Comparison of the Heller–Toupet procedure with the Heller–Dor procedure in patients who underwent laparoscopic surgery for achalasia

Purpose

We compared the outcomes of Toupet fundoplication with those of Dor fundoplication in patients with achalasia who underwent laparoscopic Heller myotomy.

Methods

Seventy-two patients with achalasia and dysphagia underwent laparoscopic Heller myotomy with fundoplication performed by a single surgeon. Heller–Toupet fundoplication (HT) was performed in 30 patients, and Heller–Dor fundoplication (HD) was done in 42. The symptoms and esophageal function were retrospectively assessed in both groups.

Results

The dysphagia scores significantly decreased after both the HT and HD procedures, and did not differ significantly between them. The incidence of reflux symptoms was significantly higher after HT (26.7 %) than after HD (7.1 %). The lower esophageal sphincter (LES) resting pressure significantly decreased after both HT and HD. Upon endoscopic examination, the incidence of reflux esophagitis was significantly higher after HT (38.5 %) than after HD (8.8 %). During esophageal pH monitoring, the fraction time at pH <4 was similar in the patients who underwent HT and HD.

Conclusions

Laparoscopic Heller myotomy provided significant improvements in the dysphagia symptoms of achalasia patients, regardless of the type of fundoplication. The incidences of reflux symptoms and reflux esophagitis were higher after HT than after HD. However, the results of pH monitoring did not differ between the procedures.     

Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial

Background

The type of fundoplication that should be performed in conjunction with Heller myotomy for esophageal achalasia is controversial. We prospectively compared anterior fundoplication (Dor) with partial posterior fundoplication (Toupet) in patients undergoing laparoscopic Heller myotomy.

Methods

A multicenter, prospective, randomized-controlled trial was initiated to compare Dor versus Toupet fundoplication after laparoscopic Heller myotomy. Outcome measures were symptomatic GERD scores (0?C4, five-point Likert scale questionnaire) and 24-h pH testing at 6?C12?months after surgery. Data are mean?±?SD. Statistical analysis was by Mann?CWhitney U test, Wilcoxon signed rank test, and Freidman??s test.

Results

Sixty of 85 originally enrolled and randomized patients who underwent 36 Dor and 24 Toupet fundoplications had follow-up data per protocol for analysis. Dor and Toupet groups were similar in age (46.8 vs. 51.7?years) and gender (52.8 vs. 62.5% male). pH studies at 6?C12?months in 43 patients (72%: Dor n?=?24 and Toupet n?=?19) showed total DeMeester scores and % time pH?p?=?0.152). Dysphagia and regurgitation symptom scores improved significantly in both groups compared to preoperative scores. No significant differences in any esophageal symptoms were noted between the two groups preoperatively or at follow-up. SF-36 quality-of-life measures changed significantly from pre- to postoperative for five of ten domains in the Dor group and seven of ten in the Toupet patients (not significant between groups).

Conclusion

Laparoscopic Heller myotomy provides significant improvement in dysphagia and regurgitation symptoms in achalasia patients regardless of the type of partial fundoplication. Although a higher percentage of patients in the Dor group had abnormal 24-h pH test results compared to those of patients who underwent Toupet, the differences were not statistically significant.     

Peroral Endoscopic Myotomy (POEM): Feasible as Reoperation Following Heller Myotomy

Purpose

The purpose of this study was to demonstrate the feasibility of performing peroral endoscopic myotomy (POEM) in the management of recurrent achalasia after failed myotomy.

Methods

Eight patients presented to our institution between October 2010 and June 2013 with recurrent/persistent symptoms after prior laparoscopic Heller myotomy. Three patients underwent redo laparoscopic Heller myotomy, and five patients consented to redo myotomy with POEM.

Results

Demographics were similar between the groups with exception of age (POEM 69.5 vs. laparoscopic Heller myotomy (LHM) 34.5, p?=?0.003). Preoperative Eckardt scores, motility, and prior interventions were not significantly different. Three patients who underwent POEM and two who underwent laparoscopic Heller myotomy had prior fundoplication. There was one perforation identified after laparoscopic Heller myotomy and one patient with persistent subcutaneous emphysema after POEM. Both POEM and laparoscopic Heller myotomy demonstrated significant improvement in symptoms and Eckardt scores at average follow-up of approximately 5 months (p?<?0.05).

Conclusion

POEM is a feasible option for patients after failed myotomy even in the presence of prior fundoplication. The procedure can be performed safely using a similar technique as for primary myotomy with the exception of creating the myotomy laterally along the right side of the esophagus and lesser curvature avoiding the previous anterior myotomy.     

Significance of Limited Hiatal Dissection in Surgery for Achalasia

Introduction

It is speculated that postoperative pathologic gastroesophageal reflux after Heller’s myotomy can be diminished if the lateral and posterior phrenoesophageal attachments are left intact. The aim of this study was to evaluate the effectiveness of limited hiatal dissection in patients operated due to achalasia.

Methods

Prospective, randomized, 3 years follow-up of 84 patients operated due to achalasia. In 26 patients, Heller–Dor with complete hiatal dissection was done (G1), limited hiatal dissection combined with myotomy and Dor’s procedure was performed in 36 patients (G2), and with Heller’s myotomy alone in 22 (G3). Stationary manometry and 24 h pH study were performed in regular postoperative intervals.

Results

Postoperatively, higher median values of lower esophageal sphincter resting pressures were marked in G2 and G3, while patients in G1 were presented with higher median values of pH acid score (p?<?0.001). Abnormal DeMeester score 3 years after surgery was present in 23.1% of patients in G1 and 8.5% and 9.1% in G2 and G3 accordingly. There was no statistical difference between the groups concerning postoperative dysphagia recurrence.

Conclusion

Indicating further long-term studies, 3 years after the operation limited hiatal dissection compared to complete obtains better reflux control in achalasia patients, regardless of Dor’s fundoplication.     

A Matched Comparison of Per Oral Endoscopic Myotomy to Laparoscopic Heller Myotomy in the Treatment of Achalasia

Background

Per oral endoscopic myotomy (POEM) is increasingly utilized to treat patients with achalasia. Early results have demonstrated significant improvement of symptoms, but there are concerns about postoperative reflux. With only limited comparative data available, we sought to compare POEM to laparoscopic Heller myotomy (LHM) with partial fundoplication.

Methods

This is a retrospective review of 42 POEM and 84 LHM patients undergoing primary myotomy for achalasia. Patients were matched by achalasia type, by Eckardt and dysphagia scores, and by quality of life (QOL) metrics. Analysis at 6–12-month follow-up evaluated these metrics, PPI use, pH, manometric, and endoscopic data.

Results

We matched 25 patients with achalasia types I (6), II (13), and III (6). Follow-up was longer for LHM at 158.1 (36.5–272.9) weeks versus 36.2 (22.2–41.2) weeks (p?=?0.001). Eckardt scores, QOL metrics, and dysphagia significantly improved in both groups. DeMeester scores and total percent time less than 4 were abnormal in both groups and comparable (p?=?0.925 and p?=?0.838). Esophagitis was seen in 53.4 % (POEM) and 31.6 % (LHM) (Yates’ p?=?0.91), and PPI use was equivalent at 36 %.

Conclusion

Early clinical outcomes are excellent with POEM and comparable to the standard of care LHM. Long-term follow-up is required as concerns for reflux persist.

     

Outcomes of Esophagectomy for Esophageal Achalasia in the United States

Background

While the outcomes after Heller myotomy have been extensively reported, little is known about patients with esophageal achalasia who are treated with esophagectomy.

Methods

This was a retrospective analysis using the Nationwide Inpatient Sample over an 11-year period (2000–2010). Patients admitted with a primary diagnosis of achalasia who underwent esophagectomy (group 1) were compared to patients with esophageal cancer who underwent esophagectomy (group 2) during the same time period. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay, postoperative complications, and total hospital charges. A propensity-matched analysis was conducted comparing the same outcomes between group 1 and well-matched controls in group 2.

Results

Nine hundred sixty-three patients with achalasia and 18,003 patients with esophageal cancer underwent esophagectomy. The propensity matched analysis showed a trend toward a higher mortality in group 2 (7.8 vs. 2.9 %, p?=?0.08). Postoperative length of stay and complications were similar in both groups. Total hospital charges were higher for the achalasia group ($115,087 vs. $99, 654.2, p?=?0.006).

Conclusion

This is the largest study to date examining outcomes after esophagectomy in patients with achalasia. Based on our findings, esophagectomy can be considered a safe option, and surgeons should not be hindered by a perceived notion of prohibitive operative risk in this patient population.     

The Preoperative Manometric Pattern Predicts the Outcome of Surgical Treatment for Esophageal Achalasia

Background

A new manometric classification of esophageal achalasia has recently been proposed that also suggests a correlation with the final outcome of treatment. The aim of this study was to investigate this hypothesis in a large group of achalasia patients undergoing laparoscopic Heller–Dor myotomy.

Methods

We evaluated 246 consecutive achalasia patients who underwent surgery as their first treatment from 2001 to 2009. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored and barium swallow X-ray, endoscopy, and esophageal manometry were performed before and again at 6 months after surgery. Patients were divided into three groups: (I) no distal esophageal pressurization (contraction wave amplitude <30 mmHg); (II) rapidly propagating compartmentalized pressurization (panesophageal pressurization >30 mmHg); and (III) rapidly propagating pressurization attributable to spastic contractions. Treatment failure was defined as a postoperative symptom score greater than the 10th percentile of the preoperative score (i.e., >7).

Results

Type III achalasia coincided with a longer overall lower esophageal sphincter (LES) length, a lower symptom score, and a smaller esophageal diameter. Treatment failure rates differed significantly in the three groups: I?=?14.6% (14/96), II?=?4.7% (6/127), and III?=?30.4% (7/23; p?=?0.0007). At univariate analysis, the manometric pattern, a low LES resting pressure, and a high chest pain score were the only factors predicting treatment failure. At multivariate analysis, the manometric pattern and a LES resting pressure <30 mmHg predicted a negative outcome.

Conclusion

This is the first study by a surgical group to assess the outcome of surgery in 3 manometric achalasia subtypes: patients with panesophageal pressurization have the best outcome after laparoscopic Heller–Dor myotomy.     

Controversies in Management of Achalasia

Background

Esophageal achalasia is a primary motility disorder of unknown etiology. It is characterized by lack of esophageal peristalsis and failure of the lower esophageal sphincter to relax appropriately in response to swallowing. The goal of treatment is to improve esophageal emptying and patient’s symptoms by decreasing the functional obstruction at the level of the gastroesophageal junction. This can be accomplished by either endoscopic modalities (intra-sphincteric injection of botulinum toxin, pneumatic dilatation, per oral endoscopic myotomy) or by a laparoscopic Heller myotomy.

Results

Review of the current literature suggests that a laparoscopic Heller myotomy should be considered today the primary form of treatment for achalasia and recommends a treatment algorithm for this disease.     

Peroral Endoscopic Myotomy (POEM) Is Safe and Effective in the Setting of Prior Endoscopic Intervention

Objective

We aimed to determine the safety and feasibility of peroral endoscopic myotomy (POEM) in the setting of prior endoscopic interventions.

Patients

This study involves 40 consecutive patients undergoing POEM.

Intervention

POEM was performed for esophageal motility disorders, including achalasia, nutcracker with nonrelaxing lower esophageal sphincter (LES), hypertensive lower esophageal sphincter, and diffuse esophageal spasm.

Main Outcome Measures

Outcome measures include length of procedure (LOP), intraoperative complications, and dysphagia relief.

Results

Forty patients, with a mean age of 54?±?19 years, underwent POEM. The pre-POEM intervention group consisted of 12 patients (nine achalasia, two nutcracker with nonrelaxing LES, and one diffuse esophageal spasm) who also had previous endoscopic treatment, while the pre-POEM non-intervention group consisted of 28 patients (22 achalasia, 3 hypertensive LES, 2 nutcracker with nonrelaxing LES, and 1 diffuse esophageal spasm). Ten patients had botox injections and two patients had large caliber balloon dilations prior to POEM. The median preoperative Eckardt score was 5 in the pre-POEM intervention group vs 6 in the pre-POEM non-intervention group (p value?=?0.4). There was no statistical difference in the mean LOP (134?±?43 vs 131?±?41, p?=?0.8) or the incidence of intraoperative complications (17 vs 3 %, p?=?0.2) between the two groups. There was also no difference in the 6-month postoperative median Eckardt scores between the two groups (1 vs 1, p?=?0.4).

Conclusion

POEM is safe and effective even following preoperative endoscopic large caliber balloon dilations or botox injection. These interventions do not seem to contribute to increased adverse intraoperative or postoperative clinical outcomes.     

Repeated Surgical or Endoscopic Myotomy for Recurrent Dysphagia in Patients After Previous Myotomy for Achalasia

Aim

Surgical myotomy of the lower esophageal sphincter has a 5-year success rate of approximately 91 %. Peroral endoscopic myotomy can provide similar results for controlling dysphagia. Some patients experience either persistent or recurrent dysphagia after myotomy. We present here a retrospective analysis of our experience with redo myotomy for recurrent dysphagia in patients with achalasia.

Methods

From March 1996 to February 2015, 234 myotomies for primary or recurrent achalasia were performed in our center. Fifteen patients (6.4 %) had had a previous myotomy and were undergoing surgical redo myotomy (n?=?9) or endoscopic redo myotomy (n?=?6) for recurrent symptoms.

Results

Patients presented at a median of 10.4 months after previous myotomy. Median preoperative Eckardt score was 6. Among the nine patients undergoing surgical myotomy, three esophageal perforations occurred intraoperatively (all repaired immediately). Surgery lasted 111 and 62 min on average (median) in the surgical and peroral endoscopic myotomy (POEM) groups, respectively. No postoperative complications occurred in either group. Median postoperative stay was 3 and 2.5 days in the surgical and POEM groups, respectively. In the surgical group, Eckardt score was <3 for seven out of nine patients after a mean follow-up of 19 months; it was <3 for all six patients in the POEM group after a mean follow-up of 5 months.

Conclusions

A redo myotomy should be considered in patients who underwent myotomy for achalasia and presenting with recurrent dysphagia. Preliminary results using POEM indicate that the technique can be safely used in patients who have undergone previous surgical myotomy.

     

Improving functional esophageal surgery with a ��smart�� bougie: endoflip

Background

An emerging imaging tool, the functional lumen imaging probe (Endoflip; Crospon Ltd, Galway, Ireland), provides a real-time measurement of esophagogastric junction (EGJ) capacity and diameter, which would be of particular interest in functional esophageal surgery such as Heller myotomy and antireflux procedures. This study aimed to demonstrate the intraoperative use of endoflip in the treatment of achalasia and gastroesophageal reflux disease (GERD).

Methods

In the first case, Heller myotomy was performed under endopflip guidance, for persistent dysphagia after failed endoscopic dilatation. In the second case, the endoflip was used to calibrate a Nissen fundoplication. With the patient under general anesthesia, the endoflip catheter was inserted orally and positioned to straddle the EGJ. At each stage of the procedure, the balloon was inflated by liquid filling at 40?C30?ml/min. Live diameter data, cross-sectional area (CSA), and balloon pressure were displayed on the system at all times.

Results

Before the myotomy, the pressure in the balloon rose to 15?mm?Hg at a CSA of 25?mm², indicating that the EGJ is rigid and tight. After the myotomy, the pressure rose to 8?mm?Hg, and the CSA opened to 34?mm², indicating that the EGJ was now very compliant and flaccid. After the Dor fundoplication, the junction became less compliant, but it could open at its narrowest point to 35?mm² at a pressure of 20?mm?Hg, suggesting that the EGJ was tighter but not as rigid as before. The second part of the video demonstrates that the Endoflip acted as a ??smart bougie,?? evaluating the orientation and position of a properly constructed floppy Nissen.

Conclusions

The endoflip provides a system in which physiology and anatomy are represented dynamically in the same image. This ??smart bougie?? could be integrated into the surgical routine to improve outcome and to facilitate surgical training and the learning curve in esophageal functional surgery.     

Causes of bolus impaction in the esophagus

Background

Bolus impaction in the esophagus is a common indication for emergency endoscopy. The aim of this study was to determine the most common causes of esophageal bolus impaction.

Methods

In this retrospective study, data of 54 patients (41 male, 13 female) with bolus impaction in the esophagus were analyzed. Type and localization of the bolus and the endoscopic extraction tool used were evaluated. In 48 of 54 patients (89%), biopsy samples were taken of the esophagus for histological examination.

Results

Mean age of the patients was 53?±?20?years. Fourteen of 54 patients (26%) had experienced bolus impaction previously. Meat bolus (n?=?35, 65%) was the most common cause of esophageal obstruction. In most cases, boluses were found in either the distal (n?=?31) or the proximal (n?=?18) esophagus. In 22 patients (41%), the bolus was pushed into the stomach by the endoscope. In most other cases the bolus, including foreign bodies, could be removed with the 5-arm polyp grasper or alligator forceps. Main causes of bolus impaction were eosinophilic esophagitis (n?=?10) or reflux disease with or without peptic stenosis (n?=?10), respectively.

Conclusion

Bolus impaction is frequently correlated with eosinophilic esophagitis and reflux esophagitis; therefore, diagnostic workup should include esophageal biopsy sampling.     

Malfunction and failure of robotic systems during general surgical procedures

Background

There has been recent interest in using robots for general surgical procedures. This shift in technique raises the issue of patient safety with automated instrumentation. Although the safety of robotics has been established for urologic procedures, there are scant data on its use in general surgical procedures. The aim of this study is to analyze the incidence of robotic malfunction and its consequences for general surgical procedures.

Methods

All robotic general surgical procedures performed at a tertiary center between 2008 and 2011 were reviewed from institutional review board (IRB)-approved prospective databases.

Results

A total of 223 cases were done robotically, including 102 endocrine, 83 hepatopancreaticobiliary, 17 upper gastrointestinal, and 21 lower gastrointestinal colorectal procedures. There were 10 cases of robotic malfunction (4.5?%). These failures were related to robotic instruments (n?=?4), optical system (n?=?3), robotic arms (n?=?2), and robotic console (n?=?1). None of these failures led to adverse patient consequences or conversion to open. Six (2.7?%) cases were converted to open due to bleeding (n?=?3), difficult dissection plane (n?=?1), invasion of tumor to surrounding structures (n?=?1), and intolerance of pneumoperitoneum due to CO₂ retention (n?=?1). There was no mortality, and morbidity was 1?% (n?=?2).

Conclusion

To our knowledge, this is the largest North American report to date on robotic general surgical procedures. Our results show that robotic malfunction occurs in a minority of cases, with no adverse consequences. We believe that awareness of these failures and knowing how to troubleshoot are important to maintain the efficiency of these procedures.     

A comparative study of endoscopic full-thickness and partial-thickness myotomy using submucosal endoscopy with mucosal safety flap (SEMF) technique

Background

Esophageal myotomy using submucosal endoscopy with mucosal safety flap (SEMF) has been proposed as a new treatment of achalasia. In this technique, a partial-thickness myotomy (PTM) preserving the longitudinal outer esophageal muscular layer is advocated, which is different from the usual full-thickness myotomy (FTM) performed surgically. The aim of this study was to compare endoscopic FTM and PTM and analyze the outcomes of each method after a 4?week survival period.

Methods

Twenty-four pigs were randomly assigned into group A (FTM, 12 animals) and group B (PTM) to undergo endoscopic myotomy. Lower esophageal sphincter (LES) pressure was assessed using pull-through manometry. For statistical analysis we compared the average esophageal sphincter pressure values at baseline, after 2?weeks, and after 4?weeks between groups A and B. The P value was set as <0.05 for significance.

Results

Eighteen animals were included for statistical analysis. Mean (SD) LES pressures were similar between groups A and B (nine animals each) at baseline [group A?=?23 (10.4)?mmHg; group B?=?20.7 (8.7)?mmHg; P?=?0.79], after 2?weeks [group A?=?19 (7.7)?mmHg; group B?=?21.8 (8.4)?mmHg; P?=?0.79], and after 4?weeks [group A?=?22.6 (10.2)?mmHg; group B?=?20.7 (9)?mmHg; P?=?0.82]. LES pressures were significantly reduced in three animals after 4?weeks: one animal (1%) in group A and two animals (2.5%) in group B. An extended myotomy (3?cm below the cardia) was achieved in three animals and was responsible for the significant drop in LES pressure seen in the two animals from group B.

Conclusion

Esophageal myotomy using SEMF is a feasible yet challenging procedure in pigs. Full-thickness myotomy does not seem to be superior to partial-thickness myotomy as demonstrated by pull-through manometry. Endoscopic esophageal myotomy results are greatly influenced by obtaining adequate myotomy extension into the gastric cardia.     

Patient outcome in primary peritoneal dialysis patients versus those transferred from hemodialysis and transplantation

Background

According to the concept of integrated care, renal transplantation, peritoneal dialysis (PD), and hemodialysis (HD) should be considered three complementary methods of renal replacement therapy. This study tried to evaluate patient outcomes in three different groups of PD patients, namely primary PD patients, those transferred to PD with failing kidney transplant, and those transferred to PD from HD.

Method

From January 1, 1995, to end of 2006 from 26 PD centers, 1,355 patients including demographic, clinical and laboratory data, which were monthly collected through questionnaires, were enrolled in the study. We compared patients?? characteristics, factors affecting patient survival, and patient outcomes between primary PD patients (group 1, n?=?1,067), patients transferred from transplantation (group 2, n?=?43) and those transferred from HD (group 3, n?=?245), which had been on HD for at least 3?months before switching to PD.

Results

There was no difference in the proportion of patients with diabetes in the three groups. Overall, 238 patients (17.5%) were transferred to HD but there was no significant difference in PD technique survival on between the three groups. Death occurred in 256 (24%), 3 (7%) and 65 (26.5%) subjects in groups 1, 2 and 3, respectively. Most patients (81.5%) in group 2 underwent re-transplantation. The Kaplan?CMeier survival rates were not different between the three groups. In the Cox multiple regression model, age, presence of diabetes and serum albumin level significantly influenced patient survival.

Conclusion

We concluded that PD could be considered safe for patients experiencing complications on HD, as well as for those with renal transplantation.     

Efficacy and durability of robotic heller myotomy for achalasia: patient symptoms and satisfaction at long-term follow-up

Background

Laparoscopic Heller myotomy (LHM) has become the standard treatment for achalasia in the USA. Robot-assisted Heller myotomy (RHM) has emerged as an alternative approach due to improved visualization and fine motor control, but long-term follow-up studies have not been reported. We sought to report the long-term outcomes of RHM and compare them to those of LHM.

Methods

A retrospective cohort study was performed for patients who underwent laparoscopic or RHM between 1995 and 2006. Long-term follow-up was performed via mail or telephone questionnaire. The primary outcome measure was durable relief of dysphagia without need for further intervention. Secondary outcomes included gastroesophageal reflux symptoms, disease-specific quality of life, and patient satisfaction with their operation.

Results

Seventy-five patients underwent laparoscopic (n = 19) or robotic (n = 56) myotomy during the study period. Long-term follow-up was obtained in 53 (71 %) patients with a median interval of 9 years. RHM was associated with a decreased mucosal injury rate (0 vs. 16 %, p = 0.01) and median hospital stay (1 vs. 2 days, p < 0.01) compared to conventional laparoscopy. All patients reported initial dysphagia relief, and 80 % required no further intervention. This did not differ between groups. Sixty-two percent required medications to control reflux symptoms at long-term follow-up, including 56 % following robotic myotomy and 80 % after laparoscopic myotomy (p = 0.27). Overall, 95 % of patients were satisfied with their operation, and 91 % would choose surgery again given the benefit of hindsight.

Conclusion

There is a dearth of long-term follow-up data to support the effectiveness of RHM. This study demonstrates durable dysphagia relief in the vast majority of patients with a high degree of patient satisfaction and a low rate of esophageal mucosal injury. While a significant proportion of patients report reflux symptoms, these symptoms are well controlled with medical acid suppression.     

Comparison of Perioperative Outcomes Between Peroral Esophageal Myotomy (POEM) and Laparoscopic Heller Myotomy

Background

Peroral esophageal myotomy (POEM) is a novel endoscopic operation for the treatment of achalasia. Few POEM outcome data exist, and no study has compared POEM with the surgical standard, laparoscopic Heller myotomy (LHM).

Methods

Perioperative outcomes were compared between POEM and LHM performed in a nonrandomized fashion. Patients in both groups met the following eligibility criteria: diagnosis of achalasia, age 18–85, and absence of prior achalasia treatment.

Results

Eighteen patients underwent POEM, and 55 patients underwent LHM. Operative times were shorter for POEM (113 vs. 125 min, p?<?.05), and estimated blood loss was less (≤10 ml in all cases vs. 50 ml, p?<?.001). Myotomy lengths, complication rates, and length of stay were similar. Pain scores were similar upon post-anesthesia care unit arrival and on postoperative day 1 but were higher at 2 h for POEM patients (3.5 vs. 2, p?=?.03). Narcotic requirements were similar, although fewer POEM patients received ketorolac. POEM patients’ Eckardt scores decreased (median 1 postop vs. 7 preop, p?<?.001), and 16 (89 %) patients had a treatment success (score ≤3) at median 6-month follow-up. Six weeks after POEM, routine follow-up manometry and esophagram showed normalization of esophagogastric junction pressures and contrast column heights.

Conclusions

POEM and LHM appear to have similar perioperative outcomes. Further investigation is needed regarding long-term results after POEM.     

Achalasia—If Surgical Treatment Fails: Analysis of Remedial Surgery

Introduction

Heller myotomy leads to good–excellent long-term results in 90% of patients with achalasia and thereby has evolved to the “first-line” therapy. Failure of surgical treatment, however, remains an urgent problem which has been discussed controversially recently.

Materials and Methods

A systematic review of the literature was performed to analyze the long-term results of failures after Heller’s operation with emphasis on treatment by remedial myotomy.

Discussion

Other reinterventions and their causes after failure of surgical treatment in patients with achalasia are discussed.

     

The Improvement of Surgical Treatment for Patients with Gallbladder Cancer: Analysis of 208 Consecutive Cases Over the Past Decade

Objectives

The aim of this study was to determine if there has been improvement in survival for patients with gallbladder cancer treated with surgical procedures.

Methods

A retrospective review of all patients with gallbladder cancer admitted during the past 11?years was conducted. The patients were categorized into two periods: period 1, from 1 January 2000 to 31 December 2005 (group 1, n?=?77); and period 2, from 1 January 2006 to 31 December 2010 (group 2, n?=?131).

Results

The two groups have similar age, sex distribution, and symptoms. There were more patients with advanced stage in group 2 (P?=?0.001). And patients in group 2 were treated with more aggressive surgical procedures compared with group 1. Patients of group 2 had a better surgical outcomes and longer 5-year overall survival (9?% vs. 19?%, P?=?0.040) and disease-free survival (P?=?0.017). Median survival in group 1 was 14.7?months, while in group 2 it was 22.3?months. Patients underwent R0 resection in group 2 had better survival than that in group 1 (P?=?0.009), while they had similar survival for those who underwent non-R0 resection in both periods (P?=?0.108).

Conclusions

A significant improvement of disease-free survival and long-term survival results was observed in the past decade.     

Surgical management of organ-contained unilateral pheochromocytoma: comparative outcomes of laparoscopic and conventional open surgical procedures in a large single-institution series

Purpose

Laparoscopic excision is preferred for small non-invasive pheochromocytoma over open approach. Applicability of laparoscopic procedures for large organ-contained pheochromocytoma is unclear. A database of 137 pheochromocytoma patients managed during 1990–2010 was reviewed to compare outcomes of open and laparoscopic procedures for 101 unilateral organ-contained pheochromocytoma patients in this retrospective non-randomized study.

Patients and methods

Forty-nine patients underwent open procedures, and 52 underwent laparoscopic procedures. Laparoscopic procedure was converted to open in 19 due to bleeding (n?=?12), concern for malignancy (n?=?5), hypertensive crisis (n?=?1), and equipment failure (n?=?1). Outcome measures were compared between open, laparoscopic, and conversion patient groups.

Results

Patient groups were well matched for age, gender, BMI, and clinical and pathological characteristics. Mean tumor size was insignificantly larger in the open (7.6?±?2.7?cm) than the laparoscopic group (6.6?±?2?cm, p?=?0.06). There were no significant differences in periop hemodynamic events. Mean blood loss, blood transfusion and analgesic requirements, and postop ICU and hospital stay were significantly lesser in laparoscopic than open and conversion groups (p?<?0.05). There was no periop mortality. Morbidity occurred more frequently in the open (n?=?12) than in the laparoscopic group (n?=?3). At follow-up (mean, 44?±?33.7; range, 6–160?months), no patient had recurrent pheochromocytoma. Outcomes in terms of cure of pheochromocytoma and hypertension were not different between the three groups.

Conclusions

Laparoscopic procedures are feasible and as safe and effective as open procedures for patients with organ-contained pheochromocytoma. In a patient cohort where majority of the patients had large (>6?cm) pheochromocytoma, laparoscopic procedures resulted in lesser morbidity and shorter convalescence and provided equal chance for cure of pheochromocytoma and hypertension as conventional open surgical procedures.