Data analyses and perspectives on laparoscopic surgery for esophageal achalasia

An overview of the efficacy, safety, and predictors of achalasia treatments

INTRODUCTION

Achalasia is a rare esophageal motility disorder characterized by abnormal esophageal peristalsis and the inability of the lower esophageal sphincter to relax, resulting in poor esophageal emptying. This can be relieved by endoscopic and surgical treatments; each comes with certain advantages and disadvantages.

AREAS COVERED

This review aims to guide the clinician in clinical decision making on the different treatment options for achalasia regarding the efficacy, safety, and important predictors.

EXPERT OPINION

Botulinum toxin injection is only recommended for a selective group of achalasia patients because of the short term effect. Pneumatic dilation improves achalasia symptoms, but this effect diminishes over time and requiring repeated dilations to maintain clinical effect. Heller myotomy combined with fundoplication and peroral endoscopic myotomy are highly effective on the long term but are more invasive than dilations. Gastro-esophageal reflux complaints are more often encountered after peroral endoscopic myotomy. Patient factors such as age, comorbidities, and type of achalasia must be taken into account when choosing a treatment. The preference of the patient is also of great importance and therefore shared decision making has to play a fundamental role in deciding about treatment.

Risk factors for the occurrence of peptic esophagitis following laparoscopic Heller-Dor surgery for esophageal achalasia

Peptic esophagitis can occur as a complication of laparoscopic Heller-Dor surgery (LHD) among patients with esophageal achalasia. The goal of this study was to identify the characteristics of patients who have developed peptic esophagitis following LHD surgery along with the risk factors associated with the occurrence of peptic esophagitis. Among the 447 cases consisting of esophageal achalasia patients who underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not peptic esophagitis occurred following surgery. We also attempted to use univariate and multivariate analyses to identify the risk factors for peptic esophagitis occurring following surgery. Esophagitis following surgery was confirmed in 67 cases (15.0%). With respect to the patient backgrounds for cases in which peptic esophagitis had occurred, a significantly higher number were male patients, with a significantly high occurrence of mucosal perforation during surgery in terms of surgical outcomes, along with a high occurrence of esophageal hiatal hernias in terms of postoperative course (P = 0.045, 0.041, and 0.022, respectively). However, there were no significant differences in terms of age, BMI, disease duration, preoperative symptoms, esophageal manometric findings, esophageal barium findings, and esophageal clearance. A multivariate analysis indicated independent risk factors for the occurrence of peptic esophagitis following LHD as being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias. Peptic esophagitis occurred following LHD in 15% of cases. Independent risk factors for the occurrence of peptic esophagitis following LHD included being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias following surgery.

Robotic esophagomyotomy for achalasia: technical note and review of the literature

INTRODUCTION

The treatment of achalasia has undergone continuous evolution with the advancement of technology. Since the beginning of the new millennium, the employment of robotics has led to technical facilitation with the execution of the myotomy and consequently to improvement of outcomes and decrease perioperative morbidity.

EVIDENCE ACQUISITION

We provide a detailed description of the surgical procedure and the perioperative management together with a literature search of Electronic PubMed/Medline database and Cochrane Library. English written studies on robotic assisted myotomy (case reports, reviews, single arm and comparative studies) were included.

EVIDENCE SYNTHESIS

Between 2001 and 2020, 10 case reports, 13 single arm studies, 10 comparative studies, 2 meta-analysis, 11 reviews and 2 technical notes on robotic assisted esophagomyotomy for achalasia were published.

CONCLUSIONS

As reported by the studies available in the literature and evaluated in this manuscript, robotic assisted cardiomyotomy seems not only feasible but also a safer operation compared with traditional laparoscopic Heller myotomy, due to a significant lower incidence of intraoperative esophageal perforation. Also if large and randomized controlled studies are advocated, robotic assisted esophagocardiomyotomy might be considered superior to laparoscopic Heller myotomy that, until now, is mostly considered the gold standard in the surgical treatment of achalasia.

Peroral endoscopic myotomy is a safe and effective treatment modality for geriatric patients with achalasia

BACKGROUND

Peroral endoscopic myotomy (POEM) is an appealing treatment for older patients, as it is minimally invasive but highly efficacious similar to surgical myotomy. However, there is a lack of systematic studies analyzing POEM outcomes in young (< 65 years) versus geriatric patients (≥ 65 years). Hence, we aimed to compare the safety and efficacy of POEM in young versus geriatric patients.

METHODS

Records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients were categorized into two groups: young (< 65 years) and old (≥ 65 years). Demographic and procedural details, timed barium esophagram (TBE), high-resolution manometry (HREM), pH study findings and Eckardt scores were compared between the two groups. Post-POEM Eckhardt score of ≤ 3 was defined as treatment success.

RESULTS

A total of 148 patients met the study criteria (young = 93; old = 55). Younger patients were more likely to have lower TBE height at 1 min but wider TBE width at 5 min. The rest of the pre-operative parameters and Eckardt scores were similar in the two groups. Young patients were more likely to have undergone prior Heller myotomy, while Botox injections were common in the older group. The operative details and outcomes were similar in the two groups. Treatment success rates were similar in both groups (94.9% young vs. 94.7% in old patients, p = 1.00). At 2-month follow-up, both groups showed significant improvements in Eckhardt scores and HREM parameters; however, older patients showed greater improvement in TBE height at 1 and 5 min. The rates of symptomatic GERD and abnormal esophageal pH study findings were similar in the two groups.

CONCLUSION

POEM was safe and highly effective treatment for geriatric patients with achalasia. These findings suggest that POEM might emerge as the preferred approach for myotomy in this patient population.

Laparoscopic Heller Myotomy for Achalasia: Experience from a Single Referral Tertiary Center

BACKGROUND

Achalasia is the most well known esophageal motility disorder. Laparoscopic Heller myotomy (LHM) is the most effective treatment for achalasia. The aim of this study was to review our results on LHM for achalasia.

METHODS

In this cross-sectional study all patients undergoing LHM between 2015 and 2017 were studied. The myotomy was followed by an anterior or posterior partial fundoplication. All patients were followed up for at least six months.

RESULTS

We conducted this prospective study on 36 consecutive patients who underwent LHM over 3 years. The mean age of the patients was 36.64 ± 13.47 years. 30 patients (83.3%) underwent Toupet and 6 patients (16.7%) received Dor fundoplication. 11 patients (30.6%) developed reflux after the procedure. According to the Eckardt Symptom Scoring (ESS), the symptoms improved in 74.2% of the patients and remained unchanged in 25.8% of the patients. Analysis of the ESS, indicated a significant change in regurgitation and retrosternal pain, dysphagia, and weight loss after the surgery (p = 0.001, p = 0.002, p = 0.046, and p = 0.001, respectively).

CONCLUSION

LHM with anterior or posterior partial fundoplication is safe and achieves a good outcome in the treatment of achalasia, especially in patients who have not responded to other methods while no serious complication was reported despite several prior endoscopic interventions.

[Esophageal achalasia]

Prevalence, clinical manifestations and of modern classifications of achalasia are reviewed in the article. Diagnosis and treatment of this pathology were analyzed by using of 58 references.

An Update on Current Management Strategies for Achalasia and Future Perspectives

The last decade has seen growing insight into the pathophysiology of achalasia, and current treatments decreasing the resting pressure in the lower esophageal sphincter by endoscopic (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy) or surgical means (Heller myotomy). Manometry is considered the gold standard to confirm the diagnosis of achalasia. Pneumatic dilation and laparoscopic Heller myotomy have similar effectiveness and are both more successful in patients with type II achalasia. Laparoscopic myotomy when combined with partial fundoplication is an effective surgical technique and has been considered the operative procedure of choice until recently. Peroral endoscopic myotomy is an emerging therapy with promising results since it offers a minimally invasive and efficacious option especially in type III achalasia. However, it remains to be determined if peroral endoscopic myotomy offers long-term efficacy.

Peroral endoscopic myotomy is safe and effective in achalasia patients aged older than 60 years compared with younger patients

AIM

Peroral endoscopic myotomy (POEM) has been proven to be effective for treating achalasia, but there are limited data on POEM in elderly patients. We therefore aimed to assess the role of POEM for achalasia in patients aged ≥60 years.

METHODS

All consecutive patients that underwent POEM between December 2011 and November 2015 at a single center were retrospectively reviewed. Patients aged ≥60 years were assigned to group A, whereas patients aged <60 years were assigned to group B. Demographic data, clinical data and treatment outcomes were compared between the two groups.

RESULTS

During the study period, 113 patients (18 in group A, and 95 in group B) were enrolled. The mean age of patients in group A was 63 ± 3.9 years (range 60-74 years; 55.6% women), and that for patients in group B was 37.7 ± 11.6 years (range 18-59 years; 42.2% women). The procedural time in group A was similar to group B (66.3 ± 33.3 vs 59.8 ± 24.2 min, P = 0.332). There were also no significant differences in the incidence of intraoperative complications (P = 1.000) and gastroesophageal reflux rate (P = 0.906) between the two groups. During the mean follow-up period of 25.2 months, treatment success (Eckardt score ≤3) was achieved in 92.9% of patients in group A, and 89.9% in group B (P = 1.000).

CONCLUSIONS

As well as in younger patients, POEM can be safely carried out in elderly patients, providing significant symptom relief. POEM might be recommended as the first therapeutic approach to elderly achalasia patients. Geriatr Gerontol Int 2017; 17: 2407-2413.

Learning curve for laparoscopic Heller myotomy and Dor fundoplication for achalasia

Purpose

Although laparoscopic Heller myotomy and Dor fundoplication (LHD) is widely performed to address achalasia, little is known about the learning curve for this technique. We assessed the learning curve for performing LHD.

Methods

Of the 514 cases with LHD performed between August 1994 and March 2016, the surgical outcomes of 463 cases were evaluated after excluding 50 cases with reduced port surgery and one case with the simultaneous performance of laparoscopic distal partial gastrectomy. A receiver operating characteristic (ROC) curve analysis was used to identify the cut-off value for the number of surgical experiences necessary to become proficient with LHD, which was defined as the completion of the learning curve.

Results

We defined the completion of the learning curve when the following 3 conditions were satisfied. 1) The operation time was less than 165 minutes. 2) There was no blood loss. 3) There was no intraoperative complication. In order to establish the appropriate number of surgical experiences required to complete the learning curve, the cut-off value was evaluated by using a ROC curve (AUC 0.717, p < 0.001). Finally, we identified the cut-off value as 16 surgical cases (sensitivity 0.706, specificity 0.646).

Conclusion

Learning curve seems to complete after performing 16 cases.