Display options
Cite
Csendes A, Orellana O, Figueroa M, et al. Long-term (17 years) subjective and objective evaluation of the durability of laparoscopic Heller esophagomyotomy in patients with achalasia of the esophagus (90% of follow-up): a real challenge to POEM. Surg Endosc. 2021;doi: 10.1007/s00464-020-08273-1.
Csendes, A., Orellana, O., Figueroa, M., Lanzarini, E., & Panza, B. (2021). Long-term (17 years) subjective and objective evaluation of the durability of laparoscopic Heller esophagomyotomy in patients with achalasia of the esophagus (90% of follow-up): a real challenge to POEM. Surgical endoscopy, . https://doi.org/10.1007/s00464-020-08273-1
Csendes, Attila, et al. "Long-term (17 years) subjective and objective evaluation of the durability of laparoscopic Heller esophagomyotomy in patients with achalasia of the esophagus (90% of follow-up): a real challenge to POEM." Surgical endoscopy vol. (2021). doi: https://doi.org/10.1007/s00464-020-08273-1
Csendes A, Orellana O, Figueroa M, Lanzarini E, Panza B. Long-term (17 years) subjective and objective evaluation of the durability of laparoscopic Heller esophagomyotomy in patients with achalasia of the esophagus (90% of follow-up): a real challenge to POEM. Surg Endosc. 2021 Jan 20; doi: 10.1007/s00464-020-08273-1. Epub 2021 Jan 20. PMID: 33471177.
Copy Download .nbib Format: NLM
Share it on

Surg Endosc. 2021 Jan 20; doi: 10.1007/s00464-020-08273-1. Epub 2021 Jan 20.

Long-term (17 years) subjective and objective evaluation of the durability of laparoscopic Heller esophagomyotomy in patients with achalasia of the esophagus (90% of follow-up): a real challenge to POEM.

Surgical endoscopy

Attila Csendes, Omar Orellana, Manuel Figueroa, Enrique Lanzarini, Benjamin Panza

Affiliations

  1. Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile. [email protected].
  2. Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile.

PMID: 33471177 DOI: 10.1007/s00464-020-08273-1

Abstract

INTRODUCTION: Laparoscopic Heller Myotomy (LHM) with partial anterior or posterior fundoplication is the standard surgical procedure for treating achalasia patients. The results reported are mainly based on symptomatic evaluations and have less than 5 years of follow-up and none more than ten.

OBJECTIVE: To determine the late results of LHM, performing endoscopic, histologic, manometric, and functional studies in addition to clinical evaluations.

MATERIALS AND METHODS: Eighty-nine consecutive patients were included in a prospective study from 1993 to 2008. Inclusion criteria corresponded to achalasia patients with Types I to III (radiological evaluation). Exclusion criteria included patients with grade IV, patients with previous procedures (surgical or endoscopic), or giant hiatal hernia. They were submitted to a radiological evaluation, over two endoscopic procedures with biopsy samples, manometric assessments, and 24-h pH monitoring late after surgery.

RESULTS: There was no operative mortality nor postoperative complications. The average hospital stay was two days. Nine patients (10.1%) were lost from follow-up. The mean late follow-up was 17 years (10-26). Visick I and II (success) corresponded to 78.7% of patients and grades III-IV (failure) to 21.3%, mainly due to gastroesophageal reflux disease (GERD). Manometric evaluations showed a significant and permanent decrease in lower esophageal sphincter pressure (LESP). 24-h pH monitoring was normal among Visick I patients and showed pathologic acid reflux in patients with GERD. Two patients (2.5%) developed Barrett's esophagus. Squamous-cell carcinoma (SCC) appeared in three patients (3.7%).

CONCLUSION: LHM controlled symptoms in 79% of achalasia patients very late (17 years) after surgery. This was corroborated by endoscopic, manometric, and functional studies. GERD symptoms developed in 18.7% and SCC in 3.7% in previously asymptomatic patients. Endoscopic surveillance at regular intervals is recommended for all patients who have had surgery. These very long-term results are a real challenge to POEM endoscopic treatment. Unique Identifying Registration Number 3743.

Keywords: 24-h pH monitoring; Achalasia; Dysphagia; Endoscopy; Heller; Laparoscopic esophagomyotomy; Manometric studies

References

  1. Uribe P Jr, Csendes A, Larrain A, Ayala M (1974) Motility studies in fifty patients with achalasia of the esophagus. Am J Gastroenterol 62(4):333–336 - PubMed
  2. Boeckxstaens GE, Zaninotto G, Richter JE (2014) Achalasia. Lancet 383(9911):83–93 - PubMed
  3. Csendes A, Smok G, Braghetto I, Gonzalez P, Henriquez A, Csendes P, Pizurno D (1992) Histological studies of Auerbach’s plexuses of the oesophagus, stomach, jejunum, and colon in patients with achalasia of the oesophagus: correlation with gastric acid secretion, presence of parietal cells and gastric emptying of solids. Gut 33(2):150–154 - PubMed
  4. Allaix ME, Patti MG (2013) What is the best primary therapy for achalasia: medical or surgical treatment? Who owns achalasia? J Gastrointest Surg 17(9):1547–1549 - PubMed
  5. Pandolfino JE, Gawron AJ (2015) Achalasia: a systematic review. JAMA 313(18):1841–1852 - PubMed
  6. Csendes A, Braghetto I, Burdiles P, Korn O, Csendes P, Henriquez A (2006) Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months. Ann Surg 243(2):196–203 - PubMed
  7. Campos GM, Vittinghoff E, Rabl C, Takata M, Gadenstatter M, Lin F, Ciovica R (2009) Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 249(1):45–57 - PubMed
  8. Csendes A, Braghetto I, Mascaro J, Henriquez A (1988) Late subjective and objective evaluation of the results of esophagomyotomy in 100 patients with achalasia of the esophagus. Surgery 104(3):469–475 - PubMed
  9. Ortiz A, de Haro LF, Parrilla P, Lage A, Perez D, Munitiz V, Ruiz D, Molina J (2008) Very long-term objective evaluation of heller myotomy plus posterior partial fundoplication in patients with achalasia of the cardia. Ann Surg 247(2):258–264 - PubMed
  10. Jara FM, Toledo-Pereyra LH, Lewis JW, Magilligan DJ Jr (1979) Long-term results of esophagomyotomy for achalasia of esophagus. Arch Surg 114(8):935–936 - PubMed
  11. Costantini M, Salvador R, Capovilla G, Vallese L, Costantini A, Nicoletti L, Briscolini D, Valmasoni M, Merigliano S (2019) A THOUSAND and One laparoscopic Heller myotomies for esophageal achalasia: a 25-year experience at a single tertiary center. J Gastrointest Surg 23(1):23–35 - PubMed
  12. Rebecchi F, Allaix ME, Schlottmann F, Patti MG, Morino M (2018) Laparoscopic Heller myotomy and fundoplication: what is THE evidence? Am Surg 84(4):481–488 - PubMed
  13. Schlottmann F, Luckett DJ, Fine J, Shaheen NJ, Patti MG (2018) Laparoscopic Heller myotomy versus Peroral Endoscopic Myotomy (POEM) for achalasia: a systematic review and meta-analysis. Ann Surg 267(3):451–460 - PubMed
  14. Csendes A, Orellana O, Cuneo N, Martinez G, Figueroa M (2019) Long-term (15-year) objective evaluation of 150 patients after laparoscopic Nissen fundoplication. Surgery 166(5):886–894 - PubMed
  15. Pinotti HW, Habr-Gama A, Cecconello I, Felix VN, Zilberstein B (1993) The surgical treatment of megaesophagus and megacolon. Dig Dis 11(4–5):206–215 - PubMed
  16. Douard R, Gaudric M, Chaussade S, Couturier D, Houssin D, Dousset B (2004) Functional results after laparoscopic Heller myotomy for achalasia: a comparative study to open surgery. Surgery 136(1):16–24 - PubMed
  17. Genta RM, Spechler SJ, Kielhorn AF (2011) The Los Angeles and Savary-Miller systems for grading esophagitis: utilization and correlation with histology. Dis Esophagus 24(1):10–17 - PubMed
  18. Csendes JA, Burdiles PP, Alvarez F (1996) Manometric features of mechanically defective lower esophageal sphincter in control subjects and in patients with different degrees of gastroesophageal reflux. Dis. Esophagus 9:290–294 - PubMed
  19. DeMeester TR, Wang CI, Wernly JA, Pellegrini CA, Little AG, Klementschitsch P, Bermudez G, Johnson LF, Skinner DB (1980) Technique, indications, and clinical use of 24 hour esophageal pH monitoring. J Thorac Cardiovasc Surg 79(5):656–670 - PubMed
  20. Csendes A, Alvarez F, Burdiles P, Braghetto I, Henriquez A, Quesada S, Csendes P (1994) Magnitude of acid gastroesophageal reflux measured by 24-hour esophageal pH monitoring compared to the degree of endoscopic esophagitis. Rev Med Chil 122(1):59–67 - PubMed
  21. Csendes JA, Braghetto MI, Burdiles PP, Korn BO, Salas J (2012) Surgical treatment of achalasia. Experience in 328 patients. Rev Chil Cir 64(1):46–51 - PubMed
  22. Heller E (1914) Extramukose kardioplastik beim charnischen kardiospasmus mit dilatation des oesphagus. Mitt Genzgeb Med Chir 27:141–148 - PubMed
  23. Zaaijer JH (1923) Cardiospasm in the aged. Ann Surg 77(5):615–617 - PubMed
  24. Dor J, Humbert P, Dor V, Figarella J (1962) L’interet de la technique de Nissen modifier dans la prevention du reflux apres cardiomiotomie extramuqueuse de Heller. Mem Acad Chir (Paris) 88:877–883 - PubMed
  25. Toupet A (1963) Technic of esophago-gastroplasty with phrenogastropexy used in radical treatment of hiatal hernias as a supplement to Heller’s operation in cardiospasms. Mem Acad Chir (Paris) 89:384–389 - PubMed
  26. Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A, Elizalde JI, Fumagalli U, Gaudric M, Rohof WO, Smout AJ, Tack J, Zwinderman AH, Zaninotto G, Busch OR, European Achalasia Trial Investigators (2011) Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med 364(19):1807–1816 - PubMed
  27. Kurian AA, Bhayani N, Sharata A, Reavis K, Dunst CM, Swanstrom LL (2013) Partial anterior vs partial posterior fundoplication following transabdominal esophagocardiomyotomy for achalasia of the esophagus: meta-regression of objective postoperative gastroesophageal reflux and dysphagia. JAMA Surg 148(1):85–90 - PubMed
  28. Illes A, Farkas N, Hegyi P, Garami A, Szabo I, Solymar M, Petervari E, Balasko M, Par G, Sarlos P, Bajor J, Szucs A, Czimmer J, Szemes K, Vincze A (2017) Is Heller myotomy better than balloon dilation? A meta-analysis. J Gastrointest Liver Dis 26(2):121–127 - PubMed
  29. Schlottmann F, Herbella F, Allaix ME, Patti MG (2018) Modern management of esophageal achalasia: from pathophysiology to treatment. Curr Probl Surg 55(1):10–37 - PubMed
  30. Repici A, Fuccio L, Maselli R, Mazza F, Correale L, Mandolesi D, Bellisario C, Sethi A, Khashab MA, Rosch T, Hassan C (2018) GERD after per-oral endoscopic myotomy as compared with Heller's myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 87(4):934–943e18 - PubMed
  31. Werner YB, Hakanson B, Martinek J, Repici A, von Rahden BHA, Bredenoord AJ, Bisschops R, Messmann H, Vollberg MC, Noder T, Kersten JF, Mann O, Izbicki J, Pazdro A, Fumagalli U, Rosati R, Germer CT, Schijven MP, Emmermann A, von Renteln D, Fockens P, Boeckxstaens G, Rosch T (2019) Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med 381(23):2219–2229 - PubMed
  32. Broman KK, Phillips SE, Faqih A, Kaiser J, Pierce RA, Poulose BK, Richards WO, Sharp KW, Holzman MD (2018) Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: long-term symptomatic follow-up of a prospective randomized controlled trial. Surg Endosc 32(4):1668–1674 - PubMed
  33. Csendes A (1991) Results of surgical treatment of achalasia of the esophagus. Hepatogastroenterology 38(6):474–480 - PubMed
  34. Ellis FH Jr, Kiser JC, Schlegel JF, Earlam RJ, McVey JL, Olsen AM (1967) Esophagomyotomy for esophageal achalasia: experimental, clinical, and manometric aspects. Ann Surg 166(4):640–656 - PubMed
  35. Richter JE, Boeckxstaens GE (2011) Management of achalasia: surgery or pneumatic dilation. Gut 60(6):869–876 - PubMed
  36. Sasaki A, Obuchi T, Nakajima J, Kimura Y, Koeda K, Wakabayashi G (2010) Laparoscopic Heller myotomy with Dor fundoplication for achalasia: long-term outcomes and effect on chest pain. Dis Esophagus 23(4):284–289 - PubMed
  37. Parise P, Santi S, Solito B, Pallabazzer G, Rossi M (2011) Laparoscopic Heller myotomy plus Dor fundoplication in 137 achalasic patients: results on symptoms relief and successful outcome predictors. Updates Surg 63(1):11–15 - PubMed
  38. Krishnamohan P, Allen MS, Shen KR, Wigle DA, Nichols FC III, Cassivi SD, Harmsen WS, Deschamps C (2014) Long-term outcome after laparoscopic myotomy for achalasia. J Thorac Cardiovasc Surg 147(2):730–736; discussion 736–737 - PubMed
  39. Rebecchi F, Giaccone C, Farinella E, Campaci R, Morino M (2008) Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results. Ann Surg 248(6):1023–1030 - PubMed
  40. Jeansonne LO, White BC, Pilger KE, Shane MD, Zagorski S, Davis SS, Hunter JG, Lin E, Smith CD (2007) Ten-year follow-up of laparoscopic Heller myotomy for achalasia shows durability. Surg Endosc 21(9):1498–1502 - PubMed
  41. Popoff AM, Myers JA, Zelhart M, Maroulis B, Mesleh M, Millikan K, Luu MB (2012) Long-term symptom relief and patient satisfaction after Heller myotomy and Toupet fundoplication for achalasia. Am J Surg 203(3):339–342; discussion 342. - PubMed
  42. Rossetti G, Brusciano L, Amato G, Maffettone V, Napolitano V, Russo G, Izzo D, Russo F, Pizza F, Del Genio G, Del Genio A (2005) A total fundoplication is not an obstacle to esophageal emptying after heller myotomy for achalasia: results of a long-term follow up. Ann Surg 241(4):614–621 - PubMed
  43. Pandolfino JE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J, Kahrilas PJ (2008) Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 135(5):1526–1533 - PubMed
  44. Rohof WO, Salvador R, Annese V, Bruley des Varannes S, Chaussade S, Costantini M, Elizalde JI, Gaudric M, Smout AJ, Tack J, Busch OR, Zaninotto G, Boeckxstaens GE (2013) Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology 144(4):718–725, quiz e13–e14 - PubMed
  45. Crespin OM, Tatum RP, Xiao K, Martin AV, Khandelwal S, Pellegrini CA, Oelschlager BK (2017) The relationship between manometric subtype and outcomes of surgical treatment for patients with achalasia: Achalasia: manometric subtypes. Surg Endosc 31(12):5066–5075 - PubMed
  46. Triantafyllou T, Theodoropoulos C, Georgiou G, Kalles V, Chrysikos D, Filis K, Zografos G, Theodorou D (2019) Long-term outcome of myotomy and fundoplication based on intraoperative real-time high-resolution manometry in achalasia patients. Ann Gastroenterol 32(1):46–51 - PubMed
  47. Sanaka MR, Thota PN, Parikh MP, Hayat U, Gupta NM, Gabbard S, Lopez R, Murthy S, Raja S (2019) Peroral endoscopic myotomy leads to higher rates of abnormal esophageal acid exposure than laparoscopic Heller myotomy in achalasia. Surg Endosc 33(7):2284–2292 - PubMed
  48. Creamer B, Ellis FH Jr, Olsen AM (1957) Cardiospasm (achalasia of the cardia). Am J Surg 93(2):299–307 - PubMed
  49. Sanderson DR, Ellis FH Jr, Schlegel JF, Olsen AM (1967) Syndrome of vigorous achalasia: clinical and physiologic observations. Dis Chest 52(4):508–517 - PubMed
  50. Henderson RD, Barichello AW, Pearson FG, Mugashe F, Szczepanski M (1972) Diagnosis of achalasia. Can J Surg 15(3):190–201 - PubMed
  51. Goldenberg SP, Burrell M, Fette GG, Vos C, Traube M (1991) Classic and vigorous achalasia: a comparison of manometric, radiographic, and clinical findings. Gastroenterology 101(3):743–748 - PubMed
  52. Todorczuk JR, Aliperti G, Staiano A, Clouse RE (1991) Reevaluation of manometric criteria for vigorous achalasia. Is this a distinct clinical disorder? Dig Dis Sci 36(3):274–278 - PubMed
  53. Camacho-Lobato L, Katz PO, Eveland J, Vela M, Castell DO (2001) Vigorous achalasia: original description requires minor change. J Clin Gastroenterol 33(5):375–377 - PubMed
  54. Golioto M, McGrath K, Smith J, Brazer S (2001) Achalasia with high-amplitude esophageal body contractions: a case presentation of truly vigorous achalasia. Dig Dis Sci 46(9):1960–1962 - PubMed
  55. Dantas RO (2002) Vigorous achalasia in Chagas’ disease. Dis Esophagus 15(4):305–308 - PubMed
  56. Dantas RO, Aprile LR (2005) Proximal and distal esophageal contractions in patients with vigorous or classic esophageal Chagas’ disease. Arq Gastroenterol 42(1):9–12 - PubMed
  57. Leeuwenburgh I, Scholten P, Alderliesten J, Tilanus HW, Looman CW, Steijerberg EW, Kuipers EJ (2010) Long-term esophageal cancer risk in patients with primary achalasia: a prospective study. Am J Gastroenterol 105(10):2144–2149 - PubMed
  58. Zendehdel K, Nyren O, Edberg A, Ye W (2011) Risk of esophageal adenocarcinoma in achalasia patients, a retrospective cohort study in Sweden. Am J Gastroenterol 106(1):57–61 - PubMed
  59. Zaninotto G, Rizzetto C, Zambon P, Guzzinati S, Finotti E, Costantini M (2008) Long-term outcome and risk of oesophageal cancer after surgery for achalasia. The British journal of surgery 95(12):1488–1494 - PubMed

Publication Types