Management of Patients after Failed Peroral Endoscopic Myotomy: a Multicenter Study

Endoscopy ◽  
2020 ◽  
Author(s):  
Yervant Ichkhanian ◽  
Daniella Assis ◽  
Pietro Familiari ◽  
Michael B Ujiki ◽  
Baily Su ◽  
...  
Keyword(s):  
Clinical Success ◽  
Management Strategies ◽  
Laparoscopic Heller Myotomy ◽  
Peroral Endoscopic Myotomy ◽  
Pneumatic Dilation ◽  
Eckardt Score ◽  
Endoscopic Myotomy ◽  
Excellent Safety Profile ◽  
International Multicenter

Background and Aims: Although Peroral Endoscopic Myotomy (POEM) is highly effective for the management of achalasia, clinical failures may occur. The optimal management of patients who fail POEM is not well known. This study aims to compare the outcomes of different management strategies in patients who had failed POEM. Patients and Methods: This is an international, multicenter, retrospective study at 16 tertiary centers between 1/2012 and 11/2019. All patients who underwent POEM and experienced persistent or recurrent symptoms (Eckardt score (ES) > 3) were included. The primary outcome was to compare the rate of clinical success (ES ≤ 3) between different management strategies. Results: A total of 99 patients (50 (50.5%) males, mean age 51.4 (16.2) yrs.) experienced clinical failure during the study period with a mean ES of 5.5 (0.2). A total of 29 (32.2%) patients were managed conservatively and 70 (71%) underwent re-treatment [repeat POEM 33 (33%), pneumatic dilation (PD) 30 (30%), and laparoscopic Heller myotomy (LHM) 7 (7.1%)]. During a median follow-up of 10 (IQR: 3-20) months, clinical success was highest in patients who underwent repeat POEM (25/33 (76%), mean ES 2.1 (2.1)), followed by PD (18/30 (60%), mean ES 2.8 (2.3)), and LHM (2/7 (29%), 4 (1.8)) (p=0.12). A total of 11 (37.9%, mean ES 4 (1.8)) patients in the conservative achieved clinical success. Conclusion: This study comprehensively assessed an international cohort of patients who underwent management of failed POEM. Repeat POEM and PD achieved acceptable clinical success with excellent safety profile.

scholarly journals Peroral endoscopic myotomy (POEM) vs pneumatic dilation (PD) in treatment of achalasia: A meta-analysis of studies with ≥ 12-month follow-up

2021 ◽  
Vol 09 (07) ◽  
pp. E1097-E1107
Author(s):  
Andrew Ofosu ◽  
Babu P. Mohan ◽  
Yervant Ichkhanian ◽  
Maen Masadeh ◽  
John Febin ◽  
...  
Keyword(s):  
Clinical Success ◽  
Meta Analysis ◽  
Balloon Dilation ◽  
Final Analysis ◽  
Peroral Endoscopic Myotomy ◽  
Pneumatic Dilation ◽  
Type I ◽  
Eckardt Score ◽  
Endoscopic Myotomy

Abstract Background and study aims Peroral endoscopic myotomy (POEM) is increasingly being used as the preferred treatment option for achalasia. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of POEM versus pneumatic balloon dilation (PD). Methods We performed a comprehensive review of studies that reported clinical outcomes of POEM and PD for the treatment of achalasia. Measured outcomes included clinical success (improvement of symptoms based on a validated scale including an Eckardt score ≤ 3), adverse events, and post-treatment gastroesophageal reflux disease (GERD). Results Sixty-six studies (6268 patients) were included in the final analysis, of which 29 studies (2919 patients) reported on POEM and 33 studies (3050 patients) reported on PD and 4 studies (299 patients) compared POEM versus PD. Clinical success with POEM was superior to PD at 12, 24, and 36 months (92.9 %, vs 76.9 % P = 0.001; 90.6 % vs 74.8 %, P = 0.004; 88.4 % vs 72.2 %, P = 0.006, respectively). POEM was superior to PD in type I, II and III achalasia (92.7 % vs 61 %, P = 0.01; 92.3 % vs 80.3 %, P = 0.01; 92.3 %v 41.9 %, P = 0.01 respectively)Pooled OR of clinical success at 12 and 24 months were significantly higher with POEM (8.97; P = 0.001 & 5.64; P = 0.006). Pooled OR of GERD was significantly higher with POEM (by symptoms: 2.95, P = 0.02 and by endoscopic findings: 6.98, P = 0.001). Rates of esophageal perforation (0.3 % vs 0.6 %, P = 0.8) and significant bleeding (0.4 % vs 0.7 %, P = 0.56) were comparable between POEM and PD groups. Conclusions POEM is more efficacious than PD in the treatment of patients with achalasia during short-term and long-term follow-up, albeit with higher risk of abnormal esophageal acid exposure.

Advanced achalasia: good candidate for peroral endoscopic myotomy

2020 ◽  
Author(s):  
Shaotian Qiu ◽  
Ningli Chai ◽  
Yaqi Zhai ◽  
Xiangyao Wang ◽  
Yan Wang ◽  
...  
Keyword(s):  
Adverse Events ◽  
Clinical Success ◽  
Laparoscopic Heller Myotomy ◽  
Peroral Endoscopic Myotomy ◽  
Symptom Duration ◽  
Technical Success ◽  
Technical Success Rate ◽  
Eckardt Score ◽  
Endoscopic Myotomy ◽  
Favorable Safety

SUMMARY Peroral endoscopic myotomy (POEM) has been increasingly accepted as the first-line treatment of achalasia. However, laparoscopic Heller myotomy or esophagectomy still remains as the mainstay treatment for advanced achalasia featured with megaesophagus and/or sigmoid-shaped esophagus. Although the efficacy of POEM for advanced achalasia with sigmoid-shaped esophagus has been described, little is known about the role of POEM for patients with megaesophagus. The aim of our study is to evaluate the efficacy and safety of POEM for advanced achalasia with megaesophagus. Patients who received initial examinations and underwent POEM in our hospital from June 2013 to December 2018 were identified and data were retrospectively analyzed. The advanced achalasia was defined as megaesophagus with a diameter of ≥6 cm. The primary outcome was clinical success. The secondary outcomes were technical success and adverse events. A total of 112 patients (50 females, 44.6%) were included with a mean age of 44.8 years. The median symptom duration was 6.5 years (IQR:3.0–13.0 years). Modified POEM techniques were used in 27.7% (31/112) of patients. Technical success rate was 99.1% (112/113) per procedure. Clinical success was seen in 93.1% patients with median Eckardt score decreasing from 8.0 to 1.0 (P < 0.001) during a median 31.0 months of follow-up. The mean LES pressure decreased from 29.5 mmHg to 14.2 mmHg after POEM (P < 0.05). Procedure-related adverse events occurred in 8.9% patients. Reflux disease was observed postoperatively in 26.7% of patients. POEM is also indicated for patients with advanced achalasia with a favorable safety and efficacy.

Outcomes of peroral endoscopic myotomy in patients with achalasia and prior bariatric surgery: A multicenter experience

2021 ◽  
Author(s):  
S Bomman ◽  
J S Klair ◽  
M Ashat ◽  
R El Abiad ◽  
H Gerke ◽  
...  
Keyword(s):  
Bariatric Surgery ◽  
Clinical Success ◽  
Botulinum Toxin Injection ◽  
Clinical Success Rate ◽  
Peroral Endoscopic Myotomy ◽  
Pneumatic Dilation ◽  
Type I ◽  
Eckardt Score ◽  
Endoscopic Myotomy ◽  
The Mean

Summary Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was <3, and improvement of symptoms. Secondary outcomes were adverse event rates and symptom recurrence. Sixteen patients status post Roux-en-Y gastric bypass (n = 14) and sleeve gastrectomy (n = 2) met inclusion criteria. Indications for POEM were achalasia type I (n = 2), type II (n = 9), and type III (n = 5). POEM was performed either by anterior or posterior approach. The pre-POEM mean integrated relaxation pressure was 26.2 ± 7.6 mm Hg. The mean total myotomy length was 10.2 ± 2.7 cm. The mean length of hospitalization was 1.4 ± 0.7 days. Pre- and postprocedure Eckardt scores were 6.1 ± 2.1 and 1.7 ± 1.8, respectively. The overall clinical success rate was 93.8% (15/16) with mean follow-up duration of 15.5 months. One patient had esophageal leak on postprocedure esophagram and managed endoscopically. Dysphagia recurred in two patients, which was successfully managed with pneumatic dilation with or without botulinum toxin injection. POEM appears to be safe and effective in the management of patients with achalasia who have undergone prior bariatric surgery.

scholarly journals Per-oral endoscopic dual myotomy for the treatment of achalasia

Esophagus ◽  
2021 ◽  
Author(s):  
Xianglei Yuan ◽  
Zhe Feng ◽  
Yanshi Zhao ◽  
Xianhui Zeng ◽  
Liansong Ye ◽  
...  
Keyword(s):  
Adverse Events ◽  
Clinical Success ◽  
Mucosal Injury ◽  
Single Session ◽  
Eckardt Score ◽  
Endoscopic Myotomy ◽  
Favorable Safety ◽  
Per Oral ◽  
Disease Questionnaire

Abstract Background Repeat per-oral endoscopic myotomy is occasionally performed for persistent/recurrent symptoms in patients with achalasia, and yields favorable outcomes. We investigated a novel technique, per-oral endoscopic dual myotomy (dual-POEM), where a second myotomy was performed during a single session to augment the efficacy and avoid repeat interventions. The aim of this study was to evaluate its feasibility, safety and efficacy. Methods Consecutive patients diagnosed with achalasia who underwent dual-POEM (1/2018–5/2019) were prospectively collected and retrospectively analyzed. Patients with baseline Eckardt score ≥ 9, ≥ 10 years of symptoms, and/or having prior interventions other than myotomy received dual-POEM. The primary outcome was clinical success (Eckardt score ≤ 3). Secondary outcomes were procedure-related adverse events, change in lower esophageal sphincter (LES) pressure, and reflux complications. Results Seventeen patients received dual-POEM. Procedure-related adverse events were observed in 2 (11.8%) patients (mucosal injury and pneumonitis). Both were minor in severity. During a median follow-up of 33 months (interquartile range, IQR [31,35]; range, 19–36), clinical success was achieved in 16 (94.1%) patients. The median Eckardt score decreased from 9 (IQR [8, 11.5]; range 7–12) to 1 (IQR [1, 2]; range 0–4) (P < 0.001), and LES pressure decreased from 25.8 mmHg (IQR [21.7, 33.5]; range 17.7–46.3) to 7.4 mmHg (IQR [6.3, 10.4]; range 2.2–12.6) (P < 0.001). Seven (41.2%) patients developed postprocedural reflux either by gastroesophageal reflux disease questionnaire or esophagitis endoscopically, all successfully treated with proton pump inhibitors. Conclusion Dual-POEM preliminarily demonstrated high efficacy with a favorable safety profile in patients with achalasia with predictors of treatment failure.

TP6.2.14 Outcome of POEM (Per-oral endoscopic myotomy) for achalasia

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Annabelle White ◽  
Woochan Hwang ◽  
Alekhaya Kotta ◽  
Daniel Beasley ◽  
Katarina Chow ◽  
...  
Keyword(s):  
Clinical Success ◽  
Pneumatic Dilatation ◽  
Demeester Score ◽  
First Line Therapy ◽  
Eckardt Score ◽  
Operative Endoscopy ◽  
Endoscopic Myotomy ◽  
Oesophageal Achalasia ◽  
Per Oral

Abstract Aims Laparoscopic Heller’s myotomy (LHM) has been the surgical gold standard for treatment of oesophageal achalasia. Peroral endoscopic myotomy (POEM) has been proposed as an alternative technique. The aim of this study was to assess the safety and efficacy of POEM for achalasia in our unit. Methods We have operated on 202 patients for oesophageal achalasia since 2005: 107 had LHM, 86 had POEM, and 9 had an oesophagectomy. We assessed the clinical outcome of POEM comparing pre- and postoperative endoscopic, radiologic and manometric findings, as well as Eckardt-, GERD- and DsQoL score for achalasia. All follow-up patients were offered endoscopy. Results Data were completed for the first 45 POEM patients. The average age was 45 years. 18 patients (40%) had prior achalasia treatment. The median hospital stay was 2 days (2-5). There was no mortality, but 4 patients (9%) had post-operative complications. The median follow-up was 24 months (12-49). Clinical success (Eckardt score ≤ 3) was achieved in 39 patients (87%). Thirteen patients (29%) were taking PPIs for chest symptoms. Eleven of these underwent pH studies of whom only 1 had a DeMeester score &gt; 14.5. Of the 24 patients who had post-operative endoscopy, 40% was diagnosed with oesophagitis grade A, yet only 5 of them were symptomatic. Conclusions POEM appears to be safe and effective and warrants consideration as first-line therapy in expert achalasia centres. Longer term randomized studies comparing the outcomes of POEM with LHM and pneumatic dilatation will determine its place in the treatment of achalasia.

One-year results of gastric peroral endoscopic myotomy for refractory gastroparesis: a French multicenter study

Endoscopy ◽  
2020 ◽  
Author(s):  
Olivier Ragi ◽  
Jérémie Jacques ◽  
Julien Branche ◽  
Sarah Leblanc ◽  
Geoffroy Vanbiervliet ◽  
...  
Keyword(s):  
Success Rate ◽  
Multicenter Study ◽  
Clinical Success ◽  
Clinical Success Rate ◽  
Peroral Endoscopic Myotomy ◽  
Gastric Retention ◽  
Endoscopic Myotomy ◽  
Cardinal Symptom

Abstract Background: Data on the long-term outcomes of gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis are lacking. We report the results of a large multicenter long-term follow-up study of G-POEM for refractory gastroparesis. Methods: This was a retrospective multicenter study of all G-POEM operations performed in seven expert French centers for refractory gastroparesis with at least 1 year of follow-up. The primary endpoint was the 1-year clinical success rate, defined as at least a 1-point improvement in the Gastroparesis Cardinal Symptom Index (GCSI). Results: 76 patients were included (60.5 % women; age 56 years). The median symptom duration was 48 months. The median gastric retention at 4 hours (H4) before G-POEM was 45 % (interquartile range [IQR] 29 % – 67 %). The median GCSI before G-POEM was 3.6 (IQR 2.8 – 4.0). Clinical success was achieved in 65.8 % of the patients at 1 year, with a median rate of reduction in the GCSI score of 41 %. In logistic regression analysis, only a high preoperative GCSI satiety subscale score was predictive of clinical success (odds ratio [OR] 3.41, 95 % confidence interval [CI] 1.01 – 11.54; P = 0.048), while a high rate of gastric retention at H4 was significantly associated with clinical failure (OR 0.97, 95 %CI 0.95 – 1.00; P = 0.03). Conclusions: The results confirm the efficacy of G-POEM for the treatment of refractory gastroparesis, as evidenced by a 65.8 % clinical success rate at 1 year. Although G-POEM is promising, prospective sham-controlled trials are urgently needed to confirm its efficacy and identify the patient populations who will benefit most from this procedure.

Peroral endoscopic myotomy versus pneumatic dilation – result from a retrospective study with 1-year follow-up

2019 ◽  
Vol 57 (03) ◽  
pp. 304-311 ◽  
Author(s):  
Zhongqing Zheng ◽  
Chunshan Zhao ◽  
Shuai Su ◽  
Xiaofei Fan ◽  
Wei Zhao ◽  
...  
Keyword(s):  
Functional Data ◽  
Peroral Endoscopic Myotomy ◽  
Type I ◽  
Exact Test ◽  
Fisher's Exact Test ◽  
Eckardt Score ◽  
Reflux Symptoms ◽  
Fisher’S Exact Test ◽  
Endoscopic Myotomy

Abstract Background and aims On the basis of lesser rates of major adverse events and a short-term efficacy as Heller’s myotomy, there is a growing enthusiasm in favor of peroral endoscopic myotomy (POEM), whereas study comparing POEM and pneumatic dilatation (PD) is quite rare. The aim of this study was to evaluate the efficacy of POEM and PD in Chinese achalasia patients in a retrospectively designed study. Methods Patients with achalasia, who underwent either PD (n = 26) or POEM (n = 40) were retrospectively recruited from September 2010 through March 2016 at a single tertiary center. During the 1-year follow-up, clinical outcome and functional data of lower esophageal sphincter (LES) were recruited. Clinical symptoms were assessed by use of the Eckardt score. The primary outcome was therapeutic success (Eckardt score ≤ 3). Functional data of LES (4-second integrated relaxation pressure [4s-IRP], LES relax rate, and LESP) at baseline and 1 month after treatment were also evaluated. Data was analyzed by SPSS 13.0 version using a significance level of p < 0.05. Results The success rates were 24/26 (92.31 %), 25/26 (96.15 %), and 24/26 (92.31 %), respectively, with POEM, as compared with 35/40 (87.50 %), 29/40 (72.50 %), and 23/40 (57.50 %), respectively, with PD, 1 month, 3 months, and 1 year after treatment. Statistically significant difference was observed between the 2 therapies (at 3 months, Fisher’s exact test, p = 0.01; at 1 year, Fisher’s exact test, p < 0.0001). Compared with PD, the Eckardt score was lower with POEM 1 month, 3 months, and 1 year after treatment. More patients in POEM group reported gastroesophageal reflux symptoms (after 3 months 7/26 (26.92 %) vs. 2/40 (5.00 %), Fisher’s exact test, p = 0.01; after 1 year 6/26 (19.23 %) vs. 1/35 (2.86 %), Fisher’s exact test, p = 0.02). The postoperative 4s-IRP and LESP were both lower with POEM than with PD, respectively. Type I achalasia had a better response with POEM than with PD. Conclusion In this retrospective analysis with 1-year follow-up, POEM presents with a higher success rate and more reflux symptoms compared with PD. Change on LES function after treatment may explain the outcome in part. Type I achalasia may respond better to therapies compared with type II.

scholarly journals Two-Person Technique of Peroral Endoscopic Myotomy for Achalasia with an Advanced Endoscopist and a Thoracic Surgeon: Initial Experience

2016 ◽  
Vol 2016 ◽  
pp. 1-6 ◽  
Author(s):  
Madhusudhan R. Sanaka ◽  
Ramprasad Jegadeesan ◽  
Prashanthi N. Thota ◽  
Udayakumar Navaneethan ◽  
Rocio Lopez ◽  
...  
Keyword(s):  
Peroral Endoscopic Myotomy ◽  
Column Height ◽  
Therapeutic Success ◽  
Delayed Bleeding ◽  
Eckardt Score ◽  
Thoracic Surgeon ◽  
Endoscopic Myotomy ◽  
Barium Esophagogram ◽  
Timed Barium Esophagogram

Background and Aims. We initiated peroral endoscopic myotomy (POEM) utilizing a two-person technique with combination of an advanced endoscopist and a thoracic surgeon with complementary skills. Our aim was to determine the feasibility and outcomes in initial 20 patients. Methods. In this observational study, main outcomes measured were therapeutic success in relieving symptoms (Eckardt score < 3), decrease in lower esophageal sphincter (LES) pressures, improvement in emptying on timed barium esophagogram (TBE), and complications.Results. POEM was successful in all 20 patients with a mean operative time of140.1+32.9minutes. Eckardt symptom scores decreased significantly at two-month follow-up (6.4+2.9versus0.25+0.45,p<0.001). Both basal and residual LES pressures decreased significantly (28.2+14.1 mmHg versus12.8+6.3and22.4+11.3versus6.3+3.4 mmHg,p=0.025and <0.001, resp.). Barium column height at 5 minutes on TBE reduced from6.8+4.9 cm to2.3+2.9 cm (p=0.05). Two patients (10%) had mucosal perforations and one had delayed bleeding (5%).Conclusions.Two-person technique of POEM with combination of an advanced endoscopist and a thoracic surgeon is highly successful with low risk of complications.

scholarly journals Single-session endoscopic fundoplication after peroral endoscopic myotomy (POEM+F) for prevention of post gastroesophageal reflux – 1-year follow-up study

Endoscopy ◽  
2020 ◽  
Author(s):  
Amol Bapaye ◽  
Parag Dashatwar ◽  
Siddharth Dharamsi ◽  
Rajendra Pujari ◽  
Harshal P Gadhikar
Keyword(s):  
Gastroesophageal Reflux ◽  
Peroral Endoscopic Myotomy ◽  
P Value ◽  
Prior Therapy ◽  
Eckardt Score ◽  
Single Center Study ◽  
Endoscopic Myotomy ◽  
Endoscopic Fundoplication ◽  
One Year

Background and Aim Peroral endoscopic myotomy (POEM) is an established treatment for achalasia cardia (AC), however post-POEM gastroesophageal reflux (GER) remains a significant problem. Concomitant endoscopic fundoplication following POEM (POEM+F) was recently described to reduce post-POEM GER. This single-center study reports medium-term outcomes of POEM+F. Patients and Methods Retrospective analysis of prospectively maintained database of patients undergoing POEM+F. Abstracted data – demographics, achalasia type, pre-POEM Eckardt score (ES), prior therapy, follow-up. Follow-up was 3-monthly for one-year. Follow-up assessments included post-POEM ES, GerdQ score, EGD – wrap integrity and esophagitis, and pH studies. GER was defined according to Lyon consensus. Data was recorded as mean (SD) or median (IQR), P-value < 0.05 was considered statistically significant. Results 25 patients underwent POEM+F, mean age (SD) – 40.13 (13.66) years, 12 females. POEM+F was technically successful in 23/25 (92%). Significant dysphagia improvement was seen in all 25 (mean [SD] pre- and post-POEM ES 8.21 [1.08] and 0.1 [0.3] respectively, p < 0.05). Mean total procedure and fundoplication time (SD) – 115.6 (27.2) and 46.7 (12.4) minutes respectively. Time reduced significantly after initial 5 cases. Median follow-up was 12-months (IQR 9 – 13). Intact wrap was seen in 19/23 (82.6%). GER (abnormal EAET) was seen in 2/18 (11.1%); one reported GerdQ > 8. Borderline GER (asymptomatic grade A esophagitis, normal EAET) was identified in 4/22 (18.1%). Two (8%) minor delayed adverse events required no intervention. Conclusions POEM+F is safe and reproducible. At 12-months follow-up, incidence of post-POEM+F GER was low and acceptable.

THE SURGICAL TREATMENT OF ACHALASIA ON LAPAROSCOPIC HELLER MYOTOMY WITH DOR ANTIREFLUX PROCEDURE AT HUE CENTRAL HOSPITAL

2020 ◽  
pp. 97-102
Author(s):  
Dung Phan Dinh Tuan ◽  
Hung Dang Ngoc ◽  
Loc Le
Keyword(s):  
Heller Myotomy ◽  
Clinical Symptoms ◽  
Laparoscopic Heller Myotomy ◽  
Antireflux Procedure ◽  
Pneumatic Dilation ◽  
Motor Disorder ◽  
Eckardt Score ◽  
Esophageal Sphincter ◽  
Prospective Analyses

Background: Achalasia is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Diagnosis is confirmed by clinical symptoms, endoscopic, radiographic and manometric. Although pneumatic dilation has a role in the treatment of achalasia, laparoscopic Heller myotomy is considered by many experts as the best treatment modality for most patients with newly diagnosed achalasia. Objective: To evaluate the efficacy and safety of laparoscopic Heller myotomy with Dor antireflux procedure. Patients and Methods: Prospective analyses of the patients of achalasia undergoing laparoscopic Heller myotomy with Dor antireflux procedure from 01/2012 to 06/2020. We evaluated the data according to outcome measures, characteristics and treatment results of achalasia after laparoscopic Heller myotomy with Dor antireflux procedure. Results: We found 11 patients with achalasia were diagnosed and treated by laparoscopic. 100% of the patients have dysphagia, weight loss; 81.8% have chest pain and regurgitation. Mean operative duration was 148 ± 21 minutes. There was no complications had found in our patients. Follow-up after 3 - 6 months by Eckardt score show that 90.9% had a good result, 01 patient with persistent symtomps (Eckardt score > 3) had to undergo a pneumatic dilation. Conclusion: The results of the laparoscopic Heller myotomy with Dor antireflux procedure were safe and effective. Keywwords: Achalasia, laparoscopic Heller myotomy, Dor antireflux procedure

Sign in / Sign up

Export Citation Format

Share Document