ESOPHAGEAL PULL-DOWN TECHNIQUE IMPROVES THE FINAL OUTCOME OF LAPAROSCOPIC HELLER-DOR FOR END-STAGE ACHALASIA
Giulia Nezi*, Francesca Forattini, Luca Provenzano, Giovanni Capovilla, Arianna Vittori, Loredana Nicoletti, Lucia Moletta, Elisa Sefora Pierobon, Andrea Costantini, Michele Valmasoni, Mario Costantini, Renato Salvador
Universita degli Studi di Padova, Padova, Italy
BACKGROUND: The results of Laparoscopic Heller-Dor for achalasia are generally consistent: a good outcome is reported in between 90%-80% of patients.
Patients with sigmoid shape (radiological stage IV achalasia) have an advanced form of the disease and are considered the most difficult to treat, with a success rate that drops to 70%-50%
A modified technique (pull-down) has been proposed to straighten the esophageal axis, but there is a limited amount of data available in literature. In this study, we aimed to compare the final outcome of the pull-down technique (PDLHD) with the results of classical myotomy (CLHD) in patients with end-stage achalasia.
METHODS: From 1995 to 2022, patients with a radiological diagnosis of end-stage achalasia undergoing laparoscopic myotomy were enrolled in the study.
CLHD was performed using the established technique. The PDLHD technique included: after circling the gastro-esophageal junction using a string, a length of approximately 10 cm of the lower mediastinal esophagus was isolated. Two stitches were applied on each side, then tied to anchor the wall of the esophagus to the diaphragmatic pillars. After verticalizing the esophageal axis, the Heller-Dor myotomy was performed.
Symptoms were quantified using the Eckardt score. Barium-swallow, endoscopy and manometry were performed before and after the treatment. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score ≥ 3, or the need for retreatment.
RESULTS: Of the 94 patients with end-stage achalasia (M:F = 52:42), 60 patients were treated with CLHD, and 34 patients with PDLHD.
The patients' demographic and clinical data are summarised in table 1. All patients had a preoperative manometric pattern I. The median duration of symptoms was longer in PDLHD (144 months, IQR 72-240) than CLHD (24 months, IQR 25-120).
The surgical procedures were completed laparoscopically in all patients. There were 2 mucosal lesions: one in each group (p=n.s).
The median follow-up was 72 months (IQR:33-113) in the CLHD and 30 months (IQR:12-99) in the PDLHD group. (p>0.01).
All patients in both groups had an improvement in their Eckardt score after surgery, but the failure rates were 27% (16/60) after CLHD and 6% (2/34) after PDLHD (p=0.01)
Amongst the patients who underwent complete post-operative follow-up, an abnormal acid exposure was detected in 2 patients after PDLH and in 6 after CLHD (p=n.s.).
CONCLUSIONS: Taken into account the intrinsic limitations of the study (different time window, and different follow-up), the results of this study indicate that performing the pull-down technique during Laparoscopic Heller-Dor improves the final outcome in end-stage achalasia patients. Therefore, PDLHD should be the first surgical option to be offered to these patients before considering esophagectomy.
Table 1. Preoperative and intraoperative data
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