|
1
|
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.
Collapse
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
| |
Collapse
|
|
2
|
Singhal R, Cardoso VR, Wiggins T, Super J, Ludwig C, Gkoutos GV, Mahawar K. 30-day morbidity and mortality of sleeve gastrectomy, Roux-en-Y gastric bypass and one anastomosis gastric bypass: a propensity score-matched analysis of the GENEVA data. Int J Obes (Lond) 2022; 46:750-757. [PMID: 34912046 PMCID: PMC8671878 DOI: 10.1038/s41366-021-01048-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/29/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a paucity of data comparing 30-day morbidity and mortality of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one anastomosis gastric bypass (OAGB). This study aimed to compare the 30-day safety of SG, RYGB, and OAGB in propensity score-matched cohorts. MATERIALS AND METHODS This analysis utilised data collected from the GENEVA study which was a multicentre observational cohort study of bariatric and metabolic surgery (BMS) in 185 centres across 42 countries between 01/05/2022 and 31/10/2020 during the Coronavirus Disease-2019 (COVID-19) pandemic. 30-day complications were categorised according to the Clavien-Dindo classification. Patients receiving SG, RYGB, or OAGB were propensity-matched according to baseline characteristics and 30-day complications were compared between groups. RESULTS In total, 6770 patients (SG 3983; OAGB 702; RYGB 2085) were included in this analysis. Prior to matching, RYGB was associated with highest 30-day complication rate (SG 5.8%; OAGB 7.5%; RYGB 8.0% (p = 0.006)). On multivariate regression modelling, Insulin-dependent type 2 diabetes mellitus and hypercholesterolaemia were associated with increased 30-day complications. Being a non-smoker was associated with reduced complication rates. When compared to SG as a reference category, RYGB, but not OAGB, was associated with an increased rate of 30-day complications. A total of 702 pairs of SG and OAGB were propensity score-matched. The complication rate in the SG group was 7.3% (n = 51) as compared to 7.5% (n = 53) in the OAGB group (p = 0.68). Similarly, 2085 pairs of SG and RYGB were propensity score-matched. The complication rate in the SG group was 6.1% (n = 127) as compared to 7.9% (n = 166) in the RYGB group (p = 0.09). And, 702 pairs of OAGB and RYGB were matched. The complication rate in both groups was the same at 7.5 % (n = 53; p = 0.07). CONCLUSIONS This global study found no significant difference in the 30-day morbidity and mortality of SG, RYGB, and OAGB in propensity score-matched cohorts.
Collapse
Affiliation(s)
- Rishi Singhal
- Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Victor Roth Cardoso
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Health Data Research UK Midlands, Birmingham, UK
| | - Tom Wiggins
- Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan Super
- General Surgery Department, Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, UK
| | - Christian Ludwig
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Georgios V Gkoutos
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Health Data Research UK Midlands, Birmingham, UK
- NIHR Experimental Cancer Medicine Centre, Birmingham, B15 2TT, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, B15 2TT, UK
| | - Kamal Mahawar
- Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, UK
| |
Collapse
|
|
3
|
Kim JD. Prognostic factors of esophageal perforation and rupture leading to mortality: a retrospective study. J Cardiothorac Surg 2021; 16:291. [PMID: 34627308 PMCID: PMC8502388 DOI: 10.1186/s13019-021-01680-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/29/2021] [Indexed: 12/05/2022] Open
Abstract
Background Esophageal perforation and rupture (EPR) is a serious, potentially life-threatening condition. However, no treatment methods have been established, and data concerning factors affecting mortality are limited. This report presents the prognostic factors of mortality in EPR based on experience in the management of such patients. Methods For this retrospective analysis, 79 patients diagnosed as having EPR between 2006 and 2016 and managed at Gyeongsang National University Hospital were examined. The management method was determined in accordance with the location and size of the EPR, laboratory findings, and radiological findings. Thirty-nine patients were treated with surgery; and 40, with nonsurgical management. Results The most common cause of EPR was foreign body (fish bone or meat bone), followed by vomiting, iatrogenic causes, and trauma. Thirty-nine patients underwent primary repair of EPR, of whom 4 patients died. Forty patients underwent nonsurgical management, of whom 3 patients died. The remaining patients were discharged. Mortality correlated with the size of the EPR (> 25 mm) and the segmented neutrophil count percentage (> 86.5%) in the white blood cell test and differential. Conclusions The mortality risk was increased when the EPR size and the segmented neutrophil count percentage in the white blood cell test and differential was high. Delayed diagnosis, which was considered an important predictive factor in previous investigations, was not statistically significant in this study. Trial registration: Not applicable.
Collapse
Affiliation(s)
- Jong Duk Kim
- Department of Cardiothoracic Surgery, School of Medicine, Gyeonsang National University, Gyeongsang National University Hospital, Jin-Ju, 79 Gangnam-ro, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea.
| |
Collapse
|
|
4
|
Xia H, Tan S, Huang S, Gan P, Zhong C, Lü M, Peng Y, Zhou X, Tang X. Scoping Review and Bibliometric Analysis of the Most Influential Publications in Achalasia Research from 1995 to 2020. BIOMED RESEARCH INTERNATIONAL 2021; 2021:8836395. [PMID: 33628819 PMCID: PMC7884120 DOI: 10.1155/2021/8836395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To identify and evaluate characteristics of the most influential articles in achalasia research during the period 1995-2020. METHODS Articles in Scopus, Web of Science Core Collection (WoSCC), and PubMed were scanned from 1995 to 2020 with achalasia as the keyword. We retrieved the articles that met all criteria by descending order after using EndNote to remove the duplicated references. Our bibliometric analysis highlighted publication year, country, journals, and networks of keywords. RESULTS Fifteen percent of the top 100 most-cited articles were published in Annals of Surgery. They were performed in 15 countries, and most (n = 55) were from the USA. The number of citations of the 482 articles ranged from 30 to 953, 38 of which had been published in American Journal of Gastroenterology. Those articles were from 31 countries, and most of the studies (n = 217) had been performed in the USA. Most of articles (n = 335) were clinical research. Treatments were hotspots in the field of achalasia in the past years. The most influential title words were "achalasia," "esophagomyotomy," "pneumatic dilation," and "lower esophageal sphincter." CONCLUSION Our study offers a historical perspective on the progress of achalasia research and identified the most significant evolution in this field. Results showed treatment was the most influence aspect in achalasia.
Collapse
Affiliation(s)
- Huifang Xia
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, The People's Hospital of Lianshui, Huaian, China
| | - Peiling Gan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chunyu Zhong
- 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
| | - Xian Zhou
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| |
Collapse
|
|
5
|
Jayabalan J, Theckumparampil N, Natarajan A, Phansalkar DS, Kurian G. Vigorous achalasia: Zebra amongst horses. SA J Radiol 2020; 24:1953. [PMID: 33354369 PMCID: PMC7736685 DOI: 10.4102/sajr.v24i1.1953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/09/2020] [Indexed: 11/04/2022] Open
Abstract
Vigorous achalasia is an oesophageal disorder with clinical and radiological characteristics of classic achalasia and diffuse oesophageal spasm. It is a rarely reported variant. A 60-year-old gentleman presented with complaints of difficulty in swallowing, regurgitation and chest pain for the past 10 years. His symptoms persisted despite the use of proton pump inhibitors. On endoscopy and barium swallow, the diagnosis of vigorous achalasia was confirmed. It is a rare variant of classic achalasia usually misdiagnosed as diffuse oesophageal spasm.
Collapse
Affiliation(s)
| | - Nithin Theckumparampil
- Department of Radiodiagnosis, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Aravintho Natarajan
- Department of Radiodiagnosis, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Dilip S. Phansalkar
- Department of Radiodiagnosis, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - George Kurian
- Department of Gastroenterology, Pondicherry Institute of Medical Sciences, Puducherry, India
| |
Collapse
|
|
6
|
Schizas D, Kapsampelis P, Tsilimigras DI, Kanavidis P, Moris D, Papanikolaou IS, Karamanolis GP, Theodorou D, Liakakos T. The 100 most cited manuscripts in esophageal motility disorders: a bibliometric analysis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:310. [PMID: 31475180 PMCID: PMC6694239 DOI: 10.21037/atm.2019.06.34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of bibliometrics can help us identify the most impactful articles on a topic or scientific discipline and their influence on clinical practice. We aimed to identify the 100 most cited articles covering esophageal motility disorders and examine their key characteristics. METHODS The Web of Science database was utilized to perform the search, using predefined search terms. The returned dataset was filtered to include full manuscripts written in the English language. After screening, we identified the 100 most cited articles and analyzed them for title, year of publication, names of authors, institution, country of the first author, number of citations and citation rate. RESULTS The initial search returned 29,521 results. The top 100 articles received a total of 20,688 citations. The most cited paper was by Inoue et al. (665 citations) who first described peroral endoscopic myotomy (POEM) for treating achalasia. The article with the highest citation rate was the third version of the Chicago Classification system, written by Kahrilas and colleagues. Gastroenterology published most papers on the list (n=32) and accrued the highest number of citations (6,675 citations). Peter Kahrilas was the most cited author (3,650 citations) and, along with Joel Richter, authored the highest number of manuscripts (n=14). Most articles were produced in the USA (n=66) between the years 1991 and 2000 (n=32). CONCLUSIONS By analyzing the most influential articles, this work is a reference on the articles that shaped our understanding of esophageal motility disorders, thus serving as a guide for future research.
Collapse
Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Panagiotis Kapsampelis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Diamantis I. Tsilimigras
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Prodromos Kanavidis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ioannis S. Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine and Research Institute, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Georgios P. Karamanolis
- Gastroenterology Unit, Second Department of Surgery, National and Kapodistrian University of Athens, Aretaieio University Hospital, Athens, Greece
| | - Dimitrios Theodorou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - Theodore Liakakos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| |
Collapse
|
|
7
|
Naspetti R, Modesti PA. Clinical decision where evidence is lacking. Intern Emerg Med 2016; 11:901-2. [PMID: 26746414 DOI: 10.1007/s11739-015-1380-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Riccardo Naspetti
- Endoscopic Surgery, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Pietro Amedeo Modesti
- Department of Medicina Sperimentale e Clinica, University of Florence, Largo Brambilla 3, 50134, Florence, Italy.
| |
Collapse
|
|
8
|
Gillaspie EA, Nichols FC, Allen MS. Mayo Clinic: An Institutional History of General Thoracic Surgery. Semin Thorac Cardiovasc Surg 2016; 27:353-9. [PMID: 26811041 DOI: 10.1053/j.semtcvs.2015.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2015] [Indexed: 11/11/2022]
Abstract
The Mayo Clinic was started in Rochester, MN after a 1883 tornado disaster. The Mayo brothers, William and Charles began thoracic surgical procedures early in their career. Dr. Samuel Robinson is recognized as the first thoracic surgeon at Mayo. He was followed by Drs. Harrington and Claret who became famous surgeons. Many other notable surgeons have help to build the thoracic surgical practice into what is today a world renown center of excellence in thoracic surgery.
Collapse
Affiliation(s)
- Erin A Gillaspie
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Francis C Nichols
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark S Allen
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
|
9
|
Abstract
Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and defective relaxation of the lower esophageal sphincter. Patients present at all ages with dysphagia and regurgitation as main symptoms. The diagnosis is suggested by barium swallow and endoscopy and confirmed by manometry. Because there is no curative treatment for achalasia, treatment is confined to disruption of the lower esophageal sphincter to improve bolus passage. The most successful therapies are pneumodilation and laparoscopic Heller myotomy, with comparable short-term clinical rates of success. The prognosis of achalasia patients is good, but re-treatment is often necessary.
Collapse
|
|
10
|
Zaninotto G, Costantini M. Laparoscopic Esophageal Myotomy. SHACKELFORD'S SURGERY OF THE ALIMENTARY TRACT 2013:354-361. [DOI: 10.1016/b978-1-4377-2206-2.00029-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
|
|
11
|
Minimally invasive myotomy for the treatment of esophageal achalasia: evolution of the surgical procedure and the therapeutic algorithm. Surg Laparosc Endosc Percutan Tech 2012; 22:83-7. [PMID: 22487617 DOI: 10.1097/sle.0b013e318243368f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare disease of the esophagus, characterized by the absence of peristalsis in the esophageal body and incomplete relaxation of the lower esophageal sphincter, which may be hypertensive. The cause of this disease is unknown; therefore, the aim of the therapy is to improve esophageal emptying by eliminating the outflow resistance caused by the lower esophageal sphincter. This goal can be accomplished either by pneumatic dilatation or surgical myotomy, which are the only long-term effective therapies for achalasia. Historically, pneumatic dilatation was preferred over surgical myotomy because of the morbidity associated with a thoracotomy or a laparotomy. However, with the development of minimally invasive techniques, the surgical approach has gained widespread acceptance among patients and gastroenterologists and, consequently, the role of surgery has changed. The aim of this study was to review the changes occurred in the surgical treatment of achalasia over the last 2 decades; specifically, the development of minimally invasive techniques with the evolution from a thoracoscopic approach without an antireflux procedure to a laparoscopic myotomy with a partial fundoplication, the changes in the length of the myotomy, and the modification of the therapeutic algorithm.
Collapse
|
|
12
|
Abstract
Despite symptom improvement offered to achalasia patients by either pneumatic dilation or surgical myotomy, 10% to 15% of those so treated will present progressive deterioration of their esophageal function and up to 5% may eventually require an esophagectomy. The natural evolution of achalasia to its end stage as well as the timing of esophagectomy in these patients form the basis of this review. The optimal reconstruction for the decompensated resected esophagus will also be explored: gastric interposition, colon interposition, and jejunal interposition all have their respective advantages and disadvantages. Their use is examined in the exclusive context of resection for achalasia.
Collapse
Affiliation(s)
- A Duranceau
- Department of Surgery, Université de Montréal, Division of Thoracic Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
| | | | | | | |
Collapse
|
|
13
|
Triadafilopoulos G, Boeckxstaens GE, Gullo R, Patti MG, Pandolfino JE, Kahrilas PJ, Duranceau A, Jamieson G, Zaninotto G. The Kagoshima consensus on esophageal achalasia. Dis Esophagus 2012; 25:337-48. [PMID: 21595779 DOI: 10.1111/j.1442-2050.2011.01207.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and a lower esophageal sphincter that fails to relax appropriately in response to swallowing. This article summarizes the most salient issues in the diagnosis and management of achalasia as discussed in a symposium that took place in Kagoshima, Japan, in September 2010 under the auspices of the International Society for Diseases of the Esophagus.
Collapse
Affiliation(s)
- G Triadafilopoulos
- Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
|
14
|
Revisional surgery after heller myotomy for treatment of achalasia: a comparative analysis focusing on operative approach. Indian J Surg 2012; 74:309-13. [PMID: 23904720 DOI: 10.1007/s12262-011-0402-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 12/22/2011] [Indexed: 10/14/2022] Open
Abstract
Surgical myotomy is the gold standard in therapy for achalasia, but treatment failures occur and require revisional surgery. A MEDLINE search of peer-reviewed articles published in English from 1970 to December 2008 was performed using the following terms: esophageal achalasia, Heller myotomy, and revisional surgery. Thirty-three articles satisfied our inclusion criteria. A total of 12,727 patients, with mean age of 43.3 years (males 46% and females 50%), underwent Heller myotomy (open 94.8% and laparoscopic 5.2%). Revisional surgery was performed in 6.19%. Procedures performed included revision of the original myotomy or creation of a new myotomy with or without an antireflux procedure or esophagectomy. Reasons for reoperation were incomplete myotomy (51.8%), onset of reflux (34%), megaesophagus (16.2%), and esophageal carcinoma (3.04%). Systematic review of the literature for revisional surgery following Heller myotomy revealed a 6.19% rate of reoperation with a low mortality rate.
Collapse
|
|
15
|
Sim HJ, Jang IS, Park HO, Lee CE, Kim JW, Choi JY, Rhie SH. Treatment of Esophageal Injury. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2010. [DOI: 10.5090/kjtcs.2010.43.6.705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hee Jae Sim
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Gyeongsang National University, Institute of Health Science, Gyeongsang National University
| | - In-Seok Jang
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Gyeongsang National University, Institute of Health Science, Gyeongsang National University
| | - Hyun Oh Park
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Gyeongsang National University, Institute of Health Science, Gyeongsang National University
| | - Chung-Eun Lee
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Gyeongsang National University, Institute of Health Science, Gyeongsang National University
| | - Jong-Woo Kim
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Gyeongsang National University, Institute of Health Science, Gyeongsang National University
| | - Jun-Young Choi
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Gyeongsang National University, Institute of Health Science, Gyeongsang National University
| | - Sang-Ho Rhie
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Gyeongsang National University, Institute of Health Science, Gyeongsang National University
| |
Collapse
|
|
16
|
Deschamps C. Laparoscopic myotomy and fundoplication for achalasia. Semin Thorac Cardiovasc Surg 2010; 22:184-6. [PMID: 21092898 DOI: 10.1053/j.semtcvs.2010.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Claude Deschamps
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
| |
Collapse
|
|
17
|
Eldaif SM, Mutrie CJ, Rutledge WC, Lin E, Force SD, Miller JI, Mansour KA, Miller DL. The Risk of Esophageal Resection After Esophagomyotomy for Achalasia. Ann Thorac Surg 2009; 87:1558-62; discussion 1562-3. [DOI: 10.1016/j.athoracsur.2009.02.078] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Revised: 02/24/2009] [Accepted: 02/26/2009] [Indexed: 10/20/2022]
|
|
18
|
Zhang Y, Xu CD, Zaouche A, Cai W. Diagnosis and management of esophageal achalasia in children: analysis of 13 cases. World J Pediatr 2009; 5:56-9. [PMID: 19172334 DOI: 10.1007/s12519-009-0010-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Accepted: 09/24/2008] [Indexed: 02/01/2023]
Abstract
BACKGROUND Esophageal achalasia is a rare disease and there have been very few reports about it, especially in children. We reviewed our experience in dealing with esophageal achalasia in 13 children. METHODS Thirteen children (6 boys and 7 girls), who had been diagnosed with achalasia over a 12-year period between May 1993 and October 2005, were analysed with regard to clinical manifestations, esophageal manometry, endoscopic findings, and treatment. Their age ranged from 3 years to 14 years and 5 months (average 10.3 years) at the time of diagnosis. RESULTS In the 13 children, 3 had a family history of esophageal achalasia, 2 of them were sisters. All the 3 children suffered from achalasia/alacrimia/ACTH deficiency. Dysphagia was the most common symptom in the affected children. Vomiting/regurgitation, retrosternal pain, retarded growth, and respiratory symptoms were also observed in some patients. Heller's esophagocardiomyotomy was performed in 9 (69.23%) children, among whom 3 had an antireflux operation at the same time. In the remaining 4 children, 3 received a pneumatic dilatation and 1 received regular administration of nifedipine. Twelve patients were followed up: 8 patients by surgery were cured and have been in perfect condition until now, 3 patients recovered fairly, and 1 patient showed improvement. CONCLUSIONS Esophageal manometry combined with X-ray examination proves to be an effective diagnostic method for achalasia. It is also effective in evaluating the result of treatment. Heller's esophagocardiomyotomy is a treatment of choice for children with achalasia because of its safety and long-term effective results after surgery.
Collapse
Affiliation(s)
- Yin Zhang
- Department of Pediatrics, Shanghai Ruijin Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, 200025, China
| | | | | | | |
Collapse
|
|
19
|
Abstract
BACKGROUND Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes mostly come from cohort studies. OBJECTIVE To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia. METHODS A systematic electronic Medline literature search of articles on esophageal achalasia. Treatment options reviewed included EBTI, EBD, and surgical myotomy using open and minimally invasive techniques. Main outcome measures were frequency of symptom relief, prevalence of post-treatment gastroesophageal reflux (GER), and complications. Outcome probability was estimated using weighted averages of the sample prevalence in each study, with weights equal to the number of patients. Outcomes, within or across studies, were compared using meta-analysis and meta-regression, respectively. RESULTS A total of 105 articles reporting on 7855 patients were selected, tabulated and reviewed. Symptom relief after EBD was better than after EBTI (68.2% vs. 40.6%; OR 3.4; 95% CI, 1.2-9.8; P = 0.02), and the need for additional therapy was greater for patients receiving EBTI (46.6% vs. 25%; OR, 2.6; 95% CI, 1.05-6.5; P = 0.04). Laparoscopic myotomy, when combined with an antireflux procedure, provided better symptom relief (90%) than all endoscopic and other surgical approaches and a low complication rate (6.3%). The incidence of postoperative GER was lower when a fundoplication was added to a laparoscopic myotomy (31.5% without a fundoplication vs. 8.8% with; OR, 6.3; 95% CI, 2.0-19.4; P = 0.003). CONCLUSIONS EBD is superior to EBTI. Laparoscopic myotomy with fundoplication was the most effective surgical technique and can be considered the operative procedure of choice.
Collapse
|
|
20
|
Affiliation(s)
- Thomas J Watson
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | | | | |
Collapse
|
|
21
|
|
|
22
|
Vaos G, Demetriou L, Velaoras C, Skondras C. Evaluating long-term results of modified Heller limited esophagomyotomy in children with esophageal achalasia. J Pediatr Surg 2008; 43:1262-9. [PMID: 18639680 DOI: 10.1016/j.jpedsurg.2008.02.074] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND/PURPOSE Modified Heller esophagomyotomy has become the initial treatment of choice for esophageal achalasia in children. However, only limited and not objective data are currently available on the long-term results of modified Heller limited esophagomyotomy (LEM). This retrospective study was undertaken to objectively assess the long-term results of LEM in childhood esophageal achalasia. METHODS Medical records of 15 patients with a median age of 9.5 years (range, 6-13 years) who underwent an LEM without an antireflux procedure from January 1991 to December 2005 were reviewed. Clinical scores, barium esophagogram, flexible upper alimentary endoscopy, 24-hour esophageal pH monitoring, and esophageal manometry before and 0.5 to 15 years after surgery were analyzed. RESULTS An excellent to good outcome was observed in 14 (93.3%) patients. One patient (6.7%) required reoperation 8 months after surgery because of persistent dysphagia. The late barium esophagogram showed a significant decrease (from 4.2 +/- 0.95 to 2.4 +/- 1.1 cm, P < .01) of esophageal diameter, as compared with preoperative values. Only 1 patient had grade II esophagitis on flexible upper alimentary endoscopy. Twenty-four- hour esophageal pH monitoring showed an abnormal acid exposure in 1 patient. The late esophageal manometry showed a significant decrease (from 31.7 +/- 7.9 to 7.8 +/- 3.7 mm Hg; < .05) of lower esophageal sphincter (LES) pressure, and only insignificant increase (from 18.8 +/- 6.2 to 21.4 +/- 8.4 mm Hg; NS) of amplitude of esophageal contractions over preoperative values. CONCLUSIONS Transabdominal LEM without an antireflux procedure is an effective and safe treatment of esophageal achalasia in children because of its long-term high rate of symptoms relief and low incidence of postoperative complications, despite the lack of esophageal motility restoration to normal.
Collapse
Affiliation(s)
- George Vaos
- Second Department of Paediatric Surgery, P. and A. Kyriakou Children's Hospital, Athens 11527, Greece.
| | | | | | | |
Collapse
|
|
23
|
Garofalo JH, Pofahl WE. Achalasia: a brief review of treatment options and efficacy. ACTA ACUST UNITED AC 2008; 59:549-53. [PMID: 16093192 DOI: 10.1016/s0149-7944(02)00658-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- James H Garofalo
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
| | | |
Collapse
|
|
24
|
Very long-term objective evaluation of heller myotomy plus posterior partial fundoplication in patients with achalasia of the cardia. Ann Surg 2008; 247:258-64. [PMID: 18216530 DOI: 10.1097/sla.0b013e318159d7dd] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To present the objectively assessed very long-term results of a prospective study of 149 patients with achalasia of the cardia who underwent Heller myotomy and posterior partial fundoplication. SUMMARY BACKGROUND DATA Very few studies evaluate objectively the very long-term results to analyze whether the effectiveness of Heller myotomy is maintained with the passing of time. METHODS The study group consisted of 149 patients who underwent a Heller myotomy plus a posterior partial fundoplication through a laparotomy. The median follow-up was 6 years (range, 1-27 years). Follow-up period was over 10 years in 53 patients and over 15 in 36. Clinical, radiologic, endoscopic, manometric, and pHmetric evaluations were performed postoperatively. RESULTS Satisfactory results were higher than 90% up to 5 years. From that time on results gradually decreased to a 75% rate after 15 years (P < 0.001) due to either heartburn or dysphagia. Both the esophageal diameter and the mean resting pressure of the lower esophageal sphincter decreased postoperatively with no significant changes during follow-up. Esophagitis appeared in 11% of the patients (47% of them being asymptomatic) and 24-hour pH monitoring showed pathologic rates of acid reflux in 14% of patients, 58% of them being asymptomatic. Both esophagitis and pathologic rates of reflux appeared in >40% of the patients late in the follow-up. CONCLUSION Results after Heller myotomy plus posterior partial fundoplication deteriorate with time, although we achieved a 75% of satisfactory results after >15 years of follow-up. Our study highlights the importance of life long follow-up and the objective assessment of the results.
Collapse
|
|
25
|
Pneumatic Balloon Dilation Therapy Is as Effective as Esophagomyotomy for Achalasia. Dysphagia 2008; 23:155-60. [DOI: 10.1007/s00455-007-9115-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2007] [Accepted: 07/03/2007] [Indexed: 01/09/2023]
|
|
26
|
Esophagus Benign Diseases of the Esophagus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
|
27
|
Roa PE, Sesto ME. Esophagogastro-Roux-en-Y Jejunostomy: A Surgical Option in Recurrent Achalasia? Case Report and Review of the Literature. Am Surg 2007. [DOI: 10.1177/000313480707300923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recurrent obstructive symptoms after cardiomyotomy for achalasia occur in approximately 10 per cent to 15 per cent of patients, but only some require reoperation. Reoperative procedures for achalasia vary, and in general, have less success in relieving symptoms than the initial procedure. We present the case of a 37-year-old male with a 15-year history of recurrent achalasia, with symptoms of heartburn and progressive dysphagia after meals. He underwent several esophageal dilatations, botox injections, and two transthoracic Heller myotomies before the transabdominal esophagogastro-Roux-en-Y jejunostomy was performed. This case represents another surgical option for management of the challenging problem of recurrent achalasia.
Collapse
Affiliation(s)
- Paul E. Roa
- Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Mark E. Sesto
- Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston, Florida
| |
Collapse
|
|
28
|
Affiliation(s)
| | - Eizo KANEKO
- First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| |
Collapse
|
|
29
|
Jeansonne LO, White BC, Pilger KE, Shane MD, Zagorski S, Davis SS, Hunter JG, Lin E, Smith CD. Ten-year follow-up of laparoscopic Heller myotomy for achalasia shows durability. Surg Endosc 2007; 21:1498-502. [PMID: 17623235 DOI: 10.1007/s00464-007-9500-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Accepted: 06/19/2007] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Reports of long-term outcomes for laparoscopic Heller myotomy (LHM) are scarce. In this work, outcomes of LHM for achalasia in patients who underwent surgery more than 10 years prior were investigated. METHODS A cohort of patients treated with LHM and partial fundoplication for achalasia between 1993 and 1996 was followed for long-term outcomes, which were compared to baseline data at presentation. RESULTS Thirty-two consecutive patients were identified, and follow-up information was obtained for 20 patients (62.5%). Mean follow-up was 11.2 years (range 10.3 to 12.3 years). Three patients (9.4%) were deceased (mean of 40 months postoperation). Of the 17 living patients, dysphagia was rated as severe in one (5.9%), mild to moderate in eight (47.1%), and absent in eight (47.1%). This was a significant improvement from preoperative scores in which dysphagia was rated as severe in 42.9%, mild to moderate in 57.1%, and absent in 0% (p < 0.05). In addition, 10-year dysphagia scores were unchanged from those at short-term follow-up (mean 27 months, p = 0.84). Other symptoms of heartburn, chest pain, voice symptoms, cough, and asthma were reported in fewer than 30% of patients at 10 years. Esophageal dilation following surgery was required in three patients, and two patients required repeat operations (esophagectomy in one patient, hiatal hernia in one patient). Satisfaction with the operation was reported by 16 patients (94.1%) at 10 years. CONCLUSIONS Most patients who underwent LHM with partial fundoplication reported satisfaction 10 years after the operation. A small number of patients required additional intervention. Dysphagia scores at 10 years were not different from those collected at short-term follow-up. Our data suggest that the efficacy of LHM is sustained at 10-year follow-up.
Collapse
Affiliation(s)
- Louis O Jeansonne
- Emory Endosurgery Unit, 1364 Clifton Road NE, Suite H124, Atlanta, Georgia 30322, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
|
30
|
Tsiaoussis J, Athanasakis E, Pechlivanides G, Tzortzinis A, Gouvas N, Mantides A, Xynos E. Long-term functional results after laparoscopic surgery for esophageal achalasia. Am J Surg 2007; 193:26-31. [PMID: 17188083 DOI: 10.1016/j.amjsurg.2006.10.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2005] [Revised: 07/08/2006] [Indexed: 01/27/2023]
Abstract
BACKGROUND Evidence on the long-term outcome of laparoscopic Heller-Dor surgery is limited. The aim of this study was to assess the long-term outcome of achalasic patients after surgery, particularly in relation to the radiologic preoperative stage of the disease. METHODS Sixty-eight patients with achalasia were assessed clinically and by esophageal radiology, manometry, and 24-hour ambulatory esophageal pH monitoring before and at 3 months, 1, 1 to 3, 3 to 5, and 5 to 8 years after a laparoscopic Heller-Dor procedure. RESULTS At 1 year after surgery the symptom score was significantly lower than the preoperative score (P < .001), and a satisfactory clinical outcome was seen in more than 90% of the patients with stage I, II, and III disease at the preoperative radiologic assessment. Only 50% of stage IV patients reported satisfactory results. An adequate opening of the lower esophageal sphincter (LES) and LES resting pressure of less than 8 mm Hg was achieved in all patients, and esophageal emptying was accelerated significantly (P < .001). At the consecutive follow-up evaluation (1-8 y), a satisfactory outcome was maintained in all stage I, II, and III responders. Stage IV patients with initially unsatisfactory results reported a worsening of symptoms (P < .02). Patients with pseudodiverticulum had a higher symptom score (P < .01). LES opening and resting pressure remained at levels of the 1-year follow-up evaluation. Esophageal emptying remained satisfactory in stage I, II, and III responders, but deteriorated in stage IV nonresponders and in 6 of the 10 patients with a pseudodiverticulum. CONCLUSIONS A satisfactory outcome of the laparoscopic Heller-Dor procedure in stage I, II, and III achalasic patients seems to last. Stage IV nonresponders tend to deteriorate over time. The development of pseudodiverticulum is associated with an increased symptom score.
Collapse
Affiliation(s)
- John Tsiaoussis
- Gastrointestinal Motility Unit, Department of General Surgery, University Hospital of Heraklion, Heraklion, Crete, GR-711 10 Greece
| | | | | | | | | | | | | |
Collapse
|
|
31
|
Zhou JH, Wang RW, Jiang YG, Fan SZ, Gong TQ, Zhao YP, Tan QY, Ma Z, Deng B. Management of achalasia with transabdominal esophagocardiomyotomy and partial posterior fundoplication. Dis Esophagus 2006; 19:389-93. [PMID: 16984538 DOI: 10.1111/j.1442-2050.2006.00590.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In this article we present our experience in the management of achalasia. From May 1988 through August 2005, 71 patients with achalasia underwent transabdominal esophagocardiomyotomy and partial posterior fundoplication. Barium swallow, manometry, and 24-h pH studies were performed in all patients preoperatively. Manometry and 24-h pH monitoring were only carried out in 58 patients at the third post-operative week and in 43 patients during follow-up, even though 52 patients were included in the follow-up. There were no operative deaths or complications. All the 71 patients were able to eat semifluid or solid food without dysphagia and heartburn at discharge. Esophageal barium studies showed that the maximum esophageal diameter decreased 2.2 cm and the minimum gastroesophageal junction diameter increased 8.4 mm after operation. Manometry examination in 58 patients revealed that the lower esophageal sphincter resting pressure decreased 15.0 mmHg in the wake of the procedure. Twenty-four hour pH monitoring demonstrated that reflux events were within the normal post-operative range. Fifty-five of the 58 patients had normal DeMeester scores. Among the patients with a mean 90-month follow-up, 49 patients had normal intake of food without reflux, the remaining three had mild dysphagia without requiring treatment. All the patients resumed their preoperative work and social activities. The manometry and 24-h pH studies in the 43 patients showed there were no significant changes between the third post-operative week and during follow-up. Transabdominal esophagocardiomyotomy and posterior partial fundoplication are able to relieve the functional outflow obstruction of the lower esophageal sphincter, obviate the rehealing of the myotomy edge and prevent gastroesophageal reflux in patients who have undergone myotomy alone.
Collapse
Affiliation(s)
- J-H Zhou
- Department of Thoracic Surgery, Daping Hospital, Third Military Medical University, Chongqing, PR China
| | | | | | | | | | | | | | | | | |
Collapse
|
|
32
|
Smith CD, Stival A, Howell DL, Swafford V. Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than heller myotomy alone. Ann Surg 2006; 243:579-84; discussion 584-6. [PMID: 16632991 PMCID: PMC1570551 DOI: 10.1097/01.sla.0000217524.75529.2d] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Heller myotomy has been shown to be an effective primary treatment of achalasia. However, many physicians treating patients with achalasia continue to offer endoscopic therapies before recommending operative myotomy. Herein we report outcomes in 209 patients undergoing Heller myotomy with the majority (74%) undergoing myotomy as secondary treatment of achalasia. METHODS Data on all patients undergoing operative management of achalasia are collected prospectively. Over a 9-year period (1994-2003), 209 patients underwent Heller myotomy for achalasia. Of these, 154 had undergone either Botox injection and/or pneumatic dilation preoperatively. Preoperative, operative, and long-term outcome data were analyzed. Statistical analysis was performed with multiple chi and Mann-Whitney U analyses, as well as ANOVA. RESULTS Among the 209 patients undergoing Heller myotomy for achalasia, 154 received endoscopic therapy before being referred for surgery (100 dilation only, 33 Botox only, 21 both). The groups were matched for preoperative demographics and symptom scores for dysphagia, regurgitation, and chest pain. Intraoperative complications were more common in the endoscopically treated group with GI perforations being the most common complication (9.7% versus 3.6%). Postoperative complications, primarily severe dysphagia, and pulmonary complications were more common after endoscopic treatment (10.4% versus 5.4%). Failure of myotomy as defined by persistent or recurrent severe symptoms, or need for additionally therapy including redo myotomy or esophagectomy was higher in the endoscopically treated group (19.5% versus 10.1%). CONCLUSION Use of preoperative endoscopic therapy remains common and has resulted in more intraoperative complications, primarily perforation, more postoperative complications, and a higher rate of failure than when no preoperative therapy was used. Endoscopic therapy for achalasia should not be used unless patients are not candidates for surgery.
Collapse
Affiliation(s)
- C Daniel Smith
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | | | | | | |
Collapse
|
|
33
|
Csendes A, Braghetto I, Burdiles P, Korn O, Csendes P, Henríquez A. Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months. Ann Surg 2006; 243:196-203. [PMID: 16432352 PMCID: PMC1448918 DOI: 10.1097/01.sla.0000197469.12632.e0] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Laparoscopic esophagomyotomy is the preferred approach to patients with achalasia of the esophagus, However, there are very few long-term follow-up studies (>10 years) in these patients. OBJECTIVE To perform a very late subjective and objective follow-up in a group of 67 patients submitted to esophagomyotomy plus a partial antireflux surgery (Dor's technique). MATERIAL AND METHODS In a prospective study that lasted 30 years, 67 patients submitted to surgery were divided into 3 groups: group I followed for 80 to 119 months (15 patients); group II, with follow-up of 120 to 239 months (35 patients); and group III, with follow-up more than 240 months (17 patients). They were submitted to clinical questionnaire, endoscopic evaluation, histologic analysis, radiologic studies, manometric determinations, and 24-hour pH studies late after surgery. RESULTS Three patients developed a squamous cell esophageal carcinoma 5, 7, and 15 years after surgery. At the late follow-up, Visick III and IV were seen in 7%, 23%, and 35%, according to the length of follow-up of each group. Endoscopic examination revealed a progressive nonsignificant deterioration of esophageal mucosa, histologic analysis distal to squamous-columnar junction showed a significant decrease of fundic mucosa in patients of group III, with increase of intestinal metaplasia, although not significant time. Lower esophageal sphincter showed a significant decrease of resting pressure 1 year after surgery, which remained similar at the late control. There was no return to peristaltic activity. Acid reflux measured by 24-hour pH studies revealed a progressive increase, and the follow-up was longer. Nine patients developed Barrett esophagus: 6 of them a short-segment and 3 a long-segment Barrett esophagus. Final clinical results in all 67 patients demonstrated excellent or good results in 73% of the cases, development of epidermoid carcinoma in 4.5%, and failures in 22.4% of the patients, mainly due to reflux esophagitis. Incomplete myotomy was seen in only 1 case. CONCLUSION In patients with achalasia submitted to esophagomyotomy and Dor's antireflux procedure, there is a progressive clinical deterioration of initially good results if a very long follow-up is performed (23 years after surgery), mainly due to an increase in pathologic acid reflux disease and the development of short- or long-segment Barrett esophagus.
Collapse
Affiliation(s)
- Attila Csendes
- Department of Surgery, University Hospital, Santiago, Chile.
| | | | | | | | | | | |
Collapse
|
|
34
|
Abstract
Achalasia is a condition of unknown etiology. It represents a motor disorder of the esophagus characterized by absent or incomplete relaxation of the lower esophageal sphincter upon swallowing and by non-propulsive swallow-induced contraction waves or amotility of the esophageal body. Dysphagia and regurgitation of ingesta are the most frequent symptoms. Medical treatment, i.e. by calcium-channel blockers and nitric oxide donors, may be tried in patients with mild dysphagia or in elderly patients but rarely yields adequate symptom relief. Mechanical dilatation of the achalasic sphincter may be performed as an initial treatment option. Intrasphincteric injections of botulinum toxin seemed to be a promising alternative, but it has become obvious that, in most cases, repeated applications of the toxin are required to maintain patients symptom-free. Myotomy of the achalasic sphincter with or without fundoplication to prevent gastroesophageal reflux, is employed mainly in patients in whom dilatations have failed, but since the introduction of minimally invasive surgery, myotomy has become the primary treatment at many centers. This article aims to provide an overview of the development of the conservative and surgical treatment of achalasia.
Collapse
Affiliation(s)
- Enrico P Cosentini
- Klinische Abteilung für Allgemeinchirurgie, Universitätsklinik für Chirurgie, Wien, Osterreich.
| | | | | |
Collapse
|
|
35
|
Bloomston M, Durkin A, Boyce HW, Johnson M, Rosemurgy AS. Early results of laparoscopic Heller myotomy do not necessarily predict long-term outcome. Am J Surg 2004; 187:403-7. [PMID: 15006571 DOI: 10.1016/j.amjsurg.2003.12.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2003] [Revised: 08/11/2003] [Indexed: 11/23/2022]
Abstract
BACKGROUND We sought to evaluate how patients' symptoms evolve after laparoscopic Heller myotomy. METHODS Before and after laparoscopic Heller myotomy, 88 patients graded dysphagia and heartburn on a Likert scale (0 = none; 5 = severe). Patients graded outcomes as excellent, good, fair, or poor. Outcomes were compared in the same patients at 1 and 3 years of follow-up. RESULTS At early follow-up (10.6 +/- 7.8 months) significant reductions were noted in dysphagia (11% versus 100%), dysphagia scores (0.6 +/- 1.1 versus 4.7 +/- 0.7), heartburn (31% versus 72%), and heartburn scores (1.2 +/- 1.6 versus 2.7 +/- 1.9). By late follow-up (37.6 months +/- 18.0) these values increased (47%, 1.9 +/- 1.7, 48%, 1.8 +/- 1.5, respectively) but remained significantly reduced compared with before operation. Excellent/good outcomes at early and late follow-up were 89% and 85%, respectively (P = not significant). CONCLUSIONS Laparoscopic Heller myotomy is highly effective at palliating the symptoms of achalasia. With time, symptoms may recur owing to esophageal dysmotility, mandating continued surveillance.
Collapse
Affiliation(s)
- Mark Bloomston
- Department of Surgery, University of South Florida, P.O. Box 1289, Room F-145, Tampa, FL 33601, USA.
| | | | | | | | | |
Collapse
|
|
36
|
Kesler KA, Tarvin SE, Brooks JA, Rieger KM, Lehman GA, Brown JW. Thoracoscopy-assisted Heller myotomy for the treatment of achalasia: results of a minimally invasive technique. Ann Thorac Surg 2004; 77:385-91; discussion 391-2. [PMID: 14759402 DOI: 10.1016/j.athoracsur.2003.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Several surgical methods have been described to treat achalasia with a recent trend toward utilizing minimally invasive techniques to perform a myotomy. Since 1998 our institution has utilized a minimally invasive thoracoscopy-assisted technique (ThAM) that allows a myotomy to be performed under direct visualization. METHODS From 1992 to 2002, 57 patients underwent transthoracic Heller myotomy at our institution. Thirty-eight patients (67%) who underwent ThAM were reviewed and compared with 19 (33%) who previously underwent myotomy through a standard open left thoracotomy (OM). RESULTS There were no operative deaths in the ThAM group (n = 38) and 4 patients (11%) experienced minor morbidity. Four ThAM patients required conversion to open thoracotomy and 2 were lost to follow-up. Of the remaining 32 patients, 29 have improved postoperative dysphagia scores after a mean follow-up of 17 months. Only 4 patients have required further endoscopic or surgical intervention. Compared with the OM group, ThAM patients experienced significantly shorter average surgery time (97 versus 139 minutes), less blood loss (80 versus 155 mL), less postoperative narcotic requirement (8 versus 20 days), and shorter recovery to normal activity (20 versus 73 days). CONCLUSIONS Thoracoscopy-assisted myotomy results in excellent relief of dysphagia in the short term and would be expected to have long-term results similar to OM. Shorter operating and recovery times as compared with OM without the need for an antireflux procedure makes ThAM an attractive minimally invasive technique.
Collapse
Affiliation(s)
- Kenneth A Kesler
- Department of Surgery, Thoracic Division, Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | | | | | | | | | | |
Collapse
|
|
37
|
Frantzides CT, Moore RE, Carlson MA, Madan AK, Zografakis JG, Keshavarzian A, Smith C. Minimally invasive surgery for achalasia: a 10-year experience. J Gastrointest Surg 2004; 8:18-23. [PMID: 14746831 DOI: 10.1016/j.gassur.2003.09.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Minimally invasive esophagomyotomy for achalasia has become the preferred surgical treatment; the employment of a concomitant fundoplication with the myotomy is controversial. Here we report a retrospective analysis of 53 patients with achalasia treated with laparoscopic Heller myotomy; fundoplication was used in all patients except one, and 48 of the fundoplications were complete (floppy Nissen). There were no deaths or reoperations, and minor complications occurred in three patients. Good-to-excellent long-term results were obtained in 92% of the subjects (median follow-up 3 years). Two cases (4%) of persistent postoperative dysphagia were documented, one of which was treated with dilatation. Postoperative reflux occurred in five patients, four of whom did not receive a complete fundoplication; these patients were well controlled with medical therapy. We suggest that esophageal achalasia may be successfully treated with laparoscopic Heller myotomy and floppy Nissen fundoplication with an acceptable rate of postoperative dysphagia.
Collapse
|
|
38
|
Eroglu A, Can Kürkçüogu I, Karaoganogu N, Tekinbaş C, Yimaz O, Başog M. Esophageal perforation: the importance of early diagnosis and primary repair. Dis Esophagus 2004; 17:91-94. [PMID: 15209749 DOI: 10.1111/j.1442-2050.2004.00382.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal perforation is associated with high morbidity and mortality rates, particularly if not diagnosed and treated promptly. Despite the many advances in thoracic surgery, the management of patients with esophageal perforation remains controversial. We performed a retrospective clinical review of 36 patients, 15 women (41.7%) and 21 men (58.3%), treated at our hospital for esophageal perforation between 1989 and 2002. The mean age was 54.3 years (range 7-76 years). Iatrogenic causes were found in 63.9% of perforations, foreign body perforation in 16.7%, traumatic perforation in 13.9% and spontaneous rupture in 5.5%. Perforation occurred in the cervical esophagus in 12 cases, thoracic esophagus in 13 and abdominal esophagus in 11. Pain was the most common presenting symptom, occurring in 24 patients (66.7%). Dyspnea was noted in 14 patients (38.9%), fever in 12 (33.3%) and subcutaneous emphysema in 25 (69.4%). Management of esophageal perforation included primary closure in 19 (52.8%), resection in seven (19.4%) and non-surgical therapy in 10 (27.8%). The 30-day mortality was found to be 13.9%, and mean hospital stay was 24.4 days. In the surgically treated group the mortality rate was three of 26 patients (11.5%), and two of 10 patients (20%) in the conservatively managed group. Survival was significantly influenced by a delay of more than 24 h in the initiation of treatment. Primary closure within 24 h resulted in the most favorable outcome. Esophageal perforation is a life threatening condition, and any delay in diagnosis and therapy remains a major contributor to the attendant mortality.
Collapse
Affiliation(s)
- Atilla Eroglu
- Department of Thoracic Surgery, Faculty of Medicine, Ataturk University, Ezurum, Turkey.
| | | | | | | | | | | |
Collapse
|
|
39
|
Abstract
Achalasia is a rare neurologic deficit of the esophagus, producing a syndrome of impaired relaxation of the lower esophageal sphincter and decreased motility of the esophageal body for which the cause is unknown. The resultant chronic esophageal stasis produces discomforting symptoms that can be managed with medication, chemical paralysis of the lower esophageal sphincter, mechanical dilation, or surgical esophagomyotomy. Chemical paralysis by injection of the esophagus with botulinum toxin and dilation with an inflatable balloon offers good short-term relief of symptoms; however, the best long-term results are produced by surgery, and advancing minimally invasive techniques continually reduce the morbidity of these operations. The type of surgical procedure, the necessity for fundoplication, and the order of treatment continue to be unresolved issues, but prospective evaluation with objective followup should allow us to provide the optimal treatment regimen to our patients.
Collapse
Affiliation(s)
- Shawn D St Peter
- Department of General Surgery, Mayo Clinic Scottsdale, Arizona, USA
| | | |
Collapse
|
|
40
|
Patti MG, Fisichella PM, Perretta S, Galvani C, Gorodner MV, Robinson T, Way LW. Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change. J Am Coll Surg 2003; 196:698-703; discussion 703-5. [PMID: 12742198 DOI: 10.1016/s1072-7515(02)01837-9] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Twenty years ago an average of 1.5 Heller myotomies were performed per year in our hospital, mostly for patients whose dysphagia did not improve following balloon dilatation or whose esophagus had been perforated during a balloon dilatation. Ten years ago we started using minimally invasive surgery to treat this disease. STUDY DESIGN This study measures the impact of minimally invasive surgery with regard to the following: the number of patients referred for treatment; the number of patients who came to surgery without previous treatment; and the results of surgical treatment. Between 1991 and 2001, 149 patients had minimally invasive surgery for achalasia: 25 patients (17%) had thoracoscopic Heller myotomy and 124 (84%) had laparoscopic Heller myotomy and Dor fundoplication. Of the 149 patients, 79 patients (53%) had previous treatment (56 patients [71%], balloon dilatation; 7 patients [9%], botulinum toxin injection; 16 patients [20%], both) and 70 patients (43%) had none of these treatments. Mean postoperative followup was 59 +/- 36 months. Patients were divided into two groups: group A, operated on between 1991 and 1995; and group B, operated on between 1996 and 2001. RESULTS In the past decade, the number of patients referred for surgery has increased substantially--group A, 48; group B, 101; an increasing proportion of patients were referred for surgery without previous treatment--group A, 38%; group B, 51%; and the outcomes of the operation progressively improved--group A, 87%; group B, 95%. CONCLUSIONS These data show that the high success rate of laparoscopic Heller myotomy for achalasia has brought a shift in practice; surgery has become the preferred treatment of most gastroenterologists and other referring physicians. This has followed documentation that laparoscopic treatment outperforms balloon dilatation and botulinum toxin injection.
Collapse
Affiliation(s)
- Marco G Patti
- Department of Surgery, University of California, San Francisco, CA 94143, USA
| | | | | | | | | | | | | |
Collapse
|
|
41
|
Bansal R, Nostrant TT, Scheiman JM, Koshy S, Barnett JL, Elta GH, Chey WD. Intrasphincteric botulinum toxin versus pneumatic balloon dilation for treatment of primary achalasia. J Clin Gastroenterol 2003; 36:209-14. [PMID: 12590230 DOI: 10.1097/00004836-200303000-00005] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
GOALS Despite a high success rate, pneumatic dilatation for achalasia is accompanied by a significant risk of esophageal perforation. Injection of botulinum toxin (botox) into the lower esophageal sphincter (LES) can lead to improvement in symptoms with reduced risk of complications. Direct comparisons of the two techniques are needed to define their role in clinical management. STUDY We compared pneumatic dilatation to botox for patients with achalasia using a double blind, randomized study design. Patients underwent clinical, manometric, radiographic and endoscopic evaluation to confirm primary achalasia. They were randomized to receive either 80 units of botox into the LES or Witzel balloon dilatation. Patients also received sham dilatation or injection, respectively. The patients and investigators assessing symptom response were blinded to therapy. Symptoms and esophageal function were assessed at 3 weeks, 3 months and 1 year after therapy. Treatment failure was defined as the lack of decrease in symptom grade more than 1 or recurrence of symptoms. Patients with treatment failure crossed over to the alternative treatment. RESULTS Thirty four patients were studied, and 31 completed the trial. Of the 18 patients randomized to Witzel dilatation, 16 (89%) of 18 remained in clinical remission. Of the two patients with treatment failure, one responded to botox injection. Of the 16 patients randomized to botox, (38%) 6 of 16 remained in clinical remission. Four patients had initial failure, and 6 relapsed at a mean of 4 months after therapy. Of the nine patients who crossed over to dilatation, seven responded well, but two required surgical management of perforation. Although both treatments had excellent initial clinical improvement, patients randomized to Witzel dilatation had superior long-term success ( < 0.01). CONCLUSION Initial therapy with Witzel dilatation is associated with better long-term outcome than a single injection of botox. Because of the risk of endoscopic perforation, botox remains a viable alternative to dilatation.
Collapse
Affiliation(s)
- Rajiv Bansal
- University of Michigan Medical Center, Division of Gastroenterology, Ann Arbor, Michigan 48109, USA
| | | | | | | | | | | | | |
Collapse
|
|
42
|
Bloomston M, Fraiji E, Boyce HW, Gonzalvo A, Johnson M, Rosemurgy AS. Preoperative intervention does not affect esophageal muscle histology or patient outcomes in patients undergoing laparoscopic Heller myotomy. J Gastrointest Surg 2003; 7:181-8; discussion 188-90. [PMID: 12600442 DOI: 10.1016/s1091-255x(02)00159-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Botox injection and pneumatic dilation are common therapies for achalasia. We sought to determine the impact of these preoperative therapies on esophageal muscle histology and outcomes after laparoscopic Heller myotomy. A total of 73 consecutive patients had esophageal muscle biopsies taken from the gastroesophageal junction at the time of myotomy between November 1998 and November 2001. Muscle fibrosis was graded by a senior pathologist who was blinded to preoperative treatments and postoperative outcomes. Patients graded their dysphagia and heartburn symptoms before and after myotomy and graded their outcomes at follow-up. Patients were grouped according to the preoperative endoscopic treatment (dilation, Botox, both, or neither) and the groups were compared. Preoperative therapy did not correlate with esophageal fibrosis or postoperative outcomes, and the degree of esophageal muscle fibrosis was not predictive of outcome. Symptom scores improved significantly for dysphagia (4.5 +/- 0.9 vs. 1.6 +/- 1.6) and heartburn (2.3 +/- 1.8 vs. 1.5 +/- 1.4) irrespective of preoperative therapy or fibrosis. Overall, excellent or good outcomes were obtained in 92% of patients at follow-up of 15.7 months +/- 14.4. Successful outcomes are highly probable after laparoscopic Heller myotomy regardless of preoperative interventions. The amount of fibrosis in the esophageal muscle is not related to preoperative intervention and is not predictive of outcomes.
Collapse
Affiliation(s)
- Mark Bloomston
- Department of Surgery, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida College of Medicine, Tampa, FL 33601, USA
| | | | | | | | | | | |
Collapse
|
|
43
|
Gastrointestinal quality of life before and after laparoscopic heller myotomy with partial posterior fundoplication. Ann Surg 2003. [PMID: 12454513 DOI: 10.1097/01.sla.0000036270.41686.b1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess the outcome of laparoscopic Heller myotomy for achalasia using a specific quality of life (QoL) instrument for gastrointestinal disorders. SUMMARY BACKGROUND DATA Current therapies for achalasia do not restore normal esophageal motility but aim at palliating dysphagia. However, many other symptoms may persist that cannot be assessed objectively by currently available symptom scores. Although generic QoL instruments have shown improvement in QoL after myotomy, disease-specific QoL instruments may be more responsive to change and therefore more reliable for comparing outcomes of therapeutic options for achalasia. METHODS The Gastrointestinal Quality of Life Index (GIQLI) was studied before and after laparoscopic Heller myotomy associated with posterior partial fundoplication. RESULTS Starting in January 1991, 73 consecutive patients were operated on laparoscopically for various clinical stages of achalasia. Since 1996, 40 patients completed a GIQLI questionnaire both preoperatively and after a minimum postoperative follow-up of 1 year. Median preoperative GIQLI score was 84 (range 34-129) out of a theoretical maximum score of 144. At a median follow-up of 31 months (range 12-54), the score had significantly improved to 119 (range 77-143), close to the range for the normal French population. Not only items assessing gastrointestinal symptoms but also the domains of physical, social, and emotional function were significantly improved. The most marked improvements were achieved in patients with the lowest preoperative scores. CONCLUSIONS The GIQLI allows us to objectify the impact of achalasia symptoms on health-related QoL. At medium-term follow-up, laparoscopic Heller myotomy, performed either as primary treatment or after endoscopic dilation, significantly improves most health-related QoL aspects. Short of randomized comparisons between the different therapeutic options available for achalasia, reported series could be made more comparable if validated QoL instruments specific for gastrointestinal disorders were used routinely for outcome evaluation.
Collapse
|
|
44
|
Decker G, Borie F, Bouamrirene D, Veyrac M, Guillon F, Fingerhut A, Millat B. Gastrointestinal quality of life before and after laparoscopic heller myotomy with partial posterior fundoplication. Ann Surg 2002; 236:750-8; discussion 758. [PMID: 12454513 PMCID: PMC1422641 DOI: 10.1097/00000658-200212000-00007] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To assess the outcome of laparoscopic Heller myotomy for achalasia using a specific quality of life (QoL) instrument for gastrointestinal disorders. SUMMARY BACKGROUND DATA Current therapies for achalasia do not restore normal esophageal motility but aim at palliating dysphagia. However, many other symptoms may persist that cannot be assessed objectively by currently available symptom scores. Although generic QoL instruments have shown improvement in QoL after myotomy, disease-specific QoL instruments may be more responsive to change and therefore more reliable for comparing outcomes of therapeutic options for achalasia. METHODS The Gastrointestinal Quality of Life Index (GIQLI) was studied before and after laparoscopic Heller myotomy associated with posterior partial fundoplication. RESULTS Starting in January 1991, 73 consecutive patients were operated on laparoscopically for various clinical stages of achalasia. Since 1996, 40 patients completed a GIQLI questionnaire both preoperatively and after a minimum postoperative follow-up of 1 year. Median preoperative GIQLI score was 84 (range 34-129) out of a theoretical maximum score of 144. At a median follow-up of 31 months (range 12-54), the score had significantly improved to 119 (range 77-143), close to the range for the normal French population. Not only items assessing gastrointestinal symptoms but also the domains of physical, social, and emotional function were significantly improved. The most marked improvements were achieved in patients with the lowest preoperative scores. CONCLUSIONS The GIQLI allows us to objectify the impact of achalasia symptoms on health-related QoL. At medium-term follow-up, laparoscopic Heller myotomy, performed either as primary treatment or after endoscopic dilation, significantly improves most health-related QoL aspects. Short of randomized comparisons between the different therapeutic options available for achalasia, reported series could be made more comparable if validated QoL instruments specific for gastrointestinal disorders were used routinely for outcome evaluation.
Collapse
Affiliation(s)
- Georges Decker
- Department of Visceral Surgery A, Hôpital Saint-Eloi, University Hospital Center Montpellier, Montpellier, France
| | | | | | | | | | | | | |
Collapse
|
|
45
|
Adrales GL, Mastrangelo MJ, Schwartz RW. The minimally invasive surgical approach to achalasia: a new standard of care? CURRENT SURGERY 2002; 59:554-62. [PMID: 16093193 DOI: 10.1016/s0149-7944(02)00673-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Affiliation(s)
- Gina L Adrales
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | | | | |
Collapse
|
|
46
|
Bloomston M, Rosemurgy AS. Selective application of fundoplication during laparoscopic heller myotomy ensures favorable outcomes. Surg Laparosc Endosc Percutan Tech 2002; 12:309-15. [PMID: 12409695 DOI: 10.1097/00129689-200210000-00001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We propose that selective fundoplication during laparoscopic Heller myotomy achieves optimal outcomes. Fundoplication was applied selectively in 21 of 100 patients undergoing laparoscopic Heller myotomy with hiatus hernia, patulous esophageal hiatus, or intraoperative perforation. Dysphagia and heartburn incidence and severity in patients undergoing myotomy with or without fundoplication were compared before and after myotomy. Median follow-up was 19 months and was similar for both groups. Preoperative symptoms were similar for both groups of patients and showed significant improvement following myotomy with or without fundoplication. As well, there were no significant differences in postoperative dysphagia (26% vs. 14%), dysphagia score (1.1 +/- 1.4 vs. 0.8 +/- 1.3), heartburn (21% vs. 27%), or heartburn score (0.9 +/- 1.5 vs. 1.4 +/- 1.6). Overall improvement was seen in 86% of patients undergoing myotomy with fundoplication and in 97% without fundoplication (P = 0.06). Selective application of fundoplication during laparoscopic Heller myotomy promotes optimal outcomes.
Collapse
Affiliation(s)
- Mark Bloomston
- Division of General Surgery, Department of Surgery, University of South Florida, Tampa 33601, USA
| | | |
Collapse
|
|
47
|
Blam ME, Delfyett W, Levine MS, Metz DC, Katzka DA. Achalasia: a disease of varied and subtle symptoms that do not correlate with radiographic findings. Am J Gastroenterol 2002; 97:1916-23. [PMID: 12190154 DOI: 10.1111/j.1572-0241.2002.05900.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Dysphagia is the hallmark of achalasia, and when frequent or marked, it is believed to be a good predictor of the clinical and radiographic severity of disease. We aimed to evaluate the presence and severity of dysphagia and other symptoms in achalasia and to correlate these symptoms with findings on barium studies. METHODS The symptoms and radiographs of 38 patients with confirmed achalasia were reviewed, 20 prospectively, 18 retrospectively. The number of typical and atypical symptoms both initially and at the time of the barium esophagogram was tallied. The severity of typical symptoms at the time of the barium esophagogram was scored on a point system. A scoring system was also devised to rate the severity of the radiographic findings. Symptoms and radiographic findings were compared. RESULTS Dysphagia was the initial symptom in only 39% of patients, whereas heartburn, regurgitation, and slow eating occurred initially in 24%, 24%, and 16% of patients, respectively. At the time of the barium esophagogram, all symptoms were reported by a greater percentage of patients than at presentation. The median time period between initial symptoms and symptoms reported at the time of the barium esophagogram was 48 months (range 2-360 months). At the time of the barium esophagogram, the most frequently reported symptoms were slow eating and regurgitation (79% each), followed by dysphagia (76%), and stereotyped movements (including arching of the neck and shoulders, raising of the arms, standing and sitting straight, and walking) with meals (60%). The mean number (+/-SD) of initial achalasia-related symptoms per patient was 1.34 (+/-0.67) and increased to 5.50 (+/-2.05) at the time of the barium esophagogram. The mean typical symptoms score at the time of the barium esophagogram was 3.4 (+/-1.5). Most patients (97%) reported a greater number of achalasia symptoms at the time of the barium esophagogram than initially, despite a mean total radiological score of only 2.58 (out of a maximum of 10 points). There was no statistically significant relationship between the total number of symptoms at the time of the barium esophagogram and the total radiographic score (r = -0.05, and p = 0.77) and between the typical symptom score at the time of the barium esophagogram and the total radiographic score (r = -0.11, and p = 0.51) by Spearman coefficient. CONCLUSIONS Achalasia is a disease with many atypical and subtle symptoms, both initially and over time. Dysphagia is initially present in only 39% of patients and is not the most frequently reported symptom over time. Neither the severity nor the total number of achalasia-related symptoms correlates with the severity of radiographic findings.
Collapse
Affiliation(s)
- Michael E Blam
- Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia 19104-4283, USA
| | | | | | | | | |
Collapse
|
|
48
|
O'Connor M, Buchman A, Marshall G. Anaphylaxis-like reaction to infliximab in a patient with Crohn's disease. Dig Dis Sci 2002; 47:1323-5. [PMID: 12064808 DOI: 10.1023/a:1015326715456] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Maeve O'Connor
- Department of Medicine, University of Texas-Houston Medical School, USA
| | | | | |
Collapse
|
|
49
|
Sharp KW, Khaitan L, Scholz S, Holzman MD, Richards WO. 100 consecutive minimally invasive Heller myotomies: lessons learned. Ann Surg 2002; 235:631-8; discussion 638-9. [PMID: 11981208 PMCID: PMC1422488 DOI: 10.1097/00000658-200205000-00004] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To evaluate the authors' first 100 patients treated for achalasia by a minimally invasive approach. METHODS Between November 1992 and February 2001, the authors performed 95 laparoscopic and 5 thoracoscopic Heller myotomies in 100 patients (age 49.5 +/- 1.5 years) with manometrically confirmed achalasia. Before presentation, 51 patients had previous dilation, 23 had been treated with botulinum toxin (Botox), and 4 had undergone prior myotomy. Laparoscopic myotomy was performed by incising the distal 4 to 6 cm of esophageal musculature and extended 1 to 2 cm onto the cardia under endoscopic guidance. Fifteen patients underwent antireflux procedures. RESULTS There were eight intraoperative perforations and only four conversions to open surgery. Follow-up is 10.8 +/- 1 months; 75% of the patients have been followed up for at least 14 months. Outcomes assessed by patient questionnaires revealed satisfactory relief of dysphagia in 93 patients and "poor" relief in 7 patients. Postoperative heartburn symptoms were reported as "moderate to severe" in 14 patients and "none or mild" in 86 patients. Fourteen patients required postoperative procedures for continued symptoms of dysphagia after myotomy. Esophageal manometry studies revealed a decrease in lower esophageal sphincter pressure (LESP) from 37 +/- 1 mm Hg to 14 +/- 1 mm Hg. Patients with a decrease in LESP of more than 18 mm Hg and whose absolute postoperative LESP was 18 or less were more likely to have relief of dysphagia after surgery. Thirty-one patients who underwent Heller alone were studied with a 24-hour esophageal pH probe and had a median Johnson-DeMeester score of 10 (normal <22.0). Mean esophageal acid exposure time was 3 +/- 0.6% (normal 4.2%). Symptoms did not correlate with esophageal acid exposure. CONCLUSIONS The results after minimally invasive treatment for achalasia are equivalent to historical outcomes with open techniques. Satisfactory outcomes occurred in 93% of patients. Patients whose postoperative LESP was less than 18 mm Hg reported the fewest symptoms. After myotomy, patients rarely have abnormal esophageal acid exposure, and the addition of an antireflux procedure is not required.
Collapse
Affiliation(s)
- Kenneth W Sharp
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
| | | | | | | | | |
Collapse
|
|
50
|
Affiliation(s)
- E J Simchuk
- University Department of Surgery, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| | | |
Collapse
|