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Accepted for Publication at the Medical Journal of Cairo University, 4-7-2018 Safety and Efficacy of Laparoscopic Cardiomyotomy for Esophageal Achalasia: A Prospective Cohort StudyMostafa M. Sayed1, Ayman Kamal1, Abdallah M. Taha2*, Mohamed G. Taher1 Zain A. Sayed3, Mohamed El- Masry3, Mostafa A. Hamad1.*Corresponding authors:1 General Surgery Department, Faculty of Medicine, Assuit University, Egypt2General Surgery Department, Faculty of Medicine, South Valley University, Egypt3Internal Medicine Department, Faculty of Medicine, Assuit University, Egyptmostafa.sayed1974@Short Title: Laparoscopic cardiomyotomy for achalasia AbstractBackground: Achalasia is a rare but troublesome disease with multiple treatment options. Currently, no treatment option can change the underlying pathology of the disease. All available options only palliate symptoms to varying degrees and for varying durations. They include medications, endoscopic balloon dilatation, Botulinum toxin injection and surgery; open and laparoscopic. Objectives: Prospective study to assess the results of laparoscopic cardiomyotomy with Dor fundoplication for treatment of esophageal achalasia.Patients and Methods: The study included 19 consecutive idiopathic achalasia patients who were admitted to the Surgery Departments in Assuit and South Valley University Hospitals, from April, 1st 2014 to March, 31st 2017. Laparoscopic cardiomyotomy with Dor fundoplication was done in all patients. Mean follow up was 19 (12-30) months. Follow up included changes in Dysphagia, regurgitation, chest pain, heartburn, and chocking during sleep, patient weight and satisfaction after surgery, and intra- and post-operative complications.Results: This study included 11 females and 8 males. Mean age was 44.5 years (range, 18 - 75 years). Mean operative time was 145.5± 36.2 (range 100-210) minutes. Mean hospital stay was 3.5 (range 2- 6) days. Dysphagia, regurgitation, chest pain, heartburn, and chocking during sleep, assessed according to Eckardt scores, improved significantly in 95%, 89%, 70%, 95%, and 75% of patients respectively. P-values were <0.001, < 0.003, < 0.01, <0.01 and < 0.01, respectively. Body weight increased in 90% of patients and 80% of patients claimed satisfaction. Mucosal perforation at the cardia occurred in 2 patients (10%); it was repaired and tested for leakage at the same time without subsequent morbidity. Repeated postprandial vomiting occurred in 5 patients (25%). No postoperative leakage or mortalities occurred.Conclusions: Laparoscopic cardiomyotomy with anterior Dor fundoplication for achalasia is feasible, safe and effective, with significant and durable relief of dysphagia and overall patient symptoms.Keywords: Achalasia, Dysphagia, Laparoscopic Myotomy.1. BackgroundIdiopathic esophageal achalasia is a rare but troublesome 1ry disorder of esophageal motility. It is characterized by spasm and defective relaxation of the lower esophageal sphincter and absent esophageal peristalsis in response to passage of food bolus. This is associated with inflammation and progressive loss of the esophageal myenteric plexus neurons ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1053/gast.1996.v111.pm8780569", "ISSN" : "00165085", "abstract" : "<h2>Abstract</h2><p>BACKGROUND & AIMS: A previous study evaluating the morphological features of esophagi resected for endstage achalasia showed marked depletion of myenteric ganglion cells, widespread destruction of nerves, and variable chronic inflammation. The aim of this study was to evaluate the histological features in esophagomyotomy specimens from 11 patients with early achalasia, defined as minimal to moderate esophageal dilation without sigmoid deformity. METHODS: The histological features of esophagomyotomy specimens from 11 patients with achalasia were analyzed and compared with the findings of control specimens obtained from 8 patients who underwent esophagectomy for intramucosal adenocarcinoma. RESULTS: Control specimens had normal numbers of ganglion cells (0.70-0.91 ganglion cells per high-power field) and minimal inflammation. Three patients with vigorous achalasia had normal ganglion cell numbers (0.79-0.91 ganglion cells per high- power field) and at least mild myenteric inflammation without neural fibrosis. The remaining 8 patients had few or no ganglion cells (0-0.30 ganglion cells per high-power field) and at least mild myenteric inflammation and neural fibrosis. Ganglionitis was found in 2 cases. Ganglion cell number was inversely correlated with degree of myenteric neural fibrosis (P < 0.001). CONCLUSIONS: Vigorous achalasia has pathological features that are distinct from classic achalasia. The earliest pathological changes consist of myenteric inflammation with injury to and subsequent loss of ganglion cells and injury to and fibrosis of myenteric nerves. 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Achalasia has equal sex distribution, no racial predilection, a 1/100,000 annual incidence, peak incidence between 30 and 60 years of age, and a 10/100,000 prevalence. The etiology may be autoimmune, viral immune, or neurodegenerative. There is degeneration of ganglion cells in the myenteric plexus of the esophageal body and the lower esophageal sphincter (LES). The end result is selective loss of inhibitory neurotransmitters (nitrous oxide and vasoactive intestinal peptide). 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This easily available and inexpensive test often helps detect the classic esophageal features of achalasia such as impaired peristalsis, dilated esophagus, and smooth tapering at the gastroesophageal junction “bird’s beak”, the pathognomonic finding in achalasia (fig. 1) ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "1841-8724", "author" : [ { "dropping-particle" : "", "family" : "Pohl", "given" : "Daniel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tutuian", "given" : "Radu", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Gastrointestinal and liver diseases", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2007" ] ] }, "page" : "297", "publisher" : "NOT KNOWN", "title" : "Achalasia: an overview of diagnosis and treatment", "type" : "article-journal", "volume" : "16" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(6)", "plainTextFormattedCitation" : "(6)", "previouslyFormattedCitation" : "(6)" }, "properties" : { }, "schema" : "" }(6). 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Various treatment options for achalasia are available. Medications (calcium channel blockers and nitrates) cause relaxation of the lower esophageal sphincter and relief of dysphagia that last for only minutes after their intake. They are only suitable for temporary symptomatic relief until definitive treatment is done. Botulinum toxin injection into the lower sphincter (LES) relaxes the sphincter and relieves symptoms for several months, but the results are still temporary and the cost is high. 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It addresses the indications, risks, benefits, outcomes, alter-natives, and controversies of the procedures used to treat this condition. The statements included in this guideline are the product of a systematic review of published work on the topic, and the recommendations are explicitly linked to the supporting evidence. The strengths and weaknesses of the available evidence are highlighted, and expert opinion is sought where published evidence lacks depth. Disclaimer Clinical practice guidelines are intended to indicate the best available approach to medical conditions as estab-lished by a systematic review of available data and expert opinion. The approach suggested may not necessarily be the only acceptable approach given the complexity of the healthcare environment. These guidelines are intended to be flexible, because the surgeon must always choose the approach best suited to the individual patient and variables in existence at the moment of decision. 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Balloon dilatation of the lower esophageal sphincter gives durable results for several months but multiple sessions of dilatation are needed. 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CME.", "type" : "article-journal", "volume" : "101" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(8,9,12)", "plainTextFormattedCitation" : "(8,9,12)", "previouslyFormattedCitation" : "(8,9,12)" }, "properties" : { }, "schema" : "" }(8,9,12). Currently, Heller cardiomyotomy seems to be the most durable treatment option for achalasia on the long term outcome ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/GUT.30.3.299", "ISSN" : "0017-5749", "PMID" : "2651226", "abstract" : "Late results in 81 patients with achalasia treated in a prospective randomised study comparing forceful pneumatic dilatation with the Mosher bag and surgical anterior oesophagomyotomy by abdominal route, are reported. There were no deaths from either of the treatments. Two patients (5.6%) had a perforation of the abdominal oesophagus after pneumatic dilatation and were excluded from late follow up. In patients having surgery at radiological evaluation there was gullet diameter significantly increased at the oesophagogastric junction and decreased at the middle third of the oesophagus. One patient was lost from follow up and one died of an oesophageal carcinoma, leaving 95% of excellent results at the late follow up (median 62 months). Resting gastro-oesophageal sphincter pressure decreased significantly to approximately 10 mmHg; this was maintained five years after surgery. By contrast, in patients having pneumatic dilatation, there were good results in only 65% (follow up median 58 months), with 30% failures. One patient was lost from follow up and one developed oesophageal carcinoma. Measurement of resting gastro-oesophageal sphincter pressure after dilatation was highly predictive of the outcome. 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The addition of antireflux procedure, especially the easier anterior Dor fundoplication has decreased the main drawback of cardiomyotomy which is gastroesophageal reflux ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "1531-0132", "author" : [ { "dropping-particle" : "", "family" : "Oelschlager", "given" : "Brant", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pellegrini", "given" : "Carlos A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "MedGenMed: Medscape general medicine", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2003" ] ] }, "page" : "31", "publisher" : "Medscape Health Network", "title" : "Surgical management of achalasia.", "type" : "article-journal", "volume" : "5" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "0930-2794", "author" : [ { "dropping-particle" : "", "family" : "Costantini", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zaninotto", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Guirroli", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rizzetto", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Portale", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ruol", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nicoletti", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ancona", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Surgical Endoscopy And Other Interventional Techniques", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2005" ] ] }, "page" : "345-351", "publisher" : "Springer", "title" : "The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up", "type" : "article-journal", "volume" : "19" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "1092-8472", "author" : [ { "dropping-particle" : "", "family" : "Kaufman", "given" : "Jedediah A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Oelschlager", "given" : "Brant K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Current treatment options in gastroenterology", "id" : "ITEM-3", "issue" : "1", "issued" : { "date-parts" : [ [ "2005" ] ] }, "page" : "59-69", "publisher" : "Springer", "title" : "Treatment of achalasia", "type" : "article-journal", "volume" : "8" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "ISSN" : "1092-6429", "author" : [ { "dropping-particle" : "", "family" : "Newlin", "given" : "Matthew E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mikami", "given" : "Dean J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Melvin", "given" : "Scott W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of laparoendoscopic & advanced surgical techniques", "id" : "ITEM-4", "issue" : "3", "issued" : { "date-parts" : [ [ "2004" ] ] }, "page" : "121-124", "publisher" : "Mary Ann Liebert, Inc.", "title" : "Initial experience with the four-arm computer-enhanced telesurgery device in foregut surgery", "type" : "article-journal", "volume" : "14" }, "uris" : [ "" ] }, { "id" : "ITEM-5", "itemData" : { "DOI" : "10.1007/s00464-011-2017-2", "abstract" : "Preamble The guidelines for the surgical treatment of esophageal achalasia are a series of systematically developed state-ments to assist surgeon (and patient) decisions about the appropriate use of minimally invasive techniques for the treatment of achalasia in specific clinical circumstances. It addresses the indications, risks, benefits, outcomes, alter-natives, and controversies of the procedures used to treat this condition. The statements included in this guideline are the product of a systematic review of published work on the topic, and the recommendations are explicitly linked to the supporting evidence. The strengths and weaknesses of the available evidence are highlighted, and expert opinion is sought where published evidence lacks depth. Disclaimer Clinical practice guidelines are intended to indicate the best available approach to medical conditions as estab-lished by a systematic review of available data and expert opinion. The approach suggested may not necessarily be the only acceptable approach given the complexity of the healthcare environment. These guidelines are intended to be flexible, because the surgeon must always choose the approach best suited to the individual patient and variables in existence at the moment of decision. These guidelines are applicable to all physicians who are appropriately credentialed and address the clinical situation in question, regardless of specialty. Guidelines are developed under the auspices of SAGES\u2014the guidelines committee\u2014and are approved by the Board of Governors. The recommendations of each guideline undergo multidisciplinary review and are con-sidered valid at the time of production based on the data available. New developments in medical research and practice pertinent to each guideline are reviewed, and guidelines will be periodically updated. Literature review method A systematic literature search was performed on MED-LINE in October 2010. The search strategy was limited to adult English language articles and is shown in Fig. 1. We identified 214 relevant articles. The abstracts were reviewed by four committee members (DS, WR, TMF, and GPK) and divided into the following categories: (a) Randomized studies, meta-analyses, and systematic reviews", "author" : [ { "dropping-particle" : "", "family" : "Stefanidis", "given" : "Dimitrios", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Richardson", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Farrell", "given" : "Timothy M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kohn", "given" : "Geoffrey P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Augenstein", "given" : "Vedra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fanelli", "given" : "Robert D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stefanidis", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "V", "family" : "Augenstein", "given" : "\u00c1", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Richardson", "given" : "W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Farrell", "given" : "T M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kohn", "given" : "G P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fanelli", "given" : "R D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Surg Endosc", "id" : "ITEM-5", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "296-311", "title" : "SAGES guidelines for the surgical treatment of esophageal achalasia", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] }, { "id" : "ITEM-6", "itemData" : { "DOI" : "10.1038/ajg.2013.196", "ISSN" : "0002-9270", "abstract" : "ACG Clinical Guideline: Diagnosis and Management of Achalasia", "author" : [ { "dropping-particle" : "", "family" : "Vaezi", "given" : "Michael F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pandolfino", "given" : "John E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vela", "given" : "Marcelo F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The American Journal of Gastroenterology", "id" : "ITEM-6", "issue" : "8", "issued" : { "date-parts" : [ [ "2013", "8", "23" ] ] }, "page" : "1238-1249", "publisher" : "Nature Publishing Group", "title" : "ACG Clinical Guideline: Diagnosis and Management of Achalasia", "type" : "article-journal", "volume" : "108" }, "uris" : [ "" ] }, { "id" : "ITEM-7", "itemData" : { "DOI" : "10.1016/j.amjsurg.2005.08.012", "ISSN" : "00029610", "abstract" : "<h2>Abstract</h2><h3>Background</h3><p>Treatment options for achalasia include medications, endoscopic balloon dilation, injection of botulinum toxin, or surgery.</p><h3>Methods</h3><p>The clinical course of 75 consecutive patients who underwent minimally invasive Heller myotomy and partial fundoplication for achalasia between 1991 and 2001 was reviewed by means of a questionnaire.</p><h3>Results</h3><p>Mean follow-up was 5.3 (range .8 to 10.9) years. Sixty-four percent of questionnaires were returned. Thirty-seven patients (84%) felt much better and 6 (14%) slightly better; 1 (2%) rated the result as unchanged. Twenty-six patients (59%) experienced weight gain. Seven patients (16%) had persistent swallowing problems and 5 (11%) reported frequent reflux. Twenty-five percent underwent additional therapy, including dilation (n = 8, 18%), repeat surgery (n = 2, 5%), and botulinum toxin injection (n = 2, 5%). Eighteen patients (41%) were using a proton pump inhibitor or H2 blocker, three were on a calcium channel blocker (7%), and 1 was using nitroglycerine (2%).</p><h3>Conclusion</h3><p>Laparoscopic Heller myotomy can achieve short- and long-term results comparable to open surgery and should be considered the treatment of choice for patients suffering from achalasia. Despite the frequent need for further therapy, patient satisfaction is good.</p>", "author" : [ { "dropping-particle" : "", "family" : "Bonatti", "given" : "Hugo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hinder", "given" : "Ronald A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Klocker", "given" : "Josef", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Neuhauser", "given" : "Beate", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Klaus", "given" : "Alexander", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Achem", "given" : "Sami R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vault", "given" : "Kenneth", "non-dropping-particle" : "de", "parse-names" : false, "suffix" : "" } ], "container-title" : "The American Journal of Surgery", "id" : "ITEM-7", "issue" : "6", "issued" : { "date-parts" : [ [ "2005", "12", "1" ] ] }, "page" : "883-887", "publisher" : "Elsevier", "title" : "Long-term results of laparoscopic Heller myotomy with partial fundoplication for the treatment of achalasia", "type" : "article-journal", "volume" : "190" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(7,11,14\u201318)", "plainTextFormattedCitation" : "(7,11,14\u201318)", "previouslyFormattedCitation" : "(7,11,14\u201318)" }, "properties" : { }, "schema" : "" }(7,11,14–18).2. Objectives The aim of this prospective study is to assess the results of laparoscopic cardiomyotomy with anterior Dor fundoplication in patients admitted to Assuit and South Valley university hospitals. Assessment includes safety (intra- and post-operative complications) and efficacy (effect of surgery on dysphagia, chest pain, heart burn, regurgitation, chocking during sleep and patient weight and satisfaction).3. Patients and MethodsPatients diagnosed with idiopathic achalasia, were treated with laparoscopic Heller cardiomyotomy with anterior Dor fundoplication in the Surgery Departments, Assuit and South Valley University hospitals from April 1st 2014 to March 31st 2017.All patients had esophagography before surgery. They also had esophageal manometry and upper GI endoscopy.Symptoms including dysphagia, chest pain, heart burn, regurgitation, chocking during sleep and patient weight were recorded before (severity and duration) and after the operation (change in severity, recurrence and symptom-free time). Also, previous treatment for achalasia and any intra- or post-operative complications were recorded.Patients who had esophageal candidiasis diagnosed by endoscopy were treated with oral antifungal (2% miconazole) for 1 week before surgery. We regularly ordered naso-gastric tube insertion for esophageal wash one day and nothing per mouth for 12 hours before surgery. Intravenous fluids were established to avoid dehydration and electrolyte imbalance. Low molecular weight heparin (enoxaparin, 1mg/ Kg body weight was injected subcutaneously 12 hours before surgery for thromboprophylaxis)Surgical Technique:Surgery was done in the supine position under general anesthesia with cuffed endotracheal intubation. Patient legs were spread apart (French position). The laparoscopy tower was placed at 12 o’clock position over the patient’s head. The main surgeon stands between the separated patient legs, the camera man on the patient right side and the second assistant on the patient left side.The 1st trocar (12 mm) for the scope was inserted “by Hasson’s or Visiport technique” just above the umbilicus, and the table was then changed into the steep reverse-Trendlenberg position. The 2nd trocar was inserted above the level of the umbilicus on the left mid-clavicular line, while the 3rd trocar was inserted at the same level on the right mid-clavicular line. A 4th trocar was inserted just below the xyphoid process to apply liver retraction and a 5th one was inserted just below the level of the umbilicus on the left anterior axillary line. The trocars 2-5 were all 5 mm.After routine abdominal exploration, a pars flaccida approach to dissect the phrenoesophageal ligament from the anterior surface of the esophagus was carried out. Dissection clarifies the anterior vagus nerve and the thickened narrowed area of the diseased lower esophageal sphincter and part of the dilated esophagus above and the anterior surface of the cardia and upper stomach below. A 6-8 cm long myotomy above the gastroesophageal junction (to the left of the anterior vagus nerve) that goes downwards to include the cardia and upper 1-1.5 cm of the stomach was performed. The initial snip of the muscle layer was done with the Harmonic Ace (Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA) dissector, just proximal to the cardioesophageal junction. Further deepening of muscle fibers separation until the mucosa and its upward and downward extension was performed by blunt graspers that elevate muscle from mucosa forming a small tunnel, grasp the already separated edges to slowly tear them apart, and so on. Muscle separation from the mucosa was done until almost half circumference of esophageal mucosa is exposed (Fig. 2).After completing the myotomy, air leak test; to detect any mucosal perforation and to show mucosal distension confirming completeness of the maneuver was done. Then, an anterior (180- degree) Dor fundoplication was done with three stitches on each side of the myotomy (2/0 silk sutures, 26 mm half-circle needle). The stitches fix the fundal gastric wall to the edge of the separated esophageal muscle on each side, thus keeping the separated muscle edges apart while buttressing the exposed esophageal mucosa. The first stitch included the diaphragm as well to prevent hiatus hernia. When a perforation was detected it was sutured with 4/0 polyglactin stitches.Finally, an intra-peritoneal drain was inserted. The duration of surgery and both intra- and post-operative complications were recorded.Follow-UpPatient follow up included observing vital signs and the content of the intraperitoneal drain. Patients remained fasting for 24 hours, and then started oral fluids as tolerated. An esophagogram before starting oral fluids was done only when there was intra-operative perforation or unexplained upper abdominal pain or fever.Oral fluids were continued as tolerated for 48 hours then semisolids were introduced and continued for 15 days, when solids were allowed.Patients were asked to come to the outpatient clinic 1 and 3 weeks after their discharge from hospital and every 3 months later for 1 year and every 6 months thereafter.3.3. Statistical Analysis Continuous data were analyzed using Student t-test. Correlation was determined using linear regression analysis. A p-value of 0.05 or less was considered significant.4. Results:The study included 19 patients (11 females and 8 males). Mean age was 44.5 years (18-75). Totally laparoscopic Heller cardiomyotomy with Dor partial anterior fundoplication was done in all the 19 patients. Mean operative time was 145.5± 36.2 (100-210) minutes. Synchronous hiatus hernia was found in 3 patients, this necessitated complete mobilization of the esophagus from the hiatus and dissection of the gastric fundus. Then the surgery was completed classically as for achalasia. Fifteen patients (79%) had recurrence of symptoms after pneumatic balloon dilatation; 11 of them (58%) had several sessions of dilatation. One patient had previous open Heller cardiomyotomy 10 years before; the same patient had hiatus hernia as well.Mean hospital stay was 3.5 (2- 6) days. Mean patient follow up was 19 2.4 (12-30) months. Follow up of our patients was based on Eckardt Achalasia Scoring System to assess the degree of change in every symptom after surgery (tab.; 4). During follow up, dysphagia, regurgitation, chest pain, heartburn, and chocking during sleep, improved significantly in 95%, 89%, 70%, 95%, and 75% of patients respectively. P values were < 0.001, < 0.003, < 0.01, <0.01 and < 0.01, respectively. Patient weight increased in 90% and satisfaction was claimed by 80% of patients. Intra-operative mucosal perforation at the cardia occurred in 2 patients (10%); perforation was repaired and tested for leakage at the same time without subsequent morbidity. Resistant vomiting after drinking that persisted despite regular antiemetic treatment for more than 3 days occurred in 5 (25%) patients. Vomiting was treated with dexamethazone, proton pump inhibitors and prokinetics (mosapride) and subsided gradually until stopped within 2 weeks in 4 of the 5 patients. In one patient, the same patient with history of previous Heller myotomy, intermittent vomiting persisted. In this patient upper GI endoscopy was done and revealed multiple gastric and duodenal ulcerations. Anti-helicobacter regimen was then added. Vomiting stopped within 2 more weeks. No other morbidities or mortalities had occurred. Table 1; Demographic dataGender11 Females8 MalesAgeMean 44.5 (18-75).OP Time145.5± 36.2 (100-210)Synchronous hiatus hernia3 patientshistory of pneumatic balloon dilatation15 (79%)previous open Heller cardiomyotomy1Mean hospital stay3.5 (range 2- 6) daysPatient follow up9-30 months (mean 17 months)Table 2; Post-operative Symptom improvementSymptom% of patientsP valueDysphagia95%<0.001Regurgitation89%< 0.003Chest pain70%< 0.01Heartburn95%<0.01Chocking during sleep75%<0.01Improved patient weight 90%<0.006Patient satisfaction80%0.002Table 3; Peri-operative complicationsIntra-operative mucosal perforation2 (10%) patientsResistant vomiting5 (25%) patientsTable 4; clinical scoring system for achalasia (Eckardt score) modified Alexander et al, 2011 ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "2251-7030", "author" : [ { "dropping-particle" : "", "family" : "Mohajeri", "given" : "Gholamreza", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mahmoudieh", "given" : "Mohsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keleidari", "given" : "Behrouz", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shahraki", "given" : "Masoud Sayadi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mostafapour", "given" : "Elyas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bahrami", "given" : "Faranak", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shahmiri", "given" : "Shahab Shahabi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Minimally Invasive Surgical Sciences", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2016" ] ] }, "publisher" : "Kowsar", "title" : "Laparoscopic Heller Myotomy and Dor Fundoplication: Prospective Evaluation of 30 Consecutive Patients", "type" : "article-journal", "volume" : "5" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(19)", "plainTextFormattedCitation" : "(19)", "previouslyFormattedCitation" : "(19)" }, "properties" : { }, "schema" : "" }(19).ScoreSymptomsWeight loss (Kg)DysphagiaChest painRegurgitationHeart burnChocking 0NonNonnonNonNonNon1<5OccasionalOccasionalOccasionalOccasionalOccasional25-10DailyDailyDailyDailyDaily3>10Each mealEach mealEach mealEach mealEach mealFigure 1. Barium esophagogram showing dilated esophagus with tapering distal end in a patient with achalasiaFigure 2; Intact esophageal mucosa pulging after muscles were widely separated.5-Discussion:Since achalasia first diagnosed by Thomas Willis more than 300 years ago, there is no definite treatment for it and all therapeutic modalities targeted at relieving the symptoms by lowering the lower esophageal sphincter (LES) pressure for the longest period of time.Achalasia initially managed by whalebone dilatation, since then various trials were done on various measures (medical treatment, endoscopic balloon dilatation, Botox injection and surgery ). In the present study laparoscopic Heller myotomy with Dor- fundoplication is the procedure of interest. Heller performed his first esophagomyotomy in 1913, he described both anterior and posterior myotomy; modification to that procedure was done by Zaaiger by doing just anterior esophagomyotomy.This study is considered one of the leading studies in upper Egypt to assess laparoscopic cardiomyotomy aith Dor fundoplication for the treatment of idiopathic esophageal achalasia. All patients were operated by the same team of surgeons.All patients were diagnosed by triple assessment (upper barium study, upper endoscopy and esophageal manometry).The current study revealed that 75% of the patients had a history of pneumatic balloon dilatation and 2 (10%) of them developed intra-operative esophageal mucosal perforation at the cardio-esophageal junction this rate is slightly higher than reported by Gholamreza et al in which the percent was 6.6% ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "2251-7030", "author" : [ { "dropping-particle" : "", "family" : "Mohajeri", "given" : "Gholamreza", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mahmoudieh", "given" : "Mohsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keleidari", "given" : "Behrouz", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shahraki", "given" : "Masoud Sayadi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mostafapour", "given" : "Elyas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bahrami", "given" : "Faranak", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shahmiri", "given" : "Shahab Shahabi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Minimally Invasive Surgical Sciences", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2016" ] ] }, "publisher" : "Kowsar", "title" : "Laparoscopic Heller Myotomy and Dor Fundoplication: Prospective Evaluation of 30 Consecutive Patients", "type" : "article-journal", "volume" : "5" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(19)", "plainTextFormattedCitation" : "(19)", "previouslyFormattedCitation" : "(19)" }, "properties" : { }, "schema" : "" }(20). This difference is probably due to the smaller sample size of the study. On the other hand, both studies agreed with that direct intra-operative suture repair was enough with no post-operative leakage or increase in the hospital stay. Generally, patients with the history of pneumatic balloon dilatation have more risk for intra-operative esophageal mucosal perforation during dissection ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s004649901050", "ISSN" : "0930-2794", "author" : [ { "dropping-particle" : "", "family" : "Alves", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Perniceni", "given" : "T.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Godeberge", "given" : "P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mal", "given" : "F.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "L\u00e9vy", "given" : "P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gayet", "given" : "B.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Surgical Endoscopy", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "1999", "6", "8" ] ] }, "page" : "600-603", "publisher" : "Springer-Verlag", "title" : "Laparoscopic Heller\u2019s cardiomyotomy in achalasia", "type" : "article-journal", "volume" : "13" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(20)", "plainTextFormattedCitation" : "(20)", "previouslyFormattedCitation" : "(20)" }, "properties" : { }, "schema" : "" }(21).laparoscopic Heller myotomy with Dor fundoplication was done for all cases in the present study. During the whole follow-up period, no post-operative gastresophageal reflux (GERD) was observed, dysphagia improved in 95% patients. This result is consistent with that reported by Rebecchi et al as they mentioned that fundoplication play an important role in preventing post-operative GERD symptoms and Dor fundoplication is preferable than Neissen fundoplication in the recurrence of dysphagia ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/SLA.0b013e318190a776", "ISSN" : "0003-4932", "author" : [ { "dropping-particle" : "", "family" : "Rebecchi", "given" : "Fabrizio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giaccone", "given" : "Claudio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Farinella", "given" : "Eleonora", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Campaci", "given" : "Roberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Morino", "given" : "Mario", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of Surgery", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2008", "12" ] ] }, "page" : "1023-1030", "title" : "Randomized Controlled Trial of Laparoscopic Heller Myotomy Plus Dor Fundoplication Versus Nissen Fundoplication for Achalasia", "type" : "article-journal", "volume" : "248" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(21)", "plainTextFormattedCitation" : "(21)", "previouslyFormattedCitation" : "(21)" }, "properties" : { }, "schema" : "" }(22).Hiatal repair was done in all the patients. Three of study patient had hiatal hernias, with hernia sacs dissected early in the procedure with no post-operative morbidity. This procedure was done based on J. Black et al recommendation of doing hiatal repair during laparoscopic Heller myotomy ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/bjs.1800631215", "ISSN" : "00071323", "author" : [ { "dropping-particle" : "", "family" : "Black", "given" : "J.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vorbach", "given" : "A. N.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collis", "given" : "J. Leigh", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British Journal of Surgery", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "1976", "12" ] ] }, "page" : "949-953", "publisher" : "Wiley-Blackwell", "title" : "Results of Heller's operation for achalasia of the oesophagus. The importance of hiatal repair", "type" : "article-journal", "volume" : "63" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(22)", "plainTextFormattedCitation" : "(22)", "previouslyFormattedCitation" : "(22)" }, "properties" : { }, "schema" : "" }(23). The average intra-operative time was 145.5±36.2 minutes which is longer than that of some Heller myotomy with Dor fundoplication studies. This may be explained by our early experience in this complex laparoscopic procedure.As regard the complications, in the study no intra-operative organ injury or post-operative bleeding or leakage had occurred. Moreover, early oral intake, early ambulance, and cosmetic scar confirmed the short-term advantage of laparoscopic procedure as reported by Ancona et al ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0002-9610", "author" : [ { "dropping-particle" : "", "family" : "Ancona", "given" : "Ermanno", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Anselmino", "given" : "Marco", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zaninotto", "given" : "Giovanni", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Costantini", "given" : "Mario", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rossi", "given" : "Mauro", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bonavina", "given" : "Luigi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Buin", "given" : "Francesca", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Peracchia", "given" : "Alberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The American journal of surgery", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "1995" ] ] }, "page" : "265-270", "publisher" : "Elsevier", "title" : "Esophageal achalasia: Laparoscopic versus conventional open Heller-Dor operation", "type" : "article-journal", "volume" : "170" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(23)", "plainTextFormattedCitation" : "(23)", "previouslyFormattedCitation" : "(23)" }, "properties" : { }, "schema" : "" }(24).In this study, no patient required further intervention for relieving dysphagia during follow up period. This may be due to the relatively short period of follow up (19 months) compared to that reported by kristy K. Brown et al (10 years) who reported that no patient required additional procedure before 5 years after surgery ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s00464-017-5845-x", "ISSN" : "0930-2794", "author" : [ { "dropping-particle" : "", "family" : "Kummerow Broman", "given" : "Kristy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Phillips", "given" : "Sharon E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Faqih", "given" : "Adil", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kaiser", "given" : "Joan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pierce", "given" : "Richard A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Poulose", "given" : "Benjamin K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Richards", "given" : "William O.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sharp", "given" : "Kenneth W.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Holzman", "given" : "Michael D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Surgical Endoscopy", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2018", "4", "18" ] ] }, "page" : "1668-1674", "publisher" : "Springer US", "title" : "Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: long-term symptomatic follow-up of a prospective randomized controlled trial", "type" : "article-journal", "volume" : "32" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(24)", "plainTextFormattedCitation" : "(24)", "previouslyFormattedCitation" : "(24)" }, "properties" : { }, "schema" : "" }(25). One of our patients had a history of open Heller myotomy with fundoplication 10 years ago.Based on results of the current study, laparoscopic Heller myotomy is a feasible procedure in our institutes, safe with low morbidity and no mortality and effective.Conclusion:Laparoscopic myotomy with anterior Dor fundoplication for achalasia is feasible, safe and effective, with significant relief of dysphagia and overall patient symptoms.ReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY 1. Goldblum J, Rice T, Richter J. Histopathologic features in esophagomyotomy specimens from patients with achalasia. Gastroenterology. 1996 Sep 1;111(3):648–54. 2. Ali A, Pellegrini CA. Laparoscopic myotomy: technique and efficacy in treating achalasia. Gastrointest Endosc Clin N Am. 2001;11(2):347–58. 3. Ackroyd R, Watson DI, Devitt PG, Jamieson GG. Laparoscopic cardiomyotomy and anterior partial fundoplication for achalasia. Surg Endosc. 2001;15(7):683–6. 4. Woltman TA, Oelschlager BK, Pellegrini CA. 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