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1
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Mustian M, Wong K. Surgical management of achalasia. Abdom Radiol (NY) 2025; 50:2351-2357. [PMID: 39585375 PMCID: PMC12069126 DOI: 10.1007/s00261-024-04664-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2024] [Revised: 10/25/2024] [Accepted: 10/28/2024] [Indexed: 11/26/2024]
Abstract
Achalasia is a chronic esophageal motility disorder comprised of ineffective esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter. This disease had historically been managed through medical means as well as endoscopic dilations. However, surgical interventions are now considered standard of care, including minimally invasive Heller myotomy, which was popularized in 1990s, followed by per oral endoscopic myotomy in the 2010s. Both surgical approaches provide acceptable resolution of dysphagia symptoms. Classification of the achalasia as well as other patient-level factors may drive the clinical decision-making between the two approaches, as well as surgical training and surgeon preference.
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Affiliation(s)
- Margaux Mustian
- University of Alabama at Birmingham, Birmingham, USA.
- Birmingham VA Medical Center, Birmingham, USA.
| | - Kristen Wong
- University of Alabama at Birmingham, Birmingham, USA
- Birmingham VA Medical Center, Birmingham, USA
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Diab ARF, Sujka JA, Mitra C, Hamza A, Ananthan YD, Docimo S, DuCoin CG. Short Versus Long Myotomy Length in Peroral Endoscopic Myotomy for Achalasia: Comparable Efficacy with Potential Reduction in Incidence of Reflux-A Meta-Analysis of 10 Comparative Studies. J Laparoendosc Adv Surg Tech A 2025; 35:300-312. [PMID: 40173097 DOI: 10.1089/lap.2024.0397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2025] Open
Abstract
Background: Shortening the myotomy length during peroral endoscopic myotomy (POEM) for achalasia has been hypothesized to reduce gastroesophageal reflux disease (GERD) incidence while maintaining procedural efficacy. This meta-analysis compares the outcomes of short POEM (S-POEM) and long POEM (L-POEM). Methods: A systematic review adhering to PRISMA guidelines identified studies directly comparing S-POEM and L-POEM. Study quality was assessed using the Risk of Bias in Non-randomized Studies of Interventions and Revised Cochrane Risk of Bias for Randomized Trials tools. A pairwise meta-analysis was conducted using the random-effects model. Results: In perioperative outcomes, S-POEM significantly reduced operative time and required fewer clips compared with L-POEM, with no significant differences in adverse events or length of stay. Regarding GERD-related outcomes, S-POEM demonstrated a statistically significant reduction in abnormal esophageal acid exposure on 24-hour pH-impedance testing, with a number needed to treat of 10. While the reduction in symptomatic GERD did not reach statistical significance (P = .06), the P value was very close to the threshold for significance (.05), and all seven included studies reported decreased symptomatic GERD with S-POEM. This is therefore considered a noteworthy finding. The rates of esophagitis and lower esophageal sphincter pressure did not differ significantly between the groups. Efficacy-related outcomes, including clinical success, Eckardt score, and barium height at 5 minutes, were comparable between S-POEM and L-POEM. However, integrated relaxation pressure was significantly higher in the S-POEM group. Conclusions: This study suggests that shortening the myotomy length may reduce GERD incidence following POEM without compromising its efficacy in achalasia treatment. In addition, a shorter myotomy length decreases operative time, potentially reducing time-related costs and improving workflow.
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Affiliation(s)
- Abdul-Rahman Fadi Diab
- University of Central Florida College of Medicine/HCA Healthcare GME Consortium, Ocala, Florida, USA
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Joseph Adam Sujka
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Chandan Mitra
- University of Central Florida College of Medicine/HCA Healthcare GME Consortium, Ocala, Florida, USA
| | - Alan Hamza
- University of Central Florida College of Medicine/HCA Healthcare GME Consortium, Ocala, Florida, USA
| | - Yasotha Diana Ananthan
- University of Central Florida College of Medicine/HCA Healthcare GME Consortium, Ocala, Florida, USA
- Heart of Florida Health Center, Ocala, Florida, USA
| | - Salvatore Docimo
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Christopher Garnet DuCoin
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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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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Gopakumar H, Annor E, Vohra I, Andalib I, Tyberg A, Sarkar A, Shahid H, Carames M, Carames JC, Gularte GP, Al-Lehibi A, Alkhiari R, Bapaye A, Robles-Medranda C, Kahaleh M. Peroral endoscopic myotomy with fundoplication (POEM-F) for achalasia: Systematic review and meta-analysis. Endosc Int Open 2025; 13:a25368132. [PMID: 40109323 PMCID: PMC11922173 DOI: 10.1055/a-2536-8132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Accepted: 01/30/2025] [Indexed: 03/22/2025] Open
Abstract
Background and study aims Gastroesophageal reflux (GER) and its long-term sequelae remain a concern following peroral endoscopic myotomy (POEM). POEM with fundoplication (POEM-F) is simultaneous fundoplication via pure natural orifice transluminal endoscopic surgery (NOTES). In this study, we evaluated the efficacy and safety of POEM-F in mitigating post-POEM GER. Methods We performed a comprehensive electronic database search from January 2008 through June 2024 for studies evaluating outcomes of POEM-F performed for managing post-POEM GER. Pooled proportions were calculated using random-effects models. Heterogeneity was assessed using I 2 and Q statistics. Results We included seven studies comprising 127 patients. Pooled technical success for POEM was 96.90%; 95% confidence interval [CI] 91.40-98.90. Pooled technical success of fundoplication was 92.30%; 95% CI 85.20-96.10. Clinical success in treating achalasia was 96.40%; 95% CI 90.70-98.60. Rate of wrap integrity on follow-up was 84.00%; 95% CI 66.00-93.40. Composite clinical success of POEM-F in mitigating post-POEM GER was 86.20%; 95% CI 73.80-93.20. Mean total procedure duration and fundoplication time was 115.74 minutes; 95% CI 103.53-126.96 and 55.28 minutes; 95% CI 47.35-63.20, respectively. The overall pooled major adverse events (AE) rate was 3.60%; 95% CI 1.40-9.40. Conclusions POEM-F is an effective procedure with an acceptable AE rate in expert hands. It appears to offer clinical benefit in mitigating post-POEM GER. However, further standardization for evaluating clinically significant post-POEM GER and long-term benefit of POEM-F is warranted.
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Affiliation(s)
- Harishankar Gopakumar
- Gastroenterology and Hepatology, OSF Saint Joseph Medical Center, Bloomington, United States
- Department of Internal Medicine, University of Illinois Chicago College of Medicine at Peoria, Peoria, United States
| | - Eugene Annor
- Department of Internal Medicine, University of Illinois Chicago College of Medicine at Peoria, Peoria, United States
| | - Ishaan Vohra
- Department of Gastroenterology, University of Illinois Chicago College of Medicine at Peoria, Peoria, United States
| | - Iman Andalib
- Gastroenterology, Hackensack Meridian Hackensack University Medical Center, Hackensack, United States
| | - Amy Tyberg
- Gastroenterology & Hepatology, Hackensack Meridian JFK University Medical Center, Edison, United States
| | - Avik Sarkar
- Gastroenterology & Hepatology, Hackensack Meridian JFK University Medical Center, Edison, United States
| | - Haroon Shahid
- Gastroenterology & Hepatology, Hackensack Meridian JFK University Medical Center, Edison, United States
| | - Mine Carames
- Gastroenterology, Santander Hospital, Bucaramanga, Colombia
| | | | - Giovanna Porfilio Gularte
- Gastroenterology, Instituto Misionero de Gastroenterología y Motilidad Digestiva, Posadas, Argentina
| | - Abed Al-Lehibi
- Gastroenterology and Hepatology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Resheed Alkhiari
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Carlos Robles-Medranda
- Gastroenterology, Instituto Ecuatoriano de Enfermedades Digestivas - IECED, Guayaquil, Ecuador
- Endoscopy, Omni Hospital, Guayaquil, Ecuador
| | - Michel Kahaleh
- Gastroenterology, Foundation of Interventional and Therapeutic Endoscopy, New Brunswick, United States
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Wang JT, Sun YX, Li RX, Zhang YF, Ding HX, Wang GJ, Gao BL. Efficacy of laparoscopic cardiectomy combined with side overlap anastomosis for the treatment of terminal achalasia. Sci Rep 2025; 15:1470. [PMID: 39789050 PMCID: PMC11718196 DOI: 10.1038/s41598-024-74143-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 09/24/2024] [Indexed: 01/12/2025] Open
Abstract
To investigate the safety and short-term effectiveness of laparoscopic-assisted cardiectomy with side-overlap esophagogastric reconstruction for the treatment of terminal or end-stage achalasia, patients with end-stage achalasia treated with laparoscopic-assisted cardiectomy with side-overlap esophagogastric reconstruction were retrospectively enrolled. The clinical data, surgical data and follow-up were analyzed. Among twenty-five patients enrolled, the achalasia type St was present in 12 (48%) patients, type Sg in 9 (36%), and type aSg in 4 (16%). The surgical time ranged 60-180 min (median 100 min) with an intraoperative blood loss 20-200 ml (median 50 ml). Five (20%) patients experienced complications within a week after surgery, with fever (> 38.5 ℃) in two (40%) patients within 3 days after surgery, abdominal incision infection in one (20%), and anastomotic leak in two (40%). The postoperative hospitalization time ranged 8-44 (median 10) days. Follow-up was conducted 6-38 months (median 16) after surgery. Compared with the preoperative Eckardt score (7.64 ± 1.32), the Eckardt score was significantly (P < 0.01) decreased at one month (0.52 ± 0.87), 6 (0.84 ± 1.11) and 12 (1.23 ± 1.23) months after surgery in all patients. The Eckardt score in type St was significantly (P < 0.05) smaller than in type Sg or aSg at 6 and 12 months after surgery. Seven patients maintained an Eckardt score 0 with complete relief of their symptoms. The effective rate was 100% for type St, 88.8% for type Sg, and 75% for type aSg. The effective rates at 1 month, 6 and 12 months after surgery were 100% (95% CI: 100% -100%), 96% (95% CI: 87.7 -100%), and 92% (95% CI: 80.6 -100%). Two patients were diagnosed with gastroesophageal reflux disease (GERD) at the end of the follow-up. The cumulative incidence of GERD at 1 month, 6 and 12 months after surgery was 0, 4% (95% confidence interval or CI: 0-12.3%), and 8% (95% CI: 0-19.4%). In conclusion, the laparoscopic-assisted cardiectomy with side-overlap esophagogastric reconstruction is safe and effective for the treatment of end-stage achalasia, and the effect is significantly better for achalasia type St than for types Sg and aSg.
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Affiliation(s)
- Jing-Tao Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Yu-Xiang Sun
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Rui-Xin Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Yun-Fei Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Heng-Xuan Ding
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Guo-Jun Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China.
| | - Bu-Lang Gao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
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Patel J, Kalikar V, Patankar R, Supe A. Is Indocyanine Green the New Gold Standard for Checking Completion of Laparoscopic Heller's Cardiomyotomy? Cureus 2024; 16:e75344. [PMID: 39781145 PMCID: PMC11707402 DOI: 10.7759/cureus.75344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2024] [Indexed: 01/12/2025] Open
Abstract
Achalasia cardia is a primary motility disorder of the esophagus marked by the absence of peristalsis and the failure of the lower esophageal sphincter (LES) to relax during swallowing. The preferred surgical approach is laparoscopic Heller's cardiomyotomy with Dor's fundoplication. Given the significant risks of mucosal perforation and the possibility of incomplete myotomy, which can lead to symptom recurrence, it is essential to ensure both the completeness of the myotomy and the preservation of the mucosal integrity. In this study, we present a case series of 15 patients diagnosed with achalasia cardia who underwent laparoscopic Heller's cardiomyotomy with Dor's fundoplication. Intraoperatively, we utilized intraluminal administration of indocyanine green (ICG) dye as an alternative to endoscopy to assess the completeness of the myotomy and to check for any mucosal perforations.
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Affiliation(s)
- Jainil Patel
- Department of Surgery, Zen Hospital, Mumbai, IND
| | | | | | - Avinash Supe
- Department of Surgery, Zen Hospital, Mumbai, IND
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Sanavio M, Vauquelin B, Picot MC, Altwegg R, Bozon A, Charpy F, Caillo L, Berger A, Zerbib F, Debourdeau A. Selective inner muscle layer myotomy is associated with lower pain and same clinical efficacy that full-thickness myotomy in patients treated by POEM for achalasia: A multicenter retrospective comparative analysis of 158 patients. Clin Res Hepatol Gastroenterol 2024; 48:102401. [PMID: 38897558 DOI: 10.1016/j.clinre.2024.102401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 05/24/2024] [Accepted: 06/15/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION The aim of this study was to compare the impact of the depth of myotomy (selective inner layer myotomy (SIM) vs. full-thickness myotomy (FTM)) on the outcome of patients treated with POEM for achalasia. METHODS This was a retrospective, observational, conducted in two tertiary centers between October 2018 and September 2022. Patients were divided into two groups: SIM and FTM. The primary endpoint was clinical efficacy at 6 months, while secondary endpoints were postoperative criteria (such as pain, length of hospital stay, complications) and occurrence of gastroesophageal reflux disease (GERD) (esophagitis at 6 months, heartburn, and pH-metry). RESULTS 158 patients were included in the study (33 in the FTM group and 125 in the SIM group). The success rates at 6 and 12 months were similar in both groups, with 84 % and 70 % in the SIM group versus 90 % and 80 % in the FTM group, respectively (p = 0.57 and p = 0.74). However, more opioid analgesics were consumed in the FTM group compared to the SIM group (41% vs 21 %, p < 0.01). The length of hospitalization was longer in the FTM group than in the SIM group (2.17 ± 2.62 vs 2.94 ± 2.33, p < 0.001). The rate of esophagitis at 6 months was comparable (16 % in the SIM group vs 12 % in the FTM group, p = 0.73). There was no significant difference in terms of heartburn at 6 or 12 months between the SIM and FTM groups (18.5% vs 3.8 %, p = 0.07 and 27% vs 12.5 %, p = 0.35, respectively). CONCLUSION There was no significant difference in terms of clinical efficacy and GERD occurrence between FTM and SIM. However, full-thickness myotomy was associated with more postoperative pain and a longer length of hospital stay. Therefore, selective internal myotomy should be preferred over full-thickness myotomy.
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Affiliation(s)
- Mathilde Sanavio
- CHU de Montpellier, Gastroenterology, Hepatology and Transplantation Department, Montpellier, Montpellier Univ, France.
| | - Blandine Vauquelin
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Marie-Christine Picot
- Department of Medical Information, University Hospital of Montpellier, Montpellier Univ, France
| | - Romain Altwegg
- CHU de Montpellier, Gastroenterology, Hepatology and Transplantation Department, Montpellier, Montpellier Univ, France
| | - Anne Bozon
- CHU de Montpellier, Gastroenterology, Hepatology and Transplantation Department, Montpellier, Montpellier Univ, France
| | - Flora Charpy
- CHU de Montpellier, Gastroenterology, Hepatology and Transplantation Department, Montpellier, Montpellier Univ, France
| | - Ludovic Caillo
- CHU de Nimes, Gastroenterology and Hepatology Department, Nimes, Montpellier Univ France
| | - Arthur Berger
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Frank Zerbib
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Antoine Debourdeau
- CHU de Montpellier, Gastroenterology, Hepatology and Transplantation Department, Montpellier, Montpellier Univ, France; CHU de Nimes, Gastroenterology and Hepatology Department, Nimes, Montpellier Univ France
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8
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Malik A, Qureshi S, Nadir A, Malik MI, Adler DG. Efficacy and safety of laparoscopic Heller's myotomy versus pneumatic dilatation for achalasia: A systematic review and meta-analysis of randomized controlled trials. Indian J Gastroenterol 2024; 43:740-747. [PMID: 38564157 DOI: 10.1007/s12664-023-01497-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/01/2023] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND OBJECTIVES: Achalasia has several treatment modalities. We aim to compare the efficacy and safety of laparoscopic Heller myotomy (LHM) with those of pneumatic dilatation (PD) in adult patients suffering from achalasia. METHODS We searched Cochrane CENTRAL, PubMed, Web of Science, SCOPUS and Embase for related clinical trials about patients suffering from achalasia. The quality appraisal and assessment of risk of bias were conducted with GRADE and Cochrane's risk of bias tool, respectively. Homogeneous and heterogeneous data was analyzed under fixed and random-effects models, respectively. RESULTS The pooled analysis of 10 studies showed that PD was associated with a higher rate of remission at three months, one year, three years and five years (RR = 1.25 [1.09, 1.42] (p = 0.001); RR = 1.13 [1.05, 1.20] (p = 0.0004); RR = 1.48 [1.19, 1.82] (p = 0.0003); RR = 1.49 [1.18, 1.89] (p = 0.001)), respectively. LHM was associated with lower number of cases suffering from adverse events, dysphagia and relapses (RR = 0.50 [0.25, 0.98] (p = 0.04); RR = 0.33 [0.16, 0.71] (p = 0.004); RR = 0.38 [0.15, 0.97] (p = 0.04)), respectively. There is no significant difference between both groups regarding the lower esophageal pressure, perforations, remission rate at two years, Eckardt score after one year and reflux. CONCLUSION PD had higher remission rates than LHM at three months, one year and three years, but not at two years or five years. More research is needed to determine whether PD has a significant advantage over LHM in terms of long-term remission rates.
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Affiliation(s)
- Adnan Malik
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, USA
| | - Shahbaz Qureshi
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, USA
| | - Abdul Nadir
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, USA
| | | | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy Centura Health, Porter Adventist Hospital, Denver, CO, USA.
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Montalva L, Farha E, Hervieux E, Ali L, Rousseau V, Schmitt F, Guinot A, Sassi N, Grosos C, Arnaud AP, Scalabre A, Dubois R, Bonnard A. Complications after Heller myotomy in children: a national multicenter study on the impact of prior endoscopic dilatation and identification of risk factors. Surg Endosc 2024; 38:3602-3608. [PMID: 38769183 DOI: 10.1007/s00464-024-10884-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/28/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Although esophageal achalasia has been historically treated by Heller myotomy, endoscopic esophageal dilatations are nowadays often the first-line treatment in children. The aim was to assess whether performing an endoscopic dilatation before a Heller myotomy is associated with higher risks of esophageal perforation in children. METHODS A retrospective multicentric study was performed, including children that underwent a Heller myotomy (2000-2022, 10 centers). Two groups were compared based on the history of previous dilatation before myotomy. Outcomes esophageal perforation (intra-operative or secondary) and post-operative complications requiring surgery (Clavien-Dindo III). Statistics Comparisons using contingency tables or Kruskal-Wallis when appropriate. Statistical significance: p-value < 0.05. RESULTS A Heller myotomy was performed in 77 children (median age: 11.8 years), with prior endoscopic dilatation in 53% (n = 41). A laparoscopic approach was used in 90%, with associated fundoplication in 95%. Esophageal perforation occurred in 19% of children (n = 15), including 12 patients with intra-operative mucosal tear and 3 with post-operative complications related to an unnoticed esophageal perforation. Previous endoscopic dilatation did not increase the risk of esophageal perforation (22% vs 17%, OR: 1.4, 95%CI: 0.43-4.69). Post-operative complications occurred in 8% (n = 6), with similar rates regardless of prior endoscopic dilatation. Intra-operative mucosal tear was the only risk factor for post-operative complications, increasing the risk of complications from 5 to 25% (OR: 6.89, 95%CI: 1.38-31.87). CONCLUSIONS Prior endoscopic dilatations did not increase the risk of esophageal perforation or postoperative complications of Heller myotomy in this cohort of children with achalasia. Mucosal tear was identified as a risk factor for post-operative complications.
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Affiliation(s)
- Louise Montalva
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France.
- Paris-Cité University, Paris, France.
| | - Elie Farha
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
| | - Erik Hervieux
- Department of Pediatric Surgery, Armand Trousseau University Hospital, Paris, France
| | - Liza Ali
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
- Paris-Cité University, Paris, France
| | - Véronique Rousseau
- Department of Pediatric Surgery, AP-HP, Necker-Enfants Malades, Paris, France
| | - Françoise Schmitt
- Department of Pediatric Surgery, Angers University Hospital, Angers, France
| | - Audrey Guinot
- Department of Pediatric Surgery, Hôtel-Dieu University Hospital, Nantes, France
| | - Nizar Sassi
- Department of Pediatric Surgery, Strasbourg University Hospital, Strasbourg, France
| | - Céline Grosos
- Department of Pediatric Surgery, Limoges University Hospital, Limoges, France
| | - Alexis P Arnaud
- Department of Pediatric Surgery, Rennes University Hospital, University of Rennes, Rennes, France
| | - Aurélien Scalabre
- Department of Pediatric Surgery, University Hospital, Saint-Etienne, France
| | - Remi Dubois
- Department of Pediatric Surgery, Hospices Civils de Lyon, Hôpital Femme Mère Enfant University Hospital, Bron, France
| | - Arnaud Bonnard
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
- Paris-Cité University, Paris, France
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Wisniowski P, Putnam LR, Samakar K, Martin M, Sundraman S, Houghton C, Lipham J. Trends and outcomes of intraoperative esophagogastroduodenoscopy during laparoscopic Heller myotomy: a National Surgical Quality Improvement Program analysis. J Gastrointest Surg 2024; 28:282-284. [PMID: 38446115 DOI: 10.1016/j.gassur.2023.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/15/2023] [Accepted: 12/16/2023] [Indexed: 03/07/2024]
Affiliation(s)
- Paul Wisniowski
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States.
| | - Luke R Putnam
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
| | - Kamran Samakar
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
| | - Matthew Martin
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
| | - Shivani Sundraman
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
| | - Caitlin Houghton
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
| | - John Lipham
- Division of Upper Gastrointestinal and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, Los Angeles, California, United States
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Chong Tai LI, Akil O, Nguyen KQ, Sharma A. End-Stage Achalasia With Megaesophagus Refractory to Two Heller Myotomies. Cureus 2024; 16:e55721. [PMID: 38586803 PMCID: PMC10998642 DOI: 10.7759/cureus.55721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Achalasia is a motility disorder of the esophagus in which the lower esophageal sphincter fails to relax. Megaesophagus is a rare complication of achalasia characterized by severe dilatation of the esophagus, often indicative of end-stage achalasia. Typical presenting symptoms include dysphagia, nausea, vomiting, weight loss, and chest pain. The majority of patients with achalasia typically have excellent outcomes after surgical intervention with Heller myotomy. We discuss an interesting case of unsuccessful surgical intervention and hypothesize the reason for its failure in our patient.
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Affiliation(s)
| | - Omar Akil
- Internal Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| | - Kimberly Q Nguyen
- Internal Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| | - Aryama Sharma
- Gastroenterology, Broward Health North, Deerfield Beach, USA
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12
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Ren L, Ye H, Zhu Y, Xie W, Liang Y, Liu Y, Dong J, Chen W, Chen X, Wang B, Pan L, Shi R. Diverticular peroral endoscopic myotomy (D-POEM) for symptomatic oesophageal diverticulum: a multicentre cohort study with a minimum follow-up of 3 years. Surg Endosc 2024; 38:253-259. [PMID: 37985492 DOI: 10.1007/s00464-023-10471-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/13/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To evaluate the medium- and long-term outcomes of diverticular peroral endoscopic myotomy (D-POEM) for symptomatic oesophageal diverticulum. METHODS Consecutive patients with symptomatic oesophageal diverticulum who underwent D-POEM from 1st May 2016 to 1st April 2020 in 6 centres were extracted and researched. Symptoms assessed by the modified Eckardt score were registered pre- and post-D-POEM at 1, 6, 12, 24 and 36 months. RESULTS A total of 34 patients with Zenker's diverticulum (ZD, n = 12), mid-oesophageal diverticulum (MED, n = 12), and epiphrenic diverticulum (ED, n = 10) were included. Complete septotomy was achieved in a mean of 39.15 min, with 100% technical success. No severe intraoperative or postoperative complications were observed. Five patients exhibited subcutaneous emphysema, while 1 had mucosal injury. The mean Eckardt score was 8.59 preoperatively and 2.56 at 1 month, 2.09 at 6 months, 2.21 at 12 months, 2.15 at 24 months, and 2.21 at 36 months postoperatively. The total clinical success rates at 1, 6, 12, 24 and 36 months postoperatively were 97.1%, 97.1%, 94.1%, 91.2%, and 88.2%, respectively. With a median follow-up of 47.2 months, four patients suffered symptom relapse, with a total clinical success rate of 88.2%. A long disease duration, a high Eckardt score, and coexistence of achalasia were identified as risk factors for symptomatic recurrence by multivariable Cox analysis. CONCLUSIONS D-POEM is an effective and durable treatment for patients with symptomatic oesophageal diverticulum.
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Affiliation(s)
- Lihua Ren
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Hui Ye
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Ye Zhu
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Weihua Xie
- Department of Quality Management, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, People's Republic of China
| | - Yan Liang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Yang Liu
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Jingwu Dong
- Department of Gastroenterology, Xuyi County Peoples' Hospital, Huaian, 211700, People's Republic of China
| | - Weixu Chen
- Department of Gastroenterology, Xuzhou Central Hospital, Xuzhou, 221009, People's Republic of China
| | - Xinfu Chen
- Department of Gastroenterology, Xuzhou First People's Hospital, Xuzhou, 221000, People's Republic of China
| | - Bin Wang
- Department of Gastroenterology, Changshu No. 1 People's Hospital, Suzhou, 215500, People's Republic of China
| | - Liang Pan
- Department of Gastroenterology, Changzhou Jintan First People's Hospital, Changzhou, 213200, People's Republic of China
| | - Ruihua Shi
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China.
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Familiari P, Borrelli de Andreis F, Landi R, Mangiola F, Boskoski I, Tringali A, Perri V, Costamagna G. Long versus short peroral endoscopic myotomy for the treatment of achalasia: results of a non-inferiority randomised controlled trial. Gut 2023; 72:1442-1450. [PMID: 37072180 DOI: 10.1136/gutjnl-2021-325579] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVE Peroral endoscopic myotomy (POEM) has become standard treatment for achalasia with comparable efficacy to surgery. In most of published series, the length of myotomy is 12-13 cm. Shorter cuts could have the advantage of shorter procedure time and possibly reduced gastro-oesophageal reflux disease (GORD) rate. DESIGN This single-centre, patient-blinded, randomised, non-inferiority clinical trial included 200 patients, who were randomly allocated, to receive either a long-POEM (13 cm; 101 patients) or a short-POEM (8 cm; 99 patients). Primary outcome was defined as an Eckardt symptom score of ≤3 at 24 months after the procedure; a non-inferiority design was chosen with an accepted success range of 6% between the two treatments. Secondary outcomes included operating time, complication rate, postoperative manometry, GORD rate and quality of life. RESULTS In the intention-to-treat analysis, clinical success rates were 89.1% in the long-POEM and 98.0% in the short-POEM group, resulting in an absolute between-group difference of -8.9% (90% CI -14.5 to -3.3).Procedure time was significantly reduced in the short-POEM as compared with the long-POEM group (40 vs 50 min, p<0.0001). Severe adverse events occurred in one patient in both groups.No differences were observed in postoperative GORD: acid exposure >6% on pH monitoring study at 6 months was seen in 34.3% (long-POEM) vs 31.1% (short-POEM), while endoscopic oesophagitis was diagnosed in 37.6% vs 51.5% at 6 months and in 21% vs 24.5% at 24 months. Regular proton pump inhibitor use was not different either (36.8% vs 37.5%). CONCLUSIONS Our study demonstrates non-inferiority of a shorter cut length of POEM as compared with the standard treatment, which saved some procedural time. GORD rate was not reduced by reducing cutting length. TRIAL REGISTRATION NUMBER NCT03450928.
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Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Federica Borrelli de Andreis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Rosario Landi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
| | - Francesca Mangiola
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
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Rezapanah A, Zandbaf T, Dalili A, Esparham A, Ahmadyar S, Zadeh SM. Post-Surgical Quality of Life After Laparoscopic Heller Myotomy with Fundoplication for the Treatment of Achalasia. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03640-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Abstract
BACKGROUND Laparoscopic Heller's cardiomyotomy (LHC) is the preferred treatment of achalasia. It improves dysphagia by dividing muscles of the lower oesophageal sphincter, but this intervention can result in debilitating gastro-oesophageal reflux symptoms in some patients. To prevent these reflux symptoms, most surgeons add a fundoplication to Heller's cardiomyotomy, but there is no consensus regarding this or the type of fundoplication which is best suited for the purpose. OBJECTIVES To assess how the addition of a fundoplication affects postoperative reflux and dysphagia in people undergoing LHC and compare the different types of fundoplications used in combination with LHC to determine which is better at controlling reflux without worsening the dysphagia. SEARCH METHODS We searched three databases (CENTRAL, MEDLINE and Embase) on 31 October 2021 and trial registers to identify all published and unpublished randomised controlled trials (RCTs) in any language, comparing different fundoplications used in combination with LHC to treat achalasia. We also included RCTs where LHC with a fundoplication is compared with LHC without any fundoplication. SELECTION CRITERIA We only included RCTs which recruited adult participants with achalasia undergoing LHC with minimal hiatal dissection. We excluded non-randomised studies or studies involving paediatric participants. We also excluded studies where the procedure was done by open surgery and where circumferential hiatal dissection of the oesophagus was carried out, unless it was necessary to reduce a hiatus hernia or to facilitate a Toupet or Nissen fundoplication. DATA COLLECTION AND ANALYSIS Two review authors independently identified studies to be included, assessed risk of bias using the Cochrane RoB 1 tool, and extracted the data. We calculated the risk ratio (RR) with 95% confidence interval (CI) using both fixed-effect and random-effect models with Review Manager (RevMan) software. MAIN RESULTS We included eight studies in this review, with a total of 571 participants with an average age of 45 years (range 33.5 to 50). LHC without any fundoplication was performed in 65 (11.3%) participants, 298 (52.1%) had Dor fundoplication, 81 (14.1%) had Toupet fundoplication, 72 (12.6%) had Nissen's fundoplication, and 55 (9.6%) participants had angle of His accentuation. Three studies with a total of 143 participants compared LHC + Dor to LHC without fundoplication. We found that the evidence is very uncertain as to whether the addition of a Dor fundoplication made any difference to the outcome of postoperative pathological acid reflux (RR 0.37, 95% CI 0.07 to 1.89; I2 = 56%; 2 studies, 97 participants; very low-certainty evidence) and uncertain for severe postoperative dysphagia (RR 3.00, 95% CI 0.34 to 26.33; I2 = 0%; 3 studies, 142 participants; low-certainty evidence). Three studies with 174 participants compared LHC + Dor to LHC + Toupet. The evidence suggests that there may be little to no difference in the outcomes of postoperative pathological acid reflux (RR 0.75, 95% CI 0.23 to 2.43; I2 = 60%; 3 studies, 105 participants; low-certainty evidence) and severe postoperative dysphagia (RR 0.78, 95% CI 0.19 to 3.15; I2 = 0%; 3 studies, 123 participants; low-certainty evidence) between the two interventions, but the certainty of the evidence is low. One study with 138 participants compared LHC + Dor to LHC + Nissen. Nissen fundoplication caused increased severe postoperative dysphagia (RR 0.19, 95% CI 0.04 to 0.83; 1 study, 138 participants; high-certainty evidence) when compared to Dor fundoplication. This study did not show a difference in postoperative pathological acid reflux (RR 4.72, 95% CI 0.23 to 96.59; 1 study, 138 participants; low-certainty evidence), but the certainty of evidence is low. One study with 110 participants compared LHC + Dor with LCH + angle of His accentuation, and reported that severe postoperative dysphagia was similar between the two interventions (RR 1.56, 95% CI 0.27 to 8.95; 1 study, 110 participants; moderate-certainty evidence), with moderate certainty of evidence. This study did not report on postoperative pathological acid reflux. AUTHORS' CONCLUSIONS When LHC was performed with minimal hiatal dissection, we were very uncertain whether the addition of a Dor fundoplication made a difference in controlling postoperative reflux, and we were uncertain if it increased the risk of severe postoperative dysphagia. There may be little to no difference in the outcomes of postoperative pathological acid reflux or severe dysphagia between Dor and Toupet fundoplications when used in combination with LHC, but the certainty of the evidence is low. Nissen (total) fundoplication used in combination with LHC for achalasia increased the risk of severe postoperative dysphagia. The angle of His accentuation and Dor fundoplication had a similar effect on severe postoperative dysphagia when combined with LHC, but their effect on postoperative pathological acid reflux was not reported.
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Affiliation(s)
- Sumit Midya
- Department of General Surgery, Frimley Park Hospital, Frimley, UK
| | - Debasish Ghosh
- Department of General Surgery, Royal Berkshire Hospital, Reading, UK
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Huang XZ, Zheng MY, Gong YY, Wu JH, Zhang L, He HY, Sun DL. Evaluation of guidelines for the diagnosis and treatment of achalasia. Dis Esophagus 2022; 36:6772439. [PMID: 36285660 DOI: 10.1093/dote/doac075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/15/2022] [Indexed: 12/11/2022]
Abstract
Due to the unclear quality of the current guidelines, users may be confused about how to diagnose and treat achalasia. The objective of this work is to systematically evaluate the methodological quality of the current guidelines for diagnosing and treating achalasia and to determine the heterogeneity among recommendations. We systematically searched literature databases to retrieve relevant guidelines for the diagnosis and treatment of achalasia. The Appraisal of Guidelines for Research and Evaluation II tool was used to evaluate the quality of the included guidelines. Key recommendations in the guidelines were extracted, and the reasons for the heterogeneity of the key recommendations between different guidelines were further analyzed. Seven guidelines on the diagnosis and treatment of achalasia are included in this study. The overall score of three guidelines exceeded 60%. The average score in domain 5 was the lowest, at 41.8%. The average scores in domain 2, domain 3, and domain 6 were also low, at 45.4%, 57.1% and 56.9%, respectively. The main recommendations and quality of evidence for different guidelines vary greatly, mainly due to the different emphases among different guidelines, the lack of systematic retrieval, or the unfairness of evidence use in some guidelines. There are considerable differences in the methodological quality of diagnosis and treatment guidelines for achalasia. Additionally, the differences in the main recommendations and evidence support among guidelines are also obvious. Guideline developers should improve the above related factors to decrease the heterogeneity, and they should further formulate or update the guidelines for the diagnosis and treatment of achalasia.
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Affiliation(s)
- Xing-Zong Huang
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Meng-Yao Zheng
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Yun-Ying Gong
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Jin-Hong Wu
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Lin Zhang
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Hai-Yu He
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Da-Li Sun
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
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Elyasinia F, Sadeghian E, Gapeleh R, Eslamian R, Najjari K, Soroush A. The Role of Fundoplication after Laparoscopic Heller Myotomy in Reducing Postoperative Symptoms in Patients with Achalasia: A Controlled Clinical Trial. Middle East J Dig Dis 2022; 14:437-442. [PMID: 37547508 PMCID: PMC10404100 DOI: 10.34172/mejdd.2022.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/18/2022] [Indexed: 08/08/2023] Open
Abstract
Background: Laparoscopic Heller myotomy (LHM) is considered the standard surgical approach in patients newly diagnosed with achalasia worldwide. However, proceeding to fundoplication after LHM remains controversial due to the observed postoperative symptoms, including dysphagia and regurgitation. This study was conducted to compare the postoperatively experienced regurgitation and dysphagia between those undergoing LHM with fundoplication and those with mere LHM. Methods: This four-year controlled clinical trial was performed on adult patients with esophageal type two achalasia, referring to the Shariati Hospital, who gave their written informed consent to enroll. The diagnosis of achalasia was confirmed using manometric assessments. The control group underwent LHM with fundoplication, while the cases received LHM without fundoplication. The validated Achalasia Patients Questionnaire was used for assessing the experienced symptoms pre- and postoperatively. Also, esophagography was used to investigate the alterations of the symptoms pre- and postoperatively. Results: A total of 48 patients were evaluated. 23 were assigned to the case group, while 25 were considered the controls (male to female ratio: 25 to 23). The mean age of the patients was 36.94 years, and the average disease duration was 6.22 years. Cases and controls were matched demographically. There was no statistically significant difference between the cases and controls regarding postoperative active or passive regurgitation or dysphagia to either solids or fluids. Also, the mean score of total clinical symptoms after the surgery was not significantly different between cases and controls. Lastly, esophagography revealed significant improvement regarding all the symptoms postoperatively (P=0.001); however, no statistically significant difference existed in this regard between cases and controls. Conclusion: Our results indicate no significant difference regarding the postoperative achalasia-related symptoms, namely regurgitation and dysphagia, between those patients undergoing LHM with and without fundoplication. However, further studies are required to thoroughly investigate the effects of various fundoplication techniques in relation to all achalasia-related symptoms to confirm these results.
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Affiliation(s)
- Fezzeh Elyasinia
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Sadeghian
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Gapeleh
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Eslamian
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Khosrow Najjari
- Department of Surgery, School of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmadreza Soroush
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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18
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Zimmermann C, Torell N, Lidor A, Funk L, Shada A. Recurrent dysphagia after myotomy for achalasia: pneumatic dilation or POEM? : Which modality offers superior outcomes? Surg Endosc 2022:10.1007/s00464-022-09556-5. [PMID: 36121502 DOI: 10.1007/s00464-022-09556-5] [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: 03/30/2022] [Accepted: 08/08/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Myotomy is the gold standard treatment for achalasia, yet long-term failure rates approach 15%. Treatment options for recurrent dysphagia include pneumatic dilation (PD), laparoscopic redo myotomy, per oral endoscopic myotomy (POEM), or esophagectomy. We employ both PD and POEM as first-line treatment for these patients. We evaluated operative success and patient reported outcomes for patients who underwent PD or POEM for recurrent dysphagia after myotomy. METHODS We identified patients with achalasia who underwent PD or POEM for recurrent dysphagia after previous myotomy within a foregut database at our institution between 2013 and 2021. Gastroesophageal Reflux Disease-Health-Related quality of Life (GERD-HRQL) and Eckardt scores, and overall change in each were compared across PD and POEM groups. Successful treatment of dysphagia was defined by Eckardt scores ≤ 3. RESULTS 103 patients underwent myotomy for achalasia. Of these, 19 (18%) had either PD or POEM for recurrent dysphagia. Nine were treated with PD and 10 with POEM. The mean change in Eckardt and GERD-HRQL scores did not differ between groups. 50% of the PD group and 67% of the POEM group had resolution of their dysphagia symptoms (p = 0.65). Mean procedure length was greater in the POEM group (267 vs 72 min, p < 0.01) as was mean length of stay (1.56 vs 0.3 days, p < 0.01). There was one adverse event after PD and three adverse events after POEM. After PD, 7 patients (70%) required additional procedures compared to four patients (44%) in the POEM group, consisting mostly of repeat PD. CONCLUSION Patients undergoing PD or POEM for recurrent dysphagia after myotomy have similar rates of dysphagia resolution and reflux symptoms. Patients undergoing PD enjoy a shorter length of stay and shorter procedure time but may require more subsequent procedures.
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Affiliation(s)
- Christopher Zimmermann
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Nate Torell
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Anne Lidor
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Luke Funk
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amber Shada
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
- Division of Minimally Invasive Surgery, Department of Surgery, University of Wisconsin-Madison, 4602 Eastpark Blvd, Suite 3525, Madison, WI, 53718, USA.
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Romanzi A, D'Alba L, Campagna P, Mancini R, Pernazza G. Robotic Heller-Dor procedure for oesophageal achalasia: Fluorescence-guided intraoperative assessment of myotomy. A retrospective single-centre experience. Int J Med Robot 2022; 18:e2411. [PMID: 35472736 DOI: 10.1002/rcs.2411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/03/2022] [Accepted: 04/21/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND The robotic Heller-Dor (RHD) procedure for oesophageal achalasia (EA) is safe and effective. We aim to evaluate the intraoperative use of fluorescence imaging, as an alternative means to intraoperative endoscopy, to assess myotomy at the end of the procedure. METHODS Thirty-four patients affected with EA underwent RHD. The myotomy was assessed intraoperatively by endoscopy in group A (17 patients), and by fluorescence imaging in group B (17 patients). Perioperative and long-term results were compared. RESULTS In group A, one mucosal tear was identified during intraoperative endoscopy. In group B, indocyanine green (ICG) helped identify residual muscle fibres in three cases. No perforation of the oesophageal mucosa occurred in group B. CONCLUSIONS Fluorescence-imaging improved the identification of residual muscle fibres and made it possible to verify the integrity of the mucosa without the use of intraoperative endoscopy. A significant reduction in operative times has been related to the use of this technique.
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Affiliation(s)
- Andrea Romanzi
- Department of General Surgery, Valduce Hospital, Como, Italy
| | - Lucia D'Alba
- Department of Gastroenterology and Digestive Endoscopy, Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy
| | | | - Raffaello Mancini
- Department of Robotic General Surgery, Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy
| | - Graziano Pernazza
- Department of Robotic General Surgery, Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy
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Endoscopic Balloon Dilation Versus Laparoscopic Heller Myotomy: Comparing Two Treatment Methods for Achalasia. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03521-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Schlottmann F, Herbella FAM, Patti MG. The Evolution of the Treatment of Esophageal Achalasia: From the Open to the Minimally Invasive Approach. World J Surg 2022; 46:1522-1526. [PMID: 35169899 DOI: 10.1007/s00268-022-06482-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Achalasia is a primary esophageal motility disorder characterized by lack of esophageal peristalsis and partial or absent relaxation of the lower esophageal sphincter in response to swallowing. This study aimed to provide an overview of the evolution of the surgical treatment for esophageal achalasia, from the open to the minimally invasive approach. METHODS Literature review. RESULTS No curative treatment exists for this disorder. At the beginning of the 20th century, surgical esophagoplasties and cardioplasties were mostly done to treat achalasia. The description of the esophageal myotomy by Heller changed the treatment paradigm and rapidly became the treatment of choice. For many years the esophagomyotomy was done with either an open transthoracic or transabdominal approach. With the advancements of minimally invasive surgery, thoracoscopic and laparoscopic operations became available. The ability to add a fundoplication for the prevention of reflux made the laparoscopic Heller myotomy with partial fundoplication the operation of choice. CONCLUSIONS Surgical management of esophageal achalasia has significantly evolved in the last century. Currently, minimally invasive Heller myotomy with partial fundoplication is the standard surgical treatment of achalasia.
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Affiliation(s)
- Francisco Schlottmann
- Division of Esophageal and Gastric Surgery, Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon1640, Buenos Aires, Argentina.
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA.
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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22
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Arcerito M, Jamal MM, Perez MG, Kaur H, Sundahl A, Moon JT. Esophageal Achalasia: From Laparoscopic to Robotic Heller Myotomy and Dor Fundoplication. JSLS 2022; 26:JSLS.2022.00027. [PMID: 35967962 PMCID: PMC9355798 DOI: 10.4293/jsls.2022.00027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: Laparoscopic Heller myotomy and Dor fundoplication has become the gold standard in treating esophageal achalasia and robotic surgical platform represents its natural evolution. The objective of our study was to assess durable long-term clinical outcomes in our cohort. Methods and Procedures: Between June 1, 1999 and June 30, 2019, 111 patients underwent minimally invasive treatment for achalasia (96 laparoscopically and 15 robotically). Fifty-two were males. Mean age was 49 years (20 – 96). Esophageal manometry confirmed the diagnosis. Fifty patients underwent pH monitoring study, with pathologic reflux in 18. Preoperative esophageal dilation was performed in 76 patients and 21 patients received botulin injection. Dysphagia was universally present, and mean duration was 96 months (5 – 480). Results: Median operative time was 144 minutes (90 – 200). One patient required conversion to open approach. Four mucosal perforations occurred in the laparoscopic group and were repaired intraoperatively. Seven patients underwent completion esophageal myotomy and added Dor fundoplication. Upper gastrointestinal series was performed before discharge. Median hospital stay was 39 hours (24 – 312). Median follow up was 157 months (6 – 240), and dysphagia was resolved in 94% of patients. Seven patients required postoperative esophageal dilation. Conclusions: Minimally invasive Heller myotomy and Dor fundoplication are feasible. The operation is challenging, but excellent results hinge on the operative techniques and experience. The high dexterity, three-dimensional view, and the ergonomic movements of robotic surgery allow application of all the technical elements, achieving the best durable outcome for the patient. Robotic surgery is the natural evolution of minimally invasive treatment of esophageal achalasia.
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Affiliation(s)
- Massimo Arcerito
- Division of Surgical Oncology and Minimally Invasive Surgery Riverside Medical Clinic Inc. Department of Surgery/Corona Regional Medical Center, Department of Surgery/Riverside Community Hospital, Temescal Valley, California
| | - M Mazen Jamal
- Oceana Gastroenterology Associates, Corona, California
| | - Martin G Perez
- Division of Surgical Oncology and Minimally Invasive Surgery, Riverside Medical Clinic Inc, Department of Surgery / Corona Regional Medical Center, Department of Surgery / Riverside Community Hospital, Riverside, California
| | - Harpreet Kaur
- Hemet Global Medical Center - KPC Health, Hemet, California
| | - Andrew Sundahl
- Department of Surgery / Riverside Community Hospital, Riverside, California
| | - John T Moon
- Department of General Surgery and Minimally Invasive Surgery, University of Maryland Shore Medical Center at Easton, Easton, Maryland
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23
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Tustumi F. Evaluating the Non-conventional Achalasia Treatment Modalities. Front Med (Lausanne) 2022; 9:941464. [PMID: 35814742 PMCID: PMC9263126 DOI: 10.3389/fmed.2022.941464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Achalasia is a primary esophageal dysmotility disorder. Despite the high volume of studies addressing the conventional treatments for achalasia, few are debated regarding the non-conventional treatments, such as cardiectomy, cardioplasty, endoluminal substances injection (ethanolamine oleate, polidocanol, botulinum toxin), stents, and certain drugs (beta-agonists, anticholinergic, nitrates, calcium channel blockers, and phosphodiesterase inhibitors). Methods A critical review was performed. Results Endoscopic, surgical, and pharmacological treatments were included. A qualitative synthesis was presented. Conclusion Non-conventional therapeutic options for treating achalasia encompass medical, endoscopic, and surgical procedures. Clinicians and patients need to know all the tools for the management of achalasia. However, several currently available studies of non-conventional treatments lack high-quality evidence, and future randomized trials are still needed.
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Affiliation(s)
- Francisco Tustumi
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
- Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
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24
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Tsuboi K, Yano F, Omura N, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Sakashita Y, Fukushima N, Ikegami T. Is an objective evaluation essential for determining the therapeutic effect of laparoscopic surgery among patients with esophageal achalasia? Surg Endosc 2022; 36:3932-3939. [PMID: 34494151 DOI: 10.1007/s00464-021-08712-7] [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: 12/02/2020] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite a high degree of satisfaction with laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia, some cases show no improvement in postoperative esophageal clearance. We investigated whether an objective evaluation is essential for determining the therapeutic effect of LHD. METHODS We investigated the difference in symptoms, regarding esophageal clearance, using timed barium esophagogram (TBE), in 306 esophageal achalasia patients with high postoperative satisfaction who underwent LHD. Furthermore, these patients were divided into two groups, in accordance with the difference in postoperative esophageal clearance, in order to compare the preoperative pathophysiology, symptoms, and surgical results. RESULTS Although the poor postoperative esophageal clearance group (117 cases, 38%) was mostly male and the ratio of Sigmoid type was high compared to the good postoperative esophageal clearance group (p = 0.046, p = 0.001, respectively); in patients with high surgical satisfaction, there was no difference in terms of preoperative symptom scores and surgical results. However, although the satisfaction level was high in the poor esophageal clearance group, the scores in terms of the postoperative dysphagia and vomiting were high (p = 0.0018 and p = 0.004, respectively). The AUC was 0.9842 upon ROC analysis regarding the presence or absence of clearance at 2 min following postoperative TBE and the postoperative feeling of difficulty swallowing score, with a cut-off value of 2 points (sensitivity: 88%, specificity: 100%) in cases with a high degree of surgical satisfaction. CONCLUSION The esophageal clearance ability can be predicted by subjective evaluation, based on the postoperative symptom scores; so, an objective evaluation is not essential in cases with high surgical satisfaction.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Fuji City General Hospital, 50 Takashima-cho, Fuji, Shizuoka, 416-0951, Japan. .,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, Nishisaitama-Chuo National Hospital, Tokorozawa, Saitama, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Se-Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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25
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Weng CY, He CH, Zhuang MY, Xu JL, Lyu B. Peroral endoscopic longer vs shorter esophageal myotomy for achalasia treatment: A systematic review and meta-analysis. World J Gastrointest Surg 2022; 14:247-259. [PMID: 35432766 PMCID: PMC8984519 DOI: 10.4240/wjgs.v14.i3.247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/09/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has been demonstrated to be safe and effective in the treatment of achalasia. Longer myotomy is the standard POEM procedure for achalasia but when compared with shorter myotomy, its effectiveness is not as well known.
AIM To compare the clinical effectiveness of longer and shorter myotomy.
METHODS PubMed, EmBase, Cochrane Library, web of science and clinicaltrials.gov were queried for studies comparing shorter and longer POEM for achalasia treatment. The primary outcome was clinical success rate. Secondary outcomes comprised of operative time, adverse events (AEs) rate, gastroesophageal reflux disease (GERD) and procedure-related parameters. The Mantel-Haenszel fixed-effects model was primarily used for the analysis. Publication bias was assessed.
RESULTS Six studies were included in this analysis with a total of 514 participants. During the follow-up period of 1-28.7 mo, longer and shorter myotomy in treating achalasia showed similar excellent effectiveness [overall clinical success (OR = 1, 95%CI: 0.46-2.17, P = 1, I2: 0%; subgroup of abstract (OR = 1.19, 95%CI: 0.38 to 3.73; P = 0.76; I2: 0%); subgroup of full text (OR = 0.86 95%CI: 0.30 to 2.49; P = 0.78; I2: 0%)]. Shorter myotomy had significantly reduced mean operative time compared with the longer procedure. There were no statistically significant differences in AEs rates, including GERD (overall OR = 1.21, 95%CI: 0.76-1.91; P = 0.42; I2: 9%; subgroup of abstract OR = 0.77, 95%CI: 0.40-1.47; P = 0.43; I2: 0%; subgroup of full text OR = 1.91, 95%CI: 0.98-3.75; P = 0.06; I2: 0%), hospital stay (overall MD = -0.07, 95%CI: -0.30 to 0.16; P = 0.55; I2: 24%; subgroup of abstract MD = 0.20, 95%CI: -0.25 to 0.65; P = 0.39; I2: 0; subgroup of full text MD = -0.16, 95%CI: -0.42 to 0.10; P = 0.23; I2: 42%), and major bleeding (overall OR = 1.25, 95%CI: 0.58-2.71; P = 0.56; I2: 0%) between the two procedures. These differences remained statistically non-significant in all sensitivity analyses.
CONCLUSION POEM was effective in treating achalasia. Shorter and longer myotomy procedures provided similar therapeutic effects in terms of long-term effectiveness. In addition, shorter myotomy reduced the operative time.
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Affiliation(s)
- Chun-Yan Weng
- Department of Gastroenterology, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Cheng-Hai He
- Department of Gastroenterology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou 310006, Zhejiang Province, China
| | - Ming-Yang Zhuang
- Internal Medicine of Chinese Medicine, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Jing-Li Xu
- Department of Surgery, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Bin Lyu
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medicine University, Hangzhou 310006, Zhejiang Province, China
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Uzunoglu M, Altintoprak F, Yalkin O, Özdemir K. Robotic Surgery for the Treatment of Achalasia Cardia: Surgical Technique, Initial Experiences and Literature Review. Cureus 2022; 14:e21510. [PMID: 35223286 PMCID: PMC8863560 DOI: 10.7759/cureus.21510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background The outcomes of surgical interventions for achalasia treatment improved with the advent of minimally invasive surgery and the introduction of robotic surgery. This article describes the technical details of robotic achalasia surgery, shares our initial experiences, and discusses why robotic surgery will become the first choice for the surgical treatment of achalasia. Methods The records of patients with a diagnosis of achalasia who underwent robotic surgery were evaluated retrospectively. The patients’ data were examined in terms of demographic parameters, duration of complaints, treatment options applied previously, robotic surgery technique, and postoperative outcomes. Results Of the six patients evaluated, four (66.7%) were males and two (33.3%) were females. Their mean age was 32 years (20-51 years), and the mean symptom duration was 4.6 years (2-9 years). All of the patients underwent robotic Heller cardiomyotomy surgery. After the myotomy procedure, five of the six patients (83.3%) underwent partial anterior fundoplication (Dor) as an antireflux procedure. The cruroraphy procedure was performed in one patient (16.7%) due to accompanying hiatal hernia, whereas the procedures were completed in five patients (83.3%) without performing posterior dissection of the oesophagus. In the postoperative follow-up period, no surgical problem was encountered, while reflux symptoms developed in one patient (16.7%) and were controlled by medical therapy. Conclusions The success of surgical treatment of achalasia is incontrovertible. Due to the various advantages of robotic surgery, it is now frequently used in narrow-area surgeries, such as achalasia surgery.
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27
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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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28
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Rolinger J, Miller J, Bolzenius R, Granderath F, Kirschniak A, Wilhelm P. [Laparoscopic Heller Myotomy in the Treatment of Achalasia]. Zentralbl Chir 2021; 147:21-24. [PMID: 34154022 DOI: 10.1055/a-1502-8175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Achalasia refers to a primary oesophageal motility disorder characterised by the absence of peristalsis and incomplete or complete lack of relaxation of the lower oesophageal sphincter. The cardinal symptom is dysphagia. The therapeutic goal is surgical or interventional repair of the oesophageal outflow tract at the level of the oesophagogastric junction. INDICATION We present the case of a 24-year-old patient with dysphagia accompanied by regurgitations, odynophagia as well as an unintentional weight loss over two years. METHODS The video describes the preoperative imaging as well as endoscopic findings and demonstrates the technique of laparoscopic Heller myotomy followed by Dor fundoplication. CONCLUSIONS Concerning the therapy of classic achalasia, laparoscopic Heller myotomy followed by Dor fundoplication - despite controversies regarding peroral endoscopic myotomy as an alternative therapeutic option - can be considered as an established standard procedure.
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Affiliation(s)
- Jens Rolinger
- Klinik für Allgemein- und Viszeralchirurgie, Kliniken Maria Hilf GmbH, Mönchengladbach, Deutschland
| | - Johanna Miller
- Klinik für Allgemein- und Viszeralchirurgie, Kliniken Maria Hilf GmbH, Mönchengladbach, Deutschland
| | - Rupert Bolzenius
- Klinik für Allgemein- und Viszeralchirurgie, Kliniken Maria Hilf GmbH, Mönchengladbach, Deutschland
| | - Frank Granderath
- Klinik für Allgemein- und Viszeralchirurgie, Krankenhaus Neuwerk Maria von den Aposteln, Mönchengladbach, Deutschland
| | - Andreas Kirschniak
- Klinik für Allgemein- und Viszeralchirurgie, Kliniken Maria Hilf GmbH, Mönchengladbach, Deutschland
| | - Peter Wilhelm
- Klinik für Allgemein- und Viszeralchirurgie, Kliniken Maria Hilf GmbH, Mönchengladbach, Deutschland
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29
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Yodice M, Mignucci A, Shah V, Ashley C, Tadros M. Preoperative physiological esophageal assessment for anti-reflux surgery: A guide for surgeons on high-resolution manometry and pH testing. World J Gastroenterol 2021; 27:1751-1769. [PMID: 33967555 PMCID: PMC8072189 DOI: 10.3748/wjg.v27.i16.1751] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/18/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most commonly encountered digestive diseases in the world, with the prevalence continuing to increase. Many patients are successfully treated with lifestyle modifications and proton pump inhibitor therapy, but a subset of patients require more aggressive intervention for control of their symptoms. Surgical treatment with fundoplication is a viable option for patients with GERD, as it attempts to improve the integrity of the lower esophageal sphincter (LES). While surgery can be as effective as medical treatment, it can also be associated with side effects such as dysphagia, bloating, and abdominal pain. Therefore, a thorough pre-operative assessment is crucial to select appropriate surgical candidates. Newer technologies are becoming increasingly available to help clinicians identify patients with true LES dysfunction, such as pH-impedance studies and high-resolution manometry (HRM). Pre-operative evaluation should be aimed at confirming the diagnosis of GERD, ruling out any major motility disorders, and selecting appropriate surgical candidates. HRM and pH testing are key tests to consider for patients with GERD like symptoms, and the addition of provocative measures such as straight leg raises and multiple rapid swallows to HRM protocol can assess the presence of underlying hiatal hernias and to test a patient’s peristaltic reserve prior to surgery.
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Affiliation(s)
- Michael Yodice
- Department of Gastroenterology, Albany Medical College, Albany, NY 12208, United States
| | - Alexandra Mignucci
- Department of Gastroenterology, Albany Medical College, Albany, NY 12208, United States
| | - Virali Shah
- Department of Gastroenterology, Albany Medical College, Albany, NY 12208, United States
| | - Christopher Ashley
- Section of Gastroenterology, Stratton VA Medical Center, Albany, NY 12208, United States
| | - Micheal Tadros
- Department of Gastroenterology, Albany Medical Center, Schenectady, NY 12309, United States
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30
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Haskins IN, Strassle PD, Parker BTN, Catterall LC, Duke MC, Farrell TM. Minimally invasive Heller myotomy with partial posterior fundoplication for the treatment of achalasia: long-term results from a tertiary referral center. Surg Endosc 2021; 36:728-735. [PMID: 33689011 DOI: 10.1007/s00464-021-08341-0] [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: 09/18/2020] [Accepted: 01/27/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Few studies have reported the long-term results of minimally invasive Heller myotomy (HM) for the treatment of achalasia. Herein, we detail our 17-year experience with HM for the treatment of achalasia from a tertiary referral center. METHODS All patients undergoing elective HM at our institution from 2000 to 2017 were identified within a prospective institutional database. These patients were sent mail and electronic surveys to capture their symptoms of dysphagia, chest pain, and regurgitation pre- and postoperatively and were asked to evaluate their postoperative gastrointestinal quality of life. Responses from adult patients who underwent minimally invasive Heller myotomy with partial posterior (i.e., Toupet) fundoplication (HM-TF) were analyzed. RESULTS 294 patients were eligible for study inclusion; 139 (47%) completed our survey. Median time from HM-TF to survey response was 5.6 years. A majority of patients reported improvement in their dysphagia (91%), chest pain (70%), and regurgitation (87%) symptoms. Patients who underwent HM-TF more than 5 years ago were most likely to report heartburn symptoms. One (1%) patient went on to require esophagectomy for ongoing dysphagia and one (1%) patient required revisional fundoplication for their heartburn symptoms. CONCLUSIONS Minimally invasive Heller myotomy and posterior partial fundoplication is a durable treatment for achalasia over the long term. Additional prospective and multi-institutional studies are needed to validate our results.
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Affiliation(s)
- Ivy N Haskins
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA. .,Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Paula D Strassle
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | | | - Lauren C Catterall
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Meredith C Duke
- Department of Surgery, Vanderbilt University, Nashville, TN, USA
| | - Timothy M Farrell
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
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31
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Dirks RC, Kohn GP, Slater B, Whiteside J, Rodriguez NA, Docimo S, Pryor A, Stefanidis D. Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis. Surg Endosc 2021; 35:1949-1962. [PMID: 33655443 DOI: 10.1007/s00464-021-08353-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Achalasia is a rare, chronic, and morbid condition with evolving treatment. Peroral endoscopic myotomy (POEM) has gained considerable popularity, but its comparative effectiveness is uncertain. We aim to evaluate the literature comparing POEM to Heller myotomy (HM) and pneumatic dilation (PD) for the treatment of achalasia. METHODS We conducted a systematic review of comparative studies between POEM and HM or PD. A priori outcomes pertained to efficacy, perioperative metrics, and safety. Internal validity of observational studies and randomized trials (RCTs) was judged using the Newcastle Ottawa Scale and the Cochrane Risk of Bias 2.0 tool, respectively. RESULTS From 1379 unique literature citations, we included 28 studies comparing POEM and HM (n = 21) or PD (n = 8), with only 1 RCT addressing each. Aside from two 4-year observational studies, POEM follow-up averaged ≤ 2 years. While POEM had similar efficacy to HM, POEM treated dysphagia better than PD both in an RCT (treatment "success" RR 1.71, 95% CI 1.34-2.17; 126 patients) and in observational studies (Eckardt score MD - 0.43, 95% CI - 0.71 to - 0.16; 5 studies; I2 21%; 405 patients). POEM needed reintervention less than PD in an RCT (RR 0.19, 95% CI 0.08-0.47; 126 patients) and HM in an observational study (RR 0.33, 95% CI 0.16, 0.68; 98 patients). Though 6-12 months patient-reported reflux was worse than PD in 3 observational studies (RR 2.67, 95% CI 1.02-7.00; I2 0%; 164 patients), post-intervention reflux was inconsistently measured and not statistically different in measures ≥ 1 year. POEM had similar safety outcomes to both HM and PD, including treatment-related serious adverse events. CONCLUSIONS POEM has similar outcomes to HM and greater efficacy than PD. Reflux remains a critical outcome with unknown long-term clinical significance due to insufficient data and inconsistent reporting.
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Affiliation(s)
- Rebecca C Dirks
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN, 46202, USA.
| | - Geoffrey P Kohn
- Department of Surgery, Monash University Eastern Health Clinical School, Melbourne, VIC, Australia
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago, Chicago, IL, USA
| | - Jake Whiteside
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN, 46202, USA
| | - Noe A Rodriguez
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Salvatore Docimo
- Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Aurora Pryor
- Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Dimitrios Stefanidis
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN, 46202, USA
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Zhong C, Ni B, Liu S, Tan S, Lü M, Peng Y, Liu L, Tang X. The Effect of Peroral Endoscopic Myotomy in Achalasia Patients with Prior Endoscopic Intervention: A Systematic Review and Meta-Analysis. Dig Surg 2021; 38:136-148. [PMID: 33556934 DOI: 10.1159/000512627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/25/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has been reported to be effective in achalasia patients with prior failed endoscopic intervention (PFI). We performed this meta-analysis to compare and summarize the clinical outcome of POEM in patients with or without prior endoscopic intervention. METHOD We searched relevant studies published up to March 2020. Meta-analysis for technical success, clinical success, Eckardt score, lower esophageal sphincter (LES) pressure, clinical reflux, and adverse event were conducted based on a random-effects model. RESULTS Eight studies enrolling 1,797 patients who underwent POEM were enrolled, including 1,128 naïve achalasia patients and 669 patients with PFI. In the PFI group, the pooled estimated rate of technical success was 97.7% (95% confidence interval [CI], 95.8-98.8%), the pooled clinical success rate was 91.0% (95% CI, 88.0-93.4%), and the pooled adverse events rate was 23.5% (95% CI, 10.6-44.1%). The Eckardt score significantly decreased by 5.95 points (95% CI, 5.50-6.40, p < 0.00001) and the LES pressure significantly reduced by 19.74 mm Hg (95% CI, 14.10-25.39, p < 0.00001) in the PFI group. There were no difference in the technical success, clinical success, and adverse events rate between the treatment-naïve group and PFI group, with a risk ratio of 1.0 (95% CI, 0.99-1.01, p = 0.89), 1.02 (95% CI, 0.98-1.06, p = 0.36), and 0.88 (95% CI, 0.67-1.16, p = 0.38), respectively. CONCLUSIONS POEM is an effective and safe treatment for achalasia patients with prior endoscopic intervention. Randomized clinical trials are needed to further verify the efficiency and safety of the POEM in those patients.
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Affiliation(s)
- Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bowen Ni
- School of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Sixiu Liu
- School of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Li Liu
- Department of Digestive Endoscopy, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China,
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Bruenderman EH, Bhutiani N, Martin RCG, Fox MP, van Berkel VH, Block SB, Kehdy FJ. Intraoperative Esophagogastroduodenoscopy During Heller Myotomy: Evaluating Guidelines. World J Surg 2020; 45:808-814. [PMID: 33230586 DOI: 10.1007/s00268-020-05870-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND National guidelines suggest routine intraoperative esophagogastroduodenoscopy (EGD) during laparoscopic Heller myotomy (LHM) to assess for mucosal perforation and myotomy adequacy, but the utility of this is unknown. This study aimed to evaluate the effect of intraoperative EGD on outcomes after LHM. METHODS Patients who underwent LHM in a single center were retrospectively identified. Outcomes were compared between patients who did and did not undergo intraoperative EGD. RESULTS Sixty-one patients were reviewed: 46 (75%) underwent intraoperative EGD and 15 (25%) did not. Mucosal perforations occurred in 2 (4%) of the EGD group and 3 (20%) of the non-EGD group (p = 0.06). All perforations, regardless of EGD use, were recognized laparoscopically. There were no postoperative leaks. Failed myotomy occurred in 5 (11%) who underwent EGD and 1 (7%) who did not (p = 0.64). CONCLUSIONS Because EGD does not appear to improve outcomes after LHM, we emphasize its selective, rather than routine, use.
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Affiliation(s)
- Elizabeth H Bruenderman
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Neal Bhutiani
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Robert C G Martin
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY, United States of America
| | - Matthew P Fox
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, United States of America
| | - Victor H van Berkel
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, United States of America
| | - Stacy B Block
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Farid J Kehdy
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America.
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Huang S, Ren Y, Peng W, Gao Q, Peng Y, Gong W, Tang X. Peroral endoscopic shorter versus longer myotomy for the treatment of achalasia: a comparative retrospective study. Esophagus 2020; 17:477-483. [PMID: 32361976 DOI: 10.1007/s10388-020-00739-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 04/14/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Peroral esophageal myotomy (POEM) is a novel endoscopic treatment for achalasia. It has gained popularity worldwide among surgeons and endoscopists, but no studies have compared peroral endoscopic short with long myotomy for achalasia. We aimed to compare the clinical efficacy and safety between peroral endoscopic shorter and longer myotomy. METHODS The retrospective study enrolled 129 achalasia patients who underwent POEM from July 2011 to September 2017. Based on the myotomy length (ML), patients were divided into shorter myotomy (SM) group (ML ≤ 7 cm, n = 36) and longer myotomy (LM) group (ML > 7 cm, n = 74). Procedure-related parameters, symptom scores, adverse events and manometric data were compared between two groups. RESULTS The mean ML was 6.0 ± 0.6 cm in SM group, and 11.5 ± 3.1 cm in LM group (p < 0.001). The mean operation time was significantly less in SM group than LM group (46.6 ± 18.5 min vs 62.1 ± 25.2 min, p = 0.001). During a mean follow-up period of 28.7 months, treatment success (Eckardt score ≤ 3) was achieved in 94.4% (34/36) of patients in SM group and 91.9% (68/74) in LM group (p = 0.926). There was no statistical difference in the incidence of intraoperative complications (8.4% vs 8.2%, p = 0.823) and reflux rate (8.3% vs. 14.9%, p = 0.510) between two groups. CONCLUSIONS Peroral endoscopic shorter myotomy is comparable with longer myotomy for treating achalasia with regard to clinical efficacy and has the advantage of shorter procedure time.
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Affiliation(s)
- Silin Huang
- Departmemt of Gastroenterology, Shenzhen Hospital, Southern Medical University, No.1333 Xinhu Road, Baoan District, Shenzhen, 518000, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Wei Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Qiaoping Gao
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Wei Gong
- Departmemt of Gastroenterology, Shenzhen Hospital, Southern Medical University, No.1333 Xinhu Road, Baoan District, Shenzhen, 518000, China.
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.
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Santes O, Coss-Adame E, Valdovinos MA, Furuzawa-Carballeda J, Rodríguez-Garcés A, Peralta-Figueroa J, Narvaez-Chavez S, Olvera-Prado H, Clemente-Gutiérrez U, Torres-Villalobos G. Does laparoscopic reoperation yield symptomatic improvements similar to those of primary laparoscopic Heller myotomy in achalasia patients? Surg Endosc 2020; 35:4991-5000. [DOI: 10.1007/s00464-020-07978-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/14/2020] [Indexed: 01/06/2023]
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Fajardo RA, Petrov RV, Bakhos CT, Abbas AE. Endoscopic and Surgical Treatments for Achalasia: Who to Treat and How? Gastroenterol Clin North Am 2020; 49:481-498. [PMID: 32718566 PMCID: PMC7387747 DOI: 10.1016/j.gtc.2020.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Achalasia is a progressive neurodegenerative disorder characterized by failure of relaxation of the lower esophageal sphincter (LES) and altered motility of the esophagus. The traditional, highly effective, surgical approach to relieve obstruction at the LES includes cardiomyotomy. Fundoplication is added to decrease risk of postoperative reflux. Per oral endoscopic myotomy is a new endoscopic procedure that allows division of the LES via transoral route. It has several advantages including less invasiveness, cosmesis, and tailored approach to the length on the myotomy. However, it is associated with increased rate of post-procedural reflux. Various endoscopic interventions are used to address this problem.
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Affiliation(s)
- Romulo A. Fajardo
- Department of General Surgery, Temple University Hospital, Philadelphia, PA, USA, 3401 N Broad St, C-401, Philadelphia, PA 19140
| | - Roman V. Petrov
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
| | - Charles T. Bakhos
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
| | - Abbas E. Abbas
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
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Abstract
Achalasia is an esophageal motility disorder characterized by aberrant peristalsis and insufficient relaxation of the lower esophageal sphincter. Patients most commonly present with dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. High-resolution manometry has identified 3 subtypes of achalasia distinguished by pressurization and contraction patterns. Endoscopic findings of retained saliva with puckering of the gastroesophageal junction or esophagram findings of a dilated esophagus with bird beaking are important diagnostic clues. In this American College of Gastroenterology guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to provide clinical guidance on how best to diagnose and treat patients with achalasia.
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Shorbagi AI. Sigmoid megaesophagus with thoracic pseudotumor appearance. Radiography (Lond) 2020; 27:247-249. [PMID: 32684331 DOI: 10.1016/j.radi.2020.06.018] [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: 06/04/2020] [Revised: 06/19/2020] [Accepted: 06/23/2020] [Indexed: 11/27/2022]
Abstract
A 61-year-old man presented with dysphagia, weight loss and shortness of breath. On examination, he had reduced lung sounds on the right, and obvious neck vein distention. Chest X-ray raised a suspicion of lung tumor with possible superior vena cava syndrome. Subsequent CT scan of chest confirmed the presence of markedly dilated and tortuous esophagus (sigmoid megaesophagus) extending to the right hemithorax and pressing on the trachea. The patient was referred for surgery.
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Affiliation(s)
- A I Shorbagi
- Clinical Sciences Department, College of Medicine, M27-166, University of Sharjah, P.O. Box 27272, Sharjah, United Arab Emirates.
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Nurczyk K, Patti MG. Surgical management of achalasia. Ann Gastroenterol Surg 2020; 4:343-351. [PMID: 32724877 PMCID: PMC7382425 DOI: 10.1002/ags3.12344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/03/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022] Open
Abstract
Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.
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Affiliation(s)
- Kamil Nurczyk
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- 2nd Department of General and Gastrointestinal Surgery, and Surgical Oncology of the Alimentary TractMedical University of LublinLublinPoland
| | - Marco G. Patti
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Masadeh M, Nau P, Chandra S, Klair J, Keech J, Parekh K, Abiad RE, Gerke H. Experience with Peroral Endoscopic Myotomy for Achalasia and Spastic Esophageal Motility Disorders at a Tertiary U.S. Center. Clin Endosc 2020; 53:321-327. [PMID: 31744270 PMCID: PMC7280846 DOI: 10.5946/ce.2019.110] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/18/2019] [Accepted: 09/16/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Peroral endoscopic myotomy (POEM) is a novel procedure for the treatment of achalasia and spastic esophageal disorders. Experience with POEM is limited, but its reported outcomes are excellent. It is deemed safe even for patients with prior interventions. METHODS This retrospective review included patients who underwent POEM at a tertiary US center. POEM was performed in a multidisciplinary approach by advanced endoscopists and foregut surgeons. Clinical success was defined as a post-POEM Eckardt score ≤3. RESULTS A total of 125 patients were included. Median follow-up period was 18 months (interquartile range, 10-22 months). Clinical success was achieved in 92% of patients and persisted at 12 months in 88% of patients. Mucosal barrier failure (MBF) occurred in 7 patients, 2 of whom required surgical intervention. MBF was more common in patients with prior laparoscopic Heller myotomy (19% vs. 3%, p=0.015). MBF requiring surgical intervention occurred early in the learning curve. CONCLUSION POEM is safe and effective in the treatment of achalasia and spastic esophageal disorders even after failed prior interventions.
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Affiliation(s)
- Maen Masadeh
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Peter Nau
- Division of Minimally Invasive and Bariatric Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Subhash Chandra
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Jagpal Klair
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - John Keech
- Division of Thoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Kalpaj Parekh
- Division of Thoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Rami El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Henning Gerke
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Orlandini B, Barret M, Guillaumot MA, Léandri C, Leblanc S, Prat F, Chaussade S. Per-oral endoscopic myotomy for esophageal diverticula with or without esophageal motility disorders. Clin Res Hepatol Gastroenterol 2020; 44:82-89. [PMID: 31080116 DOI: 10.1016/j.clinre.2019.03.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Mid-esophageal and epiphrenic diverticula (MED) can be associated with esophageal motility disorders. Per-oral endoscopic myotomy (POEM) is an established treatment for esophageal motility disorders that has also been introduced for the treatment of MED. METHODS Data were prospectively collected from patients with MED treated with POEM at our institution. When esophageal motility disorders were present, myotomy was performed extending the myotomy to the lower esophageal sphincter (LES) to treat the motility dysfunction associated with the diverticulum. In the absence of esophageal motility disorder, POEM was performed without including the LES in the myotomy to achieve diverticulotomy. RESULTS Four patients were treated with POEM for MED between April 2017 and March 2018. The patients suffered from distal esophageal spasm, jackhammer esophagus or esophago-gastric junction outflow obstruction. One patient had no esophageal motility disorder. Diverticulum size was 3 cm in one case and 6 cm in the others. Preoperative Eckardt scores ranged from 6 to 8. No life-threatening complications were reported. Intraoperative pneumoperitoneum was described in two cases and one patient experienced aspiration pneumonia. The patients with motility disorders were asymptomatic at 6-8 months follow-up. The patient without documented underlying esophageal motility disorder had an Eckardt score of 3 at 9-months follow-up. Two cases of gastro-esophageal reflux were successfully managed with proton pump inhibitors. CONCLUSIONS In the case of MED and esophageal motility disorder, POEM permitted treatment of the underlying cause of the diverticulum, achieving favorable early clinical outcomes. In the absence of motility disorder, POEM was feasible with promising early outcomes, and could be a valid alternative to surgical diverticulectomy in selected patients.
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Affiliation(s)
- Beatrice Orlandini
- Department of gastroenterology, department of experimental and clinical biomedical sciences, Careggi hospital, University of Florence, Viale San Luca, 50134, Florence, Italy; Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Maximilien Barret
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France.
| | - Marie-Anne Guillaumot
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Chloé Léandri
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Sarah Leblanc
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Frédéric Prat
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Stanislas Chaussade
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
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Costantini M, Salvador R, Valmasoni M. Comment on the Article: “The Use of Rigiflex Pneumatic Balloon Dilator during Laparoscopic Heller's Myotomy in Patients with Achalasia: A Novel Technical Method and Its Surgical Outcomes”. Am Surg 2020. [DOI: 10.1177/000313482008600127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mario Costantini
- Center for Esophageal Disease Clinica Chirurgica 3 Padua University Hospital Padua, Italy
| | - Renato Salvador
- Center for Esophageal Disease Clinica Chirurgica 3 Padua University Hospital Padua, Italy
| | - Michele Valmasoni
- Center for Esophageal Disease Clinica Chirurgica 3 Padua University Hospital Padua, Italy
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Quitadamo P, Tambucci R, Mancini V, Cristofori F, Baldassarre M, Pensabene L, Francavilla R, Di Nardo G, Caldaro T, Rossi P, Mallardo S, Maggiora E, Staiano A, Cresi F, Salvatore S, Borrelli O. Esophageal pH-impedance monitoring in children: position paper on indications, methodology and interpretation by the SIGENP working group. Dig Liver Dis 2019; 51:1522-1536. [PMID: 31526716 DOI: 10.1016/j.dld.2019.07.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/02/2019] [Accepted: 07/20/2019] [Indexed: 12/11/2022]
Abstract
Multichannel intraluminal impedance pH (MII-pH) monitoring currently represents the gold standard diagnostic technique for the detection of gastro-esophageal reflux (GER), since it allows to quantify and characterize all reflux events and their possible relation with symptoms. Over the last ten years, thanks to its strengths and along with the publication of several clinical studies, its worldwide use has gradually increased, particularly in infants and children. Nevertheless, factors such as the limited pediatric reference values and limited therapeutic options still weaken its current clinical impact. Through an up-to-date review of the available scientific evidence, our aim was to produce a position paper on behalf of the working group on neurogastroenterology and acid-related disorders of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) on MII-pH monitoring technique, indications and interpretation in pediatric age, in order to standardise its use and to help clinicians in the diagnostic approach to children with GER symptoms.
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Affiliation(s)
- Paolo Quitadamo
- Department of Pediatrics, A.O.R.N. Santobono-Pausilipon, Naples, Italy; Department of Translational Medical Science,"Federico II", University of Naples, Italy.
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Valentina Mancini
- Department of Pediatrics and Neonatology, Saronno Hospital, Saronno, Italy
| | - Fernanda Cristofori
- Department of Pediatrics, Giovanni XXIII Hospital, Aldo MoroUniversity of Bari, Bari, Italy
| | - Mariella Baldassarre
- Department of Biomedical Science and Human Oncology-neonatology and Nicu section, University "Aldo Moro", Bari, Italy
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Ruggiero Francavilla
- Department of Pediatrics, Giovanni XXIII Hospital, Aldo MoroUniversity of Bari, Bari, Italy
| | - Giovanni Di Nardo
- NESMOS Department, School of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Rossi
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Saverio Mallardo
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Elena Maggiora
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science,"Federico II", University of Naples, Italy
| | - Francesco Cresi
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, UCL Institute ofChild Health and Great OrmondStreet Hospital, London, UK
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Mirsharifi A, Ghorbani Abdehgah A, Mirsharifi R, Jafari M, Fattah N, Mikaeli J, Soroush AR. Laparoscopic Heller Myotomy for Achalasia: Experience from a Single Referral Tertiary Center. Middle East J Dig Dis 2019; 11:90-97. [PMID: 31380005 PMCID: PMC6663286 DOI: 10.15171/mejdd.2018.133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 01/20/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Achalasia is the most well known esophageal motility disorder. Laparoscopic Heller myotomy (LHM) is the most effective treatment for achalasia. The aim of this study was to review our results on LHM for achalasia. METHODS In this cross-sectional study all patients undergoing LHM between 2015 and 2017 were studied. The myotomy was followed by an anterior or posterior partial fundoplication. All patients were followed up for at least six months. RESULTS
We conducted this prospective study on 36 consecutive patients who underwent LHM over 3 years. The mean age of the patients was 36.64 ± 13.47 years. 30 patients (83.3%) underwent Toupet and 6 patients (16.7%) received Dor fundoplication. 11 patients (30.6%) developed reflux after the procedure. According to the Eckardt Symptom Scoring (ESS), the symptoms improved in 74.2% of the patients and remained unchanged in 25.8% of the patients. Analysis of the ESS, indicated a significant change in regurgitation and retrosternal pain, dysphagia, and weight loss after the surgery (p = 0.001, p = 0.002, p = 0.046, and p = 0.001, respectively).
CONCLUSION LHM with anterior or posterior partial fundoplication is safe and achieves a good outcome in the treatment of achalasia, especially in patients who have not responded to other methods while no serious complication was reported despite several prior endoscopic interventions.
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Affiliation(s)
- Alireza Mirsharifi
- Tehran University of Medical Sciences, Department of General Surgery, Shariati Hospital, Tehran, Iran
| | - Ali Ghorbani Abdehgah
- Tehran University of Medical Sciences, Department of Surgery, Research Center of Surgical Outcomes and Procedures, Shariati Hospital, Tehran, Iran
| | - Rasoul Mirsharifi
- Tehran University of Medical Sciences, Department of General Surgery, Imam Khomeini Hospital, Tehran, Iran
| | - Mehdi Jafari
- Tehran University of Medical Sciences, Department of Surgery, Research Center of Surgical Outcomes and Procedures, Shariati Hospital, Tehran, Iran
| | - Noor Fattah
- Tehran University of Medical Sciences, Department of General Surgery, Shariati Hospital, Tehran, Iran
| | - Javad Mikaeli
- Digestive Disease Research Center, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | - Ahmad Reza Soroush
- Tehran University of Medical Sciences, Department of Surgery, Research Center of Surgical Outcomes and Procedures, Shariati Hospital, Tehran, Iran
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45
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Yuan XL, Zhang QY, Liu W, Ye LS, Hu B. Double open per-oral endoscopic myotomy (D-O-POEM) for the treatment of achalasia. J Dig Dis 2019; 20:427-429. [PMID: 30917410 DOI: 10.1111/1751-2980.12723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 03/15/2019] [Accepted: 03/24/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Xiang Lei Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Chengdu Province, China
| | - Qiong Ying Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Chengdu Province, China
| | - Wei Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Chengdu Province, China
| | - Lian Song Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Chengdu Province, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Chengdu Province, China
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Aiolfi A, Bona D, Riva CG, Micheletto G, Rausa E, Campanelli G, Olmo G, Bonitta G, Bonavina L. Systematic Review and Bayesian Network Meta-Analysis Comparing Laparoscopic Heller Myotomy, Pneumatic Dilatation, and Peroral Endoscopic Myotomy for Esophageal Achalasia. J Laparoendosc Adv Surg Tech A 2019; 30:147-155. [PMID: 31364910 DOI: 10.1089/lap.2019.0432] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Laparoscopic Heller myotomy (LHM), pneumatic dilatation (PD), and peroral endoscopic myotomy (POEM) are common treatments for esophageal achalasia. Literature evidence is restricted to pairwise analysis and PD versus POEM comparison is missing. The aim of this network meta-analysis (NMA) was to comprehensively compare outcomes within these three surgical approaches with those of esophageal achalasia. Materials and Methods: PubMed, EMBASE, and Web of Science databases were consulted. A systematic review and a fully Bayesian study level arm-based random effect NMA were performed. Results: Nineteen studies (14 observational and 5 randomized controlled trial) and 4407 patients were included. Overall, 50.4% underwent LHM, 42.8% PD, and 6.8% POEM. The postoperative dysphagia remission was statistically significantly improved in POEM compared with LHM and PD (risk ratio [RR] = 1.21; 95% credible intervals [CIs] = 1.04-1.47 and RR = 1.40; 95% CIs = 1.14-1.79, respectively). Postoperative gastroesophageal reflux disease (GERD) rate was higher in POEM than in LHM and PD (RR = 1.75; 95% CIs = 1.35-2.03 and RR = 1.36; 95% CIs = 1.18-1.68, respectively). Postoperative Eckardt score was significantly lower in POEM than in LHM and PD (standardized mean difference (smd) = -0.6; 95% CIs = -1.4 to -0.2 and smd = -1.2; 95% CIs = -2.3 to -0.2, respectively). No statistically significant differences were found comparing LHM and PD in any of the analyzed outcomes. Conclusions: In the short-term follow-up, POEM seems to be associated with better dysphagia improvement and higher postoperative GERD than LHM and PD. The choice of the ideal initial management should be left to multidisciplinary team discussion and personalized on each patient basis.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Carlo Galdino Riva
- Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Giancarlo Micheletto
- Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Emanuele Rausa
- Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Giampiero Campanelli
- Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Giorgia Olmo
- Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
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47
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Midya S, Ghosh D, Mahmalat MW. Fundoplication in laparoscopic Heller's cardiomyotomy for achalasia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2019. [DOI: 10.1002/14651858.cd013386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sumit Midya
- Royal Berkshire Hospital; Department of General Surgery; Reading UK RG1 5AN
| | - Debasish Ghosh
- Royal Berkshire Hospital; Department of General Surgery; Reading UK RG1 5AN
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48
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Olson MT, Triantafyllou T, Singhal S. A Decade of Investigation: Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia. J Laparoendosc Adv Surg Tech A 2019; 29:1093-1104. [PMID: 31313957 DOI: 10.1089/lap.2019.0242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Although laparoscopic Heller myotomy (LHM) with partial fundoplication has long been considered the gold standard for treatment of patients with achalasia, peroral endoscopic myotomy (POEM) has emerged in the last decade as a viable alternative. Methods: A collective review of literature concerning investigations that have reported patient outcomes and treatment success of LHM and POEM for all achalasia subtypes. Results: While POEM has shown excellent short-term safety and efficacy in the relief of symptoms, the long-term symptomatic outcomes after the intervention are yet to be concluded. Further evaluation of patients' interpretations and answers on subjective questionnaires is warranted before determining treatment success for POEM. Use of more reliable and disease-specific health-related quality-of-life questionnaires are better justified when comparing a new endoscopic procedure to an established gold standard. The need for objective parameters to measure reflux, longer follow-up studies, and randomized trials comparing POEM to LHM is particularly important when assessing the outcome of this new technique. High incidence of post-POEM pathologic reflux and indication for daily proton pump inhibitor use is of concern, and the lack of more long-term, objective evidence leaves the clinical value of the procedure in a state of uncertainty. Conclusions: The LHM combined with partial fundoplication is still considered to be the gold standard treatment modality for achalasia, but as the POEM procedure rapidly becomes common practice, this treatment may be performed in the majority of achalasia cases. Given the number of flaws overlooked in seminal investigations, careful consideration should be given to the patients being selected for this therapy.
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Affiliation(s)
- Michael T Olson
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Tania Triantafyllou
- Hippocration General Hospital of Athens, University of Athens, Athens, Greece
| | - Saurabh Singhal
- Department of GI Surgery and Liver Transplantation, Indraprastha Apollo Hospital, New Delhi, India
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49
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Ithurralde-Argerich J, Cuenca-Abente F, Faerberg A, Rosner L, Duque-Seguro C, Ferro D. Resection of the Gastroesophageal Junction and Roux-en-Y Reconstruction as a New Alternative for the Treatment of Recurrent Achalasia: Outcomes in a Short Series of Patients. J Laparoendosc Adv Surg Tech A 2019; 30:121-126. [PMID: 31161951 DOI: 10.1089/lap.2019.0300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Heller myotomy and laparoscopic fundoplication represents the best treatment option for esophageal achalasia, with effective short- and long-term success. However, treatment options in patients in whom primary surgery failed represent a real challenge. We present the resection of the gastroesophageal junction (GEJ) along with a Roux-en-Y reconstruction as a treatment alternative. Materials and Methods: We analyzed the course of 5 patients with achalasia undergoing the resection of the GEJ along with a Roux-en-Y reconstruction for recurrent dysphagia after Heller myotomy and fundoplication, with at least 1 year of follow-up. Symptoms questionnaire and minuted esophagogram before and after treatment were performed in all the patients. Results: Five patients underwent resection of the GEJ along with a Roux-en-Y reconstruction. All the patients had dysphagia and 60% had regurgitations. Eighty percent of the patients had more than one previous redo surgery and 100% had had multiple dilations. Preoperative contrast esophagram of 3 patients show Stage II disease (mild and mark dilated esophagus) and 2 patients with Stage III disease (one esophageal curve and severe dilation). Manometry confirmed the diagnosis. At a mean follow-up of 34 months, all the patients reported a marked improvement in dysphagia, with median overall satisfaction rating of 9 (range 7-10), no symptom of gastroesophageal reflux disease (GERD), and good esophageal emptying in the postoperative contrast esophagram. Conclusions: The resection of the GEJ and Roux-en-Y reconstruction is an excellent treatment for recurrent dysphagia after Heller myotomy. All the patients reported a marked improvement of their dysphagia. No symptoms of GERD were documented after the surgery. This procedure should be taken into account as an alternative to esophagectomy for recurrent dysphagia.
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Affiliation(s)
- Javier Ithurralde-Argerich
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Federico Cuenca-Abente
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Alejandro Faerberg
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Laura Rosner
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Camilo Duque-Seguro
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Diego Ferro
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
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50
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Di Corpo M, Farrell TM, Patti MG. Laparoscopic Heller Myotomy: A Fundoplication Is Necessary to Control Gastroesophageal Reflux. J Laparoendosc Adv Surg Tech A 2019; 29:721-725. [PMID: 31009312 DOI: 10.1089/lap.2019.0155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Achalasia is a rare esophageal motility disorder that causes progressive dysphagia and regurgitation. The aim of treatment for achalasia is to provide symptom relief by reducing esophageal outflow resistance by disrupting the muscles at the level of the esophagogastric junction to allow esophageal emptying by gravity. Methods: A review of the literature concerning laparoscopic treatment of esophageal achalasia. Results: Surgical myotomy with partial fundoplication is very effective in relieving symptoms, and is able to strike a balance between relief of symptoms and control of abnormal reflux. Conclusions: Since reflux of gastric contents into the aperistaltic esophagus can cause esophagitis, peptic strictures, Barrett's esophagus, and even esophageal carcinoma, the addition of a partial fundoplication is very important. The choice of partial fundoplication is based on surgeons' preference and expertise.
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Affiliation(s)
- Marco Di Corpo
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Timothy M Farrell
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Marco G Patti
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina.,2 Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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