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Salem SA, Marom G, Shein GS, Fishman Y, Helou B, Brodie R, Elazary R, Pikarsky AJ, Mintz Y. Robotic Heller's myotomy using the new Hugo™ RAS system: first worldwide report. Surg Endosc 2024; 38:1180-1190. [PMID: 38082007 DOI: 10.1007/s00464-023-10618-5] [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] [Received: 11/02/2023] [Accepted: 11/26/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Achalasia is a rare disorder of the esophagus characterized by motor dysfunction in the esophagus and relaxation failure of the lower esophageal sphincter (LES). Currently, surgical myotomy procedures are considered the standard of care. Robotic Heller's myotomy (RHM) with fundoplication has been gaining popularity due to documented advantages in the precision of myotomy as well as avoiding the potential reflux following per-oral endoscopic myotomy (POEM). To the best of our knowledge, RHM has thus far has been performed exclusively by the da Vinci surgical system. The new Hugo RAS™ system offers a unique modular design and an open console which offers better maneuverability and docking options. In this study, we present the first worldwide series of patients undergoing RHM using the new Hugo RAS™ platform. Our objective is to propose optimal operating configuration and setup to fully harness the advantages of the unique modular design of this system. METHODS Ten consecutive achalasia patients underwent Robotic Heller's myotomy (RHM) with the Hugo RAS™ system. We prospectively collected patient data, including demographics, comorbidities, ASA class, Eckardt scores, pre-operative manometric data, and EndoFlip parameters. Additionally, we recorded the docking and total operative times. RESULTS Between December 2022 and August 2023, 10 patients underwent RHM with the Hugo™ RAS system. Patients had a median age of 42.5 years, 60% were female, and mean BMI was 23.2. Fifty percent had achalasia type 2 and 50% type 1. The median pre-operative integrated relaxation pressure (IRP) was 24.9. Median docking time was 10 min and overall operative time was 129.5 min. All patients, except one with acute coronary syndrome, had an uneventful peri-operative course and were discharged on post-operative day 2. CONCLUSION The Hugo™ RAS system is well designed for robotic Heller myotomy. The operative and clinical results are similar to the currently used robotic system; however, the modular design of the system has some differences. These translate to better docking angles and maneuverability as well as console surgeon's ergonomics. Further experience is needed to explore the advantages of the system's modular design and function.
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Affiliation(s)
- Samer Abu Salem
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
| | - Gad Marom
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gabriel Szydlo Shein
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
| | - Yuri Fishman
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Brigitte Helou
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
| | - Ronit Brodie
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
| | - Ram Elazary
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alon J Pikarsky
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel.
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Wisniowski P, Putnam LR, Samakar K, Martin M, Sundraman S, Houghton C, Lipham J. Trends and outcomes of intraoperative esophagogastroduodenoscopy during laparoscopic Heller myotomy: a National Surgical Quality Improvement Program analysis. J Gastrointest Surg 2024; 28:282-284. [PMID: 38446115 DOI: 10.1016/j.gassur.2023.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/15/2023] [Accepted: 12/16/2023] [Indexed: 03/07/2024]
Affiliation(s)
- Paul Wisniowski
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States.
| | - Luke R Putnam
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
| | - Kamran Samakar
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
| | - Matthew Martin
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
| | - Shivani Sundraman
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
| | - Caitlin Houghton
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
| | - John Lipham
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
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Palomba G, Capuano M, Pegoraro F, Basile R, Pesce M, Rurgo S, Effice E, Sarnelli G, De Palma GD, Aprea G. Laparoscopic Heller-Dor myotomy in elderly achalasia patients: a single center experience with PSM analysis. MINIM INVASIV THER 2024; 33:13-20. [PMID: 37747454 DOI: 10.1080/13645706.2023.2261032] [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] [Received: 01/21/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION Achalasia is a rare esophageal motility disorder of unknown etiology. With the ageing of the general population, treatment in elderly patients has become increasingly common; however, the gold standard treatment in this population remains unclear. The aim of this study was to evaluate the outcomes of laparoscopic Heller-Dor myotomy (LHM) in geriatric patients. MATERIAL AND METHODS In this study, consecutive achalasia patients undergoing LHM at the University Hospital 'Federico II' of Naples from November 2018 to November 2022 were prospectively enrolled. Patients were divided into two groups based on their age at intervention: elderly (≥70 years) and younger (<70 years). The two study groups were compared by minimizing the different distribution of covariates through a propensity score matching analysis (PSM). RESULTS In both populations, there was a significant improvement in terms of manometric parameters and symptoms after surgery. After applying one-on-one PSM, we obtained a total population of 48 achalasia patients divided into two groups (24 patients each). No significant differences were found in terms of demographic characteristics as well as preoperative and intraoperative variables between two groups. At 12 months from surgery, integrated relaxation pressure (IRP) was significantly lower in patients ≥ 70 years (p = 0.032), while younger patients scored significantly less at the post-operative Eckardt score (p = 0.047). CONCLUSIONS Laparoscopic Heller-Dor myotomy is a safe and effective treatment even in elderly patients with rapid post-operative recovery, improvement of symptoms and manometric parameters.
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Affiliation(s)
- Giuseppe Palomba
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Marianna Capuano
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Francesca Pegoraro
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive and Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Raffaele Basile
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Marcella Pesce
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Sara Rurgo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Eleonora Effice
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Giovanni Domenico De Palma
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Giovanni Aprea
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
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Sarici IS, Eriksson S, Abu-Nuwar MR, Kuzy J, Gardner M, Zheng P, Jobe B, Ayazi S. Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy with Dor Fundoplication for Esophagogastric Junction Outflow Obstruction (EGJOO): a Comparison of Outcomes and Impact on Physiology. J Gastrointest Surg 2023; 27:2684-2693. [PMID: 37848686 PMCID: PMC10660958 DOI: 10.1007/s11605-023-05844-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/16/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation with preserved peristalsis. Studies have shown that Heller myotomy with Dor fundoplication (HMD) and per oral endoscopic myotomy (POEM) are effective treatments for EGJOO. However, there is paucity of data comparing the efficacy and impact of these two procedures. Therefore, the aim of this study was to compare outcomes and impact on esophageal physiology in patients undergoing HMD or POEM for primary EGJOO. METHODS This was a retrospective review of patients who underwent either HMD or POEM for primary EGJOO at our institution between 2013 and 2021. Favorable outcome was defined as an Eckardt score ≤ 3 at 1 year after surgery. GERD-HRQL questionnaire, endoscopy, pH monitoring, and high-resolution manometry (HRM) results at baseline and 1 year after surgery were compared pre- and post-surgery and between groups. Objective GERD was defined as DeMeester score > 14.7 or LA grade C/D esophagitis. RESULTS The final study population consisted of 52 patients who underwent HMD (n = 35) or POEM (n = 17) for EGJOO. At a mean (SD) follow-up of 24.6 (15.3) months, favorable outcome was achieved by 30 (85.7%) patients after HMD and 14 (82.4%) after POEM (p = 0.753). After HMD, there was a decrease GERD-HRQL total score (31 (22-45) to 4 (0-19); p < 0.001), and objective reflux (54.2 to 25.9%; p = 0.033). On manometry, there was a decrease in LES resting pressure (48 (34-59) to 13 (8-17); p < 0.001) and IRP (22 (17-28) to 8 (3-11); p < 0.001), but esophageal body characteristics did not change (p > 0.05). Incomplete bolus clearance improved (70% (10-90) to 10% (0-40); p = 0.010). After POEM, there was no change in the GERD-HRQL total score (p = 0.854), but objective reflux significantly increased (0 to 62%; p < 0.001). On manometry, there was a decrease in LES resting pressure (43 (30-68) to 31 (5-34); p = 0.042) and IRP (23 (18-33) to 12 (10-32); p = 0.048), DCI (1920 (1600-5500) to 0 (0-814); p = 0.035), with increased failed swallows (0% (0-30) to 100% (10-100); p = 0.032). Bolus clearance did not improve (p = 0.539). Compared to HMD, POEM had a longer esophageal myotomy length (11 (7-15)-vs-5 (5-6); p = 0.001), more objective reflux (p = 0.041), lower DCI (0 (0-814)-vs-1695 (929-3101); p = 0.004), and intact swallows (90 (70-100)-vs-0 (0-40); p = 0.006), but more failed swallows (100 (10-100); p = 0.018) and incomplete bolus clearance (90 (90-100)-vs-10 (0-40); p = 0.004). CONCLUSION Peroral endoscopic myotomy and Heller myotomy with Dor fundoplication are equally effective at relieving EGJOO symptoms. However, POEM causes worse reflux and near complete loss of esophageal body function.
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Affiliation(s)
- Inanc S Sarici
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Sven Eriksson
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Mohamad Rassoul Abu-Nuwar
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Jacob Kuzy
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Margaret Gardner
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Blair Jobe
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Shahin Ayazi
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.
- Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA.
- Department of Surgery, Drexel University, Philadelphia, PA, USA.
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El-Magd ESA, Elgeidie A, Abbas A, Elmahdy Y, Abulazm IL. Mucosal injury during laparoscopic Heller cardiomyotomy: risk factors and impact on surgical outcomes. Surg Today 2023; 53:1225-1235. [PMID: 37052709 PMCID: PMC10600294 DOI: 10.1007/s00595-023-02680-2] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/01/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE To investigate the risk factors and outcomes of mucosal perforation (MP) during laparoscopic Heller myotomy (LHM) in patients with achalasia. METHODS We conducted a retrospective analysis of patients who underwent LHM for achalasia at a single facility. RESULTS Among 412 patients who underwent LHM for achalasia, MP was identified in 52 (12.6%). Old age, long disease duration, low albumin level, an esophageal transverse diameter > 6 cm, and a sigmoid-shaped esophagus were found to be independent predictors of MP. These factors were assigned a pre-operative score to predict the perforation risk. MP had a significant impact on intra and post-operative outcomes. Gastric side perforation was associated with a higher incidence of reflux symptoms, whereas esophageal-side perforation had a higher incidence of residual dysphagia. CONCLUSIONS Many risk factors for MP have been identified. Correctable parameters like low serum albumin should be resolved prior to surgery, while uncorrectable parameters like old age and a sigmoid-shaped esophagus should be managed by experienced surgeons in high-volume centers. Implementing these recommendations will help decrease the incidence and consequences of this serious complication.
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Affiliation(s)
- El-Sayed Abou El-Magd
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Al Dakahlia Governorate, Mansoura, 35511, Egypt.
| | - Ahmed Elgeidie
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Al Dakahlia Governorate, Mansoura, 35511, Egypt
| | - Amr Abbas
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Al Dakahlia Governorate, Mansoura, 35511, Egypt
| | - Youssif Elmahdy
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Al Dakahlia Governorate, Mansoura, 35511, Egypt
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Dilsaver DB, Walters RW, Nandipati KC. Laparoscopic Heller Myotomy vs. Peroral Endoscopic Myotomy: an Analysis of the National Inpatient Sample Database. J Gastrointest Surg 2023; 27:2608-2610. [PMID: 37580486 DOI: 10.1007/s11605-023-05801-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/29/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Danielle B Dilsaver
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, Omaha, NE, USA
| | - Ryan W Walters
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, Omaha, NE, USA
| | - Kalyana C Nandipati
- Department of Surgery, School of Medicine, Creighton University, 7710 Mercy Road, Suite 501, Creighton University Education Bldg, Omaha, NE, 68124, USA.
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Nabi Z, Ramchandani M, Basha J, Inavolu P, Kotla R, Goud R, Darisetty S, Reddy DN. Per-oral endoscopic myotomy in cases with prior Heller's myotomy: Outcomes at a median follow-up of 5 years. J Gastroenterol Hepatol 2023; 38:2035-2039. [PMID: 37571986 DOI: 10.1111/jgh.16320] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/11/2023] [Accepted: 07/23/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND AND AIM Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia cardia. However, data on the long-term efficacy of POEM in patients with failed Heller's myotomy (HM) are limited. The purpose of this study was to evaluate the long-term outcomes of POEM in patients with persistent or recurrent symptoms following HM. METHODS Data of patients with recurrence of symptoms after HM who underwent POEM (September 2013 to December 2022) were analyzed, retrospectively. Primary outcome was clinical success [Eckardt score (ES) ≤ 3]. Secondary outcomes included improvement of manometry parameters, barium emptying at 5 min and gastroesophageal reflux (esophagitis and increased esophageal acid exposure) after POEM. RESULTS Seventy-two cases (45.9 ± 13.4 years, 43 men) with history of HM were included in the study. The subtypes of achalasia were type 1 (40.3%), type 2 (37.5%), and unknown (19.4%). Prior treatment included HM in 48 (66.7%), HM plus pneumatic dilatation in 20 (27.8%), and HM plus pneumatic dilatation and Botox in 4 (5.5%). Technical success was achieved in all cases. Mean length of myotomy was 10.7 ± 3.3 cm, and mean procedure duration was 59.2 ± 25.9 min. There was significant improvement in ES (pre-POEM 6.5 ± 1.8 vs post-POEM 0.7 ± 0.7), lower esophageal sphincter pressure pressures (31.7 ± 12.5 vs 13.3 ± 5.7 mmHg) and barium emptying (14.2 ± 4.2 vs 2.4 ± 3.1 cm) after POEM. At a median follow-up of 63 months (IQR 40-95), clinical success (ES ≤ 3) was documented in 58 (80.6%) patients. Reflux esophagitis and increased esophageal acid exposure were recorded in 28 of 49 (57.1%) and 11 of 20 (55%) patients, respectively. CONCLUSION POEM is a durable treatment modality in cases with relapse of symptoms after HM.
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Affiliation(s)
- Zaheer Nabi
- Interventional Endoscopy Asian Institute of Gastroenterology, Hyderabad, India
| | | | | | | | - Rama Kotla
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Rajesh Goud
- Asian Institute of Gastroenterology, Hyderabad, India
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Zhang H, Huang Z. Long-term outcomes of peroral endoscopic myotomy in cases with previous Heller's myotomy. J Gastroenterol Hepatol 2023; 38:1856-1857. [PMID: 37670444 DOI: 10.1111/jgh.16346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/26/2023] [Indexed: 09/07/2023]
Affiliation(s)
- H Zhang
- Department of Gastroenterology, Zigong First People's Hospital, Zigong, China
| | - Z Huang
- Department of Gastroenterology, Zigong First People's Hospital, Zigong, China
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9
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Zhang ZC, Xu JQ, Liu XY, Pan HT, Chen SY, Zhong YS, Zhang YQ, Chen WF, Ma LL, Hu JW, Cai MY, Qin WZ, Li QL, Zhou PH. Salvage peroral endoscopic myotomy is a promising treatment for achalasia after myotomy failure. Gastrointest Endosc 2023; 98:543-551.e1. [PMID: 37150417 DOI: 10.1016/j.gie.2023.04.2093] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 02/01/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND AND AIMS Reintervention modalities after myotomy failure in achalasia patients have yet to be established. The efficacy and safety of salvage peroral endoscopic myotomy (POEM) for treatment of achalasia after myotomy failure were evaluated in the study. METHODS Between August 2011 and August 2021 at the Endoscopy Center of Zhongshan Hospital, 219 achalasia patients who had previously undergone a myotomy underwent a salvage POEM and were thus retrospectively enrolled in this study. After propensity score matching (PSM), operation-related parameters were compared between the salvage POEM group and the naïve POEM group. Subgroup analysis was performed between patients with previous Heller myotomy (HM) and patients with previous POEM. RESULTS With similar baseline characteristics between both groups after PSM, the salvage POEM group presented with shorter tunnel length (11.8 ± 2.2 cm vs 12.8 ± .9 cm, P < .0001) and myotomy length (9.8 ± 2.0 cm vs 10.4 ± 1.0 cm, P < .0001) than the naïve POEM group. No significant differences were found in procedure-related adverse events between patients of salvage POEM and naïve POEM. The primary outcome of treatment success occurred in 175 of 193 patients (90.7%) in the salvage POEM group versus 362 of 374 patients (96.8%) in the naïve POEM group (P = .0046). At a 2- and 5-year follow-up, significantly higher rates of clinical failures were observed in the previous HM subgroup than in the previous POEM subgroup (P = .0433 and P = .0230, respectively). CONCLUSIONS Salvage POEM after a previous myotomy failure, especially after a POEM failure, is a promising treatment option because it has a durable clinical relief rate.
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Affiliation(s)
- Zhao-Chao Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Jia-Qi Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Xin-Yang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Hai-Ting Pan
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Shi-Yao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Li-Li Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wen-Zheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
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Tassi V, Lugaresi M, Pilotti V, Bassi F, Daddi N, D'Ovidio F, Leiva-Juarez MM, Mattioli S. Outcomes of Heller Myotomy for Esophageal Achalasia: Lessons From a 48-Year Prospective Experience With 4 Different Techniques. Ann Surg 2023; 278:e27-e34. [PMID: 36082979 DOI: 10.1097/sla.0000000000005677] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide information on long-term outcomes of Heller myotomy for esophageal achalasia with or without an antireflux fundoplication. BACKGROUND Since the adoption of the Heller myotomy, surgeons have modified the original technique in order to balance the cure of dysphagia and the consequent cardial incontinence. METHODS Totally, 470 patients underwent primary Heller myotomy between 1955 and 2020. A long abdominal myotomy (AM) was performed in 83 patients, the Ellis limited transthoracic myotomy (TM) in 30, the laparotomic Heller-Dor (L-HD) in 202, the videolaparoscopic Heller-Dor (VL-HD) in 155. The HD was performed under intraoperative manometric assessment. Starting on 1973 these patients underwent a prospective follow-up program of timed lifelong clinical, radiological, endoscopic evaluations. RESULTS Median follow-up time was 23.06 years [interquantile range (IQR): 15.04-32.06] for AM, 29.22 years (IQR: 13.46-40.17) for TM, 14.85 years (IQR: 11.05-21.56) for L-HD and 7.51 years (IQR: 3.25-9.60) for VL-HD. In AM, relapse of dysphagia occurred in 25/71 (35.21%), in TM in 11/30 (36.66%), in LH-D in 10/201 (4.97%), in VL-HD in 3/155 (1.93%). Erosive-ulcerative esophagitis was diagnosed for AM in 28.16%, for TM in 30%, for L-HD in 8.45%, for VL-HD in 2.58%. Overall, the outcome was satisfactory in 52.11% for AM, 41.9% for TM, 89.05% for L-HD, 96.12% for VL-HD. CONCLUSIONS The Dor fundoplication drastically reduces postmyotomy gastroesophageal reflux. The Heller-Dor operation is a competitive option for the cure of esophageal achalasia if this operation is performed according to the rules of surgical physiology learned by means of intraoperative manometry.
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Affiliation(s)
| | - Marialuisa Lugaresi
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola
- Alma Mater Studiorum, University of Bologna, Bologna
| | | | | | - Niccolò Daddi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Frank D'Ovidio
- Division of Cardiac, Department of Surgery, Vascular, and Thoracic Surgery, New York Presbyterian Columbia University Medical Center, New York, NY
| | - Miguel M Leiva-Juarez
- Division of Cardiac, Department of Surgery, Vascular, and Thoracic Surgery, New York Presbyterian Columbia University Medical Center, New York, NY
| | - Sandro Mattioli
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola
- Alma Mater Studiorum, University of Bologna, Bologna
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Abstract
BACKGROUND Laparoscopic Heller's cardiomyotomy (LHC) is the preferred treatment of achalasia. It improves dysphagia by dividing muscles of the lower oesophageal sphincter, but this intervention can result in debilitating gastro-oesophageal reflux symptoms in some patients. To prevent these reflux symptoms, most surgeons add a fundoplication to Heller's cardiomyotomy, but there is no consensus regarding this or the type of fundoplication which is best suited for the purpose. OBJECTIVES To assess how the addition of a fundoplication affects postoperative reflux and dysphagia in people undergoing LHC and compare the different types of fundoplications used in combination with LHC to determine which is better at controlling reflux without worsening the dysphagia. SEARCH METHODS We searched three databases (CENTRAL, MEDLINE and Embase) on 31 October 2021 and trial registers to identify all published and unpublished randomised controlled trials (RCTs) in any language, comparing different fundoplications used in combination with LHC to treat achalasia. We also included RCTs where LHC with a fundoplication is compared with LHC without any fundoplication. SELECTION CRITERIA We only included RCTs which recruited adult participants with achalasia undergoing LHC with minimal hiatal dissection. We excluded non-randomised studies or studies involving paediatric participants. We also excluded studies where the procedure was done by open surgery and where circumferential hiatal dissection of the oesophagus was carried out, unless it was necessary to reduce a hiatus hernia or to facilitate a Toupet or Nissen fundoplication. DATA COLLECTION AND ANALYSIS Two review authors independently identified studies to be included, assessed risk of bias using the Cochrane RoB 1 tool, and extracted the data. We calculated the risk ratio (RR) with 95% confidence interval (CI) using both fixed-effect and random-effect models with Review Manager (RevMan) software. MAIN RESULTS We included eight studies in this review, with a total of 571 participants with an average age of 45 years (range 33.5 to 50). LHC without any fundoplication was performed in 65 (11.3%) participants, 298 (52.1%) had Dor fundoplication, 81 (14.1%) had Toupet fundoplication, 72 (12.6%) had Nissen's fundoplication, and 55 (9.6%) participants had angle of His accentuation. Three studies with a total of 143 participants compared LHC + Dor to LHC without fundoplication. We found that the evidence is very uncertain as to whether the addition of a Dor fundoplication made any difference to the outcome of postoperative pathological acid reflux (RR 0.37, 95% CI 0.07 to 1.89; I2 = 56%; 2 studies, 97 participants; very low-certainty evidence) and uncertain for severe postoperative dysphagia (RR 3.00, 95% CI 0.34 to 26.33; I2 = 0%; 3 studies, 142 participants; low-certainty evidence). Three studies with 174 participants compared LHC + Dor to LHC + Toupet. The evidence suggests that there may be little to no difference in the outcomes of postoperative pathological acid reflux (RR 0.75, 95% CI 0.23 to 2.43; I2 = 60%; 3 studies, 105 participants; low-certainty evidence) and severe postoperative dysphagia (RR 0.78, 95% CI 0.19 to 3.15; I2 = 0%; 3 studies, 123 participants; low-certainty evidence) between the two interventions, but the certainty of the evidence is low. One study with 138 participants compared LHC + Dor to LHC + Nissen. Nissen fundoplication caused increased severe postoperative dysphagia (RR 0.19, 95% CI 0.04 to 0.83; 1 study, 138 participants; high-certainty evidence) when compared to Dor fundoplication. This study did not show a difference in postoperative pathological acid reflux (RR 4.72, 95% CI 0.23 to 96.59; 1 study, 138 participants; low-certainty evidence), but the certainty of evidence is low. One study with 110 participants compared LHC + Dor with LCH + angle of His accentuation, and reported that severe postoperative dysphagia was similar between the two interventions (RR 1.56, 95% CI 0.27 to 8.95; 1 study, 110 participants; moderate-certainty evidence), with moderate certainty of evidence. This study did not report on postoperative pathological acid reflux. AUTHORS' CONCLUSIONS When LHC was performed with minimal hiatal dissection, we were very uncertain whether the addition of a Dor fundoplication made a difference in controlling postoperative reflux, and we were uncertain if it increased the risk of severe postoperative dysphagia. There may be little to no difference in the outcomes of postoperative pathological acid reflux or severe dysphagia between Dor and Toupet fundoplications when used in combination with LHC, but the certainty of the evidence is low. Nissen (total) fundoplication used in combination with LHC for achalasia increased the risk of severe postoperative dysphagia. The angle of His accentuation and Dor fundoplication had a similar effect on severe postoperative dysphagia when combined with LHC, but their effect on postoperative pathological acid reflux was not reported.
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Affiliation(s)
- Sumit Midya
- Department of General Surgery, Frimley Park Hospital, Frimley, UK
| | - Debasish Ghosh
- Department of General Surgery, Royal Berkshire Hospital, Reading, UK
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12
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Haskins IN, Duchesneau ED, Agala CB, Lumpkin ST, Strassle PD, Farrell TM. Minimally invasive, benign foregut surgery is not associated with long-term, persistent opioid use postoperatively: an analysis of the IBM® MarketScan® database. Surg Endosc 2022; 36:8430-8440. [PMID: 35229211 PMCID: PMC9733437 DOI: 10.1007/s00464-022-09123-y] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use. METHODS Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365 days postoperatively were estimated using log-binomial regression. RESULTS A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365 days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365 days postoperatively. CONCLUSIONS Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.
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Affiliation(s)
- Ivy N Haskins
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE, 68198-3280, USA.
| | - Emilie D Duchesneau
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Chris B Agala
- Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | | | - Paula D Strassle
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Timothy M Farrell
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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13
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Keane OA, Dantes G, Emani S, Garza JM, Heiss KF, Clifton MS. Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic Heller myotomy surgery. J Pediatr Surg 2022; 57:1132-1136. [PMID: 35292166 DOI: 10.1016/j.jpedsurg.2022.01.031] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/22/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Enhanced recovery protocols (ERPs) are effective means of standardizing and improving the quality of surgical care in adults. Our purpose was to retrospectively compare outcomes before and after implementation of ERPs in children undergoing laparoscopic Heller myotomy for achalasia. METHODS A pediatric-specific ERP was used for children undergoing laparoscopic Heller myotomy starting July 2017 at two pediatric surgery centers within a single metropolitan healthcare system. A retrospective review of 8 patients undergoing Heller myotomies between July 2014 and July 2017 was performed as a control. This cohort was compared to 14 patients managed post-ERP implementation (2017-2020). Outcomes of interest investigated included opioid use during admission, narcotics at discharge, time to regular diet, length of stay (LOS), and readmissions. RESULTS There was a significant decrease in opioid use both while in the hospital and at time of discharge. Mean morphine equivalent use was 4.50 mg in the pre-ERP cohort and 1.97 mg in the post-ERP cohort. Furthermore, 8 out of 14 (57%) patients in the post-ERP cohort received no opioids during the admission compared with only 2 out of 8 (25%) patients in the pre-ERP cohort. Only 1 out of 14 (7.14%) patients in the post-ERP cohort was discharged with a prescription for opioid medication while 6 out of 8 (75%) in the pre-ERP cohort were discharged with an opiate prescription. CONCLUSIONS The use of ERP in children undergoing laparoscopic Heller myotomy surgery is safe and effective and leads to a reduction in opioid use during admission and at discharge. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Olivia A Keane
- Department of Surgery, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States.
| | - Goeto Dantes
- Department of Surgery, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States
| | - Srinivas Emani
- Department of Behavioral Social and Health Education Sciences, Emory University, Atlanta, GA, United States
| | - Jose M Garza
- Department of Pediatrics, Children's Healthcare of Atlanta, GI Care for Kids, Atlanta, GA, United States
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Matthew S Clifton
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
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14
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Kumar A, Tripathi SN, Mittal S, Abraham J, Makharia GK, Parshad R. Symptomatic and Physiological Outcomes Following Laparoscopic Heller Myotomy for Achalasia Cardia: Is There a Correlation? Surg Laparosc Endosc Percutan Tech 2022; 32:299-304. [PMID: 35034067 DOI: 10.1097/sle.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 08/24/2021] [Accepted: 12/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Symptomatic evaluation using Eckardt score and achalasia-specific health-related quality-of-life and physiological evaluation using timed barium examination (TBE) and high-resolution manometry is integral to the diagnosis of achalasia. However, the correlation of physiological outcomes with symptomatic outcomes and their role in routine follow-up after laparoscopic Heller cardiomyotomy (LHCM) is controversial. In this study, we evaluated the role of physiological testing in achalasia patients undergoing LHCM and its correlation with symptomatic evaluation. MATERIALS AND METHODS Case records of patients undergoing LHCM for achalasia between January 2017 and March 2020 were reviewed for symptom scores (Eckardt score and achalasia-specific health-related quality-of-life) and physiological parameters [5-min column height on TBE and median integrated relaxation pressure (IRP) on high-resolution manometry]. Sixty-one patients with complete data in the preoperative period and on follow-up were included in the study. The data was analyzed for symptomatic and physiological outcomes and their correlation using paired t test and the Spearman correlation test. RESULTS At a median follow-up of 16 months following LHCM, there was a significant improvement in Eckardt score (7.03±1.53 to 0.93±1.10, P<0.001), achalasia-specific health-related quality-of-life (58.34±7.81 to 14.57±13.45, P<0.001), column height on TBE (115.14±46.9 to 27.89±34.31, P<0.001) and IRP (23.95±8.26 to 4.61±4.11, P<0.001). Eckardt score correlated significantly with achalasia-specific health-related quality-of-life scores preoperatively (ρ=0.410, P<0.001) and on follow-up (ρ=0.559, P<0.001). There was no correlation between symptomatic parameters and physiological parameters. CONCLUSIONS In patients of achalasia, LHCM leads to significant improvement in symptomatic and physiological parameters. Symptom scores correlate among themselves but not with physiological scores. Thus, physiological testing may not be needed for routine follow-up.
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Affiliation(s)
| | | | | | | | - Govind K Makharia
- Gastroenterology, All India Institute of Medical Sciences, New Delhi, Delhi, India
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15
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Schlottmann F, Herbella FAM, Patti MG. The Evolution of the Treatment of Esophageal Achalasia: From the Open to the Minimally Invasive Approach. World J Surg 2022; 46:1522-1526. [PMID: 35169899 DOI: 10.1007/s00268-022-06482-4] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Achalasia is a primary esophageal motility disorder characterized by lack of esophageal peristalsis and partial or absent relaxation of the lower esophageal sphincter in response to swallowing. This study aimed to provide an overview of the evolution of the surgical treatment for esophageal achalasia, from the open to the minimally invasive approach. METHODS Literature review. RESULTS No curative treatment exists for this disorder. At the beginning of the 20th century, surgical esophagoplasties and cardioplasties were mostly done to treat achalasia. The description of the esophageal myotomy by Heller changed the treatment paradigm and rapidly became the treatment of choice. For many years the esophagomyotomy was done with either an open transthoracic or transabdominal approach. With the advancements of minimally invasive surgery, thoracoscopic and laparoscopic operations became available. The ability to add a fundoplication for the prevention of reflux made the laparoscopic Heller myotomy with partial fundoplication the operation of choice. CONCLUSIONS Surgical management of esophageal achalasia has significantly evolved in the last century. Currently, minimally invasive Heller myotomy with partial fundoplication is the standard surgical treatment of achalasia.
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Affiliation(s)
- Francisco Schlottmann
- Division of Esophageal and Gastric Surgery, Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon1640, Buenos Aires, Argentina.
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA.
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Sanaka MR, Chadalavada P, Covut F, Garg R, Thota PN, Gabbard S, Alomari M, Murthy S, Raja S. Peroral endoscopic myotomy is equally safe and highly effective treatment option in achalasia patients with both lower and higher ASA classification status. Esophagus 2021; 18:932-940. [PMID: 33847859 DOI: 10.1007/s10388-021-00840-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/02/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The American Society of Anesthesiologists (ASA) physical status classification system was developed as a simple categorization of patients' physiological status that predicts the operative risk. Peroral endoscopic myotomy (POEM) is a less invasive alternative to surgical myotomy in achalasia. As such, POEM seems to be an appealing option for high-risk patients with achalasia. However, there are no studies which systematically analyzed the outcomes of POEM among patients with different ASA classes. Hence, we aimed to compare the safety and efficacy of POEM in patients with lower and higher ASA classes. METHODS Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients were categorized arbitrarily into two groups, lower ASA class (ASA I and II combined) and higher ASA class (ASA class III and IV combined). Demographic and procedural details, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), pH study findings and Eckardt scores were compared between the two groups. Baseline characteristics were compared using Chi-square test and two-sample t-test for categorical and continuous variables, respectively. RESULTS A total of 144 patients met our study criteria (lower ASA class, n = 44; and higher ASA class, n = 100). Patients in higher ASA class were significantly more obese and older. More patients in lower ASA class had prior Heller myotomy and more patients in higher ASA Class had prior botulinum toxin injections. Procedural parameters were similar in both groups. Procedural complications were infrequent and were also similar in the two groups. The length of stay, 30-day readmission rate, reflux symptoms and esophageal pH study findings were also comparable between the two groups. Treatment success was similar in both groups, 97.7% in lower ASA class versus 92% in higher ASA class (p = 0.19). At 2-month follow-up, both groups had significant improvement in HREM and TBE parameters. CONCLUSION POEM is a very safe and highly effective treatment option for achalasia patients with advanced ASA class similar to lower ASA class patients. POEM may be considered as the preferred choice for myotomy in these high-risk achalasia patients due to its low morbidity and high efficacy.
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Affiliation(s)
- Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | | | - Fahrettin Covut
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rajat Garg
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Scott Gabbard
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Mohammad Alomari
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Kohn GP, Dirks RC, Ansari MT, Clay J, Dunst CM, Lundell L, Marks JM, Molena D, Rooker C, Saxena P, Swanstrom L, Wong RK, Pryor AD, Stefanidis D. SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia. Surg Endosc 2021; 35:1931-1948. [PMID: 33564964 DOI: 10.1007/s00464-020-08282-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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] [Received: 10/19/2020] [Accepted: 12/31/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is increasingly used as primary treatment for esophageal achalasia, in place of the options such as Heller myotomy (HM) and pneumatic dilatation (PD) OBJECTIVE: These evidence-based guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) intend to support clinicians, patients and others in decisions about the use of POEM for treatment of achalasia. RESULTS The panel agreed on 4 recommendations for adults and children with achalasia. CONCLUSIONS Strong recommendation for the use of POEM over PD was issued unless the concern of continued postoperative PPI use remains a key decision-making concern to the patient. Conditional recommendations included the option of using either POEM or HM with fundoplication to treat achalasia, and favored POEM over HM for achalasia subtype III.
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Affiliation(s)
- Geoffrey P Kohn
- Department of Surgery, Eastern Health Clinical School, Monash University, Clayton, VIC, Australia.
- Melbourne Upper GI Surgical Group, Melbourne, VIC, Australia.
| | - Rebecca C Dirks
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammed T Ansari
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jason Clay
- International Foundation for Gastrointestinal Disorders, Mount Pleasant, USA
| | | | - Lars Lundell
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Jeffrey M Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Daniela Molena
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ceciel Rooker
- International Foundation for Gastrointestinal Disorders, Mount Pleasant, USA
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Newtown, Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Lee Swanstrom
- Institut de Chirugie, IHU Strasbourg, Strasbourg, France
| | - Reuben K Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Aurora D Pryor
- Department of Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Dimitrios Stefanidis
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Velotti N, Vitiello A, Berardi G, Musella M. Roux-en-Y Gastric Bypass and Heller Myotomy: One-Step Surgical Treatment of Symptomatic Achalasia in a Morbid Obese Patient. Obes Surg 2021; 31:3379-3381. [PMID: 33928522 PMCID: PMC8175316 DOI: 10.1007/s11695-021-05376-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/13/2021] [Accepted: 03/22/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Nunzio Velotti
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini n.5, 80131, Naples, Italy.
| | - Antonio Vitiello
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini n.5, 80131, Naples, Italy
| | - Giovanna Berardi
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini n.5, 80131, Naples, Italy
| | - Mario Musella
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini n.5, 80131, Naples, Italy
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Tassi V, Lugaresi M, Mattioli B, Daddi N, Pilotti V, Ferruzzi L, Longaroni M, Mattioli S. Quality of Life After Operation for End-Stage Achalasia: Pull-Down Heller-Dor Versus Esophagectomy. Ann Thorac Surg 2021; 113:271-278. [PMID: 33515542 DOI: 10.1016/j.athoracsur.2020.12.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 05/17/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Therapy for end-stage achalasia is debated, and data on long-term functional results of myotomy and esophagectomy are lacking. We compared quality of life and objective outcomes after pull-down Heller-Dor and esophagectomy. METHODS The study included 32 patients, aged 57 years (interquartile range [IQR], 49-70 years), who underwent the Heller-Dor operation with verticalization of the distal esophagus in case of first instance treatment or failed surgery caused by insufficient myotomy, and 16 patients, aged 58 years (IQR, 49-67 years; P = .806), who underwent esophagectomy after failed surgery for other causes. Data were extracted from a database designed for prospective clinical research. Postoperative dysphagia, reflux symptoms, and endoscopic esophagitis were graded by semiquantitative scales. Quality of life was assessed with the 36-Item Short Form Health Survey questionnaire. RESULTS The median follow-up period was 68 months (IQR, 40.43-94.48 months) after pull-down Heller-Dor and 61 months (IQR 43.72-181.43 months) after esophagectomy (P = .598). No statistically significant differences were observed for dysphagia (P = .948), reflux symptoms (P = .186), or esophagitis (P = .253). No statistically significant differences were observed in the domains physical functioning (P = .092), bodily pain (P = .075) or general health (P = .453). Significant differences were observed in favor of pull-down Heller-Dor for the domains role physical (100 vs 100, P = .043), role emotional (100 vs 0, P = .002), vitality (90 vs 55, P< .001), mental health (92 vs 68, P = .002), and social functioning (100 v s75, P = .011). CONCLUSIONS The pull-down Heller-Dor achieved objective results similar to those of esophagectomy with a better quality of life. This technique may be the first choice for end-stage achalasia in patients with null or low risk for cancer or after recurrent dysphagia caused by insufficient myotomy.
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Affiliation(s)
- Valentina Tassi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | | | | | - Niccolò Daddi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Vladimiro Pilotti
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
| | - Luca Ferruzzi
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
| | | | - Sandro Mattioli
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy.
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21
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Calixto-Aguilar L, Gonzales-Carazas EF, Marin Calderón L, Vásquez Quiroga J, Alva Alva E, Bardalez Cruz P, Palacios Salas F. Peroral endoscopic myotomy in a pediatric patient with refractory achalasia: a case report and review of the literature. Rev Gastroenterol Peru 2021; 41:37-40. [PMID: 34347769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
A 15-year-old male patient presented with dysphagia, regurgitation, weight loss and retrosternal pain. The diagnosis of achalasia was made 4 years before. The esophagogram revealed severe esophagus dilatation and the classic "bird-beak" termination. A Heller myotomy plus fundoplication and endoscopic balloon dilatation were conducted four months previously. Nevertheless, the symptoms persisted and the last high-resolution manometry study still showed achalasia type II. The patient underwent a peroral endoscopic esophageal myotomy (POEM). POEM is a feasible and safe procedure for experienced and properly-equipped health care delivery centers and could be used as a rescue treatment in refractory achalasia. We present the youngest patient with achalasia in our region who had a successful response to rescue POEM.
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Affiliation(s)
- Lesly Calixto-Aguilar
- Department of Gastroenterology, Hospital Nacional Edgardo Rebagliati Martins. Lima, Peru
| | | | - Luis Marin Calderón
- Department of Gastroenterology, Hospital Nacional Edgardo Rebagliati Martins. Lima, Peru
| | - Jorge Vásquez Quiroga
- Department of Gastroenterology, Hospital Nacional Edgardo Rebagliati Martins. Lima, Peru; Clínica Internacional. Lima, Peru
| | - Edgar Alva Alva
- Department of Gastroenterology, Hospital Nacional Edgardo Rebagliati Martins. Lima, Peru
| | - Paulo Bardalez Cruz
- Department of Gastroenterology, Hospital Nacional Edgardo Rebagliati Martins. Lima, Peru
| | - Fernando Palacios Salas
- Department of Gastroenterology, Hospital Nacional Edgardo Rebagliati Martins. Lima, Peru; Clínica Delgado and Oncosalud. Lima, Peru
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22
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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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23
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Bruenderman EH, Bhutiani N, Martin RCG, Fox MP, van Berkel VH, Block SB, Kehdy FJ. Intraoperative Esophagogastroduodenoscopy During Heller Myotomy: Evaluating Guidelines. World J Surg 2020; 45:808-814. [PMID: 33230586 DOI: 10.1007/s00268-020-05870-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND National guidelines suggest routine intraoperative esophagogastroduodenoscopy (EGD) during laparoscopic Heller myotomy (LHM) to assess for mucosal perforation and myotomy adequacy, but the utility of this is unknown. This study aimed to evaluate the effect of intraoperative EGD on outcomes after LHM. METHODS Patients who underwent LHM in a single center were retrospectively identified. Outcomes were compared between patients who did and did not undergo intraoperative EGD. RESULTS Sixty-one patients were reviewed: 46 (75%) underwent intraoperative EGD and 15 (25%) did not. Mucosal perforations occurred in 2 (4%) of the EGD group and 3 (20%) of the non-EGD group (p = 0.06). All perforations, regardless of EGD use, were recognized laparoscopically. There were no postoperative leaks. Failed myotomy occurred in 5 (11%) who underwent EGD and 1 (7%) who did not (p = 0.64). CONCLUSIONS Because EGD does not appear to improve outcomes after LHM, we emphasize its selective, rather than routine, use.
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Affiliation(s)
- Elizabeth H Bruenderman
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Neal Bhutiani
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Robert C G Martin
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY, United States of America
| | - Matthew P Fox
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, United States of America
| | - Victor H van Berkel
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, United States of America
| | - Stacy B Block
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Farid J Kehdy
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America.
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24
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Savarino E, di Pietro M, Bredenoord AJ, Carlson DA, Clarke JO, Khan A, Vela MF, Yadlapati R, Pohl D, Pandolfino JE, Roman S, Gyawali CP. Use of the Functional Lumen Imaging Probe in Clinical Esophagology. Am J Gastroenterol 2020; 115:1786-1796. [PMID: 33156096 PMCID: PMC9380028 DOI: 10.14309/ajg.0000000000000773] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The functional lumen imaging probe (FLIP) measures luminal dimensions using impedance planimetry, performed most often during sedated upper endoscopy. Mechanical properties of the esophageal wall and opening dynamics of the esophagogastric junction (EGJ) can be objectively evaluated in esophageal motor disorders, eosinophilic esophagitis, esophageal strictures, during esophageal surgery and in postsurgical symptomatic states. Distensibility index, the ratio of EGJ cross sectional area to intraballoon pressure, is the most useful FLIP metric. Secondary peristalsis from balloon distension can be displayed topographically as repetitive anterograde or retrograde contractile activity in the esophageal body, similar to high-resolution manometry. Real-time interpretation and postprocessing of FLIP metadata can complement the identification of esophageal outflow obstruction and achalasia, especially when findings are inconclusive from alternate esophageal tests in symptomatic patients. FLIP can complement the diagnosis of achalasia when manometry and barium studies are inconclusive or negative in patients with typical symptoms. FLIP can direct adequacy of disruption of the EGJ in achalasia when used during and immediately after myotomy and pneumatic dilation. Lumen diameter measured using FLIP in eosinophilic esophagitis and in complex strictures can potentially guide management. An abbreviated modification of the Grading of Recommendations Assessment, Development, and Evaluation was used to determine the quality of available evidence and recommendations regarding FLIP utilization. FLIP metrics that are diagnostic or suggestive of an abnormal motor pattern and metrics that define normal esophageal physiology were developed by consensus and are described in this review.
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Affiliation(s)
| | | | | | | | | | | | | | - Rena Yadlapati
- University of California in San Diego, La Jolla, California, USA
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25
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Su B, Callahan ZM, Novak S, Kuchta K, Ujiki MB. Using Impedance Planimetry (EndoFLIP) to Evaluate Myotomy and Predict Outcomes After Surgery for Achalasia. J Gastrointest Surg 2020; 24:964-971. [PMID: 31939098 DOI: 10.1007/s11605-020-04513-w] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The functional lumen imaging probe (FLIP) is an innovative tool that uses impedance planimetry to assess esophageal geometry in real time. It has been used to diagnose achalasia and evaluate treatment failure after laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). We hypothesize that impedance planimetry can be utilized intra-operatively to assess adequacy of myotomy and assist in predicting patient outcomes. METHODS A prospectively maintained patient database at a single center was queried. Seventy-seven patients with achalasia underwent POEM or LHM by a single surgeon. The FLIP was used to measure cross-sectional area (CSA), minimum diameter (Dmin), balloon pressure, and distensibility index (DI) of the lower esophageal sphincter (LES) before and after the procedure. Clinical outcomes were measured up to 2 years after treatment. RESULTS Post-operative CSA, Dmin, balloon pressure, and DI values were significantly different from pre-operative values (p < 0.001). Patients with a post-operative Eckardt score ≥ 3 were significantly more likely to have a final DI ≤ 3.1 mm2/mmHg (p = 0.014) or a change in DI ≤ 3.0 mm2/mmHg (p = 0.010). Additionally, a final CSA > 96 mm2 or Dmin > 11.0 mm was predictive of worse reflux at 2 years (p = 0.01). CONCLUSION Impedance planimetry using the FLIP can offer intra-operative feedback about the geometry of the LES. The most useful parameters in predicting patient outcomes have yet to be clearly defined, but our results demonstrate that final DI and CSA are predictive of post-operative treatment response.
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Affiliation(s)
- Bailey Su
- Department of Surgery, Northshore University HealthSystem, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA.
- Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - Zachary M Callahan
- Department of Surgery, Northshore University HealthSystem, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Stephanie Novak
- Department of Surgery, Northshore University HealthSystem, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Kristine Kuchta
- Department of Surgery, Northshore University HealthSystem, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Surgery, Northshore University HealthSystem, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
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26
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Costantini A, Familiari P, Costantini M, Salvador R, Valmasoni M, Capovilla G, Landi R, Mangiola F, Provenzano L, Briscolini D, Merigliano S, Costamagna G. Poem Versus Laparoscopic Heller Myotomy in the Treatment of Esophageal Achalasia: A Case-Control Study from Two High Volume Centers Using the Propensity Score. J Gastrointest Surg 2020; 24:505-515. [PMID: 31848870 DOI: 10.1007/s11605-019-04465-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 11/04/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND POEM has recently had a widespread diffusion, aiming at being the treatment of choice for esophageal achalasia. The results of ongoing RCTs against laparoscopic myotomy are not available, yet. We, therefore, designed this propensity score (PS) case-control study with the aim of evaluating how POEM compares to the long-standing laparoscopic Heller myotomy + Dor fundoplication (LHD) and verifying if it may really replace the latter as the first-line treatment for achalasia. METHODS Two groups of consecutive patients undergoing treatment for primary achalasia from January 2014 to November 2017 were recruited in two high-volume centers, one with extensive experience with POEM and one with LHD. Patients with previous endoscopic treatment were included, whereas patients with previous LHD or POEM were excluded. A total of 140 patients in both centers were thus matched. LHD and POEM were performed following established techniques. The patients were followed with clinical (Eckardt score), endoscopic, and pH-manometry evaluations. RESULTS The procedure was successfully completed in all the patients. POEM required a shorter operation time and postoperative stay compared to LHD (p < 0.001). No mortality was recorded in either group. Seven complications were recorded in the POEM group (five mucosal perforations) and 3 in the LHD group (3 mucosal perforations)(p = 0.33). Two patients in the POEM group and one in the LHD were lost to follow-up. One patient in both groups died during the follow-up for unrelated causes. At a median follow-up of 24 months [15-30] for POEM and 31 months [15-41] for LHD (p < 0.05), 99.3% of the POEM patients and 97.7% of the LHD patients showed an Eckardt score ≤ 3 (p < 0.12). Four years after the treatment, the probability to have symptoms adequately controlled was > 90% for both groups (p = 0.2, Log-rank test). HR-Manometry showed a similar reduction in the LES pressure and 4sIRP; 24-h pH-monitoring showed however an abnormal exposure to acid in 38.4% of POEM patients, as compared to 17.1% of LHD patients (p < 0.01) and esophagitis was found in 37.4% of the POEM and 15.2% of LHD patients (p < 0.05). CONCLUSION POEM provides the same midterm results as LHD. This study confirms, however, a higher incidence of postoperative GERD with the former, even if its real significance needs to be further evaluated.
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Affiliation(s)
- Andrea Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Center for Endoscopic Research, Therapeutics and Training (CERTT), Rome, 00168, Italy
| | - Pietro Familiari
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Center for Endoscopic Research, Therapeutics and Training (CERTT), Rome, 00168, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy.
| | - Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Michele Valmasoni
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Rosario Landi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Center for Endoscopic Research, Therapeutics and Training (CERTT), Rome, 00168, Italy
| | - Francesca Mangiola
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Center for Endoscopic Research, Therapeutics and Training (CERTT), Rome, 00168, Italy
| | - Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Dario Briscolini
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Stefano Merigliano
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Center for Endoscopic Research, Therapeutics and Training (CERTT), Rome, 00168, Italy
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27
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Costantini M, Salvador R, Valmasoni M. Comment on the Article: "The Use of Rigiflex Pneumatic Balloon Dilator during Laparoscopic Heller's Myotomy in Patients with Achalasia: A Novel Technical Method and Its Surgical Outcomes". Am Surg 2020; 86:e49-e50. [PMID: 32077439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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28
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Aghion A, Falck AJ, Sundararajan S. Case 3: Sudden Unexpected Collapse in a Full-term Infant. Neoreviews 2019; 20:e744-e747. [PMID: 31792162 DOI: 10.1542/neo.20-12-e744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Abigail Aghion
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
| | - Alison J Falck
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
| | - Sripriya Sundararajan
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
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29
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Shiwaku H, Inoue H, Onimaru M, Minami H, Sato H, Sato C, Tanaka S, Ogawa R, Okushima N. Multicenter collaborative retrospective evaluation of peroral endoscopic myotomy for esophageal achalasia: analysis of data from more than 1300 patients at eight facilities in Japan. Surg Endosc 2019; 34:464-468. [PMID: 31183791 DOI: 10.1007/s00464-019-06833-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [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: 04/14/2019] [Accepted: 05/15/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a novel, minimally invasive treatment for esophageal achalasia. We retrospectively examined and evaluated the results following POEM to verify the technique's efficacy and safety. METHODS We retrospectively analyzed data for patients who underwent POEM at eight Japanese facilities between September 2008 and October 2015. Pre- and postoperative assessments 3 months and 1 year after POEM included patient interviews, endoscopy, and manometry. RESULTS A total of 1346 patients underwent POEM during the study period. Achalasia was the straight type in 1105 patients (82%) and the sigmoid type in 241 patients (18%). The average patient age was 47.2 years (range 3-95 years); 617 patients (46%) were men and 729 (54%) were women. Previous treatment included balloon dilatation in 381 patients (28%) and Heller-Dor operation in 43 patients (3%). The average operation time was 99.6 min. The mean length of the myotomy in the esophageal body was 10.8 cm, and the myotomy extended into the stomach a mean of 2.8 cm. The response rate (Eckardt score ≤ 3) was 95.1% 3 months postoperatively and 94.7% 1 year postoperatively. We noted 50 adverse events (3.7%) of Clavien-Dindo classification grade ≤ IIIa, and all resolved with conservative treatment. There were no Clavien-Dindo classification grade ≥ IIIb adverse events. After POEM, erosive esophagitis according to the Los Angeles classification was absent in 37% of the patients, grade A in 33%, B in 24%, C in 6%, and D in 0.2%. Symptomatic gastroesophageal reflux disease after POEM was confirmed in 14.8% of the patients; both erosive esophagitis and symptomatic gastroesophageal reflux disease responded to treatment with a proton-pump inhibitor. CONCLUSION Our results confirmed the safety and efficacy of POEM in a large patient series and support POEM as the first-line and standard treatment for esophageal achalasia.
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Affiliation(s)
- Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Chiaki Sato
- Department of surgery, Tohoku University School of Medicine, Miyagi, Japan
| | - Shinwa Tanaka
- Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Oita University Faculty of Medicine, Oita, Japan
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30
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Kim D, Pullat R, Crowley N. Robotic Redo Heller Myotomy after Laparoscopic Heller Myotomy in a Patient with Recurrent Achalasia after a Roux-en-Y Gastric Bypass. Am Surg 2019; 85:e162-e163. [PMID: 30947797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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31
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Hung YC, Westfal ML, Chang DC, Kelleher CM. Heller myotomy is the optimal index procedure for esophageal achalasia in adolescents and young adults. Surg Endosc 2018; 33:3355-3360. [PMID: 30552502 DOI: 10.1007/s00464-018-06625-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 12/11/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is limited and conflicting data on the optimal intervention for the treatment of achalasia in adolescents and young adults (AYA), Heller myotomy (HM), esophageal dilation (ED) or botulinum toxin injection (botox). The goal of this study is to determine the most appropriate index intervention for achalasia in the AYA population. METHODS We completed a longitudinal, population-based analysis of the California (2005-2010) and New York (1999-2014) statewide databases. We included patients 9-25 years old with achalasia who underwent HM, ED or botox. Comparisons were made based on the patients' index procedure. Rates of 30-day complications, long-term complications, and re-intervention up to 14 years were calculated. Cox regression was performed to determine the risk of re-intervention, adjusting for patient demographics. RESULTS A total of 442 AYAs were analyzed, representing the largest cohort of young patients with this disease studied to date. Median follow-up was 5.2 years (IQR 1.8-8.0). The overall rate of re-intervention was 29.3%. Rates of re-intervention for ED and botox were equivalent and higher than HM (65.0% for ED, 47.4% for botox and 16.4% for HM, p < 0.001). Ultimately, 46.9% of ED and botox patients underwent HM. The overall short-term complication rate was 4.3% and long-term, 1.9%. There was no difference in the short-term and long-term complication rates between intervention groups (p > 0.05). On adjusted analysis, ED and botox were associated with increased risks of re-intervention when compared to HM (HR 5.9, HR 4.8, respectively, p < 0.01). Black patients were found to have a risk of re-intervention twice that of white patients (HR 2.0, p = 0.05). CONCLUSIONS HM has a similar risk of complications but a significantly lower risk of re-intervention when compared to ED and botox. Based on our findings, we recommend HM as the optimal index procedure for AYAs with achalasia.
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Affiliation(s)
- Ya-Ching Hung
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Maggie L Westfal
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
- Department of Pediatric Surgery, MassGeneral Hospital for Children, Boston, MA, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Cassandra M Kelleher
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.
- Department of Pediatric Surgery, MassGeneral Hospital for Children, Boston, MA, USA.
- Pediatric Surgery, Massachusetts General Hospital, 55 Fruit St. WRN-11, Boston, MA, 02114, USA.
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Pripisi L, Hoara P, Constantin A, Predescu D, Birla R, Gindea C, Caragui A, Constantinoiu S. The Value of Intraoperative Endoscopy and Manometry in the Surgical Treatment of Achalasia. Chirurgia (Bucur) 2018; 113:469-477. [PMID: 30183577 DOI: 10.21614/chirurgia.113.4.469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2018] [Indexed: 11/23/2022]
Abstract
Introduction: Achalasia is the most common esophageal motility disorder. So far, the treatment, which can be medical, endoscopic or surgical, provides only symptomatic relief. However, this can grant a normal life to the patients. We focused our study on the value of pre- and intraoperative endoscopy and manometry for improving outcome of surgical treatment. MATERIAL AND METHOD This is a retrospective chart review of a cohort of patients diagnosed with achalasia at St Mary Clinical Hospital, Bucharest between 2013 and 2017. The objective of this study was the assessment of the immediate and long term efficacy of laparoscopic Heller myotomy associated with Dor anterior fundoplication, intraoperative endoscopy and intraoperative manometry, as well as the assessment of late post-operative complications. The diagnosis of achalasia was based on symptoms, barium esophagogram, upper endoscopy and esophageal manometry. The immediate efficacy was assessed by comparing Eckhart score, LES pressure and LES vector volume before and after surgery. Results: In total, 47 patients, had surgical treatment for achalasia between 2013 and 2017. For 7 patients who failed prior endoscopic or surgical, this was the second therapeutic intervention. 39 patients underwent laparoscopic surgery, 30 patients had associated intraoperative endoscopy and, 22 patients had associated intraoperative manometry. There was a significant improvement in mean Eckardt score (from 6,5 to 1,26, p 0,001), mean LES pressure (from 18,5 mmHg to 7 mmHg, p 0,001). Morbidity was 2,12 % and we have had 1 recurrence and 2 postoperative esophagitis. Conclusions: At present, laparoscopic Heller myotomy with an anterior Dor fundoplication, is a standard indication in achalasia, proving its efficiency and safety. Intraoperative use of endoscopy is recommended and intraoperative manometry may provide additional information on the effectiveness of myotomy. Surgical treatment of achalasia should be performed in specialized, experienced centers.
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Brown J, Egger M, Kehdy FJ. Heller Myotomy: To Wrap or Not to Wrap? Am Surg 2018; 84:1022-1026. [PMID: 29981642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Heller myotomy (HM) is widely recognized as the most effective treatment of achalasia. Although effective in improving dysphagia symptoms, HM is associated with reflux. Over a five-year period, 63 laparoscopic HM were performed. Patients underwent myotomy alone or HM plus reconstitution of the angle of His without any fundoplication, anterior, or posterior partial fundoplication. Two postoperative outcomes were examined: dysphagia and reflux. Twenty-two patients received no fundoplication (34.9%). Forty-one (65.1%) antireflux procedures were performed, including 21 reconstitutions of the angle of His (33.3%), nine (14.3%) anterior fundoplications, and 11 (17.5%) posterior fundoplications. All patients demonstrated preoperative dysphagia. Postoperative dysphagia was present in 23 of 63 (36.5%). Of these, 13 (56.5%) patients had an antireflux procedure, whereas 28 of 40 who had an antireflux procedure (70%) had no postoperative dysphagia (P = 0.28). Thirty-nine of 62 (62.9%) had symptomatic esophageal reflux preoperatively, and postoperative reflux was reported in 22 of 63 (34.9%). Reflux was present in 72.7 per cent of patients who had an antireflux procedure versus 61 per cent of those without the addition of an antireflux procedure (P = 0.415). However, HM independently improved reflux status regardless of whether an antireflux procedure was performed using the exact McNemar's test (P = 0.0014). Although the performance of an antireflux procedure did not appear to alter the reflux status after HM for achalasia, neither was it associated with postoperative dysphagia. More importantly, HM was independently associated with an improvement of reflux symptoms regardless of the type of antireflux procedure performed or whether one was used or not.
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Molina JC, Misariu AM, Nicolau I, Spicer J, Mulder D, Ferri LE, Mueller CL. Same day discharge for benign laparoscopic hiatal surgery: a feasibility analysis. Surg Endosc 2017; 32:937-944. [PMID: 28779258 DOI: 10.1007/s00464-017-5769-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 04/18/2017] [Accepted: 07/14/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Advances in minimally invasive surgery and the development of enhanced recovery pathways have favored the spread of day-surgery programs. Despite laparoscopic approaches being accepted as the standard of care for benign hiatal diseases, safety and feasibility of same day discharges for laparoscopic hiatal surgeries other than fundoplication has yet to be established. OBJECTIVE This study aimed to assess the feasibility of same day discharge for primary and revisional laparoscopic hiatal surgeries including paraesophageal hernia repairs (PEHR), fundoplication for reflux, and Heller myotomy (±diverticulectomy). METHODS A retrospective cohort study including all patients undergoing elective laparoscopic hiatal procedures in the division of Thoracic surgery between 2011 and 2016 at McGill University Health Centre was performed. Planned day-surgery (DAYCASE) was compared to planned inpatient (INPATIENT) cohorts with respect to operative and postoperative outcomes, length of stay, readmission, and emergency room visits. RESULTS A total of 261 patients were identified, 161 female (62%); median age 62 (20). The case distribution was: PEHR (123; 47.1%), Heller myotomy (94;36%, 7 diverticulectomy), and fundoplication (44; 16.9%). Twenty patients had revisional procedures (7.7%). Same day discharge was planned in 98 cases (38%) and was successful in 80 (81.6%). Proportion of DAYCASE increased form 12% prior to 2013 to 67% in 2016. INPATIENTs were older (median 66 vs. 60 years), and had a higher proportion of PEHR (55 vs. 34%), p < 0.05. Both cohorts were comparable in gender proportion, ASA classification, and length of surgery. Complications, readmission, and emergency visits did not differ between the two cohorts. On multivariate analysis, female gender (OR 37, 95% CI 1.46-936, p = 0.028), surgery beginning after noon (OR 5.4, 95% CI 1.1-26.9, p = 0.038), intraoperative complications (OR 20.4 95% CI 1.5-286, p = 0.025), and postoperative complications (OR 52.1, 95% CI 4.5-602, p = 0.002) were independently associated with unplanned admission. CONCLUSIONS Day-case surgery for complex laparoscopic hiatal procedures is feasible and can be achieved in a significant number of patients without compromising safety.
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Affiliation(s)
- Juan Carlos Molina
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada.
| | - Ana María Misariu
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
| | - Ioana Nicolau
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
| | - Jonathan Spicer
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
| | - David Mulder
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
| | - Lorenzo E Ferri
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
| | - Carmen L Mueller
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
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De Pieri C, Cogo P, Barbato A. Tracheomalacia Due to Esophageal Achalasia. Arch Bronconeumol 2016; 53:78-79. [PMID: 27364977 DOI: 10.1016/j.arbres.2016.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/10/2016] [Accepted: 05/11/2016] [Indexed: 11/20/2022]
Affiliation(s)
- Carlo De Pieri
- Division of Pediatrics, Department of Clinical and Experimental Medical Sciences, University of Udine, Udine, Italia.
| | - Paola Cogo
- Division of Pediatrics, Department of Clinical and Experimental Medical Sciences, University of Udine, Udine, Italia
| | - Angelo Barbato
- Pediatric Bronchoscopy Unit, Department of Women's and Children's Health, University of Padova/General Hospital, Padova, Italia
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