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

Long-term outcomes of laparoscopic Heller's myotomy with angle of His accentuation in patients of achalasia cardia

BACKGROUND

Laparoscopic Heller's myotomy (LHM) is an established treatment for achalasia cardia. Anti-reflux procedures (ARP) are recommended with LHM to reduce the post-operative reflux though the optimal anti-reflux procedure is still debatable. This study reports on the long-term outcomes of LHM with Angle-of-His accentuation (AOH) in patients of achalasia cardia.

METHODS

One hundred thirty-six patients of achalasia cardia undergoing LHM with AOH between January 2010 to October 2021 with a minimum follow-up of one year were evaluated for symptomatic outcomes using Eckardt score (ES), DeMeester heartburn (DMH) score and achalasia disease specific quality of life (A-DsQoL) questionnaire. Upper gastrointestinal endoscopy, high resolution manometry (HRM) and timed barium esophagogram (TBE) were performed when feasible and rates of esophagitis and improvement in HRM and TBE parameters evaluated. Time dependent rates of success were calculated with respect to improvement in ES and dysphagia-, regurgitation- and heartburn-free survival using Kaplan-Meier analysis.

RESULTS

At a median follow-up of 65.5 months, the overall success (ES ≤ 3) was 94.1%. There was statistically significant improvement in ES, heartburn score and A-DsQoL score (p < 0.00001, p = 0.002 and p < 0.00001). Significant heartburn (score ≥ 2) was seen in 12.5% subjects with 9.5% patients reporting frequent PPI use (> 3 days per week). LA-B and above esophagitis was seen in 12.7%. HRM and TBE parameters also showed a significant improvement as compared to pre-operative values (IRP: p < 0.0001, column height: p < 0.0001, column width: p = 0.0002). Kaplan-Meier analysis showed dysphagia, regurgitation, and heartburn free survival of 75%, 96.2% and 72.3% respectively at 10 years.

CONCLUSIONS

LHM with AOH gives a lasting relief of symptoms in patients of achalasia cardia with heartburn rates similar to that reported in studies using Dor's or Toupet's fundoplication with LHM. Hence, LHM with AOH may be a preferred choice in patients of achalasia cardia given the simplicity of the procedure.

Management and outcomes of 13 dogs treated with a modified Heller myotomy and Dor fundoplication for lower esophageal sphincter achalasia-like syndrome

OBJECTIVE

To report the management and outcomes of dogs treated for lower esophageal sphincter achalasia-like syndrome (LES-AS) with modified Heller myotomy, Dor fundoplication, and with the use of a temporary gastrostomy tube.

STUDY DESIGN

Retrospective.

SAMPLE POPULATION

Thirteen client-owned dogs.

METHODS

Medical records and a client survey were used to assess frequency of vomiting/regurgitation, quality of life (QoL), bodyweight, and feeding modifications at the following time points: prior to referral, postoperatively from discharge to first recheck (4-6 weeks), and from first recheck to survey (48 months). Postoperative and gastrostomy tube complications were surveyed and recorded. Pretreatment and 4-6 weeks postoperative videofluoroscopic swallow studies (VFSS) were compared. Two-sided t-tests were used to compare outcomes between survey time points.

RESULTS

Postoperative VFSS scores (available in 9 dogs) improved over preoperative scores in 6 dogs, and 12/13 dogs survived to discharge. One dog was euthanized 3 days postoperatively due to aspiration pneumonia. Postoperative gastrostomy tube complications occurred in half of the dogs that survived to discharge. According to the owners, scores assigned to vomiting/regurgitation improved by 180% (P = .004), QoL by 100% (P = .004), and bodyweight by 63% (P = .035).

CONCLUSION

Modified Heller myotomy with Dor fundoplication and the use of a temporary gastrostomy tube improved clinical signs and owners' perceived quality of life in half of the dogs treated for LES-AS in our clinical setting. Oral sildenafil therapy discontinued postoperatively suggests that surgery was equally efficacious.

CLINICAL SIGNIFICANCE

Modified Heller myotomy with Dor fundoplication and temporary gastrostomy tube is a treatment option with potentially sustained benefits for dogs that have LES-AS.

Comparative Analysis of Heller Myotomy With Dor Versus Toupet Fundoplication for Achalasia Cardia

Background Heller myotomy (HM) with partial fundoplication is the standard of care for achalasia cardia. However, the choice of partial fundoplication is controversial. In this study, we compared both types of fundoplication concerning subjective and objective parameters. Methodology This prospective comparative study comprised a total of 30 consecutive patients who underwent laparoscopic/robotic HM with either Dor fundoplication (DF) (n = 15) or Toupet fundoplication (TF) (n = 15). Preoperative baseline characteristics, intraoperative details, and postoperative complications were recorded. Patients were followed with Eckardt score, quality of life-related scores, 24-hour pH study, and high-resolution manometry (HRM) at the one-year follow-up. Results There was no significant difference between the two groups regarding preoperative baseline parameters, length of hospital stay, and postoperative complications. The HM+DF group had four (27%) patients with recurrence/failure with none in the HM+TF, but it was not significant (p = 0.79). Symptom scores were similar between the groups at six and 12 months of follow-up. One patient in the HM+DF group and two in the HM+TF group had significant pathological acid reflux (p = 0.483). On HRM, HM+TF showed a trend toward significance in terms of esophagogastric junction (EGJ) relaxation (p = 0.058) with a non-significant difference in median integrated relaxation pressure (p = 0.081). Conclusions The study showed a trend toward lower failure rates and improved EGJ relaxation with similar reflux rates in patients who underwent HM+TF compared to HM+DF. However, long-term follow-up is required to validate our findings with well-defined subjective and objective criteria.

The Role of Fundoplication after Laparoscopic Heller Myotomy in Reducing Postoperative Symptoms in Patients with Achalasia: A Controlled Clinical Trial

Background: Laparoscopic Heller myotomy (LHM) is considered the standard surgical approach in patients newly diagnosed with achalasia worldwide. However, proceeding to fundoplication after LHM remains controversial due to the observed postoperative symptoms, including dysphagia and regurgitation. This study was conducted to compare the postoperatively experienced regurgitation and dysphagia between those undergoing LHM with fundoplication and those with mere LHM. Methods: This four-year controlled clinical trial was performed on adult patients with esophageal type two achalasia, referring to the Shariati Hospital, who gave their written informed consent to enroll. The diagnosis of achalasia was confirmed using manometric assessments. The control group underwent LHM with fundoplication, while the cases received LHM without fundoplication. The validated Achalasia Patients Questionnaire was used for assessing the experienced symptoms pre- and postoperatively. Also, esophagography was used to investigate the alterations of the symptoms pre- and postoperatively. Results: A total of 48 patients were evaluated. 23 were assigned to the case group, while 25 were considered the controls (male to female ratio: 25 to 23). The mean age of the patients was 36.94 years, and the average disease duration was 6.22 years. Cases and controls were matched demographically. There was no statistically significant difference between the cases and controls regarding postoperative active or passive regurgitation or dysphagia to either solids or fluids. Also, the mean score of total clinical symptoms after the surgery was not significantly different between cases and controls. Lastly, esophagography revealed significant improvement regarding all the symptoms postoperatively (P=0.001); however, no statistically significant difference existed in this regard between cases and controls. Conclusion: Our results indicate no significant difference regarding the postoperative achalasia-related symptoms, namely regurgitation and dysphagia, between those patients undergoing LHM with and without fundoplication. However, further studies are required to thoroughly investigate the effects of various fundoplication techniques in relation to all achalasia-related symptoms to confirm these results.

Single-session endoscopic fundoplication after peroral endoscopic myotomy (POEM+F) for prevention of post gastroesophageal reflux - 1-year follow-up study

BACKGROUND

Peroral endoscopic myotomy (POEM) is an established treatment for achalasia cardia; however, post-POEM gastroesophageal reflux (GER) remains a significant problem. Concomitant endoscopic fundoplication following POEM (POEM + F) was recently described to reduce post-POEM GER. This single-center study reports short-term outcomes of POEM + F.

METHODS

This was a retrospective analysis of a prospectively maintained database of patients undergoing POEM + F. Abstracted data included demographics, achalasia type, pre-POEM Eckardt score, prior therapy, follow-up. Follow-up assessment was 3-monthly for 1 year and included post-POEM Eckardt score, GerdQ score, wrap integrity and esophagitis on esophagogastroduodenoscopy, and pH studies. GER was defined according to Lyon Consensus.

RESULTS

25 patients underwent POEM + F (mean age 40.1 years [standard deviation (SD) 13.7]; 12 females). POEM + F was technically successful in 23/25 (92.0 %). Significant dysphagia improvement was seen in all 25 patients (mean pre- and post-POEM Eckardt scores 8.21 [SD 1.08] and 0.1 [SD 0.3], respectively; P = 0.001). Mean total procedure and fundoplication times were 115.6 (SD 27.2) minutes and 46.7 (SD 12.4) minutes, respectively; times reduced significantly after the initial five cases. Median follow-up was 12 months (interquartile range [IQR] 9-13). Intact wrap was seen in 19/23 (82.6 %). GER (abnormal esophageal acid exposure time [EAET]) was seen in 2/18 (11.1 %) and there was one reported GerdQ > 8. Borderline GER (asymptomatic grade A esophagitis, normal EAET) was identified in 4/22 (18.2 %). Three (12.0 %) minor delayed adverse events occurred but required no intervention. CONCLUSIONS : POEM + F was safe and reproducible. At 12 months' follow-up, incidence of post-POEM + F GER was low and acceptable.

Simultaneous coronary artery disease and achalasia surgery: A novel approach

A 69-year-old female patient presented to cardiac surgery department with unstable angina due to severe coronary artery disease. Coronary artery bypass grafting was indicated; however, the patient's symptoms of achalasia, previously treated by the pneumatic dilatation, exacerbated. Subsequently, the patient underwent simultaneous surgery. After sternotomy, on cardiopulmonary bypass, esophagus was exposed and Heller myotomy was performed. Following cardioplegia, coronary artery bypass grafting was completed. The postoperative course was uneventful, and the patient was discharged on postoperative Day 9. In conclusion, this novel surgical technique can be effectively used in such cases.