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Aiolfi A, Damiani R, Manara M, Cammarata F, Bonitta G, Biondi A, Bona D, Bonavina L. Robotic versus laparoscopic heller myotomy for esophageal achalasia: an updated systematic review and meta-analysis. Langenbecks Arch Surg 2025; 410:75. [PMID: 39961886 PMCID: PMC11832576 DOI: 10.1007/s00423-025-03648-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Accepted: 02/12/2025] [Indexed: 02/20/2025]
Abstract
BACKGROUND The surgical treatment for esophageal achalasia has evolved over the years, with laparoscopic Heller myotomy (LHM) and partial fundoplication becoming widely used worldwide. More recently, an increased interest in the robotic Heller myotomy (RHM) has arisen. PURPOSE Compare short-term and functional outcomes of RHM vs. LHM. METHODS Systematic review and meta-analysis. PubMed, MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried. Primary outcome was esophageal perforation (EP). Risk ratio (RR), standardized mean difference (SMD), and 95% confidence intervals (95% CI) were effect size and relative inference measures. PROSPERO Registration Number: CRD42024512644. RESULTS Fourteen observational studies (12962 patients) were included. Of those, 2503 (19.3%) underwent RHM. The patient age ranged from 34 to 66 years and 51.7% were males. EP occurred in 259 patients (1.99%). The cumulative incidence of EP was 1.67% for RHM and 2.07% for LHM. Compared to LHM, RHM was associated with a reduced risk of EP (RR: 0.31; 95% CI 0.16-0.59). No differences were found in term of dysphagia requiring reoperation or additional endoscopic procedures (RR: 0.47; 95% CI 0.20-1.09) and postoperative Eckardt score (SMD: -0.42; 95% CI -0.94, 0.11). Blood loss, conversion to open, operative time, and hospital length of stay were comparable. CONCLUSIONS RHM may be associated with a reduced risk of EP compared to LHM. However, because of selection bias, diverse surgeon expertise, variations in surgical technique, and prior endoscopic procedures these findings should not be viewed as conclusive while the superiority of one approach over the other remains to be established.
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Affiliation(s)
- Alberto Aiolfi
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi- Sant'Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Riccardo Damiani
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi- Sant'Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Michele Manara
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi- Sant'Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Francesco Cammarata
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi- Sant'Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Gianluca Bonitta
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi- Sant'Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Antonio Biondi
- Department of General Surgery and Medical Surgical Specialties, Surgical Division, G. Rodolico Hospital, University of Catania, Catania, 95131, Italy
| | - Davide Bona
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi- Sant'Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy.
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
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Pagadapelli AA, Shah J, Yewale R, Pujari R, Bapaye A. Peroral endoscopic myotomy plus natural orifice transluminal endoscopic wrap release for dysphagia after laparoscopic Heller myotomy and Dor fundoplication. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2025; 10:24-27. [PMID: 39925398 PMCID: PMC11806425 DOI: 10.1016/j.vgie.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/11/2025]
Affiliation(s)
- Arun Arora Pagadapelli
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Jimil Shah
- Department of Gastroenterology, Post Graduate Institute of Medical Research, Chandigarh, India
| | - Rohan Yewale
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Rajendra Pujari
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
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Bethea J, Peine B, Fleming T, Mendes J, Olatidoye O, Allman R, Oliver A, Iannettoni M, Speicher J, Anciano C. Clinical Outcomes and Financial Impact of a POEM Program at a Rural Tertiary Medical Center: Our First Five Years. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2025; 20:27-32. [PMID: 39819050 DOI: 10.1177/15569845241300256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2025]
Abstract
OBJECTIVE The purpose of this study was to assess the 5-year impact of a per oral endoscopic myotomy (POEM) program on both clinical and financial outcomes for our hospital system and the rural community we serve. METHODS We evaluated the clinical and financial outcomes of all patients who underwent POEM for achalasia. Patients were also contacted by phone to complete the Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire postoperatively. Financial data for all robot-assisted laparoscopic Heller myotomy patients from our institution during the same period were also obtained for cost comparison. RESULTS A total of 107 patients underwent POEM in the first 5 years following program implementation, with a mean age of 61.4 ± 17.9 years. There were 75 patients (70%) who participated in the GERD-HRQL survey at a mean follow-up of 84 weeks (range, 6 to 244 weeks). There were 88.2% of respondents who reported no or minimal dysphagia symptoms, and 93.4% of respondents reported no or minimal reflux symptoms. On postoperative upper endoscopy, 19.1% of patients had esophagitis. Implementation of the POEM program resulted in a substantial increase in case volume, growing from 5 myotomy cases per year to 24 myotomy cases per year after 2017. Cost analysis demonstrated a significantly lower index encounter cost for POEM compared with robot-assisted laparoscopic Heller myotomy of approximately $6,000. CONCLUSIONS This study demonstrates the effectiveness and positive financial impact for both our community and hospital system following implementation of a POEM program at a tertiary medical center serving a large, rural population.
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Affiliation(s)
- Joseph Bethea
- Department of General Surgery, East Carolina University, Greenville, NC, USA
| | - Brandon Peine
- Department of General Surgery, East Carolina University, Greenville, NC, USA
| | - Tyler Fleming
- Department of General Surgery, East Carolina University, Greenville, NC, USA
| | - Jesse Mendes
- Department of General Surgery, East Carolina University, Greenville, NC, USA
| | - Olajide Olatidoye
- Department of General Surgery, East Carolina University, Greenville, NC, USA
| | - Robert Allman
- Division of Thoracic Surgery, Department of Cardiovascular Sciences, East Carolina University, Greenville, NC, USA
| | - Aundrea Oliver
- Division of Thoracic Surgery, Department of Cardiovascular Sciences, East Carolina University, Greenville, NC, USA
| | - Mark Iannettoni
- Division of Thoracic Surgery, Department of Cardiovascular Sciences, East Carolina University, Greenville, NC, USA
| | - James Speicher
- Division of Thoracic Surgery, Department of Cardiovascular Sciences, East Carolina University, Greenville, NC, USA
| | - Carlos Anciano
- Division of Thoracic Surgery, Department of Cardiovascular Sciences, East Carolina University, Greenville, NC, USA
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Khazoom F, Louie BE. Management of Complications After Per Oral Endoscopic Myotomy. Thorac Surg Clin 2024; 34:341-353. [PMID: 39332859 DOI: 10.1016/j.thorsurg.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Abstract
This is a comprehensive review of intraoperative, early postoperative, and late postoperative complications of Per Oral Endoscopic Myotomy with a focus on prevention, intraoperative management, and postoperative management.
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Affiliation(s)
- Francois Khazoom
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, 1101 Madison Street, Suite 900, Seattle, WA 90814, USA
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, 1101 Madison Street, Suite 900, Seattle, WA 90814, USA.
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Tustumi F, Szachnowicz S, Andreollo NA, Seguro FCBDC, Bianchi ET, Duarte AF, Nasi A, Sallum RAA. MANAGEMENT OF SYMPTOMS RECURRENCE AFTER MYOTOMY FOR ACHALASIA. A PRACTICAL APPROACH. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1780. [PMID: 38088726 PMCID: PMC10712922 DOI: 10.1590/0102-672020230062e1780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Achalasia is an esophageal motility disorder, and myotomy is one of the most used treatment techniques. However, symptom persistence or recurrence occurs in 9 to 20% of cases. AIMS This study aims to provide a practical approach for managing the recurrence or persistence of achalasia symptoms after myotomy. METHODS A critical review was performed to gather evidence for a rational approach for managing the recurrence or persistence of achalasia symptoms after myotomy. RESULTS To properly manage an achalasia patient with significant symptoms after myotomy, such as dysphagia, regurgitation, thoracic pain, and weight loss, it is necessary to classify symptoms, stratify severity, perform appropriate tests, and define a treatment strategy. A systematic differential diagnosis workup is essential to cover the main etiologies of symptoms recurrence or persistence after myotomy. Upper digestive endoscopy and dynamic digital radiography are the main tests that can be applied for investigation. The treatment options include endoscopic dilation, peroral endoscopic myotomy, redo surgery, and esophagectomy, and the decision should be based on the patient's individual characteristics. CONCLUSIONS A good clinical evaluation and the use of proper tests jointly with a rational assessment, are essential for the management of symptoms recurrence or persistence after achalasia myotomy.
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Affiliation(s)
- Francisco Tustumi
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Sérgio Szachnowicz
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | | | | | - Edno Tales Bianchi
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | - André Fonseca Duarte
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Ary Nasi
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
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DeSouza M. Surgical Options for End-Stage Achalasia. Curr Gastroenterol Rep 2023; 25:267-274. [PMID: 37646894 DOI: 10.1007/s11894-023-00889-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE OF REVIEW Achalasia is one of the most commonly described primary esophageal motility disorders worldwide, but there is significant controversy regarding ideal management of end-stage disease. This article reviews the definition of end-stage achalasia and summarizes past and present surgical treatment. RECENT FINDINGS Myotomy of the lower esophageal sphincter remains the mainstay of treatment of achalasia, even in advanced disease. Esophagectomy may have benefit as a primary treatment modality in end-stage achalasia with sigmoid esophagus, but international guidelines recommend consideration of laparoscopic or endoscopic approaches initially in most patients. Novel peroral esophageal plication techniques may provide alternative treatment options in patients with significant esophageal dilation that fail myotomy or esophagectomy. SUMMARY End-stage achalasia is characterized by progressive tortuosity and dilation of the esophagus as a failure of primary peristalsis. Up to 20% of patients with achalasia will progress to end-stage disease. In most cases, laparoscopic or endoscopic myotomy is recommended as initial approach to surgical management.
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Affiliation(s)
- Melissa DeSouza
- Foregut Surgery, Center for Advanced Surgery, 4805 NE Glisan Ave, OR, 97,213, Portland, Oregon, USA.
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Chang KJ, Swanström LL. Per-Oral Endoscopic Myotomy (POEM). THE AFS TEXTBOOK OF FOREGUT DISEASE 2023:345-355. [DOI: 10.1007/978-3-031-19671-3_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Zimmermann C, Torell N, Lidor A, Funk L, Shada A. Recurrent dysphagia after myotomy for achalasia: pneumatic dilation or POEM? : Which modality offers superior outcomes? Surg Endosc 2022:10.1007/s00464-022-09556-5. [PMID: 36121502 DOI: 10.1007/s00464-022-09556-5] [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: 03/30/2022] [Accepted: 08/08/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Myotomy is the gold standard treatment for achalasia, yet long-term failure rates approach 15%. Treatment options for recurrent dysphagia include pneumatic dilation (PD), laparoscopic redo myotomy, per oral endoscopic myotomy (POEM), or esophagectomy. We employ both PD and POEM as first-line treatment for these patients. We evaluated operative success and patient reported outcomes for patients who underwent PD or POEM for recurrent dysphagia after myotomy. METHODS We identified patients with achalasia who underwent PD or POEM for recurrent dysphagia after previous myotomy within a foregut database at our institution between 2013 and 2021. Gastroesophageal Reflux Disease-Health-Related quality of Life (GERD-HRQL) and Eckardt scores, and overall change in each were compared across PD and POEM groups. Successful treatment of dysphagia was defined by Eckardt scores ≤ 3. RESULTS 103 patients underwent myotomy for achalasia. Of these, 19 (18%) had either PD or POEM for recurrent dysphagia. Nine were treated with PD and 10 with POEM. The mean change in Eckardt and GERD-HRQL scores did not differ between groups. 50% of the PD group and 67% of the POEM group had resolution of their dysphagia symptoms (p = 0.65). Mean procedure length was greater in the POEM group (267 vs 72 min, p < 0.01) as was mean length of stay (1.56 vs 0.3 days, p < 0.01). There was one adverse event after PD and three adverse events after POEM. After PD, 7 patients (70%) required additional procedures compared to four patients (44%) in the POEM group, consisting mostly of repeat PD. CONCLUSION Patients undergoing PD or POEM for recurrent dysphagia after myotomy have similar rates of dysphagia resolution and reflux symptoms. Patients undergoing PD enjoy a shorter length of stay and shorter procedure time but may require more subsequent procedures.
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Affiliation(s)
- Christopher Zimmermann
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Nate Torell
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Anne Lidor
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Luke Funk
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amber Shada
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
- Division of Minimally Invasive Surgery, Department of Surgery, University of Wisconsin-Madison, 4602 Eastpark Blvd, Suite 3525, Madison, WI, 53718, USA.
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Zambetti BR, Murphy WG, Craner D, Wong DL, Pettigrew BD, Webb DL, Voeller GR, Stoikes NFN. Laparoscopic Heller Myotomy With EGD and Balloon Dilation: A Durable Solution for Achalasia. Am Surg 2022:31348221101473. [PMID: 35544037 DOI: 10.1177/00031348221101473] [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: 11/17/2022]
Abstract
BACKGROUND Laparoscopic Heller myotomy (LHM) and esophageal balloon dilation (BD) are the two mainstays of achalasia treatment-this study examines the outcomes when they are performed simultaneously without fundoplication. METHODS All patients undergoing LHM&BD were reviewed for demographic and procedural data, and to see if additional procedures for achalasia had been performed. Patients were surveyed using the Eckardt score and the GERD quality-of-life score (GERD-HRQL) to assess the durability of repair. RESULTS From 2013-2020, 66 patients underwent LHM&BD. There were no esophageal perforations and a median LOS of 1 day. Seven patients have required additional operations or procedures at median 4-years follow up. 31 patients (47%) responded to the survey. The average Eckardt score was 2.9 (goal<4) with mean GERD-HRQL of 14.4 (goal<25). CONCLUSIONS LHM&BD allows for a safe, durable repair of achalasia. Reflux symptoms are manageable with PPI without fundoplication and the re-intervention rate similar to published values.
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Affiliation(s)
- Benjamin R Zambetti
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - William G Murphy
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Domenic Craner
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Denise L Wong
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Benjamin D Pettigrew
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - David L Webb
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guy R Voeller
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nathaniel F N Stoikes
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
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Milito P, Siboni S, Lovece A, Andreatta E, Asti E, Bonavina L. Revisional Therapy for Recurrent Symptoms After Heller Myotomy for Achalasia. J Gastrointest Surg 2022; 26:64-69. [PMID: 34341888 PMCID: PMC8760227 DOI: 10.1007/s11605-021-05098-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/17/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE Symptom recurrence after initial surgical management of esophageal achalasia occurs in 10-25% of patients. The aim of this study was to analyze safety and efficacy of revisional therapy after failed Heller myotomy (HM). METHODS A retrospective review of a prospective database was performed searching for patients with recurrent symptoms after primary surgical therapy for achalasia. Patients with previously failed HM were considered for the final analysis. The Foregut questionnaire, and the Atkinson and Eckardt scales were used to assess severity of symptoms. Objective investigations routinely included upper gastrointestinal endoscopy and barium swallow study. Redo treatments consisted of endoscopic pneumatic dilation (PD), laparoscopic HM, hybrid Ivor Lewis esophagectomy, or stapled cardioplasty. A yearly clinical and endoscopic follow-up was scheduled in all patients. RESULTS Over a 20-year period, 26 patients with a median age of 66 years (IQR 19.5) underwent revisional therapy after failed HM for achalasia at a tertiary-care university hospital. The median time after index procedure was 10 years (IQR 21). Revisional therapy consisted of endoscopic pneumatic dilation (n=13), laparoscopic HM and fundoplication (n=10), esophagectomy (n=2), and stapled cardioplasty and fundoplication (n=1). Nine (34.6%) of these patients required further endoscopic or surgical treatments. There was no mortality, and the overall complication rate was 7.7%. At a median follow-up of 42 months (range 10-149), a significant decrease of dysphagia, regurgitation, chest pain, respiratory symptoms, and median Eckardt score (p<0.05) was noted. CONCLUSION In specialized and multidisciplinary centers, revisional therapy for achalasia is feasible, safe, and effective.
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Affiliation(s)
- Pamela Milito
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Stefano Siboni
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Andrea Lovece
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Erika Andreatta
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy ,Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Piazza Malan 1, 20097 San Donato Milanese (Milano), Italy
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11
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Orlandini MF, Serafim MCA, Datrino LN, Tavares G, Tristão LS, Dos Santos CL, Bernardo WM, Tustumi F. Myotomy in sigmoid megaesophagus: is it applicable? A systematic review and meta-analysis. Dis Esophagus 2021; 34:6342447. [PMID: 34355243 DOI: 10.1093/dote/doab053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/02/2021] [Accepted: 07/18/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Achalasia may evolve to sigmoid megaesophagus in 10-15% of patients and is usually treated with esophagectomy, which has high morbi-mortality. Many surgeons debate the applicability of the Heller myotomy for treating sigmoid megaesophagus. This study intents to analyze the effectiveness of myotomy for treating patients with sigmoid megaesophagus. METHODS A systematic review and meta-analysis was conducted in PubMed, Cochrane, Lilacs and Embase alongside manual search of references. The inclusion criteria were clinical trials, cohort, case-series; patients with sigmoid megaesophagus and esophageal diameter ≥ 6 cm; and patients undergoing primary myotomy. The exclusion criteria were reviews, case reports, cross-sectional studies, editorials, letters, congress abstracts, full-text unavailability; previous surgical treatment for achalasia; and pediatric or animal model studies. No restrictions on language and date of publication, and no filters were applied. Subgroups analyses were performed to assess the laparoscopic myotomy perioperative outcomes. Besides, subgroup analyses were performed to assess the long-term outcomes of the studies with a follow-up time > 24 months. To verify heterogeneity, the I2 test was used. The random effects were applied, and the fixed model was evaluated as sensitivity analysis. To assess risk of bias and certainty of evidence, the tools ROBINS-I and GRADE were used, respectively. Registration number: CRD42020199667. RESULTS Sixteen articles were selected, encompassing 350 patients. The mean age ranged from 36 to 61 years old, and the mean follow-up ranged from 16 to 109 months. Complications rate was 0.08 (CI: 0.040-0.153; P = 0.01). Need for retreatment rate was 0.128 (CI: 0.031-0.409; P = 0.01). The probability of good or excellent outcomes after myotomy was 0.762 (CI: 0.703-0.812; P < 0.01). Postoperative mortality rate was 0.008 (CI: 0.004-0.015; P < 0.01). CONCLUSION Surgical myotomy is an option for avoiding esophagectomy in achalasia, with a low morbi-mortality rate and good results. It is effective for most patients and only a minority will demand retreatment.
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Affiliation(s)
| | | | | | - Guilherme Tavares
- Department of Evidence-Based Medicine, Centro Universitário Lusíada, Santos, Brazil
| | | | | | - Wanderley Marques Bernardo
- Department of Evidence-Based Medicine, Centro Universitário Lusíada, Santos, Brazil.,Department of Evidence-Based Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Francisco Tustumi
- Department of Evidence-Based Medicine, Centro Universitário Lusíada, Santos, Brazil.,Department of Evidence-Based Medicine, Universidade de São Paulo, São Paulo, Brazil.,Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
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12
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Orlandini MF, Bernardo WM, Tustumi F. Recurrence of dysphagia post-myotomy: etiologies and management. Rev Col Bras Cir 2021; 48:e20202973. [PMID: 33852705 PMCID: PMC10683442 DOI: 10.1590/0100-6991e-20202973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/14/2021] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Wanderley Marques Bernardo
- - Centro Universitário Lusíada, Departamento de Medicina Baseada em Evidências - Santos - SP - Brasil
- - Universidade de São Paulo, Departamento de Medicina Baseada em Evidências - São Paulo - SP - Brasil
| | - Francisco Tustumi
- - Centro Universitário Lusíada, Departamento de Medicina Baseada em Evidências - Santos - SP - Brasil
- - Universidade de São Paulo, Departamento de Medicina Baseada em Evidências - São Paulo - SP - Brasil
- - Hospital Israelita Albert Einstein, Departamento de Cirurgia - São Paulo - SP - Brasil
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13
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Capovilla G, Salvador R, Provenzano L, Valmasoni M, Moletta L, Pierobon ES, Merigliano S, Costantini M. Laparoscopic Revisional Surgery After Failed Heller Myotomy for Esophageal Achalasia: Long-Term Outcome at a Single Tertiary Center. J Gastrointest Surg 2021; 25:2208-2217. [PMID: 34100246 PMCID: PMC8484080 DOI: 10.1007/s11605-021-05041-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/12/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic Heller myotomy (HM) has gained acceptance as the gold standard of treatment for achalasia. However, 10-20% of the patients will experience symptom recurrence, thus requiring further treatment including pneumodilations (PD) or revisional surgery. The aim of our study was to assess the long-term outcome of laparoscopic redo HM. METHODS Patients who underwent redo HM at our center between 2000 and 2019 were enrolled. Postoperative outcomes of redo HM patients (redo group) were compared with that of patients who underwent primary laparoscopic HM in the same time span (control group). For the control group, we randomly selected patients matched for age, sex, FU time, Eckardt score (ES), previous PD, and radiological stage. Failure was defined as an Eckardt score > 3 or the need for re-treatment. RESULTS Forty-nine patients underwent laparoscopic redo HM after failed primary HM. A new myotomy on the right lateral wall of the EGJ was the procedure of choice in the majority of patients (83.7%). In 36 patients (73.5%) an anti-reflux procedure was deemed necessary. Postoperative outcomes were somewhat less satisfactory, albeit comparable to the control group; the incidence of postoperative GERD was higher in the redo group (p < 0.01). At a median 5-year FU time, a good outcome was obtained in 71.4% of patients in the redo group; further 5 patients (10.2%) obtained a long-term symptom control after complementary PD, thus bringing the overall success rate to 81.6%. Stage IV disease at presentation was independently associated with a poor outcome of revisional LHD (p = 0.003). CONCLUSIONS This study reports the largest case series of laparoscopic redo HM to date. The procedure, albeit difficult, is safe and effective in relieving symptoms in this group of patients with a highly refractory disease. The failure rate, albeit not significantly, and the post-operative reflux are higher than after primary HM. Patients with stage IV disease are at high risk of esophagectomy.
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Affiliation(s)
- Giovanni Capovilla
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Renato Salvador
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Via Giustiniani, 2, 35128, Padova, Italy.
| | - Luca Provenzano
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Michele Valmasoni
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Lucia Moletta
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Elisa Sefora Pierobon
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Stefano Merigliano
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - Mario Costantini
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Via Giustiniani, 2, 35128, Padova, Italy
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Peroral endoscopic myotomy after failed Heller-Dor: try again, fail again, fail better. Gastrointest Endosc 2021; 93:57-58. [PMID: 33353641 DOI: 10.1016/j.gie.2020.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 12/11/2022]
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15
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Discordance between high-resolution manometry, esophagoscopy and contrast esophagogram in determining landmarks for per-oral endoscopic myotomy in spastic esophageal disorders: a word of caution. Surg Endosc 2020; 35:5613-5619. [PMID: 33048228 DOI: 10.1007/s00464-020-08064-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Myotomy length for per-oral endoscopic myotomy (POEM) is standardized for type I and II achalasia. However, for type III achalasia, jackhammer esophagus, diffuse esophageal spasms and esophagogastric junction outflow obstruction, there is no standard. Determining myotomy length based on the high-pressure zone found during high-resolution manometry (HRM) and spastic length found during esophagography may be used to determine adequate myotomy length without excess muscle destruction. METHODS The records of patients who have undergone POEM procedures at our institution had the following data gleaned: age, sex, esophageal spastic diagnosis, length of high-pressure zone and lower esophageal sphincter (LES) position by HRM, length of spastic esophagus by esophagography, position of the z-line by esophagoscopy and length of myotomy performed. Outcomes were assessed based on patient symptomatic improvement and need for re-intervention. RESULTS 71 patients were evaluated for POEM, with 67 completing POEM. There was an average difference in LES position by HRM and z-line position by esophagoscopy of 3.9 ± 3.0 cm. There was an average difference in high-pressure zone by HRM and spastic length by esophagography of 4.9 ± 3.2 cm. Overall, with a median of 20 months follow-up, 74% achieved long-term symptomatic improvement, with 17 patients requiring re-intervention. CONCLUSIONS Discordance among HRM, esophagography and esophagoscopy can be significant. Caution should be employed with using these methods to determine myotomy length in POEM.
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Felix VN, Murayama KM, Bonavina L, Park MI. Achalasia: what to do in the face of failures of Heller myotomy. Ann N Y Acad Sci 2020; 1481:236-246. [PMID: 32713020 DOI: 10.1111/nyas.14440] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/07/2020] [Accepted: 06/25/2020] [Indexed: 12/21/2022]
Abstract
Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.
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Affiliation(s)
- Valter N Felix
- Nucleus of General and Specialized Surgery - São Paulo and Department of Gastroenterology - Surgical Division - São Paulo University, FMUSP, Sao Paulo, Brazil
| | - Kenric M Murayama
- Department of Surgery, John A. Burns School of Medicine, the University of Hawaii at Manoa, Honolulu, Hawaii
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, The University of Milan, San Donato Milanese, Italy
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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