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1.
JSLS ; 26(3)2022.
Artigo em Inglês | MEDLINE | ID: mdl-35967962

RESUMO

Objective: Laparoscopic Heller myotomy and Dor fundoplication has become the gold standard in treating esophageal achalasia and robotic surgical platform represents its natural evolution. The objective of our study was to assess durable long-term clinical outcomes in our cohort. Methods and Procedures: Between June 1, 1999 and June 30, 2019, 111 patients underwent minimally invasive treatment for achalasia (96 laparoscopically and 15 robotically). Fifty-two were males. Mean age was 49 years (20 - 96). Esophageal manometry confirmed the diagnosis. Fifty patients underwent pH monitoring study, with pathologic reflux in 18. Preoperative esophageal dilation was performed in 76 patients and 21 patients received botulin injection. Dysphagia was universally present, and mean duration was 96 months (5 - 480). Results: Median operative time was 144 minutes (90 - 200). One patient required conversion to open approach. Four mucosal perforations occurred in the laparoscopic group and were repaired intraoperatively. Seven patients underwent completion esophageal myotomy and added Dor fundoplication. Upper gastrointestinal series was performed before discharge. Median hospital stay was 39 hours (24 - 312). Median follow up was 157 months (6 - 240), and dysphagia was resolved in 94% of patients. Seven patients required postoperative esophageal dilation. Conclusions: Minimally invasive Heller myotomy and Dor fundoplication are feasible. The operation is challenging, but excellent results hinge on the operative techniques and experience. The high dexterity, three-dimensional view, and the ergonomic movements of robotic surgery allow application of all the technical elements, achieving the best durable outcome for the patient. Robotic surgery is the natural evolution of minimally invasive treatment of esophageal achalasia.


Assuntos
Transtornos de Deglutição , Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Transtornos de Deglutição/cirurgia , Acalasia Esofágica/cirurgia , Feminino , Fundoplicatura/métodos , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade
2.
Cir. Esp. (Ed. impr.) ; 100(7): 410-415, jul. 2022. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-207730

RESUMO

Objetivo Describir la experiencia del abordaje robótico en la cirugía de la acalasia en un centro de tercer nivel. Material y métodos Se analizaron los pacientes con acalasia intervenidos mediante cirugía robótica entre mayo de 2010 y abril de 2019. Las variables a estudio se recogieron en una base de datos prospectiva y se realizó un análisis descriptivo. Resultados Se incluyeron 45 pacientes (55,6% varones) con edad media de 44 años. El síntoma principal al diagnóstico fue la disfagia. Diecinueve pacientes (42,2%) habían recibido tratamiento endoscópico previo a la cirugía, mayoritariamente dilatación neumática (84,2%). La técnica quirúrgica empleada fue la miotomía de Heller asociada a funduplicatura tipo Toupet, con un tiempo operatorio medio de 211 minutos. La estancia media fue 5 días. Se produjeron 2 perforaciones postoperatorias (4,4%). La mortalidad peroperatoria fue del 0%. El seguimiento medio fue de 64 meses. A 3 y 5 años se evidenció una importante disminución del Eckardt score y el estudio manométrico mostró una disminución de la presión del esfínter esofágico inferior en reposo media del 58% y del 70%, respectivamente, con persistencia de hipomotilidad del cuerpo esofágico. En dos pacientes (5,4%) se diagnosticó reflujo gastroesofágico patológico y 4 (10,8%) presentaron recurrencia de los síntomas, requiriendo dilataciones neumáticas endoscópicas. En 2 casos las dilataciones no fueron efectivas por lo que se planteó la realización de una miotomía endoscópica. Conclusiones Según nuestra experiencia, la cirugía robótica constituye un procedimiento seguro y efectivo para el tratamiento de la acalasia (AU)


Objective To describe the experience of the robotic approach for achalasia surgery in a tertiary center. Material and methods Patients with achalasia who underwent robotic surgery between May 2010 and April 2019 were analyzed. The study variables were collected in a prospective database and a descriptive analysis was performed. Results 45 patients (55.6% male) with a mean age of 44 years were included. The main symptom at diagnosis was dysphagia. 19 patients (42.2%) received endoscopic treatment prior to surgery, mostly pneumatic dilation (84.2%). Heller's myotomy associated with Toupet fundoplication was the surgical technique of choice, with a mean operative time of 211minutes. The average stay was 5 days. There were 2 postoperative perforations (4.4%). Perioperative mortality was 0%. The mean follow-up was 64 months. At 3 and 5 years, a significant decrease in the Eckardt score was observed and the manometric study showed a decrease in the lower esophageal sphincter pressure at rest of 58% and 70%, respectively, with persistence of hypomotility of the esophageal body. Pathological gastroesophageal reflux was diagnosed in two patients (5.4%) and 4 (10.8%) presented recurrence of symptoms, requiring endoscopic pneumatic dilations. In 2 cases, the dilations were not effective, so an endoscopic myotomy was considered. Conclusions In our experience, robotic surgery is a safe and effective procedure for the treatment of achalasia (AU)


Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Acalasia Esofágica/cirurgia , Fundoplicatura/métodos , Miotomia de Heller/métodos , Procedimentos Cirúrgicos Robóticos , Resultado do Tratamento , Seguimentos
3.
J Pediatr Gastroenterol Nutr ; 75(3): 231-236, 2022 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-35653433

RESUMO

Esophageal achalasia is a relatively rare disease in children that has been treated with balloon dilatation, botulinum toxin injection, and Heller myotomy. Peroral endoscopic myotomy (POEM) is another treatment that has been successfully employed to treat adults with achalasia for over a decade and has been increasingly used in children. This State of the Art Review from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Endoscopy Committee reviews the current literature in pediatric POEM including the technique, success rate, complications as well as training guidelines. Though there is limited data, POEM in children has shown encouraging success rates and with further study may become the mainstay of pediatric achalasia treatment.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Adulto , Cateterismo , Criança , Endoscopia Gastrointestinal , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior/cirurgia , Miotomia de Heller/métodos , Humanos , Resultado do Tratamento
4.
Medicine (Baltimore) ; 101(24): e29441, 2022 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-35713453

RESUMO

BACKGROUND: : Current guidelines recommend per-oral endoscopic myotomy (POEM) and laparoscopic Heller's myotomy (LHM) as first-line treatment of idiopathic achalasia, but the optimum choice between different endoscopic and surgical modalities remains inconclusive. We conducted a network meta-analysis to compare the efficacy of 8 treatments for idiopathic achalasia. MATERIALS AND METHODS: : Three major bibliographic databases were reviewed for enrollment of randomized controlled trials between January 2000 and June 2021. We included adults with idiopathic achalasia and compared two or more of eight interventions including botulinum toxin injection (BTI), pneumatic dilation (PD), BTI + PD, LHM without fundoplication, LHM followed with Dor or Toupet fundoplication, and POEM using either the anterior or posterior approach. Our focus was on clinical success rate, postsurgical acid reflux, and moderate-to-severe adverse events. RESULTS: : Twenty-four studies involved a total of 1987 participants for analysis. When compared with PD, POEM with anterior approach, POEM with posterior approach, LHM + Toupet, and LHM + Dor were all significantly superior to the other regimens in short-term efficacy, with POEM with anterior approach and LHM + Dor showing better improvement in mid-term efficacy. BTI showed a significantly lower efficacy than PD in both periods. Regarding safety, only LHM without fundoplication was significantly associated with higher acid reflux than PD, while LHM + Toupet, LHM without fundoplication, and LHM + Dor showed a non-significant increase in moderate-to-severe adverse events. CONCLUSIONS: : For idiopathic achalasia, we suggest that POEM with an anterior or posterior approach and LHM with Dor or Toupet fundoplication be initially recommended. On the contrary, both LHM without fundoplication and BTI are not recommended as definitive therapy.


Assuntos
Acalasia Esofágica , Adulto , Toxinas Botulínicas/administração & dosagem , Dilatação/efeitos adversos , Acalasia Esofágica/terapia , Fundoplicatura/efeitos adversos , Refluxo Gastroesofágico/epidemiologia , Miotomia de Heller/efeitos adversos , Miotomia de Heller/métodos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Metanálise em Rede , Resultado do Tratamento
5.
Cir Esp (Engl Ed) ; 100(7): 410-415, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35550447

RESUMO

OBJECTIVE: To describe the experience of the robotic approach for achalasia surgery in a tertiary center. MATERIAL AND METHODS: Patients with achalasia who underwent robotic surgery between May 2010 and April 2019 were analyzed. The study variables were collected in a prospective database and a descriptive analysis was performed. RESULTS: 45 patients (55.6% male) with a mean age of 44 years were included. The main symptom at diagnosis was dysphagia. 19 patients (42.2%) received endoscopic treatment prior to surgery, mostly pneumatic dilation (84.2%). Heller's myotomy associated with Toupet fundoplication was the surgical technique of choice, with a mean operative time of 211 min. The average stay was 5 days. There were 2 postoperative perforations (4.4%). Perioperative mortality was 0%. The mean follow-up was 64 months. At 3 and 5 years, a significant decrease in the Eckardt score was observed and the manometric study showed a decrease in the lower esophageal sphincter pressure at rest of 58% and 70%, respectively, with persistence of hypomotility of the esophageal body. Pathological gastroesophageal reflux was diagnosed in two patients (5.4%) and 4 (10.8%) presented recurrence of symptoms, requiring endoscopic pneumatic dilations. In 2 cases, the dilations were not effective, so an endoscopic myotomy was considered. CONCLUSIONS: In our experience, robotic surgery is a safe and effective procedure for the treatment of achalasia.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Miotomia , Procedimentos Cirúrgicos Robóticos , Adulto , Acalasia Esofágica/cirurgia , Feminino , Fundoplicatura/métodos , Miotomia de Heller/métodos , Humanos , Masculino
6.
Langenbecks Arch Surg ; 407(4): 1721-1726, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35583834

RESUMO

BACKGROUND: Despite the high success rate associated with Heller myotomy in the treatment of primary achalasia, symptom persistence or relapse occurs in approximately 10-20% of patients. Unfortunately, the ideal treatment after failed myotomy is not well established yet. We present a didactical video with a stepwise technique to perform a robotic revisional procedure after failed Heller myotomy. METHODS: In this report, each surgical step is thoroughly described and visually represented with useful technical tips that might help in improving surgical results of revisional Heller myotomy. RESULTS: In patients with previous surgical myotomy, the robotic platform with its high-definition magnified view and EndoWrist instruments allow for a safe and precise redo surgical myotomy. CONCLUSIONS: Despite its improved surgical capabilities, the role of robotic redo Heller myotomy in the treatment algorithm of patients with recurrent symptoms after failed surgical myotomy should be further explored.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Robótica , Acalasia Esofágica/cirurgia , Fundoplicatura/métodos , Miotomia de Heller/métodos , Humanos , Laparoscopia/métodos , Recidiva , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do Tratamento
7.
World J Surg ; 46(7): 1531-1534, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35523962

RESUMO

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.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior/cirurgia , Fundoplicatura/métodos , Miotomia de Heller/métodos , Humanos , Laparoscopia/métodos , Resultado do Tratamento
8.
World J Surg ; 46(7): 1527-1530, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35597821

RESUMO

INTRODUCTION: Achalasia is an esophageal motility disorder characterized by disordered esophageal peristalsis with failed relaxation of the lower esophageal sphincter resulting in a functional obstruction.Treatment can include medical, endoscopic, or surgical interventions. Although none of these are curative, they each offer methods to create esophageal outflow. MATERIALS AND METHODS: This article discusses our preferred surgical technique used for laparoscopic Heller myotomy with Dor fundoplication. This technique has been developed over the author's career. CONCLUSION: The technique discussed provides a safe and effective strategy to manage achalasia.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior/cirurgia , Fundoplicatura/métodos , Miotomia de Heller/métodos , Humanos , Laparoscopia/métodos , Resultado do Tratamento
9.
JAMA Surg ; 157(6): 490-497, 2022 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-35442413

RESUMO

Importance: Several professional practice guidelines recommend per-oral endoscopic myotomy (POEM) as a potential first-line therapy for the management of achalasia, yet payers remain hesitant to reimburse for the procedure owing to unanswered questions regarding safety. Objective: To evaluate the use, safety, health care utilization, and costs associated with the use of POEM for treatment of achalasia relative to laparoscopic Heller myotomy (LHM) and pneumatic dilation (PD). Design, Setting, and Participants: This was a retrospective national cohort study of commercially insured patients, aged 18 to 63 years, who underwent index intervention for achalasia with either LHM, PD, or POEM in the US between July 1, 2010, and December 31, 2017. Patient data were obtained from a national commercial claims database. Included in the study were patients with at least 12 months of enrollment after index treatment and a minimum of 6 months of continuous enrollment before their index procedure. Patients 64 years or older were excluded to avoid underestimation of health care claims from enrollment in Medicare supplemental insurance. Data were analyzed from July 1, 2019, to July 1, 2021. Main Outcomes and Measures: Changes in the proportion of annual procedures performed for achalasia were evaluated over time. The frequency of severe procedure-related adverse events, including perforation, pneumothorax, bleeding, and death, were compared. Negative binomial regression was used to compare the incidence rates of subsequent diagnostic testing, reintervention, and unplanned hospitalization. Generalized linear models were used to compare differences in 1-year health-related expenditures across procedures. Results: This cohort study included a total of 1921 patients (median [IQR] age: LHM group, 48 [37-56] years; 737 men [51%]; PD group, 51 [41-58] years; 168 men [52%]; POEM group, 50 [40-57] years; 80 men [56%]). The use of POEM increased 19-fold over the study period, from 1.1% (95% CI, 0.2%-3.2%) of procedures in 2010 to 18.9% in 2017 (95% CI, 13.6%-25.3%; P = .01). Adverse events were rare and did not differ between procedures. Compared with LHM, POEM was associated with more subsequent diagnostic testing (incidence rate ratio [IRR], 2.2; 95% CI, 1.9-2.6) and reinterventions (IRR, 1.9; 95% CI, 1.1-3.3). When compared with PD, POEM was associated with more subsequent diagnostic testing (IRR, 1.5; 95% CI, 1.3-1.8) but fewer reinterventions (IRR, 0.4; 95% CI, 0.2-0.6). The total 1-year health care costs were similar between POEM and LHM, but significantly lower for PD (mean cost difference, $7674; 95% CI, $657-$14 692). Conclusions and Relevance: Results of this cohort study suggest that POEM was associated with higher health care utilization compared with LHM and lower subsequent health care utilization but higher costs compared with PD. The use of POEM is increasing rapidly; payers should recognize the totality of evidence and current treatment guidelines as they consider reimbursement for POEM. Patients should be informed of the trade-offs between approaches when considering treatment.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Cirurgia Endoscópica por Orifício Natural , Adulto , Idoso , Estudos de Coortes , Acalasia Esofágica/cirurgia , Miotomia de Heller/efeitos adversos , Humanos , Laparoscopia/métodos , Masculino , Medicare , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos
10.
Surg Laparosc Endosc Percutan Tech ; 32(3): 319-323, 2022 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-35297806

RESUMO

BACKGROUND: The use of robotics in foregut surgery has become more prevalent in the United States over the last 10 years. We sought to find the differences in the clinical outcomes of robotic surgery compared with traditional laparoscopy in patients undergoing Heller myotomy. MATERIALS AND METHODS: A retrospective population-based analysis was performed using the National Inpatient Sample (NIS) database for the span of 2010 to 2015. All patients who underwent laparoscopic or robotic Heller myotomy were included. Weighted multivariable random intercept linear and logistic regression models were used to assess the impact of robotic surgery on patient outcomes compared with laparoscopy. RESULTS: There was a total of 11,562 patients with a median age of 54.2 years. Robotic Heller myotomy has a significantly decreased risk of overall complications for all centers (odds ratio=0.46; 95% confidence interval=0.29, 0.74). A subset analysis was performed looking specifically at high-volume centers (>20 operations per year), and overall complications remained lower in the robotic group. However, in high-volume centers, the robotic cohort did have a higher rate of esophageal perforation (2.7% vs. 0.8%, P<0.001). There was a higher length of stay in the laparoscopic Heller cohort (3.0 vs. 2.6 d, P=0.06) but higher overall charges in the robotic Heller cohort ($42,900 vs. $34,300, P=0.03). CONCLUSIONS: Robotic Heller myotomy is associated with lower overall complications and improved outcomes compared with laparoscopic Heller myotomy, even in high-volume centers. Robotic Heller myotomy is associated with a higher rate of esophageal perforations in high-volume centers despite the reduction in overall complications.


Assuntos
Acalasia Esofágica , Perfuração Esofágica , Miotomia de Heller , Laparoscopia , Acalasia Esofágica/cirurgia , Perfuração Esofágica/cirurgia , Fundoplicatura , Miotomia de Heller/efeitos adversos , Humanos , Laparoscopia/efeitos adversos , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
11.
J Pediatr Surg ; 57(6): 1132-1136, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35292166

RESUMO

BACKGROUND: Enhanced recovery protocols (ERPs) are effective means of standardizing and improving the quality of surgical care in adults. Our purpose was to retrospectively compare outcomes before and after implementation of ERPs in children undergoing laparoscopic Heller myotomy for achalasia. METHODS: A pediatric-specific ERP was used for children undergoing laparoscopic Heller myotomy starting July 2017 at two pediatric surgery centers within a single metropolitan healthcare system. A retrospective review of 8 patients undergoing Heller myotomies between July 2014 and July 2017 was performed as a control. This cohort was compared to 14 patients managed post-ERP implementation (2017-2020). Outcomes of interest investigated included opioid use during admission, narcotics at discharge, time to regular diet, length of stay (LOS), and readmissions. RESULTS: There was a significant decrease in opioid use both while in the hospital and at time of discharge. Mean morphine equivalent use was 4.50 mg in the pre-ERP cohort and 1.97 mg in the post-ERP cohort. Furthermore, 8 out of 14 (57%) patients in the post-ERP cohort received no opioids during the admission compared with only 2 out of 8 (25%) patients in the pre-ERP cohort. Only 1 out of 14 (7.14%) patients in the post-ERP cohort was discharged with a prescription for opioid medication while 6 out of 8 (75%) in the pre-ERP cohort were discharged with an opiate prescription. CONCLUSIONS: The use of ERP in children undergoing laparoscopic Heller myotomy surgery is safe and effective and leads to a reduction in opioid use during admission and at discharge. LEVELS OF EVIDENCE: Level III.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Adulto , Analgésicos Opioides/uso terapêutico , Criança , Acalasia Esofágica/cirurgia , Fundoplicatura/métodos , Humanos , Laparoscopia/métodos , Estudos Retrospectivos , Resultado do Tratamento
12.
Gastrointest Endosc ; 96(2): 189-196, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35278427

RESUMO

Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and failed peristalsis. Common clinical manifestations include dysphagia to solid and liquid foods, chest pain, regurgitation, and weight loss, resulting in significant morbidity and healthcare burden. Historically, surgical Heller myotomy and pneumatic dilation were the first-line therapeutic options for achalasia. This convention was shaken in 2009 when Inoue and colleagues introduced an endoscopic approach to dissect the muscle fibers of the LES, known as peroral endoscopic myotomy (POEM). Since incorporation of POEM into standard practice, the overall myotomy technique has remained unchanged; however, adaptations in the thickness and length of myotomy have evolved. Full-thickness myotomy is recognized to have similar clinical success and faster procedure times compared with selective circular muscle myotomy. Although myotomy length for type 1 and type 2 achalasia has classically been >6 cm, recent studies demonstrated similar outcomes with reduction of myotomy length to <3 cm. Length of myotomy for type 3 achalasia has been tailored to treat the entire length of spastic muscle segment, and the modality to gauge the optimal thickness and length of myotomy in this group has yet to be established. In addition to changes in POEM technique, the postoperative management of POEM has also changed, favoring reduced postprocedure imaging, antibiotic use, and hospitalizations.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Miotomia , Cirurgia Endoscópica por Orifício Natural , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior/cirurgia , Miotomia de Heller/métodos , Humanos , Cirurgia Endoscópica por Orifício Natural/métodos , Resultado do Tratamento
14.
Surg Endosc ; 36(10): 7679-7683, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-35157122

RESUMO

INTRODUCTION: With the advancement of minimally invasive surgical techniques surgeons have moved away from elective open foregut surgeries. Despite studies demonstrating the safety of same day discharge in appropriate patient populations, ambulatory surgery has yet to be established as the practice norm for patients undergoing uncomplicated laparoscopic foregut surgery. METHODS: The ACS-NSQIP database was queried from 2005 to 2018 for patients who had undergone elective and non-emergent laparoscopic Heller myotomy, fundoplication, and paraesophageal hernia repairs with and without mesh. The primary endpoints in this study included number and severity of complications as classified by the Clavien-Dindo Classification, readmission, and return to the operating room. RESULTS: 6893 patients who met inclusion criteria were identified, 696 (10.1%) of which were discharged on the day of surgery. Patients who were discharged on post-operative day one were matched at a 3:1 ratio producing 2088 comparisons. There was no difference in overall morbidity (p = 0.264), readmission (OR 0.849, 95% CI 0.522-1.419), or return to the operating room (OR 1.15, 95% CI 0.531-2.761) between the two groups. CONCLUSION: Same day discharge for patients without life threatening comorbidities undergoing elective minimally invasive Heller myotomy, Nissen and Toupet fundoplication, and paraesophageal hernia repairs is safe and feasible.


Assuntos
Miotomia de Heller , Hérnia Hiatal , Laparoscopia , Fundoplicatura/métodos , Hérnia Hiatal/etiologia , Hérnia Hiatal/cirurgia , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Alta do Paciente , Estudos Retrospectivos , Resultado do Tratamento
15.
World J Surg ; 46(7): 1547-1553, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35142875

RESUMO

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.


Assuntos
Divertículo Esofágico , Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Bário , Divertículo Esofágico/diagnóstico , Divertículo Esofágico/diagnóstico por imagem , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/cirurgia , Fundoplicatura/métodos , Humanos , Resultado do Tratamento
16.
World J Surg ; 46(7): 1522-1526, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35169899

RESUMO

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.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior/cirurgia , Fundoplicatura , Humanos , Resultado do Tratamento
17.
World J Surg ; 46(7): 1535-1541, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35220453

RESUMO

Esophageal achalasia is a primary motility disorder of unknown origin. The goal of treatment is to eliminate the resistance caused by a non-relaxing lower esophageal sphincter, therefore allowing passage of food and liquid from the esophagus into the stomach. A myotomy with a partial fundoplication (anterior Dor or posterior Toupet) is considered the standard of care for patients with achalasia. In the following review, we describe the indications and technique for a posterior partial fundoplication (Toupet).


Assuntos
Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior , Fundoplicatura/métodos , Miotomia de Heller/métodos , Humanos , Laparoscopia/métodos , Resultado do Tratamento
18.
Surg Laparosc Endosc Percutan Tech ; 32(3): 299-304, 2022 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-35034067

RESUMO

BACKGROUND: Symptomatic evaluation using Eckardt score and achalasia-specific health-related quality-of-life and physiological evaluation using timed barium examination (TBE) and high-resolution manometry is integral to the diagnosis of achalasia. However, the correlation of physiological outcomes with symptomatic outcomes and their role in routine follow-up after laparoscopic Heller cardiomyotomy (LHCM) is controversial. In this study, we evaluated the role of physiological testing in achalasia patients undergoing LHCM and its correlation with symptomatic evaluation. MATERIALS AND METHODS: Case records of patients undergoing LHCM for achalasia between January 2017 and March 2020 were reviewed for symptom scores (Eckardt score and achalasia-specific health-related quality-of-life) and physiological parameters [5-min column height on TBE and median integrated relaxation pressure (IRP) on high-resolution manometry]. Sixty-one patients with complete data in the preoperative period and on follow-up were included in the study. The data was analyzed for symptomatic and physiological outcomes and their correlation using paired t test and the Spearman correlation test. RESULTS: At a median follow-up of 16 months following LHCM, there was a significant improvement in Eckardt score (7.03±1.53 to 0.93±1.10, P<0.001), achalasia-specific health-related quality-of-life (58.34±7.81 to 14.57±13.45, P<0.001), column height on TBE (115.14±46.9 to 27.89±34.31, P<0.001) and IRP (23.95±8.26 to 4.61±4.11, P<0.001). Eckardt score correlated significantly with achalasia-specific health-related quality-of-life scores preoperatively (ρ=0.410, P<0.001) and on follow-up (ρ=0.559, P<0.001). There was no correlation between symptomatic parameters and physiological parameters. CONCLUSIONS: In patients of achalasia, LHCM leads to significant improvement in symptomatic and physiological parameters. Symptom scores correlate among themselves but not with physiological scores. Thus, physiological testing may not be needed for routine follow-up.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Cárdia/cirurgia , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/cirurgia , Humanos , Manometria , Resultado do Tratamento
19.
J Surg Res ; 273: 9-14, 2022 05.
Artigo em Inglês | MEDLINE | ID: mdl-35007858

RESUMO

INTRODUCTION: Achalasia is a rare esophageal motility disorder in children and is most often treated with the Heller myotomy. This study examines the current trends in surgical management of achalasia and evaluates the safety of the Heller myotomy in children compared to the young adult population. METHODS: This is a retrospective cohort study of children and young adults aged ≤25 y undergoing a Heller myotomy for achalasia. Data were collected using the adult and pediatric National Surgical Quality Improvement Program databases from 2012 to 2018. Patient characteristics, comorbidities, and 30-d outcomes were evaluated. Operative details of interest included surgical specialty and the use of esophagogastroduodenoscopy and esophageal manometry. Outcomes included operative time, length of stay, reoperation, and other postoperative complications. RESULTS: A total of 178 pediatric and 202 young adult patients were included in the study. The majority of surgeries were performed laparoscopically (85.4% pediatric and 95.0% adult). Esophageal manometry was only used in pediatric cases, and esophagogastroduodenoscopy was used in 35 (19.7%) pediatric and 41 (20.3%) adult cases. Thirty-day complications occurred in 7 (3.9%) children and 3 (1.5%) adults. The median operative time for children was 174.5 min and the median length of stay (LOS) was 2 d. The median operative time for adults was 126 min and the median LOS was 1 d (P < 0.01 for both). There was a longer LOS for cases performed by pediatric surgeons (P = 0.03). CONCLUSIONS: Heller myotomy continues to be a very safe operation for achalasia with minimal short-term morbidity.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Criança , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/cirurgia , Fundoplicatura , Miotomia de Heller/efeitos adversos , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
20.
Surg Endosc ; 36(8): 6255-6259, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-34981240

RESUMO

BACKGROUND: Laparoscopic Heller myotomy is an effective treatment for achalasia. There are little data on the safety and feasibility of same-day discharge after laparoscopic Heller myotomy. OBJECTIVE: This study aimed to describe the experience with same-day discharge after laparoscopic Heller myotomy at one hospital. METHODS: A retrospective cohort study including all patients who underwent laparoscopic Heller myotomy between 2007 and 2016 at University Health Network (UHN), Toronto, Canada. There was no consent required as the study was retrospective study. This study was approved by the UHN IRB. Planned same-day discharge patients were compared to planned inpatient with respect to post-op complications, length of stay, and number of emergency visits. RESULTS: A total of 209 patients were identified. Same-day discharge was planned in 67 (33.5%) cases compared to 133 (66.5%) cases that were planned for inpatient. The study population was 49% male. On average, inpatients had 2.3 pre-operative comorbidities and same-day discharge patients had 1.6 pre-operative comorbidities. The average length of stay for the inpatient group was 3.5 days. Among the same-day surgery group, 15 had an unplanned admission following surgery (22%). Of those who were admitted, the average length of stay was 1.27 days. Only 1 same-day discharge was readmitted after hospital discharge, while 4 in inpatient group were readmitted. The post-operative complication rate was (15%) 20 of inpatient compared to four (6.0%) of same-day discharge. Number of emergency visits for inpatient group were 7 (5.3%) compared to 3 (4.5%) for same-day discharge group. There was one mortality case in inpatient group due to post-op complication. CONCLUSION: Same-day surgery is feasible for laparoscopic Heller myotomy, with a similar complication and readmission rate as inpatient surgery.


Assuntos
Acalasia Esofágica , Miotomia de Heller , Laparoscopia , Acalasia Esofágica/complicações , Acalasia Esofágica/cirurgia , Feminino , Fundoplicatura/métodos , Humanos , Laparoscopia/métodos , Tempo de Internação , Masculino , Alta do Paciente , Estudos Retrospectivos , Resultado do Tratamento
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