Impacto de la cardiomiotomía laparoscópica de Heller en la función del esfínter esofágico inferior y el diámetro del esófago / Impact of laparoscopic Heller cardiomyotomy on lower esophageal sphincter function and esophageal diameter

Introducción. La acalasia es un trastorno motor del esófago caracterizado por la ausencia de peristalsis y la alteración en la relajación del esfínter esofágico inferior. La cardiomiotomía laparoscópica de Heller más funduplicatura parcial es el tratamiento estándar. La mejoría sintomática ha sido bien documentada, pero no hay suficiente información objetiva respecto a los cambios fisiológicos y radiográficos luego del procedimiento. Métodos. Estudio de cohorte bidireccional de pacientes llevados a cardiomiotomía laparoscópica de Heller, entre los años 2018 y 2021, en el Hospital Universitario San Vicente Fundación de Medellín, Colombia. Se describen variables demográficas y clínicas. Se realizaron puntaje sintomático de Eckardt, manometría esofágica y radiografía de esófago en el pre y postoperatorio. Se hizo comparación de síntomas, presión basal del esfínter esofágico inferior, presión de relajación integrada y diámetro del esófago antes y después de la intervención. Resultados. Se incluyeron 24 pacientes. El 63 % fueron mujeres y la edad promedio fue de 44 años. Los valores promedio preoperatorios vs postoperatorios fueron: puntaje de Eckardt 10,6 vs 1,4 puntos (p<0,001), presión basal de 41,4 vs 18,1 mmHg (p=0,004) y presión de relajación integrada de 28,6 vs 12,5 mmHg (p=0,001). El diámetro del esófago no presentó cambios. No hubo correlación de síntomas con los cambios de presión del esfínter esofágico inferior. El tiempo de seguimiento fue de 20 meses. Conclusiones. La cardiomiotomía de Heller es un procedimiento altamente efectivo para el tratamiento definitivo de la acalasia, logrando una mejoría subjetiva y objetiva basada en síntomas y en parámetros de manometría, respectivamente

Introduction. Achalasia is a motor disorder of the esophagus characterized by the absence of peristalsis and impaired relaxation of the lower esophageal sphincter. Laparoscopic Heller ́s cardiomyotomy plus partial fundoplication is the standard treatment. Symptomatic improvement has been well documented, but there is insufficient objective information regarding physiologic and radiographic changes after the procedure. Methods. Bidirectional cohort study of patients underwent laparoscopic Heller ́s cardiomyotomy between 2018 and 2021 at the San Vicente Fundación University Hospital in Medellín, Colombia. Demographic and clinical variables are described. Eckardt symptom score, esophageal manometry, and esophageal radiography were performed pre and postoperatively. A comparison of symptoms, baseline lower esophageal sphincter pressure, integrated relaxation pressure, and esophageal diameter before and after intervention were performed.Results. 24 patients were included. 63% were women and the average age was 44 years. The preoperative vs. postoperative mean values were: Eckardt score 10.6 vs. 1.4 points (p<0.001), basal pressure of 41.4 vs. 18.1 mmHg (p=0.004) and integrated relaxation pressure of 28.6 vs. 12.5 mmHg (p=0.001). The diameter of the esophagus did not present changes. There was no correlation of symptoms with lower esophageal sphincter pressure changes. The follow-up time was 20 months. Conclusions. Heller cardiomyotomy is a highly effective procedure for the definitive treatment of achalasia, achieving subjective and objective improvements, based on symptoms and manometry parameters, respectively

Evaluating the Efficacy and Safety of Laparoscopic Heller Myotomy in Treating Achalasia

Introduction: Laparoscopic Heller myotomy (LHM) is widely recognized as the standard surgical treatment for esophageal achalasia. However, there is a lack of local data regarding the clinical characteristics of patients and the outcomes of this intervention. Methodology: This retrospective study analyzed patients who underwent LHM over an eight-year period. Demographic, operative, and postoperative variables were assessed. The Eckardt score was used to compare symptoms before and after the intervention. Continuous variables were presented as means. Results: Among the 39 patients assessed, 27 met the inclusion criteria. Of these, 51% were male, with an average age of 48 years. The average lower esophageal sphincter pressure was 36 mmHg. The mean operative time and bleeding were 133 minutes and 34 mL, respectively. The average length of the myotomy was 8.3 cm. Partial fundoplication was performed in all cases, and intraoperative endoscopy was conducted in 88% of the cases. Two intraoperative mucosal perforations occurred. The average length of hospital stay was 2.7 days. There was one medical complication but no mortality. Dysphagia significantly improved by 95%, and the mean Eckardt score decreased from 7.7 to 1.2 after surgery (p < 0.001). The average follow-up period was 24 months. Conclusion: LHM with partial fundoplication proves to be an effective and safe procedure for treating achalasia. It results in the resolution of dysphagia in 95% of cases and carries minimal morbidity. Therefore, LHM should be considered the definitive treatment of choice for achalasia.

Introducción: la miotomía de Heller laparoscópica (MHL) se considera el tratamiento quirúrgico estándar en acalasia esofágica. A nivel local se desconocen las características clínicas de los pacientes y los resultados de la intervención. Metodología: estudio retrospectivo que incluye pacientes llevados a MHL durante un periodo de 8 años. Se analizaron variables demográficas, operatorias y posoperatorias. Mediante el puntaje de Eckardt se compararon síntomas antes y después de la intervención. Las variables continuas se expresan en promedios. Resultados: 27 de 39 pacientes cumplieron los criterios de inclusión. El 51% fueron hombres y el promedio de edad fue de 48 años. La presión promedio del esfínter esofágico inferior fue de 36 mm Hg. El promedio de tiempo operatorio y sangrado fue de 133 minutos y 34 mL, respectivamente. La longitud promedio de la miotomía fue de 8,3 cm. Se adicionó funduplicatura parcial en todos los casos y en el 88% se realizó una endoscopia intraoperatoria. Se presentaron 2 perforaciones intraoperatorias de la mucosa. El promedio de estancia hospitalaria fue 2,7 días. Hubo una complicación médica y ninguna mortalidad. La disfagia mejoró en el 95% y el promedio del puntaje de Eckardt disminuyó de 7,7 a 1,2 luego de cirugía (p < 0,001). El seguimiento fue de 24 meses en promedio. Conclusión: la MHL con funduplicatura parcial es un procedimiento efectivo y seguro para el tratamiento de la acalasia. Se asocia a resolución de la disfagia en el 95% de los casos, su morbilidad es mínima y debe considerarse el tratamiento definitivo de elección.

Diagnóstico y manejo actual de la acalasia / Diagnosis and current management of achalasia

Introducción. La acalasia es un trastorno motor del esófago poco común, de etiología no clara, caracterizado por la pérdida de relajación del esfínter esofágico inferior, pérdida del peristaltismo normal, regurgitación y disfagia. Métodos. Se realizó una revisión narrativa de la literatura en revistas científicas y bases de datos en español e inglés, con el fin de presentar información actualizada en lo referente al diagnóstico y tratamiento de esta patología. Resultado. Se presenta la actualización de los criterios de los trastornos motores esofágicos según la clasificación de Chicago (CCv4.0) para el diagnóstico de acalasia y sus subtipos de acuerdo con los nuevos criterios, así como los tratamientos actuales. Conclusión. La acalasia es un trastorno esofágico multimodal, con manifestaciones de predominio gastrointestinal, por lo que su diagnóstico y abordaje terapéutico oportuno es esencial para mejorar la calidad de vida de los pacientes

Introduction. Achalasia is a rare motor disorder of the esophagus of unclear etiology, characterized by loss of lower esophageal sphincter relaxation, loss of normal peristalsis, regurgitation, and dysphagia. Methods. A narrative review of the literature in scientific journals and databases in Spanish and English was carried out, in order to present updated information regarding the diagnosis and treatment of this pathology. Result. The update of the Chicago esophageal motor disorders criteria (CCv4.0) is presented for the diagnosis of achalasia and its subtypes according to the new criteria, as well as current treatments. Conclusion. Achalasia is a multimodal esophageal disorder, with predominantly gastrointestinal manifestations, so its timely diagnosis and therapeutic approach is essential to improve the quality of life of patients.

Short-term outcomes and learning curve of the robot-assisted Heller-Dor myotomy for achalasia of cardia: A single-center retrospective study / 中国胸心血管外科临床杂志

@#Objective     To investigate short-term outcomes of robot-assisted Heller-Dor myotomy (RAHM-Dor) for achalasia of cardia and our learning curve experience. Methods     The clinical data and recent follow-up results of 42 patients who received RAHM-Dor from November 2015 to January 2020 in the Department of Thoracic Surgery of the First Affiliated Hospital of Nanchang University were retrospectively analyzed, including 20 males and 22 females with a mean age of 40.8±18.4 years. Results    Dysphagia was the most common symptom, followed by heartburn and regurgitation. The mean operation time was 122.8±23.9 min. The mean blood loss was 47.5±32.7 mL. Two patients suffered mucosal injury, and successfully repaired by suturing during surgery. There was no esophageal fistula, conversion to an open operation or perioperative death in this series. The median length of hospital stay was 8 (6, 9) d. In all patients, the Stooler and Eckardt scores of postoperative 1, 6 and 12 months decreased compared to those of pre-operation (P<0.001). Conclusion     RAHM-Dor is a safe and feasible avenue for the treatment of achalasia of cardia, and can achieve a satisfying short-term results. The learning curve shows a transition to the standard stage from the learning stage after 16-18 operations.

Abdominal esophagocardiectomy with esophagogastric anastomosis, with vagal preservation and construction of a spiral anti reflux valve in the treatment of advanced megaesophagus / Esofagocardiectomia abdominal com esofagogastro anastomose, com preservação vagal e construção de válvula antirrefluxo em espiral no tratamento do megaesôfago avançado

ABSTRACT Objective: present a new operative technique characterized by abdominal esophagocardiectomy, with esophagogastrus anastomosis, vagal preservation and spiral anti-reflux valve construction in the treatment of advanced megaesophagus in patients with severe systemic diseases, as well as its result in an initial group of 17 patients. Method: We selected 17 patients with advanced megaesophagus and comorbidities submitted to new technique. The following parameters were analyzed: age, sex, length of hospital stay, early and late complications, mortality, radiological/endoscopic aspects. Results: twelve male patients (70%) and five (30%) were operated on, with mean age of 51.5 years and mean hospital stay of 14.8 days. There was no mortality in the immediate intraoperative or postoperative period and there were no cases of postoperative fistula. During hospitalization there was one case of pulmonary atelectasis (5.8%), one of pleural effusion (5.8%), two of wall infection (11.7%) and one of urinary retention (5.8%). Discussion: We believe it to be an easy technique, made exclusively by the abdominal route, that is, without violating the thoracic cavity. Such a procedure would be beneficial in patients with advanced megaesophagus and important comorbidities, as well as in those with a history of previous surgeries. Conclusion: the technique described was easy to perform and safe, when performed by an experienced team, with low morbidity and mortality in patients with advanced megaesophagus and important comorbidities, which could increase your complications with more invasive and complex surgeries.

RESUMO Objetivo: apresentar uma nova técnica caracterizada por esofagocardiectomia abdominal com esofagogastro anastomose, preservação vagal e construção de válvula antirrefluxo em espiral no tratamento do megaesôfago avançado de pacientes com doenças sistêmicas graves, assim como seu resultado em grupo inicial de 17 pacientes. Método: foram selecionados 17 pacientes com megaesôfago avançado e comorbidades submetidos a nova técnica. Os seguintes parâmetros analisados foram: idade, sexo, tempo de permanência hospitalar, complicações precoces e tardias, mortalidade, aspectos radiológicos/endoscópicos. Resultados: foram operados 12 (70%) pacientes do sexo masculino e 5 (30%) do sexo feminino, com idade média foi de 51,5 anos e tempo de permanência hospitalar médio de 14,8 dias. Não houve mortalidade no intraoperatório ou pós-operatório imediato e não houve casos de fìstula. Durante a internação houve um caso de atelectasia pulmonar (5,8%), um de derrame pleural (5,8%), dois de infecção de parede (11,7%) e um de retenção urinária (5,8%). Discussão: acreditamos ser uma técnica de fácil realização, feita exclusivamente por via abdominal, ou seja, sem violar a cavidade torácica. Tal procedimento seria benéfico em pacientes com megaesôfago avançado e comorbidades importantes, assim como naqueles com história de cirurgias prévias. Conclusão: a técnica descrita mostrou-se de fácil execução e segura, quando realizada por equipe experiente, com baixa morbimortalidade em pacientes com megaesôfago avançado e comorbidades importantes, o que poderia aumentar suas complicações com cirurgias mais invasivas e complexas.

Esofagitis eosinofílica y acalasia esofágica / Eosinophilic esophagitis and esophageal acalasia

Introducción: La esofagitis eosinofílica es una enfermedad emergente, caracterizada por infiltración del esófago por leucocitos eosinófilos. Sus principales síntomas son la disfagia y las frecuentes impactaciones de alimento en el esófago. Actualmente existen evidencias científicas que reconocen la enfermedad como causa posible de evolución no favorable en pacientes después de miotomía de Héller. Objetivo: Describir las evidencias biomoleculares que asocian la esofagitis eosinofílica y la acalasia esofágica. Métodos: Se realizó una revisión sistemática y crítica de las evidencias sobre los mecanismos biomoleculares asociados a la esofagitis eosinofílica y la acalasia esofágica. Se consultaron artículos publicados entre 2015 y 2020 e indexados en las bases de datos PubMed, SciELO, LILACS y Scopus. Análisis e integración de la información: Se discute sobre cuestiones medulares que han sido publicadas recientemente respecto al tema en cuestión. ¿Pueden coexistir la esofagitis eosinofílica y la acalasia esofágica? ¿Influye la esofagitis eosinofílica en el resultado del tratamiento de la acalasia esofágica? ¿Qué investigaciones serían necesarias para establecer la relación entre las dos enfermedades? Conclusiones: Los mecanismos celulares y biomoleculares desencadenados por la infiltración eosinofílica contextualizan la diferencia etiológica y fisiopatológica de la esofagitis eosinofílica y la acalasia esofágica, lo cual sustenta la evolución desfavorable posmiotomía de los pacientes y motiva la realización de estudios prospectivos y controlados con el fin de ofrecer una mejor calidad de vida(AU)

Introduction: Eosinophilic esophagitis is an emerging disease characterized by infiltration of the esophagus by eosinophilic leukocytes. Its main symptoms are dysphagia and frequent food impaction in the esophagus. Scientific evidence is now available that recognizes the disease as the possible cause of unfavorable evolution in patients undergoing Heller myotomy. Objective: Describe the biomolecular evidence associating eosinophilic esophagitis to esophageal achalasia. Methods: A systematic critical review was conducted of the evidence about biomolecular mechanisms associated to eosinophilic esophagitis and esophageal achalasia. The articles consulted were published in the databases PubMed, SciELO, LILACS and Scopus from 2015 to 2020. Data analysis and integration: A discussion is provided about crucial questions published recently concerning the study topic: Can eosinophilic esophagitis and esophageal achalasia coexist? Does eosinophilic esophagitis influence the result of esophageal achalasia treatment? What studies are required to establish the relationship between the two conditions? Conclusions: The cellular and biomolecular mechanisms triggered by eosonophilic infiltration contextualize the etiological and pathophysiological difference between eosinophilic esophagitis and esophageal achalasia. This explains the unfavorable post-myotomy evolution of patients and encourages the conduct of prospective controlled studies aimed at enhancing quality of life(AU)

Long-term results and influencing factors of laparoscopic Heller myotomy for achalasia / 中华胸心血管外科杂志

Objective:To assess the long-term outcome and influencing factors of laparoscopic Heller myotomy plus Dor fundoplication(LHM+ Dor) for achalasia by a single operator.Methods:Fifty-four patients who underwent LHM+ Dor consecutively from January 2011 to December 2019 were retrospectively reviewed. Those who had already undergone surgical or endoscopic myotomy and who were complicated with cancer were ruled out. Symptom inquiry and esophagogram were conducted both before and after surgery for assessing surgical results. Esophagoscopy, esophageal manometry and 24 h pH monitoring were performed before surgery, and the effects of these preoperative factors on the long-term outcome were analyzed.Results:All patients had dysphagia for average 6.5 years, ranging from 0.5-30.0 years. Intra-operative mucosal perforation occurred in 4(7.4%) patients, and there were no postoperative morbidity and mortality. At a median follow-up of 5.2 years, the morbidity of dysphagia decreased from 100% before surgery to 5.5% after surgery( P<0.001), Eckardt scores from 4.85±1.64 to 0.71±1.08( P=0.000). After surgery, 94.4% of patients had excellent and good relief of symptoms and good control of gastroesophageal reflux, the morbidity of heartburn being 3.7%. At 5 years after surgery, the probability of being symptoms free(Eckardt score≤1) was 91.7% in patients without preoperative night cough, compared to 54.6% in those with preoperative night cough( P=0.047). The probability was 92.3% in patients with grade Ⅰ and Ⅱ dilation of the esophagus and 79.0% in patients with grade Ⅲ and Ⅳ dilation( P=0.027). At multivariate analysis, heavier esophageal dilation was the independent predicator for poor symptom control after surgery. Conclusion:LHM+ Dor can be safely performed and durably relieve achalasia symptoms. Severe esophageal dilation before surgery is an independent predictor of a poor response to surgery.

Safety and Outcome of Laparoscopic Heller’s Cardiomyotomy with Intraoperative Endoscopic Assessment and Dor’s Fundoplication in Primary Achalasia Cardia: A Single-center Prospective Study

Introduction: Achalasia cardia is a primary esophageal motility disorder of an unknown etiology, characterized by abnormal peristalsis of the esophageal body and the absence of relaxation of the lower esophageal sphincter. Laparoscopic Heller cardiomyotomy is the surgical procedure of choice for achalasia cardia. Aim: The aim of the study was to the immediate safety and long-term efficacy of laparoscopic Heller’s cardiomyotomy with intraoperative endoscopy and Dor’s anterior partial fundoplication in patients with achalasia cardia. Materials and Methods: In this prospective study, laparoscopic Heller’s myotomy with intraoperative endoscopy and anterior Dor’s fundoplication were performed in all achalasia cardia patients. Patients’ demographic, clinical features such as dysphagia grade and Eckardt score, intraoperative, post-operative parameters, and response to treatment on follow-up were analyzed. Results: In 14 patients, 10 were females (71%), the mean age was 37±14.96 years. Mean pre-operative modified Takita’s dysphagia grade was 2.93±0.73. Endoscopic classic findings and barium swallow bird beak sign were diagnostic in all cases. Preoperative Eckardt score was 8.93±1.44. Eckardt score at discharge was 0.43±0.51 and at 12th month was 0.21±0.43. On analysis, there was a significant improvement in pre-operative values of modified Takita’s dysphagia grade and Eckardt score to normal values postoperatively (P < 0.0001) and the durable effect was persistently observed in 3rd and 6th, 9th, and 12th-month follow-up. Conclusion: Laparoscopic Heller’s myotomy with intraoperative endoscopy and Dor’s fundoplication are safe and effective with significant improvement in post-operative Takita’s dysphagia score and Eckardt score.

Miotomia peroral (POEM) ou cirúrgica para o tratamento da acalasia: revisão sistemática e metanálise / Peroral (poem) or surgical myotomy for the treatment of achalasia: a systematic review and meta-analysis

ABSTRACT BACKGROUND: Achalasia is a neurodegenerative motility esophageal disorder characterized by failure of lower esophageal sphincter relaxation. The conventional treatment option for achalasia has been laparoscopic Heller myotomy (LHM). However, in 2010, Inoue et al. described peroral endoscopic myotomy (POEM), a minimally invasive procedure, as an alternative therapy. To date, some studies with small sample sizes have aimed to compare outcomes of LHM vs POEM. OBJECTIVE: Thus, the aim of this study is to perform a systematic review and meta-analysis to better evaluate the efficacy and safety of these two techniques. METHODS: Individualized search strategies were developed from inception through April 2019 in accordance with PRISMA guidelines. Variables analyzed included operative time, overall adverse events rate, post-procedure gastroesophageal reflux disease (GERD), hospitalization length, post-procedure pain score, and Eckardt Score reduction. RESULTS: Twelve cohort trials were selected, consisting of 893 patients (359 in POEM group and 534 in LHM.) No randomized clinical trials were available. There was no difference in operative time (MD= -10,26, 95% CI (-5,6 to 8,2), P<0.001) or Post-Operative Gastroesophageal Reflux (RD: -0.00, 95%CI: (-0.09, 0.09), I2: 0%). There was decreased length of hospital stay for POEM (MD: -0.6, 95% CI (-1.11, -0.09), P=0.02), and an increased mean reduction in Eckardt score in POEM patients (MD = -0.257, 95% CI: (-0.512 to -0.002), P=0.048), with similar rates of adverse events. CONCLUSION: POEM demonstrated similar results compared to laparoscopic Heller myotomy with regards to improvement of dysphagia, post-procedure reflux, and surgical time, with the benefit of shorter length of hospital stay. Therefore, POEM can be considered an option for patients with achalasia.

RESUMO CONTEXTO: A acalasia é um distúrbio esofágico da motilidade neurodegenerativa caracterizado por falha no relaxamento do esfíncter esofágico inferior (EEI). A opção de tratamento convencional para acalasia tem sido a miotomia laparoscópica de Heller (LHM). No entanto, em 2010, Inoue et al. descreveram a miotomia endoscópica peroral (POEM), um procedimento minimamente invasivo, como uma terapia alternativa. Até o momento, poucos estudos com amostras pequenas tiveram como objetivo comparar os resultados do LHM versus POEM. OBJETIVO: Assim, o objetivo deste estudo é realizar uma revisão sistemática e metanálise para melhor avaliar a eficácia e segurança dessas duas técnicas. MÉTODOS: Estratégias de busca individualizadas foram desenvolvidas desde o início até abril de 2019, de acordo com as diretrizes do PRISMA. As variáveis analisadas incluíram tempo operatório, taxa global de eventos adversos, doença de refluxo gastroesofágico (DRGE) pós-procedimento, tempo de internação, escore de dor pós-procedimento e redução do escore de Eckardt. RESULTADOS: Doze estudos de coorte foram selecionados, consistindo em 893 pacientes (359 no grupo POEM e 524 no LHM). Nenhum ensaio clínico randomizado estava disponível. Não houve diferença no tempo operatório (MD = -10,26, IC 95% (-5,6 a 8,2), P<0,001) ou refluxo gastroesofágico pós-operatório (RD: -0,00, 95% IC: (-0,09, 0,09), I2: 0%). Houve diminuição do tempo de permanência hospitalar para POEM (MD: -0,6, 95% CI (-1,11, -0,09), P=0,02) e um aumento da redução média no escore de Eckardt em pacientes POEM (MD= -0,257, IC95%: (-0,512 a -0,002), P=0,048), com taxas similares de eventos adversos. CONCLUSÃO: O POEM demonstrou resultados semelhantes aos da miotomia a Heller por videolaparoscopia, com melhora da disfagia, do refluxo pós-procedimento e tempo cirúrgico, com o benefício de menor tempo de internação hospitalar. Portanto, o POEM pode ser considerado uma opção para pacientes com acalasia.

Surgical treatment of relapsed megaesophagus / Tratamento cirúrgico do megaesôfago recidivado

ABSTRACT Objective: to analyze the surgical treatment of patients with recurrent megaesophagus followed at the esophageal-stomach-duodenal outpatient clinic of the Hospital de Clínicas - UNICAMP. Methods: a retrospective study, from 2011 to 2017, with 26 patients with Chagas or idiopathic megaesophagus, surgically treated, and who recurred with dysphagia. Clinical, endoscopic and radiographic aspects were assessed and correlated with the performed surgical procedures. Results: 50% had dysphagia for liquids, 69% regurgitation, 65.3% heartburn, 69.2% weight loss and 69.2% had Chagas disease. In addition, 38.4% had megaesophagus stage 1 and 2 and 61.5% stage 3 and 4. Regarding the reoperations, 53% of them underwent Heller-Pinotti surgery by laparoscopy, Serra-Dória in 30.7% and esophageal mucosectomy in 7.9%. In 72% of the reoperations there were no postoperative complications, and 80% of the patients had a good outcome, with reduction or elimination of dysphagia. Among the reoperated patients undergoing the laparoscopic Heller-Pinotti technique, three reported little improvement of dysphagia in the postoperative period and among those who underwent Serra-Dória surgery, 100% had no dysphagia. It was observed that, when the time between the first procedure and the reoperation was longer, the better the surgical result was, with statistical significant decreased dysphagia (p=0.0013, p<0.05). Conclusions: there was a preference to perform laparoscopic re-miotomy and, as a second option, Serra-Dória surgery, for patients with recurrent megaesophagus. Esophagectomy or esophageal mucosectomy were reserved for more severe patients.

RESUMO Objetivo: analisar o tratamento cirúrgico dos pacientes com megaesôfago recidivado acompanhados no ambulatório de cirurgia de esôfago-estômago-duodeno do Hospital de Clínicas da UNICAMP. Métodos: estudo restrospectivo no período de 2011 a 2017, com 26 pacientes portadores de megaesôfago chagásico ou idiopático, tratados cirurgicamente e que evoluíram com recidiva da disfagia. Foram avaliados aspectos clínicos, endoscópicos e radiográficos, sendo correlacionados com os procedimentos cirúrgicos realizados. Resultados: 50% apresentava disfagia para líquidos, 69% regurgitação, 65,3% pirose, 69,2% perda de peso e 69,2% era chagásico. Além disso, 38,4% apresentavam megaesôfago estágio 1 e 2 e 61,5% estágio 3 e 4. Quanto às reoperações, em 53% foi realizada a cirurgia de Heller-Pinotti videolaparoscópica, seguida de Serra-Dória em 30,7% e mucosectomia esofágica em 7,9%. Em 72% das reoperações não houve complicações pós-operatórias e 80% tiveram evolução satisfatória com redução ou ausência da disfagia. Dentre os pacientes reoperados pela técnica de Heller-Pinotti videolaparoscópica, três referiram pouca melhora da disfagia no pós-operatório. Dentre os pacientes submetidos à cirurgia de Serra-Dória, 100% tiveram evolução satisfatória da disfagia. Foi observado nos pacientes com o tempo entre a primeira cirurgia e a reoperação mais longo, um melhor resultado cirúrgico com diminuição da disfagia, com relevância estatística (p=0,0013, p<0,05). Conclusão: houve preferência nas reoperações de megaesôfago pela realização de re-miotomia por videolaparoscopia e, como segunda opção, a cirurgia de Serra-Dória. A esofagectomia ou mucosectomia esofágica foram reservadas para os casos mais avançados.

Calidad de vida y evolución clínica después de miotomía de Heller con fundoplicatura de Dor / Quality of Life and Clinical Evolution after Heller Myotomy plus Dor fundoplication

RESUMEN Introducción: La miotomía de Heller laparoscópica es considerada en la actualidad el tratamiento de elección para el alivio de la disfagia. Se ha demostrado que gracias a ella se logra una baja incidencia de reflujo gastroesofágico y una mejoría evidente de la calidad de vida Objetivo: Evaluar la calidad de vida y evolución clínica de los pacientes después de la miotomía de Heller con fundoplicatura de Dor. Método: Estudio observacional descriptivo longitudinal prospectivo mediante la aplicación del cuestionario de índice de calidad de vida gastrointestinal a pacientes operados de acalasia esofágica desde enero del 2010 hasta diciembre del 2017 en el Centro Nacional de Cirugía de Mínimo Acceso. Se aplicó un cuestionario en el preoperatorio y al año de operados. Análisis estadístico: Porcentajes para variables cualitativas, media ± desviación estándar o mediana y rango según corresponda para las cuantitativas, para la comparación de los resultados del cuestionario se emplearon pruebas de hipótesis de comparación de medias, con nivel de significación estadística α= 0,05. Resultados: Fueron incluidos en el estudio 101 pacientes. Las edades oscilaban entre 18 y 78 años con una media de 47 años. El tiempo medio de evolución de los síntomas fue de 62 meses, con una media de 3,3 en la escala de disfagia y una presión de reposo del esfínter esofágico inferior (mmHg) 38,7 ± 16,8, se obtuvo un GIQLI inicial de 85,3 ± 20,4 que aumentó al año a 131,6 ± 10,5 Conclusiones: La miotomía de Heller con fundoplicatura de Dor, mejora la calidad de vida de los pacientes con acalasia esofágica con una evolución clínica excelente(AU)

ABSTRACT Introduction: Laparoscopic Heller myotomy is now considered the treatment of choice for the relief of dysphagia. It has been shown that thanks to it a low incidence of gastroesophageal reflux and evident improvement in the quality of life is achieved. Objective: To evaluate the quality of life and clinical evolution of patients after Heller myotomy plus Dor fundoplication. Method: Prospective, longitudinal, descriptive, observational study carried out by applying the Gastrointestinal Quality of Life Index (GIQLI) questionnaire to patients operated on for esophageal achalasia, from January 2010 to December 2017, at the National Center for Minimum Access Surgery. The questionnaire was applied preoperatively and one year after surgery. Statistical analysis: Percentages for qualitative variables, mean and standard deviation, or median and range, as appropriate for quantitative variables. For the comparison of the results of the questionnaire, we used tests of hypothesis of comparison of means, with statistical significance level of 0.05. Results: The ages ranged between 18 and 78 years, with an average of 47 years. The mean time of evolution of symptoms was 62 months, with an average of 3.3 on the dysphagia scale and a resting pressure of the lower esophageal sphincter (mmHg) 38.7±16.8. An initial gastrointestinal quality of life index of 85.3±20.4 was obtained, which increased to 131.6±10.5 per year. Conclusions: Heller myotomy plus Dor fundoplication improves the quality of life of patients with esophageal achalasia and guarantees an excellent clinical evolution(AU)

Achalasia Cardia Resulting in Bronchial Obstruction: A Case Series and Literature Review / 대한소화기학회지

Achalasia is a motility disorder of the esophagus that is characterized by loss of ganglionic neurons within the myenteric plexus of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. Clinically this disorder presents with simultaneous dysphagia to solids and liquids, and if left untreated, leads to esophageal dilation, which can give rise to many adverse consequences. Extrinsic compression of respiratory structures is one such consequence, and rarely, cases of tracheal compression secondary to achalasia have been reported. However, cases of extrinsic bronchial compression are yet rarer. Here, we present a case series comprised of two patients with achalasia who presented with extrinsic bronchial compression by a dilated esophagus secondary to achalasia.

Miotomía endoscópica por vía oral (POEM) en un paciente pediátrico para tratamiento de la acalasia esofágica / Per oral endoscopic myotomy in a pediatric patient with achalasia

INTRODUCCIÓN: La acalasia es el trastorno motor primario más frecuente del esófago. Su incidencia reportada es baja, aún más en pacientes pediátricos. La miotomía de Heller laparoscópica corresponde al estándar actual de tratamiento. Durante los últimos años la miotomía endoscópica por vía oral (POEM) se ha posicionado como una alternativa terapéutica segura y tan efectiva como el Heller para la acalasia esofágica. OBJETIVO: Describir la técnica de POEM y reportar el primer caso pediátrico en nuestro país. CASO CLÍNICO: Paciente de 11 años, previamente sano, que se presentó con disfagia ilógica progresiva y baja de peso. El estudio concluyó una acalasia tipo II. Fue sometido a POEM y cursó un postoperatorio sin incidentes. A un año de la intervención se ha documentado resolución de la sintomatología, seguimiento endoscópico y manométrico sin complicaciones. CONCLUSIONES: El caso descrito corresponde al primer POEM en un paciente pediátrico en nuestro país. La acalasia esofágica es infrecuente en pediatría y el POEM ha demostrado éxito clínico y seguridad comparables a la miotomía de Heller laparoscópica en el corto y mediano plazo. El seguimiento a largo plazo permitirá determinar su rol definitivo en el tratamiento de pacientes pediátricos con acalasia esofágica.

INTRODUCTION: Achalasia is the most common primary motor disorder of the esophagus. Its reported incidence is low, even more in pediatric patients. Laparoscopic Heller myotomy is the current stan dard of treatment. During the last years, per-oral endoscopic myotomy (POEM) has been positioned as a safe and effective therapeutic alternative as the Heller procedure for esophageal achalasia. OBJECTIVE: To describe the POEM technique and report the first pediatric case in our country. CLINICAL CASE: 11-year-old patient, previously healthy, who presented with progressive dysphagia for solids and liquids and weight loss. The study concluded a type II achalasia. The patient underwent a POEM and had a postoperative course without incidents. One year after the intervention, symptomatic, endoscopic and manometric resolution have been documented. CONCLUSIONS: The described case is the first POEM in a pediatric patient in our country. Esophageal achalasia is uncommon in pediatrics and POEM has demonstrated clinical success and safety comparable to laparoscopic Heller myotomy in short and medium term. Long-term follow-up will determine its definitive role in the treatment of pediatric patients with esophageal achalasia.

Achalasia Cardia In Indian Children– Experience From A Tertiary Care Institute In Chennai, India

Introduction:Achalasia cardia a rare oesophageal motility disorder is not uncommon in children. Aim and objectives:To describe the clinical profile of achalasia from a single pediatric tertiary care centre. Materials and Methods: Retrospective analysis of case records over a period of 10 years from March 2008 to March 2018 at institute of child health and hospital for children, Chennai, India. Results: 26 children had achalasia and 11 (42.3%) were males. The mean age was 42.08±36.33 months and 19 (73.07%) were less than five years at diagnosis. Vomiting was the most common symptom (88.4%) followed by failure to thrive (80.77%). Six had features of Allgrove syndrome. Heller's cardiomyotomy with or without fundoplication was done in 24 (92.3%) and pneumatic dilatation in two. Conclusion: Achalasia cardia is not uncommon and should be considered in children presenting with vomiting, dysphagia and failure to thrive. Surgery remains to be safe and effective.

Miotomía endoscópica por vía oral (POEM) para el tratamiento de acalasia: nuestras primeras experiencias / Peroral endoscopic myotomy (POEM) for treatment of achalasia: our first experiences

Resumen Introducción: la miotomía endoscópica por vía oral (POEM) se diseñó inicialmente para el manejo de la acalasia, que es un trastorno crónico y progresivo de la motilidad esofágica con hipertensión del esfínter esofágico inferior (EEI), para la cual el manejo estándar, hasta ahora, ha sido la cirugía de Heller; sin embargo, esta nueva técnica ofrece resultados muy comparables y prometedores. Materiales y métodos: se realizó una revisión retrospectiva de las historias clínicas de los pacientes con acalasia operados por POEM en una institución de Colombia por un solo cirujano endoscopista. Resultados: se encontraron 4 pacientes con acalasia, todas con Eckardt ≥10 y presión EEI ≥30 mm Hg; el tiempo quirúrgico osciló entre 81-120 minutos; en el seguimiento, la reducción en la presión del EEI fue mayor al 50% prácticamente en todos los pacientes, encontrando valores cercanos a la normalidad y con resultados de Eckardt que demuestran éxito en la terapia POEM a los 2 meses de evaluación. Las complicaciones fueron resueltas en el intraoperatorio, con mortalidad de 0%. Conclusiones: El manejo de la acalasia mediante POEM ha demostrado ser una técnica eficaz y segura. Nuestros primeros hallazgos concuerdan con los resultados descritos en la literatura. Este es el primer paso para la implementación de este novedoso abordaje en el manejo de la acalasia en la población colombiana.

Abstract Introduction: Peroral endoscopic myotomies (POEMs) were initially designed to manage achalasia, a chronic and progressive esophageal motility disorder with lower esophageal sphincter hypertension (LES). Until recently, standard treatment had been Heller's surgery, but this new technique offers very promising pressure. Materials and methods: This is a retrospective review of the clinical histories of patients with achalasia who underwent POEM performed by one endoscopic surgeon at a Colombian institution. Results: Four patients with achalasia were found. All had Eckardt scores of ten or more and lower esophageal sphincter (LES) pressure of 30mm Hg or more. Surgical times ranged between 81 and 120 minutes. Follow-up examinations found that LES pressure had decreased by more than 50% in practically all patients. Eckardt scores were close to normal. This demonstrates success of POEM therapy after two months of evaluation. Complications were resolved intraoperatively without mortality. Conclusions: Management of achalasia by POEM has proven to be a safe and effective technique. Our first findings agree with the results described in the literature. This is the first step in the implementation of this novel approach for management of achalasia in our Colombian population.

Calidad de vida antes y después de la cirugía videolaparoscópica en la acalasia esofágica / Quality of live before and after videolaparoscopic surgery in esophageal achalasia

Introducción: la acalasia esofágica es el más frecuente de los trastornos motores. Origina disfagia, regurgitaciones y pérdida de peso con deterioro marcado de la calidad de vida. El tratamiento quirúrgico videolaparoscópico es el de elección para el alivio de la disfagia. Objetivo: evaluar la calidad de vida relacionada con la salud en pacientes con acalasia esofágica operados por videolaparoscopia. Método: se realizó estudio observacional descriptivo longitudinal prospectivo, mediante la aplicación del cuestionario GIQLI (en la consulta de preoperatorio, a los tres meses y al año del posoperatorio) a los pacientes operados de acalasia esofágica desde enero hasta diciembre del año 2015 en el Centro Nacional de Cirugía de Mínimo Acceso. Análisis estadístico: porcentajes para variables cualitativas, media ± desviación estándar para las cuantitativas. Para evaluar el comportamiento de la calidad de vida relacionada con la salud se realizó análisis de varianza (ANOVA) de medidas repetidas con nivel de significación estadística α= 0,05. Resultados: 34 pacientes fueron incluidos, se excluyeron tres, 41,2 por ciento del sexo masculino, 58,8 por ciento del femenino, predominó color de la piel blanca (66,7 por ciento), media de edad de 44,8 años, GIQLI inicial 85,6 (± 20,9) puntos, a los tres meses 125,2 (± 12,4) puntos, al año 134,0 (± 9,6) puntos, p= 0,000. Conclusiones: la esofagocardiomiotomía de Heller laparoscópica mejora la calidad de vida relacionada con la salud de los pacientes con acalasia esofágica(AU)

Introduction: Achalasia is the most frequent of motor disorders of the esophagus, producing dysphagia, regurgitation and weight loss, with a marked deterioration of the quality of life. ideolaparoscopic surgery remains the gold standard for dysphagia relief. However, the health-related quality of live measurement is still necessary to assess treatment outcome and the impact on the patients' lives. Objective: To assess the health-related quality of live in patients with esophageal achalasia who received videolaparoscopic surgery. Methods: An observational, descriptive, longitudinal and prospective study was carried out, using the questionnaire GIQLI, in the preoperative interview, three months and then a year following videolaparoscopic surgery, in patients who received achalasia surgery from January to December 2015 in the National Center for Minimally Invasive Surgery. The statistical analysis considered percentages for qualitative variables and mean standard deviation for quantitative variables. In order to assess the actual state of the health-related quality of live, a variance analysis of repetitive measures (ANOVA) was made, with a level of statistical significance α=0.05. Results: 34 patients were included, three were excluded, 41.2 percent of male sex, 58.8 percent of female sex, the white skin predominated (66.7 percent), average age of 44.8 years, baseline GIQLI score 85.6 (±20.9), after three months 125.2 (±12.4), and after one year 134.0 (±9.6), p=0,000. Conclusions: The laparoscopic Heller's esophageal cardiomyotomy improves the health-related quality of live in patients with esophageal achalasia(AU)

Reintervenciones por fracaso de la miotomía de Heller por acalasia esofágica / Reintervention after failed Heller myotomy for esophageal achalasia

Introducción: la cardiomiotomía de Heller asociada al proceder antirreflujo descrito por Dor constituye el tratamiento de elección en los pacientes con acalasia esofágica; sin embargo, las causas del fracaso del tratamiento aún son controversiales. Objetivo: describir las causas del fracaso de la miotomía de Heller en pacientes operados por acalasia esofágica y la evolución clínica de los pacientes reintervenidos. Métodos: se realizó un estudio descriptivo, retrospectivo y longitudinal de una serie de pacientes reintervenidos por fracaso de la miotomía de Heller en el Centro Nacional de Cirugía de Mínimo Acceso desde enero de 2010 hasta diciembre de 2016. Resultados: se les realizó miotomía de Heller a 253 pacientes con diagnóstico de acalasia esofágica. De ellos, 7 (2,7 por ciento) fueron reintervenidos por recurrencia de los síntomas, 4 (1,5 por ciento) fueron operados inicialmente en la institución y el resto fueron remitidos de otras instituciones del país. La edad media fue de 41 ± 15 años (rango 20-59). Los síntomas más frecuentes fueron la disfagia posoperatoria y la pérdida de peso (100 por ciento). El tiempo de recurrencia de los síntomas después de la primera operación fue de 6-12 meses en 4 (57 por ciento), de 12 a 18 meses en 1 (16 por ciento) y de 18 a 24 en 2 (33 por ciento) pacientes. Conclusiones: la miotomía incompleta fue la causa principal de reintervención. La remiotomia laparoscópica con o sin fundoplicatura fue la técnica quirúrgica de elección para estos pacientes los cuales tuvieron una evolución clínica excelente o buena en el posoperatorio(AU)

Introduction: Heller's cardiomyotomy associated with the antireflux procedure described by Dor is the treatment of choice in patients with esophageal achalasia. However, the causes of treatment failure are still controversial. Objective: To describe the causes of failure of Heller's myotomy in patients operated for esophageal achalasia and the clinical progress of patients who required another surgery. Methods: A descriptive, retrospective and longitudinal study was performed in a series of patients who required another surgery due to failed Heller's myotomy at the National Center for Minimally Invasive Surgery from January 2010 to December 2016. Results: Heller's myotomy was performed in 253 patients diagnosed with esophageal achalasia. Among these patients, 7 (2.7 percent) required another surgery due to the relapse of symptoms, 4 (1.5 percent) were initially operated at the institution, and the rest were referred from other institutions in the country. The average age was 41±15 years (range 20-59). The most frequent symptoms were postoperative dysphagia and weight loss (100 percent). The time of symptoms relapse after the first surgery was 6-12 months in 4 patients (57 percent), 12-18 months in 1 (16 percent) and 18-24 months in 2 (33 percent) patients. Conclusions: Incomplete myotomy was the main cause of reintervention, laparoscopic myotomy with or without fundoplication being the surgical technique of choice for these patients, who had an excellent or good postoperative clinical evolution(AU)

Calidad de vida en pacientes con acalasia esofágica operados por videolaparoscopia / Quality of life in patients with esophageal achalasia after video-laparoscopic surgery

Introducción: la acalasia esofágica se asocia con un marcado deterioro de la calidad de vida, el tratamiento quirúrgico videolaparoscópico es el de elección. Sin embargo, es necesario medir la calidad de vida relacionada con la salud para evaluar los resultados del tratamiento y el impacto sobre su vida. Objetivos: evaluar la calidad de vida relacionada con la salud en pacientes con acalasia esofágica operados por videolaparoscopia. Método: estudio observacional, descriptivo, longitudinal prospectivo, mediante la aplicación del cuestionario de índice gastrointestinal de calidad de vida a pacientes operados de acalasia esofágica desde enero hasta diciembre de 2015 en el Centro Nacional de Cirugía de Mínimo Acceso. Se incluyeron en el estudio 34 pacientes y se excluyeron tres. El cuestionario se aplicó en el preoperatorio y a los tres meses de operados. El análisis estadístico expresa porcentajes para variables cualitativas, media ± desviación estándar o mediana y rango según corresponda para las cuantitativas, para la comparación de los resultados del cuestionario se emplearon pruebas de hipótesis de comparación de medias, con nivel de significación estadística α= 0,05. Resultados: hubo u total de 41,2 por ciento, 14 del sexo masculino, 58,8 por ciento, 20 del sexo femenino. Predominó color de la piel blanca (66,7 por ciento), media de edad de 44,8 años, GIQLI inicial 85,6 (± 20,9), GIQLI trimestral 125,2 (± 12,4) p= 0,000. Conclusiones: la esofagocardiomiotomía de Heller videolaparoscópica mejora la calidad de vida relacionada con la salud de los pacientes con acalasia esofágica(AU)

Introduction: Esophageal achalasia is associated with a marked decay in quality of life, treatment with video-laparoscopic surgery is the chosen one. However, it is necessary to measure their health-related quality of life, in order to evaluate the results after treatment and the impact on their lives. Objective: To evaluate health-related quality of life in patients with esophageal achalasia after video-laparoscopic surgery. Methods: Observational, descriptive, longitudinal and prospective study using the questionnaire for Gastrointestinal Quality of Life Index (GIQLI) in patients who had esophageal achalasia operation from January to December 2015 at the National Center for Minimal Invasive Surgery. The study included 34 patients and excluded 3. The questionnaire was applied in the preoperatory and three months after. The statistical analysis expresses percentages for qualitative variables, mean ± average or standard deviation, and range by correspondence for the quantitative ones, to compare the questionnaire results, hypothetical tests for means comparison were used, with a level of statistical significance ?=0.05. Results: There was a total of 41.2 por ciento, 14 of male sex, 58.8 por ciento, 20 of female sex. There was a predominance of white skin color (66.7 por ciento), mean age of 44.8 years, initial GIQLI of 85.6 (± 20.9), quarterly GIQLI of 125.2 (± 12.4) p= 0.000. Conclusions: Video-laparoscopic Heller's esophagocardiomyotomy improves health-related quality of life of the patients with esophageal achalasia(AU)

Comparison of clinical effect between peroral endoscopic myotomy and Heller myotomy for achalasia / 中国内镜杂志

Objective To compare the clinical effect and safety of peroral endoscopic myotomy (POEM) with surgical therapy in treatment of esophageal achalasia. Methods 78 patients diagnosed as esophageal achalasia from January 2012 to October 2014 were enrolled in the study and divided into POME group and Heller group. There were 42 patients in POEM group and 36 patients in Heller group. The clinical symptom remission rate, LES resting pressure, Eckardt scores, complication rate, length of hospital stay and the hospitalization expenses were analyzed between the two groups. Results The patients in POEM group and Heller group both got clinical remissions after the treatment. There was no statistical difference in the rate of complication occurrence, Eckardt scores and LES resting pressure between the two groups. Patients in POEM group had shorter operation time, hospital stay and less expenses compared with the Heller group. Conclusions Compared with Heller group, the POEM group has the similar curative effect in treatment of esophageal achalasia. The POEM as a minimally invasive surgery has the advantages of less pain and trauma, shorter hospital stay, well tolerated and low cost. Therefore, the POEM is worth to be popularized and applied in treating esophageal achalasia.

Miotomía de Heller laparoscópica para el tratamiento de la acalasia esofágica en el adulto mayor / Laparoscopic Heller myotomy for the treatment of e sophageal achalasia in the elderly

Introducción: la miotomía de Heller laparoscópica como tratamiento de elección en los pacientes de edades avanzadas aun es controversial para algunos autores. Objetivo: determinar la evolución clínica posoperatoria de los pacientes adultos mayores con acalasia esofágica intervenidos con miotomía de Heller laparoscópica. Métodos: se realizó un estudio descriptivo, retrospectivo y longitudinal, donde se revisaron las historias clínicas de los pacientes con diagnóstico de acalasia esofágica a los cuales se les realizó miotomía de Heller laparoscópica en el Centro Nacional de Cirugía de Mínimo Acceso desde enero de 2010 hasta diciembre de 2014. Se clasificaron los pacientes en 2 grupos de edades: grupo 1 (< 60 años) y grupo 2 (≥60 años). El tiempo de evolución de los síntomas, tratamientos endoscópicos previos y el grado de dilatación del esófago fueron analizados. Resultados: la conversión y la mortalidad fueron nula en ambos grupos. La estadía hospitalaria de 1 día. Los pacientes del grupo 2 tuvieron una evolución clínica de excelente o buena a los 6 y 12 meses según la clasificación clínica posoperatoria de Vantrappen y Hellemans, un paciente clasificó en evolución desfavorable y el mismo pertenece al grupo de < 60 años. Conclusiones: la evolución clínica posoperatoria de los pacientes adultos mayores operados por acalasia esofágica reafirman que la miotomía de Heller laparoscópica es una alternativa de tratamiento de elección en este grupo de edad(AU)

Introduction: laparoscopic Heller myotomy treatment of choice in elderly patients with esophageal achalasia is still controversial for some authors. Objective: determine the postoperative clinical course of elderly patients with achalasia esophageal (EA) surgery with laparoscopic Heller myotomy. Methods: a descriptive, retrospective and longitudinal study, where the medical records of patients with diagnosis of EA to which underwent laparoscopic Heller myotomy in the National Center for Minimal Access Surgery (CNCMA) was conducted the period january 2010 to december 2014. Patients were classified into 2 age groups: group 1 (<60 years) and group 2 (≥60 years). The time evolution of symptoms, previous endoscopic treatment and the degree of dilation of the esophagus were analyzed. Results: the conversion and mortality was zero in both groups. The hospital stay was 1 day. Group 2 patients had a clinical evolution of excellent or good at 6 and 12 months depending on the postoperative clinical classification of Vantrappen and Hellemans, a patient classified in unfavorable and it belongs to the group of <60 years. Conclusions: the postoperative clinical course of elderly patients operated achalasia esophageal reaffirm that laparoscopic Heller myotomy is an alternative treatment of choice in this age group(AU)