Heller's Operation Research Articles

История хирургического лечения ахалазии кардии: от операции Геллера до пероральной эндоскопической миотомии

История хирургического лечения ахалазии кардии: от операции Геллера до пероральной эндоскопической миотомии

Achalasia Cardia: Short-term Results of 40 Iraqi Patients

Background: Achalasia is an uncommon but not a rare a malady. In Iraq, we lack true statistics about this condition.
 Objective: is to review the experience with trans-thoracic modified Heller operation for achalasia cardia in a major thoracic surgical centre in Iraq over a 4-year period.
 Study design: a combined retrospective and prospective study.
 Setting: Department of Thoracic Surgery in Baghdad Medical City/Baghdad/Iraq. 
 Methods: This study is both retrospective (20 cases) and prospective (20 cases); the information is collected from either patients, case sheets or obtained directly from patients, interviews. In both situations, relevant demographic and clinical information is obtained. The patients then are subjected to a standard diagnostic workup followed by preparation of patients for surgery. A trans-thoracic modified Heller's operation: esophagocardiomyotomy) is done following a standard technique. No anti-reflux procedure is added. Follow up is done to evaluate results of surgery.Patients: 40 patients (26 males and 14 females) with achalasia cardia who were admitted to the Department of Thoracic Surgery in Baghdad Medical City over a period of 4 years (2008 to 2012).
 Results: 26 males (65%) and 14 females (35%) with a mean age of 26.6 year. Patients aged 20 -40 years constituted the majority (47.5%). The commonest presenting symptom was dysphagia reported in 39 patients (75%). Cucumber dilated esophagus (rat tail sign) was the commonest appearance on contrast study found in 84% of studied patients. Ten patients (7 females and 3 males) had dilation therapy initially which failed to improve their symptoms thus scheduled for surgery. The remaining 30 patients were offered surgical treatment from the start; thus ultimately, operation was done to all 40 patients. Good to excellent results after surgery were obtained in 35 patients (87.5%).
 Conclusions: though good and excellent results followed Heller’s operation for achalasia cardia versus multiple forceful dilatations, laparoscopic Heller oesophageal myotomy reverses the symptoms of achalasia with minimal morbidity. It is recommended to learn and practice this minimal invasive procedure rather than to continue doing an old operation.

Complications of modified Heller operation and preventive management

Complications of modified Heller operation and preventive management

Surgical management of achalasia in Zaria, Northern Nigeria.

Achalasia of the cardia is generally considered a rare disease. Because the cause is uncertain, treatment is palliative and directed at relieving distal oesophageal obstruction. In developed countries, several treatment options are available, but in developing countries, achalasia is usually treated by open surgical myotomy. We reviewed the outcome of management of achalasia in our patients and the influencing factors. We retrospectively reviewed all adult patients treated for achalasia between 1991 and 2006. Diagnosis was based on clinical symptoms and barium swallow examination. The severity and frequency of dysphagia were determined before and after treatment. Barium examination was repeated 2 weeks after surgery or when the patient had recurrence of dysphagia, regurgitation or heartburn. Treatment was by modified Heller's operation, transabdominally without complementary antireflux procedure. Logistic regression modelling was performed to identify factors predictive of poor outcome. There were 47 patients, 31 (66.0%) males and 16 females, mean age (+/- standard deviation (SD) 34.6+/-9.8 years. All patients presented with dysphagia, which was severe in 31 cases (66.0%) and moderate in 14 (29.8%). Preoperative maximum oesophageal diameter ranged from 34 to 89 mm, mean 67.4+/-12.7mm. In 30 (63.8%) of the patients, the maximum diameter was >70 mm. Postoperative maximum diameter ranged from 28 to 72 mm, mean 37.5+/-8.2 mm (p=0.001). The mean preoperative diameter of the narrowest distal oesophagus was 4.6+/-2.5 mm, compared with the postoperative figure of 11.6+/-1.8 mm (p=0.015). Following surgery, 41 (87.2%) patients had complete relief of dysphagia, regurgitation and heartburn. Four patients continued to have heartburn after surgery. Patients with severe dysphagia or preoperative oesophageal dilatation >70 mm had the greatest likelihood of incomplete relief of symptoms after treatment. Achalasia can be accurately diagnosed on the basis of clinical symptoms and barium swallow examination. A modified Heller's operation provides lasting relief of symptoms. Patients with severe preoperative dysphagia or oesophageal dilatation are more likely to have poor outcome of treatment.

Long‐term Result of Total versus Partial Fundoplication after Esophagomyotomy for Primary Esophageal Motor Disorders

The selection of the type of fundoplication or the necessity for an added fundoplication after esophagomyotomy (Heller's operation) for the treatment of achalasia remains controversial. The present retrospective study was designed to compare the long-term results of total and partial fundoplication on the myotomized esophagus. Between 1978 and 1998, a total of 64 consecutive patients with achalasia or diffuse esophageal spasm underwent esophagomyotomy and an antireflux operation via a left thoracotomy approach. Twenty-one had a total fundoplication (Nissen Group) during the period 1978-1983. After 1984 and until 1998, the remaining 43 patients were treated with addition of a Belsey Mark IV partial fundoplication (Belsey Group) to protect the myotomized esophagus. Clinical, radiologic, radionuclide transit, manometric, 24-h pH monitoring, and endoscopic assessments were obtained before and after the operation. There were no operative deaths or major complications in either group. After 6 years of follow-up the Belsey group was compared to the Nissen group. A higher frequency of dysphagia (7/18 versus 3/31; p=0.025), more barium stasis (9/13 versus 10/27; p=0.056), and increased radionuclide material retention (52.4% versus 29.2%; p=0.044) were observed in the Nissen group. These findings were confirmed by endoscopy, which showed increased esophageal lumen dilation (10/15 versus 8/26; p=0.026) and more frequent food retention (11/15 versus 6/26; p=0.002). Functionally, both operations successfully reduced the lower esophageal sphincter pressure gradient (from 23.8 to 7.7 mmHg for the Nissen group, and from 27.4 to 8.2 mmHg for the Belsey group; p=0.656). In the Nissen group, the esophageal diameter observed on radiology increased from 3.9 cm preoperatively to 5.5 cm postoperatively (p=0.012), whereas it remained identical for the Belsey group (ranging from 5.4 cm to 5.3 cm; p=0.695). Reoperation to relieve recurrent dysphagia and esophageal retention was necessary in 8 patients from the Nissen group and in 1 patient from the Belsey group (p<0.001). When treating achalasia or diffuse esophageal spasm by esophageal myotomy and an antireflux operation, a total fundoplication adds too much resistance to allow esophageal emptying and is considered as inappropriate. A partial fundoplication provides proper antireflux effects without causing significant esophageal emptying difficulties.

Estudo comparativo entre as técnicas de nissen e Boix-Ochoa em ratos

OBJETIVO: Comparar, em ratos, a eficiência das técnicas de Nissen e Boix-Ochoa no tratamento do refluxo gastroesofagiano (RGE) induzido pela operação de Heller. MÉTODO: Foram usados 30 ratos Wistar, com idades entre 40 e 60 dias de vida e peso corporal entre 210 g e 342 g. Os animais foram distribuídos em três Grupos (A, B, C) de 10 ratos. Em todos os animais realizou-se a operação de Heller. No Grupo B ela foi seguida de uma operação de Nissen e, no Grupo C, de uma operação de Boix-Ochoa. A pressão intra-gástrica necessária para produzir RGE foi medida em todos os animais: antes de qualquer procedimento; imediatamente após as operações de Heller, Nissen e Boix-Ochoa; e seis semanas depois, quando os animais foram mortos. RESULTADOS: Verificou-se que tanto a recuperação da perda de peso, que caracteriza o quadro de RGE, como a reconstituição mais fisiológica dos gradientes pressóricos gastroesofagianos são obtidos de forma mais eficiente pela técnica de Boix- Ochoa. CONCLUSÃO: As operações de Nissen e Boix- Ochoa são eficientes no tratamento do RGE induzido pela técnica de Heller, em ratos. A segunda, no entanto, restaurou, de forma mais adequada, os valores fisiológicos dos parâmetros estudados neste trabalho: o peso corporal e os gradientes pressóricos gastroesofagianos.

Heller's myotomy for achalasia: Is an added anti-reflux procedure necessary?

Literature review (1970-85) indicates excellent or good results following Heller's operation in 89 per cent of 5002 patients. The overall mortality was 2.8 per cent with a reoperation rate of 2.8 per cent. When the operation was done through an abdominal incision, gastro-oesophageal reflux was almost twice as common as when it was done through a thoracic incision, regardless of whether an anti-reflux procedure was performed.

Heller's operation for achalasia of the cardia. A study of the early and late results.

Abstract Thirty patients who had undergone Heller's operation for achalasia of the cardia have been studied. All but I had relief of the dysphagia at 1 year's follow-up. Five of the 14 patients followed for 10 years or more had severe reflux oesophagitis, 3 requiring further operative treatment.

The late results of Heller's operation in the treatment of achalasia.

The late results of Heller's operation in the treatment of achalasia.

Results of Heller's operation for achalasia of the cardia.

A survey of 102 patients with achalasia of the cardia treated by cardiomyotomy is reported. The technique of operation was unchanged throughout and the patients were followed up for a maximum of 22 years. Only 6 patients (5.8 per cent) developed renewed symptoms of reflux and 7 patients (6.8 per cent) had peptic strictures. Over 80 per cent of the patients had no dysphagia or regurgitation postoperatively, but 61 per cent still complained of achalasic pain. The development of mucosal hernias after cardiomyotomy and the use of drinking times in the assessment of outflow at the cardia are discussed.

The late results of Heller's operation for cardiospasm.

The late results of Heller's operation for cardiospasm.

Laparoscopic esophagomyotomy for the treatment of achalasia in children. A preliminary report of eight cases.

Albeit rare in children, achalasia is a disorder with severe symptoms that causes growth impairment. The treatment of choice in children is the esophagomyotomy, although there are variations in the surgical approaches available and differences of opinion regarding the inclusion of an adjunctive antireflux procedure. The recent advent of the laparoscopic approach has had a profound impact on the treatment of achalasia in both adults and children. In this report, we describe eight patients with severe achalasia who were treated by laparoscopic Heller's operation associated with a fundoplication according to either Dor's or Toupet's technique. The patients' ages ranged between 2 and 13 years. A five-port technique was used: a 10-mm port placed infraumbilically for the optics and four 5-mm ports. One was placed in the right abdominal quadrant for retraction of the left hepatic lobe, one in the left abdominal quadrant for the first operative instrument, one below the xyphoid appendix for the second operative instrument, and the last one to introduce a 5-mm cannula laterally to the umbilicus to retract the stomach below. A 7-8-cm laparoscopic Heller esophagomyotomy was completed, followed by an anterior Dor fundoplication in six cases and a Toupet in two. The longitudinal division of the anterior esophageal musculature was performed with a scalpel or scissors. The myotomy was made along the stomach, extending for >/=2-3 cm. Mean operating time was 120 mins. Three complications were recorded. There were two perforations of the gastroesophageal mucosa; the first was sutured in laparoscopy and the second required a second operation. The third complication was a case of dysphagia resolved by dismounting a fundoplication that was too tight. At follow-up, which lasted from 6 months to 5 years, the children were all free of symptoms. Laparoscopic Heller esophagomyotomy appears to be a complex and difficult operation, but it is as safe and effective as laparotomy in children with achalasia. However, complications can be numerous and severe at the beginning of a surgeon's experience.

Late results of Heller operation and fundoplication for the treatment of the megaesophagus: analysis of 83 cases

Retrospective study of the late results of the Heller's cardiomyotomy and fundoplication for the treatment of the megaesophagus. Were studied 83 patients with a follow-up from one to 186 months (average 40.0 +/- 47.4 months). The fundoplications used were in three plans in 15.7% and posterior in 83.1%. The main pre-operatory complain was dysphagia followed by regurgitation and loss of weight. Chagas, Disease as the etiology was confirmed in 72.3% of the patients. In the follow-up 55.4% of the patients were assymptomatic, 34.9% complained of sporadic dysphagia, 14.4% of heartburn, 8.4% of regurgitation and 2.4% did not changed the dysphagia, these being re-operated and had improvement the symptoms. Gastro-esophageal reflux was noted in 8.4% of the patients. Other late complications were par-esophageal hernia, sliping of the fundoplication, Barrett esophagus and cancer. The necessity of a long-term clinical and endoscopical follow-up, even after surgery, owing to the possibility of late complications, especially cancer was emphasized. The late results are good in relation to the dysphagia. Myotomy is proposed as an alternative to patients with advanced megaesophagus with bad clinical conditions who can not be submitted to an esophagectomy.

Selecting the surgical procedure for simple and complicated esophageal achalasia in children

Background/Purpose: Surgical experience in children who have achalasia is limited. Surgical treatment requires esophagocardiomytomy and an antireflux procedure. However, when these operations fail, other procedures are needed. To summarize the experience treating children who have this condition, the authors reviewed retrospectively all case histories of patients treated from 1971 to 1996 at their hospital. Methods: Three boys and a girl, ranging in age from 18 months to 11 years, were treated. All had multiple previous dilatations. Two then underwent operation using an abdominal approach for a Heller procedure and a posterior fundoplasty (Guarner operation). Two children were previously treated in another hospital. One underwent a Heller operation complicated by perforation of the anterior mucosa. The other had undergone three previous abdominal approaches for esophagocardiomyotomy and a Nissen fundoplication. Symptoms persisted and imaging and endoscopy showed stenosis in both patients. In the first patient an esophagocardioplasty with transverse closure (Wendel procedure) and a posterior fundoplasty was performed. In the second child, the three previous abdominal surgical approaches mandated a transthoracic approach with transdiaphragmatic latero-lateral esophagogastric anastomosis (Heyrowsky operation) and a modified Guarner operation using the remaining fundus and gastric body. Results: There were no intraoperative or postoperative complications. Follow-up time ranged from 3 months to 17 years. All patients experienced dramatic relief of symptoms and satisfactory weight gain. No recurrence of symptomatology has occurred. Conclusions: Esophagocardiotomy associated with an antireflux procedure may be the first option in the surgical treatment of children who have achalasia. However, if this fails, esophagocardioplasty and the latero-lateral esophagogastric anastomosis associated with antireflux procedure may be successful alternatives.

Ten to 20-year clinical results after short esophagomyotomy without an antireflux procedure (modified Heller operation) for esophageal achalasia.

To determine the long-term clinical results after modified esophagomyotomy without an antireflux procedure for esophageal achalasia, the status of all patients undergoing this operation with a minimum follow-up time of 10 years was reviewed; 81 such patients were operated on between January 1970 and January 1981. Thirteen patients were lost to follow-up review permitting clinical evaluation during the past year of 68 patients (84%) observed for a median of 13.6 years. Fifty-nine patients (87%) were improved by operation; 90% of the patients who underwent a primary procedure were improved, whereas only 73% of patients undergoing reoperation benefited. Kaplan-Meier analysis of the results of all 81 patients disclosed an improvement rate of 98.5% at 5 years, 95.6% at 10 years, 85.8% at 15 years, and 67.3% at 20 years. When the level of improvement or lack thereof was analyzed, the percentage of excellent results decreased from 54% to 32% (P = 0.02). The percentage of good results remained the same, whereas fair or poor results together increased from 20% to 37% (P = 0.05). Neither age, sex, esophageal caliber, duration of symptoms, or previous therapy appeared to influence these results. We conclude that limited esophagomyotomy without an antireflux procedure results in persistent long-term improvement for the patient with esophageal achalasia. The level of improvement, however, decreases with the passage of time, presumably because of persistent disease in the body of the esophagus leading to impaired esophageal emptying in some patients and late reflux esophagitis in other patients owing to poor esophageal clearance.

Achalasia in children: Treatment by anterior esophageal myotomy (Modified heller operation)

Although rare in children, achalasia can be the cause of debilitating symptoms and growth retardation. During a 4-year period, six patients (mean age 9.9 years) underwent a modified Heller operation (anterior esophageal myotomy) without complication. A concomitant modified Belsey fundoplication was performed in three patients who were judged at the time of operation to be at high risk for postoperative gastroesophageal reflux. Preoperative symptoms of dysphagia, postprandial vomiting, retrosternal pain, and pulmonary complications were eliminated in all patients. Follow-up interviews seven to 48 months (mean 23 months) following operation revealed normal diet and normal growth in all six children, with no recurrence of preoperative symptoms or evidence of gastroesophageal reflux. Technical details which we believe contribute to success in the operative management of pediatric achalasia include the transthoracic approach and the selective performance of complementary anti-reflux procedures.

Two Decades of Experience with Modified Heller's Myotomy for Achalasia

We reviewed the hospital records of 36 patients who underwent modified Heller's myotomy for achalasia between January, 1961, and December, 1982. There were 18 male and 18 female patients ranging between 17 months and 75 years old. The most frequent symptom was dysphagia, followed by regurgitation of ingested food and weight loss. Modified Heller's myotomy was performed through a transthoracic incision in 35 patients and a transabdominal incision in 1. An antireflux procedure in addition to esophagomyotomy was performed in 20 patients. There was 1 postoperative death. Thirty-three patients were followed up for periods ranging from 9 months to 21 years. The results were considered good in 27, fair in 2, and poor in 4. One of the 4 underwent repeat esophagomyotomy 7½ years after the initial operation with a good result. The remaining 3 had an antireflux procedure at the time of esophagomyotomy. Because of recurrence of symptoms, esophagogastrostomy was performed in 1 and colon interposition in 2. These results suggest that an antireflux procedure should not be added to modified Heller's operation in the treatment of achalasia.

Cardiomyotomy associated with antireflux surgery in the treatment of achalasia

AbstractThe purpose of this report was to evaluate the efficacy of cardiomyotomy combined with fundoplication in the treatment of achalasia. Results obtained in 15 patients are compared with those collected in 19 asymptomatic patients treated by the classical Heller operation (12 patients), or by cardiomyotomy combined with suture of phrenoesophageal ligament to the underside of the diaphragm (7 patients). The preventive action of fundoplication on reflux esophagitis and especially the effect of surgery on esophageal emptying are particularly examined, using two rigorous isotopic tests. It is demonstrated that even asymptomatic patients have, after cardiomyotomy without antireflux maneuvers, a very high risk of esophagitis. The statistical comparison using the gastroesophageal reflux index between patients treated by Heller cardiomyotomy and normals wasp &lt;0.001 to the classical Heller, and 0.01 &lt;p &lt;0.05 to the group treated by cardiomyotomy plus abdominal fixation of the cardia. By contrast, the combination of a fundoplication to the myotomy provided a very high antireflux efficacy (p &gt;0.1), and maintained the improvement of the esophageal emptying.

A review of 74 patients with oesophageal achalasia: the results of Heller's cardiomyotomy, with and without Nissen fundoplication.

A survey is presented of 74 patients with achalasia of the the oesophagus treated surgically at the Royal Prince Alfred Hospital, Sydney, Australia. This survey spans a 27-year period. Thirty-nine patients underwent Heller's operation, 23 (58.9%) had excellent results six months after operation, and 17 (43.5%) still had excellent results more than two years after operation. This group had a high recurrence of symptoms due to oesophageal reflux (30.8%) and the development of strictures (20.5%) at the lower end of the oesophagus. Thirty-five patients underwent Heller's operation together with Nissen fundoplication. Thirty-two patients (91.4%) in this group had excellent results six months after operation, and 30 of these patients (85.7%) still had excellent results more than two years after operation. These results suggest that symptoms of oesophageal reflux and subsequent oesophageal stricture following Heller's operation for achalasia can be considerably reduced, if not prevented, by Nissen fundoplication--a reflux-preventing procedure.

Case for pneumatic dilatation in achalasia.

A standardized method of performing pneumatic dilatation for the treatment of achalasia is described. Twenty-five patients were treated in this manner and 80% had excellent results. There was minimal morbidity and no mortality. Pneumatic dilatation is recommended as the primary procedure for achalasia as it is a simple and safe procedure which avoids unnecessary surgery. Local topical anesthesia, rather than general, is utilized and hospitalization time is two days, rather than the 14 days required following surgery. The Heller operation can be performed when pneumatic dilatation is unsuccessful.