LAPAROSCOPIC HELLER-DOR IS AN EFFECTIVE TREATMENT FOR ESOPHAGEAL-GASTRIC JUNCTION OUTFLOW OBSTRUCTION
Luca Provenzano*, Renato Salvador, Giulia Nezi, Giovanni Capovilla, Lucia Moletta, Elisa Sefora Pierobon, Loredana Nicoletti, Michele Valmasoni, Stefano Merigliano, Mario Costantini
University of Padova, Padova, Italy
BACKGROUND: Esophago-Gastric Junction Outflow Obstruction (EGJOO) is a new clinical entity resulting from a poorly relaxing lower esophageal sphincter (i.e.: IRP>15mmHg) with preserved esophageal-peristalsis. Currently, the treatment of this new motility disorder follows that of achalasia but this is based on a few studies with small case series only. The aim of this prospective, controlled study was to evaluate the outcome of Laparoscopic Heller-Dor (LHD) in patients with EGJOO, as compared to patients with esophageal achalasia.
METHODS: From 2016 to 2019, patients with manometric diagnosis of idiopathic EGJOO (i.e. not postoperative or associated to hiatal hernia), referred for dysphagia or food regurgitation, and patients with early (radiological stage I) achalasia, both treated with LHD, were compared. The achalasia group was further analyzed by subgrouping the patients based on the manometric pattern I, II & III. Symptoms were prospectively scored using a detailed questionnaire. Barium-swallow, endoscopy and High Resolution Manometry (HRM) were performed before and after the treatment. Treatment failure was defined as a postoperative symptom score >10th percentile of the preoperative score (i.e. > 8) or the need of retreatment.
RESULTS: During the study period, 148 patients were observed: 23 patients had EGJOO and 125 radiological stage I achalasia: 25 pattern I, 74 pattern II and 26 pattern III. The patients’ demographic and clinical parameters are summarized in table 1. An history of endoscopic treatments (pneumatic dilation, botox injections, or both) was more prevalent in the EGJOO group (39%) than in pattern I group (16%), pattern II group (12.2%) and pattern III group (7.7%)(p=0.01). No mortality was recorded. In the achalasia group two patients had an intraoperative mucosal lesion, repaired during the operation and without furher consequences. The median follow-up was 20 months (IQR:30-14). All patients had a reduction in the symptom score after LHD. A positive final outcome was obtained in 95.7% of patients in the EGJOO group, as compared to 96% in the pattern I group, 98.7% in the pattern II group and 96.2% in the pattern III group (p=n.s.). HRM showed a reduction in the LES resting pressure and IRP in all patients of the 4 groups. The postoperative median IRP was similar in all groups. Also 24-h pH-monitoring showed a postoperative abnormal acid exposure comparable in all groups: 16.6% of EGJOO patients, 12.5% of pattern I, 7.5% of pattern II and 14.3% of pattern III patients (p=n.s.). (Table 2)
CONCLUSIONS: This is the first prospective-controlled study that assessed the outcome of LHD in patients with EGJOO. Laparoscopic Heller-Dor appears to be an effective treatment for EGJOO, with an excellent success rate comparable to that obtained with the same operation in early stage achalasia.
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