Surgical Treatment Of Achalasia Research Articles

Imaging following endoscopic and surgical treatment of achalasia.

Achalasia is an esophageal motility disorder characterized by absent esophageal peristalsis associated with failure of relaxation of the lower esophageal sphincter (LES). Patients with achalasia may present with long-standing and slowly progressive dysphagia to solids and liquids, heartburn, regurgitation, refractory reflux symptoms and noncardiac chest pain. The esophagram and the timed barium swallow are useful imaging studies that may contribute to the diagnosis of achalasia and may be used to determine improvement after treatment. Esophagography is also ideally suited to evaluate potential post treatment complications. Treatment options for achalasia aim to disrupt the high-pressure LES to improve esophageal emptying, improve symptoms and prevent further dilatation of the esophagus. The most common treatment options currently include esophageal botulinum toxin (Botox) injections, pneumatic dilatation, Heller myotomy (often performed in conjunction with a fundoplication) and peroral endoscopic myotomy. Potential complications of these procedures may include intramural dissection, leak, scarring and fibrosis of the lower esophagus, strictures and problems related to gastroesophageal reflux and its associated complications. Radiologists must be aware of expected findings and potential complications following these procedures for timely and accurate diagnoses. The purpose of this paper is to describe treatment options for achalasia, illustrate expected imaging findings as well as imaging findings of potential early and long-term complications following treatment for achalasia.

519. ROBOTIC HELLER DOR FOR SYMPTOMATIC ACHALASIA. A SINGLE TERTIARY CENTER EXPERIENCE

Abstract Background Minimally invasive Heller-Dor is the best therapeutic option for symptomatic achalasia. The aim of this study is to describe the introduction of Robotic program for Heller-Dor procedure (RAHD) in a tertiary center evaluating clinical and surgical outcome. Methods We performed a retrospective analysis of patients diagnosed with symptomatic achalasia through clinical, endoscopic, and manometric workup, that were eligible for RAHD. We included all consecutive patients underwent RADH between September 2019 and December 2023 using the DaVinci Xi surgical system. Patients with previous endoscopic or surgical treatment for achalasia were excluded. Results Data from 44 patients were collected. Patients’ characteristics are summarized in table 1. Most patients were in good clinical condition with an ASA score 1-2 and a CCI 1-2 in more than 80% of cases. Mean Eckhardt score (ES) was 6 (SD 2.05). Most frequent symptom was dysphagia, present in all patients but with different severity. Mean operating time was 184 minutes (SD 46). Mucosal tear occurred in three cases and all were sutured immediately, an abdominal drain was placed only in the first case. A regular postoperative course was observed in all patients. All patients underwent a post-op gastrografin esophagogram before starting a liquid diet; none revealed leakage or treatment failure. Three patients (6,8 %) experienced Clavien-Dindo grade I complication, one hepatic hematoma, one pneumothorax, and one PONV. No severe complications were reported. Maximum length of hospital stay was 4 days, mean 3.2 (SD 0.42). All patients were discharged with a well-tolerated soft diet. Mean ES at follow up was 0.58 (SD 0.7) at 1 months. After 6 months and 1 year, no patients reported recurrence of symptoms (ES <3), but three patients reported symptomatic reflux (6,8%). Conclusion Our experience suggests that introduction of RAHD is safe and effective in the treatment of symptomatic achalasia in a tertiary center for Upper Gastrointestinal Surgery.

RESULTATS DE LA SEROMYOTOMIE EXTRA-MUQUEUSE DE HELLER PAR VOIE LAPAROSCOPIQUE A L'HOPITAL GENERAL IDRISSA POUYE : NOTRE EXPERIENCE A PROPOS DE 34 CAS.

SUMMARY Introduction: Laparoscopic extra mucosal Heller seromyotomy has become the "gold standard" in the treatment of achalasia. The aim of our work was to report our experience in the surgical treatment of achalasia by laparoscopic approach and to compare our results with those of the literature. Material and method: Between January 2006 and December 2021, 34 patients with achalasia underwent laparoscopic Heller surgery. The diagnosis of achalasia was evoked clinically and confirmed in the absence of esophageal manometry by barium transit and fibroscopy. The debate on the necessity of a fundoplication and its type was not closed, and the anti-reflux procedure was not systematically performed. Results: The postoperative course was simple in all patients with a resumption of oral feeding on average on the third postoperative day and an average hospital stay of six days. Functional results were satisfactory in 91.17% of cases. Conclusion: Laparoscopic achalasia surgery is feasible in our context with good results. Key words: Achalasia, laparoscopy, seromyotomy.

Peroral endoscopic myotomy: is it better to perform it in naive patients or as second-line therapy? Results of an open-label-controlled study in 105 patients

BackgroundWhether Peroral Endoscopic Myotomy (POEM) can be proposed as a second-line treatment in patients with achalasia remains to be confirmed in real-life series.ObjectiveThis study aimed to compare the efficacy, feasibility and safety of POEM between treatment-naïve patients and patients who had prior endoscopic or surgical therapies for achalasia.MethodsAll consecutive patients who underwent a POEM procedure for achalasia in our centre from June 2015 to September 2018 were included in this retrospective study. They were classified into treatment-naïve patients (POEM1) and patients who had at least one previous endoscopic and/or surgical treatment for achalasia (POEM2).ResultsA total of 105 patients were included, 52 in the POEM1 group and 53 in the POEM2 group. Clinical success (defined as an Eckardt score ≤ 3) at 6 months was observed in 93% of POEM1 patients and 84% of POEM2 patients (p = 0.18). Technical success rate was not significantly different between the two groups (100% vs 96%, respectively; p = 0.50). No significant difference was noted in terms of adverse event rate (19% vs 19%, respectively; p = 1.00). Post-procedure pain occurred in 12% of treatment-naive and 9% of non-naïve patients (p = 0.76). The median length of hospital stay was 3 days in both groups (p = 0.17). Symptomatic gastroesophageal reflux occurred in 25% of POEM1 patients and 16% of POEM2 patients (p = 0.24).ConclusionEfficacy, feasibility and safety of POEM are not different between treatment-naïve and non-naïve patients. POEM is a valuable second-line approach in patients with persistent symptoms of achalasia after surgical or endoscopic treatments.

Surgical treatment of achalasia: results and quality of life

Abstract Achalasia is a primary defect of esophageal motility of unknown aetiology, characterised by peristaltic dysfunction of the esophagus and impaired relaxation of the lower esophageal sphincter. The most common symptoms are dysphagia, regurgitation, weight loss, and chest burning. There are various treatment options for achalasia: botulinum toxin injections, pneumatic dilatation, Heller myotomy, and peroral endoscopic myotomy. The aim of the study was to access the efficacy and quality of life of patients with achalasia after surgical treatment — laparoscopic Heller myotomy and Dor fundoplication. All of the patients after surgery had a high gastrointestinal quality of life index. For all patients, during the follow-up period (median 2.4 years), the intensity of clinical symptoms after the procedure declined. Laparoscopic Heller myotomy with Dor fundoplication is a safe and effective method of treating achalasia and can reduce clinical symptoms and improve patients' quality of life.

The Evolution of the Treatment of Esophageal Achalasia: From the Open to the Minimally Invasive Approach

Achalasia is a primary esophageal motility disorder characterized by lack of esophageal peristalsis and partial or absent relaxation of the lower esophageal sphincter in response to swallowing. This study aimed to provide an overview of the evolution of the surgical treatment for esophageal achalasia, from the open to the minimally invasive approach. Literature review. No curative treatment exists for this disorder. At the beginning of the 20th century, surgical esophagoplasties and cardioplasties were mostly done to treat achalasia. The description of the esophageal myotomy by Heller changed the treatment paradigm and rapidly became the treatment of choice. For many years the esophagomyotomy was done with either an open transthoracic or transabdominal approach. With the advancements of minimally invasive surgery, thoracoscopic and laparoscopic operations became available. The ability to add a fundoplication for the prevention of reflux made the laparoscopic Heller myotomy with partial fundoplication the operation of choice. Surgical management of esophageal achalasia has significantly evolved in the last century. Currently, minimally invasive Heller myotomy with partial fundoplication is the standard surgical treatment of achalasia.

Achalasia at the Crossroads Between Specialties.

Background: Achalasia is a condition that can be treated either by surgery, such as Heller myotomy associated with an antireflux procedure, or by pneumatic dilation, the choice of type of treatment being a widely debated topic nowadays. Methods: We selected patients with the diagnosis of achalasia, calculating the Eckardt score on admission and they were treated by pneumatic dilation, respectively by myotomy associated with fundoplication. Therapeutic success at the end of treatment was analyzed, as well as that in subsequent follow-ups. At the same time, other important aspects of the study were quality of life and complications. Results: Forty-eight patients were included, 20 in the group of those treated by pneumatic dilation, and 28 treated by surgery. The results of the therapeutic success were to the advantage of the surgery, both after the completion of the treatment, and in the follow-ups from one year to 2 years (96.4% vs 90%, respectively 92.9% vs. 85%). The quality of life was better in patients with pneumatic dilation throughout the period. Conclusions: Surgical treatment of achalasia has a higher success rate than pneumatic dilation, but the latter is associated with a better quality of life.

Robotic esophagomyotomy for achalasia: technical note and review of the literature.

The treatment of achalasia has undergone a continuous evolution with the advancement of technology. Since the beginning of the new millennium, the employment of robotics has led to technical facilitation with the execution of the myotomy and consequently to an improvement of the outcomes and a decrease in perioperative morbidity. We provide a detailed description of the surgical procedure and the perioperative management together with a literature search of Electronic PubMed/Medline database and Cochrane Library. English written studies on robotic assisted myotomy (case reports, reviews, single arm and comparative studies) were included. Between 2001 and 2020, 10 case reports, 13 single arm studies, 10 comparative studies, 2 meta-analysis, 11 reviews and 2 technical notes on robotic assisted esophagomyotomy for achalasia were published. As reported by the studies available in the literature and evaluated in this manuscript, robotic assisted cardiomyotomy seems not only feasible but also a safer operation compared with traditional laparoscopic Heller myotomy, due to a significant lower incidence of intraoperative esophageal perforation. Also if large and randomized controlled studies are advocated, robotic assisted esophago-cardiomyotomy might be considered superior to laparoscopic Heller myotomy that, until now, is mostly considered the gold standard in the surgical treatment of achalasia.

625 EFFICACY OF MYOTOMY IN PATIENTS WITH SIGMOID MEGAESOPHAGUS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Megaesophagus progress to sigmoid megaesophagus (SM) in 10–15% of patients, presenting tortuosity and sigmoid colon aspect. Esophagectomy is the choice treatment but is associated with high complications and mortality rates. To avoid the esophagectomy inherent morbidity, several authors recommend Heller myotomy (HM) with pull-down technique for SM, mainly for patients with comorbidities and the elderly. This systematic review and meta-analysis is the first to analyze the effectiveness of HM for treating SM. Methods A systematic review was conducted in PubMed, Embase, Cochrane Library Central, Lilacs (BVS), and manual search of references. Inclusion criteria were: a) clinical trials, cohort studies, case series; b) patients with SM and esophageal diameter ≥ 6 cm; and c) patients undergoing primary myotomy. The exclusion criteria were: a) reviews, case reports, cross-sectional studies, editorials, letters, congress abstracts, full-text unavailability; b) animal studies, c) previous surgical treatment for achalasia; and d) pediatric studies. There were no restrictions on language or date of publication, and no filters were applied for the selection process. Random model and a 95% confidence interval (CI) were used. Results Sixteen articles were selected, encompassing 231 patients. The mean age ranged from 36 to 61 years old, and the mean follow-up ranged from 16 to 109 months. The analyzed outcomes include mortality, complications (pneumonia, pneumothorax, gastroesophageal reflux), need for reintervention (remyotomy, dilation and esophagectomy), and results classified as ‘good’ and ‘excellent’. Mortality rate was 0.035 (CI: 0.017–0.07; p < 0.01). Complications rate was 0.08 (CI: 0.04–0.153; p = 0.01). Need for retreatment rate was 0.161 (CI: 0.053–0.399; p < 0.01). Probability of good or excellent outcomes after myotomy was 0.762 (CI: 0.693–0.819; p < 0,01). Conclusion Heller myotomy is an option for avoiding esophagectomy in achalasia, with a low morbimortality rate and good results. It is effective for most patients but will fail in a minority of patients and demand retreatment, be it a remyotomy, endoscopic treatment or esophagectomy.

Long-term results of laparoscopic Heller myotomy with Dor-fundoplication in surgical treatment of achalasia: A single-center experience

Background/Aim: Laparoscopic Heller myotomy with Dor fundoplication (LHD) is a widely used surgical method in achalasia treatment. However, it has not been well studied in terms of symptomatic relief effect and anti-reflux success in the long term. This study aimed to investigate the long-term success of LHD on symptom relief and acid reflux control. Methods: Patients who underwent LHD between February 2011 and June 2020 were included in this retrospective cohort study. Patients’ demographics, post-operative follow-up outcomes and esophagitis signs on endoscopy were retrieved from the institutional database. Eckardt scores of all study patients were calculated. Those with insufficient follow-up data were excluded. Disease free rates were calculated using the Kaplan-Meier analysis. Results: A total of 24 patients, 11 males and 13 females, were included. The mean age of all patients was 47.9 (11.3) years. The median follow-up time was 71.0 (12.0-117.0) months. Cumulative symptomatic relief (Eckardt ≤3) rate of LHD was 87.5% (21/24). Kaplan-Meier analysis showed that the time-dependent probability of Eckardt score being ≤3 at 3 and 5 years after the surgery were 100% and 94.7%, respectively. The mean expected survival time with Eckardt score ≤3 was 102.5 (95% CI: 87.6-117.3) months. The post-LHD esophagitis rate was 20.8% (5/24). The probability of no reflux esophagitis at 3 and 5 years after the surgery were 95.0% and 89.4%, respectively. The mean expected esophagitis-free survival was 94.2 (95% CI: 80.6-107.7) months. Conclusion: LHD seems successful and safe in terms of long-term symptomatic relief and acid reflux control in the surgical treatment of achalasia.

Minimally Invasive “3-Stitch” Modification of the Dor Fundoplication: Simple and Effective

A 180-degree anterior (Dor) fundoplication is usually paired with an esophagogastric myotomy in the surgical treatment of achalasia. The traditional technique, however, is not easily reversible and the execution is variable. This study examined a simplified ''3-stitch'' Dor fundoplication that addressed these challenges and presented the results. A prospectively collected, longitudinal surgical achalasia database was queried for patients undergoing a Heller myotomy with '3-stitch 180-degree fundoplication from 2008 to 2019. Preoperative and postoperative Eckardt score, postoperative DeMeester score (24- or 48-hour pH studies), and endoscopic evidence of esophagitis were collected and analyzed to determine the effectiveness and safety of the fundoplication. Length of stay and complications were also considered. The pH testing was performed in 296 patients, with 17% (50 of 296) demonstrating abnormal esophageal acid exposure. Of this group, only 8% (16 of 201) manifested clinical esophagitis on upper endoscopy. A total of 14% (7 of 50) of patients with abnormal esophageal acid exposure were symptomatic. Total postoperative Eckhardt scores for this cohort were 3 or lower in 92% of patients, with a dysphagia-specific score of 0 in 92%. The technical details of a modified 180-degree anterior fundoplication are described. The 3-stitch Dor fundoplication is an effective addition to a minimally invasive Heller myotomy, with good palliation of symptoms and an acceptable rate of acid reflux. The simplified construction anticipates the potential progression of esophageal dysmotility in patients with achalasia, and the modified technique is reproducible and readily teachable.

187 – Using a Functional Lumen Imaging Probe to Evaluate Adequacy of Intervention and Predict Patient Outcomes in the Surgical Treatment of Achalasia

187 – Using a Functional Lumen Imaging Probe to Evaluate Adequacy of Intervention and Predict Patient Outcomes in the Surgical Treatment of Achalasia

The Value of Intraoperative Endoscopy and Manometry in the Surgical Treatment of Achalasia.

This is a retrospective chart review of a cohort of patients diagnosed with achalasia at St Mary Clinical Hospital, Bucharest between 2013 and 2017. The objective of this study was the assessment of the immediate and long term efficacy of laparoscopic Heller myotomy associated with Dor anterior fundoplication, intraoperative endoscopy and intraoperative manometry, as well as the assessment of late post-operative complications. The diagnosis of achalasia was based on symptoms, barium esophagogram, upper endoscopy and esophageal manometry. The immediate efficacy was assessed by comparing Eckhart score, LES pressure and LES vector volume before and after surgery. Results: In total, 47 patients, had surgical treatment for achalasia between 2013 and 2017. For 7 patients who failed prior endoscopic or surgical, this was the second therapeutic intervention. 39 patients underwent laparoscopic surgery, 30 patients had associated intraoperative endoscopy and, 22 patients had associated intraoperative manometry. There was a significant improvement in mean Eckardt score (from 6,5 to 1,26, p 0,001), mean LES pressure (from 18,5 mmHg to 7 mmHg, p 0,001). Morbidity was 2,12 % and we have had 1 recurrence and 2 postoperative esophagitis. Conclusions: At present, laparoscopic Heller myotomy with an anterior Dor fundoplication, is a standard indication in achalasia, proving its efficiency and safety. Intraoperative use of endoscopy is recommended and intraoperative manometry may provide additional information on the effectiveness of myotomy. Surgical treatment of achalasia should be performed in specialized, experienced centers.

Long-term outcome of myotomy and fundoplication based on intraoperative real-time high-resolution manometry in achalasia patients.

BackgroundCurrent treatment options for achalasia of the esophagus predominantly consist of endoscopic myotomy or laparoscopic myotomy combined with a partial fundoplication. The intraoperative use of conventional manometry has previously been proposed with various results. The aim of the present study was to introduce the use of high-resolution manometry (HRM) during surgical treatment for achalasia and to assess the long-term outcome of this technique.MethodsWe enrolled achalasia patients within the time period November 2013 to July 2016 who underwent HRM and evaluation of Eckardt scores (ES) before and after tailored laparoscopic myotomy and fundoplication with intraoperative recording using HRM.ResultsTwenty patients were classified as having achalasia type I (20%), type II (55%), or type III (25%). During surgery, 9 myotomies were extended and 13 fundoplications were modified according to HRM findings. Mean resting (16.1 vs. 41.9 mmHg) and residual (9 vs. 28.7 mmHg) pressures of the lower esophageal sphincter and ES (0.7 vs. 6.9) were significantly eliminated postoperatively over a mean follow-up time of 17.7 months.ConclusionsThe use of intraoperative HRM gives us the advantage of simultaneous real-time estimation of intraluminal pressures of the esophagus and the ability to identify the exact points that produce pressure during laparoscopy. Consequently, it may be the key to the tailoring of the Heller-Dor technique and improving the outcomes for achalasia patients.

Laparoscopic surgical treatment of achalasia by Heller-Pinotti´s cardiomyotomy and fundoplication in patient with megaesophagus stage 4: Case report

Laparoscopic surgical treatment of achalasia by Heller-Pinotti´s cardiomyotomy and fundoplication in patient with megaesophagus stage 4: Case report

Su1154 Outcome After Surgical Treatment for Achalasia: Comparison of Sub-Classification Using High-Resolution Manometry

Su1154 Outcome After Surgical Treatment for Achalasia: Comparison of Sub-Classification Using High-Resolution Manometry

New Imaging in Gastrointestinal Tract.

Pathologies of gastrointestinal tract are various and affect patients of different ages. Both of these conditions influence the imaging modalities of gastrointestinal tract that underwent relevant changes during recent years. Magnetic Resonance (MR) and Computed Tomography (CT) techniques, optimised for gastrointestinal imaging, are playing today an increasing role in the evaluation of gastrointestinal disorders, and several studies have shown the advantage of these techniques over tradition barium fluoroscopic examinations secondary to improvements in spatial and temporal resolution combined with improved bowel distending agents. Based on recent literature and guidelines, there is a change of paradigms regarding the diagnosis of esophagus and gastrointestinal cancer towards CT, whereas for small bowel imaging in inflammatory disease MRI with a new focus on Diffusion Weighted Imaging (DWI) are the most important imaging modalities, because DWI can be easily implemented in standard MRI for routine use to further enhance the diagnostic accuracy in disease assessment [1–4]. CT and MRI play an important role also in functional disorders. In particular, the recent development of faster MRI pulse sequences provides rapid, real-time imaging of the gastrointestinal tract, pinpointing areas of stricture and providing valuable information on motility. This special issue is devoted to current and emerging techniques in gastrointestinal tract, focusing on some selected topics that are both interesting and challenging: neoplastic pathologies, chronic inflammatory diseases, functional pathologies, and nontraumatic emergency causing occlusion. The first section covers cross-sectional imaging of the gastrointestinal tract in neoplastic disease, including lymphoma, both through a review (“Radiological Features of Gastrointestinal Lymphoma” by G. Lo Re et al.) and through an original paper (“Staging of Primary Abdominal Lymphomas: Comparison of Whole-Body MRI with Diffusion-Weighted Imaging and 18F-FDG-PET/CT” by A. Stecco et al.) and small-bowel neoplasms (“Small-Bowel Neoplasms: Role of MRI Enteroclysis” by A. Faggian et al.). The imaging of hepatocellular carcinoma after locoregional treatments is also reviewed (“CT Appearance of Hepatocellular Carcinoma after Locoregional Treatments: A Comprehensive Review” by D. Marin et al.). Cross-sectional imaging modalities are fundamental also in the management of patients with inflammatory bowel disease (IBD) from the first diagnosis and throughout the entire course of the disease. In this sense, MRI, owing to the lack of ionizing radiation, represents the main technique in young patients with IBD who may require multiple studies over a lifetime. New imaging of chronic inflammatory pathologies is focused on Crohn's disease, where the imaging is essential also in scoring the activity of disease (“3D-EAUS and MRI in the Activity of Anal Fistulas in Crohn's Disease” by M. E. Alabiso et al.; “Assessment of Disease Activity in Small Bowel Crohn's Disease: Comparison between Endoscopy and Magnetic Resonance Enterography Using Mria and Modified Mria Score” by A. Scardapane et al.). Some functional pathologies are also discussed: achalasia and pelvic floor disfunction (“Imaging in the Evaluation of Endoscopic or Surgical Treatment for Achalasia” by D. Palladino et al.; “MR Imaging in Diagnosis of Pelvic Floor Descent: Supine versus Sitting Position” by F. Iacobellis et al.). Finally nontraumatic emergency causing occlusion is discussed in three different papers, with emphasis on the role of MDCT and dynamic MRI (“Intussusception in Adults: The Role of MDCT in the Identification of the Site and Cause of Obstruction” by V. Valentini et al.; “A Novel Diagnostic Aid for Detection of Intra-Abdominal Adhesions to the Anterior Abdominal Wall Using Dynamic Magnetic Resonance Imaging” by D. Randall et al.; “Adhesions to Mesh after Ventral Hernia Mesh Repair are Detected by MRI but Are Not a Cause of Long Term Chronic Abdominal Pain” by O. Langbach et al.). The contributions of this special issue could stimulate the spread of new imaging modalities in daily practice, pinpoint technical aspects, and share some strategies to optimise CT and MR protocols. Roberto Grassi Antonio Pinto Lorenzo Mannelli Daniele Marin Maria Antonietta Mazzei

Laparoscopic surgical treatment of achalasia by Heller-Pinotti´s cardiomyotomy and fundoplication in patient with megaesophagus stage 4: Case report

Laparoscopic surgical treatment of achalasia by Heller-Pinotti´s cardiomyotomy and fundoplication in patient with megaesophagus stage 4: Case report

Imaging in the Evaluation of Endoscopic or Surgical Treatment for Achalasia.

Purpose. Aim of the study is to evaluate the efficacy of the endoscopic (pneumatic dilation) versus surgical (Heller myotomy) treatment in patients affected by esophageal achalasia using barium X-ray examination of the digestive tract performed before and after the treatment. Materials and Methods. 19 patients (10 males and 9 females) were enrolled in this study; each patient underwent a barium X-ray examination to evaluate the esophageal diameter and the height of the barium column before and after endoscopic or surgical treatment. Results. The mean variation of oesophageal diameter before and after treatment is −2.1 mm for surgery and 1.74 mm for pneumatic dilation (OR 0.167, CI 95% 0.02–1.419, and P: 0.10). The variations of all variables, with the exception of the oesophageal diameter variation, are strongly related to the treatment performed. Conclusions. The barium X-ray study of the digestive tract, performed before and after different treatment approaches, demonstrates that the surgical treatment has to be considered as the treatment of choice of achalasia, reserving endoscopic treatment to patients with high operative risk and refusing surgery.

A Single-Institute Experience of Surgical Treatment for Achalasia of Cardia: Institute of Minimal Access Surgery, Royal Gwent Hospital

A Single-Institute Experience of Surgical Treatment for Achalasia of Cardia: Institute of Minimal Access Surgery, Royal Gwent Hospital