Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy.
Department of Surgical, Gastroenterological and Oncological Sciences, Unit of Surgery 1, University of Padua, Padua, Italy.
J Gastrointest Surg. 2024 Sep;28(9):1533-1539. doi: 10.1016/j.gassur.2024.06.013.
In the last 3 decades, laparoscopic Heller myotomy (LHM) has represented the treatment of choice for esophageal achalasia, solving symptoms in most patients. Little is known about the fate of patients relapsing after LHM or their treatment. In this study, we aimed at evaluating the results of complementary pneumatic dilations (CPDs) after ineffective LHM.
We evaluated the patients who underwent LHM with Dor fundoplication (LHD) from 1992 to 2022 and were submitted to CPD for persistent or recurrent symptoms. The patients were followed clinically and with manometry, barium swallow, and endoscopy when necessary. An Eckardt score (ES) of > 3 was used as threshold for failure.
Of 1420 patients undergoing LHD, 120 (8.4%) were considered failures and were offered CPD. Ten patients refused further treatment; in 5 CPD was not indicated for severe esophagitis; 1 patient had surgery for a misshaped fundoplication and 1 patient developed cancer 2 years after LHD; that leaves 103 patients who underwent a median 2 CPDs (IQR, 1-3), at a median of 15 (IQR, 8-36) months after surgery, with 3.0- to 4.0-cm Rigiflex dilator (Boston Scientific, Massachusetts, USA). No perforations were recorded. Only 6 patients were lost to follow-up. Thus, 97 were followed for a median of 37 months (IQR, 6-112) after the last CPD: 70 (72%) were asymptomatic, whereas 27 (28%) had significant persistent dysphagia (ES > 3). The only differences between the 2 groups were the ES after surgery (P < .01) and the number of required CPD. Overall, the combination of LHD + CPD provided a satisfactory outcome in 96.5% of the patients.
CPDs represent an effective and safe option to treat patients after a failed LHD: when the postsurgery ES consistently remains high and the number of CPDs required to control symptoms exceeds 2, this may suggest the need for further invasive treatments.
在过去的 30 年中，腹腔镜 Heller 肌切开术（LHM）已成为治疗食管失弛缓症的首选方法，可解决大多数患者的症状。对于 LHM 后复发的患者及其治疗方法，人们知之甚少。在这项研究中，我们旨在评估无效 LHM 后补充性气动扩张术（CPD）的结果。
我们评估了 1992 年至 2022 年间接受 LHM 加 Dor 胃底折叠术（LHD）的患者，并对持续或复发症状的患者进行 CPD。患者接受临床和测压、钡餐吞咽和必要时的内镜检查。Eckardt 评分（ES）>3 用作失败的阈值。
在 1420 例接受 LHD 的患者中，有 120 例（8.4%）被认为是失败病例，并接受了 CPD。10 名患者拒绝进一步治疗；5 名患者因严重食管炎而不适合 CPD；1 名患者因胃底折叠术变形而手术，1 名患者在 LHD 后 2 年患癌症；这剩下 103 名患者在手术后中位数为 15（IQR，8-36）个月时接受了中位数为 2 次 CPD（IQR，1-3），使用 3.0-4.0-cm Rigiflex 扩张器（波士顿科学公司，马萨诸塞州，美国）。没有穿孔记录。只有 6 名患者失访。因此，在最后一次 CPD 后中位数 37 个月（IQR，6-112）随访了 97 名患者：70 名（72%）无症状，而 27 名（28%）有明显持续的吞咽困难（ES>3）。两组唯一的区别是手术后的 ES（P<0.01）和所需 CPD 的数量。总体而言，LHD+CPD 为 96.5%的患者提供了满意的结果。
CPD 是治疗 LHM 后失败患者的有效且安全的选择：当术后 ES 持续升高且控制症状所需的 CPD 数量超过 2 时，可能需要进一步的侵入性治疗。
