48: LAPAROSCOPIC HELLER DOR IS AN EFFECTIVE TREATMENT FOR ESOPHAGEAL-GASTRIC JUNCTION OUTFLOW OBSTRUCTION

Abstract

Abstract Background and aim Esophago-gastric junction outflow obstruction (EGJOO) is a relatively new clinical entity revealed by high-resolution manometry (HRM) that can have two different etiologies, i.e. idiopathic or secondary (esophageal strictures, eosinophilic esophagitis, giant hiatal hernia, prior fundoplication or bariatric surgery, malignancy). Treatment of EGJOO currently mirrors that of achalasia, but this is based only on few studies with small case series. The aim of this study was to assess the outcome of laparoscopic Heller-Dor (LHD) in patients with EGJOO, as compared with patients with esophageal achalasia. Methods Between 2016–2019, all patients with a diagnosis of idiopathic EGJOO and referred to our Centre for dysphagia or food regurgitation were prospectively collected. Naïve EGJOO patients were first given medical treatment with Ca2+ channel blockers for 6 months. Then patients were ‘restaged’: patients without clinical improvement and/or whose integrated relaxation pressure (IRP) had not decreased were scheduled for LHD. EGJOO patients who had already been treated elsewhere with botox injections, pneumatic dilations or Ca2+ channel blockers were scheduled upfront for LHD. Patients with EGJOO who underwent LHD were compared with patients with radiological stage I achalasia. The achalasia group was further analyzed by subgrouping the patients based on the manometric-pattern. Treatment failure was defined as the persistence or reoccurrence of a Eckardt score > 3 or the need for retreatment. Results During the study period, 150 patients were enrolled: 25 EGJOO patients and 125 radiological stage I achalasia (25 pattern I, 74 pattern II, and 26 pattern III). The median follow-up was 24 months (IQR: 34–16). Treatment was successful in 96% of patients in the EGJOO group and in 96% of achalasia patients with pattern I, 98.7% in those with pattern II, and 96.2% of those with pattern III (P = 0.50). Six-month post-operative HRM showed a reduction in the LES resting pressure and IRP for all patients in all 4 groups (P < 0.001). Conclusion This is the first comparative study based on prospective data collection to assess the outcome of LHD in patients with EGJOO. LHD emerged as an effective treatment for EGJOO, with an excellent success rate, comparable with the procedure’s efficacy in treating early-stage achalasia.