Roux-en-Y Gastric Bypass and Heller Myotomy: One-Step Surgical Treatment of Symptomatic Achalasia in a Morbid Obese Patient.
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ABSTRACT:
SUBMITTER: Velotti N
PROVIDER: S-EPMC8175316 | biostudies-literature | 2021 Jul
REPOSITORIES: biostudies-literature
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Roux-en-Y Gastric Bypass and Heller Myotomy: One-Step Surgical Treatment of Symptomatic Achalasia in a Morbid Obese Patient.
Velotti Nunzio N Vitiello Antonio A Berardi Giovanna G Musella Mario M
Obesity surgery 20210429 7
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Project description:Background and aimsAlthough laparoscopic Heller myotomy (LHM) or peroral endoscopic myotomy (POEM) is highly effective, 10% to 20% of patients with achalasia remain symptomatic after treatment. In evaluating such patients, we have observed a pattern of failure associated with a pseudodiverticulum, or blown-out myotomy (BOM), in the distal esophagus. We aimed to assess risk factors and patient-reported outcomes associated with a BOM.MethodsWe reviewed our manometry database for patients with achalasia previously treated with LHM or POEM. We included patients who had a post-treatment esophagram within 1 year of their follow-up manometry. A BOM was defined radiographically as a wide-mouthed outpouching (>50% increase in esophageal diameter) in the area of the myotomy.ResultsOne hundred twenty-nine patients with achalasia who underwent treatment were included; 23 (17.8%) had a BOM. Comparing patients with a BOM with those without, post-treatment Eckardt scores were significantly greater (5 vs 2, P = .002), type III achalasia was more common (39.1% vs 14.2%, P = .005), and LHM was more common than POEM (73.9% vs 26.1%, P = .013). The integrated relaxation pressure was also significantly greater in the BOM group (15.0 mm Hg vs 11.0 mm Hg, P = .025).ConclusionsBOM is a common adverse event after myotomy for achalasia but is not seen after pneumatic dilation. Pretreatment type III achalasia, LHM as opposed to POEM, and a greater post-treatment integrated relaxation pressure were risk factors for developing a BOM. We speculate that esophageal wall strain in the area weakened by myotomy, whether from residual spastic contractility or continued esophageal outflow obstruction, may be the underlying mechanism of BOM development.
| S-EPMC7855725 | biostudies-literature
Project description:PurposeAlthough laparoscopic Heller myotomy and Dor fundoplication (LHD) is widely performed to address achalasia, little is known about the learning curve for this technique. We assessed the learning curve for performing LHD.MethodsOf the 514 cases with LHD performed between August 1994 and March 2016, the surgical outcomes of 463 cases were evaluated after excluding 50 cases with reduced port surgery and one case with the simultaneous performance of laparoscopic distal partial gastrectomy. A receiver operating characteristic (ROC) curve analysis was used to identify the cut-off value for the number of surgical experiences necessary to become proficient with LHD, which was defined as the completion of the learning curve.ResultsWe defined the completion of the learning curve when the following 3 conditions were satisfied. 1) The operation time was less than 165 minutes. 2) There was no blood loss. 3) There was no intraoperative complication. In order to establish the appropriate number of surgical experiences required to complete the learning curve, the cut-off value was evaluated by using a ROC curve (AUC 0.717, p < 0.001). Finally, we identified the cut-off value as 16 surgical cases (sensitivity 0.706, specificity 0.646).ConclusionLearning curve seems to complete after performing 16 cases.
| S-EPMC5501549 | biostudies-literature
Project description:There are various therapeutic options for achalasia. Nevertheless, peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy with fundoplication (LHM) are distinguished by their efficacy and low incidence of complications. Compare POEM and LHM regarding several outcomes in patients with achalasia. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An exhaustive literature search was performed using PubMed, Web of Science, and Cochrane Library databases. Studies comparing several outcomes between POEM and LHM in patients with achalasia were included. Data on clinical success, operative time, intraoperative complications, length of stay, reintervention rates, postoperative pain, overall complications, occurrence of GERD symptoms, use of proton bomb inhibitors and esophagitis were extracted. Quality assessment of the included studies was performed using the MINORS scale. We included 20 retrospective observational studies with a combined total of 5139 participants. The results demonstrated that there was no statistically significant difference in terms of intraoperative complications, postoperative complications, reintervention rate, occurrence of GERD symptoms, GERD HRQL, use of proton pump inhibitors, and esophagitis between POEM and LHM groups. Conversely, POEM was associated with higher clinical success and shorter operative time, length of stay, and postoperative pain. This meta-analysis concludes that both POEM and LHM, are effective and safe treatments for achalasia. However, POEM demonstrates better results regarding clinical success, operative time, length of stay, postoperative pain, and a tendency towards lower recurrence.
| S-EPMC11199208 | biostudies-literature
Project description:Laparoscopic Heller cardiomyotomy and Dor fundoplication is the surgical procedure of choice for esophageal achalasia. The aim of our study was to investigate the clinical outcome and safety of laparoscopic Heller-Dor procedure performed by using Hook electrocautery and as a teaching module for advanced laparoscopic surgery. Between January 2005 and December 2010, 25 consecutive patients with achalasia underwent laparoscopic Heller-Dor operation by a single surgeon. All the patients received upper gastrointestinal series (barium swallow), esophagogastroscopy, and esophageal manometry to exclude esophageal carcinoma and to confirm the diagnosis. All the patients were operated by laparoscopic modified Heller myotomy with Dor fundoplication by using hook electrocautery. Among 25 operated patients, 14 were male and 11 were female with a median age of 43 years (range 18-72 years). The mean operative time was 93.3 min (range 50-50 min), the mean operative blood loss was 90 ml (range 40-200 ml), the median time to oral feeding was 2 days (2-4 days), and the median hospital stay was 4 days (4-7 days). There was no conversion to open surgery. Intraoperative mucosal perforation was encountered in three patients and was repaired in all of them by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication and had excellent clinical response (96 %) during follow-up. Laparoscopic Heller-Dor operation using hook electrocautery is safe, inexpensive, and effective treatment for achalasia which is useful for teaching and training surgical residents in advanced laparoscopic surgery.
| S-EPMC3824775 | biostudies-literature
Project description:IntroductionAchalasia is a rare esophageal motility disorder causing dysphagia and weight loss. Severe cases may present with a significantly dilated and sigmoid-shaped esophagus (sigmoid achalasia). Traditionally, esophagectomy was used for such cases. However, laparoscopic Heller myotomy (LHM) is emerging as a less invasive alternative with comparable outcomes.Case presentationWe present a 45-year-old male with a seven-year history of dysphagia, regurgitation, chest pain, and recent weight loss. Barium esophagogram, high-resolution esophageal manometry, and upper endoscopy confirmed severe achalasia with a sigmoid esophagus (Type I according to Chicago classification). Esophagectomy was considered, but due to the patient's age and the lack of prior treatment attempts, LHM with Dor's fundoplication was performed successfully. At 24-month follow-up, the patient reported significant symptom improvement and weight gain.Clinical discussionWhile esophagectomy was historically used for severe achalasia, LHM is increasingly being employed due to its minimally invasive nature and favorable outcomes. This case highlights the potential benefits of LHM in carefully selected patients with severe achalasia, even those with sigmoid esophagus. However, it's important to acknowledge that LHM may not be suitable for all end-stage cases, and esophagectomy might be necessary in some situations. CONCLUSIóN: Laparoscopic Heller myotomy with Dor's fundoplication is a promising treatment option for end-stage of achalasia, offering faster recovery and improved quality of life. However, further long-term studies are needed to confirm its long-term effectiveness.
| S-EPMC11570774 | biostudies-literature
Project description:Laparoscopic Sleeve Gastrectomy (LSG) is one of the most common bariatric operations done worldwide [1]. About 6.6% of the LSG is being converted to laparoscopic roux-en-Y gastric bypass (LRYGB), most commonly due to inadequate weight loss (65%) and severe reflux (26%) [2]. The most common late complications after LRYGB are dumping, small bowel obstruction, internal hernia, weight regain, marginal ulcer, strictures of the gastro-jejunostomy [3] and rarely proximal stricture at the gastric pouch as our presented case. Treatment options for such a case may start with endoscopic dilatation and if not succeeded it may warrant surgical intervention as shortening of the pouch and redo of the gastrojejunostomy proximal to the stricture or even total gastrectomy and esophago-jejunal anastomosis. Sero-myotomy of the gastric pouch can be done as the same technique which can be used in sero-myotomy of sleeved stomach with stricture [4] and spare resection of the pouch. This report aims to present a new option of surgical management for proximal stricture of the gastric pouch after LRYGB which to our knowledge was never published in the literature.
| S-EPMC7744812 | biostudies-literature
Project description: Not available
| S-EPMC11574155 | biostudies-literature
Project description:BackgroundThe surgical treatment for esophageal achalasia has evolved over the years, with laparoscopic Heller myotomy (LHM) and partial fundoplication becoming widely used worldwide. More recently, an increased interest in the robotic Heller myotomy (RHM) has arisen.PurposeCompare short-term and functional outcomes of RHM vs. LHM.MethodsSystematic review and meta-analysis. PubMed, MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried. Primary outcome was esophageal perforation (EP). Risk ratio (RR), standardized mean difference (SMD), and 95% confidence intervals (95% CI) were effect size and relative inference measures. PROSPERO Registration Number: CRD42024512644.ResultsFourteen observational studies (12962 patients) were included. Of those, 2503 (19.3%) underwent RHM. The patient age ranged from 34 to 66 years and 51.7% were males. EP occurred in 259 patients (1.99%). The cumulative incidence of EP was 1.67% for RHM and 2.07% for LHM. Compared to LHM, RHM was associated with a reduced risk of EP (RR: 0.31; 95% CI 0.16-0.59). No differences were found in term of dysphagia requiring reoperation or additional endoscopic procedures (RR: 0.47; 95% CI 0.20-1.09) and postoperative Eckardt score (SMD: -0.42; 95% CI -0.94, 0.11). Blood loss, conversion to open, operative time, and hospital length of stay were comparable.ConclusionsRHM may be associated with a reduced risk of EP compared to LHM. However, because of selection bias, diverse surgeon expertise, variations in surgical technique, and prior endoscopic procedures these findings should not be viewed as conclusive while the superiority of one approach over the other remains to be established.
| S-EPMC11832576 | biostudies-literature
Project description:BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective treatment for morbid obesity, but might aggravate gastrointestinal complaints and food intolerance. The long-term prevalence of these symptoms has not been well studied.MethodsIn a cross-sectional study, all patients who underwent primary LRYGB from May to October 2012 were approached 2 years after surgery to complete a general health questionnaire, the Gastrointestinal Symptom Rating Scale (GSRS), and a food intolerance questionnaire. The results were compared with those for a control group of morbidly obese patients.ResultsA total of 249 patients were included for analysis, representing a response rate of 93·9 per cent. Mean(s.d.) total weight loss was 30·8(8·7) per cent. The total mean GSRS score was higher in patients who had LRYGB (median 2·19 versus 1·75 in unoperated patients; P < 0·001); the difference in symptoms of indigestion was most notable (P < 0·001). Food intolerance for specific products was reported by 70·7 (95 per cent c.i. 64·8 to 76·0) per cent of the postoperative patients, for a median of 4 foods. There was a positive correlation between food intolerance and score on the GSRS. There was no correlation between either food intolerance or the total mean GSRS score and weight loss, but there was a correlation between weight loss and abdominal pain.ConclusionAt 2 years after surgery, patients undergoing LRYGB for morbid obesity have more gastrointestinal complaints than obese controls. Food intolerance is a common side-effect of LRYGB independent of degree of weight loss or the presence of other abdominal symptoms.
| S-EPMC5324533 | biostudies-literature
Project description:AimBariatric surgery induces significant weight loss, increases insulin sensitivity, and reduces mortality, but the underlying mechanisms are not clear. It was hypothesized that Roux-en-Y gastric bypass (RYGB) surgery improves metabolic profile along with weight loss. The objective of this pilot study was to evaluate changes in serum metabolites and fatty acids (FA) at 2 weeks and 6 months after RYGB.Materials and methodsSerum samples were collected pre-surgery, at 2 weeks and 6 months post-surgery from 20 patients undergoing RYGB surgery. Serum non-esterified free FA (NEFA) were measured. Serum metabolites and FA were measured using nuclear magnetic resonance spectroscopy and improved direct fatty acid methyl ester synthesis and the gas chromatography/mass spectrometry method, respectively, in subjects who completed follow-up at 6 months (n = 8).ResultsMean (standard deviation) percent total weight loss was 6.70% (1.7) and 24.91% (6.63) at 2 weeks (n = 15) and 6 months (n = 8) post-surgery, respectively. NEFA were significantly reduced at 6 months post-surgery (P = 0.001, n = 8). Serum branched chain amino acids, 2-aminobutyrate, butyrate, 2-hydroxybutyrate, 3-hydroxybutyrate, acetone, 2-methylglutarate, and 2-oxoisocaproate were significantly reduced, while serum alanine, glycine, pyruvate, and taurine were significantly elevated at 6 months post-surgery compared with pre-surgery (n = 8, P < 0.05). Also, serum FA C10:0, C13:0, C14:0, C15:0, and C18:0 increased significantly (n = 8, P < 0.05) by 6 months post-surgery.ConclusionsChanges in serum metabolites and FA at 6 months post-RYGB surgery in this pilot study with limited number of participants are suggestive of metabolic improvement; larger studies are warranted for confirmation.
| S-EPMC6238211 | biostudies-literature