Laparoscopic Myotomy Research Articles

Comprehensive Approaches to the Treatment of Esophageal Achalasia

Introduction and purpose Achalasia is the most prevalent primary esophageal motility disorder, marked by improper relaxation of the lower esophageal sphincter (LES), increased resting pressure in the LES, and a lack of peristalsis in the esophagus. Symptoms include difficulty swallowing (dysphagia), regurgitation, chest pain, and weight loss. Due to the nonspecific nature of these symptoms, diagnosis can be delayed by several years. Since the underlying cause of achalasia is still unknown, treatment options focus on alleviating symptoms by targeting the lower esophageal sphincter. Materials and methods This paper is based on a literature review sourced from PubMed, using the following keywords: achalasia, POEM, laparoscopic cardiomyotomy, pneumatic dilation, and botulinum toxin injection. Results Various treatment options are available for achalasia, each offering unique features and results. The main approaches include Peroral Endoscopic Myotomy (POEM), Laparoscopic Myotomy (LM), Botulinum Toxin Injection, and Pneumatic Dilation (PD). Conclusion Each treatment differs in its level of invasiveness, duration of symptom relief, risk of complications, and the likelihood of requiring additional interventions. The selection of the most suitable option is influenced by individual patient factors, such as the type and severity of achalasia, overall health, and personal preference

516. HELLER MYOTOMY FOR SYMPTOMATIC ACHALASIA: TRADITIONAL LAPAROSCOPY OR ROBOTICS? A SYSTEMATIC REVIEW WITH META-ANALYSIS

Abstract Background Laparoscopic Heller myotomy (LH) has been established as the gold standard for symptomatic achalasia; robotic-assisted laparoscopic myotomy (RH) has shown promising outcomes regarding safety and effectiveness. We aim to meta-analyse data comparing LH and RH surgical outcomes and complications. Methods A systematic search was conducted in February 2024 without restrictions according to PRISMA guidelines in PubMed, Web of Science, Scopus, and Cochrane Register. Studies comparing laparoscopic and robotic approach for Heller myotomy in adults with symptomatic achalasia were included for systematic review. Meta-analysis was performed trough generalized linear mixed model in R 4.3.2. Results 16 observational studies, out of 273, were included; reporting on 15076 patients. No statistically differences in preop characteristics were noted. RH had significantly fewer intraoperative esophageal perforations (OR=7.29, p< 0.0001, 95%), fewer subsequent myotomies and endoscopic treatments for recurrence (OR= 3.64, p=0.01 and OR= 3.38, p=0.03) and better symptom score improvement (OR=0.507, p=0.04). Although not clinically significant, RH had shorter hospital stays (MD=0.45 days, p= 0.005,) and reduced intraoperative blood loss (MD=10.46 ml, p=0.0002). Although not statistically significant, RH had fewer bleeding episodes, lower conversion, reintervention and mortality rates, comparable morbidity and postoperative GERD and higher operative time. Conclusion This updated meta-analysis suggests that RH is associated with lower regarding perforations, recurrence rates and symptom improvement compared to LH, with negligible lengthening of operative times. RH for symptomatic achalasia represents a feasible treatment for symptomatic achalasia, with a satisfying safety and effectiveness profile. RCTs on the topic and about cost-effectiveness evaluations are necessary to support the reported data.

Gender medicine in diseases of the upper gastrointestinal tract

Benign and malignant diseases of the upper gastrointestinal tract show gender-specific differences. The frequent gastroesophageal reflux disease is aprime example: men have an erosive reflux disease more often than women and are also younger at the time of onset. The rate of progression to a metaplastic Barrett's esophagus is also higher in men. In the case of achalasia, there are indications that surgical treatment by laparoscopic Heller's myotomy and semifundoplication 180° according to Dor leads to amarkedly better improvement in the symptoms in women compared to men, although they showed amore pronounced dilation of the tubular esophagus. The female hormone status influences the localization and histopathology of adenocarcinoma of the esophagogastric junction and gastric carcinoma. Premenopausal and postmenopausal carcinomas differ significantly in women. In addition, high microsatellite instability (MSI high) is more frequent in women and is associated with agenerally significantly better prognosis. The MSI high gastric carcinomas of women show better survival than MSI high carcinomas of men. The future inclusion of gender-specific aspects in studies of the upper gastrointestinal tract is desirable in order to generate adequate data and to enable differentiated treatment stratification in the future.

Per oral endoscopic myotomy in esophageal achalasia in children. First endoscopic procedures

BACKGROUND: Achalasia is an esophagus lesion which is characterized by disorders of its motility. It is met extremely rare in childhood. Among the existing techniques of achalasia management, Heller's laparoscopic myotomy is a procedure of choice. Peroral endoscopic myotomy (POEM) is an endoscopic method for AP treating proposed by P. Pasricha in 2007. AIM: To describe the experience of per oral endoscopic myotomy in children. METHODS: The authors performed a retrospective analysis of data taken from the patients with confirmed esophageal achalasia who had had POEM. Clinical efficacy was assessed using the Eckard scale. RESULTS: In 2018–2021, 8 children with average age 14.4 years were treated with POEM surgery. Before POEM, 2 children underwent balloon dilatation of the cardia. The surgery was technically performed in all children. Dysphagia was eliminated in all patients, and none of them required any additional intervention. A significant decrease in Eckard scale scores was registered in all children after surgery. CONCLUSION: Our results confirm findings that POEM is an effective procedure for treating esophageal achalasia. However, a longer follow-up period and a larger group of patients are needed to confirm POEM role in the management of children with esophageal achalasia.

Case Report and Therapeutic Approach for Achalasia Cardia

Achalasia cardia is an uncommon esophageal motility disorder characterized by the impaired relaxation of the lower esophageal sphincter (LES) and the absence of peristaltic contractions in the esophageal body. This report presents a case of a 42-year-old woman with a prolonged history of dysphagia and regurgitation of solids and liquids. The patient's clinical history included a 10-year history of neck swelling, hypothyroidism, and diabetes mellitus. Physical examination and laboratory investigations revealed normal findings, except for elevated blood glucose, thyroid hormone levels, and thyroid-stimulating hormone (TSH) levels. An esophagogram showed proximal dilation of the distal esophagus with a contrast fluid level, and endoscopy revealed a tight LES, which was difficult to pass through. Based on these findings, the diagnosis of achalasia cardia was established. Initial medical management with nitrates and proton pump inhibitors did not provide significant improvement. Subsequently, the patient underwent laparoscopic Heller's myotomy with fundoplication, which successfully resolved her dysphagia symptoms. This case report highlights the diagnostic challenges and the importance of a multidisciplinary approach in managing achalasia cardia. It emphasizes the role of surgical interventions, such as Heller's myotomy with fundoplication, in alleviating symptoms and restoring esophageal function when conservative medical management fails

Efficacy and safety of laparoscopic Heller's myotomy versus pneumatic dilatation for achalasia: A systematic review and meta-analysis of randomized controlled trials.

We searched Cochrane CENTRAL, PubMed, Web of Science, SCOPUS and Embase for related clinical trials about patients suffering from achalasia. The quality appraisal and assessment of risk of bias were conducted with GRADE and Cochrane's risk of bias tool, respectively. Homogeneous and heterogeneous data was analyzed under fixed and random-effects models, respectively. The pooled analysis of 10 studies showed that PD was associated with a higher rate of remission at threemonths, oneyear, threeyears and fiveyears (RR = 1.25 [1.09, 1.42] (p = 0.001); RR = 1.13 [1.05, 1.20] (p = 0.0004); RR = 1.48 [1.19, 1.82] (p = 0.0003); RR = 1.49 [1.18, 1.89] (p = 0.001)), respectively. LHM was associated with lower number of cases suffering from adverse events, dysphagia and relapses (RR = 0.50 [0.25, 0.98] (p = 0.04); RR = 0.33 [0.16, 0.71] (p = 0.004); RR = 0.38 [0.15, 0.97] (p = 0.04)), respectively. There is no significant difference between both groups regarding the lower esophageal pressure, perforations, remission rate at twoyears, Eckardt score after oneyear and reflux. PD had higher remission rates than LHM at threemonths, oneyear and threeyears, but not at twoyears or fiveyears. More research is needed to determine whether PD has a significant advantage over LHM in terms of long-term remission rates.

Achalasia and hyperthyroidism: A co-occurrence revealing autoimmune connections

Achalasia is a rare esophageal motility disorder characterized by an unknown etiology, myenteric inflammation, and autoimmune markers. We present a case of a 43-year-old female with progressive dysphagia, regurgitation, generalized weakness, and hair loss. Despite normal cranial nerves and normal laboratory values, upper GI endoscopy revealed pangastritis, while manometry indicated type 2 achalasia cardia. The patient underwent laparoscopic Heller's myotomy for achalasia and received treatment for hyperthyroidism. The discussion explores the autoimmune aspects of achalasia and its rare association with hyperthyroidism. Early diagnosis and management are crucial for improving patient outcomes.

Sublingual Nitroglycerine Spray Facilitates Efficient Submucosal Tunneling during Per Oral Endoscopic Myotomy—A Nonrandomized Trial

Abstract Introduction In the last one decade, per oral endoscopic myotomy (POEM) has been found to be an effective minimally invasive approach for the treatment of esophageal achalasia cardia and was lately shown to be noninferior to laparoscopic Heller's myotomy in a randomized controlled trial.Here we describe a new method of using sublingual nitroglycerine spray during submucosal tunneling to facilitate the procedure. Materials and Methods This study includes a cohort of 50 patients who were diagnosed with achalasia cardia on high-resolution esophageal manometry. Out of the 50 patients, 27 patients were administered two metered doses of sublingual nitroglycerine spray during submucosal tunneling across the gastroesophageal junction (GEJ), and 23 patients were not administered nitroglycerine. This process was nonrandomized; patients were assigned sublingual nitroglycerine using alternating sequence enrollment number. Results All the procedures were technically feasible and successful without any major complications. Eckhardt's scores of all patients normalized after the procedure. The mean submucosal tunneling time and mean time across GEJ were 36.8 ± 7.9, 14.2 ± 2.9 in intervention group (sublingual nitroglycerine), and 50.2 ± 8.9 and 23.0 ± 3.6 minutes in nonintervention group, respectively. Time for each procedure was significantly less (p < 0.05) in patients who were given sublingual nitroglycerine. Mucosal injury and bleeding during procedure were not significantly different in the two groups. Conclusion This POEM technique with the use of sublingual nitroglycerine spray is simple and renders POEM easier and less time consuming.

Laparoscopic Heller’s cardiomyotomy for achalasia cardia-a case series with review of literature

Laparoscopic Heller’s cardio myotomy has almost completely replaced the open procedure performed for achalasia cardia. Several studies have suggested that long-term results with surgery for achalasia cardia are better than a medical line of management. In this retrospective study, we outline our experience with laparoscopic cardio myotomy over 15 years. Also, we compare our results with those of other interventional modalities which are known therapeutic options for achalasia cardia. We identified 10 patients (4 females and 6 males) operated upon by a single surgeon from 2008 to 2023, at our institution. The age range was 16-48 years. All patients had undergone oesophago-gastro-duodenoscopy (OGD scopy), upper gastro-intestinal (UGI) manometry and contrast enhanced computerised tomography (CECT) of the lower chest and upper abdomen. The patients were analysed for age, sex, symptoms, pre-operative evaluation, the exact procedure performed (Heller’s+Toupet’s vs Heller’s+Dorr’s), morbidity/mortality and functional outcomes. They were also reviewed to examine the length of stay, length of procedure, complications and recurrent symptoms on follow-up.

EFFICACY OF LAPROSCOPIC HELLER'S MYOTOMY IN THE TREATMENT OF ACHALASIA

In a retrospective study conducted from September 6, 2021, to September 6, 2022, at the Thoracic Surgery Department of Bakhtawar Amin Trust Hospital in Multan, the objective was to evaluate the impact of laparoscopic Heller's Myotomy on patients with achalasia. Additionally, the study sought to identify pre-operative factors that influence treatment outcomes. The methodology involved recording pre-operative patient data, including dysphagia scores, and conducting pre-operative manometry to diagnose achalasia. The diagnostic criteria included a non-relaxing lower esophageal sphincter (LES) and abnormal esophageal contractions. Post-operative changes in dysphagia scores (delta) were calculated, and a dysphagia score falling below a specified cutoff was considered an unsuccessful treatment outcome. The study's results revealed that the patients had an average age of 48.5 years, with a standard deviation of 1.6. After Heller myotomy, the average decrease in dysphagia scores was 7.2, with a standard deviation of 2.5. A change in score of ≥5 was indicative of successful treatment, leading to dysphagia relief in 69 out of 80 patients (86%). The sole pre-operative variable that significantly predicted successful dysphagia relief was the pre-operative LES pressure. The responder group displayed higher LES pressure than the non-responder group, with 41.5 mm Hg ± 12.1 and 22.9 mm Hg ± 7.1, respectively (P = 0.001). No significant correlation was observed between post-operative LES pressure and changes in dysphagia scores. In conclusion, Heller's myotomy demonstrated excellent efficacy in providing dysphagia relief for achalasia patients. Notably, a high pre-operative LES pressure was identified as a significant predictor of an excellent treatment outcome.

Protocol for an international multicenter randomized controlled trial assessing treatment success and safety of peroral endoscopic myotomy vs endoscopic balloon dilation for the treatment of achalasia in children.

Achalasia is a rare neurodegenerative esophageal motility disorder characterized by incomplete lower esophageal sphincter (LES) relaxation, increased LES tone and absence of esophageal peristalsis. Achalasia requires invasive treatment in all patients. Conventional treatment options include endoscopic balloon dilation (EBD) and laparoscopic Heller's myotomy (LHM). Recently, a less invasive endoscopic therapy has been developed; Peroral Endoscopic Myotomy (POEM). POEM integrates the theoretical advantages of both EBD and LHM (no skin incisions, less pain, short hospital stay, less blood loss and a durable myotomy). Our aim is to compare efficacy and safety of POEM vs. EBD as primary treatment for achalasia in children. This multi-center, and center-stratified block-randomized controlled trial will assess safety and efficacy of POEM vs EBD. Primary outcome measure is the need for retreatment due to treatment failure (i.e. persisting symptoms (Eckardt score > 3) with evidence of recurrence on barium swallow and/or HRM within 12 months follow-up) as assed by a blinded end-point committee (PROBE design). This RCT will be the first one to evaluate which endoscopic therapy is most effective and safe for treatment of naïve pediatric patients with achalasia.

Pre- and post-intervention oesophageal pressure topography metrics in the three subtypes of achalasia: A pilot study on Indian adults

BackgroundAchalasia is characterized by failure of relaxation of the lower oesophageal sphincter (LOS) and abnormal peristalsis during swallowing. The study aimed to observe the effects of intervention in three sub-types of achalasia and compare the intervention outcomes among the three sub-types. MethodsForty-one patients underwent Eckardt scoring for severity of achalasia, followed by high-resolution manometry (HRM). After three and six months of intervention (pneumatic dilatation or 'Heller's Cardiomyotomy), Eckardt scoring and HRM were repeated and compared with the initial results. ResultsOut of the 41 patients, 13 were diagnosed with type I achalasia (31.71%), 18 with type II (43.90%), and 10 with type III (24.39%). Significant differences between the pre- and post-intervention values of median integrated relaxation pressure (IRP) and Eckardt score were found in all three sub-types. Although the beneficial effect of intervention lasted up to six months postintervention, it was less than three months postintervention values. The intervention success rates were highest for both laparoscopic Heller's myotomy (LHM) and pneumatic dilatation (PD) in Type II Achalasia at three and six months postintervention, respectively. ConclusionOne-time intervention is effective in all three sub-types. This benefit tends to taper over time but remains significant after six months of intervention. Type II Achalasia shows the best intervention outcomes compared to the other two sub-types at three months and six months post-intervention. Type III Achalasia shows the least response compared to other sub-types and is the poorest responder to intervention. The benefit of one-time intervention also deteriorates most in type III achalasia at the end of six months.

Laparoscopic Heller-Dor myotomy in elderly achalasia patients: a single center experience with PSM analysis

Introduction Achalasia is a rare esophageal motility disorder of unknown etiology. With the ageing of the general population, treatment in elderly patients has become increasingly common; however, the gold standard treatment in this population remains unclear. The aim of this study was to evaluate the outcomes of laparoscopic Heller-Dor myotomy (LHM) in geriatric patients. Material and methods In this study, consecutive achalasia patients undergoing LHM at the University Hospital ‘Federico II’ of Naples from November 2018 to November 2022 were prospectively enrolled. Patients were divided into two groups based on their age at intervention: elderly (≥70 years) and younger (<70 years). The two study groups were compared by minimizing the different distribution of covariates through a propensity score matching analysis (PSM). Results In both populations, there was a significant improvement in terms of manometric parameters and symptoms after surgery. After applying one-on-one PSM, we obtained a total population of 48 achalasia patients divided into two groups (24 patients each). No significant differences were found in terms of demographic characteristics as well as preoperative and intraoperative variables between two groups. At 12 months from surgery, integrated relaxation pressure (IRP) was significantly lower in patients ≥ 70 years (p = 0.032), while younger patients scored significantly less at the post-operative Eckardt score (p = 0.047). Conclusions Laparoscopic Heller-Dor myotomy is a safe and effective treatment even in elderly patients with rapid post-operative recovery, improvement of symptoms and manometric parameters.

Comparison of the Clinical Efficacy, Safety, and Postoperative Outcomes Between Peroral Esophageal Myotomy and Laparoscopic Heller's Myotomy With Fundoplication: A Systematic Review.

Achalasia, a neurodegenerative disease caused by the progressive destruction of ganglion cells in the myenteric plexus, is accompanied by incomplete relaxation of the lower esophageal sphincter. Laparoscopic Heller's myotomy (LHM) coupled with fundoplication has been the gold standard procedure for achalasia. Peroral esophageal myotomy (POEM) has recently gained popularity as it is minimally invasive, has fewer adverse events, and has excellent short-term outcomes. So, we aimed to compare the clinical efficacy, safety, and postoperative outcomes between LHM and POEM. We did a systematic review by following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA)guidelines for 2020 and exploring research databases such as PUBMED and PMC Central, Google Scholar, and Research Gate. After appropriate screenings, articles relevant to the review were scrutinized based on the eligibility criteria. Quality assessment tools such as the Newcastle-Ottawa Scale (NOS) and theassessment of multiple systematic reviews(AMSTAR) were used to finalize the articles. A total of 11 articles (seven observational studies, two RCTs, and two systematic reviews) were included in the review after a quality check. The study included 2127 patients, classified into 981 for POEM and 1146 for LHM, who had undergone treatment for achalasia. Most of the studies had a follow-up of ≤ two years. Comparing efficacy, POEM had similar results to LHM in terms of Eckardt scores. However, abnormal DeMeester scores were found in POEM. Adverse events were significantly higher in LHM when compared to POEM in terms of safety. Peroral esophageal myotomy also stood out as having a shorter procedure time, a shorter hospital stay, and lesser odds of being a clinical failure. As for postoperative outcomes, despite treatment with proton pump inhibitors, LHM was more effective in preventing the development of esophagitis compared to POEM due to partial fundoplication.Postoperative reflux and the development of esophagitis remain certain with POEM and need to be followed up with more studies with longer follow-ups. However, POEM still stands as a better choice compared to LHM in terms of efficacy and safety.

Surgical Options for End-Stage Achalasia.

Achalasia is one of the most commonly described primary esophageal motility disorders worldwide, but there is significant controversy regarding ideal management of end-stage disease. This article reviews the definition of end-stage achalasia and summarizes past and present surgical treatment. Myotomy of the lower esophageal sphincter remains the mainstay of treatment of achalasia, even in advanced disease. Esophagectomy may have benefit as a primary treatment modality in end-stage achalasia with sigmoid esophagus, but international guidelines recommend consideration of laparoscopic or endoscopic approaches initially in most patients. Novel peroral esophageal plication techniques may provide alternative treatment options in patients with significant esophageal dilation that fail myotomy or esophagectomy. End-stage achalasia is characterized by progressive tortuosity and dilation of the esophagus as a failure of primary peristalsis. Up to 20% of patients with achalasia will progress to end-stage disease. In most cases, laparoscopic or endoscopic myotomy is recommended as initial approach to surgical management.

320. ESOPHAGEAL PULL-DOWN TECHNIQUE IMPROVES THE FINAL OUTCOME OF LAPAROSCOPIC HELLER-DOR FOR END-STAGE ACHALASIA

Abstract Background Patients with sigmoid shape have an advanced form of the disease and are considered the most difficult to treat. A modified technique (pull-down) has been proposed to straighten the esophageal axis, but there is a limited amount of data available in literature. In this study, we aimed to compare the final outcome of the pull-down technique (PDLHD) with the results of classical myotomy (CLHD) in patients with end-stage achalasia. Methods From 1995–2022, patients with a radiological diagnosis of end-stage achalasia undergoing laparoscopic myotomy were enrolled in the study. Symptoms were quantified using the Eckardt score. Barium-swallow, endoscopy and manometry were performed before and after the treatment. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score &amp;gt; 3, or the need for retreatment. Results Of the 94 patients with end-stage achalasia (M:F = 52:42), 60 patients were treated with CLHD, and 34 patients with PDLHD. The surgical procedures were completed laparoscopically in all patients. During follow-up, two patients (2.1%) developed squamous cell carcinoma (SCC), both in the CLHD group. All patients in both groups had an improvement in their Eckardt score after surgery, and the failure rates were 27.6% (16/58) after CLHD and 5.9% (2/34) after PDLHD (p &amp;lt; 0.01). Amongst the patients who underwent complete post-operative follow-up, an abnormal acid exposure was detected in 2 patients after PDLH, and in 6 after CLHD (p = n.s.). Conclusions Taken into account the intrinsic limitations of the study (different time window, and different follow-up), the results of this study indicate that performing the pull-down technique during Laparoscopic Heller-Dor improves the final outcome in end-stage achalasia patients.

460. INTRAEPITHELIAL EOSINOPHILS IN ACHALASIA PATIENTS ARE NOT UNCOMMON, BUT THEY SEEM NOT RELATED TO THE COURSE OF THE DISEASE

Abstract Background The presence of intraepithelial eosinophils (IE) was described in patients with esophageal motor disorders (EMD). Conversely, EMD and even achalasia were reported in patients with eosinophilic esophagitis (EoE). The purpose of this study was to further investigate this possible association. Methods From February to July 2022, patients with achalasia undergoing laparoscopic myotomy were evaluated. Patients who had previous treatment were excluded. Immediately before the operation, the patients underwent endoscopy with the addition of 4 biopsies from the proximal, middle and distal esophagus and from the Z line, respectively. Two additional samplings of the esophageal muscle were taken while performing the myotomy. The specimens were stained with H&amp;E in order to highlight the presence of eosinophils and the number of IE eventually present in a high-power field (hpf) was recorded. Patients were re-evaluated 6 months after the operation. Results A total of 30 patients with a median age of 45.5 years were studied. Their preoperative ES was 6 (5–7) and the median duration of symptoms was 42 months (12–120); there were 18 stage I, 9 stage II, 2 stage III and only one stage IV, respectively; manometric subtype 1 was found in 7 patients, subtype 2 in 18 and subtype 3 in 5. There were no complications. All the patients had a good outcome and the median ES was 0 (0–1). IE were found in 6 patients (20%) [median 6/hpf (2–10)]. Only one patient met the pathologic criteria for EoE, whereas only one additional showed eosinophils in the muscular specimen. No differences in preoperative and postoperative data were found between patients with and without IE, but the maximum diameter of the gullet was narrower in the former than in the latter (3.24 cm vs 22.50 cm, respectively, p &amp;lt; 0.05). Conclusions EoE and achalasia are 2 of the commonest causes of dysphagia and an association between them was recently hypothesized. Our study confirmed that IE are present in some patients with achalasia, but seldom meeting the criteria for EoE. Only a narrower esophagus was found in patients with IE as compared to those without, possibly reflecting an earlier stage of the disease.

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.

True peristaltic recovery is uncommon following treatment, particularly endoscopic dilation for achalasia cardia, though pseudo-recovery often occurs.

Relieving esophagogastric junction (EGJ) obstruction has been the focus of treatment for achalasia cardia. The recovery of peristalsis has been an elusive goal. Studies analyzing post-intervention peristaltic recovery have several limitations such as theuse of conventional manometry or lack of standard definitions of peristalsis. Accordingly, we undertook this study to analyze frequency and pattern of peristaltic recovery following treatment for achalasia cardia on high-resolution manometry (HRM) and standard Chicago definition of peristalsis. Pre and post-intervention HRM records of 71 treatment-naive patients diagnosed as achalasia cardia were retrospectively analyzed. Records with pre and post-intervention HRM on different systems (e.g. solid state and water perfusion) and those with inadequate information were excluded. All HRMs were interpreted as per Chicago classification version 3.0. After pneumatic dilation (PD) or laparoscopic Heller's myotomy (LHM), pseudorecovery of peristalsis was defined as any contraction at least 3cm in length along 20mmHg isobaric contour with a distal latency of less than 4.5seconds. True recovery and premature contractions were defined by standard Chicago classification v3.0 criteria. Change in diagnosis was observed in 38 of 71 (53.5%) patients after intervention. While pseudo-peristaltic recovery occurred in 11 of 71 (15.5%) patients, only three (4.2%) had a true recovery. Another nine (12.7%) patients showed new premature contractions. True peristaltic recovery is uncommon in achalasia cardia following intervention, particularly PD. Pseudo-peristaltic recovery is more common. Further research is warranted on this issue.

Achalasia Surgical Approach

Achalasia is a rare chronic esophageal disease that affects the relaxation function of the lower esophageal sphincter (LES) and peristaltic motility of the esophagus. Surgical treatment, especially laparoscopic esophageal myotomy, has been shown to be highly effective in relieving symptoms and improving esophageal function. Although there are different surgical approaches, the choice of treatment should be based on the experience of the surgeon and the individual characteristics of the patient. Long-term follow-up and consideration of complementary measures are crucial to achieve optimal results in the management of achalasia