Shunsuke Akimoto

Data analyses and perspectives on laparoscopic surgery for esophageal achalasia.

In general, the treatment methods for esophageal achalasia are largely classified into four groups, including drug therapy using nitrite or a calcium channel blocker, botulinum toxin injection, endoscopic therapy such as endoscopic balloon dilation, and surgery. Various studies have suggested that the most effective treatment of esophageal achalasia is surgical therapy. The basic concept of this surgical therapy has not changed since Heller proposed esophageal myotomy for the purpose of resolution of lower esophageal obstruction for the first time in 1913, but the most common approach has changed from open-chest surgery to laparoscopic surgery. Currently, the laparoscopic surgery has been the procedure of choice for the treatment of esophageal achalasia. During the process of the transition from open-chest surgery to laparotomy, to thoracoscopic surgery, and to laparoscopic surgery, the necessity of combining antireflux surgery has been recognized. There is some debate as to which type of antireflux surgery should be selected. The Toupet fundoplication may be the most effective in prevention of postoperative antireflux, but many medical institutions have selected the Dor fundoplication which covers the mucosal surface exposed by myotomy. Recently, a new endoscopic approach, peroral endoscopic myotomy (POEM), has received attention. Future studies should examine the long-term outcomes and whether POEM becomes the gold standard for the treatment of esophageal achalasia.

Comparison of laparoscopic Nissen and Toupet fundoplication using a propensity score matching analysis.

PurposeLaparoscopic fundoplication (LF) has become a standard operative procedure for GERD-related diseases in Japan, although meta-analyses have mainly evaluated findings from Western countries. The propensity score matching method was used to compare and investigate the treatment outcomes of two fundoplication procedures (the Nissen and Toupet methods).MethodsAmong 474 patients who underwent initial LF from December 1994 to April 2016, we extracted 401 cases (Nissen: 92 cases, Toupet: 309 cases), excluding 73 patients in whom follow-up was insufficient. We then matched 126 of these patients (63 per group).ResultsThe esophageal acid reflux time (%) was 12.2:2.8, being higher in the Nissen group than in the Toupet group (p < 0.001). Regarding the surgical outcome, the amount of bleeding was higher in the Nissen group (p = 0.001), and the number of hospitalization days following surgery was longer (p = 0.003). Furthermore, a significantly rate of postoperative difficulty in swallowing (%) was observed in the Nissen group, at 13:0 (p = 0.004). The recurrence rate (%) was 8:3, with no difference between the two groups (p = 0.243).ConclusionsAlthough there was no marked difference in the recurrence rate between the two procedures, postoperative dysphagia was observed at a higher frequency with the Nissen method than the Toupet method.

Learning curve for laparoscopic Heller myotomy and Dor fundoplication for achalasia

Purpose Although laparoscopic Heller myotomy and Dor fundoplication (LHD) is widely performed to address achalasia, little is known about the learning curve for this technique. We assessed the learning curve for performing LHD. Methods Of the 514 cases with LHD performed between August 1994 and March 2016, the surgical outcomes of 463 cases were evaluated after excluding 50 cases with reduced port surgery and one case with the simultaneous performance of laparoscopic distal partial gastrectomy. A receiver operating characteristic (ROC) curve analysis was used to identify the cut-off value for the number of surgical experiences necessary to become proficient with LHD, which was defined as the completion of the learning curve. Results We defined the completion of the learning curve when the following 3 conditions were satisfied. 1) The operation time was less than 165 minutes. 2) There was no blood loss. 3) There was no intraoperative complication. In order to establish the appropriate number of surgical experiences required to complete the learning curve, the cut-off value was evaluated by using a ROC curve (AUC 0.717, p < 0.001). Finally, we identified the cut-off value as 16 surgical cases (sensitivity 0.706, specificity 0.646). Conclusion Learning curve seems to complete after performing 16 cases.

A novel laparoscopic approach for severe esophageal stenosis due to reflux esophagitis: how to do it.

We herein report our technique for laparoscopic esophageal myotomy combined with Collis gastroplasty and Nissen fundoplication for severe esophageal stenosis. Our patient had experienced vomiting since childhood, and his dysphagia had gradually worsened. He was referred to our department for surgery because of resistance to pneumatic dilation. He was diagnosed with a short esophagus based on the findings of a preoperative upper gastrointestinal series and GI endoscopy. After exposing the abdominal esophagus, esophageal myotomy around the esophago-gastric junction (EGJ) was undertaken to introduce an esophageal bougie into the stomach. Then, stapled wedge gastroplasty was performed, and a short and loose Nissen fundoplication was performed. In addition, the bulging mucosa after myotomy was patched using the Dor method. The patient’s postoperative course was uneventful. Most patients with esophageal stricture require subtotal esophagectomy. Laparoscopic surgery for patients with benign esophageal stricture refractory to repeated pneumatic dilation is challenging. However, our current procedure might abrogate the need for invasive esophagectomy for the surgical management of severe esophageal stenosis.

Effect of preoperative balloon dilation on treatment outcomes of laparoscopic Heller–Dor surgery for achalasia: a propensity score matched study

PurposeThere is some debate about whether preoperative balloon dilation influences the outcomes of laparoscopic Heller–Dor surgery (LHD), with no consensus opinion as yet. Thus, we investigated if preoperative dilation influences the treatment outcomes of LHD for achalasia.MethodsThe subjects of this study were 526 patients with achalasia who underwent LHD as an initial treatment between August 1994 and February 2017. The patients were roughly classified by the status of preoperative balloon dilation and matched with propensity scores for age, sex, BMI, morphologic type, and maximum esophageal transverse diameter. Consequently, 94 subjects each were assigned to the balloon dilation (BD) group and to the non-balloon dilation (non-BD) group. We evaluated patient backgrounds, surgical outcomes, and incidence of postoperative reflux esophagitis.ResultsNo differences were found in surgical time, intraoperative blood loss, incidence of intraoperative mucosal injury, or postoperative hospital stay between the BD and non-BD groups. The mean patient satisfaction was significantly higher in the non-BD group (4.9) than in the BD group (4.7) and the incidence of postoperative esophagitis was significantly lower in the non-BD group (1.1%) than in the BD group (7.4%).ConclusionsPreoperative balloon dilation had no effect on intraoperative complications but did increase the incidence of postoperative reflux esophagitis in patients undergoing LHD for achalasia.

The outcomes of 400 laparoscopic Heller-Dor operations (LHD) for esophageal achalasia

METHODS: Mean age was 44.6 (9-83) years, 189 (47%) were women. These patients were divided into 4 groups: very early, early, mid, and late groups. The clinical pathway was introduced from August 2008 (62nd case). Six and 20 patients underwent RPS in both mid and late group, respectively. Their clinical data were collected in a prospectively fashion and retrospectively reviewed. Their characteristics, preoperative clinical conditions, and the therapeutic outcomes of LHD were assessed in terms of gender, age, length of symptoms, morphologic type, the maximum horizontal diameter of the esophagus (Grade I [<3.5 cm], Grade II [ 3.5 cm but <6.0 cm], and Grade III [ 6.0 cm]), operation time, blood loss, perioperative complications, time to start oral intake (TSOI), postoperative hospital stay (POHS), and the incidence of postoperative reflux esophagitis (PORE).