Heller's Esophagocardiomyotomy Research Articles

Commentary on the article by E. A. Tseimakh et al. «Results of laparoscopic Heller esophagocardiomyotomy with Dor fundoplication in patients with stages 3 and 4 of the esophageal achalasia»

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Results of laparoscopic Heller esophagocardiomyotomy with Dor fundoplication in patients with stages 3 and 4 of the esophageal achalasia

INTRODUCTION. The choice of a treatment method in patients with stages 3–4 of the esophageal achalasia remains an actual topic.The OBJECTIVE was to evaluate the long-term results of Heller esophagocardiomyotomy with Dor hemiesophagofundoplication at stages 3–4 of the esophageal achalasia by comparing the results of patient survey with data of instrumental methods of diagnosis of esophageal function.METHODS AND MATERIALS. The results of the operation were analyzed in 67 patients, including 35 patients with stage 3 and 32 patients with stage 4 of the disease. The period of postoperative follow-up was 1–5 years. The results of X-ray examination of the esophagus and stomach, esophageal manometry, 24-hour pH-metry and the data of the Eckardt and GIGLI scale questionnaires were evaluated.RESULTS. The data of X-ray examination of the esophagus and stomach, in the long-term period, showed a complete restoration of the esophagus evacuation function in all patients (p=0.001), according to manometric data, a significant decrease in the tone of the lower esophageal sphincter in all patients to normal values (p=0,001) was revealed, esophageal atony was noted in three patients with stage 4 of the disease. Pathological gastroesophageal reflux before and after surgery was not registered by pH-metry, the De Meester index was within the normal range in all groups (less than 14.72). Dysphagia in the long-term period decreased in all patients. Long-term results on the Eckardt scale in patients with stage 3 improved by 83.5 %, with stage 4 by 78.3 % (p=0.001), according to the GIGLI questionnaire, patients with stage 3 scored 83.5 %, with stage 4 by 78.3 % more than before surgery.CONCLUSION. Laparoscopic Heller esophagocardiomyotomy with Dor fundoplication reduces symptoms of the disease in patients with stages 3–4 of the esophageal achalasia, increases the gastrointestinal index of quality of life, which makes it advisable to perform organ-preserving surgery at stage 4 of the disease.

Management of achalasia in pregnancy in a resource-poor setting

Achalasia is a rare motility disorder of the esophagus. Of more rarity is its occurrence in pregnancy. The disease is associated with varying degrees of malnutrition, with intrauterine growth restriction and even fetomaternal death reported in worse cases. Its diagnosis is usually confused for hyperemesis gravidarum in early pregnancy, and diagnosis is thus often delayed until the disease is advanced. Its evaluation and treatment pose a challenge due to associated fetomaternal risks of management. A case of achalasia diagnosed in the second trimester of pregnancy was presented. The patient was evaluated and subsequently had laparotomy and modified Heller's esophagocardiomyotomy with a good outcome. Based on a review of the literature and own experience, an algorithm is proposed for its evaluation and treatment in a resource-poor setting.

Evaluation of the antireflux function of the cardia after Heller esophagocardiomyotomy with Dor fundoplication in patients with achalasia of the cardia

<h3>ОБОСНОВАНИЕ</h3> Одним из распространенных хирургических методов лечения является эзофагокардиомиотомия по Геллеру. Для предотвращения рефлюкс-эзофагита в послеоперационном периоде кардиомиотомию по Геллеру мы сочетали с фундопликацией по Дору. <h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Оценка наличия и степени выраженности рефлюкс-эзофагита после видеолапароскопической эзофагокардиомиотомии по Геллеру с фундопликацией по Дору у пациентов со II—IV стадиями ахалазии кардии (АК). <h3>МАТЕРИАЛ И МЕТОДЫ</h3> Обследованы 98 пациентов. Анализировались результаты фиброэзофагогастродуаденоэндоскопии (ФЭГДЭС), 24-часовой внутрипищеводной pH-метрии и анкетирования пациентов по опроснику GERD-HRQL (Gastroesophageal reflux disease health related quality of life scale). <h3>РЕЗУЛЬТАТЫ</h3> По данным ФГДЭС, в послеоперационном периоде явления эрозивного и фибринозного эзофагитов купировались во всех исследуемых группах, частота катарального эзофагита уменьшилась на 75,4%. По результатам 24-часовой внутрипищеводной pH-метрии до операции, случаев патологического рефлюкса у больных не выявлено. После операции процент общего времени с pH &lt;4 и число гастроэзофагеальных рефлюксов с pH &lt;4 во всех группах не превышали норму (соответственно 4,5 и 46,9). Индекс DeMeester в нижней трети пищевода до и после операции не превышал норму, составляющую меньше 14,72 (соответственно 4,6±0,8 и 3,02±0,6). Данные, полученные по опроснику GERD-HRQL, отражали улучшение самочувствия больных после операции, уменьшение суммарной балльной оценки на 64,9% по сравнению с дооперационными данными (соответственно 14,8±0,5 и 5,2±0,5 балла). <h3>ВЫВОДЫ</h3> Эзофагокардиомиотомия по Геллеру, дополненная фундопликацией по Дору в качестве антирефлюксной процедуры, сопровождается минимальным риском развития рефлюкс-эзофагита в послеоперационном периоде.

Features and results of minimally invasive treatment of recurrent achalasia

To evaluate the early and long-term postoperative outcomes in patients with recurrent achalasia, as well as the main features of surgical treatment. There were 7 patients (4 men and 3 women) with recurrent achalasia. Mean age of patients was 42.3±13.5 years, body mass index - 22.7±3.3 kg/m2. Physiological status ASA grade 1-3 was observed in all patients. Concomitant diseases were diagnosed in 5 (71.4%) cases. Six (85.7%) patients underwent laparoscopic Heller cardiomyotomy with Dor fundoplication. Peroral endoscopic myotomy (POEM) was performed in 1 (14.3%) patient. Mean preoperative Eckardt score was 10.7±1.4 points, mean GERD-HRQL score - 42.7±6.4 points. According to preoperative radiography, 5 (71.4%) patients had achalasia stage III, 2 (28.6%) ones - stage IV. All patients underwent laparoscopic Heller esophagocardiomyotomy with anterior Dor fundoplication and posterior partial fundoplication with posterior cruroraphy. Intraoperative complications (perforation of esophageal mucosa) occurred in 3 (42.9%) patients. Mean surgery time was 130±56 min, mean blood loss - 37 ml (35-205 ml), mean hospital-stay - 11.3±7.7 days. Postoperative complications Clavien-Dindo grade 3-4 were detected in 1 (14.3%) patient. One patient was diagnosed with bilateral pneumonia (SARS-Cov-2 infection) in 4 postoperative days. Median postoperative follow-up period was 22 months. Mean BMI in 6 months after surgery was 25.3±3.1 kg/m2, mean Eckardt score - 2.1±0.7 points, mean GERD-HRQL score - 3.3±0.9 points. Our data confirm the effectiveness and safety of the modified laparoscopic Heller procedure with Dor fundoplication as the main method for recurrent achalasia.

A Case of a Giant Epiphrenic Esophageal Diverticulum

Abstract The esophageal diverticula are divided into pharyngoesophageal, parabronchial and epiphrenic. They could also be divided into congenital and acquired, true and false, pulsion and traction. Pulsion diverticula are usually formed in motor disorders of the esophagus, above the place of hypertension and uncoordinated peristalsis. They are pseudo-diverticula caused by increased intramural pressure, leading to herniation of the mucosa and submucosa through the focal areas of the esophageal wall. We present a 65-year-old woman who underwent left-sided transthoracic diverticulectomy, modified Heller esophagocardiomyotomy, and modified Belsey-Mark IV fundoplication due to a huge epiphrenic esophageal diverticulum.

Esophageal achalasia in a two-year-old boy

Introduction. Esophageal achalasia is a neurodegenerative motility disorder, which is characterized by ineffective or absent esophageal peristalsis and the lack of hypertonic lower esophageal sphincter relaxation. Achalasia causes failure to thrive in children and can have serious respiratory complications. Achalasia is a very rare condition in pediatric population, and usually misdiagnosed as gastroesophageal reflux. The treatment of choice is Heller esophagocardiomyotomy. The aim of this paper is to present a rare case of a two-year-old child with achalasia, diagnostic procedures, and successful operative treatment. Case outline. The patient?s problems started at the age of six months, with audible breathing and respiratory stridor. The child was admitted at a local hospital at seven months of age, dismissed with dietary advices, again admitted at the age of 19 months, and transferred to our institution. Upper gastrointestinal series and computed tomography revealed findings characteristic for achalasia, and on esophagoscopy exam there was no opening of lower esophageal sphincter and cardia on insufflation. Pneumatic dilation was performed with temporary improvement. Laparotomic Heller esophagocardiomyotomy with Dor partial fundoplication was successfully performed. Conclusion. Achalasia is a very rare condition in infants and young children. There is often a delay when establishing the correct diagnosis. Upper gastrointestinal series and endoscopic exam are most reliable methods to detect achalasia. Pharmacological treatment, intrasphincteric injection of botulinum toxin and pneumatic dilations are not efficient methods, especially in small children. The method of choice in the treatment of achalasia is Heller esophagocardiomyotomy with partial fundoplication.

Achalasia Cardia of Infancy: Report of Two Cases

Achalasia cardia is a neuromuscular disorder of unknown etiology involving the body of the esophagus and lower esophageal sphincter (LES). It is characterized by aperistalsis of the body of the esophagus and failure of relaxation of lower esophageal sphincter. It usually affects patients between the ages of 30 and 60 years. It is unusual in childhood and extremely rare in infants. We report two cases of achalasia cardia in infants. Both cases were treated with open Heller’s esophagocardiomyotomy with anti-reflux procedure.

Diagnosis and management of esophageal achalasia in children: analysis of 13 cases

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. 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. 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. 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.

Intraoperative manometry during laparoscopic Heller myotomy improves outcome in pediatric achalasia

Achalasia is a rare disorder with less than 5% of patients diagnosed in childhood. Although Heller esophagocardiomyotomy is a proven intervention, incomplete myotomy can lead to clinical failure. Intraoperative esophageal manometry has been used to ensure adequacy of myotomies in adults. The purpose of the present study was to review our experience in the management of children with achalasia. A retrospective review was conducted on the medical records of patients with achalasia diagnosed between November 1999 and March 2007. Patient demographics and interventions were recorded. Outcomes after surgical intervention and esophageal dilation were assessed. Mean follow-up was 3.5 +/- 0.6 years. Intraoperative manometry was used over the past 3 years. Nineteen patients were treated for achalasia. The average age at diagnosis was 13.8 +/- 0.8 years. Most patients underwent esophageal dilation (14/19), receiving on average 2.1 +/- 0.3 dilations. One patient experienced a contained perforation that was treated conservatively. Eleven patients underwent myotomy, as primary therapy (n = 5) or after recurrence of symptoms after dilation (n = 6). Six patients underwent intraoperative manometry. More patients who underwent Heller myotomy without intraoperative manometry had recurrence of symptoms (80% vs 0%, P < .05). Inadequate myotomy is a potential cause for recurrent symptoms after esophagocardiomyotomy in childhood achalasia. Intraoperative esophageal manometry is a safe technique that may improve the success rate of surgery by confirming the adequacy of myotomy thereby decreasing recurrence of symptoms.

Rare Association of Achalasia with Benign Esophageal Stenosis Successfully Treated with Laparoscopic Heller's Esophagocardiomyotomy and Watson Anterior Fundoplication

Achalasia is an uncommon pediatric disease. An association with a benign esophageal stenosis is even rarer. We report this interesting case of a 9-year-old with concomitant achalasia and benign esophageal stenosis. Diagnosis was based on radiologic, endoscopic, and operative findings. The patient was successfully treated with laparoscopic Heller's esophagocardiomyotomy and Watson's fundoplication. Details of this unique case and operative technique are highlighted.

Complications of laparoscopic treatment of esophageal achalasia in children

Background/Purpose: The aim of this study was to evaluate the incidence and management of the complications that occurred in some children who underwent laparoscopic Heller's esophagocardiomyotomy in the authors' institutions. Methods: Between March 1993 and October 1998, the files of all the children with achalasia who underwent laparoscopic Heller's esophagocardiomyotomy in a community hospital in Naples, Italy, and a private hospital in Paris, France, were reviewed. A 5-port technique was used associating Heller's esophagocardiomyotomy to an antireflux surgical mechanism (Dor's or Toupet's) in all cases. Intra- and postoperative complications, as well as the postoperative outcome, were evaluated. Results: Ten laparoscopic Heller's esophagocardiomyotomies were performed in 5 girls and 5 boys with achalasia. Age ranged between 2 and 13 years. Mean operating time was 120 minutes. Hospital stay ranged between 3 and 41 days. Complications were recorded in 3 patients: in 2 an esophageal mucosal perforation and in 1 a prolonged dysphagia. Two of these complications occurred in the last patients operated on. Follow-up varied from 6 months to 6 years. All children were free of symptoms. Conclusions: The results show that laparoscopic Heller's esophagocardiomyotomy in children is a feasible procedure. Assessment of mucosal integrity immediately after the myotomy must be performed. Complications can happen even if the operation is performed by expert laparoscopic surgeons. J Pediatr Surg 35:680-683. Copyright © 2000 by W.B. Saunders Company.

Management of failed heller's operations

An analysis of 29 patients who collectively required 33 reoperations for failed Heller's esophagocardiomyotomy performed during the period between 1972 and 1992 was conducted. In the majority of patients, the reoperation was necessitated because the original myotomy was not long or deep enough, or because of iatrogenic gastroesophageal reflux and its sequelae such as strictures. Identification of the exact cause of failure requires careful analysis of the patient's symptoms and of the findings of various diagnostic examinations. The treatment for inadequate myotomy generally involves performing a second myotomy, which is completed by adding a nonobstructive antireflux repair. It appears that abolition of the "sigmoid sac" is essential even when the esophagogastric junction has a sufficiently large diameter. A so-called esophagoplication was performed in 3 patients,and an interposition at the site of esophageal resection, using an isoperistaltic esophagojejunogastric loop of appropriate length, was performed in 14 patients. There were no deaths following reoperation. In fact, the results were excellent or good in 23 cases and fair in 3.

Cardiomyotomy and fundoplication for esophageal achalasia.

To avoid gastroesophageal reflux which is reported to occur in about 4-25 per cent after Heller esophago-cardiomyotomy, a modified gastro-fundoplication was designed using a transabdominal approach. Forty patients with idiopathic esophageal achalasia were subjected to this surgery. There were no serious complications and suppression of dysphagia and gastroesophageal reflux manifestations were excellent.

Esophageal perforations after forceful dilatation in achalasia.

The reported incidence of esophageal perforation after forceful dilatation in achalasia is between 1-5%. Over the past nine years we have treated five patients with this complication. After demonstrating the perforation with a Gastrografin swallow, a left posterolateral thoracotomy is made. The full-thickness laceration is sutured in two layers. A Heller esophagocardiomyotomy is then performed on the contralateral side of the esophagus. The muscular layer on either side of the esophagocardiomyotomy is mobilized well so as to allow easy closure of the outer muscular layer of the esophagus in the area of the laceration. There were no deaths and minimal morbidity in these five patients, and functional results were excellent. It is concluded that perforations of the esophagus after dilatation in achalasia should be operated on promptly and undergo closure of the laceration with a complimentary esophagocardiomyotomy.

Physiology of the esophage-gastric junctional area studies in view of its intraluminal resting pressure

Manometric studies were performed in 1.2 unanesthetized dogs with the left sided esophagostomy and additional operative procedures of 3 different types; (A) division of the phrenico-esophageal ligament, (B) division of the phrenico-esophageal ligament and the modified Heller's esophago-cardiomyotomy (4 cm), and (C) intrathoracic lower esophagomyotomy (6 cm) just above the diaphragm. The resting pressure in the esophago-gastric junction were then measured.After division of the phrenico-esophageal ligament, the resting pressure in the esophago-cardiac sphincter fell from 13.2 to 4.8 cm H2O. After lower esophagomyotomy no obvious changes were noted in the resting pressure.The phrenico-esophageal ligament plays an important role in producing the high pressure zone in the esophago-gastric junctional area.

Achalasia of the Esophagus

Achalasia of the esophagus is characterized by lack of neuromuscular coordination, which results in an absence of normal peristalsis in the body of the esophagus and a failure of relaxation of the lower segment. It is a frequent cause of esophageal obstruction. Symptoms of achalasia include dysphagia, regurgitation (nocturnal overflow), substernal discomfort, recurrent pulmonary infection, and weight loss. The diagnosis of achalasia is established by esophagoscopy, x-ray examinations (routine posterioanterior and lateral views), barium swallow and cinefluoroscopy, and esophageal motility studies. Treatment consists of bougienage, forceful dilation, and Heller esophagocardiomyotomy.

Bougienage, Forceful Dilatation, and Surgery in Treatment of Achalasia

A study of the literature has disclosed that most authors have been prejudiced either in favor of bougienage or surgery in the treatment of achalasia. Eighty-eight cases of achalasia were studied to give an unprejudiced opinion on the best treatment of this disease. Results of various types of therapy administered to the patients under study were compared. This study concluded that esophagoscopy, followed by simple mercury bougienage, should be done first to rule out other diseases of the esophagus. If this procedure does not prove satisfactory, the next step is use of the Browne-McHardy bougie passed under fluoroscopic guidance. A Heller esophagocardiomyotomy should be recommended only if other methods fail.