Piero M. Fisichella

Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change

BACKGROUND Twenty years ago an average of 1.5 Heller myotomies were performed per year in our hospital, mostly for patients whose dysphagia did not improve following balloon dilatation or whose esophagus had been perforated during a balloon dilatation. Ten years ago we started using minimally invasive surgery to treat this disease. STUDY DESIGN This study measures the impact of minimally invasive surgery with regard to the following: the number of patients referred for treatment; the number of patients who came to surgery without previous treatment; and the results of surgical treatment. Between 1991 and 2001, 149 patients had minimally invasive surgery for achalasia: 25 patients (17%) had thoracoscopic Heller myotomy and 124 (84%) had laparoscopic Heller myotomy and Dor fundoplication. Of the 149 patients, 79 patients (53%) had previous treatment (56 patients [71%], balloon dilatation; 7 patients [9%], botulinum toxin injection; 16 patients [20%], both) and 70 patients (43%) had none of these treatments. Mean postoperative followup was 59 +/- 36 months. Patients were divided into two groups: group A, operated on between 1991 and 1995; and group B, operated on between 1996 and 2001. RESULTS In the past decade, the number of patients referred for surgery has increased substantially--group A, 48; group B, 101; an increasing proportion of patients were referred for surgery without previous treatment--group A, 38%; group B, 51%; and the outcomes of the operation progressively improved--group A, 87%; group B, 95%. CONCLUSIONS These data show that the high success rate of laparoscopic Heller myotomy for achalasia has brought a shift in practice; surgery has become the preferred treatment of most gastroenterologists and other referring physicians. This has followed documentation that laparoscopic treatment outperforms balloon dilatation and botulinum toxin injection.

Esophageal dysmotility and gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) produces a spectrum of symptoms ranging from mild to severe. While the role of the lower esophageal sphincter in the pathogenesis of GERD has been studied extensively, less attention has been paid to esophageal peristalsis, even though peristalsis governs esophageal acid clearance. The aim of this study was to evaluate the following in patients with GERD: (1) the nature of esophageal peristalsis and (2) the relationship between esophageal peristalsis and gastroesophageal reflux, mucosal injury, and symptoms. One thousand six consecutive patients with GERD confirmed by 24-hour pH monitoring were divided into three groups based on the character of esophageal peristalsis as shown by esophageal manometry: (1) normal peristalsis (normal amplitude, duration, and velocity of peristaltic waves); (2) ineffective esophageal motility (IEM; distal esophageal amplitude <30 mm Hg or >30% simultaneous waves); and (3) nonspecific esophageal motility disorder (NSEMD; motor dysfunction intermediate between the other two groups). Peristalsis was classified as normal in 563 patients (56%), IEM in 216 patients (2l%), and NSEMD in 227 patients (23%). Patients with abnormal peristalsis had worse reflux and slower esophageal acid clearance. Heartburn, respiratory symptoms, and mucosal injury were all more severe in patients with IEM. These data show that esophageal peristalsis was severely impaired (IEM) in 21 % of patients with GERD, and this group had more severe reflux, slower acid clearance, worse mucosal injury, and more frequent respiratory symptoms. We conclude that esophageal manometry and pH monitoring can be used to stage the severity of GERD, and this, in turn, should help identify those who would benefit most from surgical treatment.

Clinical, Radiological, and Manometric Profile in 145 Patients with Untreated Achalasia

BackgroundEsophageal achalasia is characterized by the absence of esophageal peristalsis and by a dysfunctional lower esophageal sphincter (LES). Descriptions of clinical, radiological, and manometric findings in patients with achalasia usually have been based on small numbers of patients. This study was designed to determine in patients with untreated achalasia: (1) clinical presentation; (2) how often a diagnosis of gastroesophageal reflux disease (GERD) was erroneously made based on the presence of heartburn; (3) manometric profile; (4) relationship between chest pain and the manometric finding of vigorous achalasia.MethodsBetween 1990 and 2004, a diagnosis of esophageal achalasia was established in 145 patients. None of them had been previously treated (no previous endoscopic or surgical treatment). We evaluated the demographic and clinical characteristics, as well as the results of the endoscopy, barium swallow, esophageal manometry, and ambulatory pH monitoring. We also compared the clinical and the manometric profile of patients with classic and patients with vigorous achalasia.ResultsMost patients with untreated achalasia had dysphagia (94%). Regurgitation was present in 76% and heartburn in 52%. Chest pain (41%) and weight loss (35%) were less common. Acid-suppressing medications had been prescribed to 65 patients (45%) who complained of heartburn on the assumption that GERD was present. The LES was hypertensive in 43% of patients only. There was no significant difference in the prevalence, severity, and duration of chest pain in patients with classic and with vigorous achalasia.ConclusionsThese results show that in patients with untreated achalasia: (1) dysphagia was the most frequent complaint, but regurgitation and heartburn were frequently present; (2) a diagnosis of GERD based on the presence of heartburn was highly unreliable; (3) the LES was hypertensive in less than half of patients; and (4) the prevalence, severity, and duration of chest pain did not correlate with the manometric finding of vigorous achalasia.

Effect of partial and total laparoscopic fundoplication on esophageal body motility

BackgroundAbnormal esophageal body motility often accompanies gastroesophageal reflux disease (GERD). Although the effect of surgery on the pressure and behavior of the lower esophageal sphincter (LES) has been extensively studied, it still is unclear whether a successful fundoplication improves esophageal peristalsis.MethodsThe pre- and postoperative esophageal manometries of 71 patients who underwent a successful laparoscopic fundoplication (postoperative DeMeester score < 14.7) were reviewed. The patients were grouped according to the type of fundoplication (partial vs total) and preoperative esophageal peristalsis (normal vs abnormal): group A (partial fundoplication and abnormal esophageal peristalsis; n = 16), group B (total fundoplication and normal peristalsis; n = 41), and group C (total fundoplication and abnormal peristalsis; n = 14).ResultsThe LES pressure was increased in all the groups. A significant increase in amplitude of peristalsis was noted in groups A and C. Normalization of peristalsis was achieved in 31% of the group A patients and 86% of the group C patients. No changes occurred in group B.ConclusionsLaparoscopic fundoplication increased LES pressure and the strength of esophageal peristalsis in patients with abnormal preoperative esophageal motility. A total fundoplication resulted in normalization of peristalsis in the majority of patients.

The evolution and long-term results of laparoscopic antireflux surgery for the treatment of gastroesophageal reflux disease.

When carefully performed, laparoscopic antireflux surgery is an effective, durable procedure for the control of gastroesophageal reflux disease.

Medium and long-term outcomes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis.

Recent randomized studies comparing outcomes after pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) for the treatment of achalasia are conflicting and limited to short-term follow-up. Our meta-analysis compared the long-term durability of these approaches, with the hypothesis that LHM offers superior long-term remission compared with PD. We identified 36 studies published between 2001 and 2011 with at least 5 years of follow-up. Those studies describing PD included 3211 patients (mean age, 49.8 y). For PD, the mean 5-year remission rate was 61.9% and the mean 10-year remission rate was 47.9%. Overall, 1526 patients (mean age, 46.3 y) were treated with LHM; 83% received a fundoplication. In contrast, the mean 5- and 10-year remission rates after LHM were 76.1% and 79.6%, respectively. Finally, the perforation rate for LHM was twice that of PD (4.8% vs. 2.4%; P<0.05). We conclude that despite a higher frequency of perforation, LHM affords greater long-term durability.

Gastroesophageal Reflux Disease and Connective Tissue Disorders: Pathophysiology and Implications for Treatment

IntroductionIt has been postulated that in patients with connective tissue disorders (CTD) and gastroesophageal reflux disease (GERD), esophageal function is generally deteriorated, often with complete absence of peristalsis. This belief has led to the common recommendation of avoiding antireflux surgery for fear of creating or worsening dysphagia.MethodsWe hypothesized that in most patients with CTD and GERD: (a) esophageal function is often preserved; (b) peristalsis is more frequently absent when end-stage lung disease (ESLD) is also present; (c) a tailored surgical approach (partial or total fundoplication) based on the findings of esophageal manometry allows control of reflux symptoms without a high incidence of postoperative dysphagia. Forty-eight patients with CTD were evaluated by esophageal manometry and 24-hour pH monitoring (EFT). Twenty patients (group A) had EFT because of foregut symptoms, and 28 patients with ESLD (group B) had EFT as part of the lung transplant evaluation. Two hundred and eighty-six consecutive patients with GERD by pH monitoring served as a control group (group C). A laparoscopic fundoplication was performed in two group A patients (total), eight group B patients (three patients total, five patients partial) and in all group C patients (total).ResultsEsophageal peristalsis was preserved in all patients with CTD and GERD. In contrast, peristalsis was absent in about half of patients when ESLD was also present. A tailored surgical approach resulted in control of reflux symptoms in all patients. One patient only developed postoperative dysphagia, which resolved with two Savary dilatations.ConclusionThese data show that esophageal motor function is preserved in most patients with CTD, so that they should be offered antireflux surgery early in the course of their disease to prevent esophageal and respiratory complications. In patients with ESLD in whom peristalsis is absent, a partial rather than a total fundoplication should be performed, as it allows control of reflux symptoms while avoiding postoperative dysphagia.

Laparoscopic Heller Myotomy and Dor Fundoplication for Esophageal Achalasia. How I do It

The advent and the success of minimally invasive surgery have changed the treatment algorithm for esophageal achalasia. Today, a laparoscopic Heller myotomy and partial fundoplication is considered the treatment of choice for this disease. This article describes the technique of laparoscopic Heller myotomy and Dor fundoplication.

Gastroesophageal reflux disease (GERD) and chest pain. Results of laparoscopic antireflux surgery.

BackgroundLaparoscopic fundoplication cures heart-burn and regurgitation in patients with gastroesophageal reflux disease (GERD) but its effect on the chest pain that is also experienced by some patients is less clear. Confusion stems from the fact that it is difficult to determine preoperatively whether the chest pain is actually caused by the reflux. Therefore, we designed a study in patients with GERD and chest pain that would assess the value of pH monitoring in establishing a correlation between the symptom and the disease, the predictive value of pH monitoring on the results of surgical treatment, and the outcome of laparoscopic fundoplication on chest pain in patients with GERD.MethodsOf 487 patients who underwent laparoscopic fundoplication for GERD at our institution between October 1992 and July 2000, 165 (34%) complained of chest pain in addition to heartburn and regurgitation. Their symptoms had been present for an average of 118 months. The pH monitoring tracings were analyzed for a correlation between episodes of reflux and chest pain. The mean length of follow-up was 13 months.ResultsAmong the 165 patients with chest pain, the relationship between pain and reflux during pH monitoring was as follows: 39 patients (group A) experienced no chest pain during the study; in 28 patients (group B), chest pain correlated with reflux in ≥40% of instances; in 98 patients (group C), chest pain correlated with reflux in ≥40% of instances. Chest pain improved post-operatively in 65% of group A patients, 79% of group B patients, and 96% of group C patients (group C vs A and B: p<0.05). Heartburn and regurgitation resolved or improved in 97% and 95% of patients, respectively.ConclusionsThese data show that pH monitoring helped to identify a relationship between chest pain and reflux; and when the two coincided, the chest pain was relieved by antireflux surgery.

Preoperative Evaluation of Patients with Gastroesophageal Reflux Disease

All patients who are candidates for laparoscopic fundoplication for the treatment of gastroesophageal reflux disease (GERD) should have a symptom review, barium swallow imaging, endoscopy, esophageal manometry, and ambulatory pH monitoring. The presence of a typical primary symptom, an abnormal 24-hour pH score, and a good response to acid-suppression therapy are predictive of a successful surgical outcome. The surgeon should be particularly wary of the following types of patients who may be referred for fundoplication but not have GERD: those who do not respond to proton pump inhibitors, those without esophagitis, those with only atypical symptoms, those in whom pH monitoring was done without previous manometry, and those with a borderline reflux score, severe vomiting, severe dysphagia and heartburn, unusual symptoms, severe depression, or morbid obesity.