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Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
G Lozano Dubernard, R Gil-Ortiz Mejía, B Rueda Torres, NS Gómez Peña-Alfaro
Surgical intervention
2 months ago
5348 views
25 likes
4 comments
12:40
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
Robotic Heller myotomy with Dor fundoplication for esophageal achalasia
Achalasia is an esophageal motility disorder characterized by an incomplete or absent esophagogastric junction (EGJ) relaxation associated with loss of peristalsis or uncoordinated contractions of the esophageal body in response to swallowing. All available treatments for achalasia are palliative, directed towards the elimination of the outflow resistance caused by abnormal lower esophageal sphincter (LES) function and aiming to improve the symptoms related to esophageal stasis, such as dysphagia and regurgitation. Laparoscopic Heller myotomy with partial fundoplication is the current standard of care for the treatment of achalasia. It is associated with symptom improvement or relief in about 90% of patients. However, it is a challenging procedure with the potential risk of esophageal perforation reported in up to 10% of cases. Interestingly, laparoscopic myotomy has some limitations which depend on the laparoscopic technique (bidimensional vision, poor range of movement) and on the surgeon’s experience. Recently, the use of the robotic technology has been proposed claiming that it might reduce intraoperative esophageal perforation rates and improve postoperative quality of life after Heller myotomy, mainly due to the 3D view and enhanced dexterity of the surgeon. Despite significant improvements in surgical treatment, the length of myotomy is still a matter of debate to date. Substantially, although some authors proposed a limited myotomy on the lower esophagus preserving a small portion of the LES to prevent postoperative reflux, most authors recommended a myotomy extending 4 to 6cm on the esophagus and 1 to 2cm on the gastric side. In this video, we performed a 6cm long esophagogastric myotomy, with a 2.5cm proximal extension above the Z-line (endoscopically recognized) and a 3.5cm distal extension below the same landmark. In a previous experimental study with intraoperative computerized manometry, we observed that myotomy of the esophageal portion of the LES (without dissection of the gastric fibers) did not lead to any significant variation in sphincteric pressure. Instead, the dissection of the gastric fibers for at least 2 to 2.5cm on the anterior gastric wall created a significant modification of the LES pressure profile. This may be due to the interruption of the anterior portion of gastric semicircular clasp and sling fibers, with consequent loss of their hook properties on the LES pressure profile.
L Marano, A Spaziani, G Castagnoli
Surgical intervention
1 year ago
1727 views
7 likes
0 comments
08:13
Robotic Heller myotomy with Dor fundoplication for esophageal achalasia
Achalasia is an esophageal motility disorder characterized by an incomplete or absent esophagogastric junction (EGJ) relaxation associated with loss of peristalsis or uncoordinated contractions of the esophageal body in response to swallowing. All available treatments for achalasia are palliative, directed towards the elimination of the outflow resistance caused by abnormal lower esophageal sphincter (LES) function and aiming to improve the symptoms related to esophageal stasis, such as dysphagia and regurgitation. Laparoscopic Heller myotomy with partial fundoplication is the current standard of care for the treatment of achalasia. It is associated with symptom improvement or relief in about 90% of patients. However, it is a challenging procedure with the potential risk of esophageal perforation reported in up to 10% of cases. Interestingly, laparoscopic myotomy has some limitations which depend on the laparoscopic technique (bidimensional vision, poor range of movement) and on the surgeon’s experience. Recently, the use of the robotic technology has been proposed claiming that it might reduce intraoperative esophageal perforation rates and improve postoperative quality of life after Heller myotomy, mainly due to the 3D view and enhanced dexterity of the surgeon. Despite significant improvements in surgical treatment, the length of myotomy is still a matter of debate to date. Substantially, although some authors proposed a limited myotomy on the lower esophagus preserving a small portion of the LES to prevent postoperative reflux, most authors recommended a myotomy extending 4 to 6cm on the esophagus and 1 to 2cm on the gastric side. In this video, we performed a 6cm long esophagogastric myotomy, with a 2.5cm proximal extension above the Z-line (endoscopically recognized) and a 3.5cm distal extension below the same landmark. In a previous experimental study with intraoperative computerized manometry, we observed that myotomy of the esophageal portion of the LES (without dissection of the gastric fibers) did not lead to any significant variation in sphincteric pressure. Instead, the dissection of the gastric fibers for at least 2 to 2.5cm on the anterior gastric wall created a significant modification of the LES pressure profile. This may be due to the interruption of the anterior portion of gastric semicircular clasp and sling fibers, with consequent loss of their hook properties on the LES pressure profile.
Laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction for a terminal achalasia
Introduction: Idiopathic achalasia is the most frequent esophageal motility disorder. Generally, treatment is the "palliation" of symptoms and improvement in quality of life. Although Heller myotomy is the standard treatment, achieving good results in 90 to 95% of cases, esophagectomy is required in 5 to 10% of cases.
The authors present a case of a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction in a woman with long-term achalasia and megaesophagus.
Clinical case: A 54-year-old woman, with a previous history of a "psychological eating disorder", was referred to the Emergency Department. She complained of epigastric pain and dysphagia. A thoraco-abdominal CT-scan was requested and revealed a dilated, tortuous, sigmoid esophagus, filled with food content, with no identifiable mass causing obstruction. The patient was admitted to hospital and further study was performed --esophagogastroscopy and esophageal manometry - which confirmed the diagnosis of achalasia with esophageal aperistalses.
The patient was proposed a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction.
No complications were reported in the postoperative period, and discharge was possible on postoperative day 7. Six months later, an esophagram showed adequate contrast passage and progression.
Discussion/Conclusion: Esophagectomy as a primary treatment of achalasia might be considered if severe symptomatic (dysphagia, regurgitation), anatomical (megaesophagus) or functional (esophagus aperistalses) disorders are contraindications to a more conservative approach.
AM Pereira, J Magalhães, R Ferreira de Almeida, G Gonçalves, M Nora
Surgical intervention
1 year ago
3595 views
290 likes
0 comments
09:29
Laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction for a terminal achalasia
Introduction: Idiopathic achalasia is the most frequent esophageal motility disorder. Generally, treatment is the "palliation" of symptoms and improvement in quality of life. Although Heller myotomy is the standard treatment, achieving good results in 90 to 95% of cases, esophagectomy is required in 5 to 10% of cases.
The authors present a case of a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction in a woman with long-term achalasia and megaesophagus.
Clinical case: A 54-year-old woman, with a previous history of a "psychological eating disorder", was referred to the Emergency Department. She complained of epigastric pain and dysphagia. A thoraco-abdominal CT-scan was requested and revealed a dilated, tortuous, sigmoid esophagus, filled with food content, with no identifiable mass causing obstruction. The patient was admitted to hospital and further study was performed --esophagogastroscopy and esophageal manometry - which confirmed the diagnosis of achalasia with esophageal aperistalses.
The patient was proposed a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction.
No complications were reported in the postoperative period, and discharge was possible on postoperative day 7. Six months later, an esophagram showed adequate contrast passage and progression.
Discussion/Conclusion: Esophagectomy as a primary treatment of achalasia might be considered if severe symptomatic (dysphagia, regurgitation), anatomical (megaesophagus) or functional (esophagus aperistalses) disorders are contraindications to a more conservative approach.
POEM endoscopic treatment of achalasia using the EndoFLIP® (Endolumenal Functional Lumen Imaging Probe) imaging system
This is the case of a 75-year-old lady who presented with recurrent symptoms of dysphagia and regurgitation associated with a significant weight loss due to recurrent achalasia. She developed progressive recurrence after a first surgical treatment by an open Heller myotomy and Dor fundoplication back in 1974. This first operation was complicated by an esophageal perforation which required a thoracotomy to be controlled. Several dilatations were attempted with no significant symptoms improvement. One of the most important aspects of POEM is to ensure that the submucosal tunnel adequately extends into the gastric cardia in order to perform a complete and adequate myotomy. To this aim, proper orientation is key but may be difficult even to the experienced eye of the interventional endoscopist familiar with ESD techniques and dissection planes. Six endoscopic cues that assist with this determination have been identified so far. The most useful cue was deemed to be the characteristic appearance of the submucosal space of the cardia of a slightly different color with a somewhat yellowish hue, more capacious than the esophageal submucosal space with more and larger vessels. Identification of the thick, cord-like circular muscle fibers of the lower esophageal sphincter was deemed as the second most useful cue, and noting a bluish coloration of the cardial mucosa from the colored submucosal injection via a retroflexed luminal view was the third most useful cue. Endoscope insertion length within the submucosal tunnel and the palisading mucosal vessels marking the gastroesophageal junction and visible also from inside the submucosal tunnel were deemed helpful but to a lesser degree. Nevertheless, identification of these endoscopic landmarks is not easy nor always reproducible. Creation of the submucosal tunnel is very sensitive to case difficulty and accounts for the large fluctuations in procedure time. Another area of technique variability involves the orientation of the myotomy. In order to improve the recognition of the essential landmarks, we developed a myotomy technique guided by the EndoFLIP® catheter. EndoFLIP® is a unique physiology test that uses both volumetric assessment and pressure readings to calculate compliance and high pressure zones as well as distensibility changes at the gastroesophageal junction. It allows intraoperative assessment of myotomy completion. The use of this device provides a direct immediate feedback with regards to the efficacy of the myotomy. The EndoFLIP® catheter used in this case (EF-325L) has been specifically modified for the POEM procedure. It differs from the standard EndoFLIP® catheter in that it contains an integrated illuminating LED adjacent to the centre measurement electrode. When the catheter is positioned intraluminally at the gastroesophageal junction and secured to this position taping the distal end to the endothracheal tube, it allows to direct dissection towards the cardia.
S Perretta, LL Swanström, B Dallemagne, J Marescaux
Surgical intervention
6 years ago
2793 views
39 likes
0 comments
07:08
POEM endoscopic treatment of achalasia using the EndoFLIP® (Endolumenal Functional Lumen Imaging Probe) imaging system
This is the case of a 75-year-old lady who presented with recurrent symptoms of dysphagia and regurgitation associated with a significant weight loss due to recurrent achalasia. She developed progressive recurrence after a first surgical treatment by an open Heller myotomy and Dor fundoplication back in 1974. This first operation was complicated by an esophageal perforation which required a thoracotomy to be controlled. Several dilatations were attempted with no significant symptoms improvement. One of the most important aspects of POEM is to ensure that the submucosal tunnel adequately extends into the gastric cardia in order to perform a complete and adequate myotomy. To this aim, proper orientation is key but may be difficult even to the experienced eye of the interventional endoscopist familiar with ESD techniques and dissection planes. Six endoscopic cues that assist with this determination have been identified so far. The most useful cue was deemed to be the characteristic appearance of the submucosal space of the cardia of a slightly different color with a somewhat yellowish hue, more capacious than the esophageal submucosal space with more and larger vessels. Identification of the thick, cord-like circular muscle fibers of the lower esophageal sphincter was deemed as the second most useful cue, and noting a bluish coloration of the cardial mucosa from the colored submucosal injection via a retroflexed luminal view was the third most useful cue. Endoscope insertion length within the submucosal tunnel and the palisading mucosal vessels marking the gastroesophageal junction and visible also from inside the submucosal tunnel were deemed helpful but to a lesser degree. Nevertheless, identification of these endoscopic landmarks is not easy nor always reproducible. Creation of the submucosal tunnel is very sensitive to case difficulty and accounts for the large fluctuations in procedure time. Another area of technique variability involves the orientation of the myotomy. In order to improve the recognition of the essential landmarks, we developed a myotomy technique guided by the EndoFLIP® catheter. EndoFLIP® is a unique physiology test that uses both volumetric assessment and pressure readings to calculate compliance and high pressure zones as well as distensibility changes at the gastroesophageal junction. It allows intraoperative assessment of myotomy completion. The use of this device provides a direct immediate feedback with regards to the efficacy of the myotomy. The EndoFLIP® catheter used in this case (EF-325L) has been specifically modified for the POEM procedure. It differs from the standard EndoFLIP® catheter in that it contains an integrated illuminating LED adjacent to the centre measurement electrode. When the catheter is positioned intraluminally at the gastroesophageal junction and secured to this position taping the distal end to the endothracheal tube, it allows to direct dissection towards the cardia.
Laparoscopic Heller procedure for achalasia
This is a 'live' surgery performed by Dr. B Dallemagne demonstrating the key steps in performing a Heller procedure. Minimal dissection is carried out to expose the anterior surface of the esophagus, after which the myotomy is delicately performed with scissors. This video is recommended to upper GI surgeons.
Barium swallow showed the classic sign of achalasia at the level of the cardia in this elderly woman with gastroesophageal reflux disease. CT-scan of the chest showed a large sigmoid-like esophagus. Mobilization of the esophagus begins with the authors opening only the anterior aspect of the hiatus to gain access to the esophagus. They dissect the upper part of the esophagus and expose the azygos vein on the right, clearing the gastroesophageal junction on the gastric side of the cardia. They continue by opening the hypertrophic musculature to enable swallowing, then continue with a Heller myotomy.
B Dallemagne, J Marescaux
Surgical intervention
12 years ago
692 views
126 likes
0 comments
11:59
Laparoscopic Heller procedure for achalasia
This is a 'live' surgery performed by Dr. B Dallemagne demonstrating the key steps in performing a Heller procedure. Minimal dissection is carried out to expose the anterior surface of the esophagus, after which the myotomy is delicately performed with scissors. This video is recommended to upper GI surgeons.
Barium swallow showed the classic sign of achalasia at the level of the cardia in this elderly woman with gastroesophageal reflux disease. CT-scan of the chest showed a large sigmoid-like esophagus. Mobilization of the esophagus begins with the authors opening only the anterior aspect of the hiatus to gain access to the esophagus. They dissect the upper part of the esophagus and expose the azygos vein on the right, clearing the gastroesophageal junction on the gastric side of the cardia. They continue by opening the hypertrophic musculature to enable swallowing, then continue with a Heller myotomy.
Laparoscopic Heller-Dor procedure for pediatric esophageal achalasia
This is a pediatric surgical video demonstrating the technique of Heller myotomy. The procedure is then concluded with a Dor fundoplication, including an anterior gastropexy. It is suitable for pediatric surgeons with an interest in laparoscopic surgery.
This approach for the myotomy concludes with a fundoplication and an anterior gastropexy. The surgeon in this clip frees the anterior and lateral sides of the esophagus to proceed cranially into the mediastinum. Identification of the anterior vagus nerve is mandatory. The anterior surface of the esophagus must be almost completely free of tissue to enable this. Hook diathermy allows close dissection, retraction and coagulation. The operation continues with monopolar diathermy to clear the tissue from the anterior surface of the stomach.
V Jasonni, G Mattioli
Surgical intervention
12 years ago
425 views
46 likes
0 comments
07:08
Laparoscopic Heller-Dor procedure for pediatric esophageal achalasia
This is a pediatric surgical video demonstrating the technique of Heller myotomy. The procedure is then concluded with a Dor fundoplication, including an anterior gastropexy. It is suitable for pediatric surgeons with an interest in laparoscopic surgery.
This approach for the myotomy concludes with a fundoplication and an anterior gastropexy. The surgeon in this clip frees the anterior and lateral sides of the esophagus to proceed cranially into the mediastinum. Identification of the anterior vagus nerve is mandatory. The anterior surface of the esophagus must be almost completely free of tissue to enable this. Hook diathermy allows close dissection, retraction and coagulation. The operation continues with monopolar diathermy to clear the tissue from the anterior surface of the stomach.
Laparoscopic robotic-assisted Heller procedure for esophageal achalasia
This video demonstrates a robotic-assisted Heller procedure for treatment of esophageal achalasia. The surgeon starts by dissecting the gastroesophageal junction. The mobilization of the stomach is limited to the anterior and lateral aspect, leaving the posterior attachments intact. The myotomy is started just above the gastroesophageal junction and extended 6 cm proximally and 2 cm distally onto the stomach using robotic articulated scissors. The extension of the myotomy on the gastric side continues to be the most difficult part of the dissection. The change in direction of the muscular fibers, from circular at the esophagus, to oblique at the stomach, makes it difficult to develop the necessary submucosal plane for dividing the muscular fibers. The video demonstrates the freedom of movement of the articulated robotic instruments that allow the surgeon to divide each individual muscular fiber achieving a precise dissection of the gastroesophageal junction. Once the myotomy is completed a standard Dor Fundoplication is performed.
B Dallemagne
Surgical intervention
13 years ago
617 views
59 likes
0 comments
12:18
Laparoscopic robotic-assisted Heller procedure for esophageal achalasia
This video demonstrates a robotic-assisted Heller procedure for treatment of esophageal achalasia. The surgeon starts by dissecting the gastroesophageal junction. The mobilization of the stomach is limited to the anterior and lateral aspect, leaving the posterior attachments intact. The myotomy is started just above the gastroesophageal junction and extended 6 cm proximally and 2 cm distally onto the stomach using robotic articulated scissors. The extension of the myotomy on the gastric side continues to be the most difficult part of the dissection. The change in direction of the muscular fibers, from circular at the esophagus, to oblique at the stomach, makes it difficult to develop the necessary submucosal plane for dividing the muscular fibers. The video demonstrates the freedom of movement of the articulated robotic instruments that allow the surgeon to divide each individual muscular fiber achieving a precise dissection of the gastroesophageal junction. Once the myotomy is completed a standard Dor Fundoplication is performed.