Heller's myotomy for achalasia: Is an added anti-reflux procedure necessary?

Andreollo, Nelson Adami; Earlam, Richard

doi:10.1002/bjs.1800740903

Cited by 136 publications

(69 citation statements)

References 36 publications

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“…Em nossos pacientes utilizávamos a fundoplicatura à Lind, porém devido a ocorrência de casos de refluxo optamos a partir de 1991 pela fundoplicatura em três planos, que, entretanto, mostrou a mesma taxa de refluxo que a opção prévia . Os índices de refluxo gastroesofágico nesse tipo de operação variam de 0% a 35,2% 10,12,13,16,17,18 . Em nossa casuística, observamos que, além dos doentes com queixa de pirose, em outros seis (8,4%), assintomáticos em relação ao refluxo, foi comprovado existência de refluxo gastroesofágico, o que demonstra a necessidade de acompanhamento clínico e com exames mesmo em pacientes assintomáticos.…”

Section: Discussionunclassified

Resultados tardios da operação de Heller associada à fundoplicatura no tratamento do megaesôfago: análise de 83 casos

Herbella¹,

Grande²,

Lourenço³

et al. 1999

Rev. Assoc. Med. Bras.

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RESUMO -OBJETIVO. Estudo retrospectivo dosde 1995, cuja idade média era de 43,2 ± 14,2 anos (variação de 79-17 anos).O sintoma principal foi disfagia, presente em 82 (98,8%) pacientes, e o tempo médio de queixa era de 8,5 ± 8,8 anos (30 dias -30 anos). Regurgitação foi referida por 63 (75,9%) doentes. Perda ponderal estava presente em 55 (66,3%) pacientes, com média de 1,37 ± 1,76 (0,05-7,75) kg/mês.Outras manifestações da doença de Chagas e outras moléstias estavam associadas em 49 (59,0%) doentes, sendo representadas por: cardiopatia, em 38 (45,8%), megacólon, em 20 (24,1%), colecistite crônica calculosa, em cinco (6,0%), nefropatia crô-nica avançada, em dois (2,4%), hérnia hiatal, em dois (2,4%), hérnia inguinal, em um (1,2%), divertículo de Zenker, em um (1,2%), acalásia do piloro, em um (1,2%), hipertensão portal, em um (1,2%) e tuberculose peritoneal, em um (1,2%). Dois doentes (2,4%) haviam sido previamente submetidos à operação de Heller e fundoplicatura em outros serviços. A etiologia chagásica foi comprovada através do teste sorológico de Machado e Guerreiro em 60 (72,3%) doentes. O exame radiológico, realizado em todos os pacientes, permitiu

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Section: Discussionunclassified

Resultados tardios da operação de Heller associada à fundoplicatura no tratamento do megaesôfago: análise de 83 casos

Herbella¹,

Grande²,

Lourenço³

et al. 1999

Rev. Assoc. Med. Bras.

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“…Simple repair was sufficient in all patients. In one patient, without [14][15][16] At the same time, postoperative esophageal perforation was <1%. Despite these excellent results, 75% of patients opted for balloon dilation as primary therapy when both options were presented fairly to the patient.9 Laparoscopic surgery, by reducing the pain, the scar, and the postoperative disability, has made surgical therapy more attractive to patients.…”

Section: Complicationsmentioning

confidence: 99%

Laparoscopic Heller Myotomy and Fundoplication for Achalasia

et al. 1997

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ObjectiveThe goal of this study was to review the authors' results with laparoscopic cardiomyotomy and partial fundoplication for achalasia. Summary Background DataPneumatic dilatation and botulinum toxin (BOTOX) injection of the lower esophageal sphincter largely have replaced cardiomyotomy for treatment of achalasia. After a brief experience with a thoracoscopic approach, the authors elected to perform cardiomyotomy laparoscopically, in combination with a partial fundoplication (anterior or posterior). Patients and MethodsForty patients were treated between July 1992 and November 1996. Thirty patients had previous therapy of achalasia, 21 with pneumatic dilation, 1 with BOTOX, 6 with balloon and BOTOX, and 2 with transthoracic cardiomyotomy. Three patients had previous laparoscopic fundoplication for gastroesophageal reflux. Symptom scores (0 = none to 4 = disabling) were obtained before surgery and after surgery. Barium swallows and esophagogastroduodenoscopy were performed in all patients. Esophageal motility study was performed in 36 patients. Laparoscopic Heller myotomy and fundoplication was performed through five upper abdominal trocars. A 7-cm myotomy extended 6 cm above the GE junction and 1 cm below the GE junction. A posterior fundoplication was performed in 32 patients, anterior fundoplication in 7 patients, and no fundoplication in 1 patient. Statistical inference was performed with a Wilcoxon signed rank test. ResultsMean operative duration was 199 ± 36.2 minutes. Mean hospital stay was 2.75 days (range, 1-13 days). Dysphagia was alleviated in all but four patients (90%), and regurgitation in all but two patients (95%) (p < 0.001). Chest pain and heartburn improved significantly (p < 0.01) as well. Intraoperative complications included mucosal laceration in six patients and hypercarbia in one. Postoperative pneumonia developed in two patients, and one patient had moderate hemorrhage from an esophageal ulcer 2 weeks after surgery. ConclusionsLaparoscopic cardiomyotomy and fundoplication appears to provide definitive treatment of achalasia with rapid rehabilitation and few complications. 655

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“…The frequency of GE reflux varies great ly depending on the definition used (symp toms. pH metry, x-rays, endoscopy), being twice as common after an abdominal com pared to thoracic approach and more com mon if the distal myotomy incision is ex tended onto the stomach [213]. If the thoracic approach is used and the distal myotomy length is no more than 0.5 cm, reflux is less of a problem [213].…”

Section: Surgerymentioning

confidence: 99%

“…The modified Heller myotomy accounts for 99% of achalasia operations, at least 56% of surgeons using the transthoracic approach [213], Good to excellent results from csophaAchalasia: W hat's New in Diagnosis and Treatm ent? gomyotomy are obtained in about 90% (range 60-94%) of achalasia patients followed from 1 to 36 years [75,213,214], Esophagomyotomy lowers LES pressure more consistently than pneumatic dilatation [187,[215][216][217][218], Depending on the distal ex tent of the myotomy, LES pressure is lowered by 55-75% with the remaining residual pres sure usually being <10 mm Hg [187,[215][216][217][218], Myotomy also lowers intraesophageal pressure but does not improve LES relaxation [219]. Partial return of peristalsis is reported in up to 14% of patients after myotomy, but these are usually manometric reports without correlation with barium clearance [199,[220][221][222].…”

Section: Surgerymentioning

confidence: 99%