P68 DEFINITIVE RESULTS OF THE HELLER MYOTOMY ASSOCIATED WITH THE DOR FUNDOPLICATION PERFORMED WITH INTRAOPERATIVE MANOMETRY FOR THE PRIMARY SURGICAL TREATMENT OF ESOPHAGEAL ACHALASIA: ONE CENTER EXPERIENCE

Objective In 1978 the Heller-Dor operation was proposed to accomplish new concepts of surgical pathophysiology: to abolish the lower esophageal sphincter with the division of the U-and sling fibers of the lesser gastric curvature, to prevent GER with an effective but not too effective partial fundoplication which protects the myotomy surface. Proponents performed this operation under intraoperative manometric control. We report on results we achieved in the period 1978-2016. Methods The Heller-Dor was performed in 367 patients (laparotomy 1978-1993, 209, 96 men; median age, 45 years; IQR 31.8–59.4 years, laparoscopy 1994-2016,158, 78 men; median age, 48 years; IQR 35.5–63.7 years; age p=0.166; gender p=0.346). Intraoperative manometry was performed and interpreted according to standard criteria. Follow-up consisted of periodical interview, endoscopy, barium swallow, which reports were graded in semiquantitative scales of evaluation. Results Mortality occurred in 1/209 (heart failure), 1/158 (coagulation disorder). Median follow-up was 193 months (IQR 137.1–273.4 months) in the laparotomy group, 95 months (IQR 71.1–140 months) in the laparoscopy group. Myotomy achieved the complete abolition of the high pressure zone in 100% of the patients in both groups. In the laparotomy group poor results were assessed in 22 (10.5%), for esophagitis in 15 and recurrent dysphagia in 7 with sigmoid achalasia. In the laparoscopy group poor results occurred in 7 (4.3%), 5 for esophagitis and 2 for recurrent dysphagia in sigmoid achalasia. In the second period the fundoplication was always sutured to the diaphragm to avoid slipping, the number of sigmoid esophagus cases decreased significantly. In the laparotomy group, gastroesophageal reflux and esophagitis appeared after a median period of 74.8 months since myotomy, recurrent dysphagia was evident shortly after surgery. Conclusions In light of the timing of appearance of causes of poor results assed in the laparotomy group, we consider the 95.7% of satisfactory results achieved with the laparoscopic Heller-Dor after 95 months median follow up, the indicator of potential of cure of this operation.

EXPERIENCE IN TREATMENT OF PATIENTS WITH ESOPHAGEAL ACHALASIA

Introduction: Esophageal achalasia is a neuromuscular disease, which is characterized by persistent impaired reflex opening of esophageal sphincter. Disease incidence is 0.6-2.0 per 100 000 population with no tendency to decrease. The aim of the study was to improve the results of treatment in patients with achalasia of cardia by differentiated approach in the choice of therapy method. Materials and methods:148 patients with esophageal achalasia aged 18 - 67 were studied between 2003 and 2018. The following degrees of the disease were determined (by Petrovskyi’s classification): first – in 8, second – in 59, third – in 70, fourth – in 11 patients. Drug therapy was administered in achalasia of first degree, and cardiodilatation courses - in second and third degree of the disease. Indications for surgical treatment were: impossibility to perform cardiodilatation, S-shaped esophageal deformation (stage IV), complications associated with cardiodilatation, achalasia combined with other surgical pathology, recurrence of disease. Review: Cardiodilatation therapy resulted in sustained clinical effect in stages I and II of the disease. In case of unsatisfactory results of cardiodilatation patients underwent elective operations. 18 patients underwent Heller-Dor plastic surgery, 4 – Heller-Petrovskiy operation, 1 – Besley plastic repair, 2 – Nissen fundoplication. In early postoperative period no failure or perforation of the esophagus occurred. The following complications developed: seroma – in 3 patients, postoperative wound infection – in 1 case. In one patient (4%) the recurrence of disease was due to scar deformation of esophagogastric junction after Heller-Petrovskiy operation on the cardia. Conclusions: Cardiodilatation is an effective method of conservative therapy in stages I and II of the disease, while in stages III and IV it is warranted as preoperative preparation measure. We think Heller-Dor operation to be the best method of plastic repair in esophageal achalasia.

Laparoscopic myotomy in achalasia cardia treatment: Experience after 36 operations

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.