Laparoscopic Heller's Cardiomyotomy Research Articles

Robotic Heller's cardiomyotomy for achalasia: early outcomes for a high-volume UK centre.

Heller's cardiomyotomy (HCM) is the gold standard treatment for achalasia. Laparoscopic HCM has been shown to be effective with low rates of symptom recurrence, though oesophageal mucosal perforation rates remain high. The aim of this prospective case series is to assess the short-term complication rates and perioperative outcomes for the first cohort of patients undergoing robotic-assisted HCM for achalasia in a single high-volume UK centre. Data were collected from a prospective cohort of patients who underwent robotic HCM at a single high-volume UK centre. Outcomes were assessed using the Eckhard score, which was calculated after their routine postoperative clinic appointments. Thirteen patients underwent robotic HCM during the study period; this is the second largest reported case series in the European literature. There were no intraoperative oesophageal perforations. Six patients were discharged as day cases, six patients were discharged on the first postoperative day and one patient's hospital stay was two nights. There was a single perioperative complication of urinary retention. All patients reported improvement of symptoms following their operation, and all had a postoperative Eckhard score of less than 3, indicating their achalasia was in remission. This cohort has demonstrated that robotic HCM has an exceptional safety profile and results in high levels of symptom resolution, even early in the learning curve. The robotic approach may be superior to laparoscopy as it allows more precise identification and dissection of the oesophageal muscle fibres, which likely reduces the risk of inadvertent mucosal damage or incomplete myotomy.

OGBN P46 Megaoesophagus in a patient with achalasia treated with laparoscopic Heller cardiomyotomy

Abstract Background Achalasia is an oesophageal motility disorder that is a rare but important differential diagnosis in patients with dysphagia. Surgical treatment with laparoscopic Heller myotomy (LHM) and fundoplication is the gold standard; other options include peroral endoscopic myotomy (POEM), dilatation in cases that are unsuitable for surgery, and esophagectomy as a last resort. Methods We describe a case reported at our institution and the relevant workup, findings and management. Results A 41-year-old woman presented with persistent cough and shortness of breath on exertion. Chest x-ray showed right basal consolidation and a dense structure along the right mediastinum. CT revealed megaoesophagus with an oesophageal diameter of 7cm. Detailed history revealed long-standing history of progressive dysphagia and acid reflux and more recent history of weight loss, retrosternal pain and shortness of breath when eating solid foods. Workup included gastroscopy, oesophageal manometry and Chagas disease testing due to potential exposure to T. cruzi. A diagnosis of idiopathic achalasia was made, and she underwent laparoscopic Heller’s cardiomyotomy and Dor fundoplication. Conclusions Achalasia is an important differential in patients presenting with symptoms of dysphagia. This case reveals an atypical presentation of the disorder, suggesting a need to consider it in a wider range of presentations. Successful treatment of achalasia depends on timely diagnosis prior to oesophageal failure when it is still possible to intervene effectively.

Laparoscopic Heller Cardiomyotomy in the Visceral Surgery Department: About 5 Cases at the Hassan II University Hospital of Fez

Achalasia is a primitive motor disorder of the esophagus characterized́ by a defect in relaxation of the lower esophageal sphincter (LES) and a complete absence of esophageal peristalsis. The etiology of this pathology is unknown. Clinical presentation is dominated by dysphagia, often associated with food regurgitation, more rarely with chest pain. Pyrosis may also be present. Symptoms have usually been evolving for many years, progressively worsening, and may be responsible for significant weight loss. Weight loss of more than 10kg, recent onset of symptoms (less than a year), and age over 60 should prompt a search for underlying neoplasia (pseudo-neoplastic achalasia). The diagnosis of achalasia was established on clinical, radiological and endoscopic grounds, in search of associated lesions. All patients underwent a Heller extra-mucosal oesocardiomyotomy associated with an anti-reflux device by cardioplasty. The post-operative course was straightforward in 4 cases, and complicated in 1 case by an iatrogenic breach of the esophageal mucosa, which was subsequently repaired. Functionally, dysphagia, regurgitation and retrosternal pain disappeared, with excellent results. The aim of this retrospective study was to investigate the im- mediate and remote results of surgical treatment of achalasia using the Heller technique.

149. LAPAROSCOPIC HELLER CARDIO-MYOTOMY IS NOT ALWAYS A SAFE OPERATION

Abstract Background Laparoscopic Heller cardio-myotomy is the standard surgical treatment of achalasia. Although POEM (Per-oral endoscopic myotomy) has gained wide acceptance among gastroenterologists, yet many surgeons are still loyal to this operation. One of the complications of the operation which could happen is esophageal or gastric perforation during the myotomy. Intra-operative detection of the perforation and meticulous repair is very important to prevent serious sequelae. Methods Between may 2021 and Jan 2023, 46 cases of achalasia (Type I and II) were treated by laparoscopic Heller cardio-myotomy and anti-reflux procedure (Dor or Toupet). Myotomy was performed using muscles splitting combined with either harmonic or hook diathermy. Intra-operative perforations were reported and were repaired in all cases and tested for absence of leakage. Post-operative follow up of cases having intraoperative perforations and its management were documented. For those having perforations postoperative gastrographin swallow and meal was done and oral fluids intake started second postoperative day. Results Perforations occurred in 11 cases (24%) and were repaired using 3 l0 suture: monofilament non-absorbable suture: prolene (polypropyelene, J&J MedTech) in 4 cases, monofilament absorbable suture monocryl (poliglecaprone 25, J&J MedTech) in 3 cases and vicryl (polyglactin 910, J&J MedTech) in 4 cases. Smooth post-operative recovery was noted in 7 cases having perforations (64%). Four patients (36%) developed Leakage second postoperative day confirmed by investigations. All these cases were repaired with Vicryl. Endoscopic stent was inserted with improvement of the condition in 3 cases (75%). One patient required reoperations twice and expired in the 29th day postoperative from ARDS. Conclusion Although perforations could happen during laparoscopic Heller cardio-myotomy, it has a benign postoperative course in most cases. This doesn’t mean that it is a simple operation. Laparoscopic Heller cardio-myotomy should be done in highly specialized esophageal center because its complications could lead to death if badly managed.

Pre-operative endoscopic balloon dilatation and its impact on outcome of laparoscopic Heller cardiomyotomy for patients with achalasia: does the frequency and interval matter?

Many surgeons believe that pre-operative balloon dilatation makes laparoscopic myotomy more difficult in achalasia patients. Herein, we wanted to see if prior pneumatic balloon dilatation led to worse outcomes after laparoscopic myotomy. We also assessed if the frequency of dilatations and the time interval between the last one and the surgical myotomy could affect these outcomes. The data of 460 patients was reviewed. They were divided into two groups: the balloon dilation (BD) group (102 patients) and the non-balloon dilatation (non-BD) group (358 patients). Although pre-operative parameters and surgical experience were comparable between the two groups, the incidence of mucosal perforation, operative time, and intraoperative blood loss significantly increased in the BD group. The same group also showed a significant delay in oral intake and an increased hospitalization period. At a median follow-up of 4 years, the incidence of post-operative reflux increased in the BD group, while patient satisfaction decreased. Patients with multiple previous dilatations showed a significant increase in operative time, blood loss, perforation incidence, hospitalization period, delayed oral intake, and reflux esophogitis compared to single-dilatation patients. When compared to long-interval cases, patients with short intervals had a higher incidence of mucosal perforation and a longer hospitalization period. Pre-operative balloon dilatation has a significant negative impact on laparoscopic myotomy short and long term outcomes. It is associated with a significant increase in operative time, blood loss, mucosal injury, hospitalization period, and incidence of reflux symptoms. More poor outcomes are encountered in patients with multiple previous dilatations and who have a short time interval between the last dilatation and the myotomy.

Mucosal injury during laparoscopic Heller cardiomyotomy: risk factors and impact on surgical outcomes

PurposeTo investigate the risk factors and outcomes of mucosal perforation (MP) during laparoscopic Heller myotomy (LHM) in patients with achalasia.MethodsWe conducted a retrospective analysis of patients who underwent LHM for achalasia at a single facility.ResultsAmong 412 patients who underwent LHM for achalasia, MP was identified in 52 (12.6%). Old age, long disease duration, low albumin level, an esophageal transverse diameter > 6 cm, and a sigmoid-shaped esophagus were found to be independent predictors of MP. These factors were assigned a pre-operative score to predict the perforation risk. MP had a significant impact on intra and post-operative outcomes. Gastric side perforation was associated with a higher incidence of reflux symptoms, whereas esophageal-side perforation had a higher incidence of residual dysphagia.ConclusionsMany risk factors for MP have been identified. Correctable parameters like low serum albumin should be resolved prior to surgery, while uncorrectable parameters like old age and a sigmoid-shaped esophagus should be managed by experienced surgeons in high-volume centers. Implementing these recommendations will help decrease the incidence and consequences of this serious complication.

Use real-time near-infrared fluorescence during Heller's cardiomyotomy for achalasia cardia.

Laparoscopic Heller's cardiomyotomy is the surgical procedure of choice in the management of oesophageal achalasia. It is critical to confirm the completeness of the myotomy and mucosal integrity at the conclusion of the procedure. This is conventionally achieved by intraoperative endoscopy and dynamic air leak test. Other modalities that can be used to confirm the myotomy and the integrity of the mucosa at the myotomy site are oesophageal manometry and a methylene blue dye study, respectively. Indocyanine green (ICG) has been in clinical use for more than six decades. The real-time integration of ICG fluorescence with laparoscopy is a relatively new breakthrough. Here, we present a novel method of using real-time near-infrared ICG fluorescence for confirming the completeness of the myotomy and mucosal integrity at the myotomy site post laparoscopic Heller's myotomy. This is the first report on the use of ICG in laparoscopic Heller's cardiomyotomy that we are aware of.

Evaluation of the Functional Outcome of Laparoscopic Heller Cardiomyotomy in Treatment of Patients with Achalasia of the Cardia

Evaluation of the Functional Outcome of Laparoscopic Heller Cardiomyotomy in Treatment of Patients with Achalasia of the Cardia

Fundoplication in laparoscopic Heller's cardiomyotomy for achalasia.

Laparoscopic Heller's cardiomyotomy (LHC) is the preferred treatment of achalasia. It improves dysphagia by dividing muscles of the lower oesophageal sphincter, but this intervention can result in debilitating gastro-oesophageal reflux symptoms in some patients. To prevent these reflux symptoms, most surgeons add a fundoplication to Heller's cardiomyotomy, but there is no consensus regarding this or the type of fundoplication which is best suited for the purpose. To assess how the addition of a fundoplication affects postoperative reflux and dysphagia in people undergoing LHC and compare the different types of fundoplications used in combination with LHC to determine which is better at controlling reflux without worsening the dysphagia. We searched three databases (CENTRAL, MEDLINE and Embase) on 31 October 2021 and trial registers to identify all published and unpublished randomised controlled trials (RCTs) in any language, comparing different fundoplications used in combination with LHC to treat achalasia. We also included RCTs where LHC with a fundoplication is compared with LHC without any fundoplication. We only included RCTs which recruited adult participants with achalasia undergoing LHC with minimal hiatal dissection. We excluded non-randomised studies or studies involving paediatric participants. We also excluded studies where the procedure was done by open surgery and where circumferential hiatal dissection of the oesophagus was carried out, unless it was necessary to reduce a hiatus hernia or to facilitate a Toupet or Nissen fundoplication. Two review authors independently identified studies to be included, assessed risk of bias using the Cochrane RoB 1 tool, and extracted the data. We calculated the risk ratio (RR) with 95% confidence interval (CI) using both fixed-effect and random-effect models with Review Manager (RevMan) software. We included eight studies in this review, with a total of 571 participants with an average age of 45 years (range 33.5 to 50). LHC without any fundoplication was performed in 65 (11.3%) participants, 298 (52.1%) had Dor fundoplication, 81 (14.1%) had Toupet fundoplication, 72 (12.6%) had Nissen's fundoplication, and 55 (9.6%) participants had angle of His accentuation. Three studies with a total of 143 participants compared LHC + Dor to LHC without fundoplication. We found that the evidence is very uncertain as to whether the addition of a Dor fundoplication made any difference to the outcome of postoperative pathological acid reflux (RR 0.37, 95% CI 0.07 to 1.89; I2 = 56%; 2 studies, 97 participants; very low-certainty evidence) and uncertain for severe postoperative dysphagia (RR 3.00, 95% CI 0.34 to 26.33; I2 = 0%; 3 studies, 142 participants; low-certainty evidence). Three studies with 174 participants compared LHC + Dor to LHC + Toupet. The evidence suggests that there may be little to no difference in the outcomes of postoperative pathological acid reflux (RR 0.75, 95% CI 0.23 to 2.43; I2 = 60%; 3 studies, 105 participants; low-certainty evidence) and severe postoperative dysphagia (RR 0.78, 95% CI 0.19 to 3.15; I2 = 0%; 3 studies, 123 participants; low-certainty evidence) between the two interventions, but the certainty of the evidence is low. One study with 138 participants compared LHC + Dor to LHC + Nissen. Nissen fundoplication caused increased severe postoperative dysphagia (RR 0.19, 95% CI 0.04 to 0.83; 1 study, 138 participants; high-certainty evidence) when compared to Dor fundoplication. This study did not show a difference in postoperative pathological acid reflux (RR 4.72, 95% CI 0.23 to 96.59; 1 study, 138 participants; low-certainty evidence), but the certainty of evidence is low. One study with 110 participants compared LHC + Dor with LCH + angle of His accentuation, and reported that severe postoperative dysphagia was similar between the two interventions (RR 1.56, 95% CI 0.27 to 8.95; 1 study, 110 participants; moderate-certainty evidence), with moderate certainty of evidence. This study did not report on postoperative pathological acid reflux. When LHC was performed with minimal hiatal dissection, we were very uncertain whether the addition of a Dor fundoplication made a difference in controlling postoperative reflux, and we were uncertain if it increased the risk of severe postoperative dysphagia. There may be little to no difference in the outcomes of postoperative pathological acid reflux or severe dysphagia between Dor and Toupet fundoplications when used in combination with LHC, but the certainty of the evidence is low. Nissen (total) fundoplication used in combination with LHC for achalasia increased the risk of severe postoperative dysphagia. The angle of His accentuation and Dor fundoplication had a similar effect on severe postoperative dysphagia when combined with LHC, but their effect on postoperative pathological acid reflux was not reported.

МАЛОИНВАЗИВНОЕ ХИРУРГИЧЕСКОЕ ЛЕЧЕНИЕ АХАЛАЗИИ КАРДИИ

Background. The article is devoted to the description and outcomes of conservative and surgical treatment of observed cases of achalasia cardia (AC). A brief literary review of the peculiarities of pathogenesis, clinical features as well as differential diagnosis of AС is presented. Objective. To analyze the treatment outcomes and evaluate the choice of the АС surgical treatment method. Material and methods. The analysis of treatment outcomes in 31 patients with AK confirmed by clinical, radiological and endoscopic findings was carried out. Results. 3 (10%) patients were opted for drug therapy only. Endoscopic balloon dilatation of the esophagus in combination with drug therapy was performed in 15 (48%) patients, mainly with stage II AC. The extent of surgical intervention in 16 (52%) operated patients was represented by laparoscopic Heller cardiomyotomy with Dor fundoplication. Conclusions. Laparoscopic Heller cardiomyotomy with Dor fundoplication for the prevention of gastroesophageal reflux was defined as the most effective surgical treatment of stage II-III AС. Endoscopic balloon dilatation of the esophagus combined with drug therapy is an effective treatment option for stage II AС, and can be used in stages II-III if there are contraindications for surgical treatment.

Risk Factors of Mucosal Injury During Laparoscopic Heller Cardiomyotomy

Risk Factors of Mucosal Injury During Laparoscopic Heller Cardiomyotomy

Symptomatic and Physiological Outcomes Following Laparoscopic Heller Myotomy for Achalasia Cardia: Is There a Correlation?

Symptomatic evaluation using Eckardt score and achalasia-specific health-related quality-of-life and physiological evaluation using timed barium examination (TBE) and high-resolution manometry is integral to the diagnosis of achalasia. However, the correlation of physiological outcomes with symptomatic outcomes and their role in routine follow-up after laparoscopic Heller cardiomyotomy (LHCM) is controversial. In this study, we evaluated the role of physiological testing in achalasia patients undergoing LHCM and its correlation with symptomatic evaluation. Case records of patients undergoing LHCM for achalasia between January 2017 and March 2020 were reviewed for symptom scores (Eckardt score and achalasia-specific health-related quality-of-life) and physiological parameters [5-min column height on TBE and median integrated relaxation pressure (IRP) on high-resolution manometry]. Sixty-one patients with complete data in the preoperative period and on follow-up were included in the study. The data was analyzed for symptomatic and physiological outcomes and their correlation using paired t test and the Spearman correlation test. At a median follow-up of 16 months following LHCM, there was a significant improvement in Eckardt score (7.03±1.53 to 0.93±1.10, P<0.001), achalasia-specific health-related quality-of-life (58.34±7.81 to 14.57±13.45, P<0.001), column height on TBE (115.14±46.9 to 27.89±34.31, P<0.001) and IRP (23.95±8.26 to 4.61±4.11, P<0.001). Eckardt score correlated significantly with achalasia-specific health-related quality-of-life scores preoperatively (ρ=0.410, P<0.001) and on follow-up (ρ=0.559, P<0.001). There was no correlation between symptomatic parameters and physiological parameters. In patients of achalasia, LHCM leads to significant improvement in symptomatic and physiological parameters. Symptom scores correlate among themselves but not with physiological scores. Thus, physiological testing may not be needed for routine follow-up.

Features and results of minimally invasive treatment of recurrent achalasia

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

Comparison of three-dimensional (3D) endovision system versus ultra-high-definition 4K endovision system in minimally invasive surgical procedures: a randomized-open label pilot study.

Experimental work comparing 3-Dimensional (3D) and 4K ultra-high-definition endovision system (4K) indicates that the latter with double the resolution of standard 2D high-definition systems may provide additional visual cues to compensate for the lack of stereoscopic vision. There is paucity of studies comparing 3D and 4K system in clinical settings. This randomized study compares 3D and 4K systems in three laparoscopic procedures of increasing complexity. 139 patients undergoing laparoscopic cholecystectomy (60 patients), transabdominal preperitoneal (TAPP) repair (49 patients) and laparoscopic Heller's cardiomyotomy with anti- reflux procedure (30 patients) between May 2018 and February 2020 were randomized to undergo surgery using either 3D or 4K systems. Primary objective was to measure total operative time. Secondary objectives were to compare workload perceived by surgeons using SURG-TLX and surgeon satisfaction score. Timings of key surgical steps and peri-operative course of the patients was also recorded. Data were analyzed using Stata Corp. 2015. Patients undergoing surgery with 3D and 4K systems were comparable in their clinical and demographic profiles. The mean total operative time in 3D and 4K groups was comparable in cholecystectomy (52.7 vs 56.2, p = 0.50), TAPP (63.8 vs 69.6, p = 0.25) and Heller's cardiomyotomy (124.7 vs 143.3, p = 0.14) with faster hiatal dissection in 3D group (8min, p = 0.02). Operative time was better in patients undergoing Heller's myotomy with Angle of His accentuation with 3D by 28min (p = 0.03). Total workload was similar in 3D and 4K groups in all the procedures but mental & physical demand was lower in 3D group in Heller's cardiomyotomy (p = 0.03, p = 0.01), Surgeon satisfaction score was comparable in all three procedures. Overall, 3D HD and 4K systems are comparable in performing laparoscopic cholecystectomy, TAPP and Heller's Cardiomyotomy. Hiatal dissection time, mental and physical task load was better with 3D in Heller's Cardiomyotomy.

387 LAPAROSCOPIC REDO HELLER’S MYOTOMY FOR ACHALASIA FOLLOWING WORSENING OF SYMPTOMS DUE TO AN INADEQUATE MYOTOMY AND INAPPROPRIATELY CHOSEN ANTIREFLUX PROCEDURE.

Abstract This patient underwent Laparoscopic heller's cardiomyotomy and Nissen fundoplication for Achalasia cardia at another institute. Following surgery his dysphagia worsened. Dysphagia persisted despite balloon dilatation. Patient was evaluated at our institute with Barium swallow and CECT thorax which showed dilated oesophagus with tight wrap. Patient was planned for laparoscopic re exploration. At surgery he had a Nissen wrap and inadequate extension of myotomy across the GE junction. Methods The video describes the procedure of laparoscopic dismantling of the wrap with extension of Heller myotomy and a Toupet Fundoplication. Results Patient had an uneventful recovery and had significant improvement in dysphagia at a follow up of 7 months. Conclusion Nissen Fundoplication is not a good choice of antireflux procedure in achalasia cardia patients following Heller Myotomy and can contribute to dysphagia in the post operative period. Extension of myotomy across the GE junction is critical to the success of Heller myotomy. Re-do surgery is difficult but can be be accomplished through approach in experienced hands. Video https://drive.google.com/file/d/1dhs-PlUm-ahDGF63VxxM0htB0dRiAGYJ/view?usp=sharing

Long-term Outcomes of Laparoscopic Heller’s Cardiomyotomy in Achalasia Cardia With Megaesophagus

Megaesophagus secondary to achalasia cardia is conventionally treated with esophagectomy. With the advent of minimal invasive surgery, laparoscopic Heller's cardiomyotomy (LHCM) has been used in the management of megaesophagus. The authors hereby report our long-term results of 19 patients of megaesophagus managed with LHCM. Prospectively collected data of 19 patients with megaesophagus were reviewed for symptomatic outcome using defined symptom scores and achalasia disease-specific quality of life (A-DsQol) after LHCM with an antireflux procedure. Follow-up was done with clinical visits and telephonic calls. The mean age of the patients was 39.8 years with 7 female and 12 male individuals. The mean duration of symptoms was 105 months. Dysphagia was the predominant symptom followed by regurgitation and heartburn. A-DsQOL was poor with a mean of 58.6±8.11. Nine patients had extra respiratory symptoms. All patients underwent LHCM with an antireflux procedure with no conversion, intraoperative perforation, or mortality. At a median follow-up of 66 months (interquartile range, 24.5 to 80), there was a significant improvement of dysphagia, regurgitation, heartburn, and Eckardt scores from 2.26±1.14, 2.05±0.62, 1.0±0.67, and 7.21±2.22 to 0.21±0.53, 0.15±0.37, 0.42±0.61, and 0.57±2.06, respectively (P<0.001). One patient (5.2%) had a recurrence of dysphagia. Sixty-three percent of patients graded their satisfaction level as fully satisfied and 31% as better. A-DsQOL of life improved significantly (P<0.001) after surgery. The respiratory symptoms improved in all. LHCM provides durable relief of symptoms in patients with megaesophagus and may be considered as the first-line treatment option in such patients.

ROLE OF PREOPERATIVE OESOPHGEALMANOMETRY IN OPERATIVE DECISION MAKING IN PATIENTS WITH CARDIAC ACHALASIA

Background: Surgery is considered the treatment of choice for esophageal achalasia, since it provides symptomatic relief that is stronger and longer lasting. Laparoscopic Heller cardiomyotomy is the preferred treatment for an anti reflux surgery with found oplication. Preoperative HRM is essential to the detection of sufficient fundoplication.Aim of the work: To assess the role of preoperative manometry in selection the type of antireflux surgery with Heller cardiomyotomy (Dor or Nissen fundoplication).Patients and methods: This prospective cohort study was conducted on twenty (20) patients presented to Ain-Shams University hospitals outpatient clinics suffering from chronic dysphagia from January 2018 through January 2020 to assess the role of preoperative manometry in selection of operative type and decision making in treatment of achalasia.Results: Using HRM ,14 patients (70%) with type 1 achalasia underwent Dor fundoplication and in these Dysphagia and regurgitation improved substantially in patients (p value = 0.001 and 0.001 respectively), also there were 4 patients (28.5%) with post-operative reflux. 6 Patients (30%) with type 2 achalasia underwent Nissen fundoplication and in these patients there was a significant improvement in dysphagia and regurgitation (p value = 0.034 and 0.023 respectively), 3 patients (50%) developed post-operative dysphagia, two of them improved on follow up. There was a significant reduction in LES pressure in both Dor and Nissen operation (p value = 0.001 and 0.026 respectively).Conclusion: Preoperative HRM is crucial in choosing type of fundoplication in achalasia as symptomatic responses vary depending on achalasia subtype.

Impact of the Myotomy Extent on Gastric Side on Surgical Outcome After Heller's Cardiomotomy for Achalasia.

Laparoscopic Heller cardiomyotomy (LHM) with Dor fundoplication represents the most commonly accepted surgical management for achalasia. The ideal extent of myotomy on the gastric side remains a matter of continuous debate. The aim of this study was to compare the impact of the extent of myotomy on the gastric side on the outcome of LHM. Patients with achalasia who underwent LHM included in the study. The patients were classified according to the length of the gastric myotomy into 3 groups (group I: <1.5 cm, group II: 1.5 to 2.5 cm, and group III: >2.5 cm). In total, 212 patients (94 males and 118 females) with achalasia treated by LHM and Dor fundoplication included in the study. No statistically significant differences were found among the 3 groups as regards preoperative data, intraoperative mucosal perforation, operative time, blood loss, and hospital stay. The incidence of persistent dysphagia was significantly higher in the group I. Postoperative GERD symptoms were significantly higher in group III (23.3%, P<0.0001). Recurrent achalasia was significantly higher in group I with 11 patients (15.9%), 8 patients in group II (7.1%), and nil in group III (P<0.02). Longer myotomy on the gastric side (>2.5 cm) ensures complete division of the LES with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative GERD. Therefore, a myotomy length of 1.5 to 2.5 cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative GERD.

Pediatric achalasia. Single-center study of interventional treatment.

IntroductionEsophageal achalasia is a rare entity in children. However, young age is a factor of failure of conservative treatment, emphasizing the role of surgery. In our institution laparoscopic Heller’s cardiomyotomy is the chosen procedure for surgical treatment.AimTo assess the outcome of surgery for achalasia treatment in children operated on in a single institution.Material and methodsA retrospective analysis of consecutive patient records from the years 1997 to 2014 was performed. There were 11 patients. Their mean age was 13 years, ranging from 6 to 17. Duration of symptoms was 2 to 36 months, mean 16. All 11 patients were operated on with a laparoscopic approach. Pneumatic dilatation was used both pre- and postoperatively but in no case was sufficient on its own. Collected data included patient demographics, preoperative symptoms and their duration, diagnostic findings and therapeutic means. Surgical procedures, complications and long-term follow-up were analyzed. The follow-up lasted from 1 to 10 years and finished when the patient reached 18 years of age.ResultsTwelve laparoscopic cardiomyotomies were performed with concomitant fundoplications, 10 Toupet and 2 Dor and one redo procedure. There were no deaths. Two perforations were repaired promptly. The success rate was 82%, though with subsequent dilatations. One failure was due to serious progression of the disease.ConclusionsIn our opinion, laparoscopic Heller’s myotomy is the procedure of choice for treating achalasia in children. Endoscopic balloon dilatation may be used as a complementary treatment, especially as a primary redo procedure.

Endosurgery of benign diseases and injuries of esophagus

To analyze the results of endoscopic interventions for benign diseases and injuries of the esophagus. 159 patients with benign diseases and perforation of the esophagus were operated. There were 72 (45.3%) cases of achalasia, 56 (35.2%) with post-ambustial stenosis of esophagus, 14 (8.8%) with esophageal perforation, 13 (8.2%) with leuomyoma of esophagus and 4 (2.5%) with diverticulum of thoracic esophagus. In long-term period 56 patients with achalasia were followed-up after laparoscopic Heller cardiomyotomy with Dor fundoplication. Good results were observed in all cases. Three patients died in early postoperative period after thoracoscopic extirpation of esophagus with esophagoplasty via laparotomy at the stage of development of the technique. There were no deaths after thoracoscopic extirpation of esophagus with simultaneous laparoscopic gastroplasty. Postoperative period was significantly less after thoracoscopic extirpation of esophagus with simultaneous laparoscopic esophagogastroplasty using whole stomach compared with esophagogastroplasty and esophagocoloplasty via laparotomy. In long-term postoperative period different complications occurred in 17 cases. Two patients with esophageal perforation died after video-assisted laparotranshiatal drainage of posterior mediastinum. Scarring of esophageal defect was observed in others. Seam failure after esophageal leuomyoma removal was diagnosed in 2 patients that required video-assisted laparotranshiatal drainage of posterior mediastinum and Maydl jejunostomy. Seam failure in thoracic esophagus after thoracoscopic removal of diverticulum was observed in 1 case. The complication was cured by video-assisted laparotranshiatal drainage of posterior mediastinum.