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French MP, Busing J, Acra S, Chen H, Stafman L, Zamora I, Holzman M, Lovvorn HN. Effects of Anterior Fundoplication on Postoperative Dysphagia and Reflux After Laparoscopic Esophagocardiomyotomy for Pediatric Achalasia. J Laparoendosc Adv Surg Tech A 2024. [PMID: 38597929 DOI: 10.1089/lap.2023.0415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Introduction: Achalasia among children often fails endoscopic management (e.g., dilation, botulinum toxin). Laparoscopic esophagocardiomyotomy (L-ECM) is a standard intervention to relieve obstruction but can induce gastroesophageal reflux (GER). Concurrent anterior fundoplication (A-fundo) has been evaluated in randomized trials among adults, demonstrating mixed results on controlling postoperative GER without exacerbating dysphagia. Furthermore, evidence for the best approach among children remains sparse. We hypothesized that, among children undergoing L-ECM without mucosal violation, routine A-fundo would not improve postoperative GER control while exacerbating dysphagia. Materials and Methods: Observational data of 47 consecutive achalasia patients ≤18 years who received L-ECM (2002-2023) at a single academic institution were collected. Patient records were culled for demographics, achalasia characteristics, and outcomes. Two L-ECM groups were identified: with or without A-fundo. Patients were screened for postoperative dysphagia (additional procedures) and GER (new antireflux medications). Univariate independence testing was conducted to identify statistically significant variables. Results: Among 47 patients undergoing L-ECM, 28 (59.6%) received concurrent A-fundo. Compared with patients undergoing L-ECM alone, patients with L-ECM/A-fundo had significantly longer hospital stays (P < .01) without statistically different rates of postoperative dysphagia (P = .81) or GER (P = .51). Five children (10.6%) experienced mucosal injury with L-ECM: 4 recognized intraoperatively received A-Fundo without subsequent leak; 1 mucosal injury was missed and did not receive A-Fundo, which subsequently leaked. Conclusion: In this largest observation of pediatric achalasia patients, A-fundo appeared clinically insignificant when determining contributors to control GER or exacerbate postoperative dysphagia. A-fundo should not be routinely adopted in children having L-ECM for achalasia without further multicenter analysis but appears beneficial in cases having inadvertent mucosal violation.
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Affiliation(s)
| | - Jordan Busing
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
| | - Sari Acra
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Laura Stafman
- Department of Pediatric Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Irving Zamora
- Department of Pediatric Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Michael Holzman
- Department of Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University, Nashville, Tennessee, USA
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El-Magd ESA, Elgeidie A, Abbas A, Elmahdy Y, Abulazm IL. Mucosal injury during laparoscopic Heller cardiomyotomy: risk factors and impact on surgical outcomes. Surg Today 2023; 53:1225-1235. [PMID: 37052709 PMCID: PMC10600294 DOI: 10.1007/s00595-023-02680-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/01/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE To investigate the risk factors and outcomes of mucosal perforation (MP) during laparoscopic Heller myotomy (LHM) in patients with achalasia. METHODS We conducted a retrospective analysis of patients who underwent LHM for achalasia at a single facility. RESULTS Among 412 patients who underwent LHM for achalasia, MP was identified in 52 (12.6%). Old age, long disease duration, low albumin level, an esophageal transverse diameter > 6 cm, and a sigmoid-shaped esophagus were found to be independent predictors of MP. These factors were assigned a pre-operative score to predict the perforation risk. MP had a significant impact on intra and post-operative outcomes. Gastric side perforation was associated with a higher incidence of reflux symptoms, whereas esophageal-side perforation had a higher incidence of residual dysphagia. CONCLUSIONS Many risk factors for MP have been identified. Correctable parameters like low serum albumin should be resolved prior to surgery, while uncorrectable parameters like old age and a sigmoid-shaped esophagus should be managed by experienced surgeons in high-volume centers. Implementing these recommendations will help decrease the incidence and consequences of this serious complication.
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Affiliation(s)
- El-Sayed Abou El-Magd
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Al Dakahlia Governorate, Mansoura, 35511, Egypt.
| | - Ahmed Elgeidie
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Al Dakahlia Governorate, Mansoura, 35511, Egypt
| | - Amr Abbas
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Al Dakahlia Governorate, Mansoura, 35511, Egypt
| | - Youssif Elmahdy
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Al Dakahlia Governorate, Mansoura, 35511, Egypt
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Patti MG, Schlottmann F, Herbella FAM. Once an achalasia patient always an achalasia patient: evaluation and treatment of recurrent symptoms. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00009-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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4
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Tsuboi K, Yano F, Omura N, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Sakashita Y, Fukushima N, Ikegami T. Is an objective evaluation essential for determining the therapeutic effect of laparoscopic surgery among patients with esophageal achalasia? Surg Endosc 2022; 36:3932-3939. [PMID: 34494151 DOI: 10.1007/s00464-021-08712-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite a high degree of satisfaction with laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia, some cases show no improvement in postoperative esophageal clearance. We investigated whether an objective evaluation is essential for determining the therapeutic effect of LHD. METHODS We investigated the difference in symptoms, regarding esophageal clearance, using timed barium esophagogram (TBE), in 306 esophageal achalasia patients with high postoperative satisfaction who underwent LHD. Furthermore, these patients were divided into two groups, in accordance with the difference in postoperative esophageal clearance, in order to compare the preoperative pathophysiology, symptoms, and surgical results. RESULTS Although the poor postoperative esophageal clearance group (117 cases, 38%) was mostly male and the ratio of Sigmoid type was high compared to the good postoperative esophageal clearance group (p = 0.046, p = 0.001, respectively); in patients with high surgical satisfaction, there was no difference in terms of preoperative symptom scores and surgical results. However, although the satisfaction level was high in the poor esophageal clearance group, the scores in terms of the postoperative dysphagia and vomiting were high (p = 0.0018 and p = 0.004, respectively). The AUC was 0.9842 upon ROC analysis regarding the presence or absence of clearance at 2 min following postoperative TBE and the postoperative feeling of difficulty swallowing score, with a cut-off value of 2 points (sensitivity: 88%, specificity: 100%) in cases with a high degree of surgical satisfaction. CONCLUSION The esophageal clearance ability can be predicted by subjective evaluation, based on the postoperative symptom scores; so, an objective evaluation is not essential in cases with high surgical satisfaction.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Fuji City General Hospital, 50 Takashima-cho, Fuji, Shizuoka, 416-0951, Japan. .,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, Nishisaitama-Chuo National Hospital, Tokorozawa, Saitama, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Se-Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Cubisino A, Schlottmann F, Dreifuss NH, Baz C, Mangano A, Masrur MA, Bianco FM, Giulianotti PC. Robotic redo Heller myotomy: how I do it? Langenbecks Arch Surg 2022; 407:1721-1726. [PMID: 35583834 DOI: 10.1007/s00423-022-02553-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/10/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the high success rate associated with Heller myotomy in the treatment of primary achalasia, symptom persistence or relapse occurs in approximately 10-20% of patients. Unfortunately, the ideal treatment after failed myotomy is not well established yet. We present a didactical video with a stepwise technique to perform a robotic revisional procedure after failed Heller myotomy. METHODS In this report, each surgical step is thoroughly described and visually represented with useful technical tips that might help in improving surgical results of revisional Heller myotomy. RESULTS In patients with previous surgical myotomy, the robotic platform with its high-definition magnified view and EndoWrist instruments allow for a safe and precise redo surgical myotomy. CONCLUSIONS Despite its improved surgical capabilities, the role of robotic redo Heller myotomy in the treatment algorithm of patients with recurrent symptoms after failed surgical myotomy should be further explored.
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Affiliation(s)
- Antonio Cubisino
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA.
| | - Francisco Schlottmann
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Nicolas H Dreifuss
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Carolina Baz
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Alberto Mangano
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Mario A Masrur
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Francesco M Bianco
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Pier Cristoforo Giulianotti
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
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6
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Esophageal Achalasia: Evaluation and Treatment of Recurrent Symptoms. World J Surg 2022; 46:1561-1566. [PMID: 35166877 DOI: 10.1007/s00268-022-06466-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Esophageal achalasia is a primary esophageal motility disorder of unknown origin. Treatment is palliative and its goal is to decrease the resistance posed by a non-relaxing and often hypertensive lower esophageal sphincter. This goal can be accomplished by different treatment modalities such as pneumatic dilatation, laparoscopic myotomy or peroral endoscopic myotomy. In some patients, however, symptoms tend to recur overtime. METHODS A comprehensive literature search was performed on PubMed focused on the management of recurrent achalasia. RESULTS The available treatment modalities can be used, alone or in combination. The goal of treatment is to resolve/improve symptoms, avoiding an esophagectomy, an operation linked to significant morbidity. CONCLUSIONS The treatment of these patients is often very challenging, and the best results are obtained in centers where a multidisciplinary team-radiologists, gastroenterologists, and surgeons-is present.
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7
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Kaushik C, Milhoan M, Khanna A, Miller A, Chawla M, Miller CC, Banki F. Laparoscopic Heller myotomy and Dor fundoplication in the same day surgery setting with a trained team and an enhanced recovery protocol. Surg Open Sci 2020; 1:64-68. [PMID: 32754694 PMCID: PMC7391888 DOI: 10.1016/j.sopen.2019.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 05/10/2019] [Accepted: 06/03/2019] [Indexed: 11/30/2022] Open
Abstract
Background The length of stay after Heller myotomy is 1–5 days. The aim was to report feasibility of the procedure as same day surgery (SDS). Methods Three steps of Enhanced Recovery After Surgery protocol: preoperatively, clear liquid diet for 24 hours, in preoperative area: antiemetics as dermal patch/IV form, 2: Intraoperatively, intubation in semi upright position, IV analgesics and antiemetics. 3: Postoperatively, clear liquid diet and discharge instructions. Patients were followed using a phone questionnaire. Values are median (interquartile range). Results Fifty-seven patients, 32 M (56%)/25F (44%), age 48 (35–59). First 45 were inpatient with LOS of 1 day. Last 12 were planned as same day surgery, 1/12 was discharged on POD#2, 11/12 (92%) were performed as same day surgery. The duration of operation: 139.5 min (114–163) inpatient: vs 123 (107–139) same day surgery, P < .01. Questionnaires were obtained in 78% inpatient at 40 months (25.6–67) vs 82% same day surgery at 8 (4–12). All were satisfied with the operation with no difference between the 2 groups. Conclusion Heller myotomy can be planned as same day surgery and performed successfully in majority of patients with a trained team and an Enhanced Recovery After Surgery protocol focused on prevention of nausea, and pain control in perioperative period.
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Affiliation(s)
- Chandni Kaushik
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth)
| | - Madison Milhoan
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth)
| | - Anshu Khanna
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth)
| | - Andre Miller
- Memorial Hermann Southeast Esophageal Disease Center
| | - Munish Chawla
- Memorial Hermann Southeast Esophageal Disease Center
| | - Charles C Miller
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth)
| | - Farzaneh Banki
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth).,Memorial Hermann Southeast Esophageal Disease Center
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Ithurralde-Argerich J, Rosner L, Faerberg A, Puma R, Ferro D, Cuenca-Abente F. Laparoscopic Heller Myotomy and Roux-en-Y Gastric Bypass as Treatment for Patients with Achalasia and Morbid Obesity: Outcomes in a Short Series of Patients. J Laparoendosc Adv Surg Tech A 2020; 31:29-35. [PMID: 32552364 DOI: 10.1089/lap.2020.0331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: The association between morbid obesity and esophageal achalasia is very infrequent. However, over the last decade, these cases started to increase because of the disturbing rise of morbid obesity worldwide. Heller myotomy (HM) and laparoscopic fundoplication represent the best treatment option for esophageal achalasia. However, in morbidly obese patients with achalasia, the best treatment option is not established. We present laparoscopic HM and Roux-en-Y gastric bypass (RYGB) as an alternative treatment for morbidly obese patients with achalasia. Materials and Methods: We analyzed the course of patients with achalasia and morbid obesity in our institution undergoing a laparoscopic HM and RYGB, with at least 1 year of follow-up. Symptoms questionnaire, body mass index (BMI), and minuted esophagogram before and after treatment were performed in all patients. Results: Seven patients underwent laparoscopic HM and RYGB. All patients had dysphagia. The mean BMI before the onset of symptoms was 42 kg/m2 (range 40 to 50). In 5 patients, preoperative contrast esophagram showed mild or marked dilated esophagus, and in 2, one esophageal curve and severe dilation. Manometry confirmed the diagnosis. At a mean follow-up of 38 months (range 14-69), all patients reported a marked improvement in dysphagia, with median overall satisfaction rating of 10 (range 9-10), and no symptom of gastroesophageal reflux disease (GERD). The mean percentage excess weight loss (%EWL) was 77.1% (range 70.1-98.1) and the mean BMI was 25.7 kg/m2 (range 23-31). Conclusion: HM and RYGB are an excellent treatment for morbidly obese patients with achalasia. All patients reported a marked improvement of their dysphagia and no symptoms of GERD. The %EWL and BMI descent was very good and maintained through time, showing also an excellent control for morbid obesity.
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Affiliation(s)
- Javier Ithurralde-Argerich
- Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Laura Rosner
- Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Alejandro Faerberg
- Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Rolando Puma
- Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Diego Ferro
- Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Federico Cuenca-Abente
- Department of Surgery, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
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Ithurralde-Argerich J, Cuenca-Abente F, Faerberg A, Rosner L, Duque-Seguro C, Ferro D. Resection of the Gastroesophageal Junction and Roux-en-Y Reconstruction as a New Alternative for the Treatment of Recurrent Achalasia: Outcomes in a Short Series of Patients. J Laparoendosc Adv Surg Tech A 2019; 30:121-126. [PMID: 31161951 DOI: 10.1089/lap.2019.0300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Heller myotomy and laparoscopic fundoplication represents the best treatment option for esophageal achalasia, with effective short- and long-term success. However, treatment options in patients in whom primary surgery failed represent a real challenge. We present the resection of the gastroesophageal junction (GEJ) along with a Roux-en-Y reconstruction as a treatment alternative. Materials and Methods: We analyzed the course of 5 patients with achalasia undergoing the resection of the GEJ along with a Roux-en-Y reconstruction for recurrent dysphagia after Heller myotomy and fundoplication, with at least 1 year of follow-up. Symptoms questionnaire and minuted esophagogram before and after treatment were performed in all the patients. Results: Five patients underwent resection of the GEJ along with a Roux-en-Y reconstruction. All the patients had dysphagia and 60% had regurgitations. Eighty percent of the patients had more than one previous redo surgery and 100% had had multiple dilations. Preoperative contrast esophagram of 3 patients show Stage II disease (mild and mark dilated esophagus) and 2 patients with Stage III disease (one esophageal curve and severe dilation). Manometry confirmed the diagnosis. At a mean follow-up of 34 months, all the patients reported a marked improvement in dysphagia, with median overall satisfaction rating of 9 (range 7-10), no symptom of gastroesophageal reflux disease (GERD), and good esophageal emptying in the postoperative contrast esophagram. Conclusions: The resection of the GEJ and Roux-en-Y reconstruction is an excellent treatment for recurrent dysphagia after Heller myotomy. All the patients reported a marked improvement of their dysphagia. No symptoms of GERD were documented after the surgery. This procedure should be taken into account as an alternative to esophagectomy for recurrent dysphagia.
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Affiliation(s)
- Javier Ithurralde-Argerich
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Federico Cuenca-Abente
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Alejandro Faerberg
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Laura Rosner
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Camilo Duque-Seguro
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Diego Ferro
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
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10
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Impact of the Myotomy Extent on Gastric Side on Surgical Outcome After Heller's Cardiomotomy for Achalasia. Surg Laparosc Endosc Percutan Tech 2019; 29:362-366. [PMID: 31012870 DOI: 10.1097/sle.0000000000000647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laparoscopic Heller cardiomyotomy (LHM) with Dor fundoplication represents the most commonly accepted surgical management for achalasia. The ideal extent of myotomy on the gastric side remains a matter of continuous debate. The aim of this study was to compare the impact of the extent of myotomy on the gastric side on the outcome of LHM. PATIENTS AND METHODS Patients with achalasia who underwent LHM included in the study. The patients were classified according to the length of the gastric myotomy into 3 groups (group I: <1.5 cm, group II: 1.5 to 2.5 cm, and group III: >2.5 cm). RESULTS In total, 212 patients (94 males and 118 females) with achalasia treated by LHM and Dor fundoplication included in the study. No statistically significant differences were found among the 3 groups as regards preoperative data, intraoperative mucosal perforation, operative time, blood loss, and hospital stay. The incidence of persistent dysphagia was significantly higher in the group I. Postoperative GERD symptoms were significantly higher in group III (23.3%, P<0.0001). Recurrent achalasia was significantly higher in group I with 11 patients (15.9%), 8 patients in group II (7.1%), and nil in group III (P<0.02). CONCLUSIONS Longer myotomy on the gastric side (>2.5 cm) ensures complete division of the LES with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative GERD. Therefore, a myotomy length of 1.5 to 2.5 cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative GERD.
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11
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Long-Term Efficacy of Peroral Endoscopic Myotomy for Patients with Achalasia: Outcomes with a Median Follow-Up of 36 Months. Dig Dis Sci 2019; 64:803-810. [PMID: 30478767 DOI: 10.1007/s10620-018-5373-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/08/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study aimed to evaluate the long-term efficacy of peroral endoscopic myotomy (POEM) for patients with achalasia. METHODS Prospective data collected from 115 patients (median age 45 years; interquartile range 34-57) with achalasia who underwent POEM at the First Affiliated Hospital of ZheJiang Chinese Medical University with a median follow-up of 36 months were retrospectively analyzed. The Eckardt score and lower esophageal sphincter pressure changes were analyzed, and the gastroesophageal reflux was observed. RESULTS During the final follow-up, the mean Eckardt score reduced from 7.5 ± 1.9 preoperatively to 2.3 ± 1.4 after 1 month of surgery (P < 0.001). Treatment success was observed in 91.3% [confidence interval (CI) 86.2-96.4], 90.3% (CI 84.8-95.8), 89.0% (CI 83.1-94.9), 83.7% (CI 75.7-91.7), and 80.1% (CI 69.7-90.5) of patients after 12, 24, 36, 48, and 60 months, respectively. A total of 16 (13.9%) failures occurred. Four patients were nonresponders (failure within 3 months), eight had an early recurrence (between 3 months and 3 years), and four had a late recurrence (after 3 years). Further, 21 (20.6%) patients had symptoms of reflux during the two-year follow-up. Only one patient with symptomatic reflux was newly added during the subsequent three-year follow-up. Moreover, 71 (61.7%) patients underwent gastroscopy after POEM, and 13 (18.3%) patients were diagnosed with reflux esophagitis. CONCLUSION POEM is safe and effective in treating achalasia and has a favorable long-term efficacy.
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12
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Fernandez-Ananin S, Fernández AF, Balagué C, Sacoto D, Targarona EM. What to do when Heller's myotomy fails? Pneumatic dilatation, laparoscopic remyotomy or peroral endoscopic myotomy: A systematic review. J Minim Access Surg 2018; 14:177-184. [PMID: 29319024 PMCID: PMC6001296 DOI: 10.4103/jmas.jmas_94_17] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/14/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Surgical treatment of achalasia fails in 10%-20% of patients. The most frequent responsible cause is the performance of an incomplete myotomy at primary surgery. The treatment when the failure happens is not well defined. In this study, we review and evaluate the possible treatments to be carried out when surgical myotomy fails. We define its benefits and results, with the purpose of defining a therapeutic algorithm. MATERIALS AND METHODS The systematic review was performed following the guidelines established by the Meta-analysis of Observational Studies in Epidemiology statement. We searched several electronic databases (MEDLINE, PubMED, EMBASE and Cochrane) from January 1991 to March 2017, with the keywords 'recurrent achalasia' 'POEM remyotomy', 'esophagomyotomy failure', 'Heller myotomy failure', 'myotomy failure', 'pneumatic balloon dilatation achalasia' and combinations between them, 'redo Heller', 'redo myotomy', 'reoperative Heller'. RESULTS A total of 61 observational studies related to the treatment of patients with failure of Heller's myotomy were initially found. Finally, 37 articles were included in our study that provided data on 289 patients. Of these 289 patients, diagnosed of failed Heller's myotomy, 87 were treated with pneumatic dilatation (PD), 166 underwent surgical revision and finally 36 were treated with POEM. No randomised controlled trial was identified. CONCLUSIONS The three therapeutic options analysed in this review are effective and safe in the treatment of patients with achalasia with failure of surgical myotomy. The best results can be achieved following an algorithm similar to the one proposed here, where each procedure must be performed by well-experienced team in the selected modality.
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Affiliation(s)
- Sonia Fernandez-Ananin
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Arnulfo F. Fernández
- Department of General and Digestive Surgery, Centro Laparoscópico Dr. Ballesta, Hospital Quirón Teknon, Barcelona, Spain
| | - Carmen Balagué
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - David Sacoto
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Eduardo Maria Targarona
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
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Li QL, Wu QN, Zhang XC, Xu MD, Zhang W, Chen SY, Zhong YS, Zhang YQ, Chen WF, Qin WZ, Hu JW, Cai MY, Yao LQ, Zhou PH. Outcomes of per-oral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 49 months. Gastrointest Endosc 2018; 87:1405-1412.e3. [PMID: 29108981 DOI: 10.1016/j.gie.2017.10.031] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 10/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) has received wide acceptance as a highly effective and safe treatment for esophageal achalasia. Short-term and small-scale studies are ample, but long-term large-scale studies are few. The aim of the study was to systematically analyze our long-term results of POEM, with particular emphasis on POEM failures and associated risk factors. METHODS In this single-center study, consecutive patients treated with POEM between August 2010 and December 2012 were included. The Kaplan-Meier survival function was used to estimate clinical success rate at each year. The Cox proportional hazards model was used to analyze risk factors related to recurrence. RESULTS A total of 564 patients were included. Major perioperative adverse events occurred in 36 patients (6.4%). After a median follow-up of 49 months (range, 3-68), the Eckardt score and lower esophageal sphincter (LES) pressure were significantly decreased (median Eckardt score, 8 to 2 [P < .05]; median LES pressure, 29.7 mm Hg to 11.9 mm Hg [P < .05]). Fifteen failures occurred within 3 months, 23 between 3 months and 3 years, and 10 after 3 years. The estimated clinical success rates at 1, 2, 3, 4, and 5 years were 94.2%, 92.2%, 91.1%, 88.6%, and 87.1%, respectively. Multivariate Cox regression revealed long disease duration (≥10 years) and history of prior interventions to be risk factors for recurrence. Clinical reflux occurred in 37.3% of patients (155/ 416). CONCLUSIONS POEM is a highly safe and effective treatment for esophageal achalasia with favorable long-term outcomes.
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Affiliation(s)
- Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiu-Ning Wu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Cen Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Zhang
- Department of Biostatistics, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shi-Yao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Zheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Qing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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Per-oral endoscopic myotomy in patients with or without prior Heller's myotomy: comparing long-term outcomes in a large U.S. single-center cohort (with videos). Gastrointest Endosc 2018; 87:972-985. [PMID: 29122601 DOI: 10.1016/j.gie.2017.10.039] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 10/23/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Heller's myotomy (HM) is one of the most effective treatments for esophageal achalasia. However, failures do exist, and the success rate tends to decrease with time. The efficacy of rescue treatments for patients with failed HM is limited. A few small-scale studies have reported outcomes of per-oral endoscopic myotomy (POEM) in these patients. We conducted this study to systematically assess feasibility, safety, and efficacy of POEM on patients who have had HM. METHODS Patients at least 3 months out from POEM were selected from our prospective database: 318 consecutive POEMs performed from October 2009 to October 2016. The efficacy and safety of POEM were compared between the 46 patients with prior HM and the remaining 272 patients. RESULTS Patients with prior HM had longer disease history, more advanced disease, more type I and less type II achalasia, lower before-POEM Eckardt scores, and lower before-POEM lower esophageal sphincter (LES) pressure (all P < .01). Procedure parameters and follow-up results (clinical success rate, Eckardt score, LES pressure, GERD score, esophagitis, and pH testing) showed no significant difference between the 2 groups. For the 46 HM-POEM patients, no clinically significant perioperative adverse events occurred. Their overall clinical success rate (Eckardt score ≤3 and no other treatment needed) was 95.7% at a median follow-up of 28 months. CONCLUSION POEM as a rescue treatment for patients with achalasia who failed HM is feasible, safe, and highly effective. It should be the treatment of choice in managing these challenging cases at centers with a high level of experience with POEM.
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Mandovra P, Kalikar V, Patel A, Patankar RV. Redo Laparoscopic Heller's Cardiomyotomy for Recurrent Achalasia: Is Laparoscopic Surgery Feasible? J Laparoendosc Adv Surg Tech A 2017; 28:298-301. [PMID: 29135385 DOI: 10.1089/lap.2017.0499] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Achalasia cardia is an esophageal motor disorder with raised lower esophageal sphincter (LES) pressure. Minimally invasive procedures have become the procedure of choice compared with conventional open surgery. After the primary surgery, recurrence or persistent symptoms have been noted in almost 10%-20% of cases. MATERIALS AND METHODS In this case series, we share our experience with a series of 7 patients who presented to us from January 2010 to January 2017 for recurrent symptoms, following Heller's myotomy for achalasia cardia. RESULTS Commonest symptom of recurrence was dysphagia with mean duration of recurrence of 17.9 months between primary and redo surgery. Revisional Heller's myotomy with Dor's fundoplication was performed in all patients laparoscopically. Mean duration of surgery was 150 minutes. Incomplete gastric myotomy and fibrosis at previous myotomy scar were the main causes of recurrence. Mean duration of hospital stay was 3.5 days. Mean follow-up period was 23.5 months. All the patients were symptomatically better following the redo surgery. Subsequent manometry was performed at the end of 3 months with mean reduction in LES pressure of 7.5 + 1.2 mmHg. CONCLUSION Laparoscopic redo Heller's cardiomyotomy is a possibly reasonable option with good long-term results and minimal postoperative complications in expert hands.
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Affiliation(s)
- Pranav Mandovra
- Digestive Disease Centre, Zen Multispecialty Hospital , Mumbai, India
| | - Vishakha Kalikar
- Digestive Disease Centre, Zen Multispecialty Hospital , Mumbai, India
| | - Ankur Patel
- Digestive Disease Centre, Zen Multispecialty Hospital , Mumbai, India
| | - Roy V Patankar
- Digestive Disease Centre, Zen Multispecialty Hospital , Mumbai, India
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Modified peroral endoscopic myotomy: a "Push and Pull" technique. Surg Endosc 2017; 32:2165-2168. [PMID: 29046961 DOI: 10.1007/s00464-017-5889-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a minimally invasive yet challenging procedure for achalasia. Additional technological innovations and improvements are important for simplifying the procedure. METHODS We report the successful use of a modified POEM procedure, which utilized a "Push and Pull" technique, on a patient with achalasia. RESULTS Our modifications resulted in a short operation time of only 35 min. No complications arose during or after the procedure, up to a follow-up period of 6 months, and symptoms were significantly and quickly improved. CONCLUSIONS This modified procedure shortens operation time and lowers the difficulty of the operation, while leaving the safety and efficacy uncompromised.
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Surgical Management of Achalasia in a Patient With Previous Gastric Bypass. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 11:214-6. [PMID: 27526345 DOI: 10.1097/imi.0000000000000274] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with previous foregut surgery who develop additional foregut pathology can be a challenge. Those who have formerly undergone gastric bypass and later develop achalasia are at increased risk related to previous surgery. In this case report, we describe an alternative approach for the Dor fundoplication after laparoscopic Heller myotomy in the setting of the altered anatomy. The technique and advantages of this approach are detailed in the discussion of this patient.
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Pacilli M, Davenport M. Results of Laparoscopic Heller's Myotomy for Achalasia in Children: A Systematic Review of the Literature. J Laparoendosc Adv Surg Tech A 2016; 27:82-90. [PMID: 27901639 DOI: 10.1089/lap.2016.0169] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Achalasia is a rare disorder in children who are commonly treated by laparoscopic Heller's myotomy (LHM). However, there are no large studies evaluating the results of LHM in the pediatric population, and the need of a concomitant fundoplication remains unclear. The aim of the study is to appraise the results of LHM based on a systematic literature review. MATERIALS AND METHODS MEDLINE search of the English literature was performed for "achalasia," "children," "laparoscopy," "Heller," "myotomy," and "cardiomyotomy." Frequency of postoperative symptoms was grouped to calculate the percentage of patients with symptoms improvement. Incidence of postoperative gastro-esophageal reflux (GER) and dysphagia between patients with and without fundoplication at the time of LHM was compared by Fisher's Exact Test. P < .05 was regarded as significant. RESULTS Twenty-one studies were analyzed (331 children, 1-19 years). All studies were retrospective case-series reviews. Intraoperative complications occurred in 33 patients (10%), with esophageal perforations in 31 (9%), and conversion to open procedure in 9 (2.7%). Fundoplication was performed in 271 (82%): Dor (n = 205, 76%), Toupet (n = 49, 18%), Thal (n = 13, 4.5%), and Nissen (n = 4, 1.5%). Incidence of postoperative GER and dysphagia was similar between children with and without fundoplication (P = 1). Forty-nine (15%) required re-intervention: pneumatic dilatations (n = 30, 9%), redo-surgery (n = 23, 7%), botox injection (n = 1, 0.3%), and medical therapy (n = 5, 1.5%). DISCUSSION LHM for achalasia is effective in 85% of children. Revision surgery is required in 7%. There is no difference in incidence of GER and dysphagia between patients with and without fundoplication. Routine use of an additional fundoplication might not be justified.
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Affiliation(s)
- Maurizio Pacilli
- Department of Paediatric Surgery, King's College Hospital , London, United Kingdom
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital , London, United Kingdom
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Johnson WD, Marshall MB. Surgical Management of Achalasia in a Patient with Previous Gastric Bypass. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - M. Blair Marshall
- Division of Thoracic Surgery, Medstar Georgetown University Hospital, Washington, DC USA
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Allaix ME, Patti MG. Toward a Tailored Treatment of Achalasia: An Evidence-Based Approach. J Laparoendosc Adv Surg Tech A 2016; 26:256-63. [PMID: 27002740 DOI: 10.1089/lap.2016.0067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The treatment options in achalasia patients aim to improve symptoms by reducing the functional obstruction at the level of the gastroesophageal junction. Available treatment modalities are endoscopic botulinum toxin injection (EBTI), pneumatic dilatation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM). We provide an evidence-based review of current indications, limitations, and future perspectives of these options for the treatment of achalasia. METHODS The PubMed/Medline electronic databases and the Cochrane Library were searched. Quality of evidence was assessed according to the GRADE system. RESULTS Functional outcomes after EBTI are significantly worse than those after PD or LHM. LHM with partial fundoplication is associated with low complication rates and provides excellent long-term results with lower need for additional treatment of recurrent dysphagia than PD. POEM is a new promising treatment option with good short-term outcomes and low morbidity in experienced hands. CONCLUSIONS LHM should be considered the procedure of choice for the treatment of achalasia in patients who are fit for surgery. Large randomized controlled trials with long follow-up are needed to validate the role of POEM.
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Affiliation(s)
| | - Marco Giuseppe Patti
- 2 Department of Surgery and Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine , Chicago, Illinois
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Repeated Surgical or Endoscopic Myotomy for Recurrent Dysphagia in Patients After Previous Myotomy for Achalasia. J Gastrointest Surg 2016; 20:494-9. [PMID: 26589525 DOI: 10.1007/s11605-015-3031-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/12/2015] [Indexed: 01/31/2023]
Abstract
AIM Surgical myotomy of the lower esophageal sphincter has a 5-year success rate of approximately 91 %. Peroral endoscopic myotomy can provide similar results for controlling dysphagia. Some patients experience either persistent or recurrent dysphagia after myotomy. We present here a retrospective analysis of our experience with redo myotomy for recurrent dysphagia in patients with achalasia. METHODS From March 1996 to February 2015, 234 myotomies for primary or recurrent achalasia were performed in our center. Fifteen patients (6.4 %) had had a previous myotomy and were undergoing surgical redo myotomy (n = 9) or endoscopic redo myotomy (n = 6) for recurrent symptoms. RESULTS Patients presented at a median of 10.4 months after previous myotomy. Median preoperative Eckardt score was 6. Among the nine patients undergoing surgical myotomy, three esophageal perforations occurred intraoperatively (all repaired immediately). Surgery lasted 111 and 62 min on average (median) in the surgical and peroral endoscopic myotomy (POEM) groups, respectively. No postoperative complications occurred in either group. Median postoperative stay was 3 and 2.5 days in the surgical and POEM groups, respectively. In the surgical group, Eckardt score was <3 for seven out of nine patients after a mean follow-up of 19 months; it was <3 for all six patients in the POEM group after a mean follow-up of 5 months. CONCLUSIONS A redo myotomy should be considered in patients who underwent myotomy for achalasia and presenting with recurrent dysphagia. Preliminary results using POEM indicate that the technique can be safely used in patients who have undergone previous surgical myotomy.
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Marano L, Pallabazzer G, Solito B, Santi S, Pigazzi A, De Luca R, Biondo FG, Spaziani A, Longaroni M, Di Martino N, Boccardi V, Patriti A. Surgery or Peroral Esophageal Myotomy for Achalasia: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e3001. [PMID: 26962813 PMCID: PMC4998894 DOI: 10.1097/md.0000000000003001] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
To date very few studies with small sample size have compared peroral esophageal myotomy (POEM) with the current surgical standard of care, laparoscopic Heller myotomy (LHM), in terms of efficacy and safety, and no recommendations have been proposed.To investigate the efficacy and safety of POEM compared with LHM, for the treatment of achalasia.The databases of Pubmed, Medline, Cochrane, and Ovid were systematically searched between January 1, 2005 and January 31, 2015, with the medical subject headings (MeSH) and keywords "achalasia," "POEM," "per oral endoscopic myotomy," and "peroral endoscopic myotomy," "laparoscopic Heller myotomy" (LHM), "Heller myotomy."All types of study designs including adult patients with diagnosis of achalasia were selected. Studies that did not report the comparison between endoscopic and surgical treatment, experimental studies in animal models, single case reports, technical reports, reviews, abstracts, and editorials were excluded.The total number of included patients was 486 (196 in POEM group and 290 in LHM group).There were no differences between POEM and LHM in reduction in Eckardt score (MD = -0.659, 95% CI: -1.70 to 0.38, P = 0.217), operative time (MD = -0.354, 95% CI: -1.12 to 0.41, P = 0.36), postoperative pain scores (MD = -1.86, 95% CI: -5.17 to 1.44, P = 0.268), analgesic requirements (MD = -0.74, 95% CI: -2.65 to 1.16, P = 0.445), and complications (OR = 1.11, 95% CI: 0.5-2.44, P = 0.796). Length of hospital stay was significantly lower for POEM (MD = -0.629, 95% CI: -1.256 to -0.002, P = 0.049). There was a trend toward significant reduction in symptomatic gastroesophageal reflux rate in favors of LHM compared to POEM group (OR = 1.81, 95% CI: 1.11-2.95, P = 0.017).All included studied were not randomized. Furthermore all selected studies did not report the results of follow-up longer than 1 year and most of them included patients who were both treatment naive and underwent previous endoscopic or surgical interventions for achalasia.POEM represents a safe and efficacy procedure comparable to the safety profile of LHM for achalasia at a short-term follow-up. Long-term clinical trials are urgently needed.
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Affiliation(s)
- Luigi Marano
- From the General, Minimally Invasive and Robotic Surgery, Department of Surgery, "San Matteo degli Infermi Hospital"-ASL Umbria 2, Spoleto (PG), Italy (LM, AS, AP), Esophageal Surgery Unit, Tuscany Regional Referral Center for the Diagnosis and Treatment of Esophageal Disease, Cisanello Hospital, Pisa, Italy (GP, BS, SS), Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine, Orange, CA (AP), Department of Surgical Oncology, National Cancer Research Centre-Istituto Tumori "G. Paolo II", Bari, Italy (RDL), Department of Abdominal and Thoracic Minimally Invasive Surgery, "San Giuseppe Moscati" Hospital, Avellino, Italy (FGB), Department of Surgery, "San Giovanni Battista Hospital"-ASL Umbria 2, Foligno (PG), Italy (ML), Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Naples, Italy (NDM), and Institute of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy (VB)
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Naumann DN, Zaman S, Daskalakis M, Nijjar R, Richardson M, Super P, Singhal R. Day surgery for achalasia cardia: Time for consensus? Ann R Coll Surg Engl 2016; 98:150-4. [PMID: 26829668 PMCID: PMC5210494 DOI: 10.1308/rcsann.2016.0063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Laparoscopic Heller's myotomy (LHM) is the most effective therapy for achalasia of the oesophagus. Most case series of LHM report a length of hospital stay (LOS) >1 day. We present 14 years of experience of LHM to examine the safety and feasibility of LHM as a day case procedure. METHODS We retrospectively examined patients undergoing elective LHM for achalasia at our institution between 2000 and 2014. Demographics, episode statistics, prior investigations and interventions were collated. Outcomes, including LOS, complications and re-interventions, were compared for the periods before and after a consensus decision at our institution in 2008 to perform LHM as a day case procedure. RESULTS Sixty patients with a mean age of 41 ± 13 years were included, of whom 58% were male. The median LOS for all patients was 1 day (interquartile range [IQR] 0-2.25). Overall, LHM was performed as a day case in 27 (45%) cases, at 2/26 (7.7%) in the first period versus 25/34 (73.5%) in the second (p<0.01). There were no significant differences in age, gender or previous interventions between day surgery and non-day surgery groups. One patient required subsequent unplanned surgery, while six (10%) needed endoscopic treatment of recurrent symptoms within 12 months. CONCLUSIONS LHM can be performed safely as a day case procedure. Complication rates are low, with only a small proportion of patients requiring endoscopic treatment for symptom recurrence within 1 year.
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Affiliation(s)
- D N Naumann
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - S Zaman
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - M Daskalakis
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - R Nijjar
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - M Richardson
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - P Super
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - R Singhal
- Heart of England NHS Foundation Trust , Birmingham , UK
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Abstract
A laparoscopic Heller myotomy with partial fundoplication is considered today in most centers in the United States and abroad the treatment of choice for patients with esophageal achalasia. Even though the operation has initially a very high success rate, dysphagia eventually recurs in some patients. In these cases, it is important to perform a careful work-up to identify the cause of the failure and to design a tailored treatment plan by either endoscopic means or revisional surgery. The best results are obtained by a team approach, in Centers where radiologists, gastroenterologists, and surgeons have experience in the diagnosis and treatment of this disease.
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Togo S, Abdoulaye OM, Xing L, Sadio Y. [Transthoracic myotomy of a case of giant megaesophagus in Mali hospital]. Pan Afr Med J 2015; 21:239. [PMID: 26523179 PMCID: PMC4607972 DOI: 10.11604/pamj.2015.21.239.7410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 07/20/2015] [Indexed: 11/11/2022] Open
Abstract
Le but de ce travail est de présenter un cas clinique de mégaœsophage « en chaussette » hyper-dilaté occupant presque l'hémithorax droit chez un patient vivant en milieu rurale qui a été pris en charge dans notre centre par une myotomie de Heller par voie transthoracique et décrire les aspects cliniques paracliniques et thérapeutiques. L’œsocardiomyotomie de Heller par voie transthoracique associé à une réduction de la taille de l’œsophage a été réalisé avec la mise en place d'un système anti retour par le biais d'un lambeau diaphragmatique. Le transit œsogastroduodénale, l'endoscopie et le scanner gardent une place importante dans la recherche diagnostique et le choix du traitement.
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Affiliation(s)
- Seydou Togo
- Service de Chirurgie Thoracique, Hôpital du Mali, Bamako, Mali
| | | | - Li Xing
- 23 Mission Médicale Chinoise au Mali, Mali
| | - Yena Sadio
- Service de Chirurgie Thoracique, Hôpital du Mali, Bamako, Mali
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Per-Oral Endoscopic Myotomy (POEM) After Previous Laparoscopic Heller Myotomy Is Feasible and Safe in a Porcine Model. Surg Laparosc Endosc Percutan Tech 2015; 25:408-11. [PMID: 26429051 DOI: 10.1097/sle.0000000000000200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We sought to evaluate the feasibility, safety, and difficulty of performing the per-oral endoscopic myotomy (POEM) procedure in the setting of a prior Heller myotomy using a survival porcine model. METHODS Four pigs underwent laparoscopic Heller myotomy with Dor partial anterior fundoplication followed by the POEM performed 4 weeks later. Two additional pigs served as controls, undergoing only the POEM. RESULTS All procedures were completed without complications. The revisional POEM was not significantly more difficult than POEM controls based on procedure time, POEM procedure components, or procedure difficulty scores. Revisional POEM had a longer mean operative time when compared with Heller myotomy (126.0 vs. 83.8 min; P<0.01) but had a lower total difficulty score (28.6 vs. 52.1; P≪0.01). CONCLUSIONS A POEM after previous Heller myotomy is safe and feasible in the porcine model and has potential as an option for patients suffering from recurrent or persistent symptoms after failed surgical myotomy.
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Revisional surgery after failed esophagogastric myotomy for achalasia: successful esophageal preservation. Surg Endosc 2015; 30:1754-61. [PMID: 26275539 DOI: 10.1007/s00464-015-4423-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 07/06/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10 % of patients, most of whom will seek repeat surgical intervention. These reoperations are technically challenging, and as such, there exist only limited reports of reoperation with esophageal preservation. METHODS We retrospectively reviewed the records of patients who sought operative intervention from March 1998 to December 2014 for obstructed swallowing after esophagogastric myotomy. All patients underwent a systematic approach, including complete hiatal dissection, takedown of prior fundoplication, and endoscopic assessment of myotomy. Patterns of failure were categorized as: fundoplication failure, inadequate myotomy, fibrosis, and mucosal stricture. RESULTS A total of 58 patients underwent 65 elective reoperations. Four patients underwent esophagectomy as their initial reoperation, while three patients ultimately required esophagectomy. The remainder underwent reoperations with the goal of esophageal preservation. Of these 58, 46 were first-time reoperations; ten were second time; and two were third-time reoperations. Forty-one had prior operations via a trans-abdominal approach, 11 via thoracic approach, and 6 via combined approaches. All reoperations at our institution were performed laparoscopically (with two conversions to open). Inadequate myotomy was identified in 53 % of patients, fundoplication failure in 26 %, extensive fibrosis in 19 %, and mucosal stricture in 2 %. Intraoperative esophagogastric perforation occurred in 19 % of patients and was repaired. Our postoperative leak rate was 5 %. Esophageal preservation was possible in 55 of the 58 operations in which it was attempted. At median follow-up of 34 months, recurrent dysphagia after reoperation was seen in 63 % of those with a significant fibrosis versus 28 % with inadequate myotomy, 25 % with failed wrap, and 100 % with mucosal stricture (p = 0.10). CONCLUSIONS Laparoscopic reoperation with esophageal preservation is successful in the majority of patients with recurrent dysphagia after Heller myotomy. The pattern of failure has implications for relief of dysphagia with reoperative intervention.
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Abstract
Peroral endoscopic myotomy (POEM) was first performed in Japan in 2008 for uncomplicated achalasia. With excellent results, it was adopted by highly skilled endoscopists around the world and the indications for POEM were expanded to include advanced sigmoid achalasia, failed surgical myotomy, patients with previous endoscopic treatments and even other spastic oesophageal motility disorders. With increased uptake and performance of POEM, variations in technique and improved management of adverse events have been developed. Now, 6 years since the first case and with >3,000 procedures performed worldwide, long-term data has shown the efficacy of POEM to be long-lasting. A growing body of literature also exists pertaining to the learning curve, application of novel technologies, extended indications and physiologic changes with POEM. Ultimately, this once experimental procedure is evolving towards becoming the preferred treatment for achalasia and other spastic oesophageal motility disorders.
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Identification of risk factors for mucosal injury during laparoscopic Heller myotomy for achalasia. Surg Endosc 2015; 30:706-714. [PMID: 26092001 DOI: 10.1007/s00464-015-4264-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/19/2015] [Indexed: 01/28/2023]
Abstract
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.
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Simic´ A, Skrobić O, Veličković D, Ražnatović Z, Šaranović Đ, Šljukić V, Jovanović S, Ivanović N, Peško P. Minimally invasive surgery for benign esophageal disorders: first 200 cases. Eur Surg 2015. [DOI: 10.1007/s10353-015-0296-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Cuttitta A, Tancredi A, Andriulli A, De Santo E, Fontana A, Pellegrini F, Scaramuzzi R, Scaramuzzi G. Fundoplication after heller myotomy: a retrospective comparison between nissen and dor. Eurasian J Med 2015; 43:133-40. [PMID: 25610181 DOI: 10.5152/eajm.2011.31] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Accepted: 10/24/2011] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE A retrospective comparison between Nissen and Dor fundoplication after laparoscopic Heller myotomy for achalasia. MATERIALS AND METHODS From 1998 to 2004 a first group of 48 patients underwent Heller myotomy and Nissen fundoplication for idiopathic achalasia (H+N group). From 2004 to 2010 a second group of 40 patients underwent Heller myotomy followed by Dor fundoplication (H+D group). Some patients received a previous endoscopic treatment with pneumatic dilatation or endoscopic injection of botulinum toxin that provided them only a temporary clinical benefit. Changes in clinical and instrumental examinations from before to after surgery were evaluated in all patients. Clinical evaluation was carried out using a modified DeMeester symptom score system. RESULTS Dor fundoplication treatment reduced both dysphagia and regurgitation severity scores significantly more than Nissen fundoplication (p<0.0001). Indeed, the incidence of dysphagia was significantly higher in patients treated with floppy-Nissen than in those treated with Dor fundoplication: by defining dysphagia as a DeMeester score equal to 3 (arbitrary cut-off), at the end of follow-up dysphagia occurred in 17.65% and 0% (p=0.037) of patients belonging to the H+N and H+D groups, respectively. CONCLUSION Heller myotomy followed by Dor fundoplication is a safe and valuable treatment. The procedure showed a lower incidence of postoperative dysphagia versus Nissen fundoplication and a negligible incidence of postoperative GERD in a long-term postoperative follow-up.
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Affiliation(s)
- Antonello Cuttitta
- Unit of General Surgery 2 and Thoracic Surgery, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy
| | - Antonio Tancredi
- Unit of General Surgery 2 and Thoracic Surgery, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy ; PhD School in Internal Medicine and Medical Therapy, Department of Internal Medicine and Medical Therapy, University of Pavia, Piazzale Golgi, Pavia, PV, Italy
| | - Angelo Andriulli
- Unit of Gastroenterology, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy
| | - Ermelinda De Santo
- Unit of Gastroenterology, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy
| | - Andrea Fontana
- Unit of Biostatistics, IRCCS "Casa Sollievo della Soff erenza" Hospital-Viale Cappuccini, San Giovanni Rotondo, FG, Italy
| | - Fabio Pellegrini
- Unit of Biostatistics, IRCCS "Casa Sollievo della Soff erenza" Hospital-Viale Cappuccini, San Giovanni Rotondo, FG, Italy ; Laboratory of Clinical Epidemiology of Diabetes and Chronic Diseases, Consorzio Mario Negri Sud-Via Nazionale, Santa Maria Imbaro, CH, Italy
| | - Roberto Scaramuzzi
- Unit of General Surgery 2 and Thoracic Surgery, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy ; Graduate School of Medicine, Catholic University of the Sacred Heart - Largo Francesco Vito, Rome, Italy
| | - Gerardo Scaramuzzi
- Unit of General Surgery 2 and Thoracic Surgery, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy
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Symptomatic outcome following laparoscopic Heller’s cardiomyotomy with Dor fundoplication versus laparoscopic Heller’s cardiomyotomy with angle of His accentuation: results of a randomized controlled trial. Surg Endosc 2014; 29:2344-51. [PMID: 25427411 DOI: 10.1007/s00464-014-3958-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 11/03/2014] [Indexed: 02/03/2023]
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Abstract
BACKGROUND Esophageal achalasia is a primary motility disorder of unknown etiology. It is characterized by lack of esophageal peristalsis and failure of the lower esophageal sphincter to relax appropriately in response to swallowing. The goal of treatment is to improve esophageal emptying and patient's symptoms by decreasing the functional obstruction at the level of the gastroesophageal junction. This can be accomplished by either endoscopic modalities (intra-sphincteric injection of botulinum toxin, pneumatic dilatation, per oral endoscopic myotomy) or by a laparoscopic Heller myotomy. RESULTS Review of the current literature suggests that a laparoscopic Heller myotomy should be considered today the primary form of treatment for achalasia and recommends a treatment algorithm for this disease.
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Vigneswaran Y, Yetasook AK, Zhao JC, Denham W, Linn JG, Ujiki MB. Peroral endoscopic myotomy (POEM): feasible as reoperation following Heller myotomy. J Gastrointest Surg 2014; 18:1071-6. [PMID: 24658904 DOI: 10.1007/s11605-014-2496-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/04/2014] [Indexed: 01/31/2023]
Abstract
PURPOSE The purpose of this study was to demonstrate the feasibility of performing peroral endoscopic myotomy (POEM) in the management of recurrent achalasia after failed myotomy. METHODS Eight patients presented to our institution between October 2010 and June 2013 with recurrent/persistent symptoms after prior laparoscopic Heller myotomy. Three patients underwent redo laparoscopic Heller myotomy, and five patients consented to redo myotomy with POEM. RESULTS Demographics were similar between the groups with exception of age (POEM 69.5 vs. laparoscopic Heller myotomy (LHM) 34.5, p = 0.003). Preoperative Eckardt scores, motility, and prior interventions were not significantly different. Three patients who underwent POEM and two who underwent laparoscopic Heller myotomy had prior fundoplication. There was one perforation identified after laparoscopic Heller myotomy and one patient with persistent subcutaneous emphysema after POEM. Both POEM and laparoscopic Heller myotomy demonstrated significant improvement in symptoms and Eckardt scores at average follow-up of approximately 5 months (p < 0.05). CONCLUSION POEM is a feasible option for patients after failed myotomy even in the presence of prior fundoplication. The procedure can be performed safely using a similar technique as for primary myotomy with the exception of creating the myotomy laterally along the right side of the esophagus and lesser curvature avoiding the previous anterior myotomy.
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Hauge T, Johnson E, Sandstad O, Johannessen HO, Trondsen E. Surgical treatment of epiphrenic oesophageal diverticulum. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:1047-50. [PMID: 24865729 DOI: 10.4045/tidsskr.13.1336] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Epiphrenic diverticula occur in the lowermost 10 cm of the oesophagus. The main symptoms are dysphagia, regurgitation and pain when swallowing food. The main purpose of the survey was to evaluate the department's results for surgical treatment of this rare and distressing condition. MATERIAL AND METHOD In the period 2002-2012, eleven patients (nine men) underwent surgery for an oesophageal diverticulum consisting of excision (n = 8), myotomy of the lower oesophageal sphincter and Dor fundoplication (n = 2) or all these procedures (n = 1). Two of them were transferred from other hospitals because of complications. Details of pre-operative symptoms and post-operative complications were retrieved retrospectively from patient records. Ten patients who agreed to take part in a retrospective survey responded to a questionnaire a median of 27.5 months (range of 2-105 months) after surgery. RESULTS There were no fatalities as a result of the treatment. Three patients developed leakage after the diverticulum excision, two of whom required reoperation. The patients experienced considerable symptomatic improvement. According to the retrospective survey, eight of the nine patients with pre-operative dysphagia no longer had it. Four of seven with regurgitation, and all five patients who experienced pain in connection with swallowing, experienced post-operative improvement. The patients reported their condition as completely well (n = 5) or improved (n = 5) after the operation. One patient who had undergone reoperation for leakage and oesophageal mediastinal fistula did not consent to further surgery. INTERPRETATION Most patients who underwent surgery for epiphrenic oesophageal diverticulum in our department experienced symptomatic improvement after surgery.
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Affiliation(s)
| | - Egil Johnson
- Avdeling for gastro- og barnekirurgi Oslo universitetssykehus, Ullevål og Institutt for klinisk medisin Universitetet i Oslo
| | - Olav Sandstad
- Gastromedisinsk avdeling Oslo universitetssykehus, Ullevål
| | | | - Erik Trondsen
- Avdeling for gastro- og barnekirurgi Oslo universitetssykehus, Ullevål
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Li QL, Chen WF, Zhou PH, Yao LQ, Xu MD, Hu JW, Cai MY, Zhang YQ, Qin WZ, Ren Z. Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg 2013; 217:442-51. [PMID: 23891074 DOI: 10.1016/j.jamcollsurg.2013.04.033] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/01/2013] [Accepted: 04/23/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during peroral endoscopic myotomy (POEM) for achalasia. However, because the longitudinal muscle fibers of the esophagus are extremely thin and fragile, and completeness of myotomy is the basis for the excellent results of conventional surgical myotomy, this modification needs to be further debated. Here, we retrospectively analyzed our prospectively maintained POEM database to compare the outcomes of endoscopic full-thickness and circular muscle myotomy. STUDY DESIGN According to the myotomy depth, 103 patients with full-thickness myotomy were assigned to group A, while 131 patients with circular muscle myotomy were assigned to group B. Symptom relief, procedure-related parameters and adverse events, manometry outcomes, and reflux complications were compared between groups. RESULTS The mean operation times were significantly shorter in group A compared with group B (p = 0.02). There was no increase in any procedure-related adverse event after full-thickness myotomy (all p < 0.05). During follow-up, treatment success (Eckardt score ≤ 3) persisted for 96.0% (95 of 99) of patients in group A and for 95.0% (115 of 121) of patients in group B (p = 0.75). There were no statistically significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both p > 0.05). The overall clinical reflux complication rates were also similar (21.2% vs 16.5%, p = 0.38). CONCLUSIONS Short-term symptom relief and manometry outcomes of each method were comparable. Full-thickness myotomy significantly reduced the procedure time but did not increase the procedure-related adverse events or clinical reflux complications.
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Affiliation(s)
- Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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The management of esophageal achalasia: from diagnosis to surgical treatment. Updates Surg 2013; 66:23-9. [PMID: 23817763 DOI: 10.1007/s13304-013-0224-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 06/21/2013] [Indexed: 02/07/2023]
Abstract
The goal of this review is to illustrate our approach to patients with achalasia in terms of preoperative evaluation and surgical technique. Indications, patient selection and management are herein discussed. Specifically, we illustrate the pathogenetic theories and diagnostic algorithm with current up-to-date techniques to diagnose achalasia and its manometric variants. Finally, we focus on the therapeutic approaches available today: medical and surgical. A special emphasis is given on the surgical treatment of achalasia and we provide the reader with a detailed description of our pre and postoperative management.
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Comparison of the Heller-Toupet procedure with the Heller-Dor procedure in patients who underwent laparoscopic surgery for achalasia. Surg Today 2013; 44:732-9. [PMID: 23793852 DOI: 10.1007/s00595-013-0640-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 04/30/2013] [Indexed: 01/01/2023]
Abstract
PURPOSE We compared the outcomes of Toupet fundoplication with those of Dor fundoplication in patients with achalasia who underwent laparoscopic Heller myotomy. METHODS Seventy-two patients with achalasia and dysphagia underwent laparoscopic Heller myotomy with fundoplication performed by a single surgeon. Heller-Toupet fundoplication (HT) was performed in 30 patients, and Heller-Dor fundoplication (HD) was done in 42. The symptoms and esophageal function were retrospectively assessed in both groups. RESULTS The dysphagia scores significantly decreased after both the HT and HD procedures, and did not differ significantly between them. The incidence of reflux symptoms was significantly higher after HT (26.7%) than after HD (7.1%). The lower esophageal sphincter (LES) resting pressure significantly decreased after both HT and HD. Upon endoscopic examination, the incidence of reflux esophagitis was significantly higher after HT (38.5%) than after HD (8.8%). During esophageal pH monitoring, the fraction time at pH <4 was similar in the patients who underwent HT and HD. CONCLUSIONS Laparoscopic Heller myotomy provided significant improvements in the dysphagia symptoms of achalasia patients, regardless of the type of fundoplication. The incidences of reflux symptoms and reflux esophagitis were higher after HT than after HD. However, the results of pH monitoring did not differ between the procedures.
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Katada N, Sakuramoto S, Yamashita K, Shibata T, Moriya H, Kikuchi S, Watanabe M. Recent trends in the management of achalasia. Ann Thorac Cardiovasc Surg 2013; 18:420-8. [PMID: 23099422 DOI: 10.5761/atcs.ra.12.01949] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Radical treatment for achalasia is currently unavailable. At present, most palliative procedures are designed improve the passage of food through the gastroesophageal junction and thereby alleviate symptoms. Drug therapy is of limited, transient effectiveness. Pneumatic dilation (PD) is considered superior to endoscopic botulinum toxin injection (EBTI). The mainstay of surgical treatment for achalasia is laparoscopic Heller myotomy (LHM) with fundoplication, currently considered superior to PD. Per oral endoscopic myotomy (POEM), a "state-of-the-art" procedure for minimally invasive surgery, holds great promise for the future management of achalasia. Definitive conclusions regarding the benefits and risks of currently available treatments for achalasia must await the accumulation of evidence from well-designed clinical trials.
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Affiliation(s)
- Natsuya Katada
- Department of Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan.
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Recurrent dysphagia after Heller myotomy: is esophagectomy always the answer? J Am Coll Surg 2013; 216:736-43; discussion 743-4. [PMID: 23415553 DOI: 10.1016/j.jamcollsurg.2012.12.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 12/07/2012] [Indexed: 01/27/2023]
Abstract
BACKGROUND Esophagectomy has been recommended for patients when recurrent dysphagia develops after Heller myotomy for achalasia. My colleagues and I prefer to correct the specific anatomic problem with redo myotomy and preserve the esophagus. We examined the results of this approach. STUDY DESIGN We analyzed the course of 43 patients undergoing redo Heller myotomy for achalasia between 1994 and 2011 with at least 1-year of follow-up. In 2012, a phone interview and a symptoms questionnaire were completed by 24 patients. RESULTS Forty-three patients underwent redo Heller myotomy. All patients had dysphagia, 80% had had multiple dilations. Manometry confirmed the diagnosis, lower esophageal sphincter pressure averaged 17 mmHg; 24-hour pH monitoring was not useful because of fermentation; patients were divided into 4 groups according to findings on upper gastrointestinal series. Three patients underwent take down of previous fundoplication only, the remainder 40 had that and a redo myotomy with 3-cm gastric extension. Two mucosal perforations were repaired with primary closure and Dor fundoplication. At a median follow-up of 63 months, 19 of 24 patients reported improvement in dysphagia, with median overall satisfaction rating of 7 (range 3 to 10); 4 patients required esophagectomy for persistent dysphagia. CONCLUSIONS The majority of failures after Heller myotomy present with dysphagia associated with esophageal narrowing. Upper gastrointestinal series is most useful to plan therapy and predicts outcomes. With few exceptions, patients improve substantially with redo myotomy, which can be accomplished laparoscopically with relatively low risk. These findings challenge the previously held concept that all myotomy failures need to be treated by an esophagectomy.
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Bello B, Herbella FA, Allaix ME, Patti MG. Impact of minimally invasive surgery on the treatment of benign esophageal disorders. World J Gastroenterol 2012; 18:6764-70. [PMID: 23239914 PMCID: PMC3520165 DOI: 10.3748/wjg.v18.i46.6764] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 05/26/2012] [Accepted: 07/18/2012] [Indexed: 02/06/2023] Open
Abstract
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.
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Robotic heller myotomy and Dor fundoplication for achalasia in a woman with morbid obesity. J Robot Surg 2012; 6:371-4. [PMID: 27628481 DOI: 10.1007/s11701-012-0357-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 05/11/2012] [Indexed: 10/28/2022]
Abstract
Achalasia is a relatively rare condition with a prevalence estimated at less than 0.001 %. Laparoscopic or robotic Heller myotomy is an effective surgical treatment for achalasia. We present the first published case of a morbidly obese achalasia patient treated with robotic Heller myotomy and Dor fundoplication. The operative time was 175 min, with an estimated blood loss of 110 ml. The patient had a normal bowel transit on postoperative day 2, and he was discharged on postoperative day 4 on a liquid diet. A follow-up at 2 months showed significant resolved symptoms of achalasia.
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Molena D, Yang SC. Surgical management of end-stage achalasia. Semin Thorac Cardiovasc Surg 2012; 24:19-26. [PMID: 22643658 DOI: 10.1053/j.semtcvs.2012.01.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2012] [Indexed: 02/07/2023]
Abstract
Esophageal achalasia is a chronic and progressive motility disorder that leads to massive esophageal dilation when left untreated. Treatment for achalasia is palliative and aimed to relieve the outflow obstruction at the level of the lower esophageal sphincter, yet protecting the esophageal mucosa from refluxing gastric acids. The best way to accomplish this goal is through an esophageal myotomy and partial fundoplication, with a success rate >90%. Progression of disease, treatment failure, and complications from gastroesophageal reflux disease cause progressive deterioration of the esophageal function to an end stage in about 5% of patients. The only chance to improve symptoms in this small group of patients is through an esophageal resection. This article will review the indications for esophagectomy in end-stage achalasia, present the different types of surgical approach and possibilities for reconstruction of the alimentary tract, and summarize the short-term and long-term postoperative results.
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Affiliation(s)
- Daniela Molena
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA
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James DRC, Purkayastha S, Aziz O, Amygdalos I, Darzi AW, Hanna GB, Zacharakis E. The feasibility, safety and outcomes of laparoscopic re-operation for achalasia. MINIM INVASIV THER 2012; 21:161-7. [PMID: 22621381 DOI: 10.3109/13645706.2011.588798] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Heller myotomy for achalasia is associated with a recurrence rate of around 10%, thus reoperative surgery is often necessitated. This paper aims to review the available literature on laparoscopic reoperation for achalasia in order to assess its feasibility and effectiveness. MATERIAL & METHODS A Medline, Embase, Ovid, Cochrane database and Google(TM) Scholar search was performed with the following Mesh terms: "laparoscopic", "redo", "reoperative", "Heller's", "esophagomyotomy" and "achalasia". Outcomes of interest included patient demographics and details of primary procedure, operative details, intra- and post operative complications and symptom scores. RESULTS Seven studies reported outcomes from 54 cases. Conversion occurred in 7% (4/54) of cases. Thirteen percent (7/54) of patients sustained intra-operative gastric or oesophageal perforation; however these were all noted and repaired intra-operatively leading to no subsequent morbidity. No deaths were reported. Pre- and post operative symptom scores were heterogeneous, however did appear to improve after the procedure. DISCUSSION This review demonstrates that laparoscopic reoperation for achalasia is feasible and safe with complication rates comparable to the primary laparoscopic operation. It is recommended that laparoscopic reoperative Heller's myotomy should only be performed by surgeons with special interest in oesophagogastric surgery and adequate experience in laparoscopic surgery for achalasia.
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Affiliation(s)
- David R C James
- Department of Surgery and Cancer, St. Mary's Hospital, London, UK
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Minimally invasive myotomy for the treatment of esophageal achalasia: evolution of the surgical procedure and the therapeutic algorithm. Surg Laparosc Endosc Percutan Tech 2012; 22:83-7. [PMID: 22487617 DOI: 10.1097/sle.0b013e318243368f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Esophageal achalasia 2011: pneumatic dilatation or laparoscopic myotomy? J Gastrointest Surg 2012; 16:870-3. [PMID: 21969248 DOI: 10.1007/s11605-011-1694-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 09/13/2011] [Indexed: 01/31/2023]
Abstract
This article reviews the changes that have taken place in the treatment of patients with achalasia in the last 20 years. It compares and contrasts treatment preferences in the USA with those of Canada and Europe. It provides a critical analysis of the recent randomized trial between laparoscopic Heller myotomy and pneumatic dilatation that was carried out in several European centers. It supports the use of laparoscopic Heller myotomy as the preferred treatment for the average patient with this disease in the USA.
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Aghajanzadeh M, Moghadam AD, Hemmati H, Aghajanzadeh G, Massahnia S. Results of short- and long-segment cardioesophageal myotomy for achalasia. Saudi J Gastroenterol 2012; 18:237-40. [PMID: 22824765 PMCID: PMC3409883 DOI: 10.4103/1319-3767.98426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND/AIM We report the results of a short- and long-segment cardiomyotomy for relief of the symptoms of achalasia. PATIENTS AND METHODS From 1997 to 2009, 41 patients (22 men, 19 women) with achalasia underwent cardiomyotomy. Patients were divided into 2 groups [short-segment group (SSG) and long-segment group (LSG)]. SSG include 22 patients with laparotomy and 8-cm short-segment myotomy and Dor fundoplication. LSG includes 19 patients with thoracotomy and 12-cm long-segment myotomy and Belsey partial fundoplication. results: Median follow up was 48 months (range: 12-70 months). Postoperative dysphagia improved in 20 patients in SSG and in 17 patients in LSG (P < 0.001). Slow emptying sensation improved in 19 patients in SSG and in 16 patients in LSG postoperatively (P < 0.001). Heartburn was present in 2 patients in SSG and 3 patients in LSG postoperatively (P = 0.179). Radiologically, barium stasis decreased significantly from 88% to 25% in SSG and from 85% to 30% in LSG. The lower esophageal sphincter (LES) gradient decreased from 32 to 10 mmHg in SSG and from 34 to 14 mmHg in LSG (P < 0.001). CONCLUSIONS Short-segment cardiomyotomy reduces the LES gradient and relieves obstructive symptoms.
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Affiliation(s)
- Manouchehr Aghajanzadeh
- Respiratory Diseases and TB Research Center of Guilan University of Medical Sciences, Razi Hospital, Rasht, Iran.
| | - Anoush D. Moghadam
- Respiratory Diseases and TB Research Center of Guilan University of Medical Sciences (GUMS), Razi Hospital, Rasht, Iran
| | - Hosein Hemmati
- Respiratory Diseases and TB Research Center of Guilan University of Medical Sciences (GUMS), Razi Hospital, Rasht, Iran
| | - Gilda Aghajanzadeh
- Respiratory Diseases and TB Research Center of Guilan University of Medical Sciences (GUMS), Razi Hospital, Rasht, Iran
| | - Sara Massahnia
- Respiratory Diseases and TB Research Center of Guilan University of Medical Sciences (GUMS), Razi Hospital, Rasht, Iran
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SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 2011; 26:296-311. [PMID: 22044977 DOI: 10.1007/s00464-011-2017-2] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/24/2011] [Indexed: 12/19/2022]
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Pontone S, Urciuoli P, Pontone P, Custureri F. Dor against toupet fundoplication after heller myotomy. Laparoscopic technical improvements and endoscopic support. J Gastrointest Surg 2011; 15:2119-20. [PMID: 21720927 DOI: 10.1007/s11605-011-1603-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 06/20/2011] [Indexed: 01/31/2023]
Affiliation(s)
- Stefano Pontone
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy.
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Bello B, Herbella FA, Patti MG. Evolution of the minimally invasive treatment of esophageal achalasia. World J Surg 2011; 35:1442-6. [PMID: 21400015 DOI: 10.1007/s00268-011-1027-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Brian Bello
- Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 South Maryland Avenue, MC 5031, Room G-201, Chicago, IL 60637, USA
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