Underwent Heller Myotomy Research Articles

A comparative study of robotic and laparoscopic approaches to Heller myotomy

ObjectiveMinimally invasive Heller myotomy for achalasia is commonly performed laparoscopically, but recently done with robotic assistance. We compare outcomes of the 2 approaches. MethodsFrom January 2010 to January 2020, 447 patients underwent Heller myotomy with anterior fundoplication (170 with robotic assistance and 277 laparoscopically). End points included short-term and longitudinal esophageal emptying according to timed barium esophagram, symptom relief according to Eckardt score, and time-related reintervention. Normal esophageal morphology, present in 328 patients, was defined as nonsigmoidal with width <5 cm. We performed a propensity score--matched analysis to evaluate outcomes among robotic and laparoscopic groups. ResultsTimed barium esophagrams showed complete emptying at 5 minutes in 58% (77/132) of the robotic group and 48% (115/241) of the laparoscopic group in the short term (within 6 months of surgery). In the propensity-matched patients with normal esophageal morphology, the robotic group had a higher longitudinal prevalence of complete emptying of barium at 5 minutes (54% vs 34% at 4 years; P = .05), better intermediate-term Eckardt scores (1.7% vs 10% > 3 at 4 years; P = .0008), and actuarially fewer reinterventions (1.2% vs 11% at 3 years; P = .04). ConclusionsBoth robotically assisted and laparoscopic Heller myotomy had excellent outcomes in patients treated for achalasia. In a matched subgroup of patients with normal esophageal morphology within this heterogeneous disease, the robotic approach might be associated with greater esophageal emptying, palliation of symptoms, and freedom from reintervention in the intermediate term. Long-term analysis would be important to determine if this trend persists.

Overall Complications Following Robotic Heller Myotomy Are Lower Compared With Laparoscopy.

The use of robotics in foregut surgery has become more prevalent in the United States over the last 10 years. We sought to find the differences in the clinical outcomes of robotic surgery compared with traditional laparoscopy in patients undergoing Heller myotomy. A retrospective population-based analysis was performed using the National Inpatient Sample (NIS) database for the span of 2010 to 2015. All patients who underwent laparoscopic or robotic Heller myotomy were included. Weighted multivariable random intercept linear and logistic regression models were used to assess the impact of robotic surgery on patient outcomes compared with laparoscopy. There was a total of 11,562 patients with a median age of 54.2 years. Robotic Heller myotomy has a significantly decreased risk of overall complications for all centers (odds ratio=0.46; 95% confidence interval=0.29, 0.74). A subset analysis was performed looking specifically at high-volume centers (>20 operations per year), and overall complications remained lower in the robotic group. However, in high-volume centers, the robotic cohort did have a higher rate of esophageal perforation (2.7% vs. 0.8%, P<0.001). There was a higher length of stay in the laparoscopic Heller cohort (3.0 vs. 2.6 d, P=0.06) but higher overall charges in the robotic Heller cohort ($42,900 vs. $34,300, P=0.03). Robotic Heller myotomy is associated with lower overall complications and improved outcomes compared with laparoscopic Heller myotomy, even in high-volume centers. Robotic Heller myotomy is associated with a higher rate of esophageal perforations in high-volume centers despite the reduction in overall complications.

Minimally invasive, benign foregut surgery is not associated with long-term, persistent opioid use postoperatively: an analysis of the IBM® MarketScan® database.

It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use. Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365days postoperatively were estimated using log-binomial regression. A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365days postoperatively. Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.

Esophageal achalasia detected by vomiting during induction of general anesthesia: a case report

BackgroundEsophageal achalasia is a rare disease with a high risk of aspiration during anesthesia induction. Here, we describe our experience involving a case of undiagnosed esophageal achalasia with profuse vomiting during anesthesia induction.Case presentationA 58-year-old woman was scheduled for orthopedic surgery under general anesthesia. She vomited a large amount of watery contents during anesthesia induction, and planned surgery was postponed. After recovery from anesthesia, she informed us that she usually had to drink a large amount of water to get food into her stomach and purged watery vomit every night before sleep. However, she attributed it to her constitutional problem, not to a specific disease. She was subsequently diagnosed with esophageal achalasia and underwent Heller myotomy with Dor fundoplication before her re-scheduled orthopedic surgery.ConclusionsA detailed history of dysphagia and regurgitation should be taken in preoperative examinations to prevent unexpected aspiration due to undiagnosed achalasia.

Akalazya Nedeniyle Ameliyat Edilen Çocukların Uzun Dönem Sonuçları

Objective: Achalasia is a disease characterized by lower esophageal sphincter motility disorder. Whereas there is no clear algorithm in treating achalasia in children, Heller myotomy is known to be as the most effective method. Gastroesophageal reflux after myotomy is a frequently reported complication. Therefore, the fundoplication procedure should be added to the myotomy simultaneously. Our study aimed to present the results of patients who underwent Heller myotomy and fundoplication for achalasia. Materails and Methods: Twelve patients who underwent laparoscopic Heller myotomy with the diagnosis of achalasia between the 2006 and 2019 have been included in the study. Results: There were 12 children. 75% of them were male, and 25% were female. Laparoscopic Heller myotomy and antireflux procedure were applied to all patients. The average nasogastric withdrawal time was 1.75 days, the average time to start feeding was 2.25 days. The average hospital stay was 6.75 days. Dysphagia persisted in 3 patients who underwent Dor fundoplication and in 1 patient who underwent Toupet fundoplication at postoperative 3rd-week controls. It was observed that the symptoms improved after the one-time endoscopic dilatation procedure. Conclusion: Heller myotomy is gold standard method in the treatment of achalasia in children.We believe that partial fundoplication added to myotomy reduces the risk of GER.

To Wrap or Not to Wrap After Heller Myotomy.

Background and Objectives:The primary aim of this study is to assess the necessity of fundoplication for reflux in patients undergoing Heller myotomy for achalasia. The secondary aim is to assess the safety of the robotic approach to Heller myotomy.Methods: This is a single institution, retrospective analysis of 61 patients who underwent robotic Heller myotomy with or without fundoplication over a 4-year period (January 1, 2015 – December 31, 2019). Symptoms were evaluated using pre-operative and postoperative Eckardt scores at < 2 weeks (short-term) and 4 – 55 months (long-term) postoperatively. Incidence of gastroesophageal reflux and use of antacids postoperatively were assessed. Long-term patient satisfaction and quality of life (QOL) were assessed with a phone survey. Finally, the perioperative safety profile of robotic Heller myotomy was evaluated.Results:The long-term average Eckardt score in patients undergoing Heller myotomy without fundoplication was notably lower than in patients with a fundoplication (0.72 vs 2.44). Gastroesophageal reflux rates were lower in patient without a fundoplication (16.0% vs 33.3%). Additionally, dysphagia rates were lower in patients without a fundoplication (32.0% vs 44.4%). Only 34.8% (8/25) of patients without fundoplication continued use of antacids in the long-term. There were no mortalities and a 4.2% complication rate with two delayed leaks.Conclusion:Robotic Heller myotomy without fundoplication is safe and effective for achalasia. The rate of reflux symptoms and overall Eckardt scores were low postoperatively. Great patient satisfaction and QOL were observed in the long term. Our results suggest that fundoplication is unnecessary when performing Heller myotomy.

Long-term risk of adult overweight and obesity among achalasia patients who underwent Heller Myotomy.

It is unknown whether surgically treated achalasia cases regain or surpass their usual weight into obesity or overweight in the long-term post-operative period. Here, we aimed to assess the incidence of overweight/obesity (Ob/Ow) and the risk for reoccurrence up to 48months post-laparoscopic Heller myotomy (LHM). We performed a cohort of 114 achalasia cases undergoing LHM. All patients had a confirmed diagnosis of achalasia and had no added comorbidities. We followed up the body mass index (BMI) at the immediate post-operative period, and at one-, six-, 12-, 24-, and 48months after LHM. We measured the incidence of Ob/Ow and its reoccurrence risk with Cox regression. In the immediate post-operative period, the incidence of Ob/Ow was significantly less than the usual BMI (before the onset of symptoms) (28.2% vs 66.3%). From the sixth to the 48th month, there was a progressive increase in the incidence of Ob/Ow and at this timepoint the percent of Ob/Ow was not statistically different from the usual BMI. The most significant hazard for Ob/Ow reoccurrence in the long term following LHM is a usual BMI with obesity grade I or III and males lacking pre-surgical weight loss. Achalasia cases undergoing surgical treatment should be monitored closely in the post-operative period for weight regain, regardless of their pre-operative BMI. Notably, males who before the onset of symptoms were obese or overweight are at significantly increased risk of regaining or surpassing their weight, despite most having lost weight pre-surgically.

1735 A Rare Case of Coexisting Achalasia and Pseudoachalasia

INTRODUCTION: Achalasia is an esophageal motility disorder in which the lower esophageal sphincter fails to relax and there is a loss of esophageal peristalsis. Pseudoachalasia closely mimics achalasia. We present a rare case of a patient who was initially diagnosed with pseudoachalasia but was later found to have achalasia after symptoms persisted following the resection of an esophageal leiomyoma. CASE DESCRIPTION/METHODS: A 39 year-old male was evaluated for weight loss and progressively worsening dysphagia to solids and eventually liquids with a 100 pound weight loss over 3 years. Esophageal manometry was consistent with achalasia with esophageal compression, subtype II (Figure 1). He underwent laparoscopic exploration and planned Heller myotomy and Dor fundoplication. During surgery, a very large submucosal mass was found in the distal esophagus extending to the gastroesophageal junction. The mass was enucleated and a Dor fundoplication was performed. Pathologic analysis showed the mass to be a leiomyoma measuring 6.7 centimeters in maximum diameter (Figure 2). Postoperatively, his symptoms of dysphagia persisted andrepeat esophageal manometry remained consistent with achalasia. He underwent Heller myotomy and redo Dor fundoplication 5 months after the initial surgery. His symptoms completely resolved after the second surgery and he has remained asymptomatic on follow-up. DISCUSSION: Patients with achalasia typically present with progressive dysphagia, initially to solids and then to liquids, due to the degeneration of ganglion cells within the myenteric plexus in the distal esophagus resulting in the loss of peristalsis. Pseudoachalasia closely mimics the presentation of idiopathic achalasia and is the diagnosis in approximately 4% of patients with achalasia-like symptoms. Intraluminal evaluation with endoscopic ultrasound may be a valuable tool to evaluate muscular wall thickness in motility disorders and could result in earlier diagnosis of pseudoachalasia. Intraoperative esophageal pressure monitoring is not used frequently but may have also been beneficial in this case. This case is unique since the patient was discovered to have an esophageal leiomyoma after he was diagnosed with primary achalasia. There are no documented cases of a patient with both primary achalasia and pseudoachalasia based on a literature review.

Heller Myotomy for Epiphrenic Diverticula Compared to Nondiverticula Esophageal Motility Disorders, A Single Institution Experience and Appraisal of Patient Characteristics, High-Resolution Manometry and Outcomes

Purpose: The purpose of this study was to compare demographics, symptoms, prior interventions, operation, and outcomes of patients who underwent Heller myotomy for esophageal motility disorders and epiphrenic diverticulectomy with Heller myotomy. Methods: We identified all patients who underwent Heller myotomy for esophageal motility disorders with and without esophageal diverticulectomy over an 80-month period. Primary data points included patient demographics, presenting symptoms, prior intervention, high-resolution manometry, surgery performed with rate of laparoscopic, conversion to open, and open procedures; postoperative complications, and symptom resolution. Results: Over the study period, 308 Heller esophagomyotomy operations were performed on 301 patients. Of these, 277 cases were without epiphrenic diverticula and 31 included diverticula. One patient with an asymptomatic epiphrenic diverticulum did not undergo surgery was included, for a total of 32 diverticula patients. Six patients in the non-diverticula group and 1 in the diverticula group required a second operation for recurrent symptoms or residual diverticulum. The diverticula group was significantly older, had different manometry findings, required more open operations, and had longer length of stay. The diverticula group had a lower frequency of patients with prior interventions, but similar postoperative leaks, higher overall postoperative complications, and no difference in reported symptomatic improvement. Conclusions: Esophageal diverticula patients have a unique profile compare to patients with non-diverticula motility disorders. Operations are more complex, with increased complication rate and a longer length of stay. In spite of this, there is no statistically significant difference in symptomatic outcomes between the groups.

Reintervention After Heller Myotomy for Achalasia: Is It Inevitable?

Few studies of reintervention after Heller myotomy for achalasia set patients' expectations, assist therapeutic decision making, and direct follow-up. Therefore, we investigated the frequency and type of symptoms and reinterventions after myotomy based on achalasia type. From January 2006 to March 2013, 248 patients who had preoperative high-resolution manometry and a timed barium esophagram (TBE) underwent Heller myotomy, 62 (25%) for type I, 162 (65%) for type II, and 24 (10%) for type III achalasia. Postoperative surveillance, including TBE, was performed at 8 weeks, then annually. Median follow-up was 36 months. End points were all symptom types and modes of reintervention, endoscopic or surgical. Reintervention was based on both symptoms and objective TBE measurements. Eventually most patients (169 of 218; 69%) experienced at least one symptom after myotomy. Fifty patients underwent 85 reinterventions, 41 endoscopic only, 4 surgical only, and 5 both. Five-year freedom from reintervention was 62% for type I, 74% for type II, and 87% for type III, most occurring within 6 months, although later in type III. At 5 years, number of reinterventions per 100 patients was 72 for type I, 51 for type II, and 13 for type III. After each reintervention, there was approximately a 50% chance of another within 2 years. Patients' expectations when undergoing Heller myotomy for achalasia must be that symptoms will only be palliated, and patients who have worse esophageal function-achalasia type I-may require one or more postoperative reinterventions. Thus, we recommend that patients with achalasia have lifelong annual surveillance after Heller myotomy that includes TBE.

Return of Peristalsis After Heller Myotomy: A Rare Case

Achalasia is characterized by esophageal aperistalsis and failure of lower esophageal sphincter (LES) relaxation. Anatomical abnormalities lead to dysphagia, heartburn, regurgitation, epigastric or noncardiac chest pain. We present a case of a patient with achalasia II who had return of peristalsis after Heller myotomy. A 48-year-old female presented with dysphagia, regurgitation and a 40 lbs weight loss in 3 months. Significant past medical history of acid reflux disease, H. Pylori and a 9.5 pack year smoking history. On upper endoscopy (EGD) the gastroesophageal junction was tight and therapeutically dilated. High-resolution esophageal manometry (HRM) confirmed achalasia II with high-integrated relaxation pressure, and panesophageal pressurization. (Image 1) One month later, she underwent Heller myotomy with Dor fundoplication. Over the next 8 months her symptoms recurred requiring 3 dilations. Repeat HRM showed LES relaxation with a high normal IRP. There was esophageal compartmentalized pressurization, esophageal foreshortening and evidence of peristaltic contractions not seen on the prior HRM (Image 2). We believe her recurrent symptoms were due to the fundoplication. HRM increased understanding of achalasia and led to the Chicago Classification currently in version 3.0. Chicago Classification has 3 subgroups with achalasia under the first group. Literature review revealed a handful of patients with return of peristalsis after intervention. Ponce et al.1 and Parrilla et al.2 reported return of peristalsis in patients after Heller's myotomy. The subset of achalasia patients that regain peristalsis after correcting LES obstruction could be explained by three scenarios. First, HRM may inadequately differentiate EGJ outflow obstruction and achalasia. Second, this may be a very early diagnosis of achalasia. Third, this may be a new phenotype that becomes apparent after intervention. Functional lumen imaging probe (FLIP) topography may have an adjunct role for clear classification of phenotypes. Carlson et al.3 reported a 31% variability in achalasia II patients using FLIP topography compared to HRM. Further research and continued monitoring is required to properly diagnose and classify patients with return of peristalsis after therapeutic intervention.1706_A Figure 1 No Caption available.1706_B Figure 2 No Caption available.

PS01.015: TIMED BARIUM ESOPHAGRAM (TBE) IS RELIABLE IN DEFINING RESPONSE TO TREATMENT AFTER HELLER-DOR FOR ACHALASIA: INITIAL SINGLE CENTER EXPERIENCE

Abstract Background Routine timed barium esophagram (TBE), before and after Heller myotomy and Dor funduplication for achalasia, could offer the unique opportunity to objectively measure the outcome of the surgical procedure. In an initial single center experience we aimed at comparing pre-operative and post-operative TBE to objectively measure esophageal emptying and dilation, and to look for possible factors related to surgery results. Methods From 2016 to 2017, 11 patients underwent Heller myotomy and Dor funduplication for achalasia at a single center; all had a pre-operative and post-operative TBE after one month of surgery. TBE measured height and width of barium column at 1 and 5 minutes. All patients were staged according to radiological achalasia staging system: 1 patient was stage 1 (pre-operative esophageal width between 2 and 3 cm), 4 stage 2 (4–6 cm) and 6 stage 3 (&gt; 6 cm). TBE height and width at 1 and 5 minutes were compared between pre-operative and post-operative TBE by the Wilcoxon signed-rank test. Moreover the association between surgery results and possible risk factors was evaluated by Spearman's rho. Results TBE height and width at 1 minute decreased in median by 79% (range 17–100%) and 57% (37–100%), respectively, from pre-operative to post-operative TBE. The decrease was more pronounced at 5 minutes, where it was 85% (40–100%) and 71% (40–100%), respectively. Although all patients reported a significant subjective improvement in symptoms, radiological stage was associated to esophageal emptying: the 4 subjects in stage 2 and the subject in stage 1 had complete or near complete emptying at 5 minutes, while the 6 patients in stage 3 had a median percent decrease at 5 min in height of 75% (40–86%) and in width of 50% (40–71%) (Spearman's rho for height = -0.87, P &lt; 0.001; Spearman's rho for width = -0.88, P &lt; 0.001). Conclusion TBE is essential post myotomy, particularly if a substantial esophageal dilatation occurs pre-operatively (stage 3). Initial stage is associated with surgical outcomes, advanced stages being related to poorer emptying and more dilated esophagus after surgery. TBE is a reliable system to objectively define surgical outcomes and preserved esophageal function after Heller-Dor procedure. Disclosure All authors have declared no conflicts of interest.

Clinical factors and high-resolution manometry predicting response to surgery for achalasia in children

BackgroundEsophageal achalasia is an uncommon condition in children. Although many interventions exist for the management of this disorder, esophageal (Heller) myotomy offers one of the most durable treatments. Our institution sought to review patients undergoing Heller myotomy concentrating on preoperative clinical factors that might predict postoperative outcomes. Materials and methodsAll patients from January 1, 2007, to December 31, 2016, who underwent surgical treatment for achalasia at our tertiary pediatric hospital were identified and included in the study cohort. Electronic medical records for these patients were reviewed for clinical presentation variables, nonsurgical preoperative treatment, surgical approach, clinical response to surgery, need for postoperative treatment for ongoing symptoms, and high-resolution manometry (HRM) data. ResultsTwenty-six patients were included in the study, and all underwent myotomy with partial fundoplication (median age: 14.4 y [interquartile range 11.6-15.5]). At a median follow-up of 9.75 mo (interquartile range 3.5-21 mo), 16 (61.5%) patients reported good resolution of their dysphagia symptoms with surgery alone. Two patients (7.7%) had perforation of the gastrointestinal tract requiring surgical intervention. Eight patients (30.8%) required additional treatment for achalasia, with 5 (19.2%) of these undergoing additional surgery or endoscopic treatment. Patients who had preoperative dilation did not have good resolution of their dysphagia (n = 2; P = 0.037). Two of four patients undergoing postoperative dilation had preoperative dilation. None of these patients underwent preoperative manometry. There was a statistically significant difference in the ages of patients who required postoperative intervention and those who did not (14.1 versus 15.2 y old, respectively; P = 0.043). In patients who reported improvement of gastroesophageal reflux disease/reflux type symptoms after Heller myotomy, lower esophageal residual pressure (29.1 versus 18.7 mmHg; P = 0.018) on preoperative HRM was significantly higher than in those who did not report improvement after surgery. Higher upper esophageal mean pressure (66.6 versus 47.8 mmHg; P = 0.05) also predicted good gastroesophageal reflux disease/reflux symptom response in a similar manner. ConclusionsCurrent analysis suggests that preoperative dilation should be used cautiously and older patients may have a better response to surgery without need for postoperative treatment. In addition, preoperative HRM can aid in counseling patients in the risk of ongoing symptoms after surgery and may aid in determining if a fundoplication should be completed at the index procedure. Further research is needed to delineate these factors. Level of evidenceLevel III.

Value of routine timed barium esophagram follow-up in achalasia after myotomy

ObjectivesThe value of routine timed barium esophagram (TBE) in longitudinal follow-up of achalasia after Heller myotomy is unknown. We prospectively prescribed a yearly follow-up TBE. Purposes were to characterize esophageal emptying over time after myotomy, identify preoperative TBE measures associated with follow-up TBE, and characterize follow-up TBE over time in relationship to reintervention. MethodsFrom March 1995 to April 2013, 635 patients underwent Heller myotomy for achalasia; 559 had at least 1 follow-up TBE. Temporal trends of 1335 follow-up TBEs in all nonreintervention and reintervention patients were assessed. Multivariable longitudinal analysis identified preoperative TBE measures associated with follow-up TBE. ResultsOn average, TBE height and width at 1 and 5 minutes decreased approximately 50% and 60%, respectively, at first postoperative follow-up, and remained stable or slightly decreased for up to 5 years. Wider TBE width at 5 minutes was associated with greater follow-up TBE height and width at 1 minute. Of 118 patients undergoing reintervention, 64 (57%) had only 1 reintervention, with follow-up TBE returning to that of nonreintervention patients. Patients whose follow-up TBE remained abnormal underwent a further reintervention, some normalizing on subsequent TBE, and some not. ConclusionsFollow-up TBE is valuable postmyotomy, particularly if there is substantial esophageal dilatation preoperatively. Follow-up TBE reassures patients with stable or decreasing TBE measures, permitting decreased follow-up intensity. Reintervention should not be considered a myotomy failure, because a successful, single, nonsurgical reintervention often results in long-term successful palliation. More than 1 reintervention requires intensification of TBE follow-up, facilitating treatment planning.

Clinical Characteristics of Malignancy-associated Secondary Achalasia: An 18-Year Assessment at a Cancer Hospital

Introduction: Achalasia is an unusual disorder of esophageal motor abnormalities with an incidence of 1.6:100, 000 individuals. Achalasia secondary to neoplasia is extremely rare, the incidence is approximately 1:750,000 people. Achalasia in malignancy may be caused by direct infiltration of the lower esophageal sphincter, as a neoplastic infiltration of the myenteric plexus, pseudoachalasia, (PA) or as a paraneoplastic process. The purpose of this study is to evaluate the characteristics of achalasia associated with malignancy. Methods: Electronic medical records were retrospectively reviewed from January 1999 to May 2017 to identify patients with a diagnosis of achalasia and a malignancy. We identified 19 patients who had a nonesophageal malignancy and a diagnosis of achalasia. Age at diagnosis of cancer, at diagnosis of achalasia, sex, type of cancer and its stage, time interval between cancer and diagnosis of achalasia, treatment and responses were reviewed. Results: The median age at diagnosis of Achalasia was 56 years (19-85). There were 11 (58%) male and 8 (42%) female patients. The most common associated malignancy was Breast cancer, N=5 (27%), and Lymphoma, N=4 (21%). Other cancers included Lung, N=3 (16%), Carcinoid tumor, N=2 (11%), Myeloma, N=1 (5%), CLL, N=1 (5%), AML, N=1 (5%), Thymoma, N=1(5%) and Sarcoma, N=1 (5%). The median time interval between the diagnosis of cancer and a diagnosis of Achalasia was 58 months (range 2-120 months). In most patients the cancer diagnosis preceded the achalasia. All patients underwent confirmation by esophageal manometry. In 15/19 patients barium studies were available. All patients underwent endoscopy to rule out psuedoachalasia. In four patients achalasia was diagnosed before the cancer was diagnosed. The median time interval between Achalasia and onset of a primary malignancy in these patients was 24 months (range 12-72 months). Patients were treated for their primary cancers with chemotherapy, radiation and/or surgery. Eight patients underwent endoscopic dilatations, 11/19 had Botulinum Toxin A injection, 6/19 had both. Two underwent Heller myotomy. Response to treatment was favorable for 6 months after treatment, except in three patients. The median overall survival time was 3 years (0-16) after the achalasia onset. Conclusion: Malignancy associated secondary achalasia is very rare. The most common malignancy according to the literature is gastric but in our population breast cancer and lymphoma were seen.Table: Table. Clinical presentation of achalasia in cancer patients

Twenty-year trends in the utilization of Heller myotomy for achalasia in the United States

IntroductionTrends in the utilization of Heller myotomy for achalasia in the U.S. over time have not been previously described. Materials and methodsUsing the Nationwide Inpatient Sample (NIS) database, we analyzed patients undergoing Heller myotomy for achalasia over a 20-year period (1992–2011) to estimate rates of Heller myotomy, locations where the procedures were performed (rural, urban or teaching) and changes in technique (laparoscopic vs open) as well as outcomes of length of stay and in-hospital mortality. ResultsOver the last 20 years, the total number of Heller myotomies performed in the U.S. has increased (1576 cases in 1992 to 5046 cases in 2011, p = 0.001). These procedures are now being performed laparoscopically (0.9%–67.0%, p < 0.001) and at urban teaching hospitals (45.4%–77.1%, p < 0.001). In-hospital mortality has decreased (0.9%–0.3%, p = 0.006). Hospital length of stay has decreased from 7 days to 2 days (p < 0.001). DiscussionThese data show a trend of increasing utilization of laparoscopic Heller myotomy at teaching institutions with decreased in-hospital mortality and shorter LOS.

The evaluation of functional results before and after laparoscopic Heller myotomy for achalasia: a single center experience.

The aim of this study was to evaluate and compare the functional results before and after laparoscopic Heller myotomy for Iranian patients with achalasia. Achalasia is a severe neuromuscular disorder of the esophagus, characterized by the loss of peristalsis and an inability of the lower esophageal sphincter (LES) to reach optimal relaxation. In this cross sectional study, patients who underwent Heller myotomy for achalasia via laparoscopy in Taleghani Hospital Tehran, Iran were evaluated. Symptoms including pressure of residual, integrated relaxation sphincter (IRP), pressure of free drinking, pressure of LES, dysphasia score and peristalsis movement was measured and recorded by manometry before and after (2 months) treating with Heller myotomy. In this study, 23 patients with achalasia (12 females and 11 males) with a mean age of 30±3.5 years (minimum 20, maximum 44 years) who met the inclusion criteria of the study were examined. Results of this study showed that, all the diagnostic criteria that were measured before the treatment was significantly different from after the treatment (P<0.05). The average decline in LES, IRP, Residual Pressure, Free drinking esophagus, and dysphasia score were 23.1 mmHg, 16.24 mmHg, 18,7 mmHg, 18.9 mmHg, and 5.0 unit, respectively. Also the average increase of the peristalsis movement was 8.26±13.7 in 8 patients. Considering the results of Heller myotomy surgery can be as a treatment of choice for achalasia. Free Drinking pressure can be a suitable criteria after treatment for evaluation and prediction of the reducing the dysphasia score after the surgery.

Laparoscopic Heller Myotomy and Dor Fundoplication: Prospective Evaluation of 30 Consecutive Patients

Background: Prospective studies evaluating outcome of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia are less in Asian people. Objectives: This study conducted to evaluate the results of laparoscopic cardiomyotomy and partial fundoplication for achalasia. Patients and Methods: Thirty patients who underwent Heller myotomy for achalasia via laparoscopy in Alzahra hospital Isfahan, Iran were recorded prospectively (2009 - 2013). Median follow-up was 18 months. Symptoms including dysphagia, regurgitation, chest pain and weight loss were recorded before and after operation. Also, previous treatment for achalasia such as endoscopic pneumatic dilatations and intrasphincteric injection of botulinum toxin or other component, duration of symptoms and duration and complication of operation was recorded. Results: Among 30 patients, there were 13 (43.3%) females and 17 (56.7%) males, and mean age was 40.8 years (range, 20 - 68 years). The operations were finished laparoscopically in all patients. Mean operative time was 137 ± 36.2 minutes. The patients were symptomatic for at least 30 months before referring for surgery. There are some difficulties in dissection in cases who received Ethanolamine or Botholinum Toxin injection as non-surgical treatment before that. Mean hospital stay was 2.45 days. Regurgitation, chest pain and heartburn relieved significantly in median follow up of 18 months, in 100%, 66.6% and 70%, respectively (P < 0.001, P < 0.01 and P < 0.01, respectively). At that time, except for two (6.6%) patients, all other patients had improvement in dysphagia (P < 0.001) .The mucosa in two (6.6%) of patients was perforated on the gastric end of the xylotomy. The perforations were repaired laparoscopically with single suture without postoperative leak. Conclusions: Our study showed that laparascopic Helermyotomy with Dor fundoplication result in significant relief of dysphagia. Overall clinical symptoms indicate improvement in patient functional status during 18-month follow-up.

Intraoperative Assessment of Esophagogastric Junction Distensibility During Laparoscopic Heller Myotomy.

We sought to characterize the changes in esophagogastric junction (EGJ) distensibility during Heller Myotomy with Dor fundoplication using the EndoFLIP device. Intraoperative distensibility measurements on 14 patients undergoing Heller myotomy with Dor fundoplication were conducted over an 18-month period. Minimum esophageal diameter, cross-sectional areas, and distensibility index were measured at 30 and 40 mL catheter volumes before myotomy, postmyotomy, and following Dor fundoplication. Distensibility index is defined as the narrowest cross-sectional area divided by the corresponding pressure expressed in mm/mm Hg. Heller myotomy was found to lead to significant changes in the distensibility characteristics of the EGJ. Minimum esophageal diameter and EGJ distensibility increased significantly with Heller myotomy.

Limited Hiatal Dissection Without Fundoplication Results in Comparable Symptomatic Outcomes to Laparoscopic Heller Myotomy with Anterior Fundoplication.

Previous randomized controlled trials have demonstrated that partial fundoplication following Heller myotomy results in less pathologic acid exposure to the esophagus when compared to myotomy without fundoplication. Recent studies have questioned the necessity of a fundoplication, especially when a limited hiatal dissection (LHD) is performed and the angle of His is preserved. This is a retrospective review of prospectively maintained data. All patients underwent primary Heller myotomy for achalasia over a 30-month period. In select patients, an LHD was performed anteriorly. Symptomatic outcomes were assessed up to 2 years postoperation using the Achalasia Severity Questionnaire (ASQ), Gastrointestinal Quality of Life Index (GIQLI), and Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL). A total of 31 patients underwent Heller myotomy during the study interval. The majority of patients underwent Heller myotomy with full hiatal dissection (FHD) (21, 68%). Intraoperative mucosal perforations occurred in 3 (14%) patients undergoing FHD. Patient demographics, surgery details, and baseline symptomatic outcomes did not differ significantly preoperatively. At greater than 1 year postoperation, there was no significant difference between the groups for ASQ, GERD-HRQL, and GIGLI (P = .76, .78, and .33, respectively). Heller myotomy with LHD and no fundoplication and Heller myotomy with FHD and partial fundoplication result in similar GERD-related quality of life outcomes. Further studies (including pH studies) are necessary to determine if fundoplication is a necessary step in selected patients in whom an LHD is possible.