178 RANDOMIZED CONTROLLED TRIAL COMPARING ANGLE OF HIS ACCENTUATION WITH TOUPET FUNDOPLICATION IN PATIENTS UNDERGOING LAPAROSCOPIC HELLERS MYOTOMY: INTERIM RESULTS

Laparoscopic Heller’s Cardiomyotomy (LHCM) is the surgical treatment of choice for achalasia. Addition of an antireflux procedure is recommended to reduce the postoperative reflux. However, there is no consensus regarding the ideal antireflux procedure. In an earlier study we have shown that Angle of His accentuation (AOH) is similar to Dor fundoplication. In this study we present the interim results of an RCT comparing AOH with Toupet fundoplication as an adjunct to LHCM. Methods Patients of Achalasia cardia presenting after October 2017 were randomised to receive either AOH or Toupet following Heller cardiomyotomy based on computer generated random sequence. Primary outcome was incidence of post-operative symptomatic reflux and esophagitis on endoscopy. Secondary outcome was relief of dysphagia and Achalasia specific health related Quality of life assessment (ASHRQoL). Symptom scores for dysphagia, regurgitation and heartburn as well as ASHRQoL were noted pre operatively and at 3 monthly intervals. Objective evaluation was done using timed barium swallow, Upper GI endoscopy and oesophageal manometry. Data was recorded on excel spreadsheet and analysis done using SPSS v5. Results A total of 52 patients (25 Toupet, 27 AOH) were included in the analysis. All patients were successfully operated laparoscopically with no conversions, intraoperative perforations or perioperative mortality. The mean operative duration was 128 min in the AOH group and 146 min in the Toupet group (p < 0.05). There was significant improvement in symptom scores as well as objective parameters in both groups with no difference between the 2 groups at a mean follow-up of 6 months (5-9 months; Table 1). 3 patients in AOH group (11%) and 4(16%) patients had new onset reflux with esophagitis in 2 patients in each group. Conclusion AOH is technically easier and can be performed in a shorter time. The symptom relief is similar in both groups with similar incidence of heartburn and esophagitis in the short term. A longer follow up is recommended in a larger number of patients.

Long-Term Outcomes of POEM for Primary Esophageal Motility Disorders

Since peroral endoscopic myotomy (POEM) emerged in 2010 as a treatment for achalasia, more than 7,000 procedures have been performed in the world. The main indication for POEM continues to be achalasia, which is a rare esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and aperistalsis. POEM has also been applied in other types of primary esophageal motility disorders. Short-term outcomes indicate that POEM has comparable results to laparoscopic Heller myotomy in terms of efficacy and safety. Studies show decrease in Eckardt scores after POEM as a reflection of symptomatic relief. Now, a decade after its introduction, long-term data have emerged for POEM and demonstrates that POEM remains effective and safe. Both POEM and laparoscopic Heller myotomy are associated with postinterventional gastroesophageal reflux disease (GERD). Antireflux mechanisms are disrupted during the procedures. However, the rate of GERD is higher after POEM than with laparoscopic Heller myotomy. Laparoscopic Heller myotomy is commonly performed with a partial fundoplication to reduce antireflux, but POEM is not typically combined with an antireflux procedure. Further studies should examine the long-term effects of postinterventional GERD.

Long-Term Follow-up Results of Children Undergoing Achalasia Surgery

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.

Esophageal Hiatus Hernia

A 83-year-old women presented to the emergency department with epigastric pain and vomiting that had progressively worsened over a period of 1 year. Her medical history was notable for type 2 diabetes and hypertension. A physical examination revealed that breath sounds were weakened. Her abdomen was soft, with moderate epigastric tenderness and normal bowel sounds. The rest of the physical examination was unremarkable. A radiograph of the chest confirmed compression of both lungs for unknown reasons (Figure 1A). Computed tomography (CT) of the chest revealed a large hiatus hernia containing almost the entire stomach (Figure 1B). A diagnosis of esophageal hiatus hernia was made. Hiatus hernia refers to a disease status involving herniation of the contents of the abdominal cavity, especially the stomach, through esophageal hiatus of the diaphragm into the mediastinum. It is accepted that the prevalence of hiatus hernia increases with age and body mass index. The typical symptom of hiatus hernia is gastroesophageal reflux and less common symptoms are epigastric or chest pain and dysphagia. It is necessary to make a critical risk-benefit assessment mandatory before complicated and surgical treatment of hiatus hernia, usually coupled with an antireflux procedure.8,9 After a well-informed discussion of treatment options with the patient and her family, the decision was made to pursue surgery. After the procedure, she clinically improved and was discharged home with outpatient follow-up.

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

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

A Team-Based Approach for Children With Congenital Cardiac Disease Undergoing Antireflux Procedure With Gastrostomy

Introduction Laparoscopic Nissen fundoplication with gastrostomy tube (LPNF-GT) placement is often indicated in children with congenital cardiac diseases (CCDs) for nutritional optimization. This study aims to evaluate institutional outcomes of LPNF-GT, with a team-based approach in operative management. Methods Five years of an institutional database at a tertiary care children’s hospital was queried for LPNF-GT in children with CCDs. Descriptive analyses were performed. A national comparison was performed utilizing the 2012-2013 Pediatrics NSQIP database, using propensity score matching. Outcome measures of interest were operative-time, unplanned readmission, and 30-day mortality. Results A team-based approach was utilized in 51 cases. Median operative time was 68.5 (IQR: 48-89) minutes. All patients tolerated tube feeds postoperatively. All patients survived 30 days post surgery. When compared to 136 similarly matched children nationally, the risk-adjusted operative time with a team-based approach was 47.38 (12.43-82.33) minutes shorter ( P < .05). There were no statistically significant differences in the likelihood of being in the hospital past 30 days, unplanned readmissions, and mortality ( P > .05). Conclusion LPNF-GT can be safely performed in children with CCDs. A team-based approach demonstrates improved operative time and achieved similar outcomes when compared nationally.

387 LAPAROSCOPIC REDO HELLER’S MYOTOMY FOR ACHALASIA FOLLOWING WORSENING OF SYMPTOMS DUE TO AN INADEQUATE MYOTOMY AND INAPPROPRIATELY CHOSEN ANTIREFLUX PROCEDURE.

This patient underwent Laparoscopic heller's cardiomyotomy and Nissen fundoplication for Achalasia cardia at another institute. Following surgery his dysphagia worsened. Dysphagia persisted despite balloon dilatation. Patient was evaluated at our institute with Barium swallow and CECT thorax which showed dilated oesophagus with tight wrap. Patient was planned for laparoscopic re exploration. At surgery he had a Nissen wrap and inadequate extension of myotomy across the GE junction. Methods The video describes the procedure of laparoscopic dismantling of the wrap with extension of Heller myotomy and a Toupet Fundoplication. Results Patient had an uneventful recovery and had significant improvement in dysphagia at a follow up of 7 months. Conclusion Nissen Fundoplication is not a good choice of antireflux procedure in achalasia cardia patients following Heller Myotomy and can contribute to dysphagia in the post operative period. Extension of myotomy across the GE junction is critical to the success of Heller myotomy. Re-do surgery is difficult but can be be accomplished through approach in experienced hands. Video https://drive.google.com/file/d/1dhs-PlUm-ahDGF63VxxM0htB0dRiAGYJ/view?usp=sharing

386 LAPAROSCOPIC HELLERS MYOTOMY AND ANGLE OF HIS ACCENTUATION FOR ACHALASIA CARDIA: 10 YEARS EXPERIENCE FROM A SINGLE SURGICAL CENTRE.

Achalasia is a rare disease with Laparoscopic Hellers cardio-myotomy (LHCM) being the gold standard surgical modality. An antireflux procedure is required along with myotomy to decrease the chances of reflux postoperatively. We have performed Angle of His Accentuation (AOH) as an anti-reflux procedure in 126 patients who underwent LHCM since 2010. This study presents the symptomatic and objective outcomes of LHCM with AOH. Methods Review of prospectively collected data of patients with Achalasia cardia undergoing LHCM with AOH from 2010–2019. Subjective symptoms were scored for dysphagia, heartburn, regurgitation and quality of life using scoring systems mentioned in table 1 and Achalasia specific health related Quality of life questionnaire (ASHRQoL). Objective tests included Timed Barium swallow, Endoscopy and high-resolution manometry. Patients were evaluated in pre and postoperative period at regular intervals. Success was defined as follows: Eckardt score of ≤3, Dysphagia score of 0/1, Regurgitation and heartburn score of 0, &gt;50% clearance on timed barium swallow, IRP &lt;15 and absence of esophagitis. Results 126 patients were operated during the study period with no mortality or conversion. Mean age was 33.5(years), symptom duration 49.8(months), 31 had preoperative dilatation. The mean operative time was 131 (minutes). Subjective outcome was available in all patients & objective data in 66. At median follow of 31 months (IQR 15–59) outcomes significantly improved (Table 1) with 93% having dysphagia relief. 14 (11%) had new onset heartburn; 6(4.7%) needed regular proton pump inhibitors. ASHRQoL improved significantly (59.51 to 19.57). Pre&post-operative IRP, Timed Barium and endoscopy available in 66,39 and 62 patients improved significantly. 6(9.6%) patients had endoscopic evidence of esophagitis (LA-A 3, B/C 3). Conclusion Laparoscopic Heller myotomy with Angle of His accentuation is safe simple and effective procedure for Achalasia cardia. It provides significant relief of symptoms, improvement in quality of life and improvement in objective parameters. Post- operative heartburn and esophagitis is acceptable. We recommend Angle of His accentuation as an adjunct to Laparoscopic Heller myotomy.