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Mucosal perforation during laparoscopic surgery for achalasia: impact of preoperative pneumatic balloon dilation

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Abstract

Background

Controversy remains whether preoperative pneumatic balloon dilation (PBD) influences the surgical outcome of laparoscopic esophagocardiomyotomy in patients with esophageal achalasia. The aim of this study was to evaluate whether preoperative PBD represents a risk factor for surgical complications and affects the symptomatic and/or functional outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD).

Methods

A retrospective chart review was conducted on a prospectively compiled surgical database of 103 consecutive patients with esophageal achalasia who underwent LHD from November 1994 to September 2014. The following data were compared between the patients with preoperative PBD (PBD group; n = 26) and without PBD (non-PBD group; n = 77): (1) patients’ demographics: age, gender, body mass index, duration of symptoms, maximum transverse diameter of esophagus; (2) operative findings: operating time, blood loss, intraoperative complications; (3) postoperative course: complications, clinical symptoms, postoperative treatment; and (4) esophageal functional tests: preoperative and postoperative manometric data and postoperative profile of 24-h esophageal pH monitoring.

Results

(1) No significant differences were observed in the patients’ demographics. (2) Operative findings were similar between the two groups; however, the incidence of mucosal perforation was significantly higher in the PBD group (n = 8; 30.7 %) compared to the non-PBD group (n = 6; 7.7 %) (p = 0.005). (3) Postoperative complications were not encountered in either group. The differences were not significant for postoperative clinical symptoms, the incidence of gastroesophageal reflux disease, or necessity of postoperative treatments. (4) Lower esophageal sphincter pressure was effectively reduced in both groups, and no differences were observed in manometric data or 24-h pH monitoring profiles between the two groups. Multivariate logistic regression analysis showed that preoperative PBD and the maximum transverse diameter of esophagus were significantly associated with intraoperative mucosal perforation.

Conclusions

Although postoperative outcomes were not affected, additional caution is recommended in identifying intraoperative mucosal perforation in patients with preoperative PBD when performing LHD.

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References

  1. Vantrappen G, Hellemans J (1980) Treatment of achalasia and related motor disorders. Gastroenterology 79:144–154

    CAS  PubMed  Google Scholar 

  2. Pohl D, Tutuian R (2007) Achalasia: an overview of diagnosis and treatment. J Gastrointestin Liver Dis 16:297–303

    PubMed  Google Scholar 

  3. Roll GR, Rabl C, Ciovica R, Peeva S, Campos GM (2010) A controversy that has been tough to swallow: is the treatment of achalasia now digested? J Gastrointest Surg 14:S33–S45

    Article  PubMed  Google Scholar 

  4. Cheatham JG, Wong RK (2011) Current approach to the treatment of achalasia. Curr Gastroenterol Rep 13:219–225

    Article  PubMed  Google Scholar 

  5. Gockel I, Sgourakis G, Drescher DG, Lang H (2011) Impact of minimally invasive surgery in the spectrum of current achalasia treatment options. Scand J Surg 100:72–77

    Article  CAS  PubMed  Google Scholar 

  6. Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A, Elizalde JI, Fumagalli U, Gaudric M, Rohof WO, Smout AJ, Tack J, Zwinderman AH, Zaninotto G, Busch OR (2011) Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med 364:1807–1816

    Article  CAS  PubMed  Google Scholar 

  7. Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, Satodate H, Odaka N, Itoh H, Kudo S (2010) Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 42:265–271

    Article  CAS  PubMed  Google Scholar 

  8. Bhayani NH, Kurian AA, Dunst CM, Sharata AM, Rieder E, Swanstrom LL (2014) A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg 259:1098–1103

    Article  PubMed  Google Scholar 

  9. Bansal R, Nostrant TT, Scheiman JM, Koshy S, Barnett JL, Elta GH, Chey WD (2003) Intrasphincteric botulinum toxin versus pneumatic balloon dilation for treatment of primary achalasia. J Clin Gastroenterol 36:209–214

    Article  CAS  PubMed  Google Scholar 

  10. Abir F, Modlin I, Kidd M, Bell R (2004) Surgical treatment of achalasia: current status and controversies. Dig Surg 21:165–176

    Article  PubMed  Google Scholar 

  11. Karamanolis G, Sgouros S, Karatzias G, Papadopoulou E, Vasiliadis K, Stefanidis G, Mantides A (2005) Long-term outcome of pneumatic dilation in the treatment of achalasia. Am J Gastroenterol 100:270–274

    Article  PubMed  Google Scholar 

  12. Eckardt VF, Gockel I, Bernhard G (2004) Pneumatic dilation for achalasia: late results of a prospective follow up investigation. Gut 53:629–633

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Andrews CN, Anvari M, Dobranowski J (1999) Laparoscopic Heller’s myotomy or botulinum toxin injection for management of esophageal achalasia. Surg Endosc 13:742–746

    Article  CAS  PubMed  Google Scholar 

  14. Beckingham IJ, Callanan M, Louw JA, Bornman PC (1999) Laparoscopic cardiomyotomy for achalasia after failed balloon dilatation. Surg Endosc 13:493–496

    Article  CAS  PubMed  Google Scholar 

  15. Deb S, Deschamps C, Allen MS, Nichols FC III, Cassivi SD, Crownhart BS, Pairolero PC (2005) Laparoscopic esophageal myotomy for achalasia: factors affecting functional results. Ann Thorac Surg 80:1191–1194

    Article  PubMed  Google Scholar 

  16. Dolan K, Zafirellis K, Fountoulakis A, Martin IG, Dexter SP, Larvin M, McMahon MJ (2002) Does pneumatic dilatation affect the outcome of laparoscopic cardiomyotomy? Surg Endosc 16:84–87

    Article  CAS  PubMed  Google Scholar 

  17. Tsuboi K, Omura N, Yano F, Kashiwagi H, Kawasaki N, Suzuki Y, Yanaga K (2009) Preoperative dilatation does not affect the surgical outcome of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia. Surg Laparosc Endosc Percutan Tech 19:98–100

    Article  PubMed  Google Scholar 

  18. Vantrappen G, Hellemans J, Deloof W, Valembois P, Vandenbroucke J (1971) Treatment of achalasia with pneumatic dilatations. Gut 12:268–275

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Daniel Smith C, Alessandro Stival D, Howell L, Vickie Swafford RN (2006) Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than Heller myotomy alone. Ann Surg 243:579–586

    Article  PubMed  PubMed Central  Google Scholar 

  20. Morino M, Rebecchi F, Festa V, Garrone C (1997) Preoperative pneumatic dilatation represents a risk factor for laparoscopic Heller myotomy. Surg Endosc 11:359–361

    Article  CAS  PubMed  Google Scholar 

  21. Nakajima K, Wasa M, Kawahara H, Soh H, Taniguchi E, Ohashi S, Okada A (2000) Laparoscopic esophagomyotomy with Dor anterior fundoplication in a child with achalasia. Surg Laparosc Endosc Percutan Tech 10:236–238

    Article  CAS  PubMed  Google Scholar 

  22. Taniguchi E, Kamiike W, Iwase K, Nishida T, Miyata M, Inoue M, Ohashi S, Okada T, Matsuda H (1995) Laparoscopic extramucosal myectomy with anterior fundoplication (Dor) for esophageal achalasia using intraoperative manometry. Surg Endosc 9:817–819

    Article  CAS  PubMed  Google Scholar 

  23. Endo S, Nakajima K, Nishikawa K, Takahashi T, Souma Y, Taniguchi E, Ito T, Nishida T (2009) Laparoscopic Heller-Dor surgery for esophageal achalasia: impact of intraoperative real-time manometric feedback on postoperative outcomes. Dig Surg 26:342–348

    Article  PubMed  Google Scholar 

  24. Stein HJ, Crookes PF, DeMeester TR (1995) Three dimensional manometric imaging of the lower esophageal sphincter. Surg Annu 27:199–214

    CAS  PubMed  Google Scholar 

  25. Jamieson JR, Stein HJ, DeMeester TR, Bonavina L, Schwizer W, Hinder RA, Albertucci M (1992) Ambulatory 24-h esophageal pH monitoring: normal values, optimal thresholds, specificity, sensitivity, and reproducibility. Am J Gastroenterol 87:1102–1111

    CAS  PubMed  Google Scholar 

  26. Heller E (1913) Extramucöse cardioplastie beim chronischen cardiospasmus mit dilatation des oesophagus. Mitt Grengeb Med Chir 2:141–149

    Google Scholar 

  27. Shimi SM, Nathanson LK, Cushieri A (1992) Laparoscopic cardiomyotomy for achalasia. J R Coll Surg Edinb 36:152–154

    Google Scholar 

  28. Ali A, Pellegrini CA (2001) Laparoscopic myotomy: technique and efficacy in treating achalasia. Gastrointest Endosc Clin N Am 11:347–358

    CAS  PubMed  Google Scholar 

  29. Schoenberg MB, Marx S, Kersten JF, Rösch T, Belle S, Kähler G, Vassiliou MC, Lüth S, von Renteln D (2013) Laparoscopic Heller myotomy versus endoscopic balloon dilatation for the treatment of achalasia: a network meta-analysis. Ann Surg 258:943–952

    Article  PubMed  Google Scholar 

  30. Yaghoobi M, Mayrand S, Martel M, Roshan-Afshar I, Bijarchi R, Barkun A (2013) Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 78:468–475

    Article  PubMed  Google Scholar 

  31. Kadakia SC, Wong RK (2001) Pneumatic balloon dilation for esophageal achalasia. Gastrointest Endosc Clin N Am 11:325–346

    CAS  PubMed  Google Scholar 

  32. Persson J, Johnsson E, Kostic S, Lundell L, Smedh U (2015) Treatment of achalasia with laparoscopic myotomy or pneumatic dilatation: long-term results of a prospective, randomized study. World J Surg 39:713–720

    Article  PubMed  Google Scholar 

  33. Moonen A, Annese V, Belmans A, Bredenoord AJ, des Varannes BS, Costantini M, Dousset B, Elizalde JI, Fumagalli U, Gaudric M, Merla A, Smout AJ, Tack J, Zaninotto G, Busch OR, Boeckxstaens GE (2015) Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 0:1–8

    Google Scholar 

  34. Gockel I, Junginger T, Bernhard G, Eckardt VF (2004) Heller myotomy for failed pneumatic dilation in achalasia: how effective is it? Ann Surg 239:371–377

    Article  PubMed  PubMed Central  Google Scholar 

  35. West RL, Hirsch DP, Bartelsman JF, de Borst J, Ferwerda G, Tytgat GN, Boeckxstaens GE (2002) Long term results of pneumatic dilation in achalasia followed for more than 5 years. Am J Gastroenterol 97:1346–1351

    Article  CAS  PubMed  Google Scholar 

  36. Farhoomand K, Connor JT, Richter JE, Achkar E, Vaezi MF (2004) Predictors of outcome of pneumatic dilation in achalasia. Clin Gastroenterol Hepatol 2:389–394

    Article  PubMed  Google Scholar 

  37. Dagli U, Kuran S, Savas N, Ozin Y, Alkim C, Atalay F, Sahin B (2009) Factors predicting outcome of balloon dilatation in achalasia. Dig Dis Sci 54:1237–1242

    Article  PubMed  Google Scholar 

  38. Rosemurgy A, Villadolid D, Thometz D, Kalipersad C, Rakita S, Albrink M, Johnson M, Boyce W (2005) Laparoscopic Heller myotomy provides durable relief from achalasia and salvages failures after botox or dilation. Ann Surg 241:725–733

    Article  PubMed  PubMed Central  Google Scholar 

  39. Lynch KL, Pandolfino JE, Howden CW, Kahrilas PJ (2012) Major complications of pneumatic dilation and Heller myotomy for achalasia: single-center experience and systematic review of the literature. Am J Gastroenterol 107:1817–1825

    Article  PubMed  Google Scholar 

  40. Gockel I, Junginger T, Eckardt VF (2007) Persistent and recurrent achalasia after Heller myotomy: analysis of different patterns and long-term results of reoperation. Arch Surg 142:1093–1097

    Article  PubMed  Google Scholar 

  41. Delgado F, Bolufer JM, Martínez-Abad M, Martín J, Blanes F, Castro C, Moreno-Osset E, Mora F, Benages A (1996) Laparoscopic treatment of esophageal achalasia. Surg Laparosc Endosc 6:83–90

    Article  CAS  PubMed  Google Scholar 

  42. Douard R, Gaudric M, Chaussade S, Couturier D, Houssin D, Dousset B (2004) Functional results after laparoscopic Heller myotomy for achalasia: a comparative study to open surgery. Surgery 136:16–24

    Article  PubMed  Google Scholar 

  43. Csendes A, Burdiles P, Korn O, Braghetto I, Díaz JC, Henríquez A (2001) Preliminary results of laparoscopic video esophagomyotomy in patients with esophageal achalasia. Rev Med Chil 129:1142–1146

    CAS  PubMed  Google Scholar 

  44. Kuster GG (1998) Local epinephrine facilitates laparoscopic Heller myotomy. Surg Endosc 12:79–81

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Osaka Central Hospital, 3-3-30, Umeda, Kita-ku, Osaka, 530-0001, Japan

    Yoshihito Souma, Tetsuhiro Hamada, Jun Yasuda, Takeyoshi Yumiba & Shuichi Ohashi

  2. Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan

    Kiyokazu Nakajima, Tsuyoshi Takahashi, Yukinori Kurokawa, Makoto Yamasaki, Yasuhiro Miyazaki, Tomoki Makino, Shuji Takiguchi, Masaki Mori & Yuichiro Doki

  3. Division of Next Generation Endoscopic Intervention, Global Center for Medical Engineering and Informatics, Osaka University, 2-2, E-2, Yamadaoka, Suita, Osaka, 565-0871, Japan

    Kiyokazu Nakajima

  4. Department of surgery, Otemae Hospital, Osaka, Japan

    Eiji Taniguchi

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  1. Yoshihito Souma
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Correspondence to Kiyokazu Nakajima.

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Dr Yoshihito Souma, Kiyokazu Nakajima, Eiji Taniguchi, Tsuyoshi Takahashi, Yukinori Kurokawa, Makoto Yamasaki, Yasuhiro Miyazaki, Tomoki Makino, Tetsuhiro Hamada, Jun Yasuda, Takeyoshi Yumiba, Shuichi Ohashi, Shuji Takiguchi, Masaki Mori, and Yuichiro Doki have no conflict of interest or financial ties to disclose.

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Souma, Y., Nakajima, K., Taniguchi, E. et al. Mucosal perforation during laparoscopic surgery for achalasia: impact of preoperative pneumatic balloon dilation. Surg Endosc 31, 1427–1435 (2017). https://doi.org/10.1007/s00464-016-5133-1

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