Heller's myotomy without fundoplication: a series of 123 patients

INTRODUCTION: Surgical treatment of achalasia of lower oesophageal sphincter is Heller's myotomy, usually associated with a fundoplication due to an high risk of postoperative gastro-oesophageal reflux. The value of this fundoplication is discussed. The aim of this study was to evaluate retrospectively the results of Heller's myotomy without fundoplication but performed according to a precise technique preventing postoperative reflux. PATIENTS AND METHODS: Between 1975 and 1999, 123 patients underwent Heller's myotomy without systematic fundoplication. Diagnosis of achalasia was performed clinically and confirmed by investigations: baryum meal, fibroscopy and manometry. Myotomy was performed through an abdominal approach in 117 (95%) patients. Dissection preserved fixity of abdominal oesophagus in all cases, particularly its posterior meso. Myotomy was performed on abdominal oesophagus but not below the cardia. Posterior fundoplication was associated in 2 patients. RESULTS: One patient (0,8%) died from massive aspiration. Morbidity (1,6%) consisted in one peritonitis and one postoperative occlusion. At follow-up (mean = 5 years; range: 1-20), functional results were satisfying (excellent and good) in 112 (92%) patients. Seven patients (6%) developed postoperative reflux, including one who need surgical treatment. Dysphagia persisted in 3 patients (2%) who had to be reoperated. CONCLUSION: Results of this series show that systematic fundoplication is not necessary in Heller's myotomy for achalasia of lower oesophageal sphincter.     

Heller's cardiomyotomy compared with pneumatic dilatation for treatment of oesophageal achalasia.

The records of 30 patients treated for oesophageal achalasia between 1976 and 1988 were analysed retrospectively. Early and late results were collected to compare the safety and efficacy of Heller's myotomy (n = 13) and pneumatic dilatation (n = 17). Unsatisfactory immediate postoperative results were found in 4 of 13 of the patients who had undergone myotomy (31%) and in 4 of the 17 patients treated by pneumatic dilatation (24%). More patients had improved swallowing during the first postoperative year after myotomy, but this difference ceased with time. The severity of the symptoms affected the results, and dilatations that had to be repeated more than twice were ineffective. We conclude that pneumatic dilatation is as safe as Heller's myotomy, and that although the early results are significantly better after myotomy, the late results are similar.     

Achalasia of the cardia: long-term results of oesophagomyotomy and posterior partial fundoplication

Forty-eight patients with achalasia of the cardia were treated by Heller's myotomy with a posterior fundoplication of approximately 270 degrees, suturing the gastric fundus to the edges of the myotomy. The mean(s.d.) postoperative follow-up period was 5.4(2.8) years. The clinical results were good to excellent in 44 cases (92 per cent) and fair in four cases (8 per cent) (two with residual dysphagia and two with gastrooesophageal reflux). Barium studies showed a decrease in oesophageal diameter and disappearance of distal narrowing but normal oesophageal emptying did not occur. Postoperative manometric studies (29 patients) revealed a significant decrease in lower oesophageal sphincter pressure and a significant increase in the length of the infradiaphragmatic segment. In the oesophageal body a recovery of peristaltic waves in the proximal third was seen in ten of the patients (34 per cent). Twenty-four-hour pH monitoring showed pathological reflux in only three of 25 patients studied, and one of these was asymptomatic. This technique is effective, improving oesophageal symptoms and controlling long-term reflux.     

Clinical results of thoracoscopic Heller's myotomy in the treatment of achalasia.

OBJECTIVES: Ideal treatment for achalasia permanently eliminates the dysfunctional lower oesophageal sphincter, relieving dysphagia and regurgitation. The aim of this study was to review the results in a series of patients undergoing video-imaged thoracoscopic Heller's myotomy (THM). METHODS: Records of all patients undergoing THM by a single surgeon at one institution were analysed. Follow-up was conducted using a structured questionnaire together with oesophageal manometry and/or 24 h pH monitoring when clinically indicated. RESULTS: Twenty-five consecutive patients (13 males, 12 females, mean age 40.3+/-19.9 years) suffering from grade 4 dysphagia underwent THM between 1993 and 2001. Preoperative mean lower oesophageal sphincter (LOS) pressure was 42.6+/-6.3 mmHg. Seven patients (28%) had undergone previous pneumatic dilatations. There were no hospital deaths and no oesophageal perforations. Length of hospital stay was 4.3+/-1.8 days. One patient died 3 years after surgery from unrelated causes. At follow-up of 5.4+/-2.1 years, freedom from any reintervention was 95.8% (23/24). Eleven patients (45.8%) were asymptomatic. In patients with residual or recurrent symptoms (n=13), their severity was significantly reduced from the preoperative period (dysphagia score 1.7+/-0.8 versus 4+/-0; P相似文献   

Long-term clinical results of thoracoscopic Heller''s myotomy in the treatment of achalasia

OBJECTIVE: The aim of this study is to review the immediate and long-term results of video-imaged thoracoscopic Heller's myotomy (THM). METHODS: All patients undergoing THM by a single surgeon at one institution were analysed. Follow-up was conducted using a structured questionnaire and oesophageal manometry and/or 24h pH monitoring were undertaken when clinically indicated. RESULTS: Fifty-six consecutive patients (32 males, 24 females, mean age 45+/-18.7 years) suffering from grade 4 dysphagia underwent THM between January 1992 and March 2006. Preoperative mean lower oesophageal sphincter (LOS) pressure was 38.4+/-10.6 mmHg. Eighteen patients (32.1%) had undergone previous pneumatic dilatations. There were no hospital deaths. Oesophageal perforation occurred in two patients; one repaired thoracoscopically and one at thoracotomy. Mean hospital stay was 4+/-1.37 days. At mean follow-up of 5.9+/-4.66 years, freedom from any reintervention was 87% (49/56). Twenty-nine patients (52%) were asymptomatic. In patients with residual or recurrent symptoms (n=27), their severity was significantly reduced from the preoperative period (dysphagia score 1.37+/-0.77 vs 4.00+/-0; p<0.001). Seven patients (12.5%) with troublesome residual or recurrent grade 3-4 dysphagia underwent repeat oesophageal manometric study, showing a mean reduction in LOS pressure from their baseline values of 46.8+/-6.1-30.0+/-5.4 mmHg (p<0.001). Of these patients, three patients with grade 4 dysphagia were reoperated: one open Heller's myotomy and two by cardia resection. Eleven patients complained of troublesome postoperative heartburn; distal oesophageal acid exposure was shown to be abnormal in nine patients (16.9%) and all were successfully managed with medical therapy. CONCLUSION: The results of thoracoscopic treatment for achalasia are at least equivalent to historical outcomes obtained with open surgery but the patient is spared major thoracotomy or the acid reflux associated with a laparoscopic approach.     

Oesophagectomy in the management of end-stage achalasia - case reports and a review of the literature

Achalasia is an oesophageal motility disorder characterised by aperistalsis and failure of relaxation of a hypertensive lower oesophageal sphincter. Treatment intent targets the sphincter, and either Heller's myotomy or pneumatic dilatation successfully relieves dysphagia in the majority of cases. End-stage achalasia, typified by a massively dilated and tortuous oesophagus, may occur in patients previously treated but where further dilatation or myotomy fails to relieve dysphagia or prevent nutritional deterioration, and oesophagectomy may be the only option. We describe two patients with end-stage achalasia and nutritional failure despite exhaustive conventional therapy including pneumatic dilatation and surgical myotomy. Both patients were successfully managed with transhiatal oesophagectomy and cervical gastro-esophageal anastomosis, with excellent symptomatic control and improved quality of life. These cases are discussed and the literature reviewed.     

Dor fundoplication after Heller myotomy: Six years of experience in a single centre

Objective

The current study evaluates six years of experience with laparoscopic Heller myotomy and Dor fundoplication for achalasia in a single-centre and single-surgeon series.

Materials and Methods

From 2004 to 2010, 40 patients underwent Heller myotomy followed by Dor fundoplication. Before and after surgery, clinical evaluation and instrumental examinations were performed; clinical evaluation involved a modified De-Meester symptom score system, while instrumental examinations included upper gastrointestinal barium meal, oesophageal manometry, upper endoscopy, and pH monitoring. Changes in clinical and instrumental data before and after surgery were assessed by the evaluation of the differences in DeMeester scores and the investigation of both the oesophageal diameter and resting LES (lower oesophageal sphincter) pressure during patient follow-up, respectively.

Results

Heller-Dor treatment significantly improved both dysphagia and regurgitation symptoms (p-values <0.001). Specifically, the DeMeester mean score for dysphagia changed from 2.88 ± 0.34 to 0.81 ±0.54 points, showing a significant estimated adjusted mean reduction of 2.08 points; the DeMeester mean score for regurgitation fell from 2.09 ± 0.53 to 0.16 ± 0.37 points, showing a significant estimated adjusted mean reduction of 2.00 points. Furthermore, our findings suggested that preoperative resting LES pressure was a statistical significant predictor of dysphagia symptom improvement: the greater the baseline preoperative resting LES pressure, the more the improvement in dysphagia symptoms (p<0.001). No statistical associations with symptom improvement were found as regards the baseline oesophagus diameter. Moreover, significant estimated reductions of both oesophageal LES pressure (p-value for linear trend <0.001) and oesophagus diameter (p-value for linear trend=0.005), at baseline and after 5,10,15,30 months post surgery were also observed.

Conclusion

Laparoscopic Heller myotomy with a Dor fundoplication is an excellent approach for achalasia, and preoperative resting LES pressure could be a relevant predictor of dysphagia symptom improvement.     

Esophageal manometry in patients with achalasia]

Fifty-eight patients with achalasia were evaluated by esophageal manometry. In the body of the esophagus, the resting pressure was elevated and the motor waves were typically of low amplitude and presented simultaneously. The LES was of normal or high tone with absent or reduced relaxation in response to deglutition. The authors noticed that the contraction pressure in the pharynx and the resting and closing pressures in the UES were markedly elevated. These features were not documented in the literature. Twenty-two patients were followed up by manometry 4 to 60 months after a Heller's myotomy. The resting pressures in the body of the esophagus and the LES were obviously reduced. We considered that esophageal manometry is an important method in the diagnosis of achalasia.     

Radionuclide esophageal transit assessment in patients after Heller's myotomy in achalasia

Radionuclide transit (RT) assessment of esophageal clearance was carried out in 40 patients after Heller's myotomy for achalasia and in 13 normal subjects as controls. The results showed that RT was significantly delayed irrespective to the length of postoperative period. This explained the cause of swallowing disorders in most patients after surgery. Our observation suggested that Heller's myotomy should be done as early as possible for the purpose of preventing esophageal dilation although esophageal peristalsis can not be restored by this procedure.     

Achalasia of the cardia in children

Fifteen children with achalasia treated surgically over a period of 21 years are reported. All had a modified Heller's myotomy as a primary treatment. The thoracic approach was used in five and the abdominal route in ten. In three patients the myotomy was confined to the oesophagus. Six patients had antireflux procedures at the time of initial myotomy. The mean follow-up period was 6.2 years. Nine patients had excellent results, three had good results, two had fair results and one had a poor result. Of the nine children who did not have an antireflux procedure, three developed symptomatic and radiologically proven gastro-oesophageal reflux. The results of myotomy in children with achalasia are satisfactory but a significant number may develop gastro-oesophageal reflux. We believe that a modified Heller's myotomy combined with a short loose Nissen fundoplication should be the primary treatment of achalasia in children.     

Laparoscopy or thoracoscopy for achalasia

Achalasia is an esophageal motor disorder of unknown etiology. Typical manometric findings include aperistalsis of the esophageal body coupled with elevated pressure and incomplete relaxation of the lower esophageal sphincter during swallowing. Medical treatments consist of pneumatic dilatation or injections of botulinum toxin. Surgical treatment consists of Heller's myotomy with or without an antireflux procedure. Relief of dysphagia symptoms can be achieved in 85% to 94% of patients undergoing surgical treatment. In the past decade, the minimally invasive approach for the treatment of achalasia has been proven feasible, safe, and effective. We review the role of thoracoscopy and laparoscopy and address controversies in the management of patients with achalasia.     

Surgical management of achalasia in Zaria, Northern Nigeria

BACKGROUND: Achalasia of the cardia is generally considered a rare disease. Because the cause is uncertain, treatment is palliative and directed at relieving distal oesophageal obstruction. In developed countries, several treatment options are available, but in developing countries, achalasia is usually treated by open surgical myotomy. We reviewed the outcome of management of achalasia in our patients and the influencing factors. PATIENTS AND METHODS: We retrospectively reviewed all adult patients treated for achalasia between 1991 and 2006. Diagnosis was based on clinical symptoms and barium swallow examination. The severity and frequency of dysphagia were determined before and after treatment. Barium examination was repeated 2 weeks after surgery or when the patient had recurrence of dysphagia, regurgitation or heartburn. Treatment was by modified Heller's operation, transabdominally without complementary antireflux procedure. Logistic regression modelling was performed to identify factors predictive of poor outcome. RESULTS: There were 47 patients, 31 (66.0%) males and 16 females, mean age (+/- standard deviation (SD) 34.6+/-9.8 years. All patients presented with dysphagia, which was severe in 31 cases (66.0%) and moderate in 14 (29.8%). Preoperative maximum oesophageal diameter ranged from 34 to 89 mm, mean 67.4+/-12.7mm. In 30 (63.8%) of the patients, the maximum diameter was >70 mm. Postoperative maximum diameter ranged from 28 to 72 mm, mean 37.5+/-8.2 mm (p=0.001). The mean preoperative diameter of the narrowest distal oesophagus was 4.6+/-2.5 mm, compared with the postoperative figure of 11.6+/-1.8 mm (p=0.015). Following surgery, 41 (87.2%) patients had complete relief of dysphagia, regurgitation and heartburn. Four patients continued to have heartburn after surgery. Patients with severe dysphagia or preoperative oesophageal dilatation >70 mm had the greatest likelihood of incomplete relief of symptoms after treatment. CONCLUSION: Achalasia can be accurately diagnosed on the basis of clinical symptoms and barium swallow examination. A modified Heller's operation provides lasting relief of symptoms. Patients with severe preoperative dysphagia or oesophageal dilatation are more likely to have poor outcome of treatment.     

Transthoracic oesophagomyotomy in the treatment of achalasia--a 15-year experience

Oesophageal achalasia was treated with modified Heller's oesophagomyotomy in 51 patients (19 males, 32 females) via thoracotomy in 47 cases and thoracoscopy in 4 cases. A Belsey Mark IV antireflux procedure was added to transthoracic oesophagomyotomy in two cases, because of extended cardiomyotomy. There were no hospital deaths. The overall improvement rate was 93.5%, with excellent results in 80.6%. Postoperative follow-up averaged 7.4 years. In all four cases of thoracoscopic oesophagomyotomy, simultaneous oesophagoscopy was performed to facilitate the procedure. One patient required repeat surgery 2 months later because of inadequate myotomy. Thirty-one patients, including three with severe gastro-oesophageal reflux, received long-term medication. Barrett's oesophagus developed in two of the 31 patients (6.5%) 4.7 and 7.6 years, respectively, after myotomy and squamous cell carcinoma was diagnosed in a 44-year-old woman 2.2 years postoperatively. The study suggests that transthoracic oesophagomyotomy without antireflux procedure can provide excellent long-term relief of dysphagia in oesophageal achalasia and carries a low risk of serious postoperative complications.     

术中食管测压对改良Heller手术的指导价值

目的 探讨改良Heller手术中食管下括约肌的压力变化,确定食管、贲门肌层切开的长度和比例.方法 2006年5月至2007年12月采用改良Heller加Toupet抗反流手术治疗贲门失弛缓症患者15例,其中男性6例,女性9例;年龄28～61岁,术前病程6个月～9年.利用台式高分辨八通道胃肠动力监测系统,术中采用定点牵拉法监测食管下段四个方向食管下括约肌压力变化,并测量食管、贲门肌层切开的适宜长度.结果 全组无手术夕匕亡病例.食管贲门肌层切开的长度为5～8 cm.当食管侧切开长度为(5.3±1.5)am时,胃-食管连接处括约肌压力切开侧由(33.6±13.3)mm Hg(1 mm Hg=0.133 kPa)降至(9.7±4.6)mm Hg.胃侧切开长度(0.8±0.4)cm后,压力降至(4.8±3.1)null Hg.食管、贲门肌层切开前后,食管下括约肌压力明显降低(P<0.05).结论 术中食管测压可指导改良Heller于术中食管、贲门肌层切开的长度,为提高改良HeUer手术技术提供有用的信息.     

The diagnosis and therapy of dysphagic disorders of the LES

Primary motor disorders of LES causing dysphagia consist in cardial achalasia and intermedius motor disorder (IMD), the last one different from achalasia because of normal motor pattern of the esophageal body. In this paper diagnostic and therapeutic procedures are examined according to an experience of 94 surgically treated cases (22 rioperations for surgical failures). Cardial dilatation as treatment of choice is recognized only for IMD in which a normal peristaltic behaviour of the esophagus can avoid the high danger of GER. Surgical procedure, now laparoscopically performed, consisting in Heller's myotomy + Dor partial fundoplication is to be preferred in cases of true achalasia.     

Long-term results and quality of life after surgery for oesophageal achalasia: one surgeon''s experience

Objective: To assess the long-term results and health-related quality of life in patients undergoing surgery for oesophageal achalasia. Methods: Thirty-nine patients with achalasia (25 males, mean age 42±13 years) underwent open-Heller myotomy and Dor fundoplication by the same surgeon. Long-term results were assessed by imaging, endoscopy, manometry, pH-metry, and Short Form 36 and Nottingham Health Profile questionnaires whenever applicable. Six patients were at radiological stage I, 20 were at stage II, 2 at stage III and 11 at stage IV. Dysphagia and regurgitation were scored according to the four-grade classification (1=no symptoms; 4=persistent symptoms). Pulmonary symptoms were present in six patients. Lower oesophageal pressure was 30±34 mmHg. Six patients had undergone previous pneumatodilation. Results: No procedure related mortality was recorded. Mean follow-up was 107±30 months (54–177). Preoperative to 5-year postoperative mean decrement in lower oesophageal sphincter pressure was 12.3±8.3 mmHg (P<0.001), in oesophageal width was 11.5±7.1 mm (P<0.001), in dysphagia 1.8±0.8 (P<0.01) and regurgitation 1.4±0.7 (P<0.01). Four patients presented relapse dysphagia and two of those were re-operated upon. Three patients developed acid reflux, which was satisfactorily treated with proton-pump inhibitors. Preoperative to 4-year postoperative quality of life scores were available for 20 patients. Questionnaires showed a significant improvement (P<0.001) especially in all psychosocial domains, which were correlated with postoperative dysphagia score and lower oesophageal sphincter pressure. Conclusion: Heller myotomy and Dor fundoplication is a safe and effective procedure that improves symptoms, functional status and especially psychosocial aspect of quality of life in the long term in oesophageal achalasia.     

Esophageal achalasia: cardiomyotomy or pneumatic dilatation?]

Sixty-four patients with achalasia of the esophagus were surgically treated during the period 1973-1990. They were analyzed a late follow-up (mean = 78 months) by means of subjective and objective parameters. The Authors emphasize the efficiency of the diagnostic approach so that surgical treatment offers better results. The surgical technique of choice consists of an anterior esophagomyotomy (extending from 6 cm above the esophagogastric junction down to 1-2 cm below it) with the addition of an anterior Dor antireflux procedure through a laparotomy. The other therapeutic approach to achalasia is pneumatic dilatation of lower esophageal sphincter. A retrospective comparison of two different treatments is made through the analysis of the literature (medlars 1986-1990). Relief of dysphagia is reported in 92.78% of patients treated by myotomy and in 78.71% of those treated by forceful dilatation. The morbidity rate is greater after pneumatic dilatation (6% vs 5%) and the mortality rate is 1.1% after myotomy and 0.2% after dilatation. There are not rigorous criteria of choice between the two treatment methods but the Authors indicate that Heller's myotomy with an antireflux procedure achieve better and lasting results.     

Patterns of esophageal acid exposure after laparoscopic Heller’s myotomy and Dor’s fundoplication for esophageal achalasia

BACKGROUND: Heller's myotomy for esophageal achalasia is associated with less esophageal acid gastroesophageal reflux when combined a Dor's fundoplication. The Aim of the study was to assess the incidence of postoperative esophageal acid exposure after laparoscopic Heller's myotomy and Dor's fundoplication (HM-DF). METHODS: Seventy six patients (37 males) with esophageal achalasia were prospectively followed-up by clinical interview and laboratory tests before and after laparoscopic HM-DF. A symptom score was used for clinical assessment. Laboratory assessment included esophageal standard manometry, esophagogram and esophageal pH 24-hour monitoring before and 1- and 5-years after surgery. RESULTS: Symptom score improved at 1-year after surgery (P < 0.001). Heartburn was only reported by 5 patients, dysphagia or/and regurgitation by 28 and substernal pain by 12. 91% of patients had satisfactory functional results. Pathological esophageal exposure to acid was seen in 21% of the cases. Pathological acid events showed the features of pseudoreflux in 66%t and those of true GER in 34%. Pathologically increased esophageal exposure to acid was more commonly detected in patients with a pseudodiverticulum (P = 0.001) and was related to the diameter of distal esophagus and symptom score (P < 0.001). There was no reduction in esophageal acid exposure after treatment with proton pump inhibitors in 16 patients. Neither the symptom score nor esophageal acid exposure at esophageal pH monitoring changed significantly at the 5-year follow-up in 35 patients. Esophageal configuration remained unchanged. CONCLUSIONS: Increased esophageal exposure to acid after laparoscopic HM-DF for esophageal achalasia i) is detected in 21% of patients, and is rather the result of food stagnation than of true GER, ii) is more commonly seen in cases with pseudodiverticulum, iii) is related to the diameter of distal esophagus, iv) does not respond to antisecretory treatment and v) does not deteriorate by time.     

Two decades of experience with modified Heller's myotomy for achalasia

We reviewed the hospital records of 36 patients who underwent modified Heller's myotomy for achalasia between January, 1961, and December, 1982. There were 18 male and 18 female patients ranging between 17 months and 75 years old. The most frequent symptom was dysphagia, followed by regurgitation of ingested food and weight loss. Modified Heller's myotomy was performed through a transthoracic incision in 35 patients and a transabdominal incision in 1. An antireflux procedure in addition to esophagomyotomy was performed in 20 patients. There was 1 postoperative death. Thirty-three patients were followed up for periods ranging from 9 months to 21 years. The results were considered good in 27, fair in 2, and poor in 4. One of the 4 underwent repeat esophagomyotomy 71/2 years after the initial operation with a good result. The remaining 3 had an antireflux procedure at the time of esophagomyotomy. Because of recurrence of symptoms, esophagogastrostomy was performed in 1 and colon interposition in 2. These results suggest that an antireflux procedure should not be added to modified Heller's operation in the treatment of achalasia.     

Long-term results of surgery for childhood achalasia.

Childhood achalasia is an uncommon condition characterised by the absence of oesophageal peristalsis together with increased resting pressure and failure of relaxation of the lower oesophageal sphincter. The currently accepted management is a modified Heller's cardiomyotomy with Nissen fundoplication; however, the long-term results are uncertain. A retrospective review of the notes of 10 children undergoing surgical treatment of achalasia at our institution over a 23-year period were reviewed. There were six boys and four girls. The median age at onset of symptoms was 123 months and at diagnosis was 133 months. Five children were below average weight at the time of presentation. All underwent a modified Heller's operation and Nissen fundoplication. The follow-up ranged from 12 to 277 months with a mean of nearly 10 years. The results were excellent in terms of symptomatic improvement in eight of ten with one good and one moderate outcome. All children below average weight have shown improvement postoperatively. We would conclude that the management of achalasia in childhood should consist of an extended Heller's cardiomyotomy performed by the abdominal approach with the addition of an antireflux procedure such as Nissen fundoplication.