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Redo laparoscopic Heller myotomy and Dor fundoplication versus rescue peroral endoscopic myotomy for esophageal achalasia after failed Heller myotomy: a single-institution experience. Surg Today 2021; 52:401-407. [PMID: 34535816 DOI: 10.1007/s00595-021-02376-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/06/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To compare the surgical outcomes of redo laparoscopic Heller-Dor procedure and rescue peroral endoscopic myotomy for patients with failed Heller myotomy. METHODS We identified patients who had undergone redo laparoscopic Heller-Dor procedure or rescue peroral endoscopic myotomy from August 1996 to September 2019 and assessed the patients' characteristics, timed barium swallow results, symptom scores before/after surgery, surgical outcomes, and postoperative outcomes. RESULTS Eleven patients underwent redo laparoscopic Heller-Dor procedure, and 14 underwent rescue peroral endoscopic myotomy. Blood loss (p = 0.001) and intraoperative complications rate (p = 0.003) were lower and the operative time (p > 0.001) and observation period (p = 0.009) shorter in patients who underwent rescue peroral endoscopic myotomy than in patients who underwent redo laparoscopic Heller-Dor procedure. Patients who underwent rescue peroral endoscopic myotomy had a higher rate of postoperative reflux esophagitis (p = 0.033) than those who underwent redo laparoscopic Heller-Dor procedure. After the interventions, the dysphagia symptoms were improved for both groups. Furthermore, both groups expressed satisfaction with their respective procedures. CONCLUSIONS Rescue peroral endoscopic myotomy was associated with better surgical outcomes than redo laparoscopic Heller-Dor for patients with failed Heller myotomy. However, rescue peroral endoscopic myotomy had higher rates of postoperative reflux esophagitis.
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Downs DJ, Jadick G, Swaid F, Ross SB, Rosemurgy AS. Age and Achalasia: How Does Age Affect Patient Presentation, Hospital Course, and Surgical Outcomes? Am Surg 2017. [DOI: 10.1177/000313481708300931] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Heller myotomy is the “gold-standard” therapy for achalasia, alleviating symptoms by defunctionalizing the lower esophageal sphincter mechanism. Observation has suggested many differences between young and old patients with achalasia, raising the question: is achalasia in younger patients a different disorder than it is in older patients? This study was undertaken to answer this question. With Institutional Review Board approval, 648 patients undergoing laparoscopic Heller myotomy from 1992–2016 were prospectively followed up. Patients self-assessed symptom frequency/severity preoperatively and postoperatively using a Likert scale; 0 (never/not bothersome) to 10 (always/very bothersome). Before myotomy, frequency/severity of many symptoms (e.g., “dysphagia,” “chest pain,” and “regurgitation”) inversely correlated with age (P < 0.01 each). Symptom duration and the number of previous abdominal operations correlated with age, as did intraoperative complications (e.g., gastrotomy), postoperative complications (e.g., atrial fibrillation), and length of stay (P < 0.01 for each). Patients experienced amelioration of all symptoms queried, regardless of age (P < 0.01 each). Age did affect outcome because older patients had less frequent and severe symptoms. Age did not affect improvement of symptoms (e.g., dysphagia) (i.e., differences between preoperative and postoperative scores) (P = 0.88). Age did not influence symptom resolution or patient satisfaction (P = 0.98 and P = 0.15, respectively). The presentation with achalasia, hospital course, and outcome after myotomy are significantly impacted by age, whereas patient improvement after myotomy is constant independent of age. Younger and older patients have different presentations, experiences, and outcomes; these patients seem to have “different disorders”, but Heller myotomy provides similar significant amelioration of symptoms independent of age.
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Affiliation(s)
- Darrell J. Downs
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Giavanna Jadick
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Forat Swaid
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Sharona B. Ross
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Alexander S. Rosemurgy
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery, Florida Hospital Tampa, Tampa, Florida
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Rosemurgy A, Downs D, Jadick G, Swaid F, Luberice K, Ryan C, Ross S. Dissatisfaction after laparoscopic Heller myotomy: The truth is easy to swallow. Am J Surg 2017; 213:1091-1097. [PMID: 28396032 DOI: 10.1016/j.amjsurg.2017.03.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 02/24/2017] [Accepted: 03/29/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although laparoscopic Heller myotomy has been shown to well palliate symptoms of achalasia, we have observed a small subset of patients who are "Dissatisfied". This study was undertaken to identify the causes of their dissatisfaction. STUDY DESIGN Patients undergoing laparoscopic Heller myotomy from 1992 to 2015 were prospectively followed. Using a Likert scale, patients rated their symptom frequency/severity before and after the procedure. Patients graded their experience from "Very Satisfying" to "Very Unsatisfying." RESULTS 647 patients underwent laparoscopic Heller myotomy. Fifty (8%) patients, median age 57 years and BMI 24 kg/m2 reported dissatisfaction at follow-up subsequent to myotomy. "Dissatisfied" patients were more likely to have undergone prior abdominal operations (p = 0.01) or previous myotomies (p = 0.02). "Dissatisfied" patients had a greater incidence of diverticulectomy (p = 0.03) and had longer postoperative LOS (p = 0.01). Symptom frequency/severity persisted after myotomy for dissatisfied patients (p > 0.05). CONCLUSION Dissatisfaction after laparoscopic Heller myotomy is directly related to persistent/recurrent symptoms. Previous abdominal operations/myotomies, diverticulectomies, and longer LOS are predictors of dissatisfaction. With this understanding, we can identify patients who might be more prone to dissatisfaction.
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Affiliation(s)
- Alexander Rosemurgy
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA.
| | - Darrell Downs
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Giavanna Jadick
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Forat Swaid
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Kenneth Luberice
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Carrie Ryan
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Sharona Ross
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
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Yeung JC, Finley C, Hanna WC, Miller L, Ferri L, Urbach DR, Darling GE. Treatment choices and outcomes of patients with manometrically diagnosed achalasia. Dis Esophagus 2016; 29:472-8. [PMID: 25809620 DOI: 10.1111/dote.12348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This prospective population-based study was designed to evaluate treatment choices in patients with new manometrically diagnosed achalasia and their outcomes. Patients referred to the esophageal function laboratory were enrolled after a new manometric diagnosis of achalasia. Patients completed an initial achalasia symptom score validated questionnaire on their symptom severity, duration, treatment pre-diagnosis and Medical Outcomes Study 36-item Short-Form (SF-36) survey. Treatment decisions were made by the referring physician and the patient. Follow-up questionnaires were completed every 3 months for 1 year. Patients who chose not to undergo treatment at 1-year follow-up completed another questionnaire after 5 years. Between January 2004 and January 2005, 83 of 124 eligible patients were enrolled. Heller myotomy was performed on 31 patients, three patients received botulinum toxin injections, and 25 patients received 29 pneumatic balloon dilatations. Twenty-four patients chose to receive no treatment. Following treatment, patients treated with surgery, dilatation and botulinum toxin had an average improvement in achalasia symptom score of 23 +/- 12.2, 17 +/- 10.9, and 9 +/- 14, respectively. Patients receiving no treatment had worsening symptoms with a symptom score change of -3.5 +/- 11.4. Surgery and dilatation resulted in significant improvement (P < 0.01) relative to no treatment. In univariate logistic regression, symptom severity score (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.00 to 1.08), sphincter tone (OR 1.04, 95% CI 1.00 to 1.09), difficulty swallowing liquids (OR 3.21, 95% 1.15 to 8.99), waking from sleep (OR 2.75, 95% 1.00 to 7.61), and weight loss (OR 5.99, 95% CI 1.93 to 18.58) were all significant in predicting that patients would select treatment. In the multivariate analysis, older age (OR 1.05, 95% CI 1.01 to 1.09) and weight loss (OR 3.91, 95% CI 1.02 to 15.2) were statistically significant for undergoing treatment. At 5 years, five (21%) of those who had initially declined treatment at 1 year ultimately chose a treatment. Patients who finally chose Heller myotomy had lower mental component dimension scores on the SF-36 at 1 year than those who did not. This study shows that almost one third of patients with manometrically diagnosed achalasia choose not to undergo treatment within 1 year of their diagnosis. Patients who are more symptomatic appear to be more likely to undergo treatment by univariate analysis. In multivariate analysis, increasing age and weight loss are predictive of those who will undergo treatment, with weight loss having the greatest influence. Patients who choose not to undergo treatment make lifestyle changes to maintain their quality of life, and only a minority of them ultimately undergo treatment.
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Affiliation(s)
- J C Yeung
- Division of Thoracic Surgery, University of Toronto, Toronto, Canada
| | - C Finley
- Division of Thoracic Surgery, McMaster University, Hamilton, Canada
| | - W C Hanna
- Division of Thoracic Surgery, McMaster University, Hamilton, Canada
| | - L Miller
- Division of Thoracic Surgery, University of Toronto, Toronto, Canada
| | - L Ferri
- Division of Thoracic Surgery, McGill University, Montreal, Canada
| | - D R Urbach
- Division of General Surgery, University of Toronto, Toronto, Canada
| | - G E Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, Canada
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Tsuboi K, Omura N, Yano F, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Kashiwagi H, Yanaga K. Data analyses and perspectives on laparoscopic surgery for esophageal achalasia. World J Gastroenterol 2015; 21:10830-10839. [PMID: 26478674 PMCID: PMC4600584 DOI: 10.3748/wjg.v21.i38.10830] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [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.
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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.
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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
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Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention. J Gastrointest Surg 2013; 17:1188-92. [PMID: 23609138 DOI: 10.1007/s11605-013-2193-6] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 03/27/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE We aimed to determine the safety and feasibility of peroral endoscopic myotomy (POEM) in the setting of prior endoscopic interventions. PATIENTS This study involves 40 consecutive patients undergoing POEM. INTERVENTION POEM was performed for esophageal motility disorders, including achalasia, nutcracker with nonrelaxing lower esophageal sphincter (LES), hypertensive lower esophageal sphincter, and diffuse esophageal spasm. MAIN OUTCOME MEASURES Outcome measures include length of procedure (LOP), intraoperative complications, and dysphagia relief. RESULTS Forty patients, with a mean age of 54 ± 19 years, underwent POEM. The pre-POEM intervention group consisted of 12 patients (nine achalasia, two nutcracker with nonrelaxing LES, and one diffuse esophageal spasm) who also had previous endoscopic treatment, while the pre-POEM non-intervention group consisted of 28 patients (22 achalasia, 3 hypertensive LES, 2 nutcracker with nonrelaxing LES, and 1 diffuse esophageal spasm). Ten patients had botox injections and two patients had large caliber balloon dilations prior to POEM. The median preoperative Eckardt score was 5 in the pre-POEM intervention group vs 6 in the pre-POEM non-intervention group (p value = 0.4). There was no statistical difference in the mean LOP (134 ± 43 vs 131 ± 41, p = 0.8) or the incidence of intraoperative complications (17 vs 3 %, p = 0.2) between the two groups. There was also no difference in the 6-month postoperative median Eckardt scores between the two groups (1 vs 1, p = 0.4). CONCLUSION POEM is safe and effective even following preoperative endoscopic large caliber balloon dilations or botox injection. These interventions do not seem to contribute to increased adverse intraoperative or postoperative clinical outcomes.
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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.
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Affiliation(s)
- Cynthia E Weber
- Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL 60153, USA
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Craft RO, Aguilar BE, Flahive C, Merritt MV, Chapital AB, Schlinkert RT, Harold KL. Outcomes of minimally invasive myotomy for the treatment of achalasia in the elderly. JSLS 2011; 14:342-7. [PMID: 21333185 PMCID: PMC3041028 DOI: 10.4293/108680810x12924466007368] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Laparoscopic Heller myotomy can safely be performed in elderly patients and can provide significant symptom relief. Background: An increasing number of elderly patients diagnosed with achalasia are being referred for minimally invasive myotomy. Little data are available about the operative outcomes in this population. The objective of this study was to review our experience with this procedure in an elderly population. Methods: A retrospective review was performed of 51 consecutive patients, 65 years of age or older, diagnosed with achalasia who underwent a minimally invasive myotomy at our institution. Prior therapies, perioperative outcomes, and postoperative interventions were also analyzed. Results: Of the 51 patients, 28 (55%) had undergone prior endoscopic therapy, and 2 patients (7%) had a prior myotomy. Mean duration of symptoms was 10.9 years (range, 0.5 to 50). No perioperative mortality occurred, and the median hospital stay was 3 days. Two patients (3.8%) had complications, including a gastric mucosal injury and one atelectasia. Eleven patients (21%) required additional therapy postoperatively. Symptom improvement was described in all patients. Conclusion: Laparoscopic Heller myotomy can safely be performed in elderly patients, providing significant symptom relief. No evidence suggests that surgery should not be considered a first-line treatment. Advanced age does not appear to adversely affect outcomes of laparoscopic Heller myotomy.
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Affiliation(s)
- Randall O Craft
- Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, Arizona 85054, USA
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Ponticelli C, Colombo D, Novara M, Basilisco G. Gastrointestinal symptoms impair quality of life in Italian renal transplant recipients but are under-recognized by physicians. Transpl Int 2010; 23:1126-34. [DOI: 10.1111/j.1432-2277.2010.01115.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nenshi R, Takata J, Stegienko S, Jacob B, Kortan P, Deitel W, Laporte A, Darling G, Urbach DR. The cost of achalasia: quantifying the effect of symptomatic disease on patient cost burden, treatment time, and work productivity. Surg Innov 2010; 17:291-4. [PMID: 20647236 DOI: 10.1177/1553350610376392] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Although the incidence of achalasia is low, the burden of suffering is high because it is a chronic incurable disease that predominantly affects young persons. This article aims to describe the impact of achalasia on health-related quality of life, patient cost burden, time dedicated to treatment, and work productivity. METHODS Consecutive patients enrolled in a clinical trial comparing laparoscopic myotomy with pneumatic dilatation from 4 sites across Canada (whose clinical and manometric diagnosis was confirmed) were studied using standardized patient-reported outcomes instruments, including the Achalasia Severity Questionnaire (ASQ), the Medical Outcomes Study 36-item Short Form Questionnaire (SF-36), and the Gastrointestinal Disease-Specific Quality of Life (GIQLI) questionnaire. The authors also measured health care utilization. RESULTS Questionnaires were completed by 54 patients (median age = 53.5 years; range = 25-78 years; 50.0% male). Patients had been experiencing symptoms for a mean of 4.5 years (standard deviation = 6.1), and 42.6% were on medication for symptom relief. Among them, 74.1% reported that their disease limited their lifestyle. Patients spent an average of CAD$30.70 a month on medication; 37.0% reported that their disease interfered with their work, and patients missed an average of 10.2 days per 6 months. Patients also spent an average of CAD$24.30 on transportation to and from each clinical appointment. CONCLUSION Achalasia substantially limits the lifestyle of patients with the disease. It also implies a financial burden of care for patients and leads to decreased work productivity.
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Garrigues V, Ortiz V, Casanova C, Bujanda L, Moreno-Osset E, Rodríguez-Téllez M, Montserrat A, Brotons A, Fort E, Ponce J. Disease-specific health-related quality of life in patients with esophageal achalasia before and after therapy. Neurogastroenterol Motil 2010; 22:739-745. [PMID: 20482702 DOI: 10.1111/j.1365-2982.2010.01515.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND To evaluate disease-specific health-related quality of life (HRQoL) in patients with symptomatic esophageal achalasia before and after therapy. METHODS Symptoms and disease-specific HRQoL were evaluated before and 3 months after therapy. Therapy selection, either dilatation or myotomy, depended exclusively on the opinion of the physician on charge of the patient. Symptom severity was graded from 0 to 3, using a scoring system. A disease-specific questionnaire for achalasia developed and validated in Spanish language with 18 items and four subscales (AE-18) was used to evaluate HRQoL. Changes after therapy in HRQoL and its association with clinical improvement were analyzed. KEY RESULTS Sixty-five patients were prospectively included in eight hospitals in Spain. Of them, 47 were treated with dilatation, and 18 with laparoscopic Heller myotomy. After therapy, AE-18 global and subscales scores improved significantly. Changes in HRQoL were associated with improvement in symptoms. An important improvement in symptoms (>or=50%) was needed to obtain a minimal clinically important improvement (>or=20%) in HRQoL. CONCLUSIONS & INFERENCES Disease-specific HRQoL improves in patients with symptomatic achalasia after therapy with dilatation or myotomy. The degree of improvement of HRQoL depends on the degree of improvement of esophageal symptoms.
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Affiliation(s)
- V Garrigues
- Servicio de Medicina Digestiva, Hospital Universitari La Fe, Valencia, Spain.
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Roll GR, Ma S, Gasper WJ, Patti M, Way LW, Carter J. Excellent outcomes of laparoscopic esophagomyotomy for achalasia in patients older than 60 years of age. Surg Endosc 2010; 24:2562-6. [PMID: 20361213 PMCID: PMC2945469 DOI: 10.1007/s00464-010-1003-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 11/12/2009] [Indexed: 12/15/2022]
Abstract
Background The effectiveness of an esophagomyotomy for dysphagia in elderly patients with achalasia has been questioned. This study was designed to provide an answer. Methods A total of 162 consecutive patients with achalasia who had a laparoscopic myotomy and Dor fundoplication and who were available for follow-up interview were divided by age: <60 years (range, 14–59; 118 patients), and ≥60 years (range, 60–93; 44 patients). Primary outcome measures were severity of dysphagia, regurgitation, heartburn, and chest pain before and after the operation as assessed on a four-point Likert scale, and the need for postoperative dilatation or revisional surgery. Results Follow-up averaged 64 months. Older patients had less dysphagia (mean score 3.6 vs. 3.9; P < 0.01) and less chest pain (1.0 vs. 1.8; P < 0.01). Regurgitation (3.0 vs. 3.2; P = not significant (NS)) and heartburn (1.6 vs. 2.0, P = NS) were similar. Older patients were no different in degree of esophageal dilation, manometric findings, number of previous pneumatic dilatations, or previous botulinum toxin therapy. None of the older patients had previously had an esophagomyotomy, whereas 14% of younger patients had (P < 0.01). After laparoscopic myotomy, older patients had better relief of dysphagia (mean score 1.0 vs 1.6; P < 0.01), less heartburn (0.8 vs. 1.1; P = 0.03), and less chest pain (0.2 vs. 0.8, P < 0.01). Complication rates were similar. Older patients did not require more postoperative dilatations (22 patients vs. 10 patients; P = 0.7) or revisional surgery for recurrent or persistent symptoms (3 vs. 1 patients; P = 0.6). Satisfaction scores did not differ, and more than 90% of patients in both groups said in retrospect they would have undergone the procedure if they had known beforehand how it would turn out. Conclusions This retrospective review with long follow-up supports laparoscopic esophagomyotomy as first-line therapy in older patients with achalasia. They appeared to benefit even more than younger patients.
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Affiliation(s)
- Garrett R Roll
- Department of Surgery, University of California San Francisco, 521 Parnassus Avenue, Room C-347, San Francisco, CA 94143, USA
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Excellent outcomes of laparoscopic esophagomyotomy for achalasia in patients older than 60 years of age. Surg Endosc 2010. [PMID: 20361213 DOI: 10.1007/s00464-010-1003-4.] [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 The effectiveness of an esophagomyotomy for dysphagia in elderly patients with achalasia has been questioned. This study was designed to provide an answer. METHODS A total of 162 consecutive patients with achalasia who had a laparoscopic myotomy and Dor fundoplication and who were available for follow-up interview were divided by age: < 60 years (range, 14-59; 118 patients), and ≥ 60 years (range, 60-93; 44 patients). Primary outcome measures were severity of dysphagia, regurgitation, heartburn, and chest pain before and after the operation as assessed on a four-point Likert scale, and the need for postoperative dilatation or revisional surgery. RESULTS Follow-up averaged 64 months. Older patients had less dysphagia (mean score 3.6 vs. 3.9; P < 0.01) and less chest pain (1.0 vs. 1.8; P < 0.01). Regurgitation (3.0 vs. 3.2; P = not significant (NS)) and heartburn (1.6 vs. 2.0, P = NS) were similar. Older patients were no different in degree of esophageal dilation, manometric findings, number of previous pneumatic dilatations, or previous botulinum toxin therapy. None of the older patients had previously had an esophagomyotomy, whereas 14% of younger patients had (P < 0.01). After laparoscopic myotomy, older patients had better relief of dysphagia (mean score 1.0 vs 1.6; P < 0.01), less heartburn (0.8 vs. 1.1; P = 0.03), and less chest pain (0.2 vs. 0.8, P < 0.01). Complication rates were similar. Older patients did not require more postoperative dilatations (22 patients vs. 10 patients; P = 0.7) or revisional surgery for recurrent or persistent symptoms (3 vs. 1 patients; P = 0.6). Satisfaction scores did not differ, and more than 90% of patients in both groups said in retrospect they would have undergone the procedure if they had known beforehand how it would turn out. CONCLUSIONS This retrospective review with long follow-up supports laparoscopic esophagomyotomy as first-line therapy in older patients with achalasia. They appeared to benefit even more than younger patients.
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Ortiz I, Targarona EM, Pallares L, Marinello F, Balague C, Trias M. Calidad de vida y resultados a largo plazo de las reintervenciones efectuadas por laparoscopia tras cirugía del hiato esofágico. Cir Esp 2009; 86:72-8. [DOI: 10.1016/j.ciresp.2009.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Accepted: 02/20/2009] [Indexed: 12/29/2022]
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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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Abstract
AIM: To evaluate the efficacy and safety of Heller myotomy (HM) for recurrent achalasia, performed after different methods of first-line treatment.
METHODS: We searched for studies published in PubMed from 1966 to March 2008 on treatment of recurrent achalasia with HM after failure with different methods of first-line treatment. The efficacy of HM was assessed by a pooled estimate of response rate with individual studies weighted proportionally to sample size.
RESULTS: Sixteen studies were eligible and included in the review. The results showed that HM has a better remission rate for recurrent achalasia after failure of HM [weighted mean (SD)] of 86.9% (21.8%) compared with 81.6% (23.8%) for pneumatic dilatation (PD). One study evaluated the efficacy of HM after failure of PD combined with botulinum toxin injection (83%). The most common complications were perforation and gastroesophageal reflux.
CONCLUSION: HM has the best efficacy in patients with recurrent achalasia who were treated with HM as first-line treatment. Future studies should focus on how to increase the success rate and decrease the complications of HM.
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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.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan.
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