How I do it: laparoscopic Heller myotomy with Toupet fundoplication for achalasia

The comparisons of different therapeutic modalities for idiopathic achalasia: A systematic review and network meta-analysis

BACKGROUND

: Current guidelines recommend per-oral endoscopic myotomy (POEM) and laparoscopic Heller's myotomy (LHM) as first-line treatment of idiopathic achalasia, but the optimum choice between different endoscopic and surgical modalities remains inconclusive. We conducted a network meta-analysis to compare the efficacy of 8 treatments for idiopathic achalasia.

MATERIALS AND METHODS

: Three major bibliographic databases were reviewed for enrollment of randomized controlled trials between January 2000 and June 2021. We included adults with idiopathic achalasia and compared two or more of eight interventions including botulinum toxin injection (BTI), pneumatic dilation (PD), BTI + PD, LHM without fundoplication, LHM followed with Dor or Toupet fundoplication, and POEM using either the anterior or posterior approach. Our focus was on clinical success rate, postsurgical acid reflux, and moderate-to-severe adverse events.

RESULTS

: Twenty-four studies involved a total of 1987 participants for analysis. When compared with PD, POEM with anterior approach, POEM with posterior approach, LHM + Toupet, and LHM + Dor were all significantly superior to the other regimens in short-term efficacy, with POEM with anterior approach and LHM + Dor showing better improvement in mid-term efficacy. BTI showed a significantly lower efficacy than PD in both periods. Regarding safety, only LHM without fundoplication was significantly associated with higher acid reflux than PD, while LHM + Toupet, LHM without fundoplication, and LHM + Dor showed a non-significant increase in moderate-to-severe adverse events.

CONCLUSIONS

: For idiopathic achalasia, we suggest that POEM with an anterior or posterior approach and LHM with Dor or Toupet fundoplication be initially recommended. On the contrary, both LHM without fundoplication and BTI are not recommended as definitive therapy.

Childhood esophageal achalasia: Case report from Afghanistan with literature review

Introduction and importance

Esophageal achalasia is a motility disorder of the esophagus with unknown etiology characterized by the failure of lower esophageal sphincter relaxation. Diagnosis is made by barium esophagography, endoscopy, and esophageal manometery. Heller Esophagomyotomy along with Dor's fundoplication is the treatment of choice. Persisting undiagnosed cases may lead to malnutrition.

Case presentation

We present a case of an 8-year-old child suffering from dysphagia and regurgitation. The child was misdiagnosed and maltreated for the suspicion of respiratory tract and gastrointestinal problems in the local clinics. During this time, he remained unresponsive to the mentioned treatments, and the local physician advised him to have an upper gastrointestinal (GI) endoscopy, which revealed esophageal achalasia (EA).

On admission to our pediatric surgery ward, the patient had coexistent parotitis, which was treated conservatively. Following recovery, the patient was prepared for surgery and underwent esophageal myotomy along with Dor's fundoplication.

Clinical discussion

Esophageal achalasia is rare in children, but poses major health challenges to children if left untreated. Symptomatic treatment may mask the actual picture of the problem and last for years. Following surgery and discharge from the hospital in a three-month follow-up interval of time, our patient exhibited full recovery, with gaining 4 kg weight.

Conclusions

Respiratory and gastrointestinal conditions with similar signs and symptoms should always be considered in differential diagnosis of esophageal achalasia, especially where there is no direct access to a pediatric specialized complex. On-time evaluation and treatment will further prevent children from malnutrition in long-lasting undiagnosed patients.

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Esophageal achalasia is a motility disorder with unknown etiology.

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Esophageal achalasia is rare in children.

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Dysphagia and respiratory infection will mask the actual picture of the problem.

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Unprofessional symptomatic treatment for a long time is the main cause of undiagnosed patient and may lead to malnutrition.

Surgical management of achalasia

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.

Laparoscopic Heller Myotomy: A Fundoplication Is Necessary to Control Gastroesophageal Reflux

Background: Achalasia is a rare esophageal motility disorder that causes progressive dysphagia and regurgitation. The aim of treatment for achalasia is to provide symptom relief by reducing esophageal outflow resistance by disrupting the muscles at the level of the esophagogastric junction to allow esophageal emptying by gravity. Methods: A review of the literature concerning laparoscopic treatment of esophageal achalasia. Results: Surgical myotomy with partial fundoplication is very effective in relieving symptoms, and is able to strike a balance between relief of symptoms and control of abnormal reflux. Conclusions: Since reflux of gastric contents into the aperistaltic esophagus can cause esophagitis, peptic strictures, Barrett's esophagus, and even esophageal carcinoma, the addition of a partial fundoplication is very important. The choice of partial fundoplication is based on surgeons' preference and expertise.

Laparoscopic esophagomyotomy for achalasia in children: A review

Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy (LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multi-institutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term (> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care.

Recurrent symptoms after Heller myotomy for achalasia: evaluation and treatment

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.

Laparoscopic Heller myotomy as the gold standard for treatment of achalasia

INTRODUCTION

The recent introductions of novel methods for the treatment of achalasia as well as ongoing controversies about the merits of surgical and endoscopic treatment options have created controversy in identifying the optimal treatment for this condition. This lack of clarity prompted this review of 206 consecutive patients treated with a laparoscopic Heller (LH) myotomy over a 16-year period.

METHODS

A retrospective review of a prospectively collected database was performed of 206 consecutive LH performed by a single surgeon.

RESULTS

In this cohort, 58 % of patients had undergone a prior therapeutic intervention. Over 90 % of patients had relief of dysphagia post-operatively. There was one intraoperative esophageal perforation. There were no mortalities. Only 4/206 patients sustained complications that required either post-op therapeutic intervention or delayed hospital discharge.

CONCLUSION

This paper outlines an operative technique that has yielded outstanding results and may be used as a benchmark against which other therapies can be judged.

Controversies in management of achalasia

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.

Esophageal achalasia 2011: pneumatic dilatation or laparoscopic myotomy?

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.

Achalasia

This article reviews the diagnosis and treatment of achalasia, a rare esophageal motility disorder characterized by absent peristalsis and failure of the lower esophageal sphincter (LES) to relax. Various treatment options including management with sublingual nitrates or calcium channel blockers, injection of the LES with botulism toxin, pneumatic dilation of the LES, and pneumatic dilation are discussed. Laparoscopic Heller myotomy is minimally invasive with incumbent low morbidity and mortality rates, and combined with a partial fundoplication is a durable, safe, and effective treatment option for patients with achalasia.

Achalasia and other esophageal motility disorders

Achalasia, diffuse esophageal spasm, nutcracker esophagus, and the hypertensive lower esophageal sphincter are considered primary esophageal motility disorder. These disorders are characterized by esophageal dysmotility that is responsible for the symptoms. While there is today a reasonable consensus about the pathophysiology, the diagnosis, and the treatment of achalasia, this has not occurred for the other disorders. A careful evaluation is therefore necessary before an operation is considered.

Improvement of respiratory symptoms following Heller myotomy for achalasia

INTRODUCTION

Although patients with achalasia complain mainly of dysphagia, we have observed that they also have a high rate of respiratory problems. We hypothesized that the latter may be due to poor esophageal clearance leading to aspiration. This study examines the effect of Heller myotomy on these symptoms.

METHODS

We studied the course of 111 patients with achalasia who underwent Heller myotomy between 1994 and 2008 and who agreed to participate in this study. All patients completed a questionnaire postoperatively assessing the preoperative and postoperative prevalence and severity of symptoms using visual analog scales. Patients were divided into two groups: one that included all those with respiratory symptoms (dyspnea, hoarseness, cough, wheezing, sore throat, and/or a history of asthma or pneumonia) prior to myotomy and one that included those without those symptoms.

RESULTS

All patients presented with dysphagia as their primary complaint, and 63 (57%) reported respiratory symptoms or disease prior to surgery. There were no significant differences in preoperative characteristics between those with and without respiratory manifestations. After a median follow-up of 71 months (range 9-186 months), 55 (87%) patients reported durable improvement of dysphagia. The frequency and severity of all respiratory symptoms decreased significantly. Twenty-four of the 29 patients (82%) who reported a history of pneumonia prior to surgery did not experience recurrent episodes after Heller myotomy.

CONCLUSIONS

A Heller myotomy is effective in improving esophageal emptying in patients with achalasia. This results in sustained improvement of dysphagia and associated respiratory symptoms/diseases. This suggests that respiratory symptoms/diseases in these patients are likely caused by esophageal retention of food and secretions, and then aspiration.

[Laparoscopic treatment of achalasia: analysis of results and reflections on the technique]

INTRODUCTION

Heller myotomy using the laparoscopic approach is the best treatment that we can offer to patients with achalasia. On not acting on the cause of the disease, we can only alleviate the persistence of the symptoms, but not make them disappear.

OBJECTIVE

To analyse the results of our group in the treatment of achalasia by laparoscopy.

MATERIAL AND METHODS

The pre- and post-operative results are analysed of a series of 20 patients intervened prospectively by laparoscopy of achalasia during a period from May 2003 to April 2010. For this we used a modification of the grading scale of pre- and post-operative symptoms described by Velanovich for GER (a scale from 0-5). Data on the complications and the hospital stay were also collected.

RESULTS

A wide Heller myotomy was performed using a Dor type antireflux mechanism. There were no oesophageal perforations or complications during the surgery. Two (10%) patients had postoperative complications. The mean hospital stay was 3.11 ± 2.13 days. After a mean follow up of 55.8 ± 14.1 months, the symptoms studied had significantly decreased after the surgery. Only 3 (15%) patients had clinical symptoms of GER after surgery. Nineteen patients (95%) said they were satisfied with the operation.

CONCLUSIONS

The laparoscopic treatment of achalasia is a safe technique, reproducible and effective technique, which achieves very satisfactory control of the achalasia symptoms with a minimum of morbidity.

Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch

BACKGROUND

Sleeve gastrectomy (SG) can be performed either as isolated (ISG), or with the malabsorptive procedure of duodenal switch (SG/DS). Among the postoperative complications, stenosis of the SG is relatively rare and only scarcely mentioned in literature. We report our experience in nine patients presenting a long stenosis, not eligible for endoscopic balloon dilation, and treated by laparoscopic seromyotomy after ISG or SG/DS.

METHODS

From March 2006 to January 2008, four patients after ISG (0.7%) and five patients after SG/DS (0.8%) were consecutively submitted to laparoscopic seromyotomy for long stenosis, not eligible for endoscopic balloon dilation. Dysphagia appeared after a mean time of 9.2 +/- 2.6 months (ISG) and of 18.6 +/- 13.2 months (SG/DS). Preoperative mean dysphagia frequency was 4 +/- 0 (ISG) and 4 +/- 0 (SG/DS). Gastroesophageal reflux disease (GERD) symptoms appeared as de novo in two patients of both groups. Barium swallow showed a stenosis at the upper part of the SG (2) and at the level of the incisura angularis (7). Gastroscopy evidenced a mean length of the stricture of 4.7 +/- 0.9 cm (ISG) and of 5.2 +/- 1.3 cm (SG/DS). The primary outcomes measure was stricture healing rate. Secondary outcomes measures included procedure time, peroperative, and postoperative complications, performance of barium swallow check, and GERD symptoms improvement.

RESULTS

There were no conversions to open surgery and no mortality. There was no peroperative gastric perforation, but one patient was converted into Roux-en-Y gastric bypass (ISG). Mean operative time was 153.7 +/- 39.4 min (ISG) and 110 +/- 6.1 min (SG/DS). One gastric leak was recorded postoperatively (ISG). Mean hospital stay was 7.6 +/- 5.8 days (ISG) and 3.4 +/- 0.8 days (SG/DS). Barium swallow check after 1 month was satisfied in all patients, and they were able to tolerate a regular diet. After a mean follow-up of 21 +/- 5.6 months (ISG), the mean dysphagia score was reduced to 0.6 +/- 0.9, and after a mean follow-up of 17.6 +/- 10.5 months (SG/DS) to 0.8 +/- 0.8. De novo GERD symptoms improved in two patients of both groups.

CONCLUSION

Laparoscopic seromyotomy after SG for long stenosis is feasible, and efficient for the treatment of symptomatic dysphagia. It has a beneficiary influence on de novo GERD symptoms improvement. There is, however, the risk of postoperative leak.