|
1
|
Fukushima N, Masuda T, Tsuboi K, Watanabe J, Yano F. Long-term outcomes of treatment for achalasia: Laparoscopic Heller myotomy versus POEM. Ann Gastroenterol Surg 2024; 8:750-760. [PMID: 39229567 PMCID: PMC11368501 DOI: 10.1002/ags3.12807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 09/05/2024] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by nonrelaxation of the lower esophageal sphincter. Laparoscopic Heller myotomy (LHM) is the gold standard treatment for achalasia. Peroral endoscopic myotomy (POEM), a less invasive treatment, is performed extensively, and the selection of the intervention method remains debatable to date. In addition to the availability of extensive studies on short-term outcomes, recent studies on the long-term outcomes of LHM and POEM have shown similar clinical success after 5 y of follow-up. However, gastroesophageal reflux disease (GERD) was more common in patients who had undergone POEM than in those who had undergone LHM. Moreover, existing studies have compared treatment outcomes in various disease states. Some studies have suggested that POEM is superior to LHM for patients with type III achalasia because POEM allows for a longer myotomy. Research on treatment for sigmoid types is currently in progress. However, the long-term results comparing LHD and POEM are insufficient, and the best treatment remains controversial. Further research is needed, and treatment options should be discussed with patients and tailored to their individual needs and pathologies.
Collapse
Affiliation(s)
- Naoko Fukushima
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Takahiro Masuda
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Kazuto Tsuboi
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Jun Watanabe
- Division of Gastroenterological, General and Transplant Surgery, Department of SurgeryJichi Medical UniversityShimotsukeTochigiJapan
| | - Fumiaki Yano
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| |
Collapse
|
|
2
|
Mittal S, Kumar A, Gunjan D, Netam RK, Anil AK, Suhani S, Joshi M, Bhattacharjee HK, Sharma R, Parshad R. Long-term outcomes of laparoscopic Heller's myotomy with angle of His accentuation in patients of achalasia cardia. Surg Endosc 2024; 38:659-670. [PMID: 38012444 DOI: 10.1007/s00464-023-10571-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Laparoscopic Heller's myotomy (LHM) is an established treatment for achalasia cardia. Anti-reflux procedures (ARP) are recommended with LHM to reduce the post-operative reflux though the optimal anti-reflux procedure is still debatable. This study reports on the long-term outcomes of LHM with Angle-of-His accentuation (AOH) in patients of achalasia cardia. METHODS One hundred thirty-six patients of achalasia cardia undergoing LHM with AOH between January 2010 to October 2021 with a minimum follow-up of one year were evaluated for symptomatic outcomes using Eckardt score (ES), DeMeester heartburn (DMH) score and achalasia disease specific quality of life (A-DsQoL) questionnaire. Upper gastrointestinal endoscopy, high resolution manometry (HRM) and timed barium esophagogram (TBE) were performed when feasible and rates of esophagitis and improvement in HRM and TBE parameters evaluated. Time dependent rates of success were calculated with respect to improvement in ES and dysphagia-, regurgitation- and heartburn-free survival using Kaplan-Meier analysis. RESULTS At a median follow-up of 65.5 months, the overall success (ES ≤ 3) was 94.1%. There was statistically significant improvement in ES, heartburn score and A-DsQoL score (p < 0.00001, p = 0.002 and p < 0.00001). Significant heartburn (score ≥ 2) was seen in 12.5% subjects with 9.5% patients reporting frequent PPI use (> 3 days per week). LA-B and above esophagitis was seen in 12.7%. HRM and TBE parameters also showed a significant improvement as compared to pre-operative values (IRP: p < 0.0001, column height: p < 0.0001, column width: p = 0.0002). Kaplan-Meier analysis showed dysphagia, regurgitation, and heartburn free survival of 75%, 96.2% and 72.3% respectively at 10 years. CONCLUSIONS LHM with AOH gives a lasting relief of symptoms in patients of achalasia cardia with heartburn rates similar to that reported in studies using Dor's or Toupet's fundoplication with LHM. Hence, LHM with AOH may be a preferred choice in patients of achalasia cardia given the simplicity of the procedure.
Collapse
Affiliation(s)
- Sonali Mittal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Ritesh Kumar Netam
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Abhijith K Anil
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Suhani Suhani
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Joshi
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanga K Bhattacharjee
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Rajinder Parshad
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 419, 4th Floor, Surgery Block, New Delhi, 110029, India.
| |
Collapse
|
|
3
|
Rasmussen M, Ward MA, Aladegbami B, Ogola GO, Leeds SG. Probability of additional intervention and long-term follow-up of esophagomyotomy. Surg Endosc 2023; 37:2347-2353. [PMID: 36656408 DOI: 10.1007/s00464-023-09872-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Two common surgical procedures used to treat esophageal motility disorders are laparoscopic Heller myotomy (LHM) with partial fundoplication and per-oral endoscopic myotomy (POEM). The difference in frequency of follow-up interventions following these procedures is unknown. This study was designed to report differences in post-surgical interventions as one of the major long-term follow-up expectations. METHODS An IRB approved registry was used to identify all patients undergoing surgery with LHM or POEM. Following surgery, patients requiring additional interventions with esophageal non-pneumatic dilation, botox injection, or repeat myotomy, as well as persistent proton pump inhibitor (PPI) use were recorded. Multivariable logistic regression analysis was performed to estimate risk factors associated with return for additional post-operative intervention. RESULTS A total of 203 patients were identified, 139 met inclusion criteria (33 LHM and 106 POEM). There was a higher rate of non-pneumatic EGD dilation (33% vs 15%, p = 0.04), repeat myotomy (18% vs 2%, p < 0.01), and higher rate of overall post-operative intervention in LHM than POEM. With POEM, there was a higher rate of post-operative PPI use (63 vs 29%, p < 0.01). There was no difference in time to post-operative intervention for either group, but if intervention were to occur the median time was within the first year. Patients with a change in pre- to post-operative Eckardt score of 4 or greater decreased their chance of having a post-operative intervention. CONCLUSION Our results for both LHM and POEM emphasize the importance of long-term follow-up in patients with an esophageal motility disorder. We have found that patients undergoing LHM are more likely to have a post-operative intervention as well as a higher rate of repeat myotomy than POEM. With both interventions, a greater change in Eckardt score decreased the likelihood of reintervention.
Collapse
Affiliation(s)
- Madeline Rasmussen
- Division of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott & White Health, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA
| | - Marc A Ward
- Division of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott & White Health, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA
| | - Bola Aladegbami
- Division of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott & White Health, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA
| | - Gerald O Ogola
- Research Institute, Baylor Scott & White Health, Dallas, TX, USA
| | - Steven G Leeds
- Division of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA.
- Center for Advanced Surgery, Baylor Scott & White Health, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA.
| |
Collapse
|
|
4
|
Forero-Vásquez BN, Yopasa-Romero JJ. Diagnóstico y manejo actual de la acalasia. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.2187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introducción. La acalasia es un trastorno motor del esófago poco común, de etiología no clara, caracterizado por la pérdida de relajación del esfínter esofágico inferior, pérdida del peristaltismo normal, regurgitación y disfagia.
Métodos. Se realizó una revisión narrativa de la literatura en revistas científicas y bases de datos en español e inglés, con el fin de presentar información actualizada en lo referente al diagnóstico y tratamiento de esta patología.
Resultado. Se presenta la actualización de los criterios de los trastornos motores esofágicos según la clasificación de Chicago (CCv4.0) para el diagnóstico de acalasia y sus subtipos de acuerdo con los nuevos criterios, así como los tratamientos actuales.
Conclusión. La acalasia es un trastorno esofágico multimodal, con manifestaciones de predominio gastrointestinal, por lo que su diagnóstico y abordaje terapéutico oportuno es esencial para mejorar la calidad de vida de los pacientes.
Collapse
|
|
5
|
Ieong K, Brown A, Yang J, Zhang X, Altieri MS, Spaniolas K, Pryor AD. The incidence of reintervention and reoperation following Heller myotomy across multiple indications. Surg Endosc 2021; 36:1619-1626. [PMID: 33733323 DOI: 10.1007/s00464-021-08357-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 02/04/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Achalasia is a debilitating primary esophageal motility disorder. Heller myotomy (HM) is a first-line therapy for the treatment of achalasia patients who have failed other modalities. Other indications for HM include diverticulum, diffuse esophageal spasm, and esophageal strictures. However, long-term outcomes of HM are unclear. This study aims to assess incidence of reintervention, either endoscopically or through minimally invasive or resectional procedures, in patients who underwent HM in New York State. METHODS The Statewide Planning and Research Cooperative System (SPARCS) administrative longitudinal database identified 1817 adult patients who underwent HM between 2000 and 2008 for achalasia, esophageal diverticulum, diffuse esophageal spasm, and esophageal strictures, based on ICD-9 and CPT codes. Through the use of unique identifiers, patients requiring reintervention were tracked up to 2016 (for at least 8 years follow-up). Primary outcome was incidence of subsequent procedures following HM. Secondary outcomes were time to reintervention and risk factors for reintervention. RESULTS Of the 1817 patients who underwent HM, 320 (17.6%) required subsequent intervention. Of the 320 patients, 234 (73.1%) underwent endoscopic reinterventions, 54 (16.9%) underwent minimally invasive procedures, and 32 (10%) underwent resectional procedures as their initial revisional intervention. Of the 234 patients who underwent endoscopic reintervention as their initial revisional procedure, only 40 (16.8%) required subsequent surgical procedures. Over a mean follow-up of 7.0 years, the mean time to a subsequent procedure was 4.3 ± 3.74 years. Reintervention rates after 10 years following HM for achalasia, diverticulum ,and other indication were 24.4%, 12.6%, and 37%, respectively. CONCLUSION The majority of HM reinterventions were managed solely by endoscopic procedures (60.6%). Heller myotomy remains an excellent procedure to prevent surgical reintervention for achalasia and diverticulum.
Collapse
Affiliation(s)
- Kelly Ieong
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA.
| | - Andrew Brown
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Jie Yang
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Xiaoyue Zhang
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Maria S Altieri
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Konstantinos Spaniolas
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Aurora D Pryor
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| |
Collapse
|
|
6
|
Csendes A, Orellana O, Figueroa M, Lanzarini E, Panza B. Long-term (17 years) subjective and objective evaluation of the durability of laparoscopic Heller esophagomyotomy in patients with achalasia of the esophagus (90% of follow-up): a real challenge to POEM. Surg Endosc 2021; 36:282-291. [PMID: 33471177 DOI: 10.1007/s00464-020-08273-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Laparoscopic Heller Myotomy (LHM) with partial anterior or posterior fundoplication is the standard surgical procedure for treating achalasia patients. The results reported are mainly based on symptomatic evaluations and have less than 5 years of follow-up and none more than ten. OBJECTIVE To determine the late results of LHM, performing endoscopic, histologic, manometric, and functional studies in addition to clinical evaluations. MATERIALS AND METHODS Eighty-nine consecutive patients were included in a prospective study from 1993 to 2008. Inclusion criteria corresponded to achalasia patients with Types I to III (radiological evaluation). Exclusion criteria included patients with grade IV, patients with previous procedures (surgical or endoscopic), or giant hiatal hernia. They were submitted to a radiological evaluation, over two endoscopic procedures with biopsy samples, manometric assessments, and 24-h pH monitoring late after surgery. RESULTS There was no operative mortality nor postoperative complications. The average hospital stay was two days. Nine patients (10.1%) were lost from follow-up. The mean late follow-up was 17 years (10-26). Visick I and II (success) corresponded to 78.7% of patients and grades III-IV (failure) to 21.3%, mainly due to gastroesophageal reflux disease (GERD). Manometric evaluations showed a significant and permanent decrease in lower esophageal sphincter pressure (LESP). 24-h pH monitoring was normal among Visick I patients and showed pathologic acid reflux in patients with GERD. Two patients (2.5%) developed Barrett's esophagus. Squamous-cell carcinoma (SCC) appeared in three patients (3.7%). CONCLUSION LHM controlled symptoms in 79% of achalasia patients very late (17 years) after surgery. This was corroborated by endoscopic, manometric, and functional studies. GERD symptoms developed in 18.7% and SCC in 3.7% in previously asymptomatic patients. Endoscopic surveillance at regular intervals is recommended for all patients who have had surgery. These very long-term results are a real challenge to POEM endoscopic treatment. Unique Identifying Registration Number 3743.
Collapse
Affiliation(s)
- Attila Csendes
- Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile.
| | - Omar Orellana
- Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile
| | - Manuel Figueroa
- Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile
| | - Enrique Lanzarini
- Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile
| | - Benjamin Panza
- Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile
| |
Collapse
|
|
7
|
Over ten-year outcomes of laparoscopic Heller-myotomy with Dor-fundoplication with achalasia: single-center experience with annual endoscopic surveillance. Surg Endosc 2020; 35:6513-6523. [DOI: 10.1007/s00464-020-08148-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022]
|
|
8
|
Attaar M, Su B, Wong HJ, Kuchta K, Denham W, Linn JG, Ujiki MB. Comparing cost and outcomes between peroral endoscopic myotomy and laparoscopic heller myotomy. Am J Surg 2020; 222:208-213. [PMID: 33162014 DOI: 10.1016/j.amjsurg.2020.10.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/20/2020] [Accepted: 10/29/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has previously been shown to be equally if not more expensive than laparoscopic Heller myotomy (LHM). We compare perioperative outcomes and charges between POEM and LHM at a single institution. METHODS Outcomes and charge data of 33 patients who underwent LHM and 126 patients who underwent POEM were analyzed. Patients who did not present electively were excluded. RESULTS There were no demographic differences between groups. Patients who underwent POEM had a significantly shorter mean operative time and median length of stay (both p < 0.001). Patients who underwent POEM stopped narcotics earlier and had faster return to activities of daily living (both p < 0.05). When adjusted for inflation, POEM incurred less in hospital charges than LHM (35.5 ± 12.8 vs 30.7 ± 10.3 in thousands of US dollars, p = 0.006). CONCLUSIONS Patients who underwent POEM compared to LHM had significantly better perioperative outcomes. Our results suggest POEM may be the more cost-effective option.
Collapse
Affiliation(s)
- Mikhail Attaar
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States; Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, United States.
| | - Bailey Su
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States; Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, United States
| | - Harry J Wong
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States; Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, United States
| | - Kristine Kuchta
- NorthShore University Research Institute, 1001 University Pl, Evanston, IL, 60201, United States
| | - Woody Denham
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States
| | - John G Linn
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, United States
| |
Collapse
|
|
9
|
Santes O, Coss-Adame E, Valdovinos MA, Furuzawa-Carballeda J, Rodríguez-Garcés A, Peralta-Figueroa J, Narvaez-Chavez S, Olvera-Prado H, Clemente-Gutiérrez U, Torres-Villalobos G. Does laparoscopic reoperation yield symptomatic improvements similar to those of primary laparoscopic Heller myotomy in achalasia patients? Surg Endosc 2020; 35:4991-5000. [DOI: 10.1007/s00464-020-07978-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/14/2020] [Indexed: 01/06/2023]
|
|
10
|
Doubova M, Gowing S, Robaidi H, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS, Villeneuve PJ, Seely AJE. Long-term Symptom Control After Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia. Ann Thorac Surg 2020; 111:1717-1723. [PMID: 32891651 DOI: 10.1016/j.athoracsur.2020.06.095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 06/03/2020] [Accepted: 06/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Achalasia is a primary esophageal motility disorder in which there is incomplete relaxation of the lower esophageal sphincter and absence of peristalsis in the lower two thirds of the esophagus. A favored treatment is laparoscopic modified Heller myotomy with Dor fundoplication (LHMDor) with more than 90% immediate beneficial effect. The short-term outcomes of LHMDor are well documented, but stability and durability of postoperative symptom control over time is less understood. METHODS Between 2004 and 2016, 54 patients with achalasia underwent LHMDor (single center). Using validated questionnaires, patients rated their symptoms in five domains: pain, gastroesophageal reflux disease (GERD), dysphagia, regurgitation, and quality of life. Symptom ratings were done preoperatively, 4 weeks postoperatively, 6 months postoperatively, and yearly after the operation. RESULTS As expected, patients reported marked improvement in dysphagia, odynophagia, regurgitation, GERD, and quality of life after the operation (P < .001). From then on, the symptom control remained durable with respect to absence of pain, regurgitation, and odynophagia; however, we observed a recurrence of GERD symptoms beginning 3 to 5 years postoperatively (P = .001 and P = .04, respectively), with associated increased antireflux medication use. After initial LHMDor, 5 patients required endoscopic dilatation an average of 1.5 years postoperatively, and no patient required reoperation. Patients reported preserved improved quality of life to 11 years after the operation (P = .001). CONCLUSIONS These results demonstrate the durability of LHMDor in the definitive management of achalasia, offering consistent symptomatic relief and significant improvement in quality of life over the decade after surgery, despite some increase in GERD symptoms and antireflux medication use.
Collapse
Affiliation(s)
- Maria Doubova
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephen Gowing
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Hassan Robaidi
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Donna E Maziak
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Farid M Shamji
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - R Sudhir Sundaresan
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrick James Villeneuve
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew J E Seely
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
| |
Collapse
|
|
11
|
Intraoperative impedance planimetry (EndoFLIP™) results and development of esophagitis in patients undergoing peroral endoscopic myotomy (POEM). Surg Endosc 2020; 35:4555-4562. [DOI: 10.1007/s00464-020-07876-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 08/05/2020] [Indexed: 12/26/2022]
|
|
12
|
Outcomes of Laparoscopic Heller Myotomy for Achalasia: 22-Year Experience. J Gastrointest Surg 2020; 24:1411-1416. [PMID: 32300963 DOI: 10.1007/s11605-020-04586-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 03/25/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Laparoscopic Heller Myotomy is the most effective treatment of achalasia. We examined the durability of symptomatic relief, with and without fundoplication. METHODS A single institution database between 1995 and 2017 was reviewed. Achalasia symptom severity was assessed by Eckardt scores (ES) obtained at 3-time points via patient questionnaire. Primary outcome was treatment success defined as ES of < 3. RESULTS Completed surveys were returned by 130 patients (median follow-up of 6.6 years). A partial fundoplication was performed in 86%. At both 1-year and late follow-up, patients reported a significant improvement in ES compared to baseline (p < 0.05). Of those followed for ≥ 10 years (n = 44), 82% reported ES < 3 at 1-year (p < 0.001), and 78% at last follow-up (p < .001). Of patients who reported treatment success 1-year postoperatively (103/130), 85% continued to report symptomatic relief at last follow-up. Five-year cohort analysis did not show deterioration of dysphagia relief over time. The presence or absence of fundoplication had no impact on long-term outcome (p > 0.05). CONCLUSIONS LHM provides immediate and durable symptomatic relief, with very few patients requiring further therapeutic intervention. Fundoplication does not appear to influence the durability of symptom relief. Treatment success at 1-year is predictive of long-lasting symptomatic relief.
Collapse
|
|
13
|
Siow SL, Mahendran HA, Najmi WD, Lim SY, Hashimah AR, Voon K, Teoh KH, Boo HS, Chuah JS, Nurazim S, Faqihuddin MH. Laparoscopic Heller myotomy and anterior Dor fundoplication for achalasia cardia in Malaysia: Clinical outcomes and satisfaction from four tertiary centers. Asian J Surg 2020; 44:158-163. [PMID: 32423838 DOI: 10.1016/j.asjsur.2020.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To evaluate the clinical outcomes and satisfaction of patients following laparoscopic Heller myotomy for achalasia cardia in four tertiary centers. METHODS Fifty-five patients with achalasia cardia who underwent laparoscopic Heller myotomy between 2010 and 2019 were enrolled. The adverse events and clinical outcomes were analyzed. Overall patient satisfaction was also reviewed. RESULTS The mean operative time was 144.1 ± 38.33 min with no conversions to open surgery in this series. Intraoperative adverse events occurred in 7 (12.7%) patients including oesophageal mucosal perforation (n = 4), superficial liver injury (n = 1), minor bleeding from gastro-oesophageal fat pad (n = 1) & aspiration during induction requiring bronchoscopy (n = 1). Mean time to normal diet intake was 3.2 ± 2.20 days. Mean postoperative stay was 4.9 ± 4.30 days and majority of patients (n = 46; 83.6%) returned to normal daily activities within 2 weeks after surgery. The mean follow-up duration was 18.8 ± 13.56 months. Overall, clinical success (Eckardt ≤ 3) was achieved in all 55 (100%) patients, with significant improvements observed in all elements of the Eckardt score. Thirty-seven (67.3%) patients had complete resolution of dysphagia while the remaining 18 (32.7%) patients had some occasional dysphagia that was tolerable and did not require re-intervention. Nevertheless, all patients reported either very satisfied or satisfied and would recommend the procedure to another person. CONCLUSIONS Laparoscopic Heller myotomy and anterior Dor is both safe and effective as a definitive treatment for treating achalasia cardia. It does have a low rate of oesophageal perforation but overall has a high degree of patient satisfaction with minimal complications.
Collapse
Affiliation(s)
- Sze Li Siow
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia; Committee of Malaysian Upper Gastrointestinal Surgical Society, Malaysia.
| | - Hans Alexander Mahendran
- Department of General Surgery, Sultanah Aminah Hospital, Johor Bahru, Johor, Malaysia; Committee of Malaysian Upper Gastrointestinal Surgical Society, Malaysia
| | - Wan Daud Najmi
- Department of General Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia; Committee of Malaysian Upper Gastrointestinal Surgical Society, Malaysia
| | - Shyang Yee Lim
- Department of General Surgery, Penang General Hospital, Pulau Pinang, Malaysia; Committee of Malaysian Upper Gastrointestinal Surgical Society, Malaysia
| | - Abdul Rahman Hashimah
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia; Committee of Malaysian Upper Gastrointestinal Surgical Society, Malaysia
| | - Kelvin Voon
- Department of General Surgery, Penang General Hospital, Pulau Pinang, Malaysia
| | - Keat How Teoh
- Department of General Surgery, Penang General Hospital, Pulau Pinang, Malaysia
| | - Han Sin Boo
- Department of General Surgery, Penang General Hospital, Pulau Pinang, Malaysia
| | - Jun Sen Chuah
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Sidi Nurazim
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | | |
Collapse
|
|
14
|
Costantini M, Salvador R, Capovilla G, Vallese L, Costantini A, Nicoletti L, Briscolini D, Valmasoni M, Merigliano S. A Thousand and One Laparoscopic Heller Myotomies for Esophageal Achalasia: a 25-Year Experience at a Single Tertiary Center. J Gastrointest Surg 2019; 23:23-35. [PMID: 30238248 DOI: 10.1007/s11605-018-3956-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/28/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to assess the long-term outcome of laparoscopic Heller-Dor (LHD) myotomy to treat achalasia at a single high-volume institution in the past 25 years. METHODS Patients undergoing LHD from 1992 to 2017 were prospectively registered in a dedicated database. Those who had already undergone surgical or endoscopic myotomy were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium swallow, endoscopy, and manometry were performed before and after surgery; and 24-h pH monitoring was done 6 months after LHD. RESULTS One thousand one patients underwent LHD (M:F = 536:465), performed by six staff surgeons. The surgical procedure was completed laparoscopically in all but 8 patients (0.8%). At a median of follow-up of 62 months, the outcome was positive in 896 patients (89.5%), and the probability of being cured from symptoms at 20 years exceeded 80%. Among the patients who had previously received other treatments, there were 25/182 failures (13.7%), while the failures in the primary treatment group were 80/819 (9.8%) (p = 0.19). All 105 patients whose LHD failed subsequently underwent endoscopic pneumatic dilations with an overall success rate of 98.4%. At univariate analysis, the manometric pattern (p < 0.001), the presence of a sigmoid megaesophagus (p = 0.03), and chest pain (p < 0.001) were the factors that predicted a poor outcome. At multivariate analysis, all three factors were independently associated with a poor outcome. Post-operative 24-h pH monitoring was abnormal in 55/615 patients (9.1%). CONCLUSIONS LHD can durably relieve achalasia symptoms in more than 80% of patients. The pre-operative manometric pattern, the presence of a sigmoid esophagus, and chest pain represent the strongest predictors of outcome.
Collapse
Affiliation(s)
- Mario Costantini
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy.
| | - Renato Salvador
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | - Giovanni Capovilla
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | - Lorenzo Vallese
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | | | - Loredana Nicoletti
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | - Dario Briscolini
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | - Michele Valmasoni
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | - Stefano Merigliano
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| |
Collapse
|
|
15
|
Lee MK, Yost KJ, Pierson KE, Schrandt AJ, Skaare BJ, Blackmon SH. Standard setting for a novel esophageal conduit questionnaire: CONDUIT Report Card. J Patient Rep Outcomes 2018; 2:51. [PMID: 30467674 PMCID: PMC6200834 DOI: 10.1186/s41687-018-0073-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 09/21/2018] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The purpose of this study was to establish the clinical thresholds for five domains (dysphagia, reflux, dumping-hypoglycemia, dumping-GI symptoms, pain) to support the use of the CONDUIT questionnaire as a screening tool to identify patients who might benefit from an educational or clinical intervention. METHODS A panel of 16 experts met to develop descriptions of "poor," "moderate," and "good" conduit performance. They were trained to use the modified and extended Angoff standard-setting method. Each judge provided item ratings that reflected borderline good and borderline moderate patients. The average item ratings were summed and transformed to a 0-100 scale to derive final cut scores. Panelist evaluation of the process and confidence with the rating tasks were collected. RESULTS Panelists expressed that the training on the method gave them information they needed to complete their assignment. Among other factors, their experience with patients was most influential on their ratings. On the 0-100 score scale, good/moderate cuts ranged from 7.2 to 20.8, and moderate/poor cuts ranged from 37.9 to 64.3, depending on domains and weights. Standard errors of one or both cut scores increased for dysphagia and dumping-GI with weighting. CONCLUSIONS We described the selection and training of panelists and panelists' evaluations of the processes they were asked to follow in detail to defend the cut scores. Further prospective validation studies are underway to compare cut scores from this study and clinicians' judgments and further refine the categorization.
Collapse
Affiliation(s)
- Minji K Lee
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | - Kathleen J Yost
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Karlyn E Pierson
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amy J Schrandt
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Bobbie J Skaare
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Shanda H Blackmon
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
|
16
|
Jakubauskas M, Jotautas V, Poskus E, Mikalauskas S, Valeikaite-Tauginiene G, Strupas K, Poskus T. Fecal incontinence after transanal endoscopic microsurgery. Int J Colorectal Dis 2018; 33:467-472. [PMID: 29470728 DOI: 10.1007/s00384-018-2983-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) procedure could potentially influence the development of fecal incontinence later in life. The aim of our study was to assess long-term functional outcomes after TEM and to determine possible variables related to incontinence. METHODS Patients, enrolled in a prospectively collected TEM operation database, were interviewed using a postal questionnaire. The questionnaire consisted of EuroQol (EQ)-5D-5L quality of life questionnaire, Wexner fecal incontinence grading scale, and additional questions about other perianal operations and obstetric history for women. We divided patients into two groups: no or minor fecal incontinence (Wexner score of 2 and less) and non-minor incontinence (Wexner score of 3 or more). RESULTS One hundred thirty-two patients were included in the study. Patients' median follow-up time was 96 (12-168) months from their operation. Thirty-eight patients (28.8%) reported Wexner score of 3 or more, and they reported significantly worse quality of life in all tested life spheres. They were older at the time of the operation (63 (18-82) vs. 68 (50-89) years; p = 0.004), underwent longer operations (50 (10-140) vs. 60 (15-210) min; p = 0.017), and more often were operated for malignant lesions (17 (18.3%) vs. 14 (36.8%); p = 0.040). Older age at the time of operation was an independent risk factor in multivariate model (OR 1.057, 95% CI 1.010-1.106; p = 0.016). CONCLUSIONS Fecal incontinence after TEM is more common than thought previously, resulting in significantly impaired quality of life. Older age at the time of operation was an independent risk factor for developing significant fecal incontinence.
Collapse
Affiliation(s)
| | - Valdemaras Jotautas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Eligijus Poskus
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Saulius Mikalauskas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Gintare Valeikaite-Tauginiene
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Kestutis Strupas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Tomas Poskus
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania.
| |
Collapse
|
|
17
|
Rahden BHAV, Filser J, Al-Nasser M, Germer CT. [Surgical treatment of achalasia - endoscopic or laparoscopic? : Proposal for a tailored approach]. Chirurg 2018; 88:204-210. [PMID: 28120018 DOI: 10.1007/s00104-016-0365-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Primary idiopathic achalasia is the most common form of the rare esophageal motility disorders. A curative therapy which restores the normal motility does not exist; however, the therapeutic principle of cardiomyotomy according to Ernst Heller leads to excellent symptom control in the majority of cases. The established standard approach is Heller myotomy through the laparoscopic route (LHM), combined with Dor anterior fundoplication for reflux prophylaxis/therapy. At least four meta-analyses of randomized controlled trials (RCTs) have demonstrated superiority of LHM over pneumatic dilation (PD); therefore, LHM should be used as first line therapy (without prior PD) in all operable patients. Peroral endoscopic myotomy (POEM) is a new alternative approach, which enables Heller myotomy to be performed though the endoscopic submucosal route. The POEM procedure has a low complication rate and also leads to good control of dysphagia but reflux rates can possibly be slightly higher (20-30%). Long-term results of POEM are still scarce and the results of the prospective randomized multicenter trial POEM vs. LHM are not yet available; however, POEM seems to be the preferred treatment option for certain indications. Within the framework of the tailored approach for achalasia management of POEM vs. LHM established in Würzburg, we recommend long-segment POEM for patients with type III achalasia (spasmodic) and other hypercontractile motility disorders and potentially type II achalasia (panesophageal compression) with chest pain as the lead symptom, whereas LHM can also be selected for type I. For sigmoid achalasia, especially with siphon-like transformation of the esophagogastric junction, simultaneous hiatal hernia and epiphrenic diverticula, LHM is still the preferred approach. The choice of the procedure for revisional surgery in case of recurrent dysphagia depends on the suspected mechanism (morphological vs. functional/neuromotor).
Collapse
Affiliation(s)
- B H A von Rahden
- Klinik für Allgemein-, Viszeral, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland.
| | - J Filser
- Klinik für Allgemein-, Viszeral, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
| | - M Al-Nasser
- Klinik für Allgemein-, Viszeral, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
| | - C-T Germer
- Klinik für Allgemein-, Viszeral, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
| |
Collapse
|
|
18
|
Kummerow Broman K, Phillips SE, Faqih A, Kaiser J, Pierce RA, Poulose BK, Richards WO, Sharp KW, Holzman MD. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: long-term symptomatic follow-up of a prospective randomized controlled trial. Surg Endosc 2017; 32:1668-1674. [PMID: 29046957 DOI: 10.1007/s00464-017-5845-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/22/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Our prior randomized controlled trial of Heller myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term. METHODS We actively engaged participants from the prior randomized cohort, making up to six contact attempts per person using telephone, mail, and electronic messaging. We collected patient-reported measures of dysphagia and gastroesophageal reflux using the Dysphagia Score and the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) instrument. Patient-reported re-interventions for dysphagia were verified by obtaining longitudinal medical records. RESULTS Among living participants, 27/41 (66%) were contacted and all completed the follow-up study at a mean of 11.8 years postoperatively. Median Dysphagia Scores and GERD-HRQL scores were slightly worse for Heller than Heller plus Dor but were not statistically different (6 vs 3, p = 0.08 for dysphagia, 15 vs 13, p = 0.25 for reflux). Five patients in the Heller group and 6 in Heller plus Dor underwent re-intervention for dysphagia with most occurring more than five years postoperatively. One patient in each group underwent redo Heller myotomy and subsequent esophagectomy. Nearly all patients (96%) would undergo operation again. CONCLUSIONS Long-term patient-reported outcomes after Heller alone and Heller plus Dor for achalasia are comparable, providing support for either procedure.
Collapse
Affiliation(s)
- Kristy Kummerow Broman
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA. .,Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Nashville, TN, USA.
| | - Sharon E Phillips
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Adil Faqih
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Joan Kaiser
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Richard A Pierce
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Benjamin K Poulose
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - William O Richards
- Department of Surgery, University of South Alabama Health System, Mobile, AL, USA
| | - Kenneth W Sharp
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| | - Michael D Holzman
- Department of Surgery, Vanderbilt University Medical Center, 1161 Medical Center Drive, D-5203 Medical Center North, Nashville, TN, 37232, USA
| |
Collapse
|
|
19
|
|
|
20
|
|
|
21
|
Tsuboi K, Omura N, Yano F, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Kashiwagi H, Yanaga K. Data analyses and perspectives on laparoscopic surgery for esophageal achalasia. World J Gastroenterol 2015; 21:10830-10839. [PMID: 26478674 PMCID: PMC4600584 DOI: 10.3748/wjg.v21.i38.10830] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 05/29/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
In general, the treatment methods for esophageal achalasia are largely classified into four groups, including drug therapy using nitrite or a calcium channel blocker, botulinum toxin injection, endoscopic therapy such as endoscopic balloon dilation, and surgery. Various studies have suggested that the most effective treatment of esophageal achalasia is surgical therapy. The basic concept of this surgical therapy has not changed since Heller proposed esophageal myotomy for the purpose of resolution of lower esophageal obstruction for the first time in 1913, but the most common approach has changed from open-chest surgery to laparoscopic surgery. Currently, the laparoscopic surgery has been the procedure of choice for the treatment of esophageal achalasia. During the process of the transition from open-chest surgery to laparotomy, to thoracoscopic surgery, and to laparoscopic surgery, the necessity of combining antireflux surgery has been recognized. There is some debate as to which type of antireflux surgery should be selected. The Toupet fundoplication may be the most effective in prevention of postoperative antireflux, but many medical institutions have selected the Dor fundoplication which covers the mucosal surface exposed by myotomy. Recently, a new endoscopic approach, peroral endoscopic myotomy (POEM), has received attention. Future studies should examine the long-term outcomes and whether POEM becomes the gold standard for the treatment of esophageal achalasia.
Collapse
|
|
22
|
Perry KA, Kanji A, Drosdeck JM, Linn JG, Chan A, Muscarella P, Melvin WS. Efficacy and durability of robotic heller myotomy for achalasia: patient symptoms and satisfaction at long-term follow-up. Surg Endosc 2014; 28:3162-7. [DOI: 10.1007/s00464-014-3576-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 04/17/2014] [Indexed: 12/18/2022]
|
|
23
|
Marinello FG, Targarona EM, Balague C, Poca M, Mones J, Trias M. [Laparoscopic approach of achalasia. Long-term clinical and functional results and quality of life]. Cir Esp 2013; 92:188-94. [PMID: 24360250 DOI: 10.1016/j.ciresp.2013.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Accepted: 06/05/2013] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Laparoscopic Heller myotomy has become the gold standard procedure for patients with achalasia. This study evaluates the clinical status, quality of life, and functional outcomes after laparoscopic Heller myotomy. MATERIAL AND METHODS We analyzed patients who underwent laparoscopic Heller myotomy with an associated anti-reflux procedure from October 1998 to December 2010. Before surgery, we administered a clinical questionnaire and as of 2002, we also evaluated quality of life using a specific questionnaire (GIQLI). In 2011, we performed a follow up for all available patients. We administered the same clinical questionnaire and quality of life test as before surgery and performed manometry and 24-hour pH monitoring. According to the length of follow up, patients were divided into 3 groups. Group 1 with a follow-up between 6 and 47 months; group 2 follow-up between 48 and 119 months, and group 3 with a follow-up of more than 120 months). Moreover, 27 patients had already been evaluated with this same protocol in 2003. Pre- and postoperative data were compared for the 3 groups and for patients who completed follow up in 2003 and 2011. RESULTS Ninety-five patients underwent laparoscopic Heller myotomy. Seventy-six (80%) were available for follow-up. Mean follow-up was 56 months (range 6-143). Global improvement in dysphagia was 89%. Total DeMeester score decreased in the 3 groups. GIQLI scores improved after surgery, reaching normal values. Manometric determinations showed normal LES pressures after myotomy in the 3 groups. Ten percent of overall 24-hour pH monitoring was abnormal. The group of patients followed up in 2003 and in 2011 showed no impairment in the variables studied in the long term. CONCLUSIONS Long-term follow up of the laparoscopic approach to achalasia showed good results concerning clinical status and quality of life, with normal sphincteric pressures and a low incidence of gastroesophageal reflux.
Collapse
Affiliation(s)
- Franco G Marinello
- Departmento de Cirugía y Digestología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - Eduardo M Targarona
- Departmento de Cirugía y Digestología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España.
| | - Carmen Balague
- Departmento de Cirugía y Digestología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - María Poca
- Departmento de Cirugía y Digestología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - Joan Mones
- Departmento de Cirugía y Digestología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - Manuel Trias
- Departmento de Cirugía y Digestología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| |
Collapse
|
|
24
|
Torres-Villalobos G, Martin-del-Campo LA. Surgical treatment for achalasia of the esophagus: laparoscopic heller myotomy. Gastroenterol Res Pract 2013; 2013:708327. [PMID: 24348542 PMCID: PMC3852767 DOI: 10.1155/2013/708327] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/27/2013] [Indexed: 02/07/2023] Open
Abstract
Achalasia is an esophageal motility disorder that leads to dysphagia, chest pain, and weight loss. Its diagnosis is clinically suspected and is confirmed with esophageal manometry. Although pneumatic dilation has a role in the treatment of patients with achalasia, laparoscopic Heller myotomy is considered by many experts as the best treatment modality for most patients with newly diagnosed achalasia. This review will focus on the surgical treatment of achalasia, with special emphasis on laparoscopic Heller myotomy. We will also present a brief discussion of the evaluation of patients with persistent or recurrent symptoms after surgical treatment for achalasia and emerging technologies such as LESS, robot-assisted myotomy, and POEM.
Collapse
Affiliation(s)
- Gonzalo Torres-Villalobos
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Vasco de Quiroga No. 15, Colonia Seccion XVI, 14000 Tlalpan, México, DF, Mexico
- Experimental Surgery Department, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Vasco de Quiroga No. 15, Colonia Seccion XVI, 14000 Tlalpan, México, DF, Mexico
| | - Luis Alfonso Martin-del-Campo
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Vasco de Quiroga No. 15, Colonia Seccion XVI, 14000 Tlalpan, México, DF, Mexico
| |
Collapse
|
|
25
|
Gyawali CP, Bredenoord AJ, Conklin JL, Fox M, Pandolfino JE, Peters JH, Roman S, Staiano A, Vaezi MF. Evaluation of esophageal motor function in clinical practice. Neurogastroenterol Motil 2013; 25:99-133. [PMID: 23336590 DOI: 10.1111/nmo.12071] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Esophageal motor function is highly coordinated between central and enteric nervous systems and the esophageal musculature, which consists of proximal skeletal and distal smooth muscle in three functional regions, the upper and lower esophageal sphincters, and the esophageal body. While upper endoscopy is useful in evaluating for structural disorders of the esophagus, barium esophagography, radionuclide transit studies, and esophageal intraluminal impedance evaluate esophageal transit and partially assess motor function. However, esophageal manometry is the test of choice for the evaluation of esophageal motor function. In recent years, high-resolution manometry (HRM) has streamlined the process of acquisition and display of esophageal pressure data, while uncovering hitherto unrecognized esophageal physiologic mechanisms and pathophysiologic patterns. New algorithms have been devised for analysis and reporting of esophageal pressure topography from HRM. The clinical value of HRM extends to the pediatric population, and complements preoperative evaluation prior to foregut surgery. Provocative maneuvers during HRM may add to the assessment of esophageal motor function. The addition of impedance to HRM provides bolus transit data, but impact on clinical management remains unclear. Emerging techniques such as 3-D HRM and impedance planimetry show promise in the assessment of esophageal sphincter function and esophageal biomechanics.
Collapse
Affiliation(s)
- C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
|
26
|
Torab FC, Hamchou M, Ionescu G, Al-Salem AH. Familial achalasia in children. Pediatr Surg Int 2012; 28:1229-33. [PMID: 23076455 DOI: 10.1007/s00383-012-3186-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2012] [Indexed: 12/22/2022]
Abstract
Achalasia is rare in the pediatric age group and in most cases it is idiopathic with no family history. Familial achalasia is very rare. This report describes two families with achalasia: in one, six children were affected while in the other a brother and a sister had Allgrove's syndrome (triple-A syndrome consisting of achalasia, adrenal insufficiency, and alacrima). Familial achalasia suggests that it is hereditary and may be transmitted as an autosomal recessive trait. The management of achalasia in children is still controversial. With the recent advances in minimal invasive surgery, laparoscopic Heller's myotomy is the procedure of choice in the management of achalasia in children.
Collapse
Affiliation(s)
- Fawaz Chikh Torab
- Division of Pediatric Surgery, Department of Surgery, Tawam Hospital, Al-Ain, Abu Dhabi, United Arab Emirates.
| | | | | | | |
Collapse
|
|
27
|
Weber CE, Davis CS, Kramer HJ, Gibbs JT, Robles L, Fisichella PM. Medium and long-term outcomes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis. Surg Laparosc Endosc Percutan Tech 2012; 22:289-96. [PMID: 22874676 DOI: 10.1097/sle.0b013e31825a2478] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recent randomized studies comparing outcomes after pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) for the treatment of achalasia are conflicting and limited to short-term follow-up. Our meta-analysis compared the long-term durability of these approaches, with the hypothesis that LHM offers superior long-term remission compared with PD. We identified 36 studies published between 2001 and 2011 with at least 5 years of follow-up. Those studies describing PD included 3211 patients (mean age, 49.8 y). For PD, the mean 5-year remission rate was 61.9% and the mean 10-year remission rate was 47.9%. Overall, 1526 patients (mean age, 46.3 y) were treated with LHM; 83% received a fundoplication. In contrast, the mean 5- and 10-year remission rates after LHM were 76.1% and 79.6%, respectively. Finally, the perforation rate for LHM was twice that of PD (4.8% vs. 2.4%; P<0.05). We conclude that despite a higher frequency of perforation, LHM affords greater long-term durability.
Collapse
Affiliation(s)
- Cynthia E Weber
- Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL 60153, USA
| | | | | | | | | | | |
Collapse
|
|
28
|
Minimally invasive myotomy for the treatment of esophageal achalasia: evolution of the surgical procedure and the therapeutic algorithm. Surg Laparosc Endosc Percutan Tech 2012; 22:83-7. [PMID: 22487617 DOI: 10.1097/sle.0b013e318243368f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare disease of the esophagus, characterized by the absence of peristalsis in the esophageal body and incomplete relaxation of the lower esophageal sphincter, which may be hypertensive. The cause of this disease is unknown; therefore, the aim of the therapy is to improve esophageal emptying by eliminating the outflow resistance caused by the lower esophageal sphincter. This goal can be accomplished either by pneumatic dilatation or surgical myotomy, which are the only long-term effective therapies for achalasia. Historically, pneumatic dilatation was preferred over surgical myotomy because of the morbidity associated with a thoracotomy or a laparotomy. However, with the development of minimally invasive techniques, the surgical approach has gained widespread acceptance among patients and gastroenterologists and, consequently, the role of surgery has changed. The aim of this study was to review the changes occurred in the surgical treatment of achalasia over the last 2 decades; specifically, the development of minimally invasive techniques with the evolution from a thoracoscopic approach without an antireflux procedure to a laparoscopic myotomy with a partial fundoplication, the changes in the length of the myotomy, and the modification of the therapeutic algorithm.
Collapse
|
|
29
|
Popoff AM, Myers JA, Zelhart M, Maroulis B, Mesleh M, Millikan K, Luu MB. Long-term symptom relief and patient satisfaction after Heller myotomy and Toupet fundoplication for achalasia. Am J Surg 2012; 203:339-42; discussion 342. [PMID: 22221997 DOI: 10.1016/j.amjsurg.2011.10.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/16/2011] [Accepted: 10/16/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND The goal of this study was to review the results, symptom relief, and patient satisfaction after laparoscopic Heller myotomy and Toupet fundoplication. METHODS A cohort of patients who underwent laparoscopic esophagomyotomy and a Toupet fundoplication was identified. A retrospective chart review was conducted and patients then were interviewed by telephone using a modified 5-point Likert scale. RESULTS Long-term follow-up data were obtained for 51 patients with a mean of 5.9 years. Thirty-two (63%) patients reported infrequent or no dysphagia. Chest pain, heartburn, or regurgitation were reported in 6 of 51 (12%) patients, 14 of 51 (27%) patients, and 11 of 51 (22%) patients, respectively. Two patients (3.9%) had pneumatic dilation and 1 patient underwent completion esophagectomy (1.9%). Thirty-three (33 of 51; 65%) patients were on acid-suppression therapy. Forty-one (80%) patients reported their overall satisfaction with the procedure was either excellent or good, and 46 of 51 (90%) patients stated they would undergo surgery again. CONCLUSIONS Our data show acceptable long-term results.
Collapse
Affiliation(s)
- Andrew M Popoff
- Department of Surgery, Rush University Medical Center, Chicago, IL 60612, USA.
| | | | | | | | | | | | | |
Collapse
|
|
30
|
SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 2011; 26:296-311. [PMID: 22044977 DOI: 10.1007/s00464-011-2017-2] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/24/2011] [Indexed: 12/19/2022]
|
|
31
|
How does the robot affect outcomes? A retrospective review of open, laparoscopic, and robotic Heller myotomy for achalasia. Surg Endosc 2011; 26:1047-50. [PMID: 22038167 DOI: 10.1007/s00464-011-1994-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 10/04/2011] [Indexed: 12/26/2022]
Abstract
BACKGROUND Robotic techniques are routinely used in urological and gynecological procedures; however, their role in general surgical procedures is limited. A robotic technique has been successfully adopted for a minimally invasive Heller myotomy procedure for achalasia. This study aims to compare perioperative outcomes following open, laparoscopic, and robotic Heller myotomy. METHODS This study is a multicenter, retrospective analysis utilizing a large administrative database. The University Health System Consortium (UHC) is an alliance between academic medical centers and affiliate hospitals. The UHC database was accessed using International Classification of Diseases, Ninth Revision, Clinical Modification codes and analyzed. RESULTS 2,683 patients with achalasia underwent Heller myotomy between October 2007 and June 2011. Myotomy was performed by open surgery (OM) in 418 patients, by laparoscopic approach (LM) in 2,116, and by robotic approach (RM) in 149. Comparison between LM and RM groups demonstrated no significant difference in mortality (0.14 vs. 0.0%; P = 1), morbidity (5.19 vs. 4.02%; P = 0.7), intensive care unit (ICU) admission (6.62 vs. 3.36%; P = 0.12), length of stay (LOS) (2.70 ± 3.87 days vs. 2.42 ± 2.69 days; P = 0.34), or 30-day readmission (1.41 vs. 2.84%; P = 0.27). However, hospital costs were significantly lower for the LM group (US $7,441 ± 7,897 vs. US $9,415 ± 5,515; P = 0.0028). Comparison between OM and RM demonstrated significant lower morbidity (9.08 vs. 4.02%; P = 0.02), ICU admission rate (14.01 vs. 3.36%, P = 0.0002), and LOS (4.42 ± 5.25 days vs. 2.42 ± 2.69 days; P = 0.0001). CONCLUSIONS The perioperative outcomes are superior in LM and RM groups when compared with OM. The outcomes for the LM and RM group are comparable, with the robotic group having slightly improved results, although with increased costs. We conclude that robotic surgery is equivalent in safety and efficacy to laparoscopic Heller myotomy, and feel that the increased cost should come down as surgeons and manufacturers work together on cost reduction strategies.
Collapse
|
|
32
|
Shaligram A, Unnirevi J, Simorov A, Kothari VM, Oleynikov D. How does the robot affect outcomes? A retrospective review of open, laparoscopic, and robotic Heller myotomy for achalasia. Surg Endosc 2011. [PMID: 22038167 DOI: 10.1007/s00464-011-1994-5.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
BACKGROUND Robotic techniques are routinely used in urological and gynecological procedures; however, their role in general surgical procedures is limited. A robotic technique has been successfully adopted for a minimally invasive Heller myotomy procedure for achalasia. This study aims to compare perioperative outcomes following open, laparoscopic, and robotic Heller myotomy. METHODS This study is a multicenter, retrospective analysis utilizing a large administrative database. The University Health System Consortium (UHC) is an alliance between academic medical centers and affiliate hospitals. The UHC database was accessed using International Classification of Diseases, Ninth Revision, Clinical Modification codes and analyzed. RESULTS 2,683 patients with achalasia underwent Heller myotomy between October 2007 and June 2011. Myotomy was performed by open surgery (OM) in 418 patients, by laparoscopic approach (LM) in 2,116, and by robotic approach (RM) in 149. Comparison between LM and RM groups demonstrated no significant difference in mortality (0.14 vs. 0.0%; P = 1), morbidity (5.19 vs. 4.02%; P = 0.7), intensive care unit (ICU) admission (6.62 vs. 3.36%; P = 0.12), length of stay (LOS) (2.70 ± 3.87 days vs. 2.42 ± 2.69 days; P = 0.34), or 30-day readmission (1.41 vs. 2.84%; P = 0.27). However, hospital costs were significantly lower for the LM group (US $7,441 ± 7,897 vs. US $9,415 ± 5,515; P = 0.0028). Comparison between OM and RM demonstrated significant lower morbidity (9.08 vs. 4.02%; P = 0.02), ICU admission rate (14.01 vs. 3.36%, P = 0.0002), and LOS (4.42 ± 5.25 days vs. 2.42 ± 2.69 days; P = 0.0001). CONCLUSIONS The perioperative outcomes are superior in LM and RM groups when compared with OM. The outcomes for the LM and RM group are comparable, with the robotic group having slightly improved results, although with increased costs. We conclude that robotic surgery is equivalent in safety and efficacy to laparoscopic Heller myotomy, and feel that the increased cost should come down as surgeons and manufacturers work together on cost reduction strategies.
Collapse
Affiliation(s)
- Abhijit Shaligram
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | | | | |
Collapse
|
|
33
|
Kashiwagi H, Omura N. Surgical treatment for achalasia: when should it be performed, and for which patients? Gen Thorac Cardiovasc Surg 2011; 59:389-98. [PMID: 21674305 DOI: 10.1007/s11748-010-0765-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 12/13/2010] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare motor disorder of the esophagus, characterized by the absence of peristalsis and impaired swallow-induced relaxation. In the past decade, evidence has been accumulated suggesting that achalasia may be an immune-mediated inflammatory disorder. With the advent of minimally invasive surgery, laparoscopic Heller myotomy (LHM) has slowly shifted the treatment of achalasia toward the greater use of surgical therapy. The goal of both surgical and nonsurgical treatment is to eliminate the outflow obstruction afforded by a nonrelaxing sphincter, relieving dysphagia and maintaining a barrier against gastroesophageal reflux (GER). Endoscopic botulinum toxin injection (EBTI) is safe, easy to perform, inexpensive, and effective in aged patients, and it is especially effective when the lower esophageal pressure is hypertonic. This therapeutic option is reserved for patients too ill to undergo any surgical procedure. Pneumatic dilation (PD) has been shown to be an effective and inexpensive treatment with few adverse effects. The long-term success rate of PD seems to drop progressively over time. Heller myotomy (HM) has shown the best clinical efficacy in achalasia as a first-line treatment. Multiple endoscopic treatments are associated with poorer outcomes after HM. EBTI also makes LHM more difficult and results in a worse surgical outcome. The inferior symptomatic outcomes after thoracoscopic HM may be caused by the difficulty in extending an adequate myotomy onto the stomach from the chest and the inability to create a fundoplication. LHM with Dor's fundoplication (LHM + Dor) is effective and is safer procedure for avoiding GER, dysphagia, mucosal perforation, and a pseudodiverticulum. LHM + Dor is also effective in the presence of sigmoid achalasia, but the clinical result is not as good as nonsigmoid achalasia. A few patients need esophagectomy for surgical failure of HM. However, considering the risk of esophagectomy, LHM + Dor is the first treatment option for patients with achalasia regardless of the degree of esophageal dilatation. This procedure is therefore considered to be an effective and safe treatment for patients of any age or with any condition.
Collapse
Affiliation(s)
- Hideyuki Kashiwagi
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo 105-8461, Japan.
| | | |
Collapse
|
|
34
|
Barry L, Ross S, Dahal S, Morton C, Okpaleke C, Rosas M, Rosemurgy AS. Laparoendoscopic single-site Heller myotomy with anterior fundoplication for achalasia. Surg Endosc 2011; 25:1766-74. [PMID: 21487889 DOI: 10.1007/s00464-010-1454-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 08/07/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND Laparoendoscopic single-site (LESS) surgery is beginning to include advanced laparoscopic operations such as Heller myotomy with anterior fundoplication. However, the efficacy of LESS Heller myotomy has not been established. This study aimed to evaluate the authors' initial experience with LESS Heller myotomy for achalasia. METHODS Transumbilical LESS Heller myotomy with concomitant anterior fundoplication for achalasia was undertaken for 66 patients after October 2007. Outcomes including operative time, complications, and length of hospital stay were recorded and compared with those for an earlier contiguous group of 66 consecutive patients undergoing conventional multi-incision laparoscopic Heller myotomy with anterior fundoplication. Symptoms before and after myotomy were scored by the patients using a Likert scale ranging from 0 (never/not severe) to 10 (always/very severe). Data were analyzed using the Mann-Whitney U test, the Wilcoxon matched-pairs test, and Fisher's exact test where appropriate. RESULTS Patients undergoing LESS Heller myotomy were similar to those undergoing conventional laparoscopic Heller myotomy in gender, age, body mass index (BMI), blood loss, and length of hospital stay. However, the patients undergoing LESS Heller myotomies had operations of significantly longer duration (median, 117 vs. 93 min with the conventional laparoscopic approach) (p<0.003). For 11 patients (16%) undergoing LESS Heller myotomy, additional ports/incisions were required. No patients were converted to "open" operations, and no patients had procedure-specific complications. Symptom reduction was dramatic and satisfying after both LESS and conventional laparoscopic myotomy with fundoplication. The symptom reduction was similar with the two procedures. The LESS approach left no apparent umbilical scar. CONCLUSION Heller myotomy with anterior fundoplication effectively treats achalasia. The findings showed LESS Heller myotomy with anterior fundoplication to be feasible, safe, and efficacious. Although the LESS approach increases operative time, it does not increase procedure-related morbidity or hospital length of stay and avoids apparent umbilical scarring. Laparoendoscopic single-site surgery represents a paradigm shift to more minimally invasive surgery and is applicable to advanced laparoscopic operations such as Heller myotomy and anterior fundoplication.
Collapse
Affiliation(s)
- Linda Barry
- The Center for Surgical Digestive Disorders, Tampa General Hospital, Tampa General Medical Group, and Department of Surgery, University of South Florida, 409 Bayshore Blvd, Tampa, FL 33606, USA
| | | | | | | | | | | | | |
Collapse
|
|
35
|
Patient satisfaction, hernia recurrence rate, and chronic pain 10 years after endoscopic total extraperitoneal inguinal hernia repair. Surg Laparosc Endosc Percutan Tech 2011; 19:405-9. [PMID: 19851272 DOI: 10.1097/sle.0b013e3181bb1bce] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Long-term outcome data after total endoscopic preperitoneal hernia repair are scarce. This study reports the 10-year results after endoscopic total extraperitoneal hernia repair in terms of recurrence rates and various patient-orientated indicators of quality of life. METHODS Between July 1995 and April 2000, 107 consecutive patients underwent endoscopic total extraperitoneal inguinal hernia repair. The follow-up assessment between December 2007 and June 2008 included a clinical examination and a patient questionnaire. RESULTS Sixty-three patients (64.3%) with 108 hernias attended follow-up, an average of 115.7 months (range 91 to 148 mo) after the index operation. The incidence of recurrence was 2.8%, of chronic pain 15.9%, and of foreign body sensation 33.3%. Patient satisfaction measured on the Visual Analogue Scale was high with a median of 9.6 (range 0.3 to 10). CONCLUSIONS Endoscopic total extraperitoneal hernia repair is a safe and effective procedure with excellent long-term results and an extremely high rate of patient satisfaction.
Collapse
|
|
36
|
Effect of laparoscopic esophagomyotomy on chest pain associated with achalasia and prediction of therapeutic outcomes. Surg Endosc 2010; 25:1048-53. [PMID: 20835730 DOI: 10.1007/s00464-010-1314-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 08/07/2010] [Indexed: 01/20/2023]
Abstract
BACKGROUND The effect of myotomy for achalasia on chest pain has not been clarified. The current study aimed to investigate the therapeutic effect of laparoscopic myotomy on chest pain associated with achalasia and to identify prognostic factors for outcomes. METHOD Between March 2005 and September 2008, 95 patients were available for detailed interviews and for assessment of clearance by timed barium esophagogram (TBE) before and after surgery. Of the 95 patients, 47 (24 men; mean age, 42.9 ± 13.5 years) who experienced chest pain before surgery were studied. The subjects were asked in detail about dysphagia and chest pain before surgery and 6 months after surgery. The frequency and severity of the symptoms were graded on a scale of 0 to 4. In addition, the values obtained by multiplying the grade for frequency by the grades for severity of the two symptoms were defined as the dysphagia score and the chest pain score, respectively. The patients with chest pain scores of 0 after surgery were defined as group A and those with scores smaller than their preoperative scores as group B. The remaining patients with other scores were defined as group C. The background factors and clinical conditions of the three groups were compared. RESULTS The mean chest pain score decreased from 5.0 ± 3.2 to 1.0 ± 1.6 (p < 0.001). The score after surgery was 0 for 27 patients and showed a decrease for 15 patients. Although the three groups did not differ in their characteristics, differences were noted in postoperative TBE factors (i.e., groups A and B had significantly shorter barium columns than group C at 1 and 5 min after surgery (p = 0.001). CONCLUSION Laparoscopic myotomy had a therapeutic effect on chest pain associated with achalasia, and improvement in postoperative esophageal clearance may influence the therapeutic effect.
Collapse
|
|
37
|
Fundoplication after laparoscopic Heller myotomy for esophageal achalasia: what type? J Gastrointest Surg 2010; 14:1453-8. [PMID: 20300876 DOI: 10.1007/s11605-010-1188-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Accepted: 02/23/2010] [Indexed: 01/31/2023]
Abstract
Because of the high success rate of minimally invasive surgery, a radical shift in the treatment algorithm of esophageal achalasia has occurred. Today, a laparoscopic Heller myotomy is the preferred treatment modality for achalasia. This remarkable change is due to the recognition by gastroenterologists and patients that a laparoscopic Heller myotomy gives better and more durable results than pneumatic dilatation and intrasphincteric injection of botulinum toxin injection, while it is associated to a short hospital stay and a fast recovery time. While there is agreement about the need of a fundoplication in conjunction to the myotomy, some questions still remain about the type of fundoplication: Should the fundoplication be total or partial, and in case a partial fundoplication is chosen, should it be anterior or posterior? The following review describes the data present in the literature in order to identify the best procedure that can achieve prevention or control of gastroesophageal reflux after a myotomy without impairing esophageal emptying.
Collapse
|
|
38
|
The evolution of oesophageal function testing and its clinical applications in the management of patients with oesophageal disorders. Dig Liver Dis 2009; 41:626-9. [PMID: 19217836 DOI: 10.1016/j.dld.2009.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 01/05/2009] [Accepted: 01/13/2009] [Indexed: 12/11/2022]
Abstract
The last decade has brought significant technical advances in laparoscopic surgery. In this constantly evolving technological climate, less told is the story of the evolution of diagnostic technology that improved the clinical management of patients with oesophageal disorders. The successful outcome of the laparoscopic treatment of oesophageal disorders is due to a combination of three different factors: the skills and the ability of the foregut surgeon, the high volume of referral, the expertise in the critical evaluation of the oesophageal function tests. This is an art per se, and it is rarely acknowledged in the achievement of the excellent results of surgery. Oesophageal function testing provides the clinician with information that cannot be obtained by the clinical, endoscopic, and radiological evaluation of patients. This expertise, intimately coupled with the other factors, allows the surgeon to better understand the pathophysiology of these diseases and to provide the optimal management. Therefore, it is essential to understand the evolution that this technology is currently undergoing, and how these changes are expanding the current indications for antireflux surgery by identifying additional predictors of successful outcome.
Collapse
|
|
39
|
Abstract
Idiopathic achalasia is a rare primary motility disorder of the esophagus. The classical features are incomplete relaxation of a frequently hypertensive lower esophageal sphincter (LES) and a lack of peristalsis in the tubular esophagus. These motor abnormalities lead to dysphagia, stasis, regurgitation, weight loss, or secondary respiratory complications. Although major strides have been made in understanding the pathogenesis of this rare disorder, including a probable autoimmune mediated destruction of inhibitory neurons in response to an unknown insult in genetically susceptible individuals, a definite trigger has not been identified. The diagnosis of achalasia is suggested by clinical features and confirmed by further diagnostic tests, such as esophagogastroduodenoscopy (EGD), manometry or barium swallow. These studies are not only used to exclude pseudoachalasia, but also might help to categorize the disease by severity or clinical subtype. Recent advances in diagnostic methods, including high resolution manometry (HRM), might allow prediction of treatment responses. The primary treatments for achieving long-term symptom relief are surgery and endoscopic methods. Although limited high-quality data exist, it appears that laparoscopic Heller myotomy with partial fundoplication is superior to endoscopic methods in achieving long-term relief of symptoms in the majority of patients. However, the current clinical approach to achalasia will depend not only on patients’ characteristics and clinical subtypes of the disease, but also on local expertise and patient preferences.
Collapse
|
|
40
|
Eldaif SM, Mutrie CJ, Rutledge WC, Lin E, Force SD, Miller JI, Mansour KA, Miller DL. The Risk of Esophageal Resection After Esophagomyotomy for Achalasia. Ann Thorac Surg 2009; 87:1558-62; discussion 1562-3. [DOI: 10.1016/j.athoracsur.2009.02.078] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Revised: 02/24/2009] [Accepted: 02/26/2009] [Indexed: 10/20/2022]
|
|
41
|
Abstract
AIM: To evaluate the efficacy and safety of Heller myotomy (HM) for recurrent achalasia, performed after different methods of first-line treatment.
METHODS: We searched for studies published in PubMed from 1966 to March 2008 on treatment of recurrent achalasia with HM after failure with different methods of first-line treatment. The efficacy of HM was assessed by a pooled estimate of response rate with individual studies weighted proportionally to sample size.
RESULTS: Sixteen studies were eligible and included in the review. The results showed that HM has a better remission rate for recurrent achalasia after failure of HM [weighted mean (SD)] of 86.9% (21.8%) compared with 81.6% (23.8%) for pneumatic dilatation (PD). One study evaluated the efficacy of HM after failure of PD combined with botulinum toxin injection (83%). The most common complications were perforation and gastroesophageal reflux.
CONCLUSION: HM has the best efficacy in patients with recurrent achalasia who were treated with HM as first-line treatment. Future studies should focus on how to increase the success rate and decrease the complications of HM.
Collapse
|
|
42
|
Abstract
Achalasia is the best understood and most readily treatable esophageal motility disorder. It serves as a prototype for disorders of the enteric nervous system with degeneration of the myenteric neurons that innervate the lower esophageal sphincter (LES) and esophageal body. Investigations into the pathogenesis have highlighted the importance of nitric oxide and the possible role of an autoimmune response to a viral insult in genetically susceptible individuals. Advances in diagnostic testing have delineated manometric variants of achalasia that have implications for management. Treatment studies have demonstrated the limited efficacy of botulinum toxin as well as less than ideal, long-term effectiveness of both pneumatic dilation and Heller myotomy. This article incorporates these recent developments into the current understanding of achalasia.
Collapse
Affiliation(s)
- Natasha Walzer
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 1400, Chicago, IL 60611-3008, USA
| | | |
Collapse
|
|
43
|
Tsuboi K, Omura N, Yano F, Kashiwagi H, Yanaga K. Results after laparoscopic Heller-Dor operation for esophageal achalasia in 100 consecutive patients. Dis Esophagus 2008; 22:169-76. [PMID: 19018850 DOI: 10.1111/j.1442-2050.2008.00891.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The laparoscopic Heller-Dor operation has been the procedure of choice for the treatment of achalasia. However, because the incidence of achalasia is low, reports on the outcome of surgical treatment for achalasia are limited. In this study, the therapeutic results after laparoscopic Heller-Dor operation for achalasia at a single university hospital were evaluated. Between August 1994 and July 2006, 100 consecutive patients underwent laparoscopic Heller-Dor operation. The therapeutic results after laparoscopic Heller-Dor operation were assessed based on complications, operation time, blood loss, postoperative hospital stay, and the standardized questionnaire for satisfaction by telephone or outpatient clinic interview. With respect to perioperative complications, lower esophageal mucosal perforation occurred in 14 patients, but all of them could be suture-obliterated laparoscopically. One patient was converted to laparotomy because of uncontrolled bleeding from the short gastric artery. The mean operative time was 169 minutes, and the mean perioperative blood loss was 22 mL. The median postoperative hospital stay was 7 days. Reflux esophagitis, which was seen in five patients, was treated successfully with a proton pump inhibitor. According to the standardized questionnaire for satisfaction, 77 patients rated their recovery as 'excellent', 17 as 'good', 4 as 'fair', and 2 as 'poor'; thus, the overall success rate was 94%. There were no significant differences in surgical outcomes by morphologic type and severity of esophageal dilatation; however, the success rate deteriorated significantly with progression of the morphologic type. Laparoscopic Heller-Dor operation is a safe and effective surgical treatment for achalasia.
Collapse
Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan.
| | | | | | | | | |
Collapse
|
|
44
|
Vaziri K, Soper NJ. Laparoscopic Heller myotomy: technical aspects and operative pitfalls. J Gastrointest Surg 2008; 12:1586-91. [PMID: 18210187 DOI: 10.1007/s11605-008-0475-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Accepted: 01/07/2008] [Indexed: 01/31/2023]
Abstract
Achalasia is a rare motor disorder of the esophagus characterized by aperistalsis and impaired relaxation of the lower esophageal sphincter (LES). The etiology of this disease remains unknown. The current treatment is palliative and relies upon surgical disruption of the fibers of the LES. The technical aspects and operative pitfalls of laparoscopic Heller myotomy are described in this article.
Collapse
Affiliation(s)
- Khashayar Vaziri
- Department of Surgery, Northwestern University Feinberg School of Medicine, 201 E. Huron Street, Galter 10-105, Chicago, IL 60611, USA
| | | |
Collapse
|
|
45
|
Abstract
Achalasia cannot be cured. Instead, our goal is to relieve symptoms of dysphagia and regurgitation, improve esophageal emptying and prevent the development of megaesophagus. The most definitive therapies are pneumatic dilation and surgical myotomy. The overall success of grade pneumatic dilation is 78%, with women and older patients performing best. Laparoscopic myotomy has an overall success rate of 85%, but can be complicated by the sequelae of severe acid reflux disease. Young patients, especially men, are the best candidates for surgical myotomy. There are no prospective, randomized studies comparing these two procedures. Botulinum toxin injections into the esophagus and smooth muscle relaxants are reserved for older patients or those with major comorbid illnesses. Some patients with end-stage achalasia will require esophagectomy.
Collapse
Affiliation(s)
- Joel E Richter
- Department of Medicine, Temple University School of Medicine, 3401, North Broad Street, 801 Parkinson Pavilion, Philadelphia, PA 19140, USA.
| |
Collapse
|