Laparoscopic Heller Myotomy For Achalasia Research Articles

Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic Heller myotomy surgery

BackgroundEnhanced recovery protocols (ERPs) are effective means of standardizing and improving the quality of surgical care in adults. Our purpose was to retrospectively compare outcomes before and after implementation of ERPs in children undergoing laparoscopic Heller myotomy for achalasia. MethodsA pediatric-specific ERP was used for children undergoing laparoscopic Heller myotomy starting July 2017 at two pediatric surgery centers within a single metropolitan healthcare system. A retrospective review of 8 patients undergoing Heller myotomies between July 2014 and July 2017 was performed as a control. This cohort was compared to 14 patients managed post-ERP implementation (2017–2020). Outcomes of interest investigated included opioid use during admission, narcotics at discharge, time to regular diet, length of stay (LOS), and readmissions. ResultsThere was a significant decrease in opioid use both while in the hospital and at time of discharge. Mean morphine equivalent use was 4.50 mg in the pre-ERP cohort and 1.97 mg in the post-ERP cohort. Furthermore, 8 out of 14 (57%) patients in the post-ERP cohort received no opioids during the admission compared with only 2 out of 8 (25%) patients in the pre-ERP cohort. Only 1 out of 14 (7.14%) patients in the post-ERP cohort was discharged with a prescription for opioid medication while 6 out of 8 (75%) in the pre-ERP cohort were discharged with an opiate prescription. ConclusionsThe use of ERP in children undergoing laparoscopic Heller myotomy surgery is safe and effective and leads to a reduction in opioid use during admission and at discharge. Levels of evidenceLevel III.

Pneumatic balloon dilatation versus laparoscopic Heller myotomy for achalasia: a failed attempt at meta-analysis.

The advent of peroral endoscopic myotomy (POEM) shed some light on the role of the current standards in the treatment of idiopathic achalasia, namely endoscopic pneumatic dilatation (PD) and laparoscopic Heller myotomy (LHM). We analyzed the quality of the current evidence comparing LHM and PD. A systematic literature search was performed in Pubmed/Medline, Web of Science, Google Scholar and Cochrane for meta-analyses/systematic reviews comparing PD and LHM or open surgery, limited to English language full-text articles. After a detailed review of these meta-analyses, all studies included were analyzed further in depth with respect to treatment protocol, assessment of success, complications and sequelae such as gastroesophageal reflux (GER), as well as follow-up details. Six randomized controlled trials (RCT), 5 with LHM and 1 with open surgery, were found, published in 10 papers. In contrast to a rather homogeneous LHM technique, PD regimens as well as the clinical dysphagia scores were different in every RCT; most RCTs also showed methodological limitations. There were nine meta-analyses which included a variable number of these RCTs or other cohort studies. Meta-analyses between 2009 and 2013 favored surgery, while the 4 most recent ones reached divergent conclusions. The main difference might have been whether repeated dilatation was regarded as part of the PD protocol or as failure. The variability in PD techniques and in definition of clinical success utilized in the achalasia RCTs on PD versus LHM render the conclusions of meta-analyses unreliable. Further randomized studies should be based on uniform criteria; in the meantime, publication of even more meta-analyses should be avoided.

Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience

Many centers have reported excellent short-term efficacy of per-oral endoscopic myotomy (POEM) for the treatment of achalasia. However, long-term data are limited and there are few studies comparing the efficacy of POEM versus Heller Myotomy (HM). To compare the long-term clinical efficacy of POEM versus HM. Using a retrospective, parallel cohort design, all cases of POEM or HM for achalasia between 2010 and 2015 were assessed. Clinical failure was defined as (a) Eckardt Score > 3 for at least 4weeks, (b) achalasia-related hospitalization, or (c) repeat intervention. All index manometries were classified via Chicago Classification v3. Pre-procedural clinical, manometric, radiographic data, and procedural data were reviewed. 98 patients were identified (55 POEM, 43 Heller) with mean follow-up of 3.94years, and 5.44years, respectively. 83.7% of HM patients underwent associated anti-reflux wrap (Toupet or Dor). Baseline clinical, demographic, radiographic, and manometric data were similar between the groups. There was no statistical difference in overall long-term success (POEM 72.7%, HM 65.1% p = 0.417, although higher rates of success were seen in Type III Achalasia in POEM vs Heller (53.3% vs 44.4%, p < 0.05). Type III Achalasia was the only variable associated with failure on a univariate COX analysis and no covariants were identified on a multivariate Cox regression. There was no statistical difference in GERD symptoms, esophagitis, or major procedural complications. POEM and HM have similar long-term (4-year) efficacy with similar adverse event and reflux rates. POEM was associated with greater efficacy in Type III Achalasia.

Laparoscopic Heller Myotomy for Achalasia: Experience from a Single Referral Tertiary Center.

BACKGROUND Achalasia is the most well known esophageal motility disorder. Laparoscopic Heller myotomy (LHM) is the most effective treatment for achalasia. The aim of this study was to review our results on LHM for achalasia. METHODS In this cross-sectional study all patients undergoing LHM between 2015 and 2017 were studied. The myotomy was followed by an anterior or posterior partial fundoplication. All patients were followed up for at least six months. RESULTS We conducted this prospective study on 36 consecutive patients who underwent LHM over 3 years. The mean age of the patients was 36.64 ± 13.47 years. 30 patients (83.3%) underwent Toupet and 6 patients (16.7%) received Dor fundoplication. 11 patients (30.6%) developed reflux after the procedure. According to the Eckardt Symptom Scoring (ESS), the symptoms improved in 74.2% of the patients and remained unchanged in 25.8% of the patients. Analysis of the ESS, indicated a significant change in regurgitation and retrosternal pain, dysphagia, and weight loss after the surgery (p = 0.001, p = 0.002, p = 0.046, and p = 0.001, respectively). CONCLUSION LHM with anterior or posterior partial fundoplication is safe and achieves a good outcome in the treatment of achalasia, especially in patients who have not responded to other methods while no serious complication was reported despite several prior endoscopic interventions.

The evaluation of functional results before and after laparoscopic Heller myotomy for achalasia: a single center experience.

The aim of this study was to evaluate and compare the functional results before and after laparoscopic Heller myotomy for Iranian patients with achalasia. Achalasia is a severe neuromuscular disorder of the esophagus, characterized by the loss of peristalsis and an inability of the lower esophageal sphincter (LES) to reach optimal relaxation. In this cross sectional study, patients who underwent Heller myotomy for achalasia via laparoscopy in Taleghani Hospital Tehran, Iran were evaluated. Symptoms including pressure of residual, integrated relaxation sphincter (IRP), pressure of free drinking, pressure of LES, dysphasia score and peristalsis movement was measured and recorded by manometry before and after (2 months) treating with Heller myotomy. In this study, 23 patients with achalasia (12 females and 11 males) with a mean age of 30±3.5 years (minimum 20, maximum 44 years) who met the inclusion criteria of the study were examined. Results of this study showed that, all the diagnostic criteria that were measured before the treatment was significantly different from after the treatment (P<0.05). The average decline in LES, IRP, Residual Pressure, Free drinking esophagus, and dysphasia score were 23.1 mmHg, 16.24 mmHg, 18,7 mmHg, 18.9 mmHg, and 5.0 unit, respectively. Also the average increase of the peristalsis movement was 8.26±13.7 in 8 patients. Considering the results of Heller myotomy surgery can be as a treatment of choice for achalasia. Free Drinking pressure can be a suitable criteria after treatment for evaluation and prediction of the reducing the dysphasia score after the surgery.

Results of Laparoscopic Heller's Myotomy for Achalasia in Children: A Systematic Review of the Literature.

Achalasia is a rare disorder in children who are commonly treated by laparoscopic Heller's myotomy (LHM). However, there are no large studies evaluating the results of LHM in the pediatric population, and the need of a concomitant fundoplication remains unclear. The aim of the study is to appraise the results of LHM based on a systematic literature review. MEDLINE search of the English literature was performed for "achalasia," "children," "laparoscopy," "Heller," "myotomy," and "cardiomyotomy." Frequency of postoperative symptoms was grouped to calculate the percentage of patients with symptoms improvement. Incidence of postoperative gastro-esophageal reflux (GER) and dysphagia between patients with and without fundoplication at the time of LHM was compared by Fisher's Exact Test. P < .05 was regarded as significant. Twenty-one studies were analyzed (331 children, 1-19 years). All studies were retrospective case-series reviews. Intraoperative complications occurred in 33 patients (10%), with esophageal perforations in 31 (9%), and conversion to open procedure in 9 (2.7%). Fundoplication was performed in 271 (82%): Dor (n = 205, 76%), Toupet (n = 49, 18%), Thal (n = 13, 4.5%), and Nissen (n = 4, 1.5%). Incidence of postoperative GER and dysphagia was similar between children with and without fundoplication (P = 1). Forty-nine (15%) required re-intervention: pneumatic dilatations (n = 30, 9%), redo-surgery (n = 23, 7%), botox injection (n = 1, 0.3%), and medical therapy (n = 5, 1.5%). LHM for achalasia is effective in 85% of children. Revision surgery is required in 7%. There is no difference in incidence of GER and dysphagia between patients with and without fundoplication. Routine use of an additional fundoplication might not be justified.

Identification of risk factors for mucosal injury during laparoscopic Heller myotomy for achalasia.

Mucosal injury during myotomy is the most frequent complication seen with the Heller-Dor procedure for achalasia. The present study aimed to examine risk factors for such mucosal injury during this procedure. This was a retrospective analysis of patients who underwent the laparoscopic Heller-Dor procedure for achalasia at a single facility. Variables for evaluation included patient characteristics, preoperative pathophysiological findings, and surgeon's operative experience. Logistic regression was used to identify risk factors. We also examined surgical outcomes and the degree of patient satisfaction in relation to intraoperative mucosal injury. Four hundred thirty-five patients satisfied study criteria. Intraoperative mucosal injury occurred in 67 patients (15.4%). In univariate analysis, mucosal injury was significantly associated with the patient age ≥60 years, disease history ≥10 years, prior history of cardiac diseases, preoperative esophageal transverse diameter ≥80 mm, and surgeon's operative experience with fewer than five cases. In multivariate analysis involving these factors, the following variables were identified as risk factors: age ≥60 years, esophageal transverse diameter ≥80 mm, and surgeon's operative experience with fewer than five cases. The mucosal injury group had significant extension of the operative time and increased blood loss. However, there were no significant differences between the two groups in the incidence of reflux esophagitis or the degree of symptom alleviation postoperatively. The fragile esophagus caused by advanced patient age and/or dilatation were risk factor for mucosal injury during laparoscopic Heller-Dor procedure. And novice surgeon was also identified as an isolated risk factor for mucosal injury.

Peroral esophageal myotomy versus laparoscopic Heller's myotomy for achalasia: a meta-analysis.

This meta-analysis aims to add convincing evidence on the application of peroral esophageal myotomy (POEM), compared with laparoscopic Heller's myotomy (LHM), for the treatment of achalasia. The electronic databases of PubMed, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Embase (up to December 2013) were systematically searched. EndNote(®) X6 citation software (Thomson Reuters, New York, NY) was used for literature management. A modification of the Newcastle-Ottawa Scale was applied for quality assessment. The data were analyzed using Review Manager version 5.1 software (The Cochrane Collaboration, Oxford, United Kingdom), and sensitivity analysis was performed by sequentially omitting each study. Overall, four studies compared the outcomes between POEM and LHM. All studies were conducted in the United States and published in 2013. POEM was associated with comparable complications (odds ratio [OR]=1.17, 95% confidence interval [CI] 0.53-2.56, P=.70), gastroesophageal reflux (OR=1.00, 95% CI 0.38-2.61, P=1.00), and symptomatic recurrence by Eckardt score (OR=0.24, 95% CI 0.04-1.55, P=.13). Other outcomes including pain score, operating time, and hospital stay were assessed with no significant difference between POEM and LHM. POEM achieves equivalent short-term outcomes compared with LHM for achalasia. This novel procedure is a promising treatment for achalasia.

Laparoscopic Heller myotomy for achalasia: does the age of the patient affect the outcome?

Esophageal achalasia is the most common primary motility disorder of the esophageal body and lower esophageal sphincter. The optimal management strategy for elderly patients with achalasia remains inconclusive, however elderly patients are still more likely to be recommended for endoscopic treatments rather than LHM, due to a perception of increased surgical risk in these patients. Advantages of surgical myotomy in the elderly over pneumatic dilation are: 1. the risk of mucosal perforation during surgery is better controlled than after endoscopic balloon dilatation and 2. the greater efficacy for the surgical approach where only one procedure is routinely required whereas pneumatic dilation often requires repeat treatment to achieve long-term relief of symptoms.

Laparoscopic Heller Myotomy for Achalasia in the Elderly: Shifting the Treatment Paradigm?

Laparoscopic Heller Myotomy for Achalasia in the Elderly: Shifting the Treatment Paradigm?

Is Dor fundoplication optimum after laparoscopic Heller myotomy for achalasia? A meta-analysis

To compare the outcome of acid reflux prevention by Dor fundoplication after laparoscopic Heller myotomy (LHM) for achalasia. Electronic database PubMed, Ovid (Evidence-Based Medicine Reviews, EmBase and Ovid MEDLINE) and Cochrane Library were searched between January 1995 and September 2012. Bibliographic citation management software (EndNote X3) was used for extracted literature management. Quality assessment of random controlled studies (RCTs) and non-RCTs was performed according to the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 and a modification of the Newcastle-Ottawa Scale, respectively. The data were analyzed using Review Manager (Version 5.1), and sensitivity analysis was performed by sequentially omitting each study. Finally, 6 studies, including a total of 523 achalasia patients, compared Dor fundoplication with other types of fundoplication after LHM (Dor-other group), and 8 studies, including a total of 528 achalasia patients, compared Dor fundoplication with no fundoplication after LHM (Dor-no group). Dor fundoplication was associated with a significantly higher recurrence rate of clinical regurgitation and pathological acid reflux compared with the other fundoplication group (OR = 7.16, 95%CI: 1.25-40.93, P = 0.03, and OR = 3.79, 95%CI: 1.23-11.72, P = 0.02, respectively). In addition, there were no significant differences between Dor fundoplication and no fundoplication in all subjects. Other outcomes, including complications, dysphagia, postoperative physiologic testing, and operation-related data displayed no significant differences in the two comparison groups. Dor fundoplication is not the optimum procedure after LHM for achalasia. We suggest more attention should be paid on quality of life among different fundoplications.

Laparoscopic Heller myotomy for achalasia: analysis of successes and failures.

The outcome of laparoscopic myotomy for achalasia is dictated by many factors. A retrospective study was conducted between 1997-2007, 58 patients who fulfilled all criteria for the diagnosis of achalasia underwent laparoscopic Heller myotomy and 45 (77.6%) were included. Mean follow-up period was 36±15 months; 56 patients had Dor fundoplication; 17 patients had been previously treated by pneumatic dilatation. All steps of the procedure, esophageal manometric findings and radiological records were analyzed to determine factors contributing to the clinical success or failure of the operation. The main outcome measure was swallowing status. Median hospital stay was 3±1 days and mean operative time was 75±20min. There were 7 intra-operative mucosal injuries; all sutured laparoscopically (5 had previous pneumatic dilatation). Good or excellent relief of dysphagia was obtained in 41 patients and was persistent among 2 patients (both had pneumatic dilatation preoperatively). The remaining 2 patients developed gastroesophageal reflux symptoms. These 41 patients had a preoperative smaller diameter of the esophagus (stage I, II and III), while those with guarding results (4) had stages III and IV. There was a decrease in LES pressure from 45±7mmHg to 10±2mmHg without evidence of restoration of esophageal peristalsis in any patient. Laparoscopic Heller myotomy with Dor fundoplication significantly relieves the symptoms of achalasia without causing the symptoms of gastroesophageal reflux disease. A good postoperative result is expected when the length of myotomy is adequate, LES pressure declines substantially, preoperative esophageal dilation is not excessive and distortion of the distal esophagus is absent.

Fundoplication after heller myotomy: a retrospective comparison between nissen and dor.

A retrospective comparison between Nissen and Dor fundoplication after laparoscopic Heller myotomy for achalasia. From 1998 to 2004 a first group of 48 patients underwent Heller myotomy and Nissen fundoplication for idiopathic achalasia (H+N group). From 2004 to 2010 a second group of 40 patients underwent Heller myotomy followed by Dor fundoplication (H+D group). Some patients received a previous endoscopic treatment with pneumatic dilatation or endoscopic injection of botulinum toxin that provided them only a temporary clinical benefit. Changes in clinical and instrumental examinations from before to after surgery were evaluated in all patients. Clinical evaluation was carried out using a modified DeMeester symptom score system. Dor fundoplication treatment reduced both dysphagia and regurgitation severity scores significantly more than Nissen fundoplication (p<0.0001). Indeed, the incidence of dysphagia was significantly higher in patients treated with floppy-Nissen than in those treated with Dor fundoplication: by defining dysphagia as a DeMeester score equal to 3 (arbitrary cut-off), at the end of follow-up dysphagia occurred in 17.65% and 0% (p=0.037) of patients belonging to the H+N and H+D groups, respectively. Heller myotomy followed by Dor fundoplication is a safe and valuable treatment. The procedure showed a lower incidence of postoperative dysphagia versus Nissen fundoplication and a negligible incidence of postoperative GERD in a long-term postoperative follow-up.

Predictors of Long-term Outcome After Laparoscopic Esophagomyotomy and Dor Fundoplication for Achalasia

To identify predictors of long-term outcome of laparoscopic Heller myotomy for achalasia, including predictors of heartburn and recurrent dysphagia, which occasionally develop postoperatively. Retrospective review using interviews of patients. Academic university hospital. One hundred sixty-five patients with achalasia who underwent a laparoscopic esophagomyotomy and Dor fundoplication. Dysphagia and heartburn before and after the operation were assessed on a 4-point Likert scale, as were postoperative dilations, reoperations, and antacid use. Potential predictors were age, race, sex, body mass index, weight loss, duration of symptoms, manometry findings, esophageal diameter, previous treatment, and operative technique. Follow-up averaged 62 (range, 1-174) months. Dysphagia frequency was once a week or less in 128 patients (78%), several times per week in 25 (15%), and daily in 12 (7%). Satisfaction scores averaged 3.7 on a 4-point scale. Thirty patients (18%) required a postoperative dilation, and 6 (4%) underwent another operation. The only predictor of postoperative dysphagia was duration of symptoms longer than 10 years (odds ratio, 0.2; P = .03). Preoperative dilations predicted the need for postoperative dilations (odds ratio, 2.4; P = .03). Only 20 patients (12%) reported heartburn more than once weekly, although 75 (45%) reported taking antacids. No variable predicted postoperative heartburn or antacid use. Long-term outcomes after laparoscopic esophagomyotomy were excellent across a wide spectrum of disease severity and presentations. Previous treatments, such as balloon dilation or botulinum toxin (Botox) injection, did not portend worse outcomes. When the myotomy was extended 2 cm onto the stomach and a Dor fundoplication was performed, severe heartburn was rare.

Minimally invasive surgery for achalasia in patients &gt;40 years: more favorable than anticipated

The efficacy of Heller myotomy in patients >40years-a significant predictor suggesting a favorable response to pneumatic dilation-has been questioned. The aim of our study was to evaluate the results obtained in patients aged <40 and >40years undergoing minimally invasive surgery (MIS) for achalasia. In January 2008, we established the MIS technique for achalasia in our clinic. In the following period from January 2008 to March 2011, 74 patients underwent primary laparoscopic myotomy for achalasia. The procedure was accomplished with an anterior 180° semifundoplication according to Dor in all patients. The Eckardt score and the Gastrointestinal Quality of Life Index (GQLI) served as outcome measures. The median age of patients was 45.5years (range, 18-85years) with a median duration of preoperative achalasia symptoms of 57months (range, 2-468months). There were no conversions to open surgery and-except for one patient with a sterile pleural effusion-no postoperative complications. At a median follow-up of 12months, the preoperative Eckardt score of 7.0 (range, 3-12) was found to be significantly decreased to a median of 2 (range, 0-6; P < 0.001). With regard to patients <40 and >40years, the postoperative Eckardt score obtained in the older patient population was not significantly lower (P = 0.074). There was no statistically significant difference between the two groups with respect to the postoperative GQLI (P = 0.860). Neither gender nor preoperative Botox injection or pneumatic dilation inserted a significant influence on the postoperative clinical outcome (P > 0.05). Laparoscopic Heller myotomy for achalasia is associated with a high success rate as the primary therapeutic option and after failure of endoscopic therapy. It can be performed safely and with favorable outcomes also in patients >40years. However, the long-term durability of the procedure remains to be established.

Invited Commentary

Achalasia is the most common and best characterized primary esophageal motility disorder with a prevalence of 10 per 100,000 individuals, with an annual incidence of 0.5 cases per 100,000 individuals. The natural pathology of achalasia is such that progressive neural degeneration leads to dysphagia, a defunctionalized esophagus, and eventually end-stage disease that requires an esophagectomy. Finley and colleagues [1Finley C. Kondra J. Clifton J. Yee J. Finley R. Factors associated with postoperative symptoms after laparoscopic Heller myotomy.Ann Thorac Surg. 2010; 89: 392-396Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar] have investigated the effects of initial nonoperative management in short- and long-term symptoms after myotomy for a 14-year period of study. The most concerning finding was that Botox therapy at initial presentation was associated with a higher rate of dysphagia 1 year after surgical myotomy. A surgical concern with Botox is the development of fibrosis leading to difficulty in submucosal dissection during the myotomy and even possible incomplete myotomy. These findings suggest that initial temporizing procedures are not without consequences. Every study has its limitations. This article provides useful information, although ascertainment bias is likely present because all subjective data were recorded by the operating surgeon. There must also be some caution used to interpret the initial treatment data because of the neat separation of the three initial treatments (ie, 62.3% medication, 38.7% pneumatic dilation, and 11.1% Botox). There is no description of overlap between the three treatments, which is common to everyday practice. Half of the patients in this study underwent fundoplication. Many United States' surgeons believe that a myotomy of this extent should be followed by a partial fundoplication to prevent reflux. A prospective randomized trial conducted in the United States on 43 patients demonstrated a lower incidence of reflux without increased dysphagia in patients who underwent myotomy plus Dor compared with myotomy alone [2Richards W.O. Torquati A. Holzman M.D. et al.Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind trial.Ann Surg. 2004; 240: 405-412Crossref PubMed Scopus (423) Google Scholar]. Despite this data, the role of fundoplication remains controversial, especially outside the United States. The myotomy does not reverse the underlying pathophysiology of neural degeneration, but it does convert the esophagus into a passive conduit dependent on gravity for evacuation. A balance between obtaining a complete myotomy and the avoidance of excessive reflux is the primary goal. Delay in surgical treatment will only increase the likelihood of long-term sequela (ie, mega-esophagus, thereby leading to esophagectomy for end-stage disease). Finley and colleagues [1Finley C. Kondra J. Clifton J. Yee J. Finley R. Factors associated with postoperative symptoms after laparoscopic Heller myotomy.Ann Thorac Surg. 2010; 89: 392-396Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar] provide additional evidence to support the early treatment of achalasia by surgical intervention rather than exhaustive conservative treatments. Factors Associated With Postoperative Symptoms After Laparoscopic Heller MyotomyThe Annals of Thoracic SurgeryVol. 89Issue 2PreviewOur objective is to ascertain if preoperative and perioperative treatments affect the short- and long-term symptom frequency or symptom scores for dysphagia, regurgitation, and heartburn in patients with laparoscopic Heller myotomy for achalasia. Full-Text PDF

Multiple Preoperative Endoscopic Interventions Are Associated with Worse Outcomes After Laparoscopic Heller Myotomy for Achalasia

BackgroundThe effect of preoperative pneumatic dilation or botulinum toxin injection on outcomes after laparoscopic Heller myotomy (LHM) for achalasia is unclear. We compared outcomes in patients with and without multiple preoperative endoscopic interventions. MethodsThis cohort study categorized achalasia patients undergoing first-time LHM by the number of preoperative endoscopic interventions: zero or one intervention vs. two or more interventions. Outcomes of interest included surgical failure (defined as the need for re-intervention), gastrointestinal symptoms, and health-related quality of life. Logistic regression modeling was performed to determine the independent effect of multiple preoperative endoscopic interventions on the likelihood of surgical failure. ResultsOne hundred thirty-four patients were included; 88 (66%) had zero to one preoperative intervention, and 46 (34%) had multiple (more than one) interventions. The incidence of surgical failure was 7% in the zero to one intervention group and 28% in the more than one intervention group (p < 0.01). Greater improvements in gastrointestinal symptoms and health-related quality of life were seen in the zero to one intervention group. On logistic regression modeling, the likelihood of surgical failure was significantly higher in the more than one intervention group (odds ratio = 5.1, 95% confidence interval 1.6–15.8, p = 0.005). ConclusionsMultiple endoscopic treatments are associated with poorer outcomes and should be limited to achalasia patients who fail surgical therapy.

Laparoscopic Heller myotomy for achalasia: results after 10 years

Laparoscopic Heller myotomy was first undertaken in the early 1990s, and appreciable numbers of patients with 10-year follow-up periods are now available. This study was undertaken to determine long-term outcomes after laparoscopic Heller myotomy used to treat achalasia. Of 337 patients who have undergone laparoscopic Heller myotomy since 1992, 47 who underwent myotomy more than 10 years ago have been followed through a prospectively maintained registry. Among many symptoms, patients scored dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn before and after myotomy using a Likert scale with choices ranging from 0 (never/not bothersome) to 10 (always/very bothersome). Symptom scores before and after myotomy were compared using a Wilcoxon matched-pairs test. Data are reported as median (mean ± standard deviation). The median length of the hospital stay was 2 days (mean, 3 ± 8.6 days; range, 1-60 days). Notable complications were infrequent after myotomy. There were no perioperative deaths. One patient required a redo myotomy after 5 years due to recurrence of symptoms. At this writing, 33 patients (70%) are still alive. The causes of death after discharge were unrelated to myotomy. The frequency and severity scores for dysphagia, chest pain, vomiting, regurgitation, choking, and heartburn all decreased significantly after laparoscopic Heller myotomy (p < 0.0001 for all). Laparoscopic Heller myotomy can be undertaken with few complications. This procedure significantly decreases the frequency and severity of achalasia symptoms without promoting heartburn. The symptoms of achalasia are durably ameliorated by laparoscopic Heller myotomy during long-term follow-up evaluation, thereby promoting application of this procedure.

286 The Extent of Resection and Insulin-Dependent Diabetes But Neither Preoperative Chemotherapy Nor (Chemotherapy-Induced) Liver Injury Influence Morbidity After Surgery for Hepatic Colorectal Metastases

OBJECTIVE: Laparoscopic Heller myotomy (LHM) provides more durable relief of achalasia symptoms than endoscopic pneumatic dilation or botulinum toxin injection. The role of pre-operative endoscopic therapy in surgical candidates is controversial. We investigated the association between multiple pre-operative endoscopic interventions and objective and subjective outcomes after LHM for achalasia. METHODS: Patients undergoing first-time LHM for achalasia between November 2001 and January 2008 were included. Demographics, comorbidities, pre-operative therapy, operative details, and clinical follow-up were obtained by chart review. Gastrointestinal (GI) symptom profile and health-related quality of life (HRQOL) was assessed pre-operatively using the GERD Symptom Assessment Scale (GSAS) and Short Form-36 (SF-36), respectively. Patients were classified on the number of preoperative endoscopic interventions: zero or one intervention (group 1) versus two or more interventions (group 2). Outcomes were assessed at a median of 22 months post-operatively using mailed GSAS, SF-36, and achalasia-specific questionnaires. The primary outcome of interest was surgical failure, defined as requiring additional surgical or interventional endoscopic therapy. Secondary outcomes of interest included gastroparesis and changes in GI symptoms and HRQOL. RESULTS: 134 patients met inclusion criteria; 88 (66%) were in group 1 and 46 (34%) in group 2. At the time of operation, patients in group 2 had a longer duration of symptoms (median 36 vs. 21mos., p=0.0026) and higher ASA classification (40% vs. 19% ASA 3-4, p=0.009) than those in group 1. No perioperative leaks or deaths occurred in either group. Group 1 patients reported significant improvements in SF-36 bodily pain, energy, social function, and general health scores, while HRQOL in group 2 remained unchanged. Five patients (3.7%) were diagnosed with symptomatic gastroparesis post-operatively. Surgical failure rate was 14.2%, and was higher in group 2 vs. group 1 (28.3% vs. 6.8%, p=0.001). On logistic regressionmodelingwith adjustment for confounders, having >1 pre-operative endoscopic intervention was found to be a significant independent predictor of surgical failure (OR=5.26, 95% C.I. 1.61-17.17, p=0.006). CONCLUSIONS: Multiple pre-operative endoscopic interventions are independently associated with a higher surgical failure rate after LHM for achalasia, suggesting that repeated interventions should be reserved only for patients who fail surgical therapy or are not surgical candidates. Potential associations between endoscopic intervention, gastroparesis, and LHM need further study.

285 Effect of Multiple Pre-Operative Endoscopic Interventions On Outcomes After Laparoscopic Heller Myotomy for Achalasia

285 Effect of Multiple Pre-Operative Endoscopic Interventions On Outcomes After Laparoscopic Heller Myotomy for Achalasia