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ESOPHAGEAL PULL-DOWN TECHNIQUE IMPROVES THE FINAL OUTCOME OF LAPAROSCOPIC HELLER-DOR FOR END-STAGE ACHALASIA
Date
May 9, 2023
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Society: SSAT
Background: Gastroesophageal reflux disease (GERD), with or without hiatal hernia (HH), affects millions of individuals worldwide, with a significant economic impact and loss of health-related quality of life. Laparoscopic fundoplication is the surgical technique of choice for treating GERD, but only few studies report a follow-up beyond 15 years. In order to determine the best treatment option, it is important to assess the long-term outcome of LARS. The aim of this study was to evaluate the results at least 20 years after LARS performed for GERD and/or large HH at a single referral center for esophageal diseases.
Methods: We prospectively collected data on a cohort of consecutive patients who underwent LARS between 1992 and 2001 at our department. Patients were divided into two groups: a GERD group, comprising patients with pathological esophageal acid exposure, and large hiatal hernia (HH), including patients with >3 cm type I HH and types II-IV hiatal hernias. The study population flowchart is shown on Figure 1. Patients were followed up for at least 20 years using a symptom score (SS), endoscopy, barium-swallow, esophageal manometry, and 24-hour pH-monitoring. LARS was judged to have failed in any of the following cases: a) GERD symptom recurrence (SS >10); b) recurrence of esophagitis; c) HH recurrence or slipped-fundoplication; d) pathological 24-hour pH-monitoring; e) BE progression or onset of adenocarcinoma.
Results: The study population consisted of 137 patients: 107 in the GERD group and 30 in the HH group. The characteristics of patients in the two groups are shown on Figure 2. Conversion to open surgery proved necessary in 8 patients (5.8%), and intraoperative and perioperative complications were recorded in 9 patients (6.5%). At a median follow-up of 22 years, the outcome was positive in 84.1% of the GERD patients, and 63.3% of the HH patients. Revisional surgery was necessary in 9 (6.5%) patients (4 GERD and 5 HH patients). Indications for revisional surgery were a slipped fundoplication or hernia recurrence in 6 cases, a pH-detected abnormal acid reflux and esophagitis resistant to medical therapy in 2 cases, and the herniation of the stomach inside the fundoplication (telescoping) in one case. Overall, GERD patients had a better failure-free survival rate than HH patients (p=0.02). Two decades after LARS, 88.8% of GERD patients and 86.7% of HH patients were satisfied with the procedure.
Conclusion: The present study concerns one of the largest populations of patients who had undergone LARS to have been followed up for more than 20 years at a single center. The findings showed that laparoscopic antireflux surgery is effective and durable (for >20 years) in patients with uncomplicated GERD and, to a lesser extent, in those with a large hiatal hernia. The satisfaction rate more than 20 years after surgery almost reached 90%.
Methods: We prospectively collected data on a cohort of consecutive patients who underwent LARS between 1992 and 2001 at our department. Patients were divided into two groups: a GERD group, comprising patients with pathological esophageal acid exposure, and large hiatal hernia (HH), including patients with >3 cm type I HH and types II-IV hiatal hernias. The study population flowchart is shown on Figure 1. Patients were followed up for at least 20 years using a symptom score (SS), endoscopy, barium-swallow, esophageal manometry, and 24-hour pH-monitoring. LARS was judged to have failed in any of the following cases: a) GERD symptom recurrence (SS >10); b) recurrence of esophagitis; c) HH recurrence or slipped-fundoplication; d) pathological 24-hour pH-monitoring; e) BE progression or onset of adenocarcinoma.
Results: The study population consisted of 137 patients: 107 in the GERD group and 30 in the HH group. The characteristics of patients in the two groups are shown on Figure 2. Conversion to open surgery proved necessary in 8 patients (5.8%), and intraoperative and perioperative complications were recorded in 9 patients (6.5%). At a median follow-up of 22 years, the outcome was positive in 84.1% of the GERD patients, and 63.3% of the HH patients. Revisional surgery was necessary in 9 (6.5%) patients (4 GERD and 5 HH patients). Indications for revisional surgery were a slipped fundoplication or hernia recurrence in 6 cases, a pH-detected abnormal acid reflux and esophagitis resistant to medical therapy in 2 cases, and the herniation of the stomach inside the fundoplication (telescoping) in one case. Overall, GERD patients had a better failure-free survival rate than HH patients (p=0.02). Two decades after LARS, 88.8% of GERD patients and 86.7% of HH patients were satisfied with the procedure.
Conclusion: The present study concerns one of the largest populations of patients who had undergone LARS to have been followed up for more than 20 years at a single center. The findings showed that laparoscopic antireflux surgery is effective and durable (for >20 years) in patients with uncomplicated GERD and, to a lesser extent, in those with a large hiatal hernia. The satisfaction rate more than 20 years after surgery almost reached 90%.
BACKGROUND: The results of Laparoscopic Heller-Dor for achalasia are generally consistent: a good outcome is reported in between 90%-80% of patients.
Patients with sigmoid shape (radiological stage IV achalasia) have an advanced form of the disease and are considered the most difficult to treat, with a success rate that drops to 70%-50%
A modified technique (pull-down) has been proposed to straighten the esophageal axis, but there is a limited amount of data available in literature. In this study, we aimed to compare the final outcome of the pull-down technique (PDLHD) with the results of classical myotomy (CLHD) in patients with end-stage achalasia.
METHODS: From 1995 to 2022, patients with a radiological diagnosis of end-stage achalasia undergoing laparoscopic myotomy were enrolled in the study.
CLHD was performed using the established technique. The PDLHD technique included: after circling the gastro-esophageal junction using a string, a length of approximately 10 cm of the lower mediastinal esophagus was isolated. Two stitches were applied on each side, then tied to anchor the wall of the esophagus to the diaphragmatic pillars. After verticalizing the esophageal axis, the Heller-Dor myotomy was performed.
Symptoms were quantified using the Eckardt score. Barium-swallow, endoscopy and manometry were performed before and after the treatment. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score ≥ 3, or the need for retreatment.
RESULTS: Of the 94 patients with end-stage achalasia (M:F = 52:42), 60 patients were treated with CLHD, and 34 patients with PDLHD.
The patients’ demographic and clinical data are summarised in table 1. All patients had a preoperative manometric pattern I. The median duration of symptoms was longer in PDLHD (144 months, IQR 72-240) than CLHD (24 months, IQR 25-120).
The surgical procedures were completed laparoscopically in all patients. There were 2 mucosal lesions: one in each group (p=n.s).
The median follow-up was 72 months (IQR:33-113) in the CLHD and 30 months (IQR:12-99) in the PDLHD group. (p>0.01).
All patients in both groups had an improvement in their Eckardt score after surgery, but the failure rates were 27% (16/60) after CLHD and 6% (2/34) after PDLHD (p=0.01)
Amongst the patients who underwent complete post-operative follow-up, an abnormal acid exposure was detected in 2 patients after PDLH and in 6 after CLHD (p=n.s.).
CONCLUSIONS: Taken into account the intrinsic limitations of the study (different time window, and different follow-up), the results of this study indicate that performing the pull-down technique during Laparoscopic Heller-Dor improves the final outcome in end-stage achalasia patients. Therefore, PDLHD should be the first surgical option to be offered to these patients before considering esophagectomy.
Patients with sigmoid shape (radiological stage IV achalasia) have an advanced form of the disease and are considered the most difficult to treat, with a success rate that drops to 70%-50%
A modified technique (pull-down) has been proposed to straighten the esophageal axis, but there is a limited amount of data available in literature. In this study, we aimed to compare the final outcome of the pull-down technique (PDLHD) with the results of classical myotomy (CLHD) in patients with end-stage achalasia.
METHODS: From 1995 to 2022, patients with a radiological diagnosis of end-stage achalasia undergoing laparoscopic myotomy were enrolled in the study.
CLHD was performed using the established technique. The PDLHD technique included: after circling the gastro-esophageal junction using a string, a length of approximately 10 cm of the lower mediastinal esophagus was isolated. Two stitches were applied on each side, then tied to anchor the wall of the esophagus to the diaphragmatic pillars. After verticalizing the esophageal axis, the Heller-Dor myotomy was performed.
Symptoms were quantified using the Eckardt score. Barium-swallow, endoscopy and manometry were performed before and after the treatment. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score ≥ 3, or the need for retreatment.
RESULTS: Of the 94 patients with end-stage achalasia (M:F = 52:42), 60 patients were treated with CLHD, and 34 patients with PDLHD.
The patients’ demographic and clinical data are summarised in table 1. All patients had a preoperative manometric pattern I. The median duration of symptoms was longer in PDLHD (144 months, IQR 72-240) than CLHD (24 months, IQR 25-120).
The surgical procedures were completed laparoscopically in all patients. There were 2 mucosal lesions: one in each group (p=n.s).
The median follow-up was 72 months (IQR:33-113) in the CLHD and 30 months (IQR:12-99) in the PDLHD group. (p>0.01).
All patients in both groups had an improvement in their Eckardt score after surgery, but the failure rates were 27% (16/60) after CLHD and 6% (2/34) after PDLHD (p=0.01)
Amongst the patients who underwent complete post-operative follow-up, an abnormal acid exposure was detected in 2 patients after PDLH and in 6 after CLHD (p=n.s.).
CONCLUSIONS: Taken into account the intrinsic limitations of the study (different time window, and different follow-up), the results of this study indicate that performing the pull-down technique during Laparoscopic Heller-Dor improves the final outcome in end-stage achalasia patients. Therefore, PDLHD should be the first surgical option to be offered to these patients before considering esophagectomy.
Table 1. Preoperative and intraoperative data
Presenter
Speakers
University of Padova
Padova University Hospital - Center for Esophageal Diseases
University of Padua
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