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Hammad A, Lu VF, Dahiya DS, Kichloo A, Tuma F. Treatment challenges of sigmoid-shaped esophagus and severe achalasia. Ann Med Surg (Lond) 2020; 61:30-34. [PMID: 33363724 PMCID: PMC7750448 DOI: 10.1016/j.amsu.2020.11.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 11/28/2020] [Accepted: 11/28/2020] [Indexed: 12/17/2022] Open
Abstract
Background Achalasia is a chronic motility disorder which may require surgical interventions to effectively manage patients’ symptoms and improve functional status. In late stage achalasia, patients may present with sigmoid-shaped esophagus which complicates traditional treatment approaches for achalasia as the esophagus is massively dilated and dysfunctional with delicate tissue integrity. Severe Achalasia with sigmoid esophagus imposes significant challenge to surgeons and treating physicians. Various assessment modalities and treatment approaches have been tried. Surgical treatment continues to be controversial. Some have argued that a less aggressive approach similar to that in early Achalasia results in satisfactory outcomes. Others have argued a more aggressive approach of esophagectomy is necessary. We present a review of the challenges encountered in each approach with recommendation for selecting the right treatment for the individual cases. Conclusions Different treatment options for sigmoid type achalasia are available with ongoing controversy among the options. Heller myotomy with Dor fundoplication can provide satisfactory symptoms improvement and treatment outcomes. Late stage achalasia may present with sigmoid-shaped esophagus. Sigmoid shaped esophagus imposes significant treatment challenges due to dilation and delicate tissue integrity. Surgical treatment continues to be controversial. Heller myotomy with Dor fundoplication can provide satisfactory symptoms improvement and treatment outcomes.
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Affiliation(s)
- Ahmed Hammad
- Department of General Surgery, Mansoura University, Egypt
| | - Vivian F Lu
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Faiz Tuma
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, MI, USA
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Bale M, Modi A, Parshad R, Suhani S, Makharia G, Sharma R. Long-term Outcomes of Laparoscopic Heller's Cardiomyotomy in Achalasia Cardia With Megaesophagus. Surg Laparosc Endosc Percutan Tech 2020; 31:175-180. [PMID: 32890251 DOI: 10.1097/sle.0000000000000854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 07/28/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Megaesophagus secondary to achalasia cardia is conventionally treated with esophagectomy. With the advent of minimal invasive surgery, laparoscopic Heller's cardiomyotomy (LHCM) has been used in the management of megaesophagus. The authors hereby report our long-term results of 19 patients of megaesophagus managed with LHCM. MATERIALS AND METHODS Prospectively collected data of 19 patients with megaesophagus were reviewed for symptomatic outcome using defined symptom scores and achalasia disease-specific quality of life (A-DsQol) after LHCM with an antireflux procedure. Follow-up was done with clinical visits and telephonic calls. RESULTS The mean age of the patients was 39.8 years with 7 female and 12 male individuals. The mean duration of symptoms was 105 months. Dysphagia was the predominant symptom followed by regurgitation and heartburn. A-DsQOL was poor with a mean of 58.6±8.11. Nine patients had extra respiratory symptoms. All patients underwent LHCM with an antireflux procedure with no conversion, intraoperative perforation, or mortality. At a median follow-up of 66 months (interquartile range, 24.5 to 80), there was a significant improvement of dysphagia, regurgitation, heartburn, and Eckardt scores from 2.26±1.14, 2.05±0.62, 1.0±0.67, and 7.21±2.22 to 0.21±0.53, 0.15±0.37, 0.42±0.61, and 0.57±2.06, respectively (P<0.001). One patient (5.2%) had a recurrence of dysphagia. Sixty-three percent of patients graded their satisfaction level as fully satisfied and 31% as better. A-DsQOL of life improved significantly (P<0.001) after surgery. The respiratory symptoms improved in all. CONCLUSIONS LHCM provides durable relief of symptoms in patients with megaesophagus and may be considered as the first-line treatment option in such patients.
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Affiliation(s)
| | | | | | | | | | - Raju Sharma
- Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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Gupta V, Hatimi H, Kumar S, Chandra A. Laparoscopic Heller's Myotomy for Achalasia Cardia: One-Time Treatment in Developing Countries? Indian J Surg 2017; 79:401-405. [PMID: 29089698 PMCID: PMC5653572 DOI: 10.1007/s12262-016-1496-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 04/28/2016] [Indexed: 11/30/2022] Open
Abstract
Laparoscopic Heller's myotomy (LHM) and endoscopic balloon dilation are two main treatment modalities for achalasia cardia. The best treatment modality in Indian setting, however, is still unknown. Here, we present the early results of LHM in achalasia. Hospital data from January 2009 to October 2013 was analyzed. Preoperative assessment included Eckardt's scoring, esophagogastroduodenoscopy, barium swallow examination, and esophageal manometry. Thirty-five patients (19 males and 16 females, median age 31 years, range 12-65) underwent LHM with partial fundoplication (with intraoperative endoscopy). All patients had dysphagia (median duration 48 months, range 1-240), and eight (22.8 %) had chest pain. Four (11 %) patients had recurrent achalasia. Most of the patients (80 %) came from rural areas, and 68.5 % were ≤40 years of age. Fundoplication was added in all except four patients (megaesophagus in one, left lobe hepatomegaly in one, and postsurgical recurrent achalasia in two). The median operative time was 180 min (range 120-300). Intraoperative complications included esophageal mucosal injury (n = 2) and pleural breach (n = 3) with one conversion. The median postoperative stay was 7 days (range 4-27) with a morbidity of 5.7 % (leak in one and subphrenic collection in one patient) and a mortality of 1 % (due to myocardial infarction). After a median follow-up of 9.5 months (range 1-47 months), four (11.4 %) patients had recurrent dysphagia and three (8.5 %) had gastroesophageal reflux. Most of the patients (six of eight) had relief in chest pain. To conclude, predominance of rural, young, and male patients in this study suggests that LHM might be the first-line treatment for achalasia in developing countries like India where predominant population is still rural that prefers one-time treatment, though it needs to be compared with a newly described procedure per oral endoscopic myotomy (POEM).
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, King George’s Medial University, Chowk, Lucknow, UP India
| | - Hunaid Hatimi
- Department of Surgical Gastroenterology, King George’s Medial University, Chowk, Lucknow, UP India
| | - Saket Kumar
- Department of Surgical Gastroenterology, King George’s Medial University, Chowk, Lucknow, UP India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George’s Medial University, Chowk, Lucknow, UP India
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Balakrishna P, Parshad R, Rohila J, Saraya A, Makharia G, Sharma R. 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 2015; 29:2344-2351. [PMID: 25427411 DOI: 10.1007/s00464-014-3958-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 11/03/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND The type of anti-reflux procedure to be used as an adjunct to laparoscopic Heller's cardiomyotomy (LHCM) in Achalasia cardia is controversial. We compared Angle of His accentuation and Dor fundoplication in a randomized controlled trial. METHODS From May 2010 to October 2013, 62 patients undergoing LHCM were randomized to receive either Dor fundoplication (Dor group) or Angle of His accentuation (AOH group) as an anti-reflux procedure. Symptomatic outcome was evaluated using modified Mellow and Pinkas scale for dysphagia and modified DeMeester's score for regurgitation and heartburn. Achalasia-specific quality-of-life (QOL) questionnaire was used to assess quality of life. The primary outcome was symptomatic relief and the secondary outcome was postoperative heartburn. Statistical analysis was done using SPSS software. RESULTS All the procedures were completed laparoscopically with no mortality. Morbidity was similar in the two groups (6.4 %). Median operative time was higher in Dor group (170 vs 130 min). At a median follow-up of 21 months relief of dysphagia, regurgitation, and heartburn was seen in 87, 90.3, and 90.3 % patients in Dor group versus 93.5, 96.7, and 77.4 % in AOH group patients with significant improvement in symptom scores. Improvement was similar in both groups with no statistically significant difference in the symptom scores (p = 0.48 for dysphagia, p = 0.37 for regurgitation, and p = 0.19 for heartburn). The QOL improved in both groups [62.3 to 12.3 (p = 0.02) in Dor group and 63.9-13 (p = 0.02) in AOH group] with no statistically significant difference between the two groups (p = 0.96). There was no statistically significant difference in the postoperative heartburn between the two groups (p = 0.19). CONCLUSION Laparoscopic Heller's cardiomyotomy with either Angle of His accentuation or Dor fundoplication leads to similar improvement in symptoms and quality of life.
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Affiliation(s)
- Pavithra Balakrishna
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, 110029, India
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Panchanatheeswaran K, Parshad R, Rohila J, Saraya A, Makharia GK, Sharma R. Laparoscopic Heller's cardiomyotomy: a viable treatment option for sigmoid oesophagus. Interact Cardiovasc Thorac Surg 2013; 16:49-54. [PMID: 23065746 PMCID: PMC3523632 DOI: 10.1093/icvts/ivs427] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 09/05/2012] [Accepted: 09/12/2012] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES It is generally believed that Heller's cardiomyotomy (HCM) cannot improve dysphagia in patients with marked dilatation and axis deviation or sigmoid oesophagus. Conventional management for sigmoid oesophagus has been oesophagectomy. We report our surgical experience in the management of 8 patients with sigmoid oesophagus with laparoscopic HCM. METHODS Eight patients with sigmoid oesophagus were retrospectively identified and their records were reviewed for symptomatic outcome evaluation following laparoscopic HCM with an antireflux procedure. Preoperative and postoperative, oesophageal and respiratory symptoms and quality of life scoring of achalasia were recorded. RESULTS The mean age was 35.5 (range 25-57) years. Males and females were equally distributed. All patients had dysphagia as their chief presenting complaint. The median duration of dysphagia was 55 (range 18-180) months. All the patients had a poor quality of life. Four patients also had chronic cough. All 8 patients underwent laparoscopic HCM with an antireflux procedure. The mean duration of operation was 203.7 min. There were no mortalities and no major postoperative complications. At a median follow-up of 19.5 (range 6-45) months, there was a significant improvement of dysphagia and regurgitation scores with P-values of 0.014 and 0.008, respectively. Quality of life also significantly (P = 0.005) improved post-surgery. Chronic cough resolved in all the 4 patients (100%) following cardiomyotomy. CONCLUSIONS Laparoscopic HCM with an antireflux procedure provides significant symptom relief in patients with sigmoid oesophagus and may be considered as the first-line treatment option in such patients. Oesophagectomy should be reserved for patients with a failed cardiomyotomy.
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Affiliation(s)
| | - Rajinder Parshad
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Jitender Rohila
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Anoop Saraya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Govind K. Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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Parshad R, Devana SK, Panchanatheeswaran K, Saraya A, Makharia GK, Sharma SK, Bhalla AS. Clinical, radiological and functional assessment of pulmonary status in patients with achalasia cardia before and after treatment. Eur J Cardiothorac Surg 2012; 42:e90-e95. [PMID: 22815333 DOI: 10.1093/ejcts/ezs421] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Patients with achalasia have respiratory symptoms due to chronic microaspiration. Achalasia can lead to radiological and functional changes in the lung. We studied the effect of either balloon dilatation or laparoscopic Heller's cardiomyotomy on the reversal of these changes in the lung. METHODS Thirty patients with achalasia were included in this study. Oesophageal symptoms and pulmonary symptoms were recorded. Pulmonary function tests (PFTs) were done at baseline and at the end of 6 months. High-resolution computed tomography of the chest was performed prior to treatment and repeated 6 months after treatment if found abnormal at the initial evaluation. RESULTS The mean age of the patients was 30.97 years and mean duration of symptoms was 22.5 months. Fifteen patients (50%) had respiratory symptoms, nocturnal cough being the commonest symptom in 13 (43.3%). Thirteen patients (43.3%) had parenchymal lung changes on high-resolution computed tomography (HRCT). Eight patients (28.5%) had functional abnormalities in the lungs in the form of restrictive airway disease. Nineteen patients opted for Laparoscopic Heller's cardiomyotomy, while 11 patients underwent pneumatic dilatation. Six months after treatment, the respiratory symptoms resolved in all except two patients (13.3%). Four patients (66.6%) with active lung changes at HRCT showed resolution at 6 months. There was improvement in functional parameters on PFT evaluation with normalization of PFT in one patient. CONCLUSIONS Pulmonary symptoms as well as radiological and functional abnormalities are common in patients with achalasia. Treatment in the form of pneumatic dilatation or Lap cardiomyotomy improves pulmonary symptoms.
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Affiliation(s)
- Rajinder Parshad
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.
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Martino ND, Brillantino A, Monaco L, Marano L, Schettino M, Porfidia R, Izzo G, Cosenza A. Laparoscopic calibrated total vs partial fundoplication following Heller myotomy for oesophageal achalasia. World J Gastroenterol 2011; 17:3431-3440. [PMID: 21876635 PMCID: PMC3160569 DOI: 10.3748/wjg.v17.i29.3431] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 12/26/2010] [Accepted: 01/02/2011] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia. METHODS Fifty-six patients (26 men, 30 women; mean age 42.8 ± 14.7 years) presenting for minimally invasive surgery for oesophageal achalasia, were enrolled. All patients underwent laparoscopic Heller myotomy followed by a 180° anterior partial fundoplication in 30 cases (group 1) and calibrated Nissen-Rossetti fundoplication in 26 (group 2). Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication. A 6-mo follow-up period with symptomatic evaluation and barium swallow was undertaken. One and two years after surgery, the patients underwent symptom questionnaires, endoscopy, oesophageal manometry and 24 h oesophago-gastric pH monitoring. RESULTS At the 2-year follow-up, no significant difference in the median symptom score was observed between the 2 groups (P = 0.66; Mann-Whitney U-test). The median percentage time with oesophageal pH < 4 was significantly higher in the Dor group compared to the Nissen-Rossetti group (2; range 0.8-10 vs 0.35; range 0-2) (P < 0.0001; Mann-Whitney U-test). CONCLUSION Laparoscopic Dor and calibrated Nissen-Rossetti fundoplication achieved similar results in the resolution of dysphagia. Nissen-Rossetti fundoplication seems to be more effective in suppressing oesophageal acid exposure.
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Kashiwagi H, Omura N. Surgical treatment for achalasia: when should it be performed, and for which patients? Gen Thorac Cardiovasc Surg 2011; 59:389-98. [PMID: 21674305 DOI: 10.1007/s11748-010-0765-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 12/13/2010] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare motor disorder of the esophagus, characterized by the absence of peristalsis and impaired swallow-induced relaxation. In the past decade, evidence has been accumulated suggesting that achalasia may be an immune-mediated inflammatory disorder. With the advent of minimally invasive surgery, laparoscopic Heller myotomy (LHM) has slowly shifted the treatment of achalasia toward the greater use of surgical therapy. The goal of both surgical and nonsurgical treatment is to eliminate the outflow obstruction afforded by a nonrelaxing sphincter, relieving dysphagia and maintaining a barrier against gastroesophageal reflux (GER). Endoscopic botulinum toxin injection (EBTI) is safe, easy to perform, inexpensive, and effective in aged patients, and it is especially effective when the lower esophageal pressure is hypertonic. This therapeutic option is reserved for patients too ill to undergo any surgical procedure. Pneumatic dilation (PD) has been shown to be an effective and inexpensive treatment with few adverse effects. The long-term success rate of PD seems to drop progressively over time. Heller myotomy (HM) has shown the best clinical efficacy in achalasia as a first-line treatment. Multiple endoscopic treatments are associated with poorer outcomes after HM. EBTI also makes LHM more difficult and results in a worse surgical outcome. The inferior symptomatic outcomes after thoracoscopic HM may be caused by the difficulty in extending an adequate myotomy onto the stomach from the chest and the inability to create a fundoplication. LHM with Dor's fundoplication (LHM + Dor) is effective and is safer procedure for avoiding GER, dysphagia, mucosal perforation, and a pseudodiverticulum. LHM + Dor is also effective in the presence of sigmoid achalasia, but the clinical result is not as good as nonsigmoid achalasia. A few patients need esophagectomy for surgical failure of HM. However, considering the risk of esophagectomy, LHM + Dor is the first treatment option for patients with achalasia regardless of the degree of esophageal dilatation. This procedure is therefore considered to be an effective and safe treatment for patients of any age or with any condition.
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Affiliation(s)
- Hideyuki Kashiwagi
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo 105-8461, Japan.
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Abstract
AIM: To evaluate the efficacy and safety of Heller myotomy (HM) for recurrent achalasia, performed after different methods of first-line treatment.
METHODS: We searched for studies published in PubMed from 1966 to March 2008 on treatment of recurrent achalasia with HM after failure with different methods of first-line treatment. The efficacy of HM was assessed by a pooled estimate of response rate with individual studies weighted proportionally to sample size.
RESULTS: Sixteen studies were eligible and included in the review. The results showed that HM has a better remission rate for recurrent achalasia after failure of HM [weighted mean (SD)] of 86.9% (21.8%) compared with 81.6% (23.8%) for pneumatic dilatation (PD). One study evaluated the efficacy of HM after failure of PD combined with botulinum toxin injection (83%). The most common complications were perforation and gastroesophageal reflux.
CONCLUSION: HM has the best efficacy in patients with recurrent achalasia who were treated with HM as first-line treatment. Future studies should focus on how to increase the success rate and decrease the complications of HM.
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