Surgical Treatment Of Esophageal Achalasia Research Articles

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.

Effects of the preoperative IRP values on the pathophysiology of patients with esophageal achalasia and on the treatment outcome of laparoscopic Heller-Dor surgery.

One diagnostic criterion of esophageal achalasia is that the integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) is at least 15 mmHg. Moreover, while the standard surgical treatment for esophageal achalasia is laparoscopic Heller-Dor surgery (LHD), there have been insufficient investigations concerning the surgical outcomes from the perspective of the preoperative IRP value. We split 121 cases in which LHD was performed as an initial treatment on patients with esophageal achalasia, into two categories according to the IRP median value, and performed a comparative investigation of the surgical outcomes with regard to the preoperative pathophysiology and symptoms. The IRP median value was 29.6 mmHg. The high IRP group consisted of younger individuals and low BMI (p = 0.004 and p = 0.0273, respectively), and the percentage of Chicago classification Type II and III was high (p = 0.029) and the regurgitation score in the preoperative symptoms was high (p = 0.0043). However, no differences in the surgical outcomes were confirmed. In patients with esophageal achalasia, the degree of the preoperative IRP value affects the age, BMI, preoperative LESP, and preoperative regurgitation symptoms. However, there were no effects on the surgical outcomes, with the surgical outcomes being satisfactory, regardless of the IRP value.

Surgical Treatment of Esophageal Achalasia in the Era of Minimally Invasive Surgery.

Introduction:We have analyzed the short- and long-term results of various surgical therapies for achalasia, especially changes in postoperative esophageal function.Patients and Methods:Between January 1, 2008 and December 31, 2017, 54 patients with esophageal achalasia were treated in our institution. Patients scheduled for surgery underwent a comprehensive gastroenterological assessment pre- and post-surgery. Forty-eight of the elective cases involved a laparoscopic cardiomyotomy with Dor’s semifundoplication, while two cases entailed an esophageal resection with an intrathoracic gastric replacement for end-stage achalasia. Torek’s operation was performed on two patients for iatrogenic esophageal perforation, and two others underwent primary suture repair with Heller–Dor surgery as an emergency procedure. The results of the different surgical treatments, as well as changes in the patients’ pre- and post-operative complaints were evaluated.Results:No intra-operative complications were observed, and no mortalities resulted. During the 12 to 24-month follow-up period, recurrent dysphagia was observed mostly in the spastic group (TIII: 33%; diffuse esophageal spasm: 60%), while its occurrence in the TI type did not change significantly (14.5%–20.8%). As a result of the follow-up of more than two years, good symptom control was achieved in 93.7% of the patients, with only four patients (8.3%) developing postoperative reflux.Conclusions:The laparoscopic Heller–Dor procedure provides satisfactory long-term results with low morbidity. In emergency and advanced cases, traditional surgical procedures are still the recommended therapy.

Surgical management of achalasia.

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience‐based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.

Heller myotomy for achalasia. From the open to the laparoscopic approach.

The last three decades have witnessed a progressive evolution in the surgical treatment of esophageal achalasia, with a shift from open to a minimally invasive Heller myotomy. The laparoscopic approach is currently the standard of care with better short-term outcomes and similar long-term functional results when compared to open surgery. More recently, the laparoscopic single-site approach and the use of the robot have been proposed to further improve the surgical outcome in achalasia patients.

Laparoscopic treatment for esophageal achalasia: experience at a single center.

Achalasia is a not frequent esophageal disorder characterized by the absence of esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter (LES). Its cause is unknown. The aim of treatment is to improve the symptoms. We report the results of the treatment of this condition achieved in one center. We conducted a retrospective study of patients with esophageal achalasia. In the period 2010-2012 we observed 64 patients, of whom 19 were referred for medical treatment. Three of the remaining patients underwent botulinum toxin injection, 17 underwent multiple endoscopic dilation procedures and 25 underwent laparoscopic surgery. There were no complications in the group undergoing endoscopic therapy, but symptom remission was only temporary. Patients undergoing surgery showed a significant improvement in symptoms and no recurrence throughout the follow-up period, that is still ongoing (3 years). There were no major complications in any case and no morbidity or mortality. Surgical treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor fundoplication gives the best and longest-lasting results in suitably selected patients. The extension of the myotomy and reduction in LES pressure are the most important parameters to achieve a good result.

SAGES guidelines for the surgical treatment of esophageal achalasia

The guidelines for the surgical treatment of esophageal achalasia are a series of systematically developed statements to assist surgeon (and patient) decisions about the appropriate use of minimally invasive techniques for the treatment of achalasia in specific clinical circumstances. It addresses the indications, risks, benefits, outcomes, alternatives, and controversies of the procedures used to treat this condition. The statements included in this guideline are the product of a systematic review of published work on the topic, and the recommendations are explicitly linked to the supporting evidence. The strengths and weaknesses of the available evidence are highlighted, and expert opinion is sought where published evidence lacks depth. Disclaimer

Robotic-assisted Heller myotomy for esophageal achalasia: feasibility, technique, and short-term outcomes.

Laparoscopic Heller myotomy is the standard surgical treatment for esophageal achalasia. The incidence of esophageal perforation is about 5-10%. Robotic-assisted Heller myotomy (RAHM) offers results at least as good as those from laparoscopic procedures, additionally yielding fewer intraoperative complications. The aim of this study was to demonstrate the safety and feasibility of RAHM and its value in the treatment of esophageal achalasia. We analyzed demographics, preoperative symptoms, esophagograms, esophageal manometry, intraoperative and postoperative data of all the patients who underwent RAHM for achalasia at three institutions: 36 women and 37 men, mean age 45±16 (13-87) years. Dysphagia was present in 100% of patients. Thirty-three patients (45%) had had previous endoscopic treatment: 23 patients had pneumatic dilation, four patients had Botox injections, and six patients had both. Surgical time averaged 119min (range of 62-211); blood loss averaged 23ml; no mucosal perforations were observed; length of hospitalization was 1.5days; there were no deaths. At 12months, 96% of patients had relief of their dysphagia. In conclusion, RAHM is safe and effective since there were no intraoperative esophageal perforations and relief of symptoms was achieved in 96% of the patients.

The Preoperative Manometric Pattern Predicts the Outcome of Surgical Treatment for Esophageal Achalasia

BackgroundA new manometric classification of esophageal achalasia has recently been proposed that also suggests a correlation with the final outcome of treatment. The aim of this study was to investigate this hypothesis in a large group of achalasia patients undergoing laparoscopic Heller–Dor myotomy. MethodsWe evaluated 246 consecutive achalasia patients who underwent surgery as their first treatment from 2001 to 2009. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored and barium swallow X-ray, endoscopy, and esophageal manometry were performed before and again at 6 months after surgery. Patients were divided into three groups: (I) no distal esophageal pressurization (contraction wave amplitude <30 mmHg); (II) rapidly propagating compartmentalized pressurization (panesophageal pressurization >30 mmHg); and (III) rapidly propagating pressurization attributable to spastic contractions. Treatment failure was defined as a postoperative symptom score greater than the 10th percentile of the preoperative score (i.e., >7). ResultsType III achalasia coincided with a longer overall lower esophageal sphincter (LES) length, a lower symptom score, and a smaller esophageal diameter. Treatment failure rates differed significantly in the three groups: I = 14.6% (14/96), II = 4.7% (6/127), and III = 30.4% (7/23; p = 0.0007). At univariate analysis, the manometric pattern, a low LES resting pressure, and a high chest pain score were the only factors predicting treatment failure. At multivariate analysis, the manometric pattern and a LES resting pressure <30 mmHg predicted a negative outcome. ConclusionThis is the first study by a surgical group to assess the outcome of surgery in 3 manometric achalasia subtypes: patients with panesophageal pressurization have the best outcome after laparoscopic Heller–Dor myotomy.

288 The Preoperative Manometric Pattern Predicts the Outcome of Surgical Treatment for Esophageal Achalasia

288 The Preoperative Manometric Pattern Predicts the Outcome of Surgical Treatment for Esophageal Achalasia

Approach to the Child Who Has Persistent Dysphagia After Surgical Treatment for Esophageal Achalasia

Approach to the Child Who Has Persistent Dysphagia After Surgical Treatment for Esophageal Achalasia

New concept on surgical treatment of esophageal achalasia

贲门失弛缓症是最常见的食管运动功能障碍性疾病,在西方国家其发病率为每年0.4～1.0/10万人口,在我国则缺乏贲门失弛缓症的流行病学资料.贲门失弛缓症的主要病理生理变化是吞咽时食管平滑肌部分缺乏蠕动和食管下括约肌不能松弛或松弛不全,引起患者的吞咽困难症状。

The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up

The aim of this study was to investigate the long-term clinical outcome of the laparoscopic Heller Dor procedure for esophageal achalasia. A total of 71 consecutive patients with a minimum 6 year follow-up were evaluated. These patients were seen at 1 and 6 months after the operation (at which time barium swallow, endoscopy, manometry, and pH monitoring were performed), and annually thereafter. A dedicated symptom score, that combined severity and frequency of symptoms was used. The median symptom score decreased from 22 (range, 9-29) preoperatively to 4 (range, 0-16) at last follow-up, (p < 0.01). During the follow-up period, 13 patients suffered symptom recurrence; seven of them (54%) had already been diagnosed at the 1-year follow-up. All of these patients were treated with complementary pneumatic dilations. Overall, at a minimum of 6- years after the operation, 81.7% of the patients were satisfied with the treatment and were able to eat normally. The long-term outcome of laparoscopic surgical treatment of esophageal achalasia is only slightly affected by the length of the follow-up and most of the symptomatic failures occur in the early period after the operation.

Surgical risk for patients with Chagasic achalasia and its correlation with the degree of esophageal dilation

To analyze the risk of cardiovascular complications in patients with indication for surgical treatment of Chagasic esophageal achalasia and to correlate the surgical risks with the degree of esophageal dilation, thereby proposing a risk scale index. One hundred and twenty-four patients with Chagasic esophageal achalasia, who received surgical treatment at the Hospital das Clinicas of the Federal University of Goias, were included in this study. The patients were mostly related to the postoperative complications due to the cardiovascular system. All the patients were submitted to: (1) clinical history to define the cardiac functional class (New York Heart Association); (2) conventional 12-lead electrocardiogram at rest; and (3) contrast imaging of the esophagus to determine esophageal dilatation according to Rezende's classification of Chagasic megaesophagus. An assessment of the functional classification (FC) of heart failure during the preoperative period determined that 67 patients (54.03%) were assigned functional class I (FC I), 46 patients (37.09%) were assigned functional class II (FC II), and 11 patients (8.87%) were assigned functional class III (FC III). None of the patients were assigned to functional class IV (FC IV). There was a positive correlation between the functional class and the postoperative complications (FC IXFC II: P<0.001; FC IXFC III: P<0.001). The ECG was normal in 44 patients (35.48%) and presented abnormalities in 80 patients (64.52%). There was a significant statistical correlation between abnormal ECG (arrhythmias and primary change in ventricular repolarization) and postoperative complications (P<0.001). With regard to the classification of the Chagasic esophageal achalasia, the following distribution was observed: group II, 53 patients (42.74%); group III, 37 patients (29.83%); and group IV, 34 patients (27.41%). There was a positive correlation between the degree of esophageal dilation and the increase in postoperative complications (grade IIXgrade III achalasia: P<0.001; grade IIXgrade IV achalasia: P<0.001; and grade IIIXgrade IV achalasia: P = 0.017). Analyzing these results and using a multivariate regression analysis associated with the probability decision analysis, a risk scale was proposed as follows: up to 21 points (mild risk); from 22 to 34 points (moderate risk); and more than 34 points (high risk). The scale had 82.4% accuracy for mild risk patients and up to 94.6% for the high risk cases. The preoperative evaluation of the cardiovascular system, through a careful anamnesis, an ECG and contrast imaging of the esophagus, makes possible to estimate the surgical risks for Chagas' disease patients who have to undergo surgical treatment for esophageal achalasia.

Tratamento do megaesôfago chagásico grau II por laparoscopia: experiência em 12 casos

OBJETIVO: Avaliar os resultados da cardiomiotomia com fundoplicatura parcial por vídeolaparoscopia (Heller-Dor) no tratamento de 12 pacientes portadores de megaesôfago grau II. MÉTODO: Foram analisados prospectivamente 12 pacientes com megaesôfago não avançado (grau II segundo classificação de Ferreira - Santos ), submetidos a cardiomiotomia à Heller por laparoscopia associado à confecção de vávula anti-refluxo ( fundoplicatura à Dor ), no Hospital Universitário da Universidade Estadual de Londrina, no período de Janeiro de 1999 a Dezembro de 2001. RESULTADOS: Não houve necessidade de conversão para laparotomia em nenhum caso. A pressão média do esfincter inferior do esôfago ( EIE ) no pré-operatório foi de 39,1 mmHg (normal de 15 a 30 mm Hg), e no pós-operatório (seis meses) de 12,5 mmHg. Em relação à sintomatologia pós-operatória, nove dos 12 pacientes ficaram assintomáticos, sendo que três pacientes apresentaram disfagia, sialorréia e pirose, respectivamente. Ocorreram três complicações intra-operatórias: dois casos de perfuração gástrica e um de perfuração esofágica. Não houve mortalidade no intra ou pós-operatório. CONCLUSÕES: Podemos concluir, baseado neste estudo, que a cardiomiotomia a Heller associada à fundoplicatura a Dor por vídeo-laparoscopia, após seis meses de acompanhamento, mostrou-se eficaz no tratamento do megaesôfago grau II.

Long-term results in surgically managed esophageal achalasia

The long-term clinical results of surgical treatment for esophageal achalasia were reviewed in 35 patients having a minimum follow-up of 10 years. Group A (n = 22) are those patients whose first procedure (myotomy and Belsey partial fundoplication) was done at our hospital. Group B (n = 13) are those who had undergone one or more previous operations elsewhere. In group A good to excellent results occurred in 21 / 22 patients (95%) at 1 year, 17 / 22 (77%) at 5 years, 15 / 22 (68%) at 10 years, 11 / 16 (69%) at 15 years, and 6 / 9 (67%) at 20 or more years. Two patients underwent early reoperation (2 and 5 years) for dysphagia due to incomplete myotomy. Three patients underwent esophagectomy (7, 19, and 23 years) and one patient underwent an antrectomy and Roux-en-Y diversion (23 years) for late-onset complications of reflux. Three of 13 group B patients had had multiple prior operations and had severe reflux damage at presentation and underwent immediate esophagectomy. Ten patients had one or more conservative operations in our hospital, and 4 of these eventually required esophagectomy for disabling reflux. Therefore, there were 10 patients (groups A + B) who underwent esophageal resection, all but 1 of whom had endoscopically documented reflux and 5 of whom had peptic strictures. Six of the 10 esophagectomies were performed more than 10 years (13 to 23 years) after the first operation. These data show that there is a deterioration of initially good results after surgical myotomy and hiatal repair for achalasia due to the late development of disabling reflux disease.

食道アカラシアの病態と外科的治療

1986年までの41年間に千葉大第2外科を訪れた食道アカラシア444例 (男200例, 女244例) の病態を食道X線, 内圧, 筋電図, 内視鏡および胃液検査で検討した.本症は内圧細分類によるA1, A2, A3型のごとき初期像 (食道緊張型) とB型のごとき末期像 (弛緩型) がある.本症に食道癌を合併した18例4.1%のうち病悩期間20年以上の症例は12例であった.外科治療を行った275例の遠隔追求245例中, 良好は165例, 軽快は43例と併せて84.9%が改善された.104例に施行された胃弁移植術の遠隔追求97例中, 良好91例, 軽快6例とすべて改善した.教室で再手術をした30例 (教室13例, 他施設17例) 45件の86.7%が通過障害を理由とした.再手術の方法は胃弁移植術14例がいずれも好成績であった.

AN EXPERIMENTAL STUDY ON TEMPORAL CHANGES OF POST-OPERATIVE ANTI-REFLUX EFFECT BY MODIFIED MARK IV OPERATION FOR ESOPHAGEAL ACHALASIA

This study was intended to elucidate possible temporal changes of the valve and fundoplication which are formed by modified Mark IV operation as a surgical treatment of esophageal achalasia. Heller's procedure was also studied in terms of its comparison with the above operation. Adult mongrel dogs were operated on as follows and studied at the following postoperative points: Heller's procedure at the forth postoperative week, Modified Mark IV operation at the forth postoperative week, Modified Mark IV operation at the third postoperative month. Postoperative comparative studies were made on temporal changes of the anti-reflux effect by intraesophagogastric pressure and withdrawal pH examinations, measurements of intragastric pressure at reflux through simultaneous evaluation of intraesophageal pH and inner pressures at 3 points, i.e. the esophagus, the high pressure zone and the stomach, and histological and morphological examination. From the above the following conclusion was drawn: The valve formed by modified Mark IV operation showed temporally a shortening tendency, and a significant shortening of the length of valve was observed also in comparisons of values between the forth postoperative week and the third postoperative month. Also in terms of the measurement of inner pressures, a significant decrease was observed in the length and the force of high pressure zone. However, comparisons of the intragastric pressure values at reflux revealed no significant difference in values between the forth week and the third month after the modified Mark IV operation and almost similar anti-reflux effects between both in spite of a shortening of the valve. The above results suggested that more reliable and long-term sustaining of the anti-reflux effect needed more extensive formation of the fundoplication.

Surgical treatment of esophageal achalasia in children

Ten cases of esophageal achalasia in children treated surgically are presented. A Wendel cardioplasty was employed in three cases, and a Heller myotomy in seven cases. Superior results were obtained with the Heller myotomy. Six cases are classified as excellent results, three cases showed significant improvement, and one case died of an unrelated cause. Differences between adult and childhood forms of achalasia are discussed.