Postoperative Esophageal Leaks Research Articles

Management of esophageal perforations and postoperative leaks

: Esophageal perforations and postoperative leaks are challenging and life-threatening conditions, with a not well-defined management, yet. Perforation is defined as a full-thickness tear in the esophageal wall due to a trauma on the esophageal lumen or to a sudden increase of endoluminal pressure, like in spontaneous perforations. The most frequent causes are: iatrogenic injuries, spontaneous perforations, foreign body or caustic ingestion, trauma, tumors etc. The onset of symptoms varies depending on the location of perforation (cervical, intrathoracic or intraabdominal), the degree of tissue destruction and extension of contamination of surrounding organs, the cause, the timing of diagnosis and the presence of underlying esophageal disorders. Post-operative esophageal leaks have a different origin but a quite similar clinical presentation and treatment to esophageal perforations. The higher reported incidence is after cervical esophagogastric anastomosis, followed by intrathoracic anastomosis (above all after trans-hiatal one). It is already proven that short diagnostic timing and correct treatment can reduce mortality of 50%. Recent evidence also shows how better outcomes are achieved when the management is multidisciplinary, led by an expert team, and individualized treatments are adopted, involving all available modalities (medical, endoscopic and surgical). The purpose of this article is to review current standard practice, expert opinions and outcomes in the management of esophageal perforations and postoperative leaks.

Magnamosis for long gap esophageal atresia: Minimally invasive “fatal attraction”

BackgroundAim of study is to report our preliminary experience with magnetic anastomosis (magnamosis) treating long-gap esophageal atresia (LGEA), the most challenging condition of esophageal atresia continuum. Magnamosis has been reported in 20 patients worldwide as an innovative and marginally invasive option. MethodsProspective evaluation of all LGEA patients treated with magnamosis was performed (study registration number: 2535/2021). Main outcomes considered were demographic and surgical features, postoperative complications and feeding within 6-month of follow-up. ResultsBetween June 2020 and January 2021, 5 LGEA patients (Type A, Gross classification) were treated. Median preoperative gap was 5 vertebral bodies. Magnetic bullets were placed at an average age of 81 days of life, leading to successful magnamosis in all cases: 4 infants had primary magnetic repair (one after thoracoscopic mobilization of the pouches), 1 patient had a delayed magnamosis after Foker's procedure.Esophageal anastomosis was achieved after an average of 8 days. No anastomotic leak was found. All patients developed anastomotic stenosis at 6-month follow-up, requiring a mean of 6 dilations each. Full oral feeding was achieved in 3 patients, while 2 were still on oral-gastrostomy feeding. One patient experienced small esophageal perforation after dilation (3 months after magnamosis), distal to the anastomotic stricture and subsequently developed oral aversion. ConclusionsOur preliminary results suggest magnamosis a safe and effective minimally invasive option in patients with LGEA. Absence of postoperative esophageal leaks may represent a major advantage of magnamosis over conventional surgery, although possible high rate of esophageal stenosis should be further evaluated. Levels of EvidenceIV (Case series with no comparison group)

Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents.

the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option. the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks. a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018. twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach. endoscopic treatment with fully covered self-expandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center.

Surgical management of Boerhaave�s syndrome with early and delayed diagnosis in adults: a retrospective study of 88 patients

spontaneous esophageal rupture (Boerhaave's syndrome) is a rare and challenging clinical condition. to evaluate the outcome of different surgical treatments for patients with Boerhaave's syndrome with an early diagnosis (< 24 h) and delayed diagnosis (> 24 h), using a retrospective cohort study in a tertiary referral center. eighty-eight patients with Boerhaave's syndrome who underwent surgical treatment were identified from March 1994 to March 2019 in the First Hospital of Shanxi Medical University. Subsequently, they were retrospectively divided into two groups according to time from symptom onset to diagnosis (group 1, < 24 h, n = 16; group 2, > 24 h, n = 72). Primary suture repair was used in group 1 and reinforcement with a vascular muscle flap was used in group 2, in order to reduce the incidence of fistula. Patients in group 2 were further divided into two subgroups according to reinforcement using diaphragmatic flaps (subgroup 1) or intercostal muscle flaps (subgroup 2). the duration of hospitalization and stay in Intensive Care Unit (ICU) was significantly shorter in group 1 (p = 0.027 and p = 0.001). Group 1 had fewer postoperative esophageal leaks (p = 0.037) compared to group 2. Various aspects were compared in the two subgroups and the differences were not statistically significant (p > 0.05). it is very important to establish an early diagnosis for patients with Boerhaave's syndrome. Early (< 24 h) and primary suture repair is superior to delayed (> 24 h) primary repair, even for those reinforced with vascular muscle flaps. Furthermore, repair reinforcement with different muscle flaps appears to render similar results for patients with delayed diagnosis.

Postoperative Esophageal Leaks in Malignant Pathology - Optimal Management: A Systematic Review

Postoperative esophageal leaks are one of the major causes of postoperative mortality and morbidity. The purpose of this study was to review current knowledge of current methods of diagnosis and management of postoperative esophageal leaks. Methods: A systematic literature search was performed in the PubMed/Medline database using the terms "postoperative esophageal leaks" and "postesophagectomy complications" to identify articles relevant to the current diagnostic and prophylactic and curative treatment of post-oesophagectomy anastomotic fistulas. Results: Several papers have shown that the incidence of fistulas varies and is dependent on several factors: the location of the anastomosis, the type of suture used, the biological condition of the patient. Due to the severity of the mediastinal anastomotic fistula, great importance is being given to the methods of preventing its occurrence by intraoperative testing or improving the gastric tube vascularity. The most recent articles present endoscopic methods of treating this complication by using coated esophageal stents and endoluminal vacuum therapy. In patients with mediastinal postoperative esophageal fistulas, diagnosis and management represent a real challenge for the surgeon-endoscopist-therapist team. The early diagnosis and the establishment of an optimal therapy to address the parietal defect and the biological status of the patient are mandatory conditions for resolving this postoperative complication.

Minimally Invasive Intragastric Approach to Gastroesophageal Junction Disease

A minimally invasive intragastric approach to the gastroesophageal junction (GEJ) allows resection of intramural disease while avoiding disruption of the lower esophageal sphincter and vagus nerves. Few surgeons use this approach; thus little is known regarding its indications, feasibility, technical aspects, complication profile, and long-term outcomes. This study reviewed the experience with this technique. A retrospective review was performed of a prospectively maintained, Institutional Review Board-approved database covering the period from January 1, 2005 to August 1, 2017. Indications, operative details, postoperative complications, and outcomes were assessed. There were 12 patients identified. The mean age of these patients was 51.9 years. The indications for resection included 10 symptomatic leiomyomas, one gastrointestinal stromal tumor, and three cancers of the GEJ. Mean and median length of stay were 4.9 and 2.5 days, respectively. There were two postoperative esophageal leaks managed with laparoscopic repair. Of the 3 patients with cancer, 2 underwent an R0 resection, whereas 1 patient underwent an R1 resection. There were no other complications or recurrences. Mean follow-up was 6.0 years (range, 0.5 to 12.6 years); no patients had stricture or symptomatic gastroesophageal reflux on long term follow-up. Resection of selected intramural GEJ disorders through a minimally invasive transgastric approach can be performed safely with acceptable morbidity and good long-term results. The approach allows preservation of the lower esophageal sphincter and vagus nerves, a potential advantage compared with other surgical alternatives to resection in this region.

Successful Endoscopic Esophageal Stent Placement for Esophageal Anastomotic Leak

An anastomotic leak is one of the leading causes of death following gastric bypass surgery and sleeve gastrectomy. In patients who undergo sleeve gastrectomy, the most common site for these leaks is the proximal one-third of the stomach, near the gastroesophageal junction. Evaluation by Upper GI (UGI) contrast study will show extravasation at the site of the leak. Treatment options include surgical management, conservative management with percutaneous drainage, or endoluminal stent placement. This case report presents an endoscopic challenge that was overcome with the replacement of an esophageal stent and subsequent resolution of an esophageal anastomotic leak. A 60 year-old Hispanic female with a past medical history of morbid obesity status-post laparoscopic sleeve gastrectomy presented to the emergency department with a one day history of subjective fever, chills, right upper quadrant abdominal pain, and one episode of non-bloody diarrhea. A UGI series would reveal a proximal gastric anastomotic leak. An EGD was subsequently performed which revealed a fistula approximately 35cm from the incisors; as such, a 25mm diameter/12cm length self-expandable metal esophageal stent was deployed and appropriate placement was confirmed endoscopically and by fluoroscopy (Figure 1). After removal of the esophageal stent, there was persistence of the anastomotic leak, so a new 28mm diameter/12cm length self-expandable metal esophageal stent was placed to cover the fistula. Approximately 6 weeks after the deployment of the 2ndesophageal stent, an EGD was repeated to remove the stent (Figure 2) and a UGI series revealed no extravasation of contrast from the site of the previous anastomotic leak.2966_A Figure 1 No Caption available.2966_B Figure 2 No Caption available.Multiple sources have cited more favorable outcomes with early recognition and prompt management of anastomotic leaks. Criteria for removal of a patient's esophageal stent vary slightly from clinician to clinician, but some common factors include: (1) lack of a leak on esophagram, (2) lack of fever, (3) lack of leukocytosis, (4) absence of an ipsilateral pleural effusion, and (5) resolution of ileus. Despite aggressive therapy, mortality rate of postoperative esophageal leaks remain as high as 20%, with treatment delays being associated with higher mortality rates. Although our experience with esophageal stent placement has evolved and matured, there are unfortunately still complications that arise during and after the procedure.

Epidemiology, diagnosis, and management of esophageal perforations: systematic review

We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.

Self-expanding metal stents in postoperative esophageal leaks

Postoperative esophageal leaks have a high morbidity and mortality. Self-expanding metal stents (SEMS) have been used as an alternative to re-operation. Evaluating predictors of success of SEMS in postoperative esophageal leaks. Retrospective study of patients with postoperative esophageal leaks referred for SEMS placement in a reference center during a period of 3 years. Technical success was defined as closure of the leak in barium swallow at 15 days. Clinical success was considered as endoscopic and/or radiographic confirmation of closure after stent removal. Thirteen patients placed SEMS. Median follow-up was 58 days. Leaks had a median size of 20 mm. Time between surgery and SEMS placement was 20 days. One patient died 2 days after SEMS placement and one had worsening of the fistula after SEMS expansion. Time till stent migration was 9 days. Technical success was achieved in 9 of 11 patients, with clinical success without recurrence in 5 patients. All leaks with less than 20 mm were solved endoscopically. Technical and clinical success was higher when time between surgery and SEMS placement was lower, even though without statistical significance (respectively, p = 0.228 and 0.374). In the 8 patients who died during follow-up, median survival was 59 days. Technical success of SEMS was higher than 80%; however, due to high morbidity and mortality, only 45% of patients had their stent removed. Lower time from diagnosis to SEMS placement and leak size less than 20 mm may be associated with better results.

Endoscopic closure devices

Endoscopic closure devices

A minimally invasive option for the treatment of persistent postoperative esophageal leak

Persistent postoperative leaks in esophageal surgery in children are highly morbid. They usually require technically difficult major reoperations. A less invasive approach is always desirable. During the period 2003 to 2007, we used a minimally invasive approach for the treatment of persistent postoperative esophageal leaks in two children by injection of fibrin glue into the leak site through a small catheter that was introduced through the chest tube. The procedure was successful in one case. We introduce this approach as an alternative to surgery. We found it to be a safe and viable option for the treatment of persistent postoperative esophageal leaks. Keywords: chest tube, esophageal leak, fibrin glue

Endoscopic closure of postoperative esophageal leaks with a novel over-the-scope clip system

Management of esophageal anastomotic leaks is associated with high morbidity and mortality and remains an interdisciplinary challenge. We describe the first two cases of endoscopic closure of postoperative leaks following gastrectomy and primary repair after spontaneous acute esophageal perforation, using the over-the-scope clip (OTSC) system (Ovesco Endoscopy GmbH, Tübingen, Germany). Both leaks were successfully sealed with one clip. While one patient recovered without reintervention, in the other patient the postoperative leak reappeared following clip displacement 13 days later.

Proximal-releasing stent insertion under transnasal endoscopic guidance in patients with postoperative esophageal leakage

Covered metallic or plastic stent placement has become an important treatment for postoperative esophageal leakage; however, fluoroscopic guidance is also required. Here we present a novel stent insertion technique with a newly designed proximal-releasing, self-expanding metallic stent (PR-SEMS) and transnasal endoscope that can enable stent insertion without fluoroscopy as a new method to prevent stent migration. To describe our experience with 7 patients who underwent PR-SEMS insertion with the direct-vision technique and our use of the transnasal endoscope without fluoroscopy. Prospective outcome study. A tertiary-care referral university hospital. This study involved all patients at our center who experienced postoperative esophageal leakage after esophagectomy, primary closure, or total gastrectomy. PR-SEMS insertion with the direct vision technique and use of transnasal endoscopy without fluoroscopy. Success rate of stent insertion, healing rate of postoperative esophageal leaks, and stent migration rate. All stents were placed at the expected location without complications. One patient had massive hematemesis and underwent surgery. The bleeding focus was the splenic artery, which was damaged during gastrectomy. A significant marginal ulcer occurred in one patient, and the stent was immediately retrieved with an endoscope. After stent removal, 4 postoperative leakages were completely healed, and 2 lesions were not occluded. The 2 remaining minimal lesions became completely occluded with conservative management after stent removal. Stent migration did not occur. A small number of patients. Further prospective, randomized, controlled trials are needed. PR-SEMS insertion under transnasal endoscopic guidance is a feasible, safe, and effective treatment for postoperative esophageal leakage, and it can be performed as a bedside procedure. Our anchoring method is effective for the prevention of migration from nonobstructed lesions.

Postoperative esophageal leak management with the Polyflex esophageal stent

Leak after esophageal anastomosis or perforation repair prolongs hospitalization, prevents oral hydration and nutrition, and can produce localized infection or sepsis. This investigation reviews our experience treating postoperative esophageal leaks with the Polyflex esophageal stent (Boston Scientific, Natick, Mass). Over a 30-month period, patients with a postoperative esophageal leak were treated with the Polyflex stent for leak occlusion. Leak occlusion was confirmed by means of esophagraphy. Patients were followed until their stent was removed and their esophageal leak had resolved. Twenty-one patients had 27 stents placed for leak occlusion after esophagectomy (n = 5), esophageal perforation (n = 5), surgical (n = 4) or endoscopic (n = 2) antireflux procedure, and esophageal diverticulectomy (n = 3) or myotomy (n = 2). The mean interval between surgical intervention and stent placement was 12 +/- 8 days (range, 3-31 days). Occlusion of the leak occurred in 20 patients. One patient experienced a dehiscence of the surgical esophageal perforation repair requiring esophageal diversion. Stent migration requiring repositioning (n = 3) or replacement (n = 4) occurred in 5 (24%) patients. Twenty (95%) stents were removed without residual leak (mean, 51 +/- 43 days; range, 15-175 days). One patient had a stricture after stent removal that required endoscopic dilatation. One patient in this series died. The Polyflex esophageal stent is an effective method for occluding a postoperative esophageal leak. It rapidly eliminates contamination of the mediastinum, pleura, and peritoneum; allows oral hydration and nutrition; and is easily removable. These stents also offer an appealing alternative to traditional esophageal diversion and subsequent reconstruction in patients with a persistent esophageal leak.

Laparoscopic Heller myotomy for achalasia

Background Achalasia is an uncommon illness affecting 1 per 100,000 patients yearly. There is evidence to suggest viral, autoimmune, and hereditary etiologies. There are many treatment options available including medications, botulinum toxin injection, pneumatic dilation, and surgical myotomy. Methods We present a retrospective review of patients undergoing laparoscopic-modified Heller myotomy at a large referral and surgical training center. Results There were 36 patients identified. Thirty patients had undergone prior treatment with botulinum toxin injection, pneumatic dilation, previous Heller myotomy, or esophageal stenting. Immediate complications included mucosal perforation (2), spleen injury (1), and trocar-site infection (1). There were no postoperative esophageal leaks. Three patients suffered reflux requiring the daily use of a proton pump inhibitor 9 months after surgery. Three patients suffered recurrent dysphagia. Conclusions Presently, there are little data to suggest an ideal management strategy in patients with achalasia. Our patient population consists predominantly of failures of other treatment methods submitted for laparoscopic myotomy. Our data suggest that laparoscopic Heller myotomy can be safely undertaken in this population, without a higher than expected rate of recurrent symptoms or reflux.

Management of Postoperative Esophageal Leaks With the Polyflex Self-Expanding Covered Plastic Stent

Esophageal anastomotic leaks can lead to prolonged hospitalization. In this article we present our experience with the placement of the Polyflex self-expanding plastic stent (Willy Ruesch GMBH, Kernen, Germany) for leak occlusion. Between April 2000 and November 2003, 24 patients were included into this prospective study and underwent Polyflex stent placement for postoperative esophageal anastomotic leaks. The primary operation was esophagectomy in 13 patients, gastrectomy in 7, cardia resection in 2, and other procedures in 2 patients. The median interval between operation and stent placement was 19 days (range, 4 to 65). The effectiveness of leak occlusion was evaluated by water-soluble contrast swallow and the clinical course. In 2 patients stent misplacement produced an enlarged anastomotic dehiscence that necessitated reoperation. Radiologic evaluation was impossible in 4 patients because of their generally restricted condition. Among 18 evaluable patients, leak occlusion was successful with a single stent in 16 patients (89%) based on radiologic evaluation. Immediate oral feeding was well tolerated by these patients. After a median follow-up of 220 days (range, 7 to 1221), 9 cases of late stent dislocation were observed. Stent removal in patients after esophagectomy with gastric pull-up led to dysphagia from anastomotic strictures in 2 patients. Symptomatic strictures did not develop in the 5 evaluable postgastrectomy patients after stent removal. The placement of self-expanding plastic stents is a highly effective treatment for esophageal anastomotic leaks. Because clinically-relevant anastomotic strictures can be expected, we do not recommend stent removal after esophagectomy with gastric pull-up reconstruction.

INVITED COMMENTARY

Technologic advances have facilitated the management of many postsurgical complications. When applied to the correct patient, at the appropriate time, these techniques can facilitate recovery of the patient and avoid the morbidity and possible mortality associated with an operative reintervention, often in a critically ill patient. Crucial to the success of these endeavors is early intervention when a complication develops, and also the ability to recognize the failure of nonoperative intervention early enough in the course to resort to an alternate plan to salvage the situation. Langer and colleagues report on the use of stents to manage esophageal anastomotic leaks, both cervical and intrathoracic. Despite many modifications, this complication still occurs in 10% to 33% of resections. The authors utilized the Polyflex stent (Willy Ruesch GMBH, Kernan, Germany) to endoscopically manage this vexing, and potentially lethal complication. The goals of stenting appeared twofold; one to prevent death from continued soiling of the mediastinum, and one for the cervical anastomoses, prevention of the strictures often associated with a cervical leak. This report clearly describes the good, the bad, and the ugly associated with this technique. The good is those patients whose leaks were successfully managed nonoperatively. Their leaks were sealed and no further operative intervention was required. The bad were the patients who succumbed despite having been stented, leaving one to question the timeliness and adequacy of the intervention. Would takedown of the anastomosis and/or diversion been the optimum choice? The ugly may be seen in an early and a late phase. The early phase occurring in the patients whose anastomoses were further disrupted by stent placement, thus requiring an emergent operation to achieve any chance of survival. The late phase we can foresee in the group of patients left with those “benign” stents in place. Gaissert and colleagues [1Gaissert H.A. Grillo H.C. Wright C.D. et al.Complications of benign tracheobronchial strictures by self-expanding metal stents.J Thorac Cardiovasc Surg. 2003; 126: 744-747Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar] have recently described the problems resulting from the placement of stents in the airway in lieu of definitive surgical repair. One has to be concerned regarding the development of vascular and airway fistulas in the patients left stented indefinitely. Stenosis of the esophagus proximal to these stents will not leave us much room to work, and result in a miserable existence for the patient. As esophageal surgeons we should keep an open mind to the use of these devices in the management of our postoperative complications, but not be lulled into a false sense of security that a nonoperative approach is always better than a well done operation. Management of Postoperative Esophageal Leaks With the Polyflex Self-Expanding Covered Plastic StentThe Annals of Thoracic SurgeryVol. 79Issue 2PreviewEsophageal anastomotic leaks can lead to prolonged hospitalization. In this article we present our experience with the placement of the Polyflex self-expanding plastic stent (Willy Ruesch GMBH, Kernen, Germany) for leak occlusion. Full-Text PDF

Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients

Background Giant paraesophageal hernias (GPEH) have traditionally required open operations. Increasingly, a laparoscopic approach is being applied to more complex esophageal surgery. Our objective was to update our growing experience with laparoscopic repair of GPEH. Methods We performed a retrospective review at our institution of patients undergoing laparoscopic repair of GPEH from July 1995 to July 2001. The GPEH was defined as greater than one-third of the stomach in the chest. Results Elective laparoscopic repair of a GPEH was attempted in 203 patients. Mean age was 67 years. The most common symptoms included heartburn (96 patients), dysphagia (72), epigastric pain (56), and vomiting (47 patients). Laparoscopic procedures included 69 Nissens, 112 Collis-Nissens, and 19 other procedures. There were three open conversions due to adhesions, but no intraoperative emergencies. Median length of stay was 3 days (range, 1 to 120 days). Minor or major complications occurred in 57 patients (28%). There were six postoperative esophageal leaks (3%), and 1 death. Median follow-up was 18 months. Five patients required reoperation for recurrent hiatal hernia. Excellent results were reported in 128 (84%) patients, 12 (8%) had a good result, 7 (5%) fair, and 5 (3%) poor (based on postoperative follow-up and GERD questionnaire). The mean postoperative GERD Health-related Quality of Life Score was 2.4 (scale 0 to 45; 0 = no symptoms, 45 = worst). Conclusions Laparoscopic repair of GPEH is possible in the majority of patients with acceptable morbidity, a median length of hospital stay of 3 days and excellent intermediate-term results in an experienced center.

Thoracoscopic versus laparoscopic modified Heller myotomy for achalasia: efficacy and safety in 87 patients

Background: The ideal treatment for achalasia permanently eliminates the dysfunctional lower esophageal sphincter, relieving dysphagia and regurgitation; prevents gastroesophageal reflux; and has an acceptable morbidity rate. Controversy exists concerning whether the thoracoscopic Heller Myotomy (THM) or laparoscopic Heller myotomy (LHM) technique is the best approach to a modified Heller myotomy for achalasia. Study Design: We performed a retrospective comparison of the patient characteristics, operative results, postoperative symptoms, and the learning curves for the procedures of 24 patients undergoing THM and 63 patients undergoing LHM between 1991 and 1998. Results: Preoperative patient variables in each group revealed similar distributions for age, gender, and prevalence of previous pneumatic dilation. Mean operating room (OR) times were 4.3 hours (range 2.9 to 5.6 hours) for THM and 3.0 hours (range 1.5 to 6.5 hours) for LHM (p = 0.01). Three esophageal perforations occurred in the THM group and two in the LHM group. Conversion to an open procedure took place in five THM operations (21%) and one LHM operation (2%) (p = 0.005). There were no postoperative esophageal leaks. Mean postoperative length of stay (LOS) for THM was 6.1 days (range 1 to 17 days) and for LHM was 4.0 days (range 1 to 12 days) (p = 0.03). Learning-curve analysis of the first 24 LHM patients compared with the most recent 24 revealed greater OR time in the first 24 mean 3.6 hours, (range 2.0 to 6.5 hours) versus mean 2.3 hours, (range 1.5 to 3.7 hours; p = 0.01), and greater LOS mean 5.5 days, (range 3 to 12 days) versus mean 3.1 days, (range 1 to 8 days; p < 0.01). One esophageal perforation occurred in each subgroup. A similar analysis in the first 12 THM patients compared with the most recent 12 revealed no significant improvement in OR times or LOS. Three esophageal perforations occurred in the latter subgroup only. All patients had preoperative daily dysphagia to solids. Followup data for LHM (n = 49) (median 17 months, range 1 to 39 months) and THM (n = 15) (median 42 months, range 1 to 69 months) revealed no or minimal dysphagia in 90% (44 of 49) after LHM and 31% (4 of 13) after THM (p < 0.01). No or minimal heartburn was present in 89% (41 of 46) after LHM and 67% (8 of 12) after THM (p < 0.05). Regurgitation was absent or minimal in 94% (46 of 49) after LHM and 86% (12 of 14) after THM (p = 0.3). Conclusions: LHM was associated with decreased OR time, decreased rate of conversion to an open procedure, and shorter LOS compared with THM. LHM was superior to THM in relieving dysphagia and preventing heartburn. LHM may be the preferred surgical treatment of achalasia in some patients.

Barium sulfate: a new (old) contrast agent for diagnosis of postoperative esophageal leaks.

To determine whether esophagography with use of barium alone is safe for detection of postoperative leaks of the esophagus. A review was performed of 29 postoperative esophagograms that showed 29 leaks in 12 patients. All studies were performed with a 50% dilution of barium sulfate. Leak volumes were calculated as the product (in cubic centimeters) of the length, width, and height. The safety and efficacy of barium were determined on the basis of development of mediastinitis and retention of barium in the mediastinum that would interfere with subsequent patient care. In 11 of the 12 patients, follow-up studies were performed 4-48 days (mean, 10.2 days) after diagnosis. Leaks were 0.25-375 cm3 (mean, 31.4 cm3). In five of 17 (29%) follow-up procedures, small amounts of residual barium were detectable on the scout radiograph, none of which interfered with interpretation of the new images. During a follow-up period of 7-448 days (mean, 226 days), no cases of mediastinitis were found. Esophagography can be performed safely with barium to rule out an anastomotic esophageal leak.