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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] [What about the content of this article? (0)] [Affiliation(s)] [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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2
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Alkadour A, Panaitescu E, Hoară P, Constantinoiu S, Mitrea-Tocitu M, Ciuc D, Dinca VG, Bîrla R. Laparoscopic Esocardiomyotomy-Risk Factors and Implications of Intraoperative Mucosal Perforation. Life (Basel) 2023; 13. [PMID: 36836695 DOI: 10.3390/life13020340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Mucosal perforation during laparoscopic esocardiomyotomy is quite frequent, and its consequences cannot always be neglected. The purpose of the study is to investigate the risk factors for intraoperative mucosal perforation and its implications on the postoperative outcomes and the functional results three months postoperatively. MATERIAL AND METHODS We retrospectively identified the patients with laparoscopic esocardiomyotomy performed at Sf. Maria Hospital Bucharest, in the period between January 2017-January 2022 and collected the data (preoperative-clinic, manometric and imaging, intra-and postoperative). To identify the risk factors for mucosal perforations, we used logistic regression analysis. RESULTS We included 60 patients; intraoperative mucosal perforation occurred in 8.33% of patients. The risk factors were: the presence of tertiary contractions (OR = 14.00, 95%CI = [1.23, 158.84], p = 0.033206), the number of propagated waves ≤6 (OR = 14.50), 95%CI = [1.18, 153.33], p < 0.05), the length of esophageal myotomy (OR = 1.74, 95%CI = [1.04, 2.89] p < 0.05), the length of esocardiomyotomy (OR = 1.74, 95%CI = [1.04, 2.89] p < 0.05), and a protective factor-the intraoperative upper endoscopy (OR = 0.037, 95%CI = [0.003, 0.382] p < 0.05). CONCLUSIONS Identifying risk factors for this adverse intraoperative event may decrease the incidence and make this surgery safer. Although mucosal perforation resulted in prolonged hospital stays, it did not lead to significant differences in functional outcomes.
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Patti MG, Schlottmann F, Herbella FAM. Esophageal Achalasia: Evaluation and Treatment of Recurrent Symptoms. World J Surg 2022. [PMID: 35166877 DOI: 10.1007/s00268-022-06466-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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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: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Tan S, Zhong C, Ren Y, Luo X, Xu J, Fu X, Peng Y, Tang X. Efficacy and Safety of Peroral Endoscopic Myotomy in Achalasia Patients with Failed Previous Intervention: A Systematic Review and Meta-Analysis. Gut Liver 2021; 15:153-167. [PMID: 32616678 PMCID: PMC7960968 DOI: 10.5009/gnl19234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/04/2019] [Accepted: 11/04/2019] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) has emerged as a rescue treatment for recurrent or persistent achalasia after failed initial management. Therefore, we aimed to investigate the efficacy and safety of POEM in achalasia patients with failed previous intervention. We searched the MEDLINE, Embase, Cochrane, and PubMed databases using the queries “achalasia,” “peroral endoscopic myotomy,” and related terms in March 2019. Data on technical and clinical success, adverse events, Eckardt score and lower esophageal sphincter (LES) pressure were collected. The pooled event rates, mean differences (MDs) and risk ratios (RR) were calculated. A total of 15 studies with 2,276 achalasia patients were included. Overall, the pooled technical success, clinical success and adverse events rate of rescue POEM were 98.0% (95% confidence interval [CI], 96.6% to 98.8%), 90.8% (95% CI, 88.8% to 92.4%) and 10.3% (95% CI, 6.6% to 15.8%), respectively. Seven studies compared the clinical outcomes of POEM between previous failed treatment and the treatment naïve patients. The RR for technical success, clinical success, and adverse events were 1.00 (95% CI, 0.98 to 1.01), 0.98 (95% CI, 0.92 to 1.04), and 1.17 (95% CI, 0.78 to 1.76), respectively. Overall, there was significant reduction in the pre- and post-Eckardt score (MD, 5.77; p<0.001) and LES pressure (MD, 18.3 mm Hg; p<0.001) for achalasia patients with failed previous intervention after POEM. POEM appears to be a safe, effective and feasible treatment for individuals who have undergone previous failed intervention. It has similar outcomes in previously treated and treatment-naïve achalasia patients.
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Affiliation(s)
- Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yutang Ren
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital, Tsinghua University School of Clinical Medicine, Beijing, China
| | - Xujuan Luo
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jin Xu
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiangsheng Fu
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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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: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Hashimoto R, Inoue H, Shimamura Y, Sakuraba A, Tomizawa Y. Per oral endoscopic myotomy as salvage therapy in patients with achalasia refractory to endoscopic or surgical therapy is technically feasible and safe: Systematic review and meta-analysis. Dig Endosc 2020; 32:1042-1049. [PMID: 32012360 DOI: 10.1111/den.13643] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/31/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUNDS AND AIMS Per oral endoscopic myotomy (POEM) has been reported as an effective and safe salvage therapy for achalasia but there is limited composite data. We performed a systematic review and meta-analysis of studies that reported the rates of clinical success and adverse events among patients who underwent POEM after failed conventional endoscopic or surgical therapy. METHODS Electronic literature search was conducted from inception through December 2018 for articles reporting the efficacy and safety of POEM in patients with achalasia who failed endoscopic or surgical therapy. Primary outcome was the pooled estimated rates of clinical success, defined as Eckardt score ≤ 3 after POEM. Secondary outcomes were procedural time, the rates of POEM-related gastroesophageal reflux disease (GERD) and procedure-related adverse events. RESULTS Seven studies reporting outcomes on 487 patients met our criteria. Pooled estimated rate of clinical success of POEM was 88% (95% confidence interval (CI) 79-94%). Mean procedural time was 64 minutes (95% CI 44-85 minutes). POEM-related GERD was found in 20% (95% CI 16-24%) of patients. Estimated incidence of overall adverse events was 10% (95% CI 5-18%) with individual risk of bleeding, mucosotomy, pneumothorax, pneumoperitoneum hydrothorax/mediastinitis, and subcutaneous emphysema ranging from 1 to 4%. CONCLUSIONS Per oral endoscopic myotomy after failed endoscopic or surgical therapy in patients with achalasia is an effective and safe treatment. Further long-term follow-up studies in a larger number of patients are warranted to validate the sustainable efficacy of POEM for achalasia.
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Affiliation(s)
- Rintaro Hashimoto
- Division of Gastroenterology, University of California Irvine Medical Center, Orange, USA
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Atsushi Sakuraba
- Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, USA
| | - Yutaka Tomizawa
- Division of Gastroenterology, Harborview Medical Center, University of Washington, Seattle, USA
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Santes O, Coss-Adame E, Valdovinos MA, Furuzawa-Carballeda J, Rodríguez-Garcés A, Peralta-Figueroa J, Narvaez-Chavez S, Olvera-Prado H, Clemente-Gutiérrez U, Torres-Villalobos G. Does laparoscopic reoperation yield symptomatic improvements similar to those of primary laparoscopic Heller myotomy in achalasia patients? Surg Endosc 2020; 35:4991-5000. [DOI: 10.1007/s00464-020-07978-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/14/2020] [Indexed: 01/06/2023]
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11
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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: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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12
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Smith KE, Saad AR, Hanna JP, Tran T, Jacobs J, Richter JE, Velanovich V. Revisional Surgery in Patients with Recurrent Dysphagia after Heller Myotomy. J Gastrointest Surg 2020; 24:991-999. [PMID: 31147973 DOI: 10.1007/s11605-019-04264-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/06/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recurrent/persistent symptoms of achalasia occur in 10-20% of individuals after Heller myotomy. The causes and treatment outcomes are ambiguous. Our aim is to assess the causes and outcomes of a multidisciplinary approach to this patient population. METHODS All patients undergoing revisional operations after a Heller myotomy were reviewed retrospectively. DATA COLLECTED demographics, date of initial Heller myotomy, preoperative evaluation, etiology of recurrent symptoms, date of revisional operation, and surgical outcomes. RESULTS A total of 34 patients underwent 37 revisional operations. Operations were tailored based on preoperative multidisciplinary evaluation. Causes of symptoms: periesophageal/perihiatal fibrosis 11 (27%), obstructing fundoplication 11 (27%), incomplete myotomy 8 (20%), progression of disease 9 (22%), and epiphrenic diverticulum 1 (2%). Operations performed: reversal/no creation of fundoplication with or without re-do myotomy 22 (59%), revision/creation of fundoplication with or without myotomy 6 (16%), and esophagectomy 9 (24%). Ten patients in the 37 operations (27%) developed postoperative complications. Of 33 patients for 36 operations with follow-up, 25 patient-operations (69%) resulted in resolution or improved dysphagia. Although there was variation in symptomatic improvement by cause and operation type, none reached statistical significance. CONCLUSION There are several causes of dysphagia after Heller myotomy and a thoughtful evaluation is required. Complication rates are higher than first-time operations. Symptomatic improvement occurs in the majority of cases, but a significant minority will have persistent dysphagia. Although an individualized approach to dysphagia after Heller myotomy may improve symptoms and passage of food, the perception of dysphagia may persist in patients.
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Affiliation(s)
- Kaylee E Smith
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Adham R Saad
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.,The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA
| | - John P Hanna
- Division of Surgical Research, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Thanh Tran
- Division of Surgical Research, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - John Jacobs
- The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida, Tampa, FL, USA
| | - Joel E Richter
- The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA. .,The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.
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13
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Weche M, Saad AR, Richter JE, Jacobs JJ, Velanovich V. Revisional Procedures for Recurrent Symptoms After Heller Myotomy and Per-Oral Endoscopic Myotomy. J Laparoendosc Adv Surg Tech A 2020; 30:110-116. [DOI: 10.1089/lap.2019.0277] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- McWayne Weche
- Division of General Surgery, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Adham R. Saad
- Division of General Surgery, the University of South Florida Morsani College of Medicine, Tampa, Florida
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Joel E. Richter
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
- Division of Gastroenterology, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - John J. Jacobs
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
- Division of Gastroenterology, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Vic Velanovich
- Division of General Surgery, the University of South Florida Morsani College of Medicine, Tampa, Florida
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
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Khashab MA, Vela MF, Thosani N, Agrawal D, Buxbaum JL, Abbas Fehmi SM, Fishman DS, Gurudu SR, Jamil LH, Jue TL, Kannadath BS, Law JK, Lee JK, Naveed M, Qumseya BJ, Sawhney MS, Yang J, Wani S. ASGE guideline on the management of achalasia. Gastrointest Endosc 2020; 91:213-227.e6. [PMID: 31839408 DOI: 10.1016/j.gie.2019.04.231] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 04/22/2019] [Indexed: 12/11/2022]
Abstract
Achalasia is a primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, which results in impaired relaxation of the esophagogastric junction (EGJ), along with the loss of organized peristalsis in the esophageal body. The criterion standard for diagnosing achalasia is high-resolution esophageal manometry showing incomplete relaxation of the EGJ coupled with the absence of organized peristalsis. Three achalasia subtypes have been defined based on high-resolution manometry findings in the esophageal body. Treatment of patients with achalasia has evolved in recent years with the introduction of peroral endoscopic myotomy. Other treatment options include botulinum toxin injection, pneumatic dilation, and Heller myotomy. This American Society for Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of the 4 aforementioned achalasia therapies.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Marcelo F Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Nirav Thosani
- Interventional Gastroenterologists of the University of Texas, Department of Internal Medicine, McGovern Medical School, Houston, Texas, USA
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Syed M Abbas Fehmi
- Division of Gastroenterology/Hepatology, University of California, San Diego, San Diego, California, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Baylor College of Medicine; Texas Children's Hospital, Houston, Texas, USA
| | | | - Laith H Jamil
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Terry L Jue
- The Permanente Medical Group, Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Bijun Sai Kannadath
- Interventional Gastroenterologists of the University of Texas, Department of Internal Medicine, McGovern Medical School, Houston, Texas, USA
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Division of Gastroenterology and Hepatology, University of Iowa Hospital & Clinics, Iowa City, Iowa, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Archbold Medical Group, Thomasville, Georgia, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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15
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Evensen H, Kristensen V, Larssen L, Sandstad O, Hauge T, Medhus AW. Outcome of peroral endoscopic myotomy (POEM) in treatment-naive patients. A systematic review. Scand J Gastroenterol 2019; 54:1-7. [PMID: 30650313 DOI: 10.1080/00365521.2018.1549271] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Achalasia is a primary motility disorder of the esophagus characterized by aperistalsis and failure of lower esophageal sphincter (LES) relaxation. Treatment of achalasia aims at reducing LES pressure. The common treatment modalities are laparoscopic Heller myotomy and pneumatic dilatation, but during the last decade, a promising treatment, per oral endoscopic myotomy (POEM), has been introduced. The aim of the present study was to perform a systematic review of the literature to assess the outcome of POEM in treatment-naive patients. MATERIALS AND METHODS A systematic literature search in PubMed, Embase and Cochrane databases was performed using the terms 'Achalasia AND (POEM OR peroral endoscopic myotomy OR per-oral endoscopic myotomy)'. Inclusion criteria were: original article; English language; n ≥ 20 with ≥90% treatment-naive patients; follow-up ≥3 months; and outcome evaluation of POEM including symptom score and objective tests. Exclusion criteria were: reviews and meta-analyses; pediatric data; duplicates; and articles with overlapping data material. RESULTS Of the 1641 articles identified, seven were included. The included studies all reported a short-term clinical success of >90%. Clinical success including post-POEM reflux was mainly estimated by symptom scorings. There were few procedure-related complications. CONCLUSIONS The studies of treatment-naive patients indicate a high rate of clinical success. Nevertheless, a more systematic and standardized evaluation is recommended to improve the reports on outcome of POEM. The follow-up rate should be high and the evaluation protocol should include both symptom scoring and objective testing with predefined treatment goals.
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Affiliation(s)
- Helge Evensen
- a Department of Gastroenterology , Oslo University Hospital.,b Faculty of Medicine , University of Oslo
| | | | - Lene Larssen
- a Department of Gastroenterology , Oslo University Hospital
| | - Olav Sandstad
- a Department of Gastroenterology , Oslo University Hospital
| | - Truls Hauge
- a Department of Gastroenterology , Oslo University Hospital.,b Faculty of Medicine , University of Oslo
| | - Asle W Medhus
- a Department of Gastroenterology , Oslo University Hospital
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17
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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Abstract
Achalasia is a rare disease characterized by impaired lower esophageal sphincter relaxation loss and of peristalsis in the esophageal body. Endoscopic balloon dilation and laparoscopic surgical myotomy have been established as initial treatment modalities. Indications and outcomes of esophagectomy in the management of end-stage achalasia are less defined. A literature search was conducted to identify all reports on esophagectomy for end-stage achalasia between 1987 and 2017. MEDLINE, Embase, and Cochrane databases were consulted matching the terms “achalasia,” “end-stage achalasia,” “esophagectomy,” and “esophageal resection.” Seventeen articles met the inclusion criteria and 1422 patients were included in this narrative review. Most of the patients had previous multiple endoscopic and/or surgical treatments. Esophagectomy was performed through a transthoracic (74%) or a transhiatal (26%) approach. A thoracoscopic approach was used in a minority of patients and seemed to be safe and effective. In 95 per cent of patients, the stomach was used as an esophageal substitute. The mean postoperative morbidity rate was 27.1 per cent and the mortality rate 2.1 per cent. Symptom resolution was reported in 75 to 100 per cent of patients over a mean follow-up of 43 months. Only five series including 195 patients assessed the long-term follow-up (>5 years) after reconstruction with gastric or colon conduits, and the results seem similar. Esophagectomy for end-stage achalasia is safe and effective in tertiary referral centers. A thoracoscopic approach is a feasible and safe alternative to thoracotomy and may replace the transhiatal route in the future.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Stefano Siboni
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
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19
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Zhang X, Modayil RJ, Friedel D, Gurram KC, Brathwaite CE, Taylor SI, Kollarus MM, Modayil S, Halwan B, Grendell JH, Stavropoulos SN. 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; 87:972-85. [PMID: 29122601 DOI: 10.1016/j.gie.2017.10.039] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [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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21
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Ngamruengphong S, Inoue H, Ujiki MB, Patel LY, Bapaye A, Desai PN, Dorwat S, Nakamura J, Hata Y, Balassone V, Onimaru M, Ponchon T, Pioche M, Roman S, Rivory J, Mion F, Garros A, Draganov PV, Perbtani Y, Abbas A, Pannu D, Yang D, Perretta S, Romanelli J, Desilets D, Hayee B, Haji A, Hajiyeva G, Ismail A, Chen YI, Bukhari M, Haito-Chavez Y, Kumbhari V, Saxena P, Talbot M, Chiu PWY, Yip HC, Wong VWY, Hernaez R, Maselli R, Repici A, Khashab MA. Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy. Clin Gastroenterol Hepatol 2017; 15:1531-1537.e3. [PMID: 28189695 DOI: 10.1016/j.cgh.2017.01.031] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 01/21/2017] [Accepted: 01/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM. METHODS We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non-HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months. RESULTS POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non-HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non-HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non-HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups. CONCLUSIONS POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.
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Affiliation(s)
- Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Michael B Ujiki
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Lava Y Patel
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | | | - Shivangi Dorwat
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Jun Nakamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Yoshitaka Hata
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Valerio Balassone
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Thierry Ponchon
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - Mathieu Pioche
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - Sabine Roman
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Jérôme Rivory
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - François Mion
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Aurélien Garros
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Yaseen Perbtani
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Ali Abbas
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Davinderbir Pannu
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Dennis Yang
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Silvana Perretta
- Department of Gastrointestinal and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - John Romanelli
- Department of Surgery, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts
| | - David Desilets
- Division of Gastroenterology, Department of Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts
| | - Bu Hayee
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Amyn Haji
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Gulara Hajiyeva
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Amr Ismail
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Yamile Haito-Chavez
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Michael Talbot
- University of New South Wales, Sydney, New South Wales, Australia
| | | | - Hon-Chi Yip
- Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | | | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Roberta Maselli
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milan, Italy Digestive Endoscopy Unit, Humanitas Unversity, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milan, Italy Digestive Endoscopy Unit, Humanitas Unversity, Milan, Italy
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
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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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23
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Fumagalli U, Rosati R, De Pascale S, Porta M, Carlani E, Pestalozza A, Repici A. 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] [What about the content of this article? (0)] [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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Abstract
Achalasia is a disease for which treatments are palliative in nature. Success of therapy is judged by a number of metrics, the most important being relief of symptoms, such as dysphagia and regurgitation. Patients often compensate for symptoms though a variety of dietary and lifestyle modifications, making symptomatic assessment of therapeutic outcome unreliable. Given this fact, and the progressive nature of the condition if left inadequately treated, patients not infrequently present with the disabling manifestations of end-stage disease for which esophagectomy is the best option. In appropriately selected patients, and when performed in experienced centers, esophagectomy with foregut reconstruction can be undertaken successfully with acceptable rates of morbidity and mortality, as well as a good long-term symptomatic outcome, in cases of end-stage achalasia.
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Affiliation(s)
- Thomas J Watson
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box Surgery, Rochester, NY, 14642, USA,
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25
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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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Tsuboi K, Omura N, Yano F, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Kashiwagi H, Yanaga K. Data analyses and perspectives on laparoscopic surgery for esophageal achalasia. World J Gastroenterol 2015; 21:10830-10839. [PMID: 26478674 PMCID: PMC4600584 DOI: 10.3748/wjg.v21.i38.10830] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 05/29/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
In general, the treatment methods for esophageal achalasia are largely classified into four groups, including drug therapy using nitrite or a calcium channel blocker, botulinum toxin injection, endoscopic therapy such as endoscopic balloon dilation, and surgery. Various studies have suggested that the most effective treatment of esophageal achalasia is surgical therapy. The basic concept of this surgical therapy has not changed since Heller proposed esophageal myotomy for the purpose of resolution of lower esophageal obstruction for the first time in 1913, but the most common approach has changed from open-chest surgery to laparoscopic surgery. Currently, the laparoscopic surgery has been the procedure of choice for the treatment of esophageal achalasia. During the process of the transition from open-chest surgery to laparotomy, to thoracoscopic surgery, and to laparoscopic surgery, the necessity of combining antireflux surgery has been recognized. There is some debate as to which type of antireflux surgery should be selected. The Toupet fundoplication may be the most effective in prevention of postoperative antireflux, but many medical institutions have selected the Dor fundoplication which covers the mucosal surface exposed by myotomy. Recently, a new endoscopic approach, peroral endoscopic myotomy (POEM), has received attention. Future studies should examine the long-term outcomes and whether POEM becomes the gold standard for the treatment of esophageal achalasia.
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Vigneswaran Y, Ujiki MB. Peroral endoscopic myotomy: An emerging minimally invasive procedure for achalasia. World J Gastrointest Endosc 2015; 7:1129-1134. [PMID: 26468336 PMCID: PMC4600178 DOI: 10.4253/wjge.v7.i14.1129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/25/2015] [Accepted: 09/08/2015] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) is an emerging minimally invasive procedure for the treatment of achalasia. Due to the improvements in endoscopic technology and techniques, this procedure allows for submucosal tunneling to safely endoscopically create a myotomy across the hypertensive lower esophageal sphincter. In the hands of skilled operators and experienced centers, the most common complications of this procedure are related to insufflation and accumulation of gas in the chest and abdominal cavities with relatively low risks of devastating complications such as perforation or delayed bleeding. Several centers worldwide have demonstrated the feasibility of this procedure in not only early achalasia but also other indications such as redo myotomy, sigmoid esophagus and spastic esophagus. Short-term outcomes have showed great clinical efficacy comparable to laparoscopic Heller myotomy (LHM). Concerns related to postoperative gastroesophageal reflux remain, however several groups have demonstrated comparable clinical and objective measures of reflux to LHM. Although long-term outcomes are necessary to better understand durability of the procedure, POEM appears to be a promising new procedure.
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Veenstra BR, Goldberg RF, Bowers SP, Thomas M, Hinder RA, Smith CD. Revisional surgery after failed esophagogastric myotomy for achalasia: successful esophageal preservation. Surg Endosc 2016; 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] [What about the content of this article? (0)] [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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Jones EL, Meara MP, Pittman MR, Hazey JW, Perry KA. Prior treatment does not influence the performance or early outcome of per-oral endoscopic myotomy for achalasia. Surg Endosc 2015; 30:1282-6. [PMID: 26123336 DOI: 10.1007/s00464-015-4339-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 06/13/2015] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Per-oral endoscopic myotomy (POEM) is an emerging treatment for achalasia. Pneumatic dilation, botulinum toxin injection, and previous myotomy increase the difficulty of subsequent Heller myotomy, but their impact on POEM remains unknown. The purpose of this study was to compare patients who had undergone prior treatment for their achalasia to those undergoing POEM as an initial therapy. METHODS AND PROCEDURES All patients undergoing POEM were entered into a prospective database from August 2012 to October 2014. Data collected included demographics, dysphagia and symptom survey scores, operative time, clips required for mucosotomy closure, perioperative complications and length of hospital stay. RESULTS Forty-five patients underwent POEM during the study period. Fifteen (30%) had undergone previous treatment (seven Botox injection, five pneumatic dilation and three Heller myotomy). Primary POEM patients were younger than those who had had prior treatment (mean age 46 ± 17 vs. 64 ± 12 years, p < 0.001), but gender, body mass index and ASA class were not significantly different. There were no conversions to Heller myotomy or perioperative complications in either group. Operative time for primary POEM was 103 ± 27 versus 102 ± 29 min following prior treatment (p = 0.84). Mucosotomy closure required a median 7 (4-16) and 8 (5-16) clips, respectively (p = 0.08). Length of stay was 1 day in each group. Median dysphagia scores decreased from 4 (0-5) to 1 (0-4) following primary POEM and 4 (0-5) to 0 (0-4) in the prior treatment group (p = 0.45) during a median follow-up of 10 months (5-17 months). All patients in each group expressed satisfaction with their procedure and would undergo the procedure again given the benefit of hindsight. CONCLUSION Per-oral endoscopic myotomy is a safe and effective treatment for achalasia which improves dysphagia and disease-specific quality of life. Previous endoscopic or laparoscopic treatment of achalasia does not affect the performance or early outcome of POEM.
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Affiliation(s)
- Edward L Jones
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.
| | - Michael P Meara
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Matthew R Pittman
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Jeffrey W Hazey
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Kyle A Perry
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
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Abstract
OBJECTIVE Per-oral endoscopic myotomy (POEM) has recently been introduced as a minimal invasive alternative to conventional treatment for achalasia. This study aimed to clarify the feasibility and the short-term clinical efficacy of POEM as compared to laparoscopic Heller myotomy (LHM). METHODS Treatment outcomes were prospectively recorded and compared between the procedures in a nonrandomized fashion. Reduction rate (RR) in timed barium esophagogram (TBE) was calculated at 1, 2 and 5 min after barium ingestion as: RR = 1- postoperative barium height/preoperative barium height. Risk factors for treatment failure defined as the proportion of patients with RR <0.5 (1 min) and gastroesophageal reflux (GER) after POEM were analyzed. RESULTS Forty-two consecutive patients who underwent POEM were compared to 41 patients who had a LHM during the immediate time period prior to the introduction of POEM. Ninety percent of the cases reported complete symptom relief after POEM. The percentage of esophageal emptying and RR in TBE improved dramatically by both procedures without significant difference. A longer operation time (odds ratio [OR] 32.80, 95%CI 2.99-359.82, p = 0.004) and younger age (OR 26.81, 95%CI 2.09-344.03, p = 0.012) were the independent predictors of treatment failure after POEM. GER was observed in seven patients where previous dilatation (OR 8.59, 95%CI 1.16-63.45, p = 0.035) and higher body mass index (OR 8.69, 95%CI 1.13-66.63, p = 0.037) were the independent predictors for symptomatic GER after POEM. CONCLUSION POEM seems to be a safe and effective treatment option for achalasia in the short-term perspective; an effect well comparable to LHM.
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Affiliation(s)
- Koshi Kumagai
- Gastrocentrum, Karolinska University Hospital and CLINTEC, Karolinska Institutet , Stockholm , Sweden
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Orenstein SB, Raigani S, Wu YV, Pauli EM, Phillips MS, Ponsky JL, Marks JM. Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy. Surg Endosc 2014; 29:1064-70. [PMID: 25249143 DOI: 10.1007/s00464-014-3782-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 07/24/2014] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Traditional treatment for the esophageal motility disorder, achalasia, ranges from endoscopic botulinum toxin (Botox) injections or balloon dilatation, to laparoscopic or open surgical myotomy. Recent advances in endoscopic therapy have led to peroral endoscopic myotomy (POEM) as a viable alternative to traditional techniques for myotomy. Uncertainty exists as to whether the procedure is feasible for patients who have already received prior endoscopic or surgical procedures for therapy, as these groups experience higher failure rates as well as intraoperative mucosal perforations and technical difficulty during Heller myotomy. We describe our first 40 patients who have undergone POEM and compare outcomes between patients who have or have not received previous treatment for achalasia. METHODS AND PROCEDURES We evaluated our prospectively collected database of POEM procedures performed by two surgeons (JLP and JMM) at a single institution. Perioperative data was collected for operative and hospital outcomes. Patients completed pre- and postoperative GERD-Health-Related Quality of Life Questionnaires (GERD-HRQL) and SF-12 surveys for symptom scoring. RESULTS Forty patients received a POEM procedure between 2011 and 2013. Of these, 40% (n = 16) had had at least one prior endoscopic or surgical procedure. Nine had prior Botox injections, 7 had balloon dilations, 3 had both Botox and dilations, and 3 received prior laparoscopic Heller myotomy (two with Dor fundoplication). Mean operative time was 102 min for patients with prior procedures (Prior Tx) and 118 min for patients without any prior procedure (No Tx) (p = 0.07). Intraoperative complication rates for the Prior Tx group were 12.5 versus 16.7% for the No Tx group. Mean follow-up was 10 months. Both groups independently demonstrated clinical improvement in both the GERD-HRQL and SF-12 scores following POEM. There were no statistical differences between the two groups for GERD-HRQL reflux and dysphagia subset scores, or SF-12 mental component summary. CONCLUSION We found favorable outcomes following POEM in patients who have had prior endoscopic or surgical treatments for achalasia, as well as for patients without prior intervention. There were no significant differences between these two groups with regards to operative times, GERD-HRQL scores, and mental component SF-12 scores. One complication requiring intervention occurred in a patient that had received multiple prior Botox injections and balloon dilatations. POEM appears to be a viable alternative for treatment of achalasia compared to traditional techniques, however, long-term data are needed to establish the durability of this technique and to determine whether symptoms will recur necessitating re-intervention.
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Affiliation(s)
- Sean B Orenstein
- Department of Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
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Onimaru M, Inoue H, Ikeda H, Yoshida A, Santi EG, Sato H, Ito H, Maselli R, Kudo SE. Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study. J Am Coll Surg 2013; 217:598-605. [PMID: 23891071 DOI: 10.1016/j.jamcollsurg.2013.05.025] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 05/31/2013] [Accepted: 05/31/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical Heller myotomy has high rates of successful long-term results, but failed cases still remain. Moreover, the treatment strategy in patients with surgical myotomy failure is controversial. Recently, peroral endscopic myotomy (POEM) was reported to be efficient and safe in primary treatment of achalasia. In this study, we aimed to evaluate the efficacy and safety of POEM for surgical myotomy failure as a rescue second-line treatment, and we discuss the treatment options adapted in achalasia recurrence. STUDY DESIGN A total of 315 consecutive achalasia patients received POEM from September 2008 to December 2012 in our hospital. Eleven (3.5%) patients who had persistent or recurrent achalasia and had received surgical myotomy as a first-line treatment from other hospitals were included in this study. Patient background, barium swallow studies, esophagogastroduodenoscopy (EGD), manometry, and symptom scores were prospectively evaluated. In principle, all patients in whom surgical myotomy failed received pneumatic balloon dilatation (PBD) as the first line "rescue" treatment, and only if PBD failed were patients considered for rescue POEM. RESULTS The PBD alone was effective in 1 patient, and in the remaining 10 patients, rescue POEM was performed successfully without complications. Three months after rescue POEM, significant reduction in lower esophageal sphincter (LES) resting pressures (22.1 ± 6.6 mmHg vs 10.9 ± 4.5 mmHg, p < 0.01) and Eckardt symptom scores (6.5 ± 1.3 vs 1.1 ± 1.3, p < 0.001) were observed. CONCLUSIONS Short-term results of POEM for failed surgical myotomy were excellent. Long-term results are awaited.
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Affiliation(s)
- Manabu Onimaru
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan.
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Griffiths EA, Devitt PG, Jamieson GG, Myers JC, Thompson SK. Laparoscopic stapled cardioplasty for end-stage achalasia. J Gastrointest Surg 2013; 17:997-1001. [PMID: 23233272 DOI: 10.1007/s11605-012-2111-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 11/22/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The standard of care for achalasia is laparoscopic Heller's cardiomyotomy. This procedure achieves satisfactory and long-standing results in over 85 % of patients. However, in 10-15 % of patients, esophageal function will progressively deteriorate, and up to 5 % will develop end-stage achalasia. Options in these difficult patients are limited, and include redo cardiomyotomy, repeat dilatation, and in severe cases, esophagectomy. METHODS In this report, we describe an alternate approach, a cardioplasty, which was originally described by Heyrovsky in 1913. RESULTS The development of an angulated stapling device now makes this operation feasible by a laparoscopic approach. CONCLUSION This report highlights our technique for laparoscopic cardioplasty in patients with end-stage achalasia.
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Loviscek MF, Wright AS, Hinojosa MW, Petersen R, Pajitnov D, Oelschlager BK, Pellegrini CA. Recurrent dysphagia after Heller myotomy: is esophagectomy always the answer? J Am Coll Surg. 2013;216:736-743; discussion 743-744. [PMID: 23415553 DOI: 10.1016/j.jamcollsurg.2012.12.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
Abstract
Background
Treatment of primary achalasia includes injection of botulinum toxin, pneumatic dilatation or surgical myotomy. All of these procedures have an associated failure rate. Laparoscopic stapled cardioplasty (LSC) may be an alternative to failed pneumatic dilatation and laparoscopic Heller's myotomy where oesophagectomy has previously been the only surgical option.
Methods
Selected patients with recurrent achalasia following multiple failed medical treatments, including myotomies, were managed by LSC. Patients had postoperative contrast swallows before discharge with clinical follow-up.
Results
All seven patients treated with LSC were discharged within 5 days. Rapid oesophageal emptying was noted on all post-LSC contrast swallows. No patient had an anastomotic leak. After 1 year, all but one patient was free from dysphagia, all had gained weight, and four patients had heartburn controlled by a proton pump inhibitor.
Conclusion
LSC may be a useful procedure for resistant achalasia.
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Affiliation(s)
- T C B Dehn
- Department of Upper Gastrointestinal Surgery, Royal Berkshire Hospital, Reading, UK
| | - M Slater
- Department of Upper Gastrointestinal Surgery, Royal Berkshire Hospital, Reading, UK
| | - N J Trudgill
- Department of Gastroenterology, Sandwell and West Birmingham Hospital, Sandwell, Birmingham, UK
| | - P M Safranek
- Department of Upper Gastrointestinal Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - M I Booth
- Department of Upper Gastrointestinal Surgery, Royal Berkshire Hospital, Reading, UK
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Omura N, Kashiwagi H, Yano F, Tsuboi K, Yanaga K. Reoperations for esophageal achalasia. Surg Today 2012; 42:1078-81. [PMID: 22790707 DOI: 10.1007/s00595-012-0204-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 09/07/2011] [Indexed: 01/04/2023]
Abstract
PURPOSE To define the factors predisposing to recurrence and evaluate the results of reoperations for achalasia. METHODS We reviewed the medical records of ten patients (4 men and 6 women; mean age, 51.5 ± 11.0 years), who underwent reoperations for achalasia between August 1994 and August 2010. RESULTS The primary surgical procedures were Heller-Dor (HD) cardioplasty in nine patients and Heller myotomy in one patient. The factors contributing to failure of the primary operation included inadequate myotomy (n = 2), recurrent adhesion after myotomy (n = 2), reflux esophagitis (n = 2), difficulty in passage caused by tortuosity of the esophagus (n = 2), difficulty in passage through the thoracic esophagus (n = 1), and severe chest pain (n = 1). The reoperations included repeated HD procedures (n = 4), repair of an esophageal hiatal hernia (n = 2), thoracic esophageal myotomy (n = 2), straightening of the lower esophagus with gastropexy (n = 1), and subtotal esophagectomy (n = 1). The success rate of the reoperations for resolving symptoms was 90 % (9 patients). CONCLUSION Selecting surgical procedures based on the causes and conditions of recurrence led to symptomatic improvement and acceptable outcomes.
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Affiliation(s)
- Nobuo Omura
- Department of Surgery, Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan.
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Abstract
PURPOSE To define the factors predisposing to recurrence and evaluate the results of reoperations for achalasia. METHODS We reviewed the medical records of ten patients (4 men and 6 women; mean age, 51.5 ± 11.0 years), who underwent reoperations for achalasia between August 1994 and August 2010. RESULTS The primary surgical procedures were Heller-Dor (HD) cardioplasty in nine patients and Heller myotomy in one patient. The factors contributing to failure of the primary operation included inadequate myotomy (n = 2), recurrent adhesion after myotomy (n = 2), reflux esophagitis (n = 2), difficulty in passage caused by tortuosity of the esophagus (n = 2), difficulty in passage through the thoracic esophagus (n = 1), and severe chest pain (n = 1). The reoperations included repeated HD procedures (n = 4), repair of an esophageal hiatal hernia (n = 2), thoracic esophageal myotomy (n = 2), straightening of the lower esophagus with gastropexy (n = 1), and subtotal esophagectomy (n = 1). The success rate of the reoperations for resolving symptoms was 90 % (9 patients). CONCLUSION Selecting surgical procedures based on the causes and conditions of recurrence led to symptomatic improvement and acceptable outcomes.
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Affiliation(s)
- Nobuo Omura
- Department of Surgery, Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan.
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Bonin EA, Moran E, Bingener J, Knipschield M, Gostout CJ. A comparative study of endoscopic full-thickness and partial-thickness myotomy using submucosal endoscopy with mucosal safety flap (SEMF) technique. Surg Endosc. 2012;26:1751-1758. [PMID: 22258295 DOI: 10.1007/s00464-011-2105-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 11/26/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Esophageal myotomy using submucosal endoscopy with mucosal safety flap (SEMF) has been proposed as a new treatment of achalasia. In this technique, a partial-thickness myotomy (PTM) preserving the longitudinal outer esophageal muscular layer is advocated, which is different from the usual full-thickness myotomy (FTM) performed surgically. The aim of this study was to compare endoscopic FTM and PTM and analyze the outcomes of each method after a 4 week survival period. METHODS Twenty-four pigs were randomly assigned into group A (FTM, 12 animals) and group B (PTM) to undergo endoscopic myotomy. Lower esophageal sphincter (LES) pressure was assessed using pull-through manometry. For statistical analysis we compared the average esophageal sphincter pressure values at baseline, after 2 weeks, and after 4 weeks between groups A and B. The P value was set as <0.05 for significance. RESULTS Eighteen animals were included for statistical analysis. Mean (SD) LES pressures were similar between groups A and B (nine animals each) at baseline [group A = 23 (10.4) mmHg; group B = 20.7 (8.7) mmHg; P = 0.79], after 2 weeks [group A = 19 (7.7) mmHg; group B = 21.8 (8.4) mmHg; P = 0.79], and after 4 weeks [group A = 22.6 (10.2) mmHg; group B = 20.7 (9) mmHg; P = 0.82]. LES pressures were significantly reduced in three animals after 4 weeks: one animal (1%) in group A and two animals (2.5%) in group B. An extended myotomy (3 cm below the cardia) was achieved in three animals and was responsible for the significant drop in LES pressure seen in the two animals from group B. CONCLUSION Esophageal myotomy using SEMF is a feasible yet challenging procedure in pigs. Full-thickness myotomy does not seem to be superior to partial-thickness myotomy as demonstrated by pull-through manometry. Endoscopic esophageal myotomy results are greatly influenced by obtaining adequate myotomy extension into the gastric cardia.
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Abstract
Recurrent dysphagia and/or gastroesophageal reflux (GER) are failures of treatment after Heller myotomy for achalasia. We present our single center experience with surgical interventions for these failures. We did a retrospective analysis of a prospectively collected database. Based on preoperative symptoms and endoscopy, esophagogram, and manometry results, patients were divided into three groups to guide management. Telephone follow-up was done using a structured foregut questionnaire. Between December 2003 and June 2009, 16 patients underwent operative interventions for disabling symptoms after previous Heller myotomy. Eight patients presented primarily with recurrent dysphagia and underwent transabdominal Heller myotomy with partial fundoplication. Seven patients reported good to excellent symptom relief at mean follow-up of 42 months. One patient reported no relief and eventually required esophageal bypass with retrosternal gastric pull-up. Four patients presented with uncontrolled GER. Two patients who underwent redo partial fundoplication reported poor symptomatic outcome and one patient has since undergone short limb Roux-en-y gastric bypass (SLRNYGB) with excellent symptom relief. The other two patients underwent SLRNYGB with excellent relief at 10 months. Four patients had end stage achalasia and underwent esophageal resection with reconstruction. All reported excellent symptom relief at mean follow-up of 36 months. Transabdominal redo Heller myotomy for dysphagia has good outcomes. Redo fundoplication for GER after previous myotomy has poor results and SLRNYGB is an effective option in these patients. Esophageal resection remains an effective, albeit morbid, option for end-stage achalasia.
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Affiliation(s)
- Pradeep K. Pallati
- Department of Esophageal Surgery, Creighton University Medical Center, Omaha, Nebraska
| | - Sumeet K. Mittal
- Department of Esophageal Surgery, Creighton University Medical Center, Omaha, Nebraska
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Abstract
Revisional surgery for persistent or recurrent dysphagia following Heller myotomy is rare and should become even more rare if an extended myotomy has been carried out. It is important to work-up patients who experience persistent or recurrent dysphagia in a systematic fashion that includes the determination of the diagnosis of achalasia, the type of operation performed, the results obtained with the primary operation, and to further classify the type of recurrence. Use of adjunctive studies, including upper gastrointestinal study, endoscopy, manometry, and pH monitoring is critical to guiding clinical decision making. This article will review the differential diagnosis, diagnostic workup, and available treatment options for patients with achalasia who present with persistent or recurrent dysphagia following Heller myotomy.
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Sabirov AG, Raginov IS, Burmistrov MV, Chelyshev YA, Khasanov RSh, Moroshek AA, Grigoriev PN, Zefirov AL, Mukhamedyarov MA. Morphofunctional analysis of experimental model of esophageal achalasia in rats. Bull Exp Biol Med 2010; 149:466-70. [PMID: 21234445 DOI: 10.1007/s10517-010-0972-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We carried out a detailed analysis of rat model of esophageal achalasia previously developed by us. Manifest morphological and functional disorders were observed in experimental achalasia: hyperplasia of the squamous epithelium, reduced number of nerve fibers, excessive growth of fibrous connective tissue in the esophageal wall, high contractile activity of the lower esophageal sphincter, and reduced motility of the longitudinal muscle layer. Changes in rat esophagus observed in experimental achalasia largely correlate with those in esophageal achalasia in humans. Hence, our experimental model can be used for the development of new methods of disease treatment.
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Salvador R, Costantini M, Zaninotto G, Morbin T, Rizzetto C, Zanatta L, Ceolin M, Finotti E, Nicoletti L, Da Dalt G, Cavallin F, Ancona E. The preoperative manometric pattern predicts the outcome of surgical treatment for esophageal achalasia. J Gastrointest Surg 2010; 14:1635-45. [PMID: 20830530 DOI: 10.1007/s11605-010-1318-4] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Accepted: 08/09/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND A new manometric classification of esophageal achalasia has recently been proposed that also suggests a correlation with the final outcome of treatment. The aim of this study was to investigate this hypothesis in a large group of achalasia patients undergoing laparoscopic Heller-Dor myotomy. METHODS We evaluated 246 consecutive achalasia patients who underwent surgery as their first treatment from 2001 to 2009. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored and barium swallow X-ray, endoscopy, and esophageal manometry were performed before and again at 6 months after surgery. Patients were divided into three groups: (I) no distal esophageal pressurization (contraction wave amplitude <30 mmHg); (II) rapidly propagating compartmentalized pressurization (panesophageal pressurization >30 mmHg); and (III) rapidly propagating pressurization attributable to spastic contractions. Treatment failure was defined as a postoperative symptom score greater than the 10th percentile of the preoperative score (i.e., >7). RESULTS Type III achalasia coincided with a longer overall lower esophageal sphincter (LES) length, a lower symptom score, and a smaller esophageal diameter. Treatment failure rates differed significantly in the three groups: I = 14.6% (14/96), II = 4.7% (6/127), and III = 30.4% (7/23; p = 0.0007). At univariate analysis, the manometric pattern, a low LES resting pressure, and a high chest pain score were the only factors predicting treatment failure. At multivariate analysis, the manometric pattern and a LES resting pressure <30 mmHg predicted a negative outcome. CONCLUSION This is the first study by a surgical group to assess the outcome of surgery in 3 manometric achalasia subtypes: patients with panesophageal pressurization have the best outcome after laparoscopic Heller-Dor myotomy.
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Affiliation(s)
- Renato Salvador
- Department of Surgical and Gastroenterological Sciences, Clinica Chirurgica I, School of Medicine, University of Padova, Padova, Italy
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Gockel I, Timm S, Sgourakis GG, Musholt TJ, Rink AD, Lang H. Achalasia--if surgical treatment fails: analysis of remedial surgery. J Gastrointest Surg 2010; 14 Suppl 1:S46-57. [PMID: 19856034 DOI: 10.1007/s11605-009-1018-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 08/25/2009] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Heller myotomy leads to good-excellent long-term results in 90% of patients with achalasia and thereby has evolved to the "first-line" therapy. Failure of surgical treatment, however, remains an urgent problem which has been discussed controversially recently. MATERIALS AND METHODS A systematic review of the literature was performed to analyze the long-term results of failures after Heller's operation with emphasis on treatment by remedial myotomy. DISCUSSION Other reinterventions and their causes after failure of surgical treatment in patients with achalasia are discussed.
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Affiliation(s)
- Ines Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany.
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Finan KR, Renton D, Vick CC, Hawn MT. Prevention of post-operative leak following laparoscopic Heller myotomy. J Gastrointest Surg 2009; 13:200-5. [PMID: 18781365 DOI: 10.1007/s11605-008-0687-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Accepted: 08/20/2008] [Indexed: 01/31/2023]
Abstract
PURPOSE Laparoscopic Heller myotomy is the preferred treatment for achalasia. Post-operative leaks cause significant morbidity and impair functional outcome. This study assesses the efficacy of intra-operative leak testing on post-operative leak rate. METHODS A retrospective analysis of 106 consecutive patients undergoing laparoscopic Heller myotomy by a single surgeon between November 2001 and August 2006 was undertaken. Intra-operative leak testing was performed in all patients. Variables associated with intra-operative mucosotomy were assessed by univariate analysis and logistic regression modeling. RESULTS Intra-operative mucosotomy occurred in 25% of patients. All mucosotomies were repaired primarily and tested with methylene-blue-stained saline. Dor fundoplication was performed in 74% of the patients. There were no post-operative leaks and patients were started on diet day of surgery. Mean LOS was 1.4(+/-0.7) days. Logistic regression modeling demonstrated that prior myotomy was associated with a statistically significant increase in the rate of mucosotomy (p = 0.033), while previous botox injection (p = 0.193), pneumatic dilation (p = 0.599) or concomitant hiatal hernia (p = 0.874) were not significantly associated with mucosotomy. CONCLUSION Laparoscopic Heller myotomy for the treatment of achalasia is a safe procedure. Intra-operative leak testing minimizes the risk of post-operative leaks and expedites post-operative management. Prior endoscopic treatment does not impair operative results.
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Affiliation(s)
- Kelly R Finan
- Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, KB 417 1530 3rd Ave S, Birmingham, AL 35294, USA
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Oezcelik A, Hagen JA, Halls JM, Leers JM, Abate E, Ayazi S, Zehetner J, DeMeester SR, Banki F, Lipham JC, DeMeester TR. An improved method of assessing esophageal emptying using the timed barium study following surgical myotomy for achalasia. J Gastrointest Surg 2009; 13:14-8. [PMID: 18949523 DOI: 10.1007/s11605-008-0730-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Accepted: 10/06/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The timed barium study (TBS) is used to assess esophageal emptying in patients with achalasia. Improvement in emptying correlates with outcome after endoscopic therapy, but the results of the TBS have been variable after myotomy. Our aim was to evaluate a new method for assessing improvement in emptying after myotomy. METHODS A TBS was performed before and 3-6 months after myotomy in 30 patients. Emptying was assessed by measuring the percent difference in area of the barium column on films obtained 1 and 5 min after ingesting 150 ml of barium. Initial esophageal clearance was also assessed by comparing the area of the barium column on 1-min images obtained before and after therapy. Both measures were compared to clinical outcome. RESULTS After myotomy, 21 patients (70%) had no symptoms, four (13%) had mild, and five (17%) had moderate/severe symptoms. Using the standard method, esophageal emptying before and after surgery were not significantly different (25% vs. 37%; p = 0.22) and did not correlate with clinical outcome. In contrast, initial esophageal clearance improved significantly (median 81%) and correlated with clinical outcome. CONCLUSION Esophageal emptying measured by the standard method is not useful to assess outcome after myotomy. However, initial esophageal clearance correlates well with clinical outcome.
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Affiliation(s)
- Arzu Oezcelik
- Department of Surgery, University of Southern California, Keck School of Medicine, 1510 San Pablo Street, Los Angeles, CA 90033, USA
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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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Abstract
The laparoscopic Heller-Dor operation has been the procedure of choice for the treatment of achalasia. However, because the incidence of achalasia is low, reports on the outcome of surgical treatment for achalasia are limited. In this study, the therapeutic results after laparoscopic Heller-Dor operation for achalasia at a single university hospital were evaluated. Between August 1994 and July 2006, 100 consecutive patients underwent laparoscopic Heller-Dor operation. The therapeutic results after laparoscopic Heller-Dor operation were assessed based on complications, operation time, blood loss, postoperative hospital stay, and the standardized questionnaire for satisfaction by telephone or outpatient clinic interview. With respect to perioperative complications, lower esophageal mucosal perforation occurred in 14 patients, but all of them could be suture-obliterated laparoscopically. One patient was converted to laparotomy because of uncontrolled bleeding from the short gastric artery. The mean operative time was 169 minutes, and the mean perioperative blood loss was 22 mL. The median postoperative hospital stay was 7 days. Reflux esophagitis, which was seen in five patients, was treated successfully with a proton pump inhibitor. According to the standardized questionnaire for satisfaction, 77 patients rated their recovery as 'excellent', 17 as 'good', 4 as 'fair', and 2 as 'poor'; thus, the overall success rate was 94%. There were no significant differences in surgical outcomes by morphologic type and severity of esophageal dilatation; however, the success rate deteriorated significantly with progression of the morphologic type. Laparoscopic Heller-Dor operation is a safe and effective surgical treatment for achalasia.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan.
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