Fundoplication after Laparoscopic Myotomy for Achalasia

Introduction. Laparoscopic Heller?Dor operation, a standard method in the treatment of achalasia, has been performed at the Center for Esophageal Surgery of the First Surgical Clinic since April 2006. Objective. The aim of this study was to present this surgical procedure and initial experiences after 36 consecutive laparoscopic Heller?Dor operations. Methods. This partly retrospective, partly prospective study presented our results after laparoscopic Heller?Dor operation (presentation of the treatment method). We performed a standard anterior esophagocardioymiotomy, without releasing the posterior aspect of the cardia, and anterior partial fundoplication. The type and severity of symptoms and their duration were evaluated based on questionnaires fulfilled by patients. The diagnosis was made based on radiological, endoscopic and manometric findings. Laparoscopic surgery as the method of treatment was evaluated based on the duration of surgery, intra? and postoperative complications, time interval until the initiation of oral feeding, length of hospital stay, need for additional therapeutic measures after the operation and effect of surgery on the severity of symptoms. Results. Preopereratively, dysphagia was the predominant symptom in all patients, while regurgitation was much lower (44%). The average duration of operation was 127 minutes. Postoperative hospitalization lasted on the average 5.7 days. From 36 treated patients, 34 (94.4%) considered that the effect of treatment was good or excellent. Postoperative dysphagia was present in two patients (5.6%) and was successfully solved by balloon dilatation. Conclusion. Laparoscopic Heller?Dor operation is an effective and safe surgical procedure in resolving symptoms of achalasia and today presents the method of the first choice in the treatment of this disease.

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Laparoscopic myotomy in achalasia: intraoperative evidence for myotomy of the gastric cardia *

Diseases of the Esophagus ◽

10.1046/j.1442-2050.1999.00003.x ◽

1999 ◽

Vol 12 (1) ◽

pp. 30-36 ◽

Cited By ~ 20

Author(s):

P. E. Donahue ◽

M. Teresi ◽

S. Patel ◽

P. K. Schlesinger

Keyword(s):

Gastric Cardia ◽

Laparoscopic Myotomy

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655 EVALUATION OF THE MODIFIED DOR TECHNIQUE FOR SURGICAL TREATMENT OF ACALASIA

Diseases of the Esophagus ◽

10.1093/dote/doab052.655 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Author(s):

Fernando Freire Lisboa ◽

Nathan Xavier Gomes ◽

Pedro Arthur Nascimento Silva

Keyword(s):

Negative Impact ◽

Remission Rate ◽

Clinical Stage ◽

Stage I ◽

University Hospital ◽

Laparoscopic Myotomy ◽

Therapeutic Success ◽

Esophageal Motility Disorder ◽

Eckardt Score ◽

Before And After

Abstract Achalasia is the main esophageal motility disorder and has a significant negative impact on the patient's quality of life. Achalasia patients have dysphagia and vomiting, often associated with chest pain, leading to significant weight loss. The treatment of achalasia should be primarily to decrease the pressure of the lower esophageal sphincter. There are different therapeutic options for the treatment, and laparoscopic myotomy is the standard treatment, despite the improvement of new techniques such as POEM. Methods Prospective and retrospective study carried out in a university hospital with 33 patients with achalasia, operated with the wide myotomy technique associated with modified Dor fundoplication, from January 2017 to November 2020. The diagnosis was made by clinical, endoscopic, radiological and manometric studies. Symptomatic assessment and therapeutic success were performed using the Eckardt score before and after the operation. Rezende's classification was used to classify the degree of megaesophagus. The degree of megaesophagus was correlated with the result of the technique. The results were analyzed using the IBM SPSS Statistics Version 26 software. Results Patients with idiopathic achalasia 28 (84.8%). Preoperative Eckardt score average 5.93 points, preoperative clinical stage I = 7 (21.2%), clinical stage II = 12 (36.4%) and clinical stage III = 14 (42.4%). 48-hour postoperative hospital stay. Average postoperative Eckardt score 0.30 points, with 32 (97%) clinical stage 0, and 1 (3%) in clinical stage I in the postoperative period. Remission rate of the disease after treatment 100%. There was no correlation between the degree of the megaesophagus with the preoperative symptoms or with the therapeutic result. There were no complications or need for reintervention. There were no reports of symptoms of GERD. Conclusion According to clinical, radiological and endoscopic data, the technique was considered safe and effective for the treatment and regression of achalasia symptoms in all degrees of megaesophagus in the present study. In addition, the technique was also effective as an anti-reflux mechanism, preventing the onset of symptoms of iatrogenic GERD.

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P150 ULCERATING CMV ESOPHAGITIS – A UNIQUE COMPLICATION OF ACHALASIA

Diseases of the Esophagus ◽

10.1093/dote/doz092.150 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

F Corvinus ◽

H Neumann ◽

B Babic ◽

I Kovalets ◽

P Grimminger

Keyword(s):

High Resolution ◽

Complete Remission ◽

Symptom Relief ◽

Barium Swallow ◽

Residual Pressure ◽

Type Ii ◽

Laparoscopic Myotomy ◽

Inflammatory Infiltration ◽

High Resolution Manometry ◽

Endoscopic Placement

Abstract Aim Ulcerating CMV associated esophagitis in an immuncompetent patient has not been described before. This case report highlights diagnostic pitfalls in differentiating achalasia from pseudo achalasia. Background & Methods A 41-year-old man presented to the high resolution manometry lab with progressive retrosternal dysphagia and regurgitation. Endoscopy revealed a dilated esophagus with a passable stenosis of the esophagogastric junction. Between 27 to 39 cm a deep 3 x 12 cm ulcer reaching the lamina muscularis was detected. Biopsies were taken and processed to the institute for pathology and microbiology. A barium swallow revealed typical features of achalasia. A dilated hypomotile esophagus and a beak sign were seen. Histopathology described a deep ulcer with a mixed inflammatory infiltration without any signs for malignancy. The virology finally revealed a strong positivity for CMV in PCR. Therefor the diagnosis of CMV esophagitis was made. Reasons for an immunodeficiency (HIV, Trypanosoma pallidum etc.) could be excluded. After endoscopic placement of a probe, high resolution manometry was performed. It showed a disturbed EGJ relaxation, an enhanced residual pressure (IRP) and panesophageal pressurizations in almost every swallow. These are typical features of Type II Achalasia (Chicago Classification v 3.0). Results The patient received antiviral therapy (Ganciclovir) for 2 months. Only a moderate symptom relief was achieved. Endoscopic reevaluation showed a complete remission of the huge esophageal ulcer. There was no esophageal scar or other reason for EGJ obstruction. CMV was no longer detected. A second high resolution manometry confirmed again a Type II Achalasia. The patient underwent laparoscopic myotomy an 180° degree fundoplication. 6 months after the intervention the patient is well and has a complete remission of his symptoms. Conclusion Although ulcerating CMV esophagitis may be a cause of pseudoachalasia, in this case for the first time primary achalasia is described to be the reason for ulcerating CMV esophagitis.

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PS01.005: HIGH-RESOLUTION MANOMETRY GUIDING SURGICAL PROCEDURE FOR TREATMENT OF ACHALASIA OF THE ESOPHAGUS. LONG-TERM RESULTS OF A PROSPECTIVE STUDY

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps01.005 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 51-51

Author(s):

Tania Triantafyllou ◽

Georgia Doulami ◽

Charalampos Theodoropoulos ◽

Georgios Zografos ◽

Dimitrios Theodorou

Keyword(s):

High Resolution ◽

Prospective Study ◽

Conflicts Of Interest ◽

Long Term Results ◽

Type I ◽

Laparoscopic Myotomy ◽

Term Outcome ◽

Long Term Outcome ◽

High Resolution Manometry

Abstract Background Laparoscopic myotomy and fundoplication for the treatment of achalasia presents with 90% success rate. The intraoperative use of manometry during surgery has been previously introduced to improve the outcome. Recently, we presented our pilot study proposing the use of the HRM during surgery. The aim of this study is to evaluate the long-term outcome of the intraoperative use of High-Resolution Manometry (HRM) in achalasia patients. Methods In this prospective study, consecutive achalasia patients underwent laparoscopic myotomy and fundoplication along with real-time use of HRM. Eckardt scores (ES) and HRM results were collected before and after surgery. Results Twenty-three achalasia patients (22% Type I, 57% Type II, 22% Type III, according to Chicago Classification v3.0) with a mean age 48 years underwent calibrated and uneventful myotomy and fundoplication. Eleven myotomies were further extended, while sixteen fundoplications were intraoperatively modified, according to manometric findings. During postoperative follow-up, mean resting and residual pressures of the LES were significantly decreased after surgery (16,1 vs. 41,9, P = 0 and 9 vs. 28,7, P = 0, respectively). The ES was also diminished (1 vs. 7, P = 0). Conclusion The intraoperative use of HRM during laparoscopic myotomy and fundoplication for the treatment of achalasia of the esophagus is a safe, promising and efficient approach aiming to individualize both myotomy and fundoplication for each achalasia patient. Disclosure All authors have declared no conflicts of interest.

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PS01.030: ROBOTIC LAPAROSCOPIC HELLER-DOR FOR ACHALASIA: SINGLE INSTITUTION’S EXPERIENCE ON 89 FIRST PATIENTS

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps01.030 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 58-58

Author(s):

Jari Rasanen

Keyword(s):

Operative Time ◽

Conflicts Of Interest ◽

Symptom Relief ◽

Symptom Control ◽

University Hospital ◽

Dor Fundoplication ◽

Robot Assisted ◽

Proximal Stomach ◽

Laparoscopic Myotomy

Abstract Background Robotics allows precise dissection during the Heller-Dor. We wanted clarify whether this has produced good results in achalasia treatment of our patients in our institution. Methods We reviewed eighty-nine patients who were treated with robot-assisted laparoscopic Heller-Dor between October 2010 and January 2018 at Helsinki University Hospital. They all underwent laparoscopic myotomy for achalasia extending 8 cm onto esophagus and 3 cm onto proximal stomach with partial Dor fundoplication by two surgeons. Diagnosis of achalasia was confirmed by radiography, endoscopy, and manometry. Success of the myotomy was verified by intraoperative EGD, postoperative contrast radiography, and subjective postoperative symptom recording. Results There were 44 men and 45 women, with a mean age 43 + /- 15 years. Thirty-three percent of patients reported weight loss and 95% of patients experienced dysphagia at least once every week preoperatively. Mean operative time was 124 + /- 34 minutes. There were no conversions. Intraoperatively there were 6 patients with minor tears in mucosa of esophagus and 1 patient with minor tear in the mucosa of stomach. They were all recognized and repaired intraoperatively without any significant consequences to the patients (no deaths or ICU admissions). Median hospitalization was 4 days (2 - 17). Postoperatively 93% of patients reported significant improvement in dysphagia. All 6 patients with intra-operative mucosal tear experienced good or excellent symptom relief. Three of patients experienced significant pain in their esophagus even after surgery. All patients but 3 rated their overall symptom control either excellent or good after median follow-up of 31 months. Conclusion Robotic-assisted laparoscopic Heller-Dor is feasible with good median term results although some patients may experience intraoperative mucosal tears during the learning curve Disclosure All authors have declared no conflicts of interest.

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