, botulinum toxin injection, endoscopic therapy such as endoscopic balloon dilation, and surgery. Various studies have suggested that the most effective treatment of esophageal achalasia is surgical therapy. The basic concept of this surgical therapy has not changed since Heller proposed esophageal myotomy for the purpose of resolution of lower esophageal obstruction for the first time in 1913, but the most common approach has changed from open-chest surgery to laparoscopic surgery. Currently, the laparoscopic surgery has been the procedure of choice for the treatment of esophageal achalasia. During the process of the transition from open-chest surgery to laparotomy, to thoracoscopic surgery, and to laparoscopic surgery, the necessity of combining antireflux surgery has been recognized. There is some debate as to which type of antireflux surgery should be selected. The Toupet fundoplication may be the most effective in prevention of postoperative antireflux, but many medical institutions have selected the Dor fundoplication which covers the mucosal surface exposed by myotomy. Recently, a new endoscopic approach, peroral endoscopic myotomy (POEM), has received attention. Future studies should examine the long-term outcomes and whether POEM becomes the gold standard for the treatment of esophageal achalasia.

A prospective analysis of GERD after POEM on anterior myotomy

Background

Peroral endoscopic myotomy (POEM) is an emerging, minimally invasive procedure capable of overcoming limitations of achalasia treatments, but gastroesophageal reflux disease (GERD) after POEM is of concern and its risk factors have not been evaluated. This prospective study examined GERD and the association of POEM with reflux esophagitis.

Methods

Achalasia patients were recruited from a single center. The pre- and postoperative assessments included Eckardt scores, manometry, endoscopy, and pH monitoring.

Results

Between September 2011 and November 2014, 105 patients underwent POEM; 70 patients were followed up 3 months after POEM. Postoperatively, significant reductions were observed in lower esophageal sphincter (LES) pressure [from 40.0 ± 22.8 to 20.7 ± 14.0 mmHg (P < 0.05)], LES residual pressure [from 22.1 ± 13.3 to 11.4 ± 6.6 mmHg (P < 0.05)], and Eckardt scores [from 5.7 ± 2.5 to 0.7 ± 0.8 (P < 0.05)]. Symptomatic GERD and moderate reflux esophagitis developed in 5 and 11 patients (grade B, n = 8; grade C, n = 3), respectively, and were well controlled with proton pump inhibitors. Univariate logistic regression analysis revealed integrated relaxation pressure was a predictor of ≥grade B reflux esophagitis. No POEM factors were found to be associated with reflux esophagitis.

Conclusion

POEM is effective and safe in treating achalasia, with no occurrence of clinically significant refractory GERD. Myotomy during POEM, especially of the gastric side, was not associated with ≥grade B (requiring medical intervention) reflux esophagitis. Extended gastric myotomy (2–3 cm) during POEM is recommended to improve outcomes.

Minimally invasive myotomy for the treatment of esophageal achalasia: evolution of the surgical procedure and the therapeutic algorithm

Achalasia is a rare disease of the esophagus, characterized by the absence of peristalsis in the esophageal body and incomplete relaxation of the lower esophageal sphincter, which may be hypertensive. The cause of this disease is unknown; therefore, the aim of the therapy is to improve esophageal emptying by eliminating the outflow resistance caused by the lower esophageal sphincter. This goal can be accomplished either by pneumatic dilatation or surgical myotomy, which are the only long-term effective therapies for achalasia. Historically, pneumatic dilatation was preferred over surgical myotomy because of the morbidity associated with a thoracotomy or a laparotomy. However, with the development of minimally invasive techniques, the surgical approach has gained widespread acceptance among patients and gastroenterologists and, consequently, the role of surgery has changed. The aim of this study was to review the changes occurred in the surgical treatment of achalasia over the last 2 decades; specifically, the development of minimally invasive techniques with the evolution from a thoracoscopic approach without an antireflux procedure to a laparoscopic myotomy with a partial fundoplication, the changes in the length of the myotomy, and the modification of the therapeutic algorithm.

24-h pH monitoring patterns and clinical response after achalasia treatment with pneumatic dilation or laparoscopic Heller myotomy

BACKGROUND

The most effective treatment for achalasia is pneumatic dilation or myotomy. The best option is still controversial and incidence of complications could help choosing. Gastro-oesophageal reflux (GER) is the most frequent complication after treatment for achalasia. The 24-h pH monitoring (24-h pH) is the best method to evaluate true GER.

AIM

To analyse the 24-h pH patterns after treatment, correlating with therapeutic success.

METHODS

Untreated patients with achalasia were randomized to pneumatic dilation or laparoscopic Heller myotomy with fundoplication (LHM+Fp) and evaluated with clinical/manometric results and 24-h pH.

RESULTS

Ninety-four patients were analysed pre-treatment and 85 post-treatment. Clinical success was 73.8% in pneumatic dilation group and 88.3% in LHM+Fp group (P = 0.08). The incidence of GER was 31% in pneumatic dilation, and 4.7% in LHM+Fp (P = 0.001). The occurrence of hypotensive lower oesophageal sphincter (LES) was 53.3% in patients who developed GER and 28.6% in patients with 24-h pH suggesting fermentation (P = 0.019). The rates of dysphagia resolution in patients with 24-h pH of GER and fermentation were respectively 86.7% and 85.7% (P = 0.89).

CONCLUSIONS

True GER 24-h pH is more frequent after pneumatic dilation for achalasia, and it is associated with a hypotensive LES. A 24-h pH suggestive of fermentation or true GER is not associated with worse clinical/manometric results.

Results of laparoscopic Heller myotomy without anti-reflux procedure in achalasia. Monocentric prospective study of 106 cases

BACKGROUND

Heller myotomy (HM) combined with an anti-reflux procedure has been shown to be effective for the treatment of achalasia, as postoperative gastro-esophageal reflux (GER) is observed in about 10% of the cases. Laparoscopy has brought an undeniable benefit in providing excellent visualisation of the gastro-esophageal junction (GEJ) without lateral and posterior dissection. Respecting the anatomical fixation of the GEJ seems to permit the performing of HM without an anti-reflux procedure, the need for which is therefore debatable. The purpose of this study was to analyse the results of this controversial procedure.

METHODS

A monocentric prospective study was carried out on 106 patients who underwent HM without an anti-reflux procedure. The postoperative assessment consisted of a manometry and a 24-hour pH study two months after surgery, and a yearly clinical examination for a minimum of five years. The data capture was done using a statistical analysis.

RESULTS

There was no mortality, one conversion to an open procedure, and four mucosal perforations. Postoperative morbidity was 2%. The average follow-up period was 55 months (range, 2 to 166), with 10 patients lost to follow-up. Good functional results were observed in 91.4% of patients at one year, and 78.6% at five years. Two months after surgery, a 9.4% prevalence of GER was detected in the pH study, and the lower esophageal sphincter pressure had significantly decreased. After a long term follow-up we observed an 11.3% global rate of GER. No repeat surgery was necessary to control postoperative GER.

CONCLUSIONS

Laparoscopic HM without anti-reflux procedure gives good functional results provided the anatomical fixation of the GOJ is respected.

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.

Behandlung der Achalasie

Achalasia is a condition of unknown etiology. It represents a motor disorder of the esophagus characterized by absent or incomplete relaxation of the lower esophageal sphincter upon swallowing and by non-propulsive swallow-induced contraction waves or amotility of the esophageal body. Dysphagia and regurgitation of ingesta are the most frequent symptoms. Medical treatment, i.e. by calcium-channel blockers and nitric oxide donors, may be tried in patients with mild dysphagia or in elderly patients but rarely yields adequate symptom relief. Mechanical dilatation of the achalasic sphincter may be performed as an initial treatment option. Intrasphincteric injections of botulinum toxin seemed to be a promising alternative, but it has become obvious that, in most cases, repeated applications of the toxin are required to maintain patients symptom-free. Myotomy of the achalasic sphincter with or without fundoplication to prevent gastroesophageal reflux, is employed mainly in patients in whom dilatations have failed, but since the introduction of minimally invasive surgery, myotomy has become the primary treatment at many centers. This article aims to provide an overview of the development of the conservative and surgical treatment of achalasia.

Reoperative esophageal surgery

Reoperative esophageal surgery can be a very challenging endeavor. Preoperative evaluation, planning and preparation are essential to optimize results. A general reoperative approach and the range of reconstructive options are outlined. Management of specific problems is discussed including stricture, recurrent gastroesophageal reflux, recurrent tracheoesophageal fistula, esophageal interposition, and recurrent achalasia.

Floppy Dor fundoplication after esophagocardiomyotomy for achalasia

BACKGROUND

When esophagocardiomyotomy (ECM) is performed for achalasia, a complementary antireflux procedure of the surgeon's choice is usually performed to minimize postoperative gastroesophageal reflux. This retrospective analysis describes patients after laparoscopic ECM, most of whom had a modified Dor fundoplication.

METHODS

Between 1994 and 2001, 81 patients with achalasia of the esophagus had laparoscopic ECM. We have previously described the use of intraoperative endoscopy to verify completion of ECM in a cohort of 48 patients who had either Toupet fundoplication (n = 25) or floppy Dor fundoplication (n = 23). Since then floppy Dor fundoplication has been the preferred antireflux procedure for ease of performance and safety reasons. This article describes the floppy Dor fundoplication as we have performed it since 1997, anchoring the wrap to both crura of the hiatus. In addition, the anterior gastric wall is sutured to the anterior rim of the esophageal hiatus, avoiding creation of the paraesophageal hernia that occurs if the gastric wall abuts the entire the length of a long ECM.

RESULTS

During the 1- to 70-month follow up period (mean 45 months), patients who were symptomatic were evaluated by radiographic, manometric, or endoscopic methods; pH studies were not done systematically. The 70% of patients who could be evaluated had postoperative quality of life and symptom assessment interviews that revealed willingness to repeat the operation. Overall satisfaction was high (8.4/10 where 10 is perfect); moderate dysphagia was seen in 11 (16%) 3 to 16 months postoperatively, but patients reverted to a satisfaction score of 8.2 after endoscopic dilation. Occasional heartburn was present in 15 (26%) patients with regular, 5-use proton pump inhibitors (PPI), including 1 with Barrett's esophagus. Others use these medications for gastric disorders. No patient has had cancer of the esophagus develop, but endoscopic surveillance has been inconstant.

CONCLUSIONS

Swallowing was improved in patients without sigmoid esophagus and overall satisfaction was high. New-onset heartburn is an unpredictable problem that can be treated in most patients. Endoscopic dilatation may be required at intervals after ECM-fundoplication for bridging fibrosis at the cardia, but has not required reoperation, as a rule. Laparoscopic ECM is an attractive operation for achalasia.