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Recurrent achalasia after Heller-Toupet procedure: Laparoscopic extended redo heller myotomy and floppy Dor.

Golash V - J Minim Access Surg (2007)

Bottom Line: These recurrences can be managed by regular dilation failing which a redo surgery is indicated.Laparoscopic approach is now standard because of the obvious benefits for patients and surgeons.Patient is asymptomatic six months after the surgery and radiologically there is free passage of barium in the stomach.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Sultan Qaboos Hospital, P.O. Box: 98, Salalah, 211, Sultanate of Oman.

ABSTRACT
Recurrences of symptoms after the surgery for achalasia cardia are not uncommon. There are several causes of recurrences but the early recurrences are speculated to be secondary to incomplete myotomy and late recurrence due to fibrosis after the myotomy or megaesophagus. These recurrences can be managed by regular dilation failing which a redo surgery is indicated. Laparoscopic approach is now standard because of the obvious benefits for patients and surgeons. Extent of myotomy and addition of fundoplication are debatable issue in the management of achalasia cardia but evidence suggests that some kind of fundoplication would be necessary after the complete division of lower esophageal sphincter. We present our experience in a case of recurrent achalasia, secondary to incomplete myotomy managed laparoscopically by extended myotomy and a floppy anterior fundoplication. Patient is asymptomatic six months after the surgery and radiologically there is free passage of barium in the stomach.

No MeSH data available.


Related in: MedlinePlus

Myotomy with ultracision shears
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Figure 0005: Myotomy with ultracision shears

Mentions: The port positions were same as for laparoscopic hiatus hernia repair [Figure 1A]. The liver was completely adherent to the diaphragm and retraction of liver was not necessary requiring only four ports [Figure 1D]. The surgery was difficult because of loss of planes, distorted anatomy, excessive scarring and severe adhesions in the esophagogastric region. After adhesiolysis around the hiatus area, it became clear that a posterior fundoplication was attempted at previous surgery, which had disrupted. We chipped away slowly and steadily and the hiatus and the crure were cleared. The esophagus was mobilized circumferentially in the posterior mediastinum and was straightened. The posterior vagus nerve was identified after undoing the fundoplication, the anterior vagus nerve was seen proximally in the mediastinum to the left of the previous myotomy and was lifted away to complete the myotomy, excessive care was taken not to injure the vagi. The proximal myotomy was extended to 8-9 cm and the lower limit of the cardiomyotomy was extended up to 3 cm on the stomach to completely divide the lower esophageal sphincter.[1] Myotomy was performed using ultracision shears [Figure 2A, B]. Per-operative endoscopy was helpful during the surgery. Completeness of the myotomy was confirmed on table endoscopy and at the same time air leak test was done to rule out any mucosal perforation. The posterior fundoplication was converted to floppy Dor fundoplication after dividing the short gastric vessels [Figure 2C, D]. The Surgery lasted for 180 minutes. There were no per-operative complications and no blood transfusion required. He was fed liquids on first postoperative day. His dysphasia and regurgitation improved considerably and postoperative barium meal done at one month and six months showed the cardia diameter of more than 1 cm, significant reduction in the esophageal diameter and free passage of barium in the stomach.


Recurrent achalasia after Heller-Toupet procedure: Laparoscopic extended redo heller myotomy and floppy Dor.

Golash V - J Minim Access Surg (2007)

Myotomy with ultracision shears
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2749184&req=5

Figure 0005: Myotomy with ultracision shears
Mentions: The port positions were same as for laparoscopic hiatus hernia repair [Figure 1A]. The liver was completely adherent to the diaphragm and retraction of liver was not necessary requiring only four ports [Figure 1D]. The surgery was difficult because of loss of planes, distorted anatomy, excessive scarring and severe adhesions in the esophagogastric region. After adhesiolysis around the hiatus area, it became clear that a posterior fundoplication was attempted at previous surgery, which had disrupted. We chipped away slowly and steadily and the hiatus and the crure were cleared. The esophagus was mobilized circumferentially in the posterior mediastinum and was straightened. The posterior vagus nerve was identified after undoing the fundoplication, the anterior vagus nerve was seen proximally in the mediastinum to the left of the previous myotomy and was lifted away to complete the myotomy, excessive care was taken not to injure the vagi. The proximal myotomy was extended to 8-9 cm and the lower limit of the cardiomyotomy was extended up to 3 cm on the stomach to completely divide the lower esophageal sphincter.[1] Myotomy was performed using ultracision shears [Figure 2A, B]. Per-operative endoscopy was helpful during the surgery. Completeness of the myotomy was confirmed on table endoscopy and at the same time air leak test was done to rule out any mucosal perforation. The posterior fundoplication was converted to floppy Dor fundoplication after dividing the short gastric vessels [Figure 2C, D]. The Surgery lasted for 180 minutes. There were no per-operative complications and no blood transfusion required. He was fed liquids on first postoperative day. His dysphasia and regurgitation improved considerably and postoperative barium meal done at one month and six months showed the cardia diameter of more than 1 cm, significant reduction in the esophageal diameter and free passage of barium in the stomach.

Bottom Line: These recurrences can be managed by regular dilation failing which a redo surgery is indicated.Laparoscopic approach is now standard because of the obvious benefits for patients and surgeons.Patient is asymptomatic six months after the surgery and radiologically there is free passage of barium in the stomach.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Sultan Qaboos Hospital, P.O. Box: 98, Salalah, 211, Sultanate of Oman.

ABSTRACT
Recurrences of symptoms after the surgery for achalasia cardia are not uncommon. There are several causes of recurrences but the early recurrences are speculated to be secondary to incomplete myotomy and late recurrence due to fibrosis after the myotomy or megaesophagus. These recurrences can be managed by regular dilation failing which a redo surgery is indicated. Laparoscopic approach is now standard because of the obvious benefits for patients and surgeons. Extent of myotomy and addition of fundoplication are debatable issue in the management of achalasia cardia but evidence suggests that some kind of fundoplication would be necessary after the complete division of lower esophageal sphincter. We present our experience in a case of recurrent achalasia, secondary to incomplete myotomy managed laparoscopically by extended myotomy and a floppy anterior fundoplication. Patient is asymptomatic six months after the surgery and radiologically there is free passage of barium in the stomach.

No MeSH data available.


Related in: MedlinePlus