Laparoscopic heller myotomy versus peroral endoscopic myotomy for the treatment of achalasia.

PURPOSE OF REVIEW: To compare different therapeutic modalities and determine their role in the treatment of esophageal achalasia. RECENT FINDINGS: The last 3 decades have seen a significant improvement in the diagnosis and treatment of esophageal achalasia. Conventional manometry has been replaced by high-resolution manometry, which has determined a more precise classification of achalasia in three subtypes, with important treatment implications. Therapy, while still palliative, has evolved tremendously. While pneumatic dilatation was for a long time the main choice of treatment, this approach slowly changed at the beginning of the nineties when minimally invasive surgery was adopted, initially thoracoscopically and then laparoscopically with the addition of partial fundoplication. And in 2010, the first report of a new endoscopic technique - peroral endoscopic myotomy (POEM) - was published, revamping the interest in the endoscopic treatment of achalasia. SUMMARY: This review focuses particularly on the comparison of POEM and laparoscopic Heller myotomy (LHM) with partial fundoplication as primary treatment modality for esophageal achalasia. Based on the available data, we believe that LHM with partial fundoplication should be the primary treatment modality in most patients. POEM should be selected when surgical expertise is not available, for type III achalasia, for the treatment of recurrent symptoms, and for patients who had prior abdominal operations that would make LHM challenging and unsafe.

High-resolution 3-dimensional tomography may be a useful tool for understanding the anatomy of hiatal hernias and surgical planning of patients eligible for laparoscopic or robotic antireflux surgery.

BACKGROUND: 3D computed tomography (CT) has been seldom used for the evaluation of hiatal hernias (HH) in surgical patients. This study aims to describe the 3D CT findings in candidates for laparoscopic or robotic antireflux surgery or HH repair and compare them with other tests. METHODS: Thirty patients with HH and/or gastroesophageal reflux disease (GERD) who were candidates for surgical treatment and underwent high-resolution CT were recruited. The variables studied were distance from the esophagogastric junction (EGJ) to the hiatus; total gastric volume and herniated gastric volume, percentage of herniated volume in relation to the total gastric volume; diameters and area of the esophageal hiatus. RESULTS: HH was diagnosed with CT in 21 (70%) patients. There was no correlation between the distance EGJ-hiatus and the herniated gastric volume. There was a statistically significant correlation between the distance from the EGJ to the hiatus and the area of the esophageal hiatus of the diaphragm. There was correlation between tomographic and endoscopic findings for the presence and size of HH. HH was diagnosed with manometry in 9 (50%) patients. There was no correlation between tomographic and manometric findings for the diagnosis of HH and between hiatal area and lower esophageal sphincter basal pressure. There was no correlation between any parameter and DeMeester score. CONCLUSIONS: The anatomy of HH and the hiatus can be well defined by 3D CT. The EGJ-hiatus distance may be equally measured by 3D CT or upper digestive endoscopy. DeMeester score did not correlate with any anatomical parameter.

Modern insights into the pathophysiology and treatment of pseudoachalasia.

BACKGROUND: Secondary achalasia or pseudoachalasia is a clinical presentation undistinguishable from achalasia in terms of symptoms, manometric, and radiographic findings, but associated with different and identifiable underlying causes. METHODS: A literature review was conducted on the PubMed database restricting results to the English language. Key terms used were "achalasia-like" with 63 results, "secondary achalasia" with 69 results, and "pseudoachalasia" with 141 results. References of the retrieved papers were also manually reviewed. RESULTS: Etiology, diagnosis, and treatment were reviewed. CONCLUSIONS: Pseudoachalasia is a rare disease. Most available evidence regarding this condition is based on case reports or small retrospective series. There are different causes but all culminating in outflow obstruction. Clinical presentation and image and functional tests overlap with primary achalasia or are inaccurate, thus the identification of secondary achalasia can be delayed. Inadequate diagnosis leads to futile therapies and could worsen prognosis, especially in neoplastic disease. Routine screening is not justifiable; good clinical judgment still remains the best tool. Therapy should be aimed at etiology. Even though Heller's myotomy brings the best results in non-malignant cases, good clinical judgment still remains the best tool as well.

Esophageal high-resolution manometry demands visual interpretation in addition to mathematical software-based analysis.

PURPOSE: Esophageal high-resolution manometry (HRM) revolutionized esophageal function testing due to the intuitive colorful and agreeable-to-the-eyes plots (Clouse plots). HRM execution and interpretation is guided by the Chicago Classification. The well-established metrics for interpretation allows a reliable automatic software analysis. Analysis based on these mathematical parameters, however, ignores the valuable visual interpretation unique to human eyes and based on expertise. METHODS: We compiled some situations where visual interpretation added useful information for HRM interpretation. RESULTS: Visual interpretation may be useful in cases of hypomotility, premature waves, artifacts, segmental abnormalities of peristalsis, and extra-luminal non-contractile findings. CONCLUSION: These extra findings can be reported apart from the conventional parameters.

Laparoscopic Heller Myotomy with Dor Fundoplication: An Operation that has Withstood the Test of Time.

BACKGROUND: Achalasia is a primary esophageal motility disorder characterized by aperistalsis and defective relaxation of the lower esophageal sphincter in response to swallowing. Patients' symptoms include dysphagia, regurgitation, weight loss, chest pain and aspiration. The disease is idiopathic, and the goal of treatment is to eliminate the resistance determined by the abnormal lower esophageal sphincter, therefore allowing passage of the ingested food from the esophagus into the stomach. Three effective treatment modalities are available today-pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller myotomy with a partial fundoplication. METHODS: We described the technique to perform a laparoscopic Heller myotomy and a Dor fundoplication. RESULTS: Five steps to perform a laparoscopic Heller myotomy and a Dor fundoplication were described. CONCLUSIONS: The surgical approach is favored in many centers as it is very effective in relieving symptoms, while avoiding pathologic gastroesophageal reflux in most patients.

The Evolution of the Treatment of Esophageal Achalasia: From the Open to the Minimally Invasive Approach.

BACKGROUND: Achalasia is a primary esophageal motility disorder characterized by lack of esophageal peristalsis and partial or absent relaxation of the lower esophageal sphincter in response to swallowing. This study aimed to provide an overview of the evolution of the surgical treatment for esophageal achalasia, from the open to the minimally invasive approach. METHODS: Literature review. RESULTS: No curative treatment exists for this disorder. At the beginning of the 20th century, surgical esophagoplasties and cardioplasties were mostly done to treat achalasia. The description of the esophageal myotomy by Heller changed the treatment paradigm and rapidly became the treatment of choice. For many years the esophagomyotomy was done with either an open transthoracic or transabdominal approach. With the advancements of minimally invasive surgery, thoracoscopic and laparoscopic operations became available. The ability to add a fundoplication for the prevention of reflux made the laparoscopic Heller myotomy with partial fundoplication the operation of choice. CONCLUSIONS: Surgical management of esophageal achalasia has significantly evolved in the last century. Currently, minimally invasive Heller myotomy with partial fundoplication is the standard surgical treatment of achalasia.

Esophageal Achalasia: Evaluation and Treatment of Recurrent Symptoms.

BACKGROUND: Esophageal achalasia is a primary esophageal motility disorder of unknown origin. Treatment is palliative and its goal is to decrease the resistance posed by a non-relaxing and often hypertensive lower esophageal sphincter. This goal can be accomplished by different treatment modalities such as pneumatic dilatation, laparoscopic myotomy or peroral endoscopic myotomy. In some patients, however, symptoms tend to recur overtime. METHODS: A comprehensive literature search was performed on PubMed focused on the management of recurrent achalasia. RESULTS: The available treatment modalities can be used, alone or in combination. The goal of treatment is to resolve/improve symptoms, avoiding an esophagectomy, an operation linked to significant morbidity. CONCLUSIONS: The treatment of these patients is often very challenging, and the best results are obtained in centers where a multidisciplinary team-radiologists, gastroenterologists, and surgeons-is present.

Treatment of Achalasia and Epiphrenic Diverticulum.

BACKGROUND: Epiphrenic diverticulum (ED) is a pulsion pseudodiverticulum found in the distal 10 cm of the esophagus. Motility disorders are present in the majority of patients with ED explaining the pathophysiology of this rare disease. Achalasia is the most common underlying disorder. We present a review on the diagnosis and management of ED in the setting of achalasia. METHODS: Literature review. RESULTS: Symptoms are most related to the underlying motility disorder. The diagnostic workup should always include an upper digestive endoscopy and a barium esophagogram. Esophageal manometry identifies the motility disorder in most patients. Therapeutic options include laparoscopic, thoracoscopic and endoscopic procedures. While a myotomy must always be performed, diverticulectomy is not always necessary. CONCLUSIONS: Epiphrenic diverticulum is a rare condition whose pathophysiology involves an underlying motility disorder-achalasia in most cases. Symptoms usually include dysphagia, regurgitation, heartburn, and respiratory complaints and correlate with the motility disorder rather than the diverticulum per se. Upper digestive endoscopy and barium esophagogram are needed for the diagnosis-manometry may add useful information but is not imperative for the treatment. Laparoscopic Heller myotomy with a partial fundoplication is the procedure of choice, with satisfactory symptom relief and several advantages over the thoracic approach. Diverticulectomy may be performed in selected patients. Peroral endoscopic myotomy (POEM) are novel techniques, effective and minimally invasive that can be an option for patients unfit for surgery.

The prevalence of gastroesophageal reflux disease in named manometric patterns of dysmotility according to the Chicago Classification 4.0.

Esophageal motility disorders (EMD) may be considered primary disorders only in the absence of gastroesophageal reflux disease (GERD). If GERD is present, treatment should be directed toward correction of the abnormal reflux. The actual prevalence of GERD in manometric dysmotility patterns according to the new Chicago Classification 4.0 (CC4) is still elusive. This study aims to evaluate the prevalence of GERD in patients with esophageal motility disorders according to the CC4. We reviewed 400 consecutive patients that underwent esophageal manometry and pH monitoring. Esophageal motility was classified according to the CC4 and GERD + was defined by a DeMeester score > 14.7. Normal motility or unclassified dysmotility was present in 290 (73%) patients, with GERD+ in 184 of them (63%). There were a total of 110 patients (27%) with named esophageal motility disorders, with GERD+ in 67 (61%). The incidence of ineffective esophageal motility was 59% (n = 65) with 69% GERD +, diffuse esophageal spasm was 40% (n = 44) with 48% GERD +, and hypercontractile esophagus was 0.01% (n = 1) with 100% GERD +. There was no correlation between the presence of GERD and the number of non-peristaltic swallows. Our results show that: (i) manometry only is not enough to select patients' treatment as >60% of patients with named esophageal motility disorders have GERD; (ii) there was no correlation between the presence of GERD and the number of non-peristaltic swallows.

Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF). SUMMARY OF BACKGROUND DATA: Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair. METHODS: A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies. RESULTS: A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%). CONCLUSIONS: LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.

The upper esophageal sphincter in the high-resolution manometry era.

BACKGROUND: The evaluation of the upper esophageal sphincter (UES) has been neglected during routine manometric tests for decades, mostly due to the limitations of the conventional manometry which were eventually overcome by high-resolution manometry (HRM). METHODS: This study reviewed the current knowledge of the manometric evaluation of the UES in health and disease in the HRM era. RESULTS: We found that HRM allowed more precise measurements, in addition to the parameters as compared to conventional manometry, but most of them still need confirmation of the clinical significance. The parameters used to evaluate the UES were extension, basal pressure, residual pressure, relaxation duration, relaxation time to nadir, recovery time, intrabolus pressure, and deglutitive sphincter resistance. UES may be affected by different diseases: achalasia (UES is hypertonic with impaired relaxation), gastroesophageal reflux disease (UES is short and hypotonic), globus (UES ranges from normal to impaired relaxation to hypertonic), neurologic diseases (stroke and Parkinson - UES is hypotonic in early-stage to impaired relaxation in end-stage disease), and Zenker's diverticulum (UES has impaired relaxation). CONCLUSION: This review shows that UES dysfunction is part of several disease processes and that the study of the UES is possible and valuable with the aid of HRM.

Status of Simulation-Based Training in Departments of Surgery in the United States.

BACKGROUND: Surgical simulation is particularly attractive because it allows training in a safe, controlled, and standardized environment. However, the status of surgical simulation among Departments of Surgery (DoS) in the United States is unknown. The objective of this study was to characterize the status of simulation-based training in DoS in the United States. MATERIALS AND METHODS: A Qualtrics online survey was sent to 177 chairs of DoS in the United States in March 2018 regarding the utilization of surgical simulation in their department. Questions in the survey were focused on simulation capacities and activities as well as chairs' perception of the value and purpose of simulation. RESULTS: A total of 87 of 177 chairs responded to the survey (49% response rate). Most programs had either 20-50 trainees (42 of 87; 48%) or more than 50 trainees (37 of 87; 43%). Most chairs reported having a simulation center in their institution (85 of 87; 98%) or department (60 of 86; 70%) with a formal simulation curriculum for their trainees (83 of 87; 95%). Ninety percent (78 of 87) of DoS had protected time for simulation education for their residents, with most residents engaging in activities weekly or monthly (65 of 85; 76%). Although most chairs felt simulation improves patient safety (72 of 84; 86%) and is useful for practicing surgeons (68 of 84; 81%), only 40% reported that faculty use simulation to maintain technical skills and only 17% reported that faculty use simulation to address high complication rates. CONCLUSIONS: The vast majority of the DoS in the United States have established simulation activities for their trainees. However, engagement of faculty in simulation to maintain or improve their skills remains low.

Upper Esophageal Sphincter Motility and Thoracic Pressure are Determinants of Pressurized Waves in Achalasia Subtypes According to the Chicago Classification.

BACKGROUND: Phenotypes of achalasia are based on esophageal body pressurization during swallow. The reasons that lead to pressurized waves are still unclear. This study aims to evaluate manometric parameters that may determine pressurized waves in patients with achalasia. METHODS: A total of 100 achalasia high-resolution manometry tests were reviewed. We measured before each swallow: upper esophageal sphincter (UES) basal pressure, esophageal length, lower esophageal sphincter (LES) basal pressure, LES length, gastric and thoracic pressure, transdiaphragmatic pressure gradient and the LES retention pressure (LES basal pressure-TPG); during swallow: UES pressure, UES residual pressure, UES recovery time, LES relaxation pressure, gastric and thoracic pressure, transdiaphragmatic pressure gradient and after swallow: esophageal length, LES length, wave pressure, gastric and thoracic pressure and transdiaphragmatic gradient pressure. RESULTS: Univariate analysis showed in pressurized waves before swallow: higher thoracic, UES and LES basal pressure, longer LES length and decrease in LES retention pressure; during swallow: higher thoracic, gastric and UES pressure, higher UES and LES relaxation pressure and after swallow: higher thoracic and gastric pressure. Multivariate analysis in pressurized waves showed as significant before swallow: thoracic and UES basal pressure; during swallow: thoracic, gastric and UES pressure, UES residual pressure and UES recovery time and after swallow: thoracic pressure. CONCLUSIONS: Basal esophageal pressurization and the UES are independent variables that may be associated with pressurized waves.

University Hospital Financial Status Does Not Influence Subjective Perception of General Surgery Residents on Training Adequacy.

BACKGROUND: Surgical residency training is a complex and costly task. Hospital economic health is dependent on different variables, but it is especially linked to the country macroeconomics that may be extremely fluctuating, especially in underdeveloped countries. This study analyzed the correlation between a single-center university hospital financial status and subjective perception of general surgery residents on program support and adequacy. METHODS: We surveyed former residents that started general surgery residency program in a tertiary university hospital between 1999 and 2017. Individuals answered a questionnaire about the perception of the influence of the hospital´s financial status on training. Hospital´s financial status was estimated yearly by the current liquidity ratio (CLR) that measures whether or not a company has enough resources to meet its short-term obligations. RESULTS: Two hundred and fifty-seven (96%) were still in surgical practice; 242 (93%) were satisfied with their residency training; 210 (78%) believed training was affected by financial status; 183 (68%) believed they were prepared for independent practice; 180 (67%) practiced in an academic environment; 146 (54%) felt the need to complete specialty training beyond residency; and 56 (21%) believed hospital financial status was adequate. The rate of positive or negative answers did not correlate with the current liquidity ratio, except for the need to complete specialty training that was indirectly related to CLR. CONCLUSIONS: University hospital financial status did not influence subjective perception of general surgery residents on training, program support and adequacy.

Disparities in esophageal cancer: less treatment, less surgical resection, and poorer survival in disadvantaged patients.

The incidence of esophageal cancer has increased steadily in the last decades in the United States. The aim of this paper was to characterize disparities in esophageal cancer treatment in different racial and socioeconomic population groups and compare long-term survival among different treatment modalities. A retrospective analysis of the National Cancer Database was performed including adult patients (≥18 years old) with a diagnosis of resectable (stages I-III) esophageal cancer between 2004 and 2015. Multivariable logistic regression models were used to determine the odds of being offered no treatment at all and surgical treatment across race, primary insurance, travel distance, income, and education levels. Multivariable Cox proportional hazards models were used to compare 5-year survival rates across different treatment modalities. A total of 60,621 esophageal cancer patients were included. Black patients, uninsured patients, and patients living in areas with lower levels of education were more likely to be offered no treatment. Similarly, black race, female patients, nonprivately insured patients, and those living in areas with lower median residential income and lower education levels were associated with lower rates of surgery. Patients receiving surgical treatment, compared to both no treatment and definitive chemoradiation, had significant better long-term survival in stage I, II, and III esophageal cancer. In conclusion, underserved patients with esophageal cancer appear to have limited access to surgical care, and are, in fact, more likely to not be offered any treatment at all. Considering the survival benefits associated with surgical resection, greater public health efforts to reduce disparities in esophageal cancer are needed.

Minor psychiatric disorders and objective diagnosis of gastroesophageal reflux disease.

BACKGROUND: Symptoms may be unreliable to diagnose gastroesophageal reflux disease (GERD) in patients with minor psychiatric disorders (MPD). This study aims to evaluate the influence of MPD in the diagnosis of GERD. METHODS: We prospectively studied 245 patients (based on a sample size calculation) with suspected GERD. All patients underwent manometry and pH monitoring and MPD evaluation based on the Hospital Anxiety and Depression Scale (HADS). RESULTS: Based on the results of the pH monitoring, patients were classified as GERD + (n = 136, 55% of the total, mean age 46 years, 47% females) or GERD - (n = 109, 45% of the total, mean age 43 years, 60% females). The mean HADS score for GERD + and GERD - for anxiety was 7.8 and 8.5, respectively (p = 0.8) and for depression was 5.4 and 6.1, respectively (p = 0.1). DeMeester score (DS) did not correlate with total HADS score (p = 0.08) or depression domain (p = 0.9) but there was a negative correlation between DS and anxiety level (p < 0.001). A significant threshold accuracy value for HADS to diagnose GERD was not found on receiver operating characteristics curve analysis. CONCLUSION: Almost half of the patients evaluated for GERD did not have the disease on objective evaluation. GERD + and GERD - patients had similar levels of MPD. However, the amount of reflux correlated negatively with the severity of anxiety. Symptoms and HADS cannot accurately diagnose or exclude GERD. pH monitoring should be more liberally used especially in patients with high levels of anxiety.

Cognitive Assessment of Surgeons During Surgical Procedures: Influence of Time and Intraoperative Complications.

INTRODUCTION: Surgeon's performance may be influenced by several factors that may affect skills and judgement, which ultimately represents surgeon´s cognition. Cognition refers to all forms of knowing and awareness, such as perceiving, conceiving, remembering, reasoning, judging, imagining, and problem solving. This report aims to evaluate the effect of operative time and operative complications on surgeon´s cognition. METHODS: Forty-six surgeons (mean age 31 years, 78% males) assigned to an operation expected to last for at least 2 h, volunteered for the study. All participants underwent 3 cognitive tests at the beginning of the operation and hourly, until the end of the procedure: (a) concentration (serial sevens, counting down from 100 by sevens); (b) visual (fast counting, counting the number of circles with the same color among a series of circles); and (c) motor (trail making, connecting a set of numbered dots). Intraoperative complications were recorded. RESULTS: The visual test had a stable behavior along time. Concentration and motor tests tend to be performed faster. Intraoperative complications occurred in 5 (11%) cases (3 hemorrhage and 2 organ injuries). Performance time was stable for concentration and motor tests but visual test tends to be performed faster in cases with an intraoperative complication. CONCLUSION: Our results showed that (1) time does not jeopardize surgeons' cognition, but rather surgeons learned to perform the tests faster, and (2) complications do not decrease surgeons' cognition.

Racial and Socioeconomic Disparities in the Surgical Management and Outcomes of Patients with Colorectal Carcinoma.

INTRODUCTION: Colorectal cancer (CRC) is the second leading cause of cancer mortality in the USA. We aimed to determine racial and socioeconomic disparities in the surgical management and outcomes of patients with CRC in a contemporary, national cohort. METHODS: We performed a retrospective analysis of the National Inpatient Sample for the period 2009-2015. Adult patients diagnosed with CRC and who underwent colorectal resection were included. Multivariable linear and logistic regressions were used to assess the effect of race, insurance type, and household income on patient outcomes. RESULTS: A total of 100,515 patients were included: 72,552 (72%) had elective admissions and 27,963 (28%) underwent laparoscopic surgery. Patients with private insurance and higher household income were consistently more likely to have laparoscopic procedures, compared to other insurance types and income levels, p < 0.0001. Black patients, compared to white patients, were more likely to have postoperative complications (OR 1.23, 95% CI, 1.17, 1.29). Patients with Medicare and Medicaid, compared to private insurance, were also more likely to have postoperative complications (OR 1.30, 95% CI, 1.24, 1.37 and OR 1.40, 95% CI, 1.31, 1.50). Patients in low-household-income areas had higher rates of any complication (OR 1.11, 95% CI 1.06, 1.16). CONCLUSIONS: The use of laparoscopic surgery in patients with CRC is strongly influenced by insurance type and household income, with Medicare, Medicaid and low-income patients being less likely to undergo laparoscopic surgery. In addition, black patients, patients with public insurance, and patients with low household income have significant worse surgical outcomes.

Anatomical analysis of gastric lymph nodes in cancer-free individuals.

Lymphadenectomy is a crucial part of the surgical therapy for gastric cancer. The number of normal lymph nodes could indicate the number of nodes that need to be retrieved during the procedure. The aim of this study is to analyze the number of lymph nodes in cadavers without gastric cancer according to the Japanese Gastric Cancer Association guidelines. Twenty fresh adult cadavers (14 males, mean age 55, range 24-93 years) were used. Abdominal lymph nodes were dissected and classified according to the Japanese Gastric Cancer Association. For total gastrectomy, the median number of lymph nodes that comprised D1 + dissection was 27 (range 15-42). The median and mean number of lymph nodes that comprised D2 dissection was 33, ranging from 18 to 50. For distal gastrectomy, the D1 + level comprised a median of 21 lymph nodes (range 11-38), and the D2 level 22 lymph nodes (range 11-39). In conclusion, considering gastrectomy + D2 lymphadenectomy as the standard treatment for gastric cancer, our results show that adequate lymphadenectomy must encompass around 30 lymph nodes. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc.

Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis.

OBJECTIVE: To compare the outcome of per oral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia. BACKGROUND: Over the last 2 decades, LHM has become the primary form of treatment in many centers. However, since the first description of POEM in 2010, this technique has widely disseminated, despite the absence of long-term results and randomized trials. METHODS: A systematic Medline literature search of articles on LHM and POEM for the treatment of achalasia was performed. The main outcomes measured were improvement of dysphagia and posttreatment gastroesophageal reflux disease (GERD). Linear regression was used to model the effect of each procedure on the different outcomes. RESULTS: Fifty-three studies reported data on LHM (5834 patients), and 21 articles examined POEM (1958 patients). Mean follow-up was significantly longer for studies of LHM (41.5 vs. 16.2 mo, P < 0.0001). Predicted probabilities for improvement in dysphagia at 12 months were 93.5% for POEM and 91.0% for LHM (P = 0.01), and at 24 months were 92.7% for POEM and 90.0% for LHM (P = 0.01). Patients undergoing POEM were more likely to develop GERD symptoms (OR 1.69, 95% CI 1.33-2.14, P < 0.0001), GERD evidenced by erosive esophagitis (OR 9.31, 95% CI 4.71-18.85, P < 0.0001), and GERD evidenced by pH monitoring (OR 4.30, 95% CI 2.96-6.27, P < 0.0001). On average, length of hospital stay was 1.03 days longer after POEM (P = 0.04). CONCLUSIONS: Short-term results show that POEM is more effective than LHM in relieving dysphagia, but it is associated with a very high incidence of pathologic reflux.