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Aitali A, Bourouail O, Elmahdaouy Y, Elhjouji A. Limited hiatal dissection versus Dor-fundoplication in laparoscopic Heller myotomy for achalasia: First experience in Morocco - A case control comparison study. Int J Surg Case Rep 2025; 129:111137. [PMID: 40117832 PMCID: PMC11979429 DOI: 10.1016/j.ijscr.2025.111137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2025] [Revised: 02/25/2025] [Accepted: 03/10/2025] [Indexed: 03/23/2025] Open
Abstract
INTRODUCTION AND IMPORTANCE Laparoscopic Heller myotomy is a primary treatment for achalasia, addressing impaired esophageal motility. Fundoplication is typically added to prevent postoperative reflux. This study compares outcomes of limited hiatal dissection without antireflux system in laparoscopic Heller myotomy to Dor fundoplication. CASE PRESENTATION A retrospective analysis was conducted on 45 patients treated at visceral surgery department (2008-2022). Of these, 29 patients underwent limited hiatal dissection, and 16 underwent Dor fundoplication. A liquid diet was followed on day one, with discharge on day two, and a semi-liquid diet for three weeks. Outcomes included dysphagia resolution, postoperative Eckardt scores <3, and postoperative reflux incidence. The study compared operative and postoperative data between the two groups. CLINICAL DISCUSSION The limited hiatal dissection group had a slightly younger mean age (46.97 years) compared to the Dor fundoplication group (51.75 years). The limited hiatal dissection group had a higher proportion of men (58.6 %) while the Dor group had more women (56.3 %). Dysphagia (100 %) and weight loss (68.9 %) were prevalent symptoms. Perioperative complications and hospital stay duration were similar. Operative time was significantly shorter in the limited hiatal dissection group (96.7 vs. 118.3 min, p = 0.004). Both groups showed similar (OR = 0.519, CI = 0.066-4.083) and significant improvement in dysphagia (91.3 % vs. 87.5 %, p < 0.001) with comparable postoperative gastroesophageal disease (20.7 % vs. 25 %, p = 0.726 OR = 1.278, 95 % CI: 0.301-5.420). CONCLUSION Limited hiatal dissection provides comparable symptom relief and reflux prevention, offering a viable alternative to routine antireflux in achalasia treatment.
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Affiliation(s)
- Abdelmounaim Aitali
- Visceral Surgery Service II Department, Military Teaching Hospital Mohamed V, Rabat UHC IBN Sina, Rabat, Morocco
| | - Othmane Bourouail
- Visceral Surgery Service II Department, Military Teaching Hospital Mohamed V, Rabat UHC IBN Sina, Rabat, Morocco.
| | - Youssef Elmahdaouy
- Visceral Surgery Service II Department, Military Teaching Hospital Mohamed V, Rabat UHC IBN Sina, Rabat, Morocco
| | - Abderrahman Elhjouji
- Visceral Surgery Service II Department, Military Teaching Hospital Mohamed V, Rabat UHC IBN Sina, Rabat, Morocco
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Darwish MB, Logarajah SI, Nagatomo K, Jackson T, Benzie AL, McLaren PJ, Cho E, Osman H, Jeyarajah DR. To Wrap or Not to Wrap After Heller Myotomy. JSLS 2021; 25:JSLS.2021.00054. [PMID: 34803368 PMCID: PMC8580166 DOI: 10.4293/jsls.2021.00054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background and Objectives: The primary aim of this study is to assess the necessity of fundoplication for reflux in patients undergoing Heller myotomy for achalasia. The secondary aim is to assess the safety of the robotic approach to Heller myotomy. Methods: This is a single institution, retrospective analysis of 61 patients who underwent robotic Heller myotomy with or without fundoplication over a 4-year period (January 1, 2015 – December 31, 2019). Symptoms were evaluated using pre-operative and postoperative Eckardt scores at < 2 weeks (short-term) and 4 – 55 months (long-term) postoperatively. Incidence of gastroesophageal reflux and use of antacids postoperatively were assessed. Long-term patient satisfaction and quality of life (QOL) were assessed with a phone survey. Finally, the perioperative safety profile of robotic Heller myotomy was evaluated. Results: The long-term average Eckardt score in patients undergoing Heller myotomy without fundoplication was notably lower than in patients with a fundoplication (0.72 vs 2.44). Gastroesophageal reflux rates were lower in patient without a fundoplication (16.0% vs 33.3%). Additionally, dysphagia rates were lower in patients without a fundoplication (32.0% vs 44.4%). Only 34.8% (8/25) of patients without fundoplication continued use of antacids in the long-term. There were no mortalities and a 4.2% complication rate with two delayed leaks. Conclusion: Robotic Heller myotomy without fundoplication is safe and effective for achalasia. The rate of reflux symptoms and overall Eckardt scores were low postoperatively. Great patient satisfaction and QOL were observed in the long term. Our results suggest that fundoplication is unnecessary when performing Heller myotomy.
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Affiliation(s)
- Muhammad B Darwish
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | | | - Kei Nagatomo
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | - Terence Jackson
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | | | | | - Edward Cho
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | - Houssam Osman
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | - D Rohan Jeyarajah
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
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Rebecchi F, Allaix ME, Schlottmann F, Patti MG, Morino M. Laparoscopic Heller Myotomy and Fundoplication: What Is the Evidence? Am Surg 2018. [DOI: 10.1177/000313481808400418] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
There is no agreement about the best type of fundoplication to add in patients undergoing laparoscopic Heller myotomy (LHM) for achalasia to reduce the risk of postoperative gastroesophageal reflux. This article reviews the current evidence about the outcomes in achalasia patients undergoing LHM with a partial anterior, a partial posterior, or a total fundoplication. We performed a review of the literature in PubMed/Medline electronic databases, which was evaluated according to the GRADE system. The results of the published randomized controlled trials show with a high level of evidence that the addition of a fundoplication reduces the risk of postoperative abnormal reflux, without impairing the food emptying of the esophagus. LHM with partial fundoplication is considered in most centers worldwide the standard of care for the treatment of patients with achalasia. The current evidence fails to show any significant difference between partial anterior and posterior fundoplication. In the absence of further large randomized controlled trial, the decision of performing an anterior or a posterior wrap is based on the surgeon's experience and preference. The addition of a partial fundoplication to LHM leads to a significantly lower rate of postoperative pathological reflux without impairing the esophageal emptying.
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Affiliation(s)
- Fabrizio Rebecchi
- Department of Surgical Sciences, University of Torino, Torino, Italy and
| | - Marco E. Allaix
- Department of Surgical Sciences, University of Torino, Torino, Italy and
| | - Francisco Schlottmann
- Department of Medicine and Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marco G. Patti
- Department of Medicine and Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Torino, Italy and
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Balakrishna P, Parshad R, Rohila J, Saraya A, Makharia G, Sharma R. Symptomatic outcome following laparoscopic Heller's cardiomyotomy with Dor fundoplication versus laparoscopic Heller's cardiomyotomy with angle of His accentuation: results of a randomized controlled trial. Surg Endosc 2015; 29:2344-2351. [PMID: 25427411 DOI: 10.1007/s00464-014-3958-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 11/03/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND The type of anti-reflux procedure to be used as an adjunct to laparoscopic Heller's cardiomyotomy (LHCM) in Achalasia cardia is controversial. We compared Angle of His accentuation and Dor fundoplication in a randomized controlled trial. METHODS From May 2010 to October 2013, 62 patients undergoing LHCM were randomized to receive either Dor fundoplication (Dor group) or Angle of His accentuation (AOH group) as an anti-reflux procedure. Symptomatic outcome was evaluated using modified Mellow and Pinkas scale for dysphagia and modified DeMeester's score for regurgitation and heartburn. Achalasia-specific quality-of-life (QOL) questionnaire was used to assess quality of life. The primary outcome was symptomatic relief and the secondary outcome was postoperative heartburn. Statistical analysis was done using SPSS software. RESULTS All the procedures were completed laparoscopically with no mortality. Morbidity was similar in the two groups (6.4 %). Median operative time was higher in Dor group (170 vs 130 min). At a median follow-up of 21 months relief of dysphagia, regurgitation, and heartburn was seen in 87, 90.3, and 90.3 % patients in Dor group versus 93.5, 96.7, and 77.4 % in AOH group patients with significant improvement in symptom scores. Improvement was similar in both groups with no statistically significant difference in the symptom scores (p = 0.48 for dysphagia, p = 0.37 for regurgitation, and p = 0.19 for heartburn). The QOL improved in both groups [62.3 to 12.3 (p = 0.02) in Dor group and 63.9-13 (p = 0.02) in AOH group] with no statistically significant difference between the two groups (p = 0.96). There was no statistically significant difference in the postoperative heartburn between the two groups (p = 0.19). CONCLUSION Laparoscopic Heller's cardiomyotomy with either Angle of His accentuation or Dor fundoplication leads to similar improvement in symptoms and quality of life.
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Affiliation(s)
- Pavithra Balakrishna
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, 110029, India
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Paediatric laparoscopic Heller's cardiomyotomy: a single centre series. J Pediatr Surg 2014; 49:289-92; discussion 292. [PMID: 24528969 DOI: 10.1016/j.jpedsurg.2013.11.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 11/10/2013] [Indexed: 01/18/2023]
Abstract
BACKGROUND The optimal management of oesophageal achalasia remains unclear in the paediatric population due to the rarity of the disease. This study reviews the institutional experience of the laparoscopic Heller's cardiomyotomy (HC) procedure and attempts to define the most appropriate treatment. METHODS A retrospective review of children undergoing HC at a single institution was performed. Demographics, pre-operative investigations, and interventions were reviewed. Post-operative outcomes and follow up were evaluated. Data is expressed as median (range). RESULTS Twenty-eight children were included (13 male, 15 female) whose median age was 13 (3.2-17.4) years. Nine children underwent a pre-operative oesophageal balloon dilatation (OBD) a median of 1(1-6) times. Others included botulinum toxin injection (n=1) and Nifedipine (n=1). All had a pre-operative upper gastrointestinal contrast series, and twenty-five had upper gastrointestinal endoscopy and manometry. All had laparoscopic HC with no conversions, and ten had a concomitant fundoplication. Post-operative intervention occurred in eight (28%) incorporating OBD (n=7), of whom four required a redo HC. One patient underwent a redo without intervening OBD. Follow-up was for a median of 0.83 (0-5) years with fourteen children discharged from surgical follow-up. Twenty-seven have thus far had a good outcome. CONCLUSION This study comprises the largest series of paediatric laparoscopic HC reported to date. It is effective with or without a fundoplication and is the best long term treatment modality available. OBD for persisting symptoms following HC may obviate the need for redo myotomy.
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Stefanidis D, Richardson W, Farrell TM, Kohn GP, Augenstein V, Fanelli RD. SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 2012; 26:296-311. [PMID: 22044977 DOI: 10.1007/s00464-011-2017-2] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/24/2011] [Indexed: 12/19/2022]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, Carolinas HealthCare System, CMC Specialty Surgery Center Suite 300, 1025 Morehead Medical Plaza, Charlotte, NC 28204, USA.
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Rosemurgy AS, Morton CA, Rosas M, Albrink M, Ross SB. A single institution's experience with more than 500 laparoscopic Heller myotomies for achalasia. J Am Coll Surg 2010; 210:637-45, 645-7. [PMID: 20421021 DOI: 10.1016/j.jamcollsurg.2010.01.035] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Accepted: 01/20/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Long-term symptom relief and patient satisfaction after Heller myotomy are being reported. Herein, we report the largest experience of laparoscopic Heller myotomy for the treatment of achalasia. STUDY DESIGN Since 1992, 505 patients have been prospectively followed after laparoscopic Heller myotomy. Until 2004, concomitant fundoplication was undertaken for a patulous hiatus, a large hiatal hernia, or to buttress the repair of an esophagotomy, then concomitant fundoplication became routinely applied. More recently, laparo-endoscopic single site (LESS) Heller myotomy has been performed when possible to improve cosmesis. Before and after myotomy, patients scored their symptoms. RESULTS Before myotomy, 60% of patients underwent endoscopic therapy; of these patients, 27% had Botox (Allergan) therapy alone, 52% underwent dilation therapy alone, and 21% had both. Esophagotomy occurred in 7% of patients. Concomitant diverticulectomy was undertaken in 7%, fundoplication was performed in 59%, and LESS Heller myotomy was done in 12%. Median length of stay was 1 day. With mean follow-up at 31 months, the severity of all symptoms improved significantly. After myotomy, 95% experienced symptoms less than once per week, 86% believed their outcome is satisfying or better, and 92% would undergo myotomy again, if necessary. Symptoms after myotomy are similar with or without fundoplication and regardless of the laparoscopic approach used. CONCLUSIONS Laparoscopic Heller myotomy safely and durably relieves symptoms of dysphagia. Confinement is short and satisfaction is very high. Relief of esophageal obstruction is paramount; the approach used or the application of a fundoplication has a lesser impact. Laparoscopic Heller myotomy, preferably with anterior fundoplication using a single site laparoscopic approach, is strongly encouraged for patients with symptomatic achalasia and is efficacious even after failures of dilation and/or Botox therapy.
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Affiliation(s)
- Alexander S Rosemurgy
- Department of Surgery, University of South Florida College of Medicine, Tampa General Hospital, Tampa, FL, USA
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Cowgill SM, Villadolid D, Boyle R, Al-Saadi S, Ross S, Rosemurgy AS. Laparoscopic Heller myotomy for achalasia: results after 10 years. Surg Endosc 2009; 23:2644-9. [PMID: 19551442 DOI: 10.1007/s00464-009-0508-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2008] [Revised: 11/08/2008] [Accepted: 12/16/2008] [Indexed: 10/20/2022]
Abstract
BACKGROUND Laparoscopic Heller myotomy was first undertaken in the early 1990s, and appreciable numbers of patients with 10-year follow-up periods are now available. This study was undertaken to determine long-term outcomes after laparoscopic Heller myotomy used to treat achalasia. METHODS Of 337 patients who have undergone laparoscopic Heller myotomy since 1992, 47 who underwent myotomy more than 10 years ago have been followed through a prospectively maintained registry. Among many symptoms, patients scored dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn before and after myotomy using a Likert scale with choices ranging from 0 (never/not bothersome) to 10 (always/very bothersome). Symptom scores before and after myotomy were compared using a Wilcoxon matched-pairs test. Data are reported as median (mean ± standard deviation). RESULTS The median length of the hospital stay was 2 days (mean, 3 ± 8.6 days; range, 1-60 days). Notable complications were infrequent after myotomy. There were no perioperative deaths. One patient required a redo myotomy after 5 years due to recurrence of symptoms. At this writing, 33 patients (70%) are still alive. The causes of death after discharge were unrelated to myotomy. The frequency and severity scores for dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn all decreased significantly after laparoscopic Heller myotomy (p < 0.0001 for all). CONCLUSIONS Laparoscopic Heller myotomy can be undertaken with few complications. This procedure significantly decreases the frequency and severity of achalasia symptoms without promoting heartburn. The symptoms of achalasia are durably ameliorated by laparoscopic Heller myotomy during long-term follow-up evaluation, thereby promoting application of this procedure.
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Affiliation(s)
- Sarah M Cowgill
- Digestive Disorders Center, Tampa General Hospital, Tampa, FL, USA
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Abstract
INTRODUCTION Achalasia is a primary oesophageal motility disorder resulting from damage to the ganglion cells of the myenteric plexus. Impaired relaxation of the lower oesophageal sphincter and aperistalsis causes its cardinal symptoms of dysphagia, chest pain and reflux-type symptoms. Management is somewhat controversial, with options including systemic and local pharmacotherapy, dilatation and oesophagomyotomy. We review the presentation, investigation and management of oesophageal achalasia and make an argument for primary surgical management. METHODS We performed a Medline search of the term 'achalasia', limiting the search to clinical trials and meta-analyses. We then selected articles based on their abstracts using four main criteria: previously unreported findings, previously unreported techniques, size of patient cohort and journal impact factor. References in selected articles were manually searched for other relevant articles. FINDINGS Achalasia has been managed using a variety of techniques including systemic and local pharmacotherapy, forced dilatation and oesophagomyotomy. Success rates vary widely between techniques. Mechanical disruption ofthe lower oesophageal sphincter is most successful. DISCUSSION In achalasia, mechanical disruption of the lower oesophageal sphincter using forced dilatation or surgical myotomy offers the only realistic prospect of long-term symptom relief. Recent evidence suggests that previous medical treatment or dilatation makes oesophagomyotomy more difficult and increases the risk of complications. As the morbidity associated with surgery continues to decrease with improvements in minimal access techniques, the argument for primary management of achalasia with oesophagomyotomy becomes more compelling.
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Affiliation(s)
- D S Leonard
- Department of Surgery Beaumont Hospital, Dublin, Ireland.
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Tapper D, Morton C, Kraemer E, Villadolid D, Ross SB, Cowgill SM, Rosemurgy AS. Does Concomitant Anterior Fundoplication Promote Dysphagia after Laparoscopic Heller Myotomy? Am Surg 2008. [DOI: 10.1177/000313480807400710] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Concerns for gastroesophageal reflux after laparoscopic Heller myotomy for achalasia justify considerations of concomitant anterior fundoplication. This study was undertaken to determine if concomitant anterior fundoplication reduces symptoms of reflux after myotomy without promoting dysphagia. From 1992 to 2004, 182 patients underwent laparoscopic Heller myotomy without fundoplication. After a prospective randomized trial justified its concomitant application, anterior fundoplication was undertaken with laparoscopic Heller myotomy in 171 patients from 2004 to 2007. All patients have been prospectively followed. Pre and postoperatively, patients scored the frequency and severity of symptoms of achalasia (including dysphagia, choking, vomiting, regurgitation, chest pain, and heartburn) using a Likert Scale (0 = never/not bothersome to 10 = always/very bothersome). Before myotomy, symptoms of achalasia were frequent and severe for all patients. After myotomy, the frequency and severity of all symptoms of achalasia significantly decreased for all patients ( P < 0.001, Wilcoxon matched pairs test). Notably, relative to patients undergoing laparoscopic Heller myotomy alone, concomitant anterior fundoplication led to significantly less frequent and severe heartburn after myotomy ( P < 0.05, Mann-Whitney Test) and to less frequent and severe dysphagia and choking ( P < 0.05, Mann-Whitney Test). Laparoscopic Heller myotomy reduces the frequency and severity of symptoms of achalasia. Concomitant anterior fundoplication decreases the frequency and severity of heartburn and dysphagia after laparoscopic Heller myotomy. Concomitant anterior fundoplication promotes salutary relief in the frequency and severity of symptoms after myotomy and is warranted.
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Affiliation(s)
- Donovan Tapper
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Connor Morton
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Emily Kraemer
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Desiree Villadolid
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Sharona B. Ross
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Sarah M. Cowgill
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Alexander S. Rosemurgy
- From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
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11
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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.
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Affiliation(s)
- Joel E Richter
- Department of Medicine, Temple University School of Medicine, 3401, North Broad Street, 801 Parkinson Pavilion, Philadelphia, PA 19140, USA.
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Parshad R, Hazrah P, Saraya A, Garg P, Makharia G. Symptomatic outcome of laparoscopic cardiomyotomy without an antireflux procedure: experience in initial 40 cases. Surg Laparosc Endosc Percutan Tech 2008; 18:139-143. [PMID: 18427330 DOI: 10.1097/sle.0b013e318168db86] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The aim of surgical treatment in achalasia cardia is symptom relief. Most studies have evaluated the results of laparoscopic cardiomyotomy with an antireflux procedure. However, data on the effectiveness of laparoscopic cardiomyotomy without an antireflux procedure is sparse. We describe our experience of laparoscopic cardiomyotomy without antireflux procedure in 40 consecutive patients with respect to symptom relief and complications. There was no mortality and 1 conversion. Preoperatively dysphagia, regurgitation, and heartburn were present in 40, 39, and 11 patients. At a mean follow-up of 26 months, there was a significant improvement in symptom scores. Two patients (5%) had persistent postoperative dysphagia. One improved on conservative therapy, whereas other was treated with relaparoscopic cardiomyotomy. Three patients (7.5%) developed heartburn in the postoperative period, which was well controlled with proton pump inhibitors. Laparoscopic cardiomyotomy without antireflux procedure results in excellent relief of dysphagia without producing significant symptomatic reflux in the follow-up.
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Affiliation(s)
- Rajinder Parshad
- Department of Surgery, All India Institute of Medical Sciences, New Delhi, India.
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13
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Cowgill SM, Villalodid D, Al-Saadi S, Hedgecock J, Rosemurgy AS. Postmyotomy recollection of premyotomy symptoms of achalasia is very accurate, supporting longitudinal studies of symptom improvement. Surg Endosc 2007; 21:2183-6. [PMID: 17522934 DOI: 10.1007/s00464-007-9332-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Revised: 10/17/2006] [Accepted: 01/05/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recollection of preoperative symptom frequency and severity may change postoperatively, thus invalidating longitudinal studies. This study was undertaken to compare symptoms of achalasia before myotomy to patients' postoperative recollection of premyotomy symptoms. METHODS A total of 173 patients, 54% male, of median age 48 years, have undergone laparoscopic Heller myotomy and have been followed through a prospectively maintained registry. Preoperatively, patients scored the frequency and severity of their symptoms on a Likert scale: 0 (never/very bothersome) to 10 (always/very bothersome). Similarly, after laparoscopic Heller myotomy, patients scored the frequency and severity of their symptoms, and re-scored their preoperative symptoms. Data are presented as median, mean +/- SD. RESULTS Before myotomy, dysphagia, regurgitation, choking, chest pain, vomiting, and heartburn were particularly notable; symptom scores nearly globally improved after myotomy (p < 0.05 for all, Wilcoxon matched pairs test), especially obstructive symptoms. Postmyotomy recollection of premyotomy symptom frequency and severity was neither substantively nor consistently different from premyotomy scoring. CONCLUSIONS Before myotomy, patient symptom scores reflected the deleterious impact of achalasia. After myotomy, patient symptom scores dramatically improved, reflecting the favorable impact of laparoscopic Heller myotomy. Even years after myotomy, patient recollection of premyotomy symptom severity and frequency is very accurate and supports longitudinal studies of symptom improvement after myotomy.
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Affiliation(s)
- S M Cowgill
- Digestive Disorders Center, Tampa General Hospital, and Department of Surgery, University of South Florida College of Medicine, P.O. Box 1289, Rm F145, Tampa, Florida 33601, USA
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14
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Rakita S, Villadolid D, Kalipersad C, Thometz D, Rosemurgy A. Outcomes promote reoperative Heller myotomy for symptoms of achalasia. Surg Endosc 2007; 21:1709-14. [PMID: 17440784 DOI: 10.1007/s00464-007-9226-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Revised: 09/25/2006] [Accepted: 11/20/2006] [Indexed: 01/27/2023]
Abstract
BACKGROUND Heller myotomy is accepted as first-line therapy for achalasia, yet for a small number of patients, symptoms persist or recur after myotomy. This study was undertaken to report our results with reoperative laparoscopic Heller myotomy for recurrent symptoms of achalasia. METHODS We have undertaken laparoscopic Heller myotomy in 275 patients and reoperative myotomy in 12 patients for recurrent dysphagia, of which three had their initial myotomy undertaken by us. For each, studies prior to reoperative Heller myotomy documented a nonrelaxing lower esophageal sphincter without stricture. Patients scored symptoms before and after reoperative myotomy. RESULTS Before reoperative myotomy, 75% underwent dilation and 42% underwent Botox injection. Ten of twelve reoperative myotomies were undertaken and completed laparoscopically. Median follow-up is 24.1 months (29.0 months + 25.89). Symptom frequency and severity scores improved significantly after reoperative myotomy. Frequency of vomiting and frequency and severity of heartburn were improved after reoperative myotomy, but not to a significant extent. However, they were not particularly notable prior to surgery, compared to obstructive symptoms, such as dysphagia. Excellent or good outcomes were reported in 73%, and notably, 91% stated that they would have the operation again after having been through the process firsthand and knowing their outcomes. CONCLUSION Patient outcomes promote the application of reoperative Heller myotomy for recurrent or persistent symptoms of achalasia following Heller myotomy.
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Affiliation(s)
- S Rakita
- Department of Surgery, University of South 12901 Florida, Bruce B. Downs Blvd., Tampa, Florida 33612, USA.
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15
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Rakita SS, Villadolid D, Kalipersad C, Thometz D, Rosemurgy A. BMI affects presenting symptoms of achalasia and outcome after Heller myotomy. Surg Endosc 2006; 21:258-64. [PMID: 17146597 DOI: 10.1007/s00464-006-0113-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Accepted: 06/07/2006] [Indexed: 01/03/2023]
Abstract
BACKGROUND Obesity has reached epidemic proportions in the United States and worldwide. The impact of obesity on health is increasingly recognized; however, its impact on achalasia has not been established. METHODS The present study was undertaken to determine the impact of body mass index (BMI) on the symptoms of achalasia and outcome after myotomy. In our institution, 262 patients have undergone laparoscopic Heller myotomy and scored their symptoms before and after myotomy on a Likert scale (frequency: 0 = never to 10 = every time I eat/always; severity 0 = not bothersome to 10 = very bothersome). Patients were stratified by BMI > or = 30 kg/m2 or BMI < 30 kg/m2, and preoperative symptom scores and postmyotomy outcomes were compared. RESULTS Patients with BMI > or = 30 had higher symptom scores for frequency of choking and vomiting before myotomy (p < 0.05). All symptom scores improved significantly after myotomy, except heartburn frequency and severity for patients with BMI > or = 30. By regression analysis, increasing BMI tended to exacerbate the frequency of choking and vomiting before myotomy and the frequency of heartburn after myotomy. Among the patients with BMI > or = 30 kg/m2, 73% reported excellent or good outcomes compared to 91% for patients with BMI < 30 kg/m2 (p = 0.02, Fisher's exact test). However, 96% of patients with BMI > or = 30 kg/m2, as well as 93% of patients with BMI < 30 kg/m2 would still elect to have the operation if they were asked to make the decision over again. CONCLUSIONS Although some preoperative symptoms are exacerbated by elevated BMI, all symptoms of achalasia are improved with myotomy, even when undertaken for obese patients.
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Affiliation(s)
- S S Rakita
- Department of Surgery, University of South Florida College of Medicine, Tampa General Hospital, P.O. Box 1289, Room F-145, Tampa, Florida 33601, USA
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16
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Abstract
The goals in the treatment of achalasia are threefold: 1) relieving the symptoms, particularly dysphagia and bland regurgitation; 2) improving esophageal emptying by disrupting the poorly relaxing lower esophageal sphincter (LES); and 3) preventing the development of megaesophagus. Although achalasia cannot be permanently cured, excellent palliation is available in over 90% of patients, especially those with pneumatic dilation and laparoscopic Heller myotomy. The efficacy for short- and long-term therapy seems to be similar when performed by experts. Pneumatic dilation done as an outpatient surgery disrupts the LES muscle from within by using balloons of progressively larger diameter (3.0, 3.5, and 4.0 cm). Repeat dilations may be required; secondary severe gastroesophageal reflux disease (GERD) is rare, but approximately 2% of patients will have an esophageal perforation. A surgical Heller myotomy is now being done laparoscopically through the abdomen that cuts the LES and extends the myotomy 2 to 3 cm onto the stomach. Usually 2 days of hospitalization is required, and patients can normally return to work in 1 to 2 weeks. Severe GERD with esophagitis and peptic stricture is a common complication; therefore, most surgeons combine the myotomy with an incomplete fundoplication. Medical therapy is much less effective than these invasive procedures. Smooth muscle relaxants (nitrates and calcium channel blockers) taken immediately before meals improve dysphagia, but side effects and drug tolerance are common. The injection of botulinum toxin (100 to 200 units) endoscopically into the LES gives short-term relief of symptoms and improves esophageal emptying. This treatment is most effective in the elderly, as symptom relief can last up to 1 to 2 years with a single injection. Several studies suggest the most cost-effective management of achalasia is initial treatment with pneumatic dilation.
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Affiliation(s)
- Joel E Richter
- Temple University School of Medicine, 3420 North Broad Street, Philadelphia, PA 19140, USA.
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Rosemurgy A, Villadolid D, Thometz D, Kalipersad C, Rakita S, Albrink M, Johnson M, Boyce W. Laparoscopic Heller myotomy provides durable relief from achalasia and salvages failures after botox or dilation. Ann Surg 2005; 241:725-33; discussion 733-5. [PMID: 15849508 PMCID: PMC1357127 DOI: 10.1097/01.sla.0000160702.31452.d5] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To report outcome after laparoscopic Heller myotomy in a large number of patients. SUMMARY BACKGROUND DATA Laparoscopic Heller myotomy has been undertaken for over a decade, but most studies involve small numbers of patients with limited follow-up. METHODS Since 1992, 262 patients have undergone laparoscopic Heller myotomy and been prospectively followed. Concomitant fundoplication was undertaken for a patulous hiatus or large hiatal hernia or to buttress the repair of an esophagotomy until recently when it became routinely applied. With mean follow-up at 32 months, symptoms were scored by patients on a Likert scale (frequency: 0 = Never to 10 = Every time I eat/always; severity: 0 = Not bothersome to 10 = Very bothersome). RESULTS Before myotomy, 79% received Botox or bag dilation: 52% had Botox, 59% underwent dilation, and 36% had both. Inadvertent esophagotomy occurred in 5%. Concomitant diverticulectomy was undertaken in 4%, and fundoplication was undertaken in 30%. Complications were infrequent. Median length of stay was 1 day. After myotomy, the frequency and severity of symptoms of achalasia and reflux significantly decreased. Eighty-eight percent of patients felt their symptoms were greatly improved or resolved, and 90% felt their outcome was satisfying or better. Ninety-three percent felt they would undergo myotomy again, if necessary. CONCLUSIONS Laparoscopic Heller myotomy can safely and durably relieve symptoms of dysphagia while also reducing symptoms of reflux. Length of stay is short and patient satisfaction is very high with extended follow-up. Laparoscopic Heller myotomy is strongly encouraged for patients with symptomatic achalasia and is efficacious even after failures of dilation and/or Botox therapy.
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Affiliation(s)
- Alexander Rosemurgy
- Department of Surgery, University of South Florida College of Medicine, Tampa, Florida 33601, USA.
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18
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Rakita S, Bloomston M, Villadolid D, Thometz D, Boe B, Rosemurgy A. Age Affects Presenting Symptoms of Achalasia and Outcomes after Myotomy. Am Surg 2005. [DOI: 10.1177/000313480507100512] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Older patients with achalasia presumably have had a longer, more indolent course than younger patients. This study was undertaken to determine the impact of patient age and duration of symptoms on symptom severity and outcome after Heller myotomy. Two hundred sixty-two patients (142 men and 120 women), of average age 49 years ± 17.7 (SD), have undergone laparoscopic Heller myotomy. Patients scored their symptoms using a Likert scale and subjectively rated their overall outcome. Data are presented as median, mean ± SD, when appropriate. Follow-up is 25 months, 32 months ± 28.7. Symptom severity scores improved after myotomy ( P < 0.001 for all, paired Student's t test). Before myotomy, older patients had less dysphagia, regurgitation, choking, and chest pain ( P < 0.05). Duration of preoperative symptoms did not correlate with frequency of symptoms. After myotomy, older patients had lower scores for dysphagia, chest pain, choking, and heartburn ( P < 0.01); patients with prolonged durations of symptoms had lower dysphagia and choking scores. Neither age nor duration of symptoms had a significant effect on overall subjective outcomes. All patients should expect significant reductions in symptoms of achalasia following myotomy. Age and duration of symptoms impact symptoms before and after myotomy, but neither seem to impact subjective measure of outcome.
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Affiliation(s)
- Steven Rakita
- Department of Surgery, University of South Florida College of Medicine, Tampa, Florida
| | - Mark Bloomston
- Department of Surgery, University of South Florida College of Medicine, Tampa, Florida
| | - Desiree Villadolid
- Department of Surgery, University of South Florida College of Medicine, Tampa, Florida
| | - Donald Thometz
- Department of Surgery, University of South Florida College of Medicine, Tampa, Florida
| | - Brian Boe
- Department of Surgery, University of South Florida College of Medicine, Tampa, Florida
| | - Alexander Rosemurgy
- Department of Surgery, University of South Florida College of Medicine, Tampa, Florida
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Ramacciato G, D'Angelo FA, Aurello P, Del Gaudio M, Varotti G, Mercantini P, Bellagamba R, Ercolani G. Laparoscopic Heller myotomy with or without partial fundoplication: a matter of debate. World J Gastroenterol 2005; 11:1558-1561. [PMID: 15770738 PMCID: PMC4305704 DOI: 10.3748/wjg.v11.i10.1558] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Revised: 09/02/2004] [Accepted: 10/07/2004] [Indexed: 02/06/2023] Open
Abstract
AIM To present our experience of laparoscopic Heller stretching myotomy followed by His angle reconstruction as surgical approach to esophageal achalasia. METHODS Thirty-two patients underwent laparoscopic Heller myotomy; an anterior partial fundoplication in 17, and angle of His reconstruction in 15 cases represented the antireflux procedure of choice. RESULTS There were no morbidity and mortality recorded in both anterior funduplication and angle of His reconstruction groups. No differences were detected in terms of recurrent dysphagia, p.o. reflux or medical therapy. CONCLUSION To reduce the incidence of recurrent achalasia after laparoscopic Heller myotomy, we believe that His' angle reconstruction is a safe and effective alternative to the anterior fundoplication.
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Affiliation(s)
- G Ramacciato
- Facolta' di Medicina e Chirurgia, Universita' degli Studi di Roma La Sapienza, Ospedale Sant'Andrea, UOC Chirurgia D, Via di Grottarossa no. 1035-1037, 00189 Rome, Italy
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20
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Rakita S, Bloomston M, Villadolid D, Thometz D, Zervos E, Rosemurgy A. Esophagotomy during laparoscopic Heller myotomy cannot be predicted by preoperative therapies and does not influence long-term outcome. J Gastrointest Surg 2005; 9:159-64. [PMID: 15694811 DOI: 10.1016/j.gassur.2004.10.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The conventional wisdom is that inadvertent esophagotomy complicates laparoscopic Heller myotomy. This study was undertaken to determine if esophagotomy at myotomy can be predicted by preoperative therapy, and if esophagotomy and/or its repair jeopardizes outcomes. Of 222 laparoscopic Heller myotomies undertaken since 1992, inadvertent esophagotomy occurred in 16 patients (7%); 60 patients who underwent myotomy without esophagotomy were utilized for comparison. Dysphagia and reflux before/after myotomy were scored by patients on a Likert scale (0-5). The median (mean +/- SD) follow-up after myotomy with esophagotomy was 38.8 months (31.6 +/- 21.9 months) versus 46.3 months (51.0 +/- 21.2 months) after myotomy alone. All esophagotomies were immediately recognized and repaired. Patients who experienced esophagotomy were similar to those who did not in application of Botox (56% vs. 77%) or dilation (44% vs. 65%), years of dysphagia (7.3 +/- 5.4 vs. 7.4 +/- 6.0), and mean preoperative dysphagia score (4.9 +/- 0.4 vs. 4.8 +/- 0.4). Esophagotomy led to longer hospitalizations (5.2 days +/- 2.5 days vs. 1.5 days +/- 0.7 days, P < 0.05) but not different postoperative dysphagia scores (1.5 +/- 1.7 vs. 2.1 +/- 1.4), reflux scores (1.4 +/- 1.7 vs. 2.3 +/- 1.3), or good or excellent outcomes (86% vs 84%). Esophagotomy during laparoscopic Heller myotomy is infrequent and cannot be predicted by preoperative therapy or duration or severity of dysphagia. Furthermore, complications after esophagotomy are infrequent and outcomes are indistinguishable from those of patients undergoing uneventful myotomy.
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Affiliation(s)
- Steven Rakita
- Department of Surgery, University of South Florida College of Medicine, Tampa, Florida, USA
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21
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Tello E, de la Garza L, Valdovinos MA, Tielve M, Valdovinos F, Herrera MF. Laparoscopic Heller myotomy for classic achalasia: results of our initial series of 20 patients. Surg Endosc 2005; 19:338-41. [PMID: 15645330 DOI: 10.1007/s00464-003-8285-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2003] [Accepted: 07/29/2004] [Indexed: 01/24/2023]
Abstract
BACKGROUND The aim of this study was to review our results in the surgical management of achalasia by laparoscopic esophageal cardiomyotomy and partial fundoplication. METHODS The patient population was comprised of a consecutive series of 20 patients with classic achalasia who underwent laparoscopic cardiomyotomy and partial fundoplication. Clinical, radiological, and physiological characteristics were analyzed prospectively, with an emphasis on the outcome and complications. RESULTS There were 12 women and eight men; their mean age was 37 years. Four intraoperative complications occurred-two mucosal perforations that were resolved laparoscopically and two cases of pneumothorax. The median hospital stay was 4 days (range, 2-14) and the median time to start oral feeding was 3 days (range, 1-7). After a median follow-up of 14 months (range, 2-83), 16 patients were asymptomatic and four had mild heartburn and/or dysphagia. All patients gained weight (median, 8.0 kg; range, 1-23). We observed a median postoperative decrease in esophageal diameter of 1.6 cm (range, 0.2-2.9). Fifteen patients were subjected to physiological esophageal studies; the results showed that power esophageal sphincter pressure had decreased from 32 (range, 15-60) to 12 mmHg (range, 6-25). The median DeMeester score was 14.5 (range, 0.9-194). The median esophageal acid exposure was 3% (range 0-34.6). CONCLUSIONS Our initial experience with the laparoscopic management of classic achalasia yielded satisfactory clinical, radiological, and physiological results.
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Affiliation(s)
- E Tello
- Department of Surgery, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Tlalpan 14000, Mexico
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22
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Burpee SE, Mamazza J, Schlachta CM, Bendavid Y, Klein L, Moloo H, Poulin EC. Objective analysis of gastroesophageal reflux after laparoscopic heller myotomy: an anti-reflux procedure is required. Surg Endosc 2004; 19:9-14. [PMID: 15531966 DOI: 10.1007/s00464-004-8932-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2004] [Accepted: 06/30/2004] [Indexed: 01/27/2023]
Abstract
BACKGROUND Controversy exists over the necessity of performing a concurrent antireflux procedure with a Heller myotomy. We therefore sought to objectively analyze gastroesophageal reflux following laparoscopic Heller myotomy where an antireflux procedure was not performed. METHODS A prospective database of 66 cases of laparoscopic Heller myotomy performed between November 1996 and June 2002 was reviewed. Previous, concurrent, or subsequent fundoplication was performed in 12 patients; therefore 54 patients without antireflux procedures were available for analysis. Follow-up included symptomatic assessment in 50 patients (93%). Heartburn was assessed on a four-point scale with clinical significance defined as >2 episodes/week. Objective testing, including endoscopy, esophagogram, manometry, and 24-h pH monitoring, was offered to all patients. Objective evidence of reflux was defined as the composite endpoint of positive 24-h pH monitoring or esophagitis on endoscopy. RESULTS Significant heartburn was reported in 15 of 50 patients (30%). Positive 24-h pH recordings were seen in 11 of 22 patients tested while esophagitis was seen in 13 of 21 patients tested, resulting in objective evidence of reflux in 18 of 30 patients tested (60%). Of these 18 patients, seven did not have significant heartburn. All 12 patients without objective reflux did not have significant heartburn. Therefore, of the 30 patients with objective testing, seven (23%) had objective reflux without subjective heartburn (silent reflux). CONCLUSION Objective analysis reveals an unacceptable rate of gastroesophageal reflux in laparoscopic Heller myotomy without an antireflux procedure. We therefore recommend performing a concurrent antireflux procedure.
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Affiliation(s)
- S E Burpee
- The Centre for Minimally Invasive Surgery, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
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Frantzides CT, Moore RE, Carlson MA, Madan AK, Zografakis JG, Keshavarzian A, Smith C. Minimally invasive surgery for achalasia: a 10-year experience. J Gastrointest Surg 2004; 8:18-23. [PMID: 14746831 DOI: 10.1016/j.gassur.2003.09.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Minimally invasive esophagomyotomy for achalasia has become the preferred surgical treatment; the employment of a concomitant fundoplication with the myotomy is controversial. Here we report a retrospective analysis of 53 patients with achalasia treated with laparoscopic Heller myotomy; fundoplication was used in all patients except one, and 48 of the fundoplications were complete (floppy Nissen). There were no deaths or reoperations, and minor complications occurred in three patients. Good-to-excellent long-term results were obtained in 92% of the subjects (median follow-up 3 years). Two cases (4%) of persistent postoperative dysphagia were documented, one of which was treated with dilatation. Postoperative reflux occurred in five patients, four of whom did not receive a complete fundoplication; these patients were well controlled with medical therapy. We suggest that esophageal achalasia may be successfully treated with laparoscopic Heller myotomy and floppy Nissen fundoplication with an acceptable rate of postoperative dysphagia.
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Abstract
Achalasia is a rare neurologic deficit of the esophagus, producing a syndrome of impaired relaxation of the lower esophageal sphincter and decreased motility of the esophageal body for which the cause is unknown. The resultant chronic esophageal stasis produces discomforting symptoms that can be managed with medication, chemical paralysis of the lower esophageal sphincter, mechanical dilation, or surgical esophagomyotomy. Chemical paralysis by injection of the esophagus with botulinum toxin and dilation with an inflatable balloon offers good short-term relief of symptoms; however, the best long-term results are produced by surgery, and advancing minimally invasive techniques continually reduce the morbidity of these operations. The type of surgical procedure, the necessity for fundoplication, and the order of treatment continue to be unresolved issues, but prospective evaluation with objective followup should allow us to provide the optimal treatment regimen to our patients.
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Affiliation(s)
- Shawn D St Peter
- Department of General Surgery, Mayo Clinic Scottsdale, Arizona, USA
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