Prevention of Post-operative Leak Following Laparoscopic Heller Myotomy

Finan, Kelly R.; Renton, David; Vick, Catherine C.; Hawn, Mary T.

doi:10.1007/s11605-008-0687-4

Cited by 14 publications

(17 citation statements)

References 35 publications

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“…15 However, our findings appear inconsistent with several previous studies, including an earlier work from our own institution, which found no difference in outcomes. [18][19][20][21] Such apparent inconsistencies are possibly explained by our approach to patient categorization. Previous studies have compared patients with any preoperative endoscopic treatment to those receiving no prior treatment.…”

Section: Discussionmentioning

confidence: 99%

“…12,13 Studies evaluating the association of preoperative endoscopic interventions with surgical outcomes have yielded conflicting results, with some showing worse outcomes among those treated endoscopically [14][15][16][17] and others showing no difference. [18][19][20][21] The association between preoperative endoscopic treatments and surgical outcomes is further clouded by varying definitions of surgical failure based on postoperative symptoms. Postoperative dysphagia may arise from recurrence or persistence of achalasia, possibly due to endoscopic LES trauma, inadequate myotomy, or a different subtype or severity of achalasia.…”

Section: Introductionmentioning

confidence: 99%

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Multiple Preoperative Endoscopic Interventions Are Associated with Worse Outcomes After Laparoscopic Heller Myotomy for Achalasia

Snyder

Burton

Brown

et al. 2009

Journal of Gastrointestinal Surgery

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Multiple Preoperative Endoscopic Interventions Are Associated with Worse Outcomes After Laparoscopic Heller Myotomy for Achalasia

Snyder

Burton

Brown

et al. 2009

Journal of Gastrointestinal Surgery

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“…Many reports have revealed that preoperative endoscopic treatments did not lead to deterioration of the clinical results after LHM. [26][27][28][29][30][31] However, other reports have shown that previous endoscopic treatment increased the intraoperative complications and affected the long-term results. [32][33][34] In multivariate regression analysis controlling for age and sex by Finley et al, preoperative PD, EBTI, and a fundoplication were associated with a signifi cantly worse early postoperative dysphagia, with OR of 2.11, 2.56, and 2.80, respectively.…”

Section: Introductionmentioning

confidence: 99%

“…67 Intraoperative leak testing minimizes the risk of postoperative leaks and expedites postoperative management. 30 Dor's fundoplication prevents the risk of mucosal perforation to cover the exposed mucosa. Pathologically increased esophageal exposure to acid was more commonly detected in patients with a pseudodiverticulum.…”

Section: Introductionmentioning

confidence: 99%

Surgical treatment for achalasia: when should it be performed, and for which patients?

Kashiwagi

Omura

2011

Gen Thorac Cardiovasc Surg

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Achalasia is a rare motor disorder of the esophagus, characterized by the absence of peristalsis and impaired swallow-induced relaxation. In the past decade, evidence has been accumulated suggesting that achalasia may be an immune-mediated inflammatory disorder. With the advent of minimally invasive surgery, laparoscopic Heller myotomy (LHM) has slowly shifted the treatment of achalasia toward the greater use of surgical therapy. The goal of both surgical and nonsurgical treatment is to eliminate the outflow obstruction afforded by a nonrelaxing sphincter, relieving dysphagia and maintaining a barrier against gastroesophageal reflux (GER). Endoscopic botulinum toxin injection (EBTI) is safe, easy to perform, inexpensive, and effective in aged patients, and it is especially effective when the lower esophageal pressure is hypertonic. This therapeutic option is reserved for patients too ill to undergo any surgical procedure. Pneumatic dilation (PD) has been shown to be an effective and inexpensive treatment with few adverse effects. The long-term success rate of PD seems to drop progressively over time. Heller myotomy (HM) has shown the best clinical efficacy in achalasia as a first-line treatment. Multiple endoscopic treatments are associated with poorer outcomes after HM. EBTI also makes LHM more difficult and results in a worse surgical outcome. The inferior symptomatic outcomes after thoracoscopic HM may be caused by the difficulty in extending an adequate myotomy onto the stomach from the chest and the inability to create a fundoplication. LHM with Dor's fundoplication (LHM + Dor) is effective and is safer procedure for avoiding GER, dysphagia, mucosal perforation, and a pseudodiverticulum. LHM + Dor is also effective in the presence of sigmoid achalasia, but the clinical result is not as good as nonsigmoid achalasia. A few patients need esophagectomy for surgical failure of HM. However, considering the risk of esophagectomy, LHM + Dor is the first treatment option for patients with achalasia regardless of the degree of esophageal dilatation. This procedure is therefore considered to be an effective and safe treatment for patients of any age or with any condition.

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“…This can be done with methelyne blue or as an air leak test performed with intraoperative endoscopy. 9,10 In addition, there is wide spread use of postoperative check swallows before commencement of oral feed to determine whether there is any mucosal injury and thus risk of leak. 11 This usually necessitates a hospital inpatient stay that can lead to a delayed discharge and subsequent increase in the cost of the procedure.…”

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confidence: 99%

Are Contrast Swallows Necessary Immediately Postlaparoscopic Heller Cardiomyotomy?

Madhavan

Phillips

Carr

et al. 2014

Surgical Laparoscopy, Endoscopy &Amp; Percutaneous Techniques

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Laparoscopic cardiomyotomy is an effective treatment for achalasia. Intraoperative leak tests are carried out to exclude mucosal perforations, additionally some surgeon perform postoperative contrast swallows. The aim of the study was to identify whether postoperative contrast swallows were necessary in all patients who undergo laparoscopic cardiomyotomy. All patients who underwent a laparoscopic cardiomyotomy at a single center between 2004 and 2011 were identified. Median age was 55 (18 to 79), median body mass index 26 (17 to 37), and median length of stay was 1 day (1 to 4). A total of 54% of patients had previous pneumatic dilatations. One intraoperative mucosal perforation was identified and repaired. No leaks were seen on the postoperative swallow; however, 1 patient was readmitted with a contained leak, 8 days after surgery. Postoperative contrast swallow did not have any clinical impact. We suggest that they are only indicated if there is a clinical concern and that laparoscopic cardiomyotomy can be safely carried out as a day case procedure.

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Prevention of Post-operative Leak Following Laparoscopic Heller Myotomy

Abstract: Laparoscopic Heller myotomy for the treatment of achalasia is a safe procedure. Intra-operative leak testing minimizes the risk of post-operative leaks and expedites post-operative management. Prior endoscopic treatment does not impair operative results.

Cited by 14 publications

References 35 publications

Multiple Preoperative Endoscopic Interventions Are Associated with Worse Outcomes After Laparoscopic Heller Myotomy for Achalasia

Multiple Preoperative Endoscopic Interventions Are Associated with Worse Outcomes After Laparoscopic Heller Myotomy for Achalasia

Surgical treatment for achalasia: when should it be performed, and for which patients?

Are Contrast Swallows Necessary Immediately Postlaparoscopic Heller Cardiomyotomy?

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