Minimally invasive surgical treatment of esophageal achalasia.

BACKGROUND AND OBJECTIVES: A minimally invasive approach is considered the treatment of choice for esophageal achalasia. We report the evolution of our experience from thoracoscopic Heller myotomy (THM) to laparoscopic Heller myotomy (LHM). Our objective is to define the efficacy and safety of these 2 approaches. METHODS: Between March 1993 and December 2001, 36 patients underwent minimally invasive surgery for achalasia. Sixteen patients underwent THM without an antireflux procedure, and 20 patients underwent LHM with partial anterior fundoplication (n = 13) or closure of the angle of His (n = 7). RESULTS: Mean operative time and mean hospital stay were significantly shorter for LHM compared with that of THM (148.3 +/- 38.7 vs 222 +/- 46.1 min, respectively; P = 0.0001) and (2.06 +/- 0.65 days vs 5.06 +/- 0.85 days, respectively; P = 0.0001). Six of 16 patients (37.5%) in the THM group experienced persistent or recurrent dysphagia compared with 1 of 20 patients (5%) in the LHM group (P = 0.01). Heartburn developed in 5 patients (31.2%) after THM and in 1 patient (5%) after LHM (P = 0.06). Regurgitation developed in 4 patients (25%) after THM and in 2 patients (10%) after LHM (P = 0.2). Lower esophageal sphincter (LES) basal pressure decreased significantly from 30.1 +/- 5.07 to 15.3 +/- 2.1 after THM and from 31.8 +/- 6.2 to 10.4 +/- 1.7 after LHM (P = 0.0001). Mean esophageal diameter was significantly reduced after LHM compared with that after THM (from 53.9 +/- 5.9 mm to 27.2 +/- 3.3 mm vs 50.8 +/- 7.6 mm to 37.2 +/- 6.9 mm respectively: P = 0.0001). CONCLUSION: In our experience, LHM is associated with better short-term results and is superior to THM in relieving dysphagia. LHM with partial anterior fundoplication should be considered the treatment of choice for achalasia.     

贲门失弛缓症外科治疗新观念

贲门失弛缓症是最常见的食管运动功能障碍性疾病,在西方国家其发病率为每年0．4～1．0／10万人口,在我国则缺乏贲门失弛缓症的流行病学资料。贲门失弛缓症的主要病理生理变化是吞咽时食管平滑肌部分缺乏蠕动和食管下括约肌不能松弛或松弛不全,引起患者的吞咽困难症状。一般认为贲门失弛缓症患者的食管缺乏蠕动是难以恢复的,治疗的目的主要是降低食管下括约肌的压力,目前常用的治疗方法有3种：一是肉毒毒素食管下括约肌注射,其1年后的症状缓解率为15％～30％;二是气囊扩张治疗,其1年后的症状缓解率约为50％,且需反复进行扩张;三是手术治疗,Heller手术后经长期随访,其症状缓解率持续在80％以上,因此手术治疗仍然是目前治疗贲门失弛缓症最有效的方法。     

Current treatment of esophageal achalasia. Surgeons' opinion

This present paper is proposing a presentation of the current therapeutical possibilities in the esophageal achalazia. This severe esophagian motility disorder is profiting, in the current context of minim invasive therapy, of either pneumatic dilatation, either esocardiomyotonomy. Both methods have given favorable results, but degradable in time. Starting from the experience of my gastroentheriologists colleagues, presented in previous papers, we insist on minim invasive therapeutical gestures. And, because the pneumatical dilatation, besides the smaller percentage of favorable results and the need of being periodically repeated, determines anatomical alterations of the esopagian junction that make difficult and even dangerous the surgical intervention, we plead for esocardiomyotonomy from the beginning. The possibility of operating videooscopically is imposing this therapeutical method. Regarding the videoscopic alternative, we are pleading for the abdominal way and for the Bailey esomyotomy or Heller esocardiomyotomy with fundoplicatura.     

Surgical treatment of stage IV cardial achalasia

An original method of surgical treatment of patients with stage IV cardial achalasia was developed. Seven patients aged 42 to 59 years underwent surgery according this method. Objective methods of examination and life quality study with GIQLI carried out 3 months to 5 years after surgery demonstrate satisfactory anatomic and functional results.     

Repair of esophageal perforation after treatment for achalasia

Esophageal perforation after treatment for achalasia is a devastating complication. Successful closure of the perforation and relief of the obstruction from achalasia are paramount. This can be accomplished by careful closure of the mucosa. The mucosal closure is buttressed by a pedicled intercostal muscle carefully sewn to the edges of the muscular defect. This approach deals effectively with the perforation and maintains the myotomy for relief of esophageal obstruction from achalasia.     

Diagnosis and treatment of esophageal achalasia in children

The article shows the results of diagnosis and treatment of achalasia of the esophagus in 21 children aged from 20 months to 15 years. Radiological examination with the use of the nitroglycerin test was highly informative and authentic in all cases. To evaluate the condition of the esophagus, additional endoscopic and esophagomanometric examination is necessary. From analysis of the results of drug therapy in all patients, operative in 13, and pneumocardiodilatation in 7 children it was found that treatment of achalasia of the esophagus in children should begin with forced pneumodilatation. Modified Heller's operation with fundoplication produces good results.     

Impact of esophageal flexion level on the surgical outcome in patients with sigmoid esophageal achalasia

Purpose

Esophageal achalasia can be roughly divided into non-sigmoid and sigmoid types. Laparoscopic surgery has been reported to be less than optimally effective for sigmoid type. The aim of this study was to examine the impact of the esophageal flexion level on the clinical condition and surgical outcomes of patients with sigmoid esophageal achalasia.

Methods

The subjects were 36 patients with sigmoid esophageal achalasia who had been observed for >1 year after surgery. The subjects were divided into sigmoid type (Sg) and advanced sigmoid type (aSg) groups based on the flexion level of the lower esophagus to compare their clinical parameters and surgical outcomes.

Results

The Sg and aSg groups included 26 (72%) and 10 subjects, respectively. There were no marked differences in the clinical parameters or surgical outcomes between the two groups. However, the clearance rate calculated using the timed barium esophagogram was lower in the aSg group than in the Sg group. No differences were found in the postoperative symptom scores between the two groups, and both reported a high level of satisfaction.

Conclusions

Although laparoscopic surgery for symptoms of sigmoid esophageal achalasia was highly successful regardless of the flexion level, the improvement in esophageal clearance was lower when the flexion level was higher.

     

Evolution of the minimally invasive treatment of esophageal achalasia

Thanks to the advent of laparoscopic techniques, the last decade and a half have witnessed a radical change in the treatment of esophageal achalasia. Because of the high success rate of the laparoscopic Heller myotomy, surgery has now become in many centers the first modality of treatment for achalasia. This shift in the treatment algorithm reflects the fact that laparoscopic Heller myotomy with partial fundoplication outperforms nonsurgical approaches, such as balloon dilatation and intrasphincteric botulinum toxin injection.