Improved outcome after extended gastric myotomy for achalasia

HYPOTHESIS: There is general agreement that a Heller myotomy should extend 6 to 7 cm above the gastroesophageal junction. Results of most previous studies have recommended that the myotomy extend 1 to 1.5 cm below the gastroesophageal junction. We speculated that the effectiveness of the operation could be improved if a longer, 3-cm myotomy was carried out below the gastroesophageal junction, as it would more completely obliterate the lower esophageal sphincter. We, therefore, changed our technique in 1998. Concurrently, we converted from a Dor fundoplication to a Toupet fundoplication. This study analyzes the results of our new strategy. DESIGN: A case series using a prospectively maintained database. SETTING: Tertiary referral center. PATIENTS: One hundred ten consecutive patients with achalasia undergoing laparoscopic Heller myotomy. INTERVENTION: We analyzed the course of 52 patients treated with a standard laparoscopic esophagogastric myotomy (1.5 cm in the stomach) and a Dor fundoplication between September 1, 1994, and August 31, 1998, and 58 treated with an extended gastric myotomy (3 cm below the gastroesophageal junction) and a Toupet fundoplication between September 1, 1998, and August 31, 2001. MAIN OUTCOME MEASURES: Esophageal function testing (esophageal manometry and 24-hour pH monitoring), symptom questionnaire (frequency and severity), and postoperative interventions required. RESULTS: Postoperatively the lower esophageal sphincter pressure was significantly lower after extended gastric myotomy and a Toupet fundoplication vs standard myotomy and a Dor fundoplication (9.5 vs 15.8 mm Hg). Dysphagia was both less frequent (1.2 vs 2.1) and less severe (visual analog scale, 3.2 vs 5.3) after extended gastric myotomy and Toupet fundoplication. In the standard laparoscopic esophagogastric myotomy and a Dor fundoplication group, 9 patients (17%) had recurrent, severe dysphagia, which was treated by dilation in 5 patients and by reoperation in 4 patients. In the extended gastric myotomy and Toupet fundoplication group, 2 patients (3%) developed recurrent dysphagia that resolved with dilatation. There were no reoperations in the extended gastric myotomy and Toupet fundoplication group. No difference was noted in the frequency of heartburn (1.3 vs 1.7), regurgitation (0.3 vs 0.8), and chest pain (0.3 vs 0.6), nor was there a difference between the 2 groups in proximal (1.7% vs 2.3%) and distal (6.0% vs 5.9%) esophageal acid exposure. CONCLUSION: An extended gastric myotomy (3 cm) more effectively disrupts the lower esophageal sphincter, thus improving the results of surgical therapy for achalasia for dysphagia without increasing the rate of abnormal gastroesophageal reflux provided that a Toupet fundoplication is added.     

Laparoscopic Heller myotomy for achalasia in 101 patients: can successful symptomatic outcomes be predicted?

We aimed to evaluate the clinical outcomes of patients undergoing laparoscopic esophageal myotomy for achalasia and identify the factors that might predict postoperative dysphagia or symptomatic reflux. A retrospective analysis of all patients undergoing laparoscopic Heller myotomy from January 1997 to June 2004 was performed. Postoperative frequency and severity of reflux, dysphagia, chest pain, and regurgitation were evaluated using a standardized telephone interview. Forty-eight males and 53 females, with an average age of 45 years, underwent laparoscopic Heller myotomy during the study period. Prior to presentation, 65% of patients had undergone pneumatic dilatation (52%) and/or Botox injection (28%). The mean lower esophageal sphincter pressure was 44 mmHg. A Toupet fundoplication was performed in 89 patients, and 12 patients had no fundoplication. There were no intraoperative complications and 10 minor postoperative complications. During an average follow-up of 34 months (range 2-90), 15% of patients had a weekly dysphagia, and 16% had subjective reflux. Only an older age predicted higher incidence of postoperative dysphagia. No factors were identified to predict postoperative symptomatic reflux. Eighty-one percent of patients rated their outcome as excellent, 14% good, 4% fair, and 1% poor. Ninety-nine percent of patients would choose surgery over other treatment options again. Laparoscopic anterior esophageal myotomy is a safe and effective treatment for achalasia. Improvement in dysphagia can be expected in more than 95% of patients. Younger patients tended to have better improvement of dysphagia. Predicting the patients at higher risk for postoperative reflux remains elusive at this time.     

Preoperative lower esophageal sphincter pressure affects outcome of laparoscopic esophageal myotomy for achalasia

The primary aim of this study was to identify factors that influence outcome of the surgical treatment of achalasia. A secondary aim was to compare outcomes after laparoscopic Heller myotomy and partial fundoplication using either a Dor or Toupet hemifundoplication. Between 1994 and 2002, a total of 78 patients underwent laparoscopic Heller myotomy and partial fundoplication. Preoperative investigations included esophageal manometry, a videoesophogram, and upper gastrointestinal endoscopy with biopsy. In 64 patients (35 males and 29 females), telephone contact was possible at a median 24 months (IQR 14–34). A Dor fundoplication was performed in 41 patients and a Toupet fundoplication in 23. Symptoms were assessed prior to surgery and at follow-up by an independent physician using standardized definitions to grade the severity of dysphagia, regurgitation, and chest pain. To assess outcome, dysphagia was categorized as persistent or resolved. Persistent was defined as dysphagia that occurred on a weekly or daily basis. Resolved was defined as dysphagia that occurred occasionally or not at all. At follow-up, patients were asked to make a personal evaluation of their outcome as to whether (1) their swallowing was improved by the procedure, (2) they were satisfied with the outcome, and (3) they would undergo surgery again under the same circumstances. There was a significant improvement in dysphagia and regurgitation scores after surgery (P<0.05). The scores for chest pain/heartburn remained unchanged. By physician assessment, dysphagia was resolved in 49 patients (77%) and persisted in 15 (33%). By patient assessment, 62 patients (97%) reported an improvement in the symptom of dysphagia, and 60 (94%) stated that they were satisfied with their improvement and would undergo surgery if they had to make the choice again. On univariate analysis, patients who had resolution of their dysphagia had a significantly higher resting lower esophageal sphincter (LES) pressure prior to myotomy (P=0.01) and on multivariate analysis only a high resting LES pressure prior to surgery was a predictor of resolution of dysphagia (P=0.015). Outcome comparison of patients with Dor and Toupet fundoplications showed no significant differences in physician assessment of postoperative symptom scores and resolution of dysphagia, patient assessment of outcome, or postoperative use of proton pump inhibitors. Ninety-four percent of patients are satisfied with their surgical myotomy for achalasia. By physician assessment dysphagia was resolved in 77% of patients. Ahigh LES resting pressure before surgery predicted resolution of dysphagia.     

Achalasia and chest pain: Effect of laparoscopic heller myotomy

Some patients with achalasia complain of chest pain in addition to dysphagia and regurgitation. Chest pain is said to be most common in young patients who have been symptomatic for a short time, and who often have vigorous achalasia (distal esophageal amplitude ≥37 mm Hg). Although pneumatic dilatation is reported to improve chest pain in 20% of patients, the effect of laparoscopic Heller myotomy on chest pain is unknown. The aim of this study was to determine the following in achalasia: (1) the prevalence of chest pain; (2) the clinical and manometric profiles of patients with chest pain; and (3) the effect of laparoscopic Heller myotomy. Between 1990 and 2001, a total of 211 patients with achalasia were studied (upper gastrointestinal series, esophagoduodenoscopy, and manometry). A total of 117 patients (55%) had chest pain in addition to dysphagia and regurgitation; 63 (54%) of these 117 patients underwent laparoscopic Heller myotomy and Dor fundoplication. Median follow up was 24 months. Age (49 ± 16 years vs. 51 ± 14 years [mean ± SD]), duration of symptoms (71 ± 91 months vs. 67 ± 92 months [mean ± SD]), and presence of vigorous achalasia (50% vs. 47%) were similar in those with and without chest pain. Ten (16%) of the 63 patients with chest pain who underwent Heller myotomy had vigorous achalasia. Postoperatively chest pain resolved in 84% and improved in 11 % of patients. There was no difference in clinical outcome between patients with and without vigorous achalasia. These data demonstrate the following: (1) chest pain was present in 55% of patients with esophageal achalasia; (2) chest pain was not related to age, duration of symptoms, or manometric findings; and (3) laparoscopic Heller myotomy improved chest pain in 95% of patients, regardless of the manometric findings. Thus laparoscopic Heller myotomy was highly effective in treating achalasia with chest pain. Considered for the 2002 Grassi Prize, International Society of Digestive Surgery, Hong Kong, China, December 11, 2002.     

Does concomitant anterior fundoplication promote dysphagia after laparoscopic Heller myotomy?

Concerns for gastroesophageal reflux after laparoscopic Heller myotomy for achalasia justify considerations of concomitant anterior fundoplication. This study was undertaken to determine if concomitant anterior fundoplication reduces symptoms of reflux after myotomy without promoting dysphagia. From 1992 to 2004, 182 patients underwent laparoscopic Heller myotomy without fundoplication. After a prospective randomized trial justified its concomitant application, anterior fundoplication was undertaken with laparoscopic Heller myotomy in 171 patients from 2004 to 2007. All patients have been prospectively followed. Pre and postoperatively, patients scored the frequency and severity of symptoms of achalasia (including dysphagia, choking, vomiting, regurgitation, chest pain, and heartburn) using a Likert Scale (0 = never/not bothersome to 10 = always/very bothersome). Before myotomy, symptoms of achalasia were frequent and severe for all patients. After myotomy, the frequency and severity of all symptoms of achalasia significantly decreased for all patients (P < 0.001, Wilcoxon matched pairs test). Notably, relative to patients undergoing laparoscopic Heller myotomy alone, concomitant anterior fundoplication led to significantly less frequent and severe heartburn after myotomy (P < 0.05, Mann-Whitney Test) and to less frequent and severe dysphagia and choking (P < 0.05, Mann-Whitney Test). Laparoscopic Heller myotomy reduces the frequency and severity of symptoms of achalasia. Concomitant anterior fundoplication decreases the frequency and severity of heartburn and dysphagia after laparoscopic Heller myotomy. Concomitant anterior fundoplication promotes salutary relief in the frequency and severity of symptoms after myotomy and is warranted.     

Midterm follow-up evaluation after a novel approach to anterior fundoplication for achalasia

Background This study aimed to compare the outcomes for Heller myotomy alone and combined with different partial fundoplications. Methods The authors retrospectively reviewed their experience with 69 laparoscopic myotomies and 14 Heller myotomies, 80% of which were performed with partial fundoplication including 20 Toupet, 18 Dor, and 17 modified Dor procedures, in which the fundoplication is sutured to both sides of the crura and not the myotomy. Results The mean age of the study patients was 69 years (range, 15–80 years). Four mucosal perforations were repaired intraoperatively. There was one small bowel fistula in an area of open hernia repair distant from the myotomy. One patient with severe chronic obstructive pulmonary disease died of pneumonia. Phone follow-up evaluation was achieved in 68% of the cases at a mean of 37 months (range, 2–97 months). The results for no dysphagia and for heartburn requiring proton pump inhibitors, respectively, were as follows: Heller myotomy (85.7%, 28.5%), Toupet (66.6%, 33.3%), Dor (83.3%, 20%), and modified Dor (84.6%, 15.3%). Two patients with reflux strictures required annual dilation (Toupet, Dor). Two patients required revisions: one redo Heller myotomy (Dor) and one esophageal replacement (Toupet). Conclusion Heller myotomy provides excellent dysphagia relief with or without fundoplication. Heartburn is a significant problem for a minority of patients. In the authors’ hands, Toupet had the worst results and modified Dor was most protective for heartburn. Presented at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) 13–16 April 2005 in Hollywood, Florida     

Laparoscopic Heller myotomy with Toupet fundoplication: outcomes predictors in 121 consecutive patients

HYPOTHESIS: This study was performed to assess the intermediate-term outcomes after laparoscopic Heller myotomy and posterior Toupet fundoplication in a single-surgeon series with the expectation of identifying patient and disease factors associated with poor outcomes. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Tertiary care teaching hospital with a comprehensive esophageal physiology laboratory. PATIENTS: A total of 121 patients undergoing laparoscopic Heller myotomy with Toupet fundoplication (between December 1, 1996, and December 31, 2004) for achalasia were included. INTERVENTIONS: All patients had preoperative objective documentation of achalasia. A 5- to 6-cm-long myotomy was performed on the distal esophagus. The myotomy incision was extended 2 cm onto the stomach. A partial (270 degrees ) posterior Toupet fundoplication was performed as an antireflux mechanism in all patients. MAIN OUTCOME MEASURES: Data on preoperative and postoperative symptoms, manometry, and 24-hour ambulatory pH were prospectively collected. Symptoms were recorded with a standardized assessment tool. Patients with postoperative dysphagia scores of 2 or greater were considered treatment failure. Logistic regression modeling was performed to identify variables significant for poor outcomes. RESULTS: Preoperatively, 89 patients (73.6%) had severe dysphagia (dysphagia score, 3 or 4) and 32 patients (26.4%) had mild or moderate dysphagia (dysphagia score, 1 or 2). After a median follow-up period of 9 months, 102 patients (84.3%) (P<.001) had excellent relief of dysphagia (dysphagia score, 0 or 1). Eight additional patients (6.6%) demonstrated a significant (25%-75% [P=.01]) improvement in dysphagia scores. Only 11 patients (9.0%) had either no change or worse dysphagia. Postoperatively, all patients with manometry had a normal lower esophageal sphincter pressure (mean +/- SD, 14.7 +/- 6.6 mm Hg; P<.001) and good lower esophageal sphincter relaxation. Odds of failure were greatest for patients with severe preoperative dysphagia, male patients, and patients with classic amotile achalasia. Of the 60 patients having heartburnlike symptoms preoperatively (mean +/- SD score, 2.52 +/- 1.00), 19 (31.7%) continued to have similar symptoms after surgery. Sixteen (33.3%) of the 48 patients having postoperative pH studies demonstrated objective reflux (DeMeester score, >14.7). Five (31.2%) of these patients had symptoms of their reflux. CONCLUSIONS: Dysphagia improves in most patients after laparoscopic Heller myotomy with partial fundoplication. Patients with severe preoperative dysphagia, esophageal dilation, or amotile achalasia may have greater chances of a poor outcome.     

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 Heller myotomy with anterior fundoplication ameliorates symptoms of achalasia in pediatric patients

BACKGROUND: This study was undertaken to define outcomes after laparoscopic Heller myotomy with anterior fundoplication in pediatric patients and compare their outcomes with those in adults. STUDY DESIGN: A total of 337 patients have undergone laparoscopic Heller myotomy with anterior fundoplication since 1992, and were prospectively followed; 14 were pediatric patients of median age 17 years (range 11 to 19 years). Symptoms noted by pediatric patients before and after myotomy were compared with symptoms of 56 concurrently treated adults (4 treated adults for each pediatric patient) of median age 48 years. Among many symptoms, patients scored the severity and frequency of dysphagia, chest pain, regurgitation, choking, vomiting, and heartburn before and after myotomy using a Likert scale, ranging from 0 (never/not bothersome) to 10 (always/very bothersome). Followups were 38 months, 42 months+/-33.1. Data are reported as median, mean +/- SD. RESULTS: For pediatric patients, length of stay after myotomy was 2 days, 3 days+/-2.9 versus 2 days, 2+/-2.1 for adults. Before myotomy, symptom frequency and severity were similar between groups. After myotomy, symptom frequency and severity were similar between pediatric and adult patients, except for the frequency of chest pain. CONCLUSIONS: Achalasia can produce disabling symptoms, which were similar between pediatric and adult patients before myotomy. Laparoscopic Heller myotomy with anterior fundoplication ameliorated symptoms of achalasia in all patients, with postmyotomy symptoms similar between pediatric and adult patients. Laparoscopic Heller myotomy dramatically improved symptoms of achalasia in pediatric patients and its use is encouraged.     

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.     

Videoscopic Heller myotomy with intraoperative endoscopy promotes optimal outcomes.

BACKGROUND AND OBJECTIVES: Minimally invasive surgical techniques are applicable to achalasia, but the optimum approach to intraoperative assessment of adequacy of myotomy remains unestablished. We set out to show that videoscopic Heller myotomy with concurrent endoscopy ensures adequacy of myotomy while limiting postoperative clinically apparent reflux. METHODS: Seventy-eight consecutive patients with achalasia underwent videoscopic Heller myotomy with concomitant endoscopy between 1992 and 1998. Fundoplication was not routinely undertaken. RESULTS: Preoperative symptoms consisted of dysphagia (100%), emesis/regurgitation (68%), heartburn (58%), and postprandial chest pain (49%). Following myotomy, significant improvement (P < 0.0001) was seen in dysphagia (43%), postprandial chest pain (13%), and emesis/regurgitation (9%) at a mean follow-up of 33+/-2.2 months. Mean reflux score (scale 0 to 5) improved from 3.7+/-0.3 to 1.5+/-0.2 (P < 0.0001). Improvement in symptoms was reported in 96% of patients. Fundoplication was used in 8 patients as part of hiatus reconstruction (n = 6) or repair of esophageal perforation (n = 2). CONCLUSIONS: Intraoperative endoscopy during videoscopic Heller myotomy guides the extent and adequacy of myotomy. By utilizing a focused dissection with preservation of the natural antireflux mechanisms around the gastroesophageal junction and limiting the extent of myotomy along the cardia, postoperative reflux symptoms are minimized. We advocate concomitant endoscopy during Heller myotomy to guide myotomy and submit that routine fundoplication is clinically unnecessary.     

Laparoscopic myotomy vs endoscopic dilation in the treatment of achalasia

BACKGROUND: The aim of this study was to compare the results obtained in 14 patients with achalasia who underwent laparoscopic Heller's myotomy and Dor's fundoplication with those of 16 patients who had endoscopic dilation. METHODS: The diagnosis of achalasia was confirmed by manometry, endoscopy, and barium swallow. Esophageal symptoms were quantified before and after treatment using a clinical scale. Six patients had had endoscopic dilation prior to surgery. RESULTS: Before treatment, the patients in the surgical group complained of more severe dysphagia (median, 5; range, 0-5 vs median 4; range, 3-5) and chest pain (median, 3; range, 0-5 vs median, 1.5; range, 0-5), but both groups were comparable with respect to regurgitation, heartburn, and manometric results. Both groups achieved significant clinical improvement. The severity score decreased from 5 (range, 0-5) to 1 (range, 0-3) (p < 0.05) for dysphagia to solids in the laparoscopic group and from 4 (range, 3-5) to 1 (range, 0-5) (p < 0.05) in the endoscopic group. Lower esophageal sphincter (LES) basal pressure decreased significantly in both groups (from 29.3 to 11.8 mmHg in the laparoscopic group and from 28.9 to 16.5 mmHg in the endoscopic group). After treatment, there were no significant clinical differences between the two groups. Two patients in the surgical group were converted to open surgery. CONCLUSION: Laparoscopic myotomy is as save and effective as endoscopic dilation in the treatment of achalasia.     

Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula

Purpose  The purpose of this study is to characterize the esophageal motor and lower esophageal sphincter (LES) abnormalities associated with epiphrenic esophageal diverticula and analyze outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication. Methods  The endoscopic, radiographic, manometric, and perioperative records for patients undergoing laparoscopic esophageal diverticulectomy, anterior esophageal myotomy, and partial fundoplication from 8/99 until 9/06 were reviewed from an Institutional Review Board (IRB)-approved outcomes database. Data are given as mean ± standard deviation (SD). Results  An esophageal body motor disorder and/or LES abnormalities were present in 11 patients with epiphrenic diverticula; three patients were characterized as achalasia, one had vigorous achalasia, two had diffuse esophageal spasm, and five had a nonspecific motor disorder. Presenting symptoms included dysphagia (13/13), regurgitation (7/13), and chest pain (4/13). Three patients had previous Botox injections and three patients had esophageal dilatations. Laparoscopic epiphrenic diverticulectomy with an anterior esophageal myotomy was completed in 13 patients (M:F; 3:10) with a mean age of 67.6 ± 4.2 years, body mass index (BMI) of 28.1 ± 1.9 kg/m² and American Society of Anesthesiologists (ASA) 2.2 ± 0.1. Partial fundoplication was performed in 12/13 patients (Dor, n = 2; Toupet, n = 10). Four patients had a type I and one patient had a type III hiatal hernia requiring repair. Mean operative time was 210 ± 15.1 min and mean length of stay (LOS) was 2.8 ± 0.4 days. Two grade II or higher complications occurred, including one patient who was readmitted on postoperative day 4 with a leak requiring a thoracotomy. After a mean follow-up of 13.6 ± 3.0 months (range 3–36 months), two patients complained of mild solid food dysphagia and one patient required proton pump inhibitor (PPI) for gastroesophageal reflux disease (GERD) symptoms. Conclusion  The majority of patients with epiphrenic esophageal diverticula have esophageal body motor disorders and/or LES abnormalities. Laparoscopic esophageal diverticulectomy and anterior esophageal myotomy with partial fundoplication is an appropriate alternative with acceptable short-term outcomes in symptomatic patients.     

Laparoscopic Heller myotomy with Toupet fundoplication for achalasia straightens the esophagus and relieves dysphagia

BACKGROUND: A standard procedure for the treatment of achalasia remains to be established. We assessed the usefulness of a laparoscopic Heller myotomy with a Toupet fundoplication (LHT). METHODS: LHT was performed in 30 patients (12 men, 18 women; mean age, 41.8 y) who had esophageal achalasia with severe dysphagia. Caution was exercised when the esophagus was pulled downward and straightened. Symptoms and esophageal function were evaluated before and after surgery. RESULTS: The esophagus was straightened surgically in 22 (88%) of 25 patients with esophageal curvature on preoperative esophagography. The dysphagia score decreased to 1.7 +/- 1.2 (mean +/- SD) points from a preoperative value of 10. The lower esophageal sphincter pressure decreased significantly. Two patients (7%) had esophageal diverticula as postoperative sequelae. Pathologic acid reflex was noted in 3 patients (12%). CONCLUSIONS: LHT is a useful procedure for straightening the esophagus, reducing lower esophageal sphincter pressure, and relieving dysphagia in patients with achalasia.     

Laparoscopic heller myotomy and anterior fundoplication for achalasia results in a high degree of patient satisfaction

HYPOTHESIS: Laparoscopic Heller myotomy with anterior fundoplication will alleviate the symptoms of achalasia and result in excellent patient satisfaction. DESIGN: Retrospective study of consecutive patients who underwent laparoscopic Heller myotomy with anterior fundoplication for achalasia between October 1995 and July 1999. A telephone survey assessed symptoms and satisfaction. Patients were asked to quantitate their symptoms on a scale of 0 to 3 (0 = none; 1, mild; 2, moderate; and 3, severe). SETTING: University referral center. PATIENTS: Twenty-four patients who underwent laparoscopic Heller myotomy with anterior fundoplication for achalasia. MAIN OUTCOME MEASURES: Postoperative symptoms and satisfaction. RESULTS: Twenty-one patients (88%) were successfully contacted. Mean follow-up was 16.5 months. The laparoscopic approach was successful in all but 3(88%). The mean dysphagia score was 2.81 preoperatively and 0.81 postoperatively (P<.000). The mean chest pain score was 1. 57 preoperatively and 0.86 postoperatively (P<.015). The mean supine regurgitation score was 2.10 preoperatively and 0.57 postoperatively (P<.000). The mean upright regurgitation score was 1.57 preoperatively and 0.52 postoperatively (P<.000). The mean heartburn score was 1.57 preoperatively and 0.57 postoperatively (P<.000). Postoperatively, 18 (86%) of 21 patients could swallow bread without difficulty and 17 (89%) of 19 patients could eat meat without difficulty (2 were excluded as they were vegetarians). Twenty (95%) of 21 patients reported improvement after the operation. CONCLUSIONS: Laparoscopic Heller myotomy with anterior fundoplication significantly relieves the symptoms of achalasia without causing the symptoms of gastroesophageal reflux disease. This procedure results in excellent overall patient satisfaction.     

Laparoscopic reoperation as management of severe gastroesophageal reflux following laparoscopic Heller myotomy for achalasia: a case report

Achalasia is a rare disorder of the esophagus. Nonsurgical management includes oral medication, pneumatic dilatation, and injections of botulinum toxin. Surgical intervention was traditionally limited to patients with residual dysphagia after nonsurgical treatment. With the popularization of minimally invasive surgery, myotomy was increasingly performed via a laparoscopic approach. The procedure was found to be safe and efficient and is now used with increasing frequency as a primary therapeutic option. We report the case of a 17-year-old patient with achalasia in whom symptoms of gastroesophageal reflux developed following laparoscopic Heller myotomy without an antireflux procedure. Five years after surgery, the patient underwent reoperation with Toupet fundoplication. Five months after surgery, we found a normal De Meester Score and no pathologic gastroesophageal reflux. The authors conclude that laparoscopic Heller myotomy is the treatment of choice for achalasia and recommend that an antireflux procedure be included routinely.     

Treatment of esophageal achalasia with Heller myotomy: retrospective evaluation of patient satisfaction and disease-specific quality of life.

BACKGROUND: Prospective randomized studies have suggested that surgery palliates esophageal achalasia more effectively than pneumatic dilatation, but for some dilatation is still the procedure of choice for initial treatment. We decided to compare achalasia symptoms before and after Heller myotomy by means of postoperative questionnaires. METHODS: The study included 22 patients who underwent Heller myotomy for achalasia at the Hotel Dieu Hospital, Queen's University, Kingston, Ont., since July 1990; 5 of them required repeat myotomy for symptom recurrence, for a total of 9 open and 18 laparoscopic procedures. Median follow-up was 43 (range 6-109) months. Preoperative and postoperative data regarding dysphagia, regurgitation, chest pain and overall patient satisfaction were gathered. Symptom scores were calculated by adding severity (0 = none, 2 = mild, 4 = moderate, 6 = severe) to frequency (0 = never, 1 = occasionally, 2 = once a month, 3 = every week, 4 = twice a week, 5 = daily). Patients having a repeat procedure were instructed to evaluate symptoms with respect to their initial myotomy. RESULTS: Seventeen (77%) patients were successfully contacted, 4 of them had subsequent repeat myotomy for symptom recurrence. Initially, overall symptom scores decreased for all but 1 patient, with mean preoperative and postoperative values of 23.1 and 7.3 respectively (p < 0.001). The patient in whom symptoms did not improve is a candidate for a repeat procedure. Repeat myotomy was performed after a median of 38 (range 23-75) months, corresponding to an overall 3-year positive outcome in 13 (76%) of the 17 patients. Fifteen (88%) patients considered their myotomies a success and 16 (94%) would choose to have this procedure again given the outcome. CONCLUSION: Heller myotomy appears to be effective in alleviating the symptoms of achalasia. Repeat myotomy is occasionally required.     

Laparoskopische Fundoplicatio nach Nissen und Toupet bei Patienten mit gastroösophagealer Refluxkrankheit und Motilitätsstörung des distalen Ösophagus

INTRODUCTION: A Nissen fundoplication for gastrooesophageal reflux disease may more often lead to persistent dysphagia than a Toupet fundoplication. The aim of this study was to assess the results of laparoscopic Nissen versus Toupet fundoplication in patients with reflux disease and impaired distal esophageal motility. PATIENTS AND METHODS: In 15 patients a laparoscopic Nissen and in 17 a laparoscopic Toupet fundoplication was carried out. Criteria for an impaired motility of the distal esophagus were a mean amplitude of < 30 mm Hg of swallow-induced contractions, or > 33% non-propulsive or non-transmitted contraction waves. Before surgery, heartburn, dysphagia, regurgitation and other symptoms were scored and endoscopic, manometric and 24 hour pH-metric investigations performed. Patients were reinvestigated 3 to 30 (median 15) months after Nissen and 3 to 42 (median 7) months after Toupet fundoplication. RESULTS: After Nissen as well as after Toupet fundoplication heartburn was significantly less frequent, whereas dysphagia and all other symptom-scores remained unchanged. In the 26 patients reinvestigated manometrically, the resting pressure of the lower esophageal sphincter was significantly higher following both operations and the residual sphincter pressure upon swallowing higher only after Nissen fundoplication. The amplitude of swallow-induced contractions and the percentages of non-propulsive and non-transmitted contraction waves were not significantly changed after either operation. In the 23 patients restudied pH-metrically, reflux activity was significantly reduced after both Nissen and Toupet fundoplication. CONCLUSION: In patients with reflux disease and impaired distal esophageal motility, laparoscopic Nissen and Toupet fundoplication both yielded satisfactory results and neither operation led to increased dysphagia.     

Heartburn is more likely to recur after Toupet fundoplication than Nissen fundoplication

Toupet (270 degrees) fundoplication is commonly recommended for patients with gastroesophageal reflux (GER) and esophageal dysmotility. However, Toupet fundoplication may be less effective at protecting against reflux than Nissen (360 degrees) fundoplication. We therefore compared the effectiveness and durability of both types of fundoplication as a function of preoperative esophageal motility. From January 1992 through January 1998, 669 patients with GER underwent laparoscopic fundoplication (78 Toupet, 591 Nissen). Patients scored heartburn, regurgitation, and dysphagia preoperatively, and at 6 weeks and 1 year postoperatively, using a 0 ("none") to 3 ("severe") scale. We compared symptom scores (Wilcoxon rank sum test) and redo fundoplication rates (Fisher exact test) in Toupet and Nissen patients. We also performed subgroup analyses on 81 patients with impaired esophageal motility (mean peristaltic amplitude, <30 mm Hg or peristalsis <70% of wet swallows) and 588 patients with normal esophageal motility. Toupet and Nissen patients reported similar preoperative heartburn, regurgitation, and dysphagia. At 6 weeks after operation, heartburn and regurgitation were similarly improved in both groups, but dysphagia was more prevalent among Nissen patients. After 1 year, heartburn and regurgitation were re-emerging in Toupet patients, and dysphagia was again similar between groups. Patients with impaired motility who have Nissen fundoplication are no more likely to suffer persistent dysphagia than their counterparts who have Toupet fundoplication. In addition, patients with normal motility are more likely to develop symptom recurrence after Toupet fundoplication than Nissen fundoplication, with no distinction in dysphagia rates. We conclude that since Toupet patients suffer more heartburn recurrence than Nissen patients, with similar dysphagia, selective use of Toupet fundoplication requires further study.     

Video-assisted surgical management of achalasia of the esophagus.

PURPOSE: Video-assisted surgical approaches to esophageal achalasia continue to be explored by many surgeons involved in the management of this motor disorder. We report our experience with thoracoscopic and laparoscopic esophagomyotomy to more clearly define the efficacy and safety of these approaches. PATIENTS: Over 73 months, 58 patients with achalasia underwent thoracoscopic myotomy (n = 19) alone or laparoscopic myotomy (n = 39) with partial fundoplication (anterior = 15; posterior = 24). Mean age was 47.2 years and average length of symptoms was 60 months. Primary symptoms were as follows: dysphagia, 100%; pulmonary abnormalities, 22%; weight loss; 47%, and pain, 45%. Mean esophageal diameter was 6 cm and tortuosity was present in 16% (9/58) of patients. Prior management consisted of dilation (n = 47), botulinum toxin injection (n = 8), and prior myotomy (n = 1). METHODS: In the operating room all patients underwent endoscopic examination and evacuation of retained esophageal contents. The esophagomyotomy was extended 4 cm superiorly and inferiorly to 1 cm beyond the lower esophageal sphincter. Thoracoscopic and laparoscopic procedures were completed in all patients without conversion to an open operation. Mean operative time was 183 minutes (+/-58.1) and hospital stay averaged 2.3 days (+/-0.8). There was no operative mortality. The 1 operative complication was a perforation that was identified during the operation and repaired thoracoscopically. RESULTS: Symptoms improved in 97% of patients. Mean dysphagia scores (range 0-10) decreased from 9.8 +/- 1.6 before the operation to 2.0 +/- 1.5 after the operation (P <.001) at a mean follow-up of 6 months. Postoperative reflux symptoms developed in 5% (1/19) of the thoracoscopy group and 8% (4/39) of the laparoscopy group. Nine patients have persistent or recurrent dysphagia (16%). Seven patients have successfully undergone Savary dilation, and 2 required esophagectomy to manage recalcitrant dysphagia. CONCLUSION: At this intermediate term analysis, video-assisted approaches for management of achalasia are a reasonable alternative to extended medical therapy or open operations.