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

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.

MINIMALLY INVASIVE TREATMENT FOR ACHALASIA OF CARDIA

Summary. Aim. The aim of the work is to evaluate the effectiveness of the minimally invasive technique in the treatment of patients with achalasia of cardia. Materials and methods. In the Department of Surgery of the digestive organs of the Institute from February 2017 to December 2019, comprehensive treatment was examined and carried out using balloon pneumatic dilatation (PD) and Heller laparoscopic myotomy (LMH) in 21 patients with achalasia cardia. Including Men 8 (38.1 %), women 13 (61.9 %) at the age of 28 to 75 years ((51.47 ± 3.63) years). Results and discussion. Using radiation methods for examining the diameter of the esophagus, patients were divided into 4 stages: stage I with an esophagus diameter of up to 4 cm — 5 (23.8 %), stage II — 4–6 cm — 6 (28.6 %), III — 6–8 cm — 5 (23.8 %), IV — more than 8 cm with an S-shaped curved configuration — 5 (23.8 %) patients. The duration of the disease is from one month to 8 years, on average (3.05 ± 0.49) years. The symptomatic treatment efficacy after PD according to the Eckardt scale was 66.7-76.2 %, while after LMH it was 80.0%. The level of relaxation efficiency of the lower esophagus according to manometry was achieved in 81 % of cases. The effectiveness of a barium esophagogram in changing the height of a barium column after a bolus was successful in 76.2-85.7 % of cases. There were no complications when performing balloon PD and LMH. Conclusions. Relapses of achalasia of cardia after balloon PD were established in the period from 2 to 10 months in 33.3 % of cases: 4.7 % in stage I and 9.5 % of cases in stages II, III, IV. With AK relapses in 5 (23.8 %) cases, repeated use of dilatation was ineffective. Performed by LMH and fundoplication Door. The efficiency of balloon PD was 66.7 % after the initial course and 76.2 % after the second course, and the LMH efficiency after the failed PD was 80.0 %.

P150 ULCERATING CMV ESOPHAGITIS – A UNIQUE COMPLICATION OF ACHALASIA

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.

P88 EXTENDING MYOTOMY BOTH DOWNWARDS AND UPWARDS IMPROVES THE FINAL OUTCOME IN MANOMETRIC PATTERN III ACHALASIA PATIENTS

Background Achalasia is at present classified in 3 manometric patterns. Pattern III is the most unfrequent pattern and is correlated with the worst outcome after all available treatments. We aimed to investigate the final outcome after classic laparoscopic myotomy (CLM) as compared with a longer laparoscopic myotomy both downwards and upwards with (LLM) in patients with pattern III achalasia. Methods The study population consisted of 61 consecutive patients with pattern III achalasia who underwent laparoscopic myotomy between 1997-2017. Patients who had already been treated with surgical or endoscopic procedures were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium-swallow, endoscopy, manometry were performed, before and after surgical treatment. In CLM the total length of the myotomy was ≤ 9 cm, while myotomies extended both downwards and upwards to a length >9 cm were defined as LLM. Results Of the 61 patients representing the study population, 24 had CLM and 37 had LLM. In addition, all the patients add an anterior, partial fundoplication (Dor). The patients’ demographic and clinical parameters (sex, symptom-score, duration of symptoms, esophageal-diameter) were similar in both groups. One mucosal perforation was detected and repaired intraoperatively in the LLM group. The median length of the myotomy was 8 cm (IQR:8-9) in the CLM and 10 cm (IQR:10-12) in the LLM (p<0.001). The median of follow-up was 94 months (IQR:52-126) in the CLM and 24 months (IQR:16-40) in the LLM. As a whole, the two groups had a different drop in their symptom score: 22 (17-26) versus 4 (0-8), and 20 (18-27) versus 3 (0-6) for the CLM and LLM respectively (p<0.01). Moreover, failures were 8/24 (33.3%) in the CLM and 4/37 (10.8%) in the LLM (p<0.05). An abnormal acid exposure was detected after the treatment in 4 patients of CLM and in 3 of LLM (p=n.s.). Conlcusions The extension of the length of the myotomy both downwards and upwards improves the final outcome of the laparoscopic Heller-Dor procedure in patients with pattern III achalasia. On the other hand, a longer myotomy does not influence the development of postoperative gastroesophageal reflux.

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

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.

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

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.

PS01.023: EXTENDING MYOTOMY BOTH DOWNWARDS AND UPWARDS FOR MANOMETRIC PATTERN III ACHALASIA PATIENTS IMPROVES THE FINAL OUTCOME

Background Achalasia is at present classified in 3 manometric patterns. Pattern III is the most unfrequent pattern and is correlated with the worst outcome after all available treatments. We aimed to investigate the final outcome after classic laparoscopic myotomy (length ≤ 8cm, CLM) as compared with a longer laparoscopic myotomy both downwards and upwards with (length > 8cm, LLM) in patients with pattern III achalasia. Methods The study population consisted of 50 consecutive patients with pattern III achalasia who underwent laparoscopic myotomy between 1997–2017. Patients who had already been treated with surgical or endoscopic procedures were ruled out. Patients before 2010 had a traditional CLM procedure while patients after 2010 had a LLM. Symptoms were collected and scored using a detailed questionnaire; barium-swallow, endoscopy, manometry (conventional or HRM) were performed, before and after surgical treatment. Results Of the 50 patients representing the study population, 23 had CLM and 27 had LLM. In addition, all the patients add an anterior, partial fundoplication (Dor). The patients’ demographic and clinical parameters (sex, symptom-score, duration of symptoms, esophageal-diameter) were similar in both groups. No intraoperative mucosal lesions were detected. The median length of the myotomy was 7 cm (IQR:7–8) in the CLM and 10 cm (IQR:10–11) in the LLM (P < 0.001). The median of follow-up was 61 months (IQR:35–93) in the CLM and 24 months (IQR:16–36) in the LLM. As a whole, the two groups had a different drop in their symptom score: 21 (17–26) versus 6 (0–8), and 21 (18–27) versus 3 (0–6) for the CLM and LLM respectively (P < 0.05). Moreover, failures were 7/23 (30%) in the CLM and 3/27 (11.1%) in the LLM (P < 0.001). An abnormal acid exposure was detected after the treatment in 4 patients of CLM and in 3 of LLM (P = n.s.). Conclusion In spite of intrinsic limitations of the study (retrospective, different time window of the two procedures and different follow-up), the extension of the length of the myotomy both downwards and upwards improves the final outcome of the laparoscopic Heller-Dor procedure in patients with pattern III achalasia. On the other hand, a longer myotomy does not influence the development of postoperative gastroesophageal reflux. Disclosure All authors have declared no conflicts of interest.

PS01.032: OUTCOMES OF MINIMALLY INVASIVE MYOTOMY FOR THE TREATMENT OF ESOPHAGEAL ACHALASIA

Background Laparoscopic Heller myotomy and fundoplication is considered today the treatment of choice for achalasia. The primary objective of this study was to review our experience in minimally invasive myotomy as primary therapy for the treatment of esophageal achalasia. Methods A retrospective analysis of a prospective database was made in which 253 clinical histories of patients diagnosed with EA were reviewed. These patients underwent primary laparoscopic Heller´s myotomy from January 2010 to December 2016. Duration of symptoms, previous endoscopic treatments, degree of dilation of the esophagus and clinical progress were some of the variables assessed. Postoperative assessment was obtained through the attending physicians’ consultations and recorded in the clinical history at six months and one year. Vantrappen and Helleman´s classification was used. Results 253 Heller´s myotomies were performed by laparoscopic approach. The mean age of the patients was 47 years (range, 16 to 86). Duration of the symptoms was between 7 and 360 months, with an average of 54 months. The mean operative time was 100 minutes (range 90–210). Average hospital stay was one day. There were no conversions and no mortalities. Four patients (1,1%) underwent redo surgery. The clinical progress was excellent in 98,5% of patients. Conclusion Laparoscopic myotomy is the first line of treatment of esophageal achalasia. In this series of patients, laparoscopic Heller´s myotomy was an effective and safe treatment for esophageal achalasia. Disclosure All authors have declared no conflicts of interest.

Dor fundoplication for achalasia of the esophagus: is it time to simplify the established technique? evaluation of clinical outcome

Background: Surgery is the most efficient treatment to achalasia of the esophagus with a success rate estimated 90%. Laparoscopic myotomy is combined with a fundoplication. One of the most common types of wrap is the anterior partial fundoplication, also known as Dor fundoplication. The 10% of surgical failure has been attributed to incomplete myotomy and/or tight fundoplication. The present study describes a modified anterior partial fundoplication that may have the potential to improve the clinical outcome of surgical treatment for achalasia.Methods: In this prospective study, we describe a modification of the standardized technique of Dor fundoplication applied to twenty-nine achalasia patients with intention to decrease the rates of failure. Short-term clinical result was evaluated with preoperative and six- months postoperative Eckardt scores (ES).Results: The mean number of months from initial symptoms to the time of diagnosis was 35.5 months (range 3-156 months). According to the Chicago Classification (CC v3.0), 11 patients (37.9%) were classified as achalasia type I, 17 (58.6%) as type II and 1 (3.4%) as type III. The mean ES was diminished from 7.8 to 0.6 postoperatively.Conclusions: The modification proposed in the present study omits the fixation of the right side of the myotomy to the right crus. This alteration may have the potential to anatomically and functionally affect postoperative rates of dysphagia and antireflux result among patients surgically treated for achalasia.