End-stage Achalasia Research Articles

Efficacy and outcomes of per oral plication of the (neo)esophagus (POPE) for impaired emptying in achalasia and post-esophagectomy patients.

Per-oral plication of the (neo)esophagus (POPE) is an endoscopic procedure used to improve emptying of the defunctionalized esophagus or gastric conduit, with the hope of improving symptoms andquality of life. As this procedure has only been performed in the United States for the past 4years, safety and efficacy have not been well established. This is a retrospective case series for patients who underwent POPE from a single institution between 2019 and 2023. Data collected included demographics, preoperative diagnoses and treatments, imaging, endoscopic data,operative intervention, 90-day complications, andresponse to treatment. Quality of life and patient satisfaction data were collected by phone survey. Seventeen cases were identified, encompassing 13 primary procedures and 4 repeat POPEs (re-POPE). Eight patients had end-stage achalasia and 5 had impaired gastric emptying after esophagectomy with gastric conduits. Median age was 65years and median ASA was 3, with 38.5% female patients. POPE was performed with 2-6 plication sutures in an average of 75min. The majority of patients discharged home the same day. For the 17 procedures, there were 4 complications. Two patients required antibiotics for pneumonia, while 4 required procedural intervention. There were no deaths. Preoperative symptoms improved or resolved at initial follow up in 82.3% of patients. Four patients experienced symptom recurrence and required re-POPE, 1 with achalasia and 3 with gastric conduits. Although all achalasia patients had an "end-stage esophagus," none have required esophagectomy since the introduction of POPE. POPE is an endoscopicprocedure that is efficacious in relieving emptying difficulties for the end-stage esophagus andgastric conduit. It may obviate the need for esophagectomy or conduit replacement. Also, it can be repeated in select patients. While the risk profile of complications is favorable compared to alternative operations, patients with gastric conduits are at higher risk.

Heller Cardiomyotomy in end stage of achalasia with mega esophagus: Results in five cases

Achalasia is a motility disorder of esophagus with poor emptying and, characterised by a lack of peristalsis and impaired relaxation of the lower esophageal sphincter with high LES pressure,diameter of esophsgous can increase, and some patients progress to develop end-stage achalasia as megaesophagus or sigmoid esophagus and significant form dilation and tortuosity.These omplications occurs in between 5% and 20% of patients with acha­lasia. This group of patients if untreated are at risk of aspiration, aspiration pneumonia, and malnutrition. The management of this type of achalasia, aims to palliate symptoms by improving esophagus emptying and reducing the pressure gradient. In this group of patients, pneumatic dilatation (PD), surgical myotomy, or peroral endoscopic myotomy (POEM) may be less or not effective. Esophagectomy for the treatment of end-stage achalasia remains a controversial topic and has been recommended by some authors. We describe 5 patients with end-stage achalasia who was been successfully managed with laparotomy heller cardiomyotomy . In 4,12,18,24 months follow- up the condition of patients was good.

Two-Stage Esophagectomy for End-Stage Achalasia with Low Cardiac Function and Severe Malnutrition

Two-Stage Esophagectomy for End-Stage Achalasia with Low Cardiac Function and Severe Malnutrition

The esophageal pull-down technique improves the outcome of laparoscopic Heller-Dor myotomy in end-stage achalasia

The treatment of patients with end-stage achalasia with a sigmoid-shaped esophagus is particularly challenging. A modified technique (pull-down technique) has been developed to straighten the esophageal axis, but only a limited number of studies on this topic are available in the literature. This study aimed to compare the outcome of patients who underwent the pull-down technique with that of patients who had a classical laparoscopic Heller-Dor (CLHD) myotomy. All patients with a radiologic diagnosis of end-stage achalasia who underwent an LHD myotomy between 1995 and 2022 were considered eligible for the study. All patients underwent symptom score, barium swallow, endoscopy, and manometry tests before and after the procedure was performed. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score (ES) of >3 or the need for retreatment. Of the 94 patients who were diagnosed with end-stage achalasia (male-to-female ratio of 52:42), 60 were treated with CLHD myotomy, and 34 were treated with the pull-down technique. Of note, 2 patients (2.1%), both belonging to the CLHD myotomy group, developed a squamous cell carcinoma during the follow-up. The overall success of LHD myotomy was seen in 76 of 92 patients (82.6%). All patients in both groups achieved a lower ES after surgery. The failure rates were 27.6% (16/58) in the CLHD myotomy group and 5.9% (2/34) in the pull-down technique group (P<.01). Our findings confirm that LHD myotomy is an effective treatment of end-stage achalasia and that the pull-down technique further improves the outcome in patients with end-stage achalasia who are difficult to treat.

Severe esophageal candidiasis in a megaesophagus patient: a rare case

Megaesophagus is a largely dilated esophagus, an uncommon condition that could be the end-stage of preceding esophageal achalasia. Chronic food stasis such as in achalasia and megaesophagus could cause fungi infection in the esophagus. This report aimed to raise awareness of these rare cases. A 68-year-old male with two decades of swallowing difficulty was referred to Sardjito Hospital. Computed tomography esophagography showed megaesophagus and bird beak sign suggesting achalasia. Both esophagoscopy and esophageal tissue biopsy showed consistent results of severe esophageal candidiasis (EC). The patient was also suspected to have a mass at the distal part of the esophagus and gastric cardia, which could also contribute to the esophageal obstruction. We consulted the gastroenterologist for gastrostomy feeding and exploration of the suspected tumor. EC is known mainly in patients with immunodeficiency, while food stasis is a lesser-known cause. End-stage achalasia not only could lead to megaesophagus, but chronic food stasis is the perfect environment for fungi growth. Other causes of food stasis such as distal esophageal and gastric cardia tumors could also be the predisposition of EC. We reported a rare case of a patient with EC as a complication of megaesophagus and esophageal achalasia.

403. END-STAGE ACHALASIA: FEASIBILITY OF CARDIOMYOTOMY WITH ANTERIOR 90-DEGREE FUNDOPLICATION AS TREATMENT

Abstract Achalasia is a primary motor disorder of the oesophagus. End-stage achalasia is characterised by a grossly dilated sigmoid-shaped oesophagus with food stasis leading to chronic inflammation. Despite treatment, approximately 5% of patients progress to this late stage, needing oesophagectomy. Current guidelines recommend oesophagectomy as the last resort after failure of first-line endoscopic treatment or cardiomyotomy. We review a case of a 70 years old female with end-stage achalasia who successfully underwent cardiomyotomy but required a looser wrap for oesophageal emptying. Patient first presented in her 50s with dysphagia and Oesophago-Gastro-Duodenoscopy (OGD) showed a dilated oesophagus with food stasis and no contractions. Barium swallow confirmed the diagnosis of achalasia. She underwent pneumatic dilatations with minimal symptom improvement and eventually defaulted follow-up. Several years later she presented with haematemesis due to severe oesophagitis and Eckardt score of 7. Both OGD and CT scans showed a grossly dilated megaoesophagus. High-resolution manometry confirmed Type I achalasia with IRP (integrated relaxation pressure) 25.8 and complete absence of peristalsis. She was initiated on nasogastric feeding and was also diagnosed with pulmonary embolism (PE). In view of PE and patient’s comorbidities, she was not fit for oesophagectomy. Peroral endoscopic myotomy (POEM) was also deemed challenging in the presence of severe, chronic oesophagitis and patient’s need for anticoagulation with potential difficulty in endoscopic haemostasis. She underwent laparoscopic cardiomyotomy with anterior 180-degree fundoplication. However, post-operation contrast swallow showed hold up of contrast despite intraoperative OGD showing smooth passage of scope through LES. Decision was made for revision of fundoplication to anterior 90-degree to further promote oesophageal emptying. Post-operation contrast swallow showed satisfactory drainage into stomach and patient tolerated post-fundoplication diet regime. This case illustrates the role of cardiomyotomy as first-line in patients with end-stage achalasia who are not fit for oesophagectomy. However, an anterior 180-degree fundoplication may not allow adequate drainage from a megaoesophagus and a less tight wrap should be considered in such cases. Post-operation, reported Eckardt score of our patient was 1 with no reflux symptoms, indicating marked alleviation of symptoms. Thus, cardiomyotomy with a lesser 90-degree fundoplication is feasible as first-line treatment in end-stage achalasia.

Surgical Options for End-Stage Achalasia.

Achalasia is one of the most commonly described primary esophageal motility disorders worldwide, but there is significant controversy regarding ideal management of end-stage disease. This article reviews the definition of end-stage achalasia and summarizes past and present surgical treatment. Myotomy of the lower esophageal sphincter remains the mainstay of treatment of achalasia, even in advanced disease. Esophagectomy may have benefit as a primary treatment modality in end-stage achalasia with sigmoid esophagus, but international guidelines recommend consideration of laparoscopic or endoscopic approaches initially in most patients. Novel peroral esophageal plication techniques may provide alternative treatment options in patients with significant esophageal dilation that fail myotomy or esophagectomy. End-stage achalasia is characterized by progressive tortuosity and dilation of the esophagus as a failure of primary peristalsis. Up to 20% of patients with achalasia will progress to end-stage disease. In most cases, laparoscopic or endoscopic myotomy is recommended as initial approach to surgical management.

320. ESOPHAGEAL PULL-DOWN TECHNIQUE IMPROVES THE FINAL OUTCOME OF LAPAROSCOPIC HELLER-DOR FOR END-STAGE ACHALASIA

Abstract Background Patients with sigmoid shape have an advanced form of the disease and are considered the most difficult to treat. A modified technique (pull-down) has been proposed to straighten the esophageal axis, but there is a limited amount of data available in literature. In this study, we aimed to compare the final outcome of the pull-down technique (PDLHD) with the results of classical myotomy (CLHD) in patients with end-stage achalasia. Methods From 1995–2022, patients with a radiological diagnosis of end-stage achalasia undergoing laparoscopic myotomy were enrolled in the study. Symptoms were quantified using the Eckardt score. Barium-swallow, endoscopy and manometry were performed before and after the treatment. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score &amp;gt; 3, or the need for retreatment. Results Of the 94 patients with end-stage achalasia (M:F = 52:42), 60 patients were treated with CLHD, and 34 patients with PDLHD. The surgical procedures were completed laparoscopically in all patients. During follow-up, two patients (2.1%) developed squamous cell carcinoma (SCC), both in the CLHD group. All patients in both groups had an improvement in their Eckardt score after surgery, and the failure rates were 27.6% (16/58) after CLHD and 5.9% (2/34) after PDLHD (p &amp;lt; 0.01). Amongst the patients who underwent complete post-operative follow-up, an abnormal acid exposure was detected in 2 patients after PDLH, and in 6 after CLHD (p = n.s.). Conclusions Taken into account the intrinsic limitations of the study (different time window, and different follow-up), the results of this study indicate that performing the pull-down technique during Laparoscopic Heller-Dor improves the final outcome in end-stage achalasia patients.

Management of Leakage after Gastroesophageal Anastomosis

Abstract Background Esophagectomy is needed for a variety of esophageal disorders, the most common indication is cancer esophagus, however, it is needed in benign disorders as postcorrosive strictures &amp; endstage achalasia with esophageal dilatation. Anastomotic leakage is one of the most severe complications leading to significant morbidity and increased risk of mortality. Objective To evaluate different approaches in management of leakage after gastroesophageal anastomosis in Upper GIT surgery unit in Ain Shams University Hospitals. Patients and Methods This study was conducted at General surgery department, Ain Shams University Hospitals. Approval of the Ethical Committee was obtained. The study was conducted over patients with postoperative gastroesophageal leakage during the period from 3/2019 to 3/2021. Results Patients managed after cervical anastomosis leakage needed less time to start oral intake&amp; had shorter hospital stay in comparison to those managed after thoracic leakage. There was a higher perioperative morbidity and mortality in patients who underwent surgical intervention as compared with patients who underwent conservative treatment. Conclusion Anastomotic leak after surgery for esophageal diseases can vary in location, onset time, size, and extent. For local management, personalized treatment should be decided based on patient’s particular situations. Cervical anastomosis leakage has less morbidity &amp; mortality compared to thoracic anastomosis. Conservative treatment is safe and successful in many cases, in cervical leakage conservative management is effective in most cases. Stent implantation is an effective method with other emerging endoscopic techniques. Resurgery should be considered carefully and reserved to uncontrolled leakage or patients with failed conservative management.

Per-Oral Plication of (Neo)Esophagus: Technical Feasibility and Early Outcomes

BackgroundEndoscopic sleeve gastroplasty is an example of endoscopic sutured plications being used to remodel a gastrointestinal organ. With per-oral plication of the esophagus (POPE), similar plications are used to remodel the dilated and redundant megaesophagus of end-stage achalasia. Redundancies and dilations can also develop in the neoesophagus of a patient with prior esophagectomy. Megaesophagus and a redundant neoesophagus can both lead to debilitating dysphagia, regurgitation, and recurrent aspiration pneumonia. Traditionally, this anatomic problem requires complex revisional or excisional surgery, to which POPE offers an incisionless alternative. MethodsThis is a dynamic manuscript with video demonstration of POPE, as well as review of five cases performed in 1 year. Data were collected in a prospectively maintained database, and the institutional review board approved retrospective review for this publication. The procedure is performed using a dual-channel upper endoscope fixed with an endoscopic suturing device, with the patient supine under general anesthesia. ResultsPOPE was technically completed in all cases with no serious complications, and patients either went home the same day or spent one night for observation. Most patients reported immediate and substantial symptomatic improvement. Objective pre- and post-measures include esophagram and nuclear gastric emptying studies. ConclusionThis article discusses early experience at one institution with POPE, with detailed description of the procedure and technical considerations. An accompanying video reviews two cases, one with megaesophagus and one with a gastric conduit. While this novel procedure has limited and rare indications, it offers a low-morbidity solution to a challenging anatomic problem that traditionally requires invasive surgery.

Mini-invasive approach for end-stage achalasia

End-stage achalasia is characterized by a significant esophageal dilatation

End-Stage Achalasia: Hard to Define, and Even Harder to Treat

End-Stage Achalasia: Hard to Define, and Even Harder to Treat

Minimally Invasive Esophagectomy for End-Stage Achalasia: A Single Institution Experience and Literature Review

Background: Surgical outcomes after minimally invasive esophagectomy (MIE) for patients with end-stage achalasia are limited. This study presents a case series of end-stage achalasia patients who underwent MIE at a high-volume institution and review of the literature. Methods: We conducted a retrospective review of a single academic institution from 2010 to 2019. Patients with end-stage achalasia who underwent a MIE were included. Descriptive statistics for demographics as well as 90-day surgical outcomes (length of stay, readmission, reoperation, overall complications, and mortality) were included. Results: A total of 16 patients underwent MIE for achalasia during the study period, 14 (87.5%) 3-field and 2 (12.5%) trans-hiatal esophagectomies. The mean age was 52.5 (SD ± 10.5) years and 56.3% (9/16) were women. Mean operative time was 456.6 (SD ± 83.96) minutes. Within 90-days, the overall complication rate was 50% (8 patients). Of these complications, 4 had minor complications (Clavian-Dindo Grade I and II) and 4 had complications that required further interventions (Clavian-Dindo Grade ≥ III). Four (26.7%) patients were readmitted, 3 (18.8%) patients required reoperation, and 1 (6.3%) had an anastomotic leak. The reasons for reoperation included: 1 anastomotic leak, 1 chyle leak, and 1 incarcerated paraconduit hernia. No mortalities occurred. Conclusion: MIE should be considered for end-stage achalasia only as a last resort for patients with debilitating symptoms. While mortality was low, overall complications were high, even at a high-volume institution.

Management of End-Stage Achalasia

Background: End-stage Achalasia correspond to the final stage in the evolution of this disease, characterized by the presence of severe dysphagia and weight loss despite aggressive treatment, associated to massive esophageal dilatation and tortuosity of the esophagus, with loss of its axis and adopting a sigmoid-shape or L-shape distal esophagus. It is also called advanced sigmoid esophagus. The diagnosis is based on radiological evaluations, but different authors use different criteria to define end-stage. This fact makes difficult to compare the results, due to a great heterogeneity of the patients. Methods: Total of 65 reports contently treatment of patients with end stage achalasia were carefully review. Results: Until the year 2000 subtotal esophagectomy with gastric or long-colon interposition was employed as primary treatment or after several medical and endoscopic failed treatments. The mean mortality rate range 3% to 5%, with a high morbidity rate and 10 to 12 days of hospital stay. From 2000 to 2015 Laparoscopic Heller Myotomy (LHM) was employed as the primary treatment, with a mortality rate of 0%, low postoperative morbidity (6%-8%) and 2 days of Hospital stay. The long-term follow up was satisfactory in near 2/3 of the patients with end-stage esophagus. In the last years POEM (Peroral endoscopic Myotomy) has been employed mainly by Asian authors, reporting 0% mortality, high rate of postoperative morbidity (over 20%), a hospital stay of 5 to 7 days and a very short follow up, usually less than 2 years. Although the control of dysphagia is high, the main problem with this technique is the marked increase in pathologic acid reflux to the esophagus, with values near to 50% of the patients. It is not known the late effect 10 to 15 years after this procedure of this severe reflux in an aperistaltic esophagus, with retention of food and acid inside the esophageal lumen. Conclusion: Up to now Laparoscopic Heller Myotomy seems the best option for these patients with severe end-stage esophagus. If there is a failure after this procedure, thoracoscopic esophagectomy would be the best option.

Laparoscopic Heller-Dor is an effective long-term treatment for end-stage achalasia

BackgroundThe end-stage achalasia is a difficult condition to treat, for the esophageal diameter and conformation of the gullet, that may progress to a sigmoid shape. The aim of this study was to examine the outcome of Laparoscopic Heller-Dor in patients with end-stage achalasia, comparing them with patients who had mega-esophagus without a sigmoid shape.MethodsFrom 1992 to 2020, patients with a diagnosis of sigmoid esophagus, or radiological stage IV achalasia (the SE group), and patients with a straight esophagus larger than 6 cm in diameter, or radiological stage III achalasia (the NSE group), were all treated with LHD. The two groups were compared in terms of patients’ symptoms, based on the Eckardt score, and on barium swallow, endoscopy and manometry performed before and after the treatment. The failure of the treatment was defined as an Eckardt score > 3, or the need for further treatment.ResultsThe study involved 164 patients: 73 in the SE group and 91 in the NSE group. No intra- or postoperative mortality was recorded. The median follow-up was 51 months (IQR 25–107). The outcome was satisfactory in 71.2% of patients in the SE group, and in 89% of those in the NSE group (p = 0.005).ConclusionsSE is certainly the worst condition of the disease and the final outcome of LHD, in term of symptom control, is inferior compared to NSE. Despite this, almost 3/4 of the SE patients experienced a significant relieve in symptoms after LHD, which may therefore still be the first surgical option to offer to these patients, before considering esophagectomy.

579. LONG TERM RESULTS OF THE PULL-DOWN HELLER-DOR TECHNIQUE FOR ACHALASIA PATIENTS WITH SIGMOID ESOPHAGUS

Abstract The outcome of achalasia treatment in patients with sigmoid esophagus is worse than that achieved for fusiform achalasia. We compared two groups of sigmoid achalasia patients, in which we performed the standard Heller-Dor procedure (HD) and the Heller-Dor plus a technique aimed to restore the vertical axis of the intraabdominal portion of the esophagus pull-down Heller-Dor (PD-HD). Long-term results were evaluated. We considered 48 patients affected by primitive esophageal sigmoid achalasia operated upon consecutively (1979-2021) in first instance. After 1987, we routinely isolated 360° of the gastro-esophageal junction and the lower esophagus and applied U stitches at the right side of the lower esophagus to pull down and rotate the gastro-esophageal junction toward the right. Twenty-five patients underwent the standard HD and 23 patients underwent the PD-HD technique. Postoperative follow-up included barium swallow, clinical interview investigating dysphagia and reflux symptoms and endoscopy. The overall outcome was graded from excellent to poor according to the severity of symptoms and esophagitis. The median follow-up period was 11 years (IQR 6-22) for HD group and 9 (IQR 6-14) for PD-HD (p=0.22). At postoperative barium swallow, patients in the PD-DH group had smaller esophageal diameter [4 cm (IQR 4-4.7) vs 4.7 cm (IQR 4-5), p=0.04] and lower residual barium column [10 cm (IQR 6-13) vs 6 cm (IQR 0-8), p=0.001] than those in the HD group. Postoperative moderate-severe (D2-D3) dysphagia rates were 40% for HD and 13% for PD-HD group (p=0.003). The outcome of treatment revealed satisfactory (excellent, good, fair) results in 68% and 91.4% of HD and PD-HD group patients, respectively. The Heller-Dor operation is effective in the presence of sigmoid achalasia. The clinical and instrumental evaluations showed better results with the PD-HD technique. This technique may be the first choice for end-stage achalasia with null or low risk for cancer.

Achalasia.

Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.

Long‐term outcomes after esophagectomy for end‐stage achalasia: A bridge to a better quality of life?

AbstractObjectiveWe sought to evaluate the outcomes of patients with end‐stage achalasia (ESA) who underwent esophagectomy.MethodsAll patients who underwent esophagectomy for ESA and replied to a QoL‐centred questionnaire from 2002 to 2015 were included.ResultsOverall, 14 patients underwent esophagectomy for ESA, 12 (85.7%) patients completed the questionnaire and were included in the study. Patients were referred for esophagectomy after 18.5 median years (IQR1‐3 13.5–35.25) since presentation of symptoms. Heller's myotomy was previously performed in eight patients (66.7%). Major postoperative complications occurred in 2 (16.7%) patients. No patients required reoperation, and there was no postoperative mortality. At a median follow‐up of 84 months (IQR1‐3 60–84 months), satisfaction in postoperative symptom control was reported in 10 (83.3%) patients. Patients reported significant improvements in frequency of dysphagia (p &lt; .001), regurgitation (p = .004), heartburn (p = .034), cough (p = .003), and odynophagia (p = .001). Specifically, incidence of dysphagia for liquid food was reduced from 100% to 16.7% (p &lt; .001), for semisolid food from 81.8% to 16.7% (p = .003), and for solid food from 100% to 41.7% (p = .005).ConclusionsIn select patients suffering from long‐standing ESA, esophagectomy is feasible and is associated with good perioperative and long‐term outcomes.

42: THE LAPAROSCOPIC HELLER-DOR IS AN EFFECTIVE LONG-TERM TREATMENT FOR END-STAGE ACHALASIA

Abstract Background and aim Laparoscopic Heller-Dor (LHD) is an effective treatment for esophageal achalasia, with good long-term results in more than 85–90% of patients. It remains controversial whether LHD is also indicated in the end-stage disease when the esophagus has a sigmoid shape. The aim of this study was to evaluate the outcome of LHD in patients with end-stage achalasia, as compared to patients with megaesophagus but without a sigmoid shape. Methods From 1992 to 2020, patients with a radiological diagnosis of sigmoid-shaped esophagus (radiological stage IV achalasia: group SE) and patients with straight, larger than 6 cm in diameter esophagus (radiological stage III achalasia: group NSE), both treated with LHD, were compared. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score &amp;gt; 3, or the need for retreatment. Results During the study period, 164 such patients were observed: 73 patients in the SE group and 91 in the NSE group. The patients’ demographic and clinical parameters are summarised in Table 1. The median follow-up was 67 months (IQR: 24–106). No intra or postoperative mortality was recorded. There were 7 mucosal lesions: 2 in the SE group and 5 in the NSE group (P = 0.45). A positive outcome was obtained in 73% of patients in the SE group, as compared to 90% in the NSE group (P = 0.007, Table 2). All the patients whose surgery failed subsequently underwent one or more endoscopic pneumatic dilations. The overall success rate of the combination of LHD and endoscopic dilations was 83.6% in the SE group and all patients in the NSE group. The persisting failures had additional treatments: 4 patients a redo-myotomy, one each a botox injection, POEM and only one patient had an esophagectomy; the remaining 5 patients refused additional treatments. Postoperative 24-hour pH-monitoring was abnormal in 16.6% in SE group and 8.3% in NSE group (P = 0.33). Conclusion In end-stage achalasia patients, LHD may still achieve good results by relieving symptoms in more than 70% of patients. Therefore, LHD may still be the first surgical option to be offered to these patients before esophagectomy.

Long-Term Quality of Life in Achalasia Patients After Esophagectomy: A Single Center Experience

Introduction: Achalasia is a chronic motility disorder of the esophagus with difficult to manage symptoms. Despite multi-modal therapies, some patients progress to end-stage disease requiring esophagectomy. Quality of life (QOL) has not been fully described in this population. Methods: A cross-sectional QOL study was performed on a cohort of end-stage achalasia patients who underwent an esophagectomy (2010-2020). Patients who met inclusion criteria were contacted by phone in 2021 to complete GIQLI and OES-18 questionnaires. Descriptive statistics were performed. Results: Of 14 patients who met inclusion criteria, 9 (64.3%) completed the QOL questionnaires. Mean age was 53-years, and the majority were white (88.9%) women (63.7%). Prior to esophagectomy, management of achalasia included Botox (33.3%), dilation (66.7%), and Heller myotomy (100%). All patients reported dysphagia and 88.9% reported regurgitation prior to esophagectomy. All patients underwent a minimally invasive surgical approach. At the time of QOL surveillance, the mean time from operation was 66 months. The mean GIQLI score in this population was 97 (Max 144), compared to previously reported scores of 126 in a healthy population and 119 after Heller myotomy. Only ICU and hospital LOS had a statistically significant association with poorer GIQLI scores. The results of the OES-18 showed higher median severity scores for reflux, dry mouth and trouble with coughing. Conclusions: Even after esophagectomy for end stage achalasia, symptoms can be persistent and impact QOL. While some patients may benefit from esophagectomy, future research should aim to identify which patients will benefit the most from this operation.