The effect of laparoscopic partial fundoplication on dysphagia, esophageal and lower esophageal sphincter motility

It has been suggested that dysphagia is less common after partial versus complete fundoplication. The mechanisms contributing to postoperative dysphagia remain unclear. The objective of the present prospective study was to investigate esophageal motility and the prevalence of dysphagia in patients who have undergone laparoscopic partial fundoplication. Symptoms, lower esophageal sphincter (LES) characteristics and esophageal body motility were evaluated prospectively in 62 patients before and after laparoscopic partial fundoplication: 33 women and 29 men with a mean age of 44 +/- 1.5 years (range, 21-71). The patients filled in symptom questionnaires and underwent stationary and ambulatory manometry and 24-h pH-metry before and after operation. A small but significant increase in LES pressure from 14.8 +/- 0.9 to 17.8 +/- 0.8 mmHg was seen after laparoscopic partial fundoplication. Further, LES characteristics and esophageal body motility were not different post- versus preoperation. Three months after surgery, dysphagia was present in eight patients. No differences in LES characteristics or body motility were present between patients with and without dysphagia. Six months after the operation dysphagia was present in only three patients (3.2% mild and 1.6% severe dysphagia). Adequate reflux control was obtained in 85% of the patients. Laparoscopic partial fundoplication offers adequate reflux control without affecting esophageal body motility and with a very low incidence of postoperative dysphagia.     

Recent trends in endoscopic management of achalasia

Esophageal achalasia is a chronic and progressive motility disorder characterized by absence of esophageal body peristalsis associated with an impaired relaxation of lower esophageal sphincter(LES) and usually with an elevated LES pressure, leading to an altered passage of bolus through the esophago-gastric junction. A definitive cure for achalasia is currently unavailable. Palliative treatment options provide only food and liquid bolus intake and relief of symptoms. Endoscopic therapy for achalasia aims to disrupt or weaken the lower esophageal sphincter. Intra-sphincteric injection of botulinum toxin is reserved for elderly or severely ill patients. Pneumatic dilation provides superior results than botulinum toxin injection and a similar mediumterm efficacy almost comparable to that attained after surgery. Per oral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and further objective and long-term follow up. This article will review different endoscopic treatments in achalasia, and summarize the short-term and long-term outcomes.     

Achalasia: current treatment options

Achalasia is a rare esophageal motility disorder, characterized by impaired swallow-induced, lower esophageal sphincter (LES) relaxation and defective esophageal peristalsis. Unfortunately, there are no etiological therapies for achalasia. Patients present with dysphagia, chest pain and regurgitation of undigested food, often leading to weight loss. The currently available treatments have the common aim of relieving symptoms by decreasing the pressure of the LES. This can be achieved with some medications, by inhibiting the cholinergic innervation (botulinum toxin), by stretching (endoscopic dilation) or cutting (surgery) the LES. Recently, other therapeutic options, including per-oral endoscopic myotomy have been developed and are gaining international consensus. The authors report on the benefits and weaknesses of the different therapies and provide an updated approach to the management of achalasia.     

Case Report: Botulinum Toxin in Hypertensive Lower Esophageal Sphincter: A Manometric Case Study

The hypertensive lower esophageal sphincter (HLES) is a disorder of esophageal motility associated with dysphagia and chest pain. Although well characterized manometrically, opinions differ greatly with regard to its pathophysiology and its management. Therapy is limited to a few medications, esophageal dilatation, and even surgery, although none of these options are consistently successful. In this case report we describe a 54-year-old woman with HLES and dysphagia who was successfully treated with botulinum toxin injection of the lower esophageal sphincter (LES). Esophageal manometry after botulinum toxin therapy revealed normalization of LES pressures. Three months after therapy, symptoms returned and repeat esophageal manometry demonstrated the return of elevated LES pressures. This report is the only published case of botulinum toxin injection into the LES with both pre- and post-treatment esophageal manometric data. This case report is evidence that LES dysfunction produces symptoms in patients with HLES, and that reduction in LES pressure improves symptoms. Current pathophysiologic hypotheses for HLES-associated dysphagia and its treatment are briefly reviewed in this report.     

Current clinical approach to achalasia

Idiopathic achalasia is a rare primary motility disorder of the esophagus. The classical features are incomplete relaxation of a frequently hypertensive lower esophageal sphincter （LES） and a lack of peristalsis in the tubular esophagus. These motor abnormalities lead to dysphagia, stasis, regurgitation, weight loss, or secondary respiratory complications. Although major strides have been made in understanding the pathogenesis of this rare disorder, including a probable autoimmune mediated destruction of inhibitory neurons in response to an unknown insult in genetically susceptible individuals, a definite trigger has not been identified. The diagnosis of achalasia is suggested by clinical features and confirmed by further diagnostic tests, such as esophagogastroduodenoscopy （EGD）, manometry or barium swallow. These studies are not only used to exclude pseudoachalasia, but also might help to categorize the disease by severity or clinical subtype. Recent advances in diagnostic methods, including high resolution manometry （HRM）, might allow prediction of treatment responses. The primary treatments for achieving long-term symptom relief are surgery and endoscopic methods. Although limited high-quality data exist, it appears that laparoscopic Heller myotomy with partial fundoplication is superior to endoscopic methods in achieving long-term relief of symptoms in the majority of patients. However, the current clinical approach to achalasia will depend not only on patients＇ characteristics and clinical subtypes of the disease, but also on local expertise and patient preferences.     

Modern management of achalasia

Opinion statement The goals in the treatment of achalasia are threefold: 1) relieving the symptoms, particularly dysphagia and bland regurgitation; 2) improving esophageal emptying by disrupting the poorly relaxing lower esophageal sphincter (LES); and 3) preventing the development of megaesophagus. Although achalasia cannot be permanently cured, excellent palliation is available in over 90% of patients, especially those with pneumatic dilation and laparoscopic Heller myotomy. The efficacy for short- and long-term therapy seems to be similar when performed by experts. Pneumatic dilation done as an outpatient surgery disrupts the LES muscle from within by using balloons of progressively larger diameter (3.0, 3.5, and 4.0 cm). Repeat dilations may be required; secondary severe gastroesophageal reflux disease (GERD) is rare, but approximately 2% of patients will have an esophageal perforation. A surgical Heller myotomy is now being done laparoscopically through the abdomen that cuts the LES and extends the myotomy 2 to 3 cm onto the stomach. Usually 2 days of hospitalization is required, and patients can normally return to work in 1 to 2 weeks. Severe GERD with esophagitis and peptic stricture is a common complication; therefore, most surgeons combine the myotomy with an incomplete fundoplication. Medical therapy is much less effective than these invasive procedures. Smooth muscle relaxants (nitrates and calcium channel blockers) taken immediately before meals improve dysphagia, but side effects and drug tolerance are common. The injection of botulinum toxin (100 to 200 units) endoscopically into the LES gives short-term relief of symptoms and improves esophageal emptying. This treatment is most effective in the elderly, as symptom relief can last up to 1 to 2 years with a single injection. Several studies suggest the most cost-effective management of achalasia is initial treatment with pneumatic dilation.     

Endoscopic treatment of esophageal achalasia

Achalasia is a motility disorder of the esophagus characterized by dysphagia, regurgitation of undigested food, chest pain, weight loss and respiratory symptoms. The most common form of achalasia is the idiopathic one. Diagnosis largely relies upon endoscopy, barium swallow study, and high resolution esophageal manometry(HRM). Barium swallow and manometry after treatment are also good predictors of success of treatment as it is the residue symptomatology. Short term improvement in the symptomatology of achalasia can be achieved with medical therapy with calcium channel blockers or endoscopic botulin toxin injection. Even though few patients can be cured with only one treatment and repeat procedure might be needed, long term relief from dysphagia can be obtained in about 90% of cases with either surgical interventions such as laparoscopic Heller myotomy or with endoscopic techniques such pneumatic dilatation or, more recently, with per-oral endoscopic myotomy. Age, sex, and manometric type by HRM are also predictors of responsiveness to treatment. Older patients, females and type Ⅱ achalasia are better after treatment compared to younger patients, males and type Ⅲ achalasia. Self-expandable metallic stents are an alternative in patients non responding to conventional therapies.     

Esophageal motor disorders in patients with dysphagia

Endoscopy and radiology are usually suggested as the first line investigations in patients with dysphagia. Esophageal manometry is indicated if the above studies are unfruitful. Our aim was to evaluate the role of manometry in diagnosing motor disorders of the esophagus in patients with non-organic dysphagia. We retrospectively evaluated the results of seven years' experience with esophageal manometry performed in 114 patients with difficulty in swallowing not due to esophageal structural lesions or reflux esophagitis, both escluded by endoscopic and/or radiologic studies prior to manometric investigation. A variety of nonspecific esophageal motor disorders were the most common (32%) manometric abnormalities seen in patients with dysphagia. Achalasia was common (23%) too, whereas diffuse esophageal spasm (8%), nutcracker esophagus (6%) and hypertensive LES (1%) accounted for a few motility disorders associated with dysphagia. Low LES pressure was found in 3% of the patients, suggesting gastroesophageal reflux as the cause of their difficulty in swallowing. The study confirms the role of esophageal manometry in diagnosing the cause of a swallowing disorder, identified in 83 out of 114 patients (73%). Achalasia and nonspecific esophageal motor disorders accounted for more than 50% of the motility disorders in patients with dysphagia.     

Peroral endoscopic myotomy outcomes: Efficacy and gastroesophageal reflux disease

Achalasia is a well-defined neuromuscular disorder of esophageal swallowing function characterized by a nonrelaxing lower esophageal sphincter (LES) and aperistalsis of the esophageal body. Peroral endoscopic myotomy (POEM) is a flexible endoscopic approach to perform a selective circular myotomy of the distal esophagus and proximal stomach. More than a thousand cases have been performed worldwide. Most early reports on POEM focus on its feasibility and safety. Emerging long-term series have reported excellent subjective and objective outcomes of dysphagia relief for achalasia. With increasing experience, centers are expanding indications to end-stage achalasia and nonachalasia neuromuscular disorders such as diffuse esophageal spasm and nonrelaxing LES with hypertensive esophageal body contractions. The postoperative gastroesophageal reflux post-POEM is an issue that requires close objective follow-up, as the correlation of subjective reflux symptoms and objective testing in this setting is poor. Few series have indeed reported on equivalent excellent outcomes post-POEM as compared with a laparoscopic myotomy. This early experience with POEM has demonstrated the validity of this new technique in the management of benign disorders of esophageal swallowing. Refinements in technique and decreases in gastroesophageal reflux disease may make this procedure even more desirable, and potentially the first-line therapy in the management of spastic disorders of the esophagus.     

Endoscopic injection therapy for achalasia and other esophageal motilitydisorders

Botulinum toxin (BT) injections have been proposed to treat achalasia and hypertensive esophageal motility disorders. They affect lower esophageal sphincter (LES) and esophageal muscle function by inhibiting acetylcholine release and thus preventing neuromuscular conduction. BT injection in the LES is effective to treat achalasia but the improvement is limited to few months. As a consequence, recent guidelines recommend BT in achalasia patients who are not good candidates for more definitive therapy with pneumatic dilation or myotomy. BT might be a good option for patients with esophago-gastric junction obstruction without a firm diagnosis of achalasia. However, response to BT injection is not predictive of response to a more invasive therapy. BT injection in both the LES and the esophageal body might have a short-term efficacy to relieve dysphagia in patients with diffuse esophageal spasm or nutcracker esophagus. Usually BT is administrated as 1 cc aliquots with 20 units of toxin per milliliter into the LES and/or the esophageal body for a total dose of 100 unit international. BT injections are usually safe. Moderate chest pain might be reported following the injection. Three cases of death were reported due to acute mediastinitis and pseudoaneurysm. Finally, there is a theoretical risk of increased difficulty to perform esophageal myotomy in patients who previously received BT therapy due to the potential risk of fibrosis.     

Preoperative esophageal manometry does not predict postoperative dysphagia following anti-reflux surgery

This prospective study was undertaken to determine the value of manometric studies in predicting postoperative dysphagia in patients undergoing laparoscopic Toupet fundoplication. Two hundred and twenty-nine out of 401 patients (57%) had preoperative dysphagia, and 26 patients had late postoperative dysphagia (6.5%). Eight patients who had no preoperative dysphagia developed dysphagia following surgery. There were no significant differences in esophageal motility for patients without postoperative dysphagia (n = 375) compared with those with postoperative dysphagia (n = 26). Among patients with postoperative dysphagia as a new symptom (n = 8), six had normal preoperative distal esophageal pressures, and none had esophageal hypomotility. In those with both pre- and postoperative dysphagia 15 of 18 had normal esophageal motility and hypomotility was only found in one. The positive predictive values of distal esophageal hypomotility and other measures for postoperative dysphagia are poor. In conclusion, preoperative manometry does not predict postoperative dysphagia following laparoscopic Toupet partial fundoplication.     

Laparoscopic antireflux surgery: indications, preoperative evaluation, techniques, and outcomes

BACKGROUND/AIMS: During the past decade, the development of mini-invasive surgery has determined a resurgence in popularity of the antireflux surgery. The purpose of this study is to examine indications, preoperative evaluation, surgical techniques, and outcomes after mini-invasive surgery. METHODOLOGY: From 1996 to 2000, 25 patients with gastroesophageal reflux disease associated to hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24h-pH monitoring, endoscopic evidence of esophagitis, and defective lower esophageal sphincter. Nissen fundoplication was performed in 16 patients with normal esophageal body motility, and 270 degrees posterior fundoplication in 9 patients with low esophageal motility. RESULTS: Mortality and conversion rate were 0. Mean operative time was 130 minutes and mean postoperative hospital stay 5 days. Twenty-four (96%) patients were completely cured of reflux symptoms off all medications. Transient, mild postoperative dysphagia occurred in 3 patients (12%). There was a significant improvement of the results in postoperative esophageal manometry and 24h-pH monitoring. CONCLUSIONS: Despite the fact that few patients were treated by using laparoscopic approach, results are encouraging with less morbidity and great advantages for patients. Precise selection of patients and surgical techniques are essential.     

Preoperative esophageal body motility does not influence the outcome of laparoscopic Nissen fundoplication for gastroesophageal reflux disease.

We evaluated a policy of performing laparoscopic antireflux surgery without tailoring the procedure to the results of preoperative esophageal motility tests. A total of 117 patients (82 with normal esophageal motility; 35 with ineffective motility, IEM) underwent laparoscopic Nissen fundoplication for symptomatic gastroesophageal reflux. There were no significant differences in preoperative symptom length, dysphagia, DeMeester symptom scores, acid exposure times or lower esophageal sphincter pressures between the two groups. Both groups showed postoperative improvements in DeMeester symptom scores, dysphagia and acid exposure, with no differences between groups. At 1 year after surgery, 95% of the normal motility group and 91% of the IEM group had a good/excellent outcome from surgery. None of the IEM group required postoperative dilatation or reoperation. Patients with IEM fare equally well from laparoscopic Nissen fundoplication as those with normal esophageal motility. There is no merit in tailoring antireflux surgery to the results of preoperative motility tests.     

Dysphagia in aging

Dysphagia is a common problem in older patients and is becoming a larger health care problem as the populations of the United States and other developed countries rapidly age. Changes in physiology with aging are seen in the upper esophageal sphincter and pharyngeal region in both symptomatic and asymptomatic older individuals. Age related changes in the esophageal body and lower esophageal sphincter are more difficult to identify, while esophageal sensation certainly is blunted with age. Stroke, Parkinson's disease, amyotrophic lateral sclerosis, Zenker's diverticula, and several other motility and structural disorders may cause oropharyngeal dysphagia in an older patient. Esophageal dysphagia can also be caused by both disorders of motility (achalasia, diffuse esophageal spasm, scleroderma and others) and structure (malignancy, strictures, rings, external compression, and others). Many of these disorders have an increased prevalence in older patients and should be sought with an appropriate diagnostic evaluation in older patients. The treatment of dysphagia in older patients is similar to that in younger patients, but more invasive therapies such as surgery may not be possible in some older patients making less aggressive medical and endoscopic therapy more attractive.     

Treatment of gastroesophageal reflux disease: endoscopic aspects

Gastroesophageal reflux disease (GERD) is a very common chronic disorder manifesting itself as heartburn, regurgitation, or dysphagia, possibly leading to esophagitis, Barrett's esophagus and adenocarcinoma, and has a major impact on the patient's quality of life. Both medical treatment and surgery are well-established methods with several limitations. Recently, three types of endoscopic methods in several modifications have been developed: (1) Radiofrequency therapy (Stretta procedure) is available both in Europe and USA and more than 5,000 patients have been treated to date. (2) Injection therapy requires the injection of bulking agents or implantation of bioprosthesis into the lower esophageal sphincter (LES) zone. Both Enteryx was withdrawn from the market in 2005, and Gatekeeper was suspended before FDA approval. (3) Suturing/plication therapy is based on the plication at the level of the LES, and most of all techniques resemble the principle of surgical treatment. Despite sophisticated technologies and promising short-term results, all these techniques are associated with inconsistencies, controversies, and relevant adverse affects. According to current practice, use of endoscopic methods is justifiable only as part of clinical trials. Many aspects, including commercial ones, will influence future developments in this area, which are difficult to predict.     

Current Approach to the Treatment of Achalasia

Achalasia is a primary esophageal motility disorder characterized by aperistalsis and incomplete or absent relaxation of the lower esophageal sphincter (LES). The cause of the disease remains elusive and there is no intervention that improves the esophageal body function. Currently, treatment options focus on palliation of symptoms by reducing the LES pressure. The most effective and well-tolerated treatments continue to be the laparoscopic Heller myotomy and endoscopic pneumatic dilation; however, newer techniques (eg, peroral endoscopic myotomy and self-expanding metal stents) show promise. Botulinum toxin and pharmacologic therapy are reserved for those who are unable to undergo more effective therapies. Treatment options should be tailored to the patient, using current predictors of outcome such as the patient’s age and post-treatment LES pressures. The aim of this article is to highlight current literature and provide an up-to-date approach to the treatment of achalasia.     

Clinical and manometric features of the lower esophageal muscular ring

OBJECTIVE: In contrast to the well-recognized Schatzki's ring, the lower esophageal muscular ring remains a poorly defined entity. The purpose of this study is to report on the clinical features of three patients with lower esophageal muscular rings and review the literature on this disorder, to better understand its importance as a cause of dysphagia. METHODS: Three patients presenting to the West Roxbury VA Medical Center were identified as having a contractile, focal narrowing in the distal esophagus by upper GI series. Clinical histories were obtained and endoscopic and manometric evaluations were performed. RESULTS: The three patients had symptoms consisting of chronic, intermittent dysphagia for both liquids and solids. The results of barium swallows and upper endoscopic examinations were similar and revealed a focal, thick constriction of variable luminal diameter located a few centimeters above the squamocolumnar junction. Esophageal motility testing revealed peristaltic, high-amplitude, long-duration, and multiple peaked contractions. Lower esophageal sphincter function was normal. The patients derived partial or only temporary relief of dysphagia with esophageal dilation with rigid dilators. All three patients had significant symptomatic responses to anticholinergic agents. CONCLUSIONS: Lower esophageal muscular rings are an uncommon but important cause of dysphagia. Significant esophageal motility abnormalities can be found in symptomatic patients. Distinguishing the lower esophageal muscular ring from the Schatzki's ring is important because of differences in the treatment and outcome of the two conditions.     

Esophageal ileus following laparoscopic fundoplication

Early postoperative dysphagia occurs in most patients following laparoscopic fundoplication. Whether dysphagia is associated with a change in esophageal motor function and/or a change in gastroesophageal junction characteristics is unknown. Esophageal motility in the early postoperative period has not been evaluated previously. Esophageal motility was studied on the first postoperative day in 10 patients who underwent laparoscopic Nissen fundoplication and 10 patients who underwent laparoscopic cholecystectomy (control group), using standard perfusion manometry. Primary peristalsis on water swallows following fundoplication elicted a median response of 5% successful peristalsis compared with median response of 100% successful peristalsis following cholecystectomy (P = 0.05). The fundoplication was associated with failure of primary esophageal peristalsis in 7/10 patients, compared to 2/10 patients who underwent cholecystectomy (P = 0.068 Fisher's exact test). Three months after fundoplication, in nine patients studied, primary peristalsis was similar to peristalsis observed preoperatively in seven patients and two patients still had an aperistaltic esophagus. In this study, esophageal manometry 1 day after surgery demonstrated grossly disturbed esophageal motility in most patents following laparoscopic fundoplication, compared to normal motility following laparoscopic cholecystectomy. Peristalsis improved at 3 months or more following surgery. This suggests that an 'esophageal ileus' occurs during the early period after laparoscopic fundoplication.     

Childhood achalasia: A comprehensive review of disease,diagnosis and therapeutic management

Achalasia is an esophageal motility disorder character-ized by failure of lower esophageal sphincter(LES) relaxation and is rare in children. The most common symptoms are vomiting, dysphagia, regurgitation, and weight loss. Definitive diagnosis is made with barium swallow study and esophageal manometry. In adults, endoscopic biopsy is recommended to exclude malig-nancy however; it is not as often indicated in children. Medical management often fails resulting in recurrent symptoms and the ultimate definitive treatment is sur-gical. Laparoscopic Heller myotomy with or without an anti-reflux procedure is the treatment of choice and has become standard of care for children with achala-sia. Peroral endoscopic myotomy is a novel therapy uti-lized with increasing frequency for achalasia treatment in adults. More experience is needed to determine the safety, efficacy, and feasibility of peroral endoscopic myotomy in children.     

Utility of dysphagia grade in predicting endoscopic ultrasound T‐stage of non‐metastatic esophageal cancer

Patients with non‐metastatic esophageal cancer routinely undergo endoscopic ultrasound (EUS) for loco‐regional staging. Neoadjuvant therapy is recommended for ≥T3 tumors while upfront surgery can be considered for ≤T2 lesions. The aim of this study was to determine if the degree of dysphagia can predict the EUS T‐stage of esophageal cancer. One hundred eleven consecutive patients with non‐metastatic esophageal cancer were retrospectively reviewed from a database. Prior to EUS, patients' dysphagia grade was recorded. Correlation between dysphagia grade and EUS T‐stage, especially in reference to predicting ≥T3 stage, was determined. The correlation of dysphagia grade with EUS T‐stage (Kendall's tau coefficient) was 0.49 (P < 0.001) for the lower and 0.59 (P = 0.008) for the middle esophagus. The sensitivity and specificity of dysphagia grade ≥2 (can only swallow semi‐solids/liquids) for T3 cancer were 56% (95% confidence interval [CI] 43–67%) and 93% (95% CI 79–98%), respectively. The sensitivity, specificity, and positive predictive value of dysphagia grade ≥3 (can only swallow liquids or total dysphagia) for T3 lesions were 36% (95% CI 25–48%), 100% (95% CI 89–100%), and 100% (95% CI 83–100%), respectively. Overall, there was a significant positive correlation between dysphagia grade and the EUS T‐stage of esophageal cancer. All patients with dysphagia grade ≥3 had T3 lesions. This may have clinical implications for patients who can only swallow liquids or have complete dysphagia by allowing for prompt initiation of neoadjuvant therapy, especially in countries/centers where EUS service is difficult to access in a timely manner or not available.