Laparoscopic Heller-Dor Operation Research Articles

325. SURGERY FOR EPIPHRENIC ESOPHAGEAL DIVERTICULUM, SHORT AND LONG TERM RESULTS

Abstract Background and Objectives We present our experience with laparoscopic surgery for epiphrenic oesophageal diverticulum. We wanted to assess our surgical results focusing on the patients’ quality of life. Short- and long-term results of surgical therapy were analysed. Methods 14 patients were examined with a symptomatic causing epiphrenic diverticulum. Patients underwent complex gastroenterological examinations before and after surgery (swallowing x-ray, oesophagogastroscopy, oesophageal manometry/pH monitoring). Surgery: laparoscopic transhiatal epiphrenic diverticulectomy with Heller cardiomyotomy and Dor anterior partial fundoplication were performed in 9 patients; laparoscopic diverticulectomy in 2 patients, laparoscopic Heller-Dor operation without diverticulectomy was 1 case (small (< 3cm) diverticulum) and laparoscopic diverticulectomy + Heller myotomy + Nissen fundoplication in 2 cases. Changes in quality of life with regard to symptoms related to oesophageal function were evaluated in our long-term studies (averaging 60 months, 10–138 months) by Eckardt-Zaninotto score. Results We had no intraoperative complication except one. In one case, a staple line leak developed (1/14 (7%), which was resolved with conservative therapy. Functional check-ups confirmed adequate oesophageal function in majority of the patients. The total symptom score for the patients was 6.3 points before surgery, and it decreased to 1.6 (P .001) after surgery, an average of 74% subjective improvement. During the follow-up period, proton pump inhibitor therapy was started in 4 patients to treat gastroesophageal reflux. In 3 cases, drug therapy was successful; in one case, Nissen antireflux surgery was performed. Conclusion Laparoscopic transhiatal diverticulectomy and Heller–Dor surgery are effective interventions with low morbidity. Patient quality of life significantly improves in the long term, but gastroesophageal reflux disease may occur. Key Words Epiphrenic oesophageal diverticulum, Laparoscopic transhiatal surgery, Long-term results

Nasogastric tube after laparoscopic Heller-Dor surgery: Do you really need it?

BackgroundAchalasia is a rare esophageal motor disorder. Laparoscopic Heller-Dor surgery (LHD) is among the most effective treatments. The use of nasogastric tube (NGT) following LHD is still controversial. The aim of our study was to evaluate the role of NGT in achalasia patients undergoing LHD. MethodsWe prospectively enrolled achalasia patients treated with LHD from January 2019 until June 2022 at our institution and randomly assigned them to two groups: one group with NGT and group without (noNGT). Perioperative outcomes were compared between the two groups. ClinicalTrials.gov Identifier: NCT05729971. ResultsSeventy-nine patients who underwent LHD surgery were prospectively enrolled. Patients were divided in two groups: 38 with NGT and 41 noNGT. There were no significant differences between two groups in terms of demographic data, preoperative characteristics, length of stay, start of liquid and solid diet, intraoperative and postoperative complications. First flatus was shorter in the noNGT group (p= 0.03). ConclusionNasogastric tube placement following LHD surgery does not reduce nausea, vomiting and chest pain, while it increased patients discomfort and time of first flatus.

Minimally invasive surgery for motility disorders of the oesophagus

Introduction and aims. We present our experience with minimally invasive surgery for pharyngoesophageal (Zenker) diverticulums, epiphrenic diverticulums and achalasia cardiae focusing on the perioperative features and patients’ quality of life. Patients and methods. Between 1 January 2003 and 31 December 2020, patients were selected with a symptom-causing Zenker diverticulum, epiphrenic diverticulum and achalasia cardiae. In 17 cases, transoral stapler diverticulostomy, in 23 cases transcervical diverticulectomy and cricomyotomy were done because of Zenker diverticulum, in 14 cases, laparoscopic transhiatal surgery was performed because of epiphrenic diverticula, while in 63 cases, laparoscopic Heller–Dor operation were carried out because of achalasia cardiae. Perioperative results, the quality of life outcomes of various surgeries were evaluated in mid- and long-term. Results/conclusions. The surgeries were performed with minimal blood loss, zero mortality and low morbidity. According to our result, the two different surgical approaches in the therapy of Zenker’s diverticulum, the laparoscopic Heller–Dor procedure applied in the management of epiphrenic diverticulas and achalasia cardiae are safe and effective operations. In the long term, the symptom control in patients after minimally invasive surgeries is sufficient and only a small percentage of the patients may require additional medication therapy and/or reintervention due to persistent complaints.

Is an objective evaluation essential for determining the therapeutic effect of laparoscopic surgery among patients with esophageal achalasia?

Despite a high degree of satisfaction with laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia, some cases show no improvement in postoperative esophageal clearance. We investigated whether an objective evaluation is essential for determining the therapeutic effect of LHD. We investigated the difference in symptoms, regarding esophageal clearance, using timed barium esophagogram (TBE), in 306 esophageal achalasia patients with high postoperative satisfaction who underwent LHD. Furthermore, these patients were divided into two groups, in accordance with the difference in postoperative esophageal clearance, in order to compare the preoperative pathophysiology, symptoms, and surgical results. Although the poor postoperative esophageal clearance group (117 cases, 38%) was mostly male and the ratio of Sigmoid type was high compared to the good postoperative esophageal clearance group (p = 0.046, p = 0.001, respectively); in patients with high surgical satisfaction, there was no difference in terms of preoperative symptom scores and surgical results. However, although the satisfaction level was high in the poor esophageal clearance group, the scores in terms of the postoperative dysphagia and vomiting were high (p = 0.0018 and p = 0.004, respectively). The AUC was 0.9842 upon ROC analysis regarding the presence or absence of clearance at 2min following postoperative TBE and the postoperative feeling of difficulty swallowing score, with a cut-off value of 2 points (sensitivity: 88%, specificity: 100%) in cases with a high degree of surgical satisfaction. The esophageal clearance ability can be predicted by subjective evaluation, based on the postoperative symptom scores; so, an objective evaluation is not essential in cases with high surgical satisfaction.

Risk factors for the occurrence of peptic esophagitis following laparoscopic Heller-Dor surgery for esophageal achalasia.

Peptic esophagitis can occur as a complication of laparoscopic Heller-Dor surgery (LHD) among patients with esophageal achalasia. The goal of this study was to identify the characteristics of patients who have developed peptic esophagitis following LHD surgery along with the risk factors associated with the occurrence of peptic esophagitis. Among the 447 cases consisting of esophageal achalasia patients who underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not peptic esophagitis occurred following surgery. We also attempted to use univariate and multivariate analyses to identify the risk factors for peptic esophagitis occurring following surgery. Esophagitis following surgery was confirmed in 67 cases (15.0%). With respect to the patient backgrounds for cases in which peptic esophagitis had occurred, a significantly higher number were male patients, with a significantly high occurrence of mucosal perforation during surgery in terms of surgical outcomes, along with a high occurrence of esophageal hiatal hernias in terms of postoperative course (P = 0.045, 0.041, and 0.022, respectively). However, there were no significant differences in terms of age, BMI, disease duration, preoperative symptoms, esophageal manometric findings, esophageal barium findings, and esophageal clearance. A multivariate analysis indicated independent risk factors for the occurrence of peptic esophagitis following LHD as being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias. Peptic esophagitis occurred following LHD in 15% of cases. Independent risk factors for the occurrence of peptic esophagitis following LHD included being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias following surgery.

The patient characteristics of esophageal carcinoma following laparoscopic myotomy for esophageal achalasia.

It is common knowledge that esophageal achalasia patients have a high risk of developing esophageal carcinoma. The present study assessed the characteristics of esophageal carcinoma patients following laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia. Among 622 cases which were esophageal achalasia patients and underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not esophageal carcinoma occurred following surgery. Six cases (0.96%) of postoperative esophageal carcinoma were confirmed. The characteristics of the cases in which esophageal carcinoma occurred were older age, longer disease duration (p = 0.0362 and 0.0028, respectively), decreased sphincter pressure of the lower esophagus, a high rate of sigmoid esophagus, and a long esophagus lateral diameter (p = 0.0214, 0.001, and 0.0416, respectively). Moreover, no differences in surgical outcomes were confirmed and there were no differences in symptoms from before and following surgery. The characteristics of esophageal carcinoma patients with achalasia following laparoscopic myotomy were an older age, longer disease duration, and greater progression of disease pathophysiology.

Effects of the preoperative IRP values on the pathophysiology of patients with esophageal achalasia and on the treatment outcome of laparoscopic Heller-Dor surgery.

One diagnostic criterion of esophageal achalasia is that the integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) is at least 15 mmHg. Moreover, while the standard surgical treatment for esophageal achalasia is laparoscopic Heller-Dor surgery (LHD), there have been insufficient investigations concerning the surgical outcomes from the perspective of the preoperative IRP value. We split 121 cases in which LHD was performed as an initial treatment on patients with esophageal achalasia, into two categories according to the IRP median value, and performed a comparative investigation of the surgical outcomes with regard to the preoperative pathophysiology and symptoms. The IRP median value was 29.6 mmHg. The high IRP group consisted of younger individuals and low BMI (p = 0.004 and p = 0.0273, respectively), and the percentage of Chicago classification Type II and III was high (p = 0.029) and the regurgitation score in the preoperative symptoms was high (p = 0.0043). However, no differences in the surgical outcomes were confirmed. In patients with esophageal achalasia, the degree of the preoperative IRP value affects the age, BMI, preoperative LESP, and preoperative regurgitation symptoms. However, there were no effects on the surgical outcomes, with the surgical outcomes being satisfactory, regardless of the IRP value.

75 LONG-TERM OUTCOME OF LAPAROSCOPIC HELLER–DOR OPERATION: RESULTS AT A MEDIAN 20-YEAR FOLLOW UP.

Abstract Since its introduction in 1993, Laparoscopic Heller-Dor (LHD) operation has been the gold standard treatment for esophageal achalasia. Little is known, however, of the natural story of the operated patients in the long run. The aim of this study was to assess the long-term outcome of patients who underwent LHD more than 20 years ago, in order to provide benchmark data to which new techniques should compare. Methods All the patients who underwent LHD from 1992 to 1999 at our Institution were evaluated. Patients with previous endoscopic treatment with pneumatic dilations (PD) or Botox were included, whereas patients with previous myotomy were ruled out. Symptoms were prospectively collected and scored using a detailed questionnaire. Barium swallow, endoscopy and manometry were performed before and 6–12 months after the operation, when also pH-metry was performed. Endoscopy was then suggested every 2 years. Treatment failure was defined as a postoperative symptom score > 10th percentile of the preoperative score (i.e. > 8) or the need for further treatment. Results Eighty-seven patients with a minimum 10-year follow-up were evaluated (median f/u 20 years). One patient died for esophageal cancer 11.5 years after LHD; 8 patients died 11–24 years after LHD for unrelated causes. All were highly satisfied with the results of the operation. Symptoms recurred in 23 patients (26.4%) 1 month to 13.5 years after LHD: all received 1 to 6 PD, effective in 16: 3 required revisional myotomy and 3 need periodic PD. Good long-term outcome was recorded in 73.6% of patients, and in 92% with combined treatment. Post-operative reflux (pH and/or endoscopy-proven) developed in 10 patients only (11.5%). Conclusion LHD can durably relieve symptoms in the majority of patients, though some of them may require complementary PD to maintain effective symptom control. LHD confirms to be an excellent long-term treatment for achalasia and these results represent the reference point for all other treatments.

Is esophageal manometry essential for the diagnosis of achalasia? Identifying patients with achalasia by the esophageal clearance method.

Achalasia is a disease characterized by inadequate relaxation of the lower esophageal sphincter (LES) and impaired peristalsis, for which esophageal motor function testing is essential in making a definitive diagnosis. However, the diffusion rate of esophageal pressure testing in Japan is low. We, therefore, examined whether achalasia could be identified by esophageal clearance testing with low-density barium (Timed Barium Esophagogram: TBE). 126 cases (62 males, median age of 46years), excluding those who had not undergone TBE during their initial laparoscopic Heller-Dor surgery, were chosen as the subjects from among those who were diagnosed with achalasia from November 2012 when HRM was introduced. The type of dilation, maximum esophageal transverse diameter, and esophageal clearance measurements by TBE were retrospectively examined. With respect to TBE, 200mL of 45 weight% low-density barium was ingested as quickly as possible, after which the barium column heights (H0, H1, H2, and H5) were measured 1min, 2min, and 5min following ingestion. The types of dilation indicated included: straight type (105 cases, 83%); sigmoid type (20 cases, 16%); and advanced sigmoid type (1 case, 1%). The maximum transverse diameter of the esophagus was 45 (34-54) mm, with Grade I (d < 30mm) in 33 cases, Grade II (35mm < d < 60mm) in 75 cases, and Grade III (d < 60mm) in 18 cases. The values for H0, H1, H2, and H5 were 162 (117-201) mm, 142 (98-199) mm, 130 (94-183) mm, and 119 (77-178) mm, respectively. 114 cases (90.5%) were not cleared after 5min, while 12 cases (9.5%) were cleared by 5min later (H1 = 0 + H2 = 0 + H5 = 0) and 7 cases (5.6%) by 2min later (H1 = 0 + H2 = 0), with only 6 cases (4.8%) having complete clearance within 1min (H1 = 0). Moreover, the degree of dilatation in patients with complete clearance within 1min was three patients (2.4%) each for Grade I and Grade II, respectively. Approximately 2.4% of achalasia cases had mostly normal esophageal clearance and no esophageal dilation. Based on the state of esophageal clearance by TBE and the maximum transverse diameter of the esophagus, it seems by and large possible to identify achalasia cases.

Therapeutic efficacy of laparoscopic Heller-Dor surgery for chest pain in patients with achalasia: a single institutional experience.

Chest pain reduces the quality of life of patients with achalasia. Although laparoscopic Heller-Dor surgery (LHD) is a standard surgical treatment for achalasia, its therapeutic efficacy for chest pain is not clear. The present study evaluated the therapeutic efficacy of LHD for chest pain and tried to identify factors associated with the relief of chest pain. The study included 244 patients with preoperative chest pain who underwent LHD as the first surgical intervention. The questionnaire-based symptom frequency score was multiplied by the severity score, and the calculated metric was defined as the symptom score. The study population was stratified, by the change in the chest pain symptom score, into Complete Remission (CR), Partial Remission (PR), and No Remission (NR) groups, which were compared for patient background and surgical outcome. Multivariate analysis was also performed to determine factors associated with the relief of chest pain. As for preoperative clinicopathological conditions, the CR subgroup was older (p = 0.0169) with fewer previous balloon dilatations (p = 0.009). Although no difference was detected in the surgical outcome, the NR group had higher postoperative symptom scores for both difficulty in swallowing and vomiting and a lower score for patient satisfaction with surgery (p = 0.0141). Multivariate analysis detected two factors associated with CR: disease duration over 60months and less than two previous balloon dilatations. LHD improved chest pain symptoms in 90% of patients with achalasia. The patients who achieved relief of chest pain were characterized by disease duration over 60months and less than two previous balloon dilatations.

Extending Myotomy Both Downward and Upward Improves the Final Outcome in Manometric Pattern III Achalasia Patients.

Background: Achalasia is currently classified in three manometric patterns. Pattern III is the least common pattern, and reportedly correlated with the worst outcome after all available treatments. We aimed to investigate the final outcome in pattern III achalasia patients after classic laparoscopic myotomy (CLM) as compared with a myotomy lengthened both downward and upward (long laparoscopic myotomy [LLM]). Materials and Methods: The study population consisted of 61 consecutive patients with a diagnosis of pattern III achalasia who underwent laparoscopic myotomy between 1997 and 2017. In CLM the total length of the myotomy was ≤9 cm, whereas myotomies extending both downward and upward to a length >9 cm were defined as LLM. Results: Of the 61 patients considered, 24 had CLM and 37 had LLM. The postoperative improvement in symptom score differed between the two groups: it dropped from 22 (17-26) to 4 (0-8) in the CLM group and from 20 (17-24) to 3 (0-6) in the LLM group (P < .001). There were 8 of 24 failures (33.3%) in the former group and 4 of 37 (10.8%) in the latter group (P < .05). An abnormal acid exposure was detected after the treatment of CLM in 4 patients and after the treatment of LLM in 3 patients (P = n.s.). Conclusions: Although with the intrinsic limitations of this study (retrospective, different time windows of the two procedures, and different lengths of follow-up), the results indicate that extending the myotomy both downward and upward improves the final outcome of laparoscopic Heller-Dor surgery in pattern III achalasia patients. A longer myotomy does not affect any onset of postoperative gastroesophageal reflux.

Effect of preoperative balloon dilation on treatment outcomes of laparoscopic Heller-Dor surgery for achalasia: a propensity score matched study.

There is some debate about whether preoperative balloon dilation influences the outcomes of laparoscopic Heller-Dor surgery (LHD), with no consensus opinion as yet. Thus, we investigated if preoperative dilation influences the treatment outcomes of LHD for achalasia. The subjects of this study were 526 patients with achalasia who underwent LHD as an initial treatment between August 1994 and February 2017. The patients were roughly classified by the status of preoperative balloon dilation and matched with propensity scores for age, sex, BMI, morphologic type, and maximum esophageal transverse diameter. Consequently, 94 subjects each were assigned to the balloon dilation (BD) group and to the non-balloon dilation (non-BD) group. We evaluated patient backgrounds, surgical outcomes, and incidence of postoperative reflux esophagitis. No differences were found in surgical time, intraoperative blood loss, incidence of intraoperative mucosal injury, or postoperative hospital stay between the BD and non-BD groups. The mean patient satisfaction was significantly higher in the non-BD group (4.9) than in the BD group (4.7) and the incidence of postoperative esophagitis was significantly lower in the non-BD group (1.1%) than in the BD group (7.4%). Preoperative balloon dilation had no effect on intraoperative complications but did increase the incidence of postoperative reflux esophagitis in patients undergoing LHD for achalasia.

Impact of preoperative balloon dilatation on outcomes of laparoscopic surgery in young patients with esophageal achalasia.

Balloon dilatation is reportedly less effective for young patients with esophageal achalasia than for older patients. However, there is no consensus on the impact of prior balloon dilatation on outcomes of surgical treatment. This study investigated the significance of preoperative balloon dilatation on surgical outcomes in young patients with esophageal achalasia. Of patients aged less than 40years who had undergone a laparoscopic Heller-Dor operation for esophageal achalasia, 201 with a postoperative follow-up period of at least 1year were included. They were divided into two groups with and without a history of balloon dilatation, and compared preoperative pathological conditions and surgical outcomes. This study included 100 men and 101 women with a median age of 31years, of whom 158 patients without a history of pneumatic dilatation (79%, non-PD group) and 43 with a history of pneumatic dilatation (21%, PD group) The preoperative symptom scores for dysphagia and regurgitation were significantly higher in the non-PD group. Although no differences were observed in surgical outcomes or postoperative course, the esophageal clearance rates calculated on preoperative and postoperative timed barium esophagograms were lower in terms of both height and width of the barium column in the PD group than in the non-PD group. Subjectively, both groups expressed equally high satisfaction. In patients aged less than 40years with esophageal achalasia, although preoperative balloon dilatation did not affect subjective levels of satisfaction with surgery, postoperative improvement in esophageal clearance in the lower esophagus was inhibited.

Laparoscopic surgery for esophageal achalasia: Multiport vs single-incision approach.

SILS can potentially improve aesthetic outcomes without adversely affecting treatment outcomes, but these outcomes are uncertain in laparoscopic Heller-Dor surgery. We determined if the degree of patient satisfaction with aesthetic outcomes progressed with the equivalent treatment outcomes after the introduction of a single-incision approach to laparoscopic Heller-Dor surgery. We retrospectively reviewed 20 consecutive esophageal achalasia patients (multiport approach, n = 10; single-incision approach, n = 10) and assessed the treatment outcomes and patient satisfaction with the aesthetic outcomes. In the single-incision approach, thin supportive devices were routinely used to gain exposure to the esophageal hiatus. No statistically significant differences in the operating time (210.2 ± 28.8 vs 223.5 ± 46.3 min; P = 0.4503) or blood loss (14.0 ± 31.7 vs 16.0 ± 17.8 mL; P = 0.8637) were detected between the multiport and single-incision approaches. We experienced no intraoperative complications. Mild dysphagia, which resolved spontaneously, was noted postoperatively in one patient treated with the multiport approach. The reduction rate of the maximum lower esophageal sphincter pressure was 25.1 ± 34.4% for the multiport approach and 21.8 ± 19.2% for the single-incision approach (P = 0.8266). Patient satisfaction with aesthetic outcomes was greater for the single-incision approach than for the multiport approach. When single-incision laparoscopic Heller-Dor surgery was performed adequately and combined with the use of thin supportive devices, patient satisfaction with the aesthetic outcomes was higher and treatment outcomes were equivalent to those of the multiport approach.

Transumbilical Single-Incision Laparoscopic Fundoplication: A New Technique for Liver Retraction Using Cyanoacrylate

Single-incision laparoscopic fundoplication is not widespread because of its technical difficulty. An additional stay suture or retractor is often needed for liver retraction during the procedure. Here, we share our 7 cases to demonstrate the feasibility of transumbilical single-incision laparoscopic fundoplication with a new technique for liver retraction without any stay suture or retractor. From March 2010 to October 2011, 3 patients with achalasia underwent a transumbilical single-incision laparoscopic Heller-Dor operation, and 4 patients with hiatus hernia underwent transumbilical single-incision laparoscopic hernioplasty and Nissen fundoplication. The procedures were attempted transumbilically by using three rigid trocars (one was 10 mm, and two were 5 mm) inserted through the 2-cm umbilicus incision. Conventional laparoscopic instruments were used. Adequate retraction of the liver was achieved by binding the lateral left lobe of the liver to the diaphragm with cyanoacrylate. The pneumoperitoneal time was 115-170 minutes, and blood loss was 15-50 mL. There were no intra- or postoperative complications. The hospital stay was under 6 days for all patients. The umbilical incision healed well with satisfactory cosmetic effect. The transumbilical single-incision laparoscopic technique in the treatment of achalaisa and hiatus hernia is feasible for an experienced laparoscope surgeon with excellent cosmetic effect. Cyanoacrylate, when used as described, offers a safe and simple solution to the problem of liver retraction, thus obviating the need for a stay suture or liver retractor.

Gastric volvulus after laparoscopic fundoplication: a rare complication after Heller-Dor operation for achalasia

A laparoscopic Heller-Dor operation is a safe and effective procedure for esophageal achalasia. We experienced postoperative gastric volvulus after performing a laparoscopic Heller-Dor operation. This was successfully treated with laparoscopic-assisted gastropexy. A 56-year-old Japanese woman had complained of dysphagia for 3 years. She was diagnosed as having achalasia and then underwent a laparoscopic Heller-Dor operation. She complained of nausea and abdominal fullness on postoperative day 5 and gastrography revealed organoaxial gastric volvulus. We performed a reoperation using a laparoscopic-assisted approach. Because of preexisting gastric ptosis, the stomach was unusually movable. In addition, a rotational torque due to the fundoplication might have caused the volvulus. We performed an anterior gastropexy. The patient’s dysphagia disappeared after the second surgery, and recurrent volvulus has not been observed for 13 months. In cases with an unusually movable stomach, the addition of gastropexy may be effective in preventing postoperative gastric volvulus, which is rare but may possibly occur after laparoscopic fundoplication.

Laparoscopic Heller Myotomy for Achalasia Cardia—Initial Experience in a Teaching Institute

Laparoscopic Heller cardiomyotomy and Dor fundoplication is the surgical procedure of choice for esophageal achalasia. The aim of our study was to investigate the clinical outcome and safety of laparoscopic Heller-Dor procedure performed by using Hook electrocautery and as a teaching module for advanced laparoscopic surgery. Between January 2005 and December 2010, 25 consecutive patients with achalasia underwent laparoscopic Heller-Dor operation by a single surgeon. All the patients received upper gastrointestinal series (barium swallow), esophagogastroscopy, and esophageal manometry to exclude esophageal carcinoma and to confirm the diagnosis. All the patients were operated by laparoscopic modified Heller myotomy with Dor fundoplication by using hook electrocautery. Among 25 operated patients, 14 were male and 11 were female with a median age of 43years (range 18-72years). The mean operative time was 93.3min (range 50-50min), the mean operative blood loss was 90ml (range 40-200ml), the median time to oral feeding was 2days (2-4days), and the median hospital stay was 4days (4-7days). There was no conversion to open surgery. Intraoperative mucosal perforation was encountered in three patients and was repaired in all of them by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication and had excellent clinical response (96%) during follow-up. Laparoscopic Heller-Dor operation using hook electrocautery is safe, inexpensive, and effective treatment for achalasia which is useful for teaching and training surgical residents in advanced laparoscopic surgery.

Misinsertion of an Esophageal Bougie Between the Mucosa and Muscular Layer of the Lower Esophagus During Operation in a Case of Achalasia

Laparoscopic fundoplication is the current standard operation for gastroesophageal reflux disease and achalasia. An esophageal bougie is often placed for constructing a wrap or performing myotomy easily during the operation. The surgical complications reportedly include hemorrhage, esophageal perforation, gastric perforation, and vagus nerve damage. However, to the best of our knowledge, there is no report of any case of esophageal bougie misinsertion into the lower esophageal mucosa. The patient was a woman in her 50s who underwent laparoscopic Heller-Dor operation for achalasia in April 2007. During myotomy, we encountered difficulty in inserting a 56Fr-bougie and eventually realized that we had misinserted the Endolumina through the pyriform sinus into the esophageal mucosa. As the pyriform sinus injury was limited to the mucosa and there was no evidence of mediastinal perforation as assessed by intraoperative endoscopic examination, we continued the laparoscopic operation. On postoperative day 1, the patient complained of mild chest pain and pharyngeal pain, but there were only few signs of inflammation. Chest computed tomography revealed findings suggestive of a hematoma extending from the neck to the lower chest, most prominently in the right esophageal wall, however, the patient was followed up conservatively as there was no clear indication of perforation. Subsequently, both the chest pain and pharyngeal pain subsided. On postoperative day 5, the patient was allowed oral water intake, as a gastrografin swallow study did not indicate any problems. On postoperative day 6, the patient was allowed semiliquid foods orally. She was discharged from the hospital on day 11, without any particular problems. Currently, 10 months postsurgery, she is doing well, without any recurrence of symptoms such as dysphagia.

A case of sigmoid-type achalasia treated with hand-assisted laparoscopic Heller-Dor procedure

A male patient in his thirties was referred with dysphagia lasting 8 years. He had a history of a laparotomy for a testicular tumor in his twenties. From an upper gastrointestinal contrast X-ray, he was diagnosed to have sigmoid-type achalasia (greatest transverse diameter, 80 mm). Hand-assisted laparoscopic Heller-Dor surgery was performed because straightening of the esophagus using only a laparoscope was difficult due to the marked curvature of the lower mediastinal part of the esophagus and the history of a laparotomy. The postoperative course was excellent; the patient was discharged on day 9. At present, his dysphagia has disappeared and oral intake is satisfactory. Marked improvement was also found on a timed barium esophagogram. In sigmoid-type achalasia, there are limitations to straightening of the lower esophagus, so the improvement of symptoms is frequently insufficient. The present surgical method allows overcoming these difficulties and is very effective.

Results after laparoscopic Heller-Dor operation for esophageal achalasia in 100 consecutive patients

The laparoscopic Heller-Dor operation has been the procedure of choice for the treatment of achalasia. However, because the incidence of achalasia is low, reports on the outcome of surgical treatment for achalasia are limited. In this study, the therapeutic results after laparoscopic Heller-Dor operation for achalasia at a single university hospital were evaluated. Between August 1994 and July 2006, 100 consecutive patients underwent laparoscopic Heller-Dor operation. The therapeutic results after laparoscopic Heller-Dor operation were assessed based on complications, operation time, blood loss, postoperative hospital stay, and the standardized questionnaire for satisfaction by telephone or outpatient clinic interview. With respect to perioperative complications, lower esophageal mucosal perforation occurred in 14 patients, but all of them could be suture-obliterated laparoscopically. One patient was converted to laparotomy because of uncontrolled bleeding from the short gastric artery. The mean operative time was 169 minutes, and the mean perioperative blood loss was 22 mL. The median postoperative hospital stay was 7 days. Reflux esophagitis, which was seen in five patients, was treated successfully with a proton pump inhibitor. According to the standardized questionnaire for satisfaction, 77 patients rated their recovery as 'excellent', 17 as 'good', 4 as 'fair', and 2 as 'poor'; thus, the overall success rate was 94%. There were no significant differences in surgical outcomes by morphologic type and severity of esophageal dilatation; however, the success rate deteriorated significantly with progression of the morphologic type. Laparoscopic Heller-Dor operation is a safe and effective surgical treatment for achalasia.