Esophagogastric junction outflow obstruction successfully treated with laparoscopic Heller myotomy and Dor fundoplication: First case report in the literature

Abstract

BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) is a rare syndrome, characterized by an elevation of the integrated relaxation pressure of the lower esophageal sphincter, not accompanied by alterations in esophageal motility that may lead to the criteria for achalasia. We were unable to find any prior report of the combination of Heller myotomy with anterior partial fundoplication (Dor) as the treatment for EGJOO. We herein report a case of EGJOO treated with laparoscopic Heller myotomy combined with Dor fundoplication. CASE SUMMARY A 26-year-old man presented with a 3-year history of solid dysphagia and a 30-kg weight loss. He was treated with oral nifedipine, isosorbide, and omeprazole, without resolution of symptoms. An upper gastrointestinal series (barium swallow) revealed a “bird’s beak” sign. Esophagogastroduodenoscopy was positive for Los Angeles grade A peptic esophagitis. High-resolution esophageal manometry was compatible with EGJOO. Esophageal pH monitoring showed pathological acid reflux both in orthostatic and decubitus position. An 8-cm laparoscopic Heller myotomy combined with an anterior 220° Dor fundoplication was performed. Solid diet was introduced on postoperative day 2, and the patient was discharged home the same day. At 17-mo follow-up, he reported no symptoms. Barium swallow was compatible with complete radiologic resolution. Both esophageal manometry and upper endoscopy showed normal findings 9 mo after the operation. CONCLUSION Surgical treatment with Heller myotomy and Dor fundoplication is a potential treatment option for EGJOO refractory to medical treatment.

Esophageal peroral endoscopic myotomy (POEM) for treatment of esophagogastric junction outflow obstruction: results from the first prospective trial

“…Since its introduction [15], POEM has established itself as a minimally invasive LES-targeted therapy for management of achalasia; however, its role in non-▶ achalasia esophageal dysmotility disorders, such as EGJOO, remains poorly defined. A recent case report described the feasibility of laparoscopic Heller myotomy for management of EGJOO [16]. Few studies have assessed the role of POEM in EGJOO and reported shortterm clinical efficacy ranging from 90 % to 100 % [7][8][9][10][11].…”

“…A recent case report described the feasibility of laparoscopic Heller myotomy for management of EGJOO 16 . Few studies have assessed the role of POEM in EGJOO and reported short-term clinical efficacy ranging from 90 % to 100 % 7 8 9 10 11 .…”

Multifactorial dysphagia: Azygos vein aneurysm (AVA) and esophagogastric junction outflow obstruction (EGJOO)

“…While the treatment was very successful, and even quoted to be the procedure of choice, their study only identified two patients total with EGJOO [ 12 ]. A case report by Pereira et al showed a complete response of GEJOO to LHM-DF, suggesting that this would be an ideal operation for these patients [ 13 ]. A subsequent review by Hungness et al enrolled 112 patients, 9 with EGJOO, for the POEM procedure and close follow up to assess resolution of their disease.…”

Is EGJOO a Purely Manometric Diagnosis?

“…Heller myotomy has been shown to have efficacy in treatment of EGJOO with durable symptomatic relief in 96% to 100% of patients. 6,15,[54][55][56] The largest prospective study of surgical treatment of EGJOO was recently reported and included 25 patients who underwent laparoscopic Heller myotomy with Dor fundoplication. Patients in this study had EGJOO with ongoing symptoms of dysphagia and regurgitation despite prior treatment with botulinum toxin, pneumatic dilation, or calcium channel blockers.…”