Journal of Gastrointestinal Surgery

, Volume 18, Issue 1, pp 106–112

Laparoscopic Heller Myotomy Can Be Used As Primary Therapy for Esophageal Achalasia Regardless of Age

  • Renato Salvador
  • Mario Costantini
  • Francesco Cavallin
  • Lisa Zanatta
  • Elena Finotti
  • Cristina Longo
  • Loredana Nicoletti
  • Giovanni Capovilla
  • Romeo Bardini
  • Giovanni Zaninotto
2013 SSAT Plenary Presentation

Abstract

Introduction

Laparoscopic Heller-Dor surgery is the current treatment of choice for patients with esophageal achalasia, but elderly patients are generally referred for less invasive treatments (pneumatic dilations or botulinum toxin injections).

Aim

To assess the effect of age on the surgical outcome of patients receiving laparoscopic Heller-Dor as primary treatment.

Methods

Demographic and clinical findings were prospectively collected on patients undergoing laparoscopic Heller-Dor from 1992 to 2012. Patients were classified in three age brackets: group A (≤45 years), group B (45–70), and group C (≥70). Treatment was defined as a failure if the postoperative symptom score was >10th percentile of the preoperative score (i.e., >8). We consecutively performed the Heller-Dor in 571 achalasia patients, 305 (53.4 %) in group A, 226 (39.6 %) in group B, and 40 (7 %) in group C.

Results

The mortality was nil; the conversion and morbidity rates were both 1.1 %. Group C patients had higher preoperative symptom scores (p = 0.02), while the symptom duration was similar in all three groups. Mucosal tears occurred in 17 patients (3 %): 6 (2 %) in group A, 8 (3.5 %) in group B, and 3 (7.5 %) in group C (p = 0.09). The postoperative hospital stay was slightly longer for group C (p = 0.06).

Discussion

The treatment failure rate was quite similar: 31 failures in group A (10.1 %), 19 in group B (8.4 %), and 3 in group C (7.5 %; p = 0.80). These failures were seen more in manometric pattern III (22.2 %, p = 0.002). Laparoscopic Heller-Dor can be used as the first therapeutic approach to achalasia even in elderly patients with an acceptable surgical risk.

Keywords

Esophageal achalasia Heller-Dor Elderly 

References

  1. 1.
    Richter JE. Achalasia. In: Richter JE, Castell DO (eds.). The esophagus, 4th ed. New York: Lippincott, 2005: pp 221–261.Google Scholar
  2. 2.
    Park W, Vaezi MF. Etiology and pathogenesis of achalasia: the current understanding. Am J Gastroenterol 2005;100:1404–14.PubMedCrossRefGoogle Scholar
  3. 3.
    Sonnenberg A. Hospitalization for achalasia in the United States 1997–2006. Dig Dis Sci 2009;54:1680–85.PubMedCrossRefGoogle Scholar
  4. 4.
    Gennaro N, Portale G, Gallo C, Rocchietto S, Caruso V et al. Esophageal achalasia in the Veneto region: epidemiology and treatment. Epidemiology and treatment of achalasia. J Gastrointest Surg 2011; 15:423–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Mayberry JF. Epidemiology and demographics of achalasia. Gastrointest Endosc Clin N Am. 2001;11:235–48.PubMedGoogle Scholar
  6. 6.
    Steven R, Bloomston M, Villadolid D. Age affects presenting symptoms of achalasia and outcomes after myotomy. Am Surg. 2005;71:424–29.Google Scholar
  7. 7.
    Gockel I, Junginger T, Eckardt VF. Long-term results of conventional myotomy in patients with achalasia: a prospective 20-year analysis. J Gastrointest Surg 2006;10:1400–10.PubMedCrossRefGoogle Scholar
  8. 8.
    Triadafidapulos G, Boeckstaens GE, Gullo R, Patti MG, Pandolfino JE et al. The Kagoshima consensus on esophageal achalasia. Dis Esophagus 2012; 25:337–34.CrossRefGoogle Scholar
  9. 9.
    Craft RO, Aguilar BE, Flahive C et al. Outcomes of minimally invasive myotomy for the treatment of achalasia in the elderly. JSLS. 2010;14:342–7.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Williams VA, Peters JH. Achalasia of the esophagus: a surgical disease. J Am Coll Surg. 2009; 208(1):151–62.PubMedCrossRefGoogle Scholar
  11. 11.
    Richter JE. Oesophageal motility disorders. Lancet 2001; 358 (9284): 823–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Passaretti S, Zaninotto G, DiMartino N, Leo P, Costantini M, Baldi F. Standards for oesophageal manometry. A position statement from the Gruppo Italiano di Studio per la Motilità dell'Apparato Digerente. Dig Liv Dis 2001; 32: 46–55.CrossRefGoogle Scholar
  13. 13.
    Zaninotto G, Costantini M, Bonavina L, Merigliano S, Baessato M, Iuliani M, Anselmino M, Ancona E. Manometric characteristics of the distal oesophageal sphincter and patterns of gastro-esophageal reflux in healthy volunteers and patients. Eur Surg Res. 1987; 19(4):217–24.PubMedCrossRefGoogle Scholar
  14. 14.
    Pandolfino JE, Ghosh SK, Zhang Q, Jarosz A, Shah N, Kahrilas PJ. Quantifying EGJ morphology and relaxation with high-resolution manometry: a study of 75 asymptomatic volunteers. Am J Physiol Gastrointest Liver Physiol 2006; 290(5): G1033–40Google Scholar
  15. 15.
    Salvador R, Dubecz A, Polomsky M, Gellerson O, Jones CE, Raymond DP, Watson TJ, Peters JH. A new era in esophageal diagnostics: the image-based paradigm of high-resolution manometry. J Am Coll Surg 2009; 208(6):1035–44.PubMedCrossRefGoogle Scholar
  16. 16.
    Pandolfino JE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J, Kahrilas PJ. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 2009; 135 (5):1526–33.CrossRefGoogle Scholar
  17. 17.
    Salvador R, Costantini M, Zaninotto G, Morbin T, Rizzetto C, Zanatta L, Ceolin M, Finotti E, Nicoletti L, Da Dalt G, Cavallin F, Ancona E. The preoperative manometric pattern predicts the outcome of surgical treatment for esophageal achalasia. J Gastrointest Surg 2010; 14(11):1635–45.PubMedCrossRefGoogle Scholar
  18. 18.
    Ancona E, Peracchia A, Zaninotto G, Rossi M, Bonavina L, Segalin A. Heller laparoscopic cardiomyotomy with antireflux anterior fundoplication (Dor) in the treatment of esophageal achalasia. Surg Endosc 1993; 7 (5): 459–61.PubMedCrossRefGoogle Scholar
  19. 19.
    Zaninotto G, Costantini M, Molena D, Buin F, Carta A, Nicoletti L, Ancona E. Treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor partial anterior fundoplication: prospective evaluation of 100 consecutive patients. J Gastrointest Surg 2000; 4(3):282–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Crookes PF, Corkill S, DeMeester TR. Gastroesophageal reflux in achalasia. When is reflux really reflux? Dig Dis Sci 1997; 42(7):1354–61.PubMedCrossRefGoogle Scholar
  21. 21.
    Zaninotto G, Costantini M, Rizzetto C, Zanatta L, Guirroli E, et al. Four hundred laparoscopic myotomies for esophageal achalasia: a single center experience. Ann Surg 2008; 248:986–93.PubMedCrossRefGoogle Scholar
  22. 22.
    Boeckstaens GE, Annese V, des Varennes SB, Chaussade S Costantini M et al. Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia. New Engl J Med 2011; 364(19):1807–16CrossRefGoogle Scholar
  23. 23.
    Roll GR, Sandi M, Gasper WJ, Patti M, Way LW, Carter J. Excellent outcomes of laparoscopic esophagomyotomy for achalasia patients older than 60 years of age. Surg Endosc 2010; 24:2562–66.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Gockel I, Gith A, Drescher D, Jungmann F, Eckhard L, Lang H. Minimally invasive surgery for achalasia patients >40 years: more favorable than anticipated . Langebeck Arch Surg 2012; 397:69–74.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2013

Authors and Affiliations

  • Renato Salvador
    • 1
  • Mario Costantini
    • 1
  • Francesco Cavallin
    • 3
  • Lisa Zanatta
    • 1
  • Elena Finotti
    • 1
  • Cristina Longo
    • 1
  • Loredana Nicoletti
    • 1
  • Giovanni Capovilla
    • 1
  • Romeo Bardini
    • 1
  • Giovanni Zaninotto
    • 2
    • 4
  1. 1.Department of Surgery, Oncology and GastroenterologyUniversity of PadovaPadovaItaly
  2. 2.Department of General SurgerySS Giovanni e Paolo HospitalVeniceItaly
  3. 3.Surgical OncologyIstituto Oncologico Veneto, IOV-IRCCSPaduaItaly
  4. 4.Unità Operativa Complessa Chirurgia GeneraleUniversity of Padova Department of Surgery, Oncology and GastoenterologyVeniceItaly

Personalised recommendations