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Multi-technique Management of Persistent Postintubation Tracheoesophageal Fistula in a Patient with Achalasia
Published in Wickii T. Vigneswaran, Thoracic Surgery, 2019
Nonmalignant recurrent TEFs require meticulous evaluation to determine the reasons for failure to close. It is important to rule out underlying malignancy, granulomatous disease, foreign bodies, or distal obstruction, all of which can prevent healing of the fistula. In the case of our patient, achalasia was identified as a contributing factor for failure of closure of the TEF after two surgical attempts. The delayed esophageal emptying likely elevated the intraluminal esophageal pressure, which was presumed to contribute to the patency of the fistula. We believe that the probability of closure with subsequent repair increased after relieving the distal obstruction by Heller myotomy.
Laparoscopic cardiomyotomy for achalasia
Published in Larry R. Kaiser, Sarah K. Thompson, Glyn G. Jamieson, Operative Thoracic Surgery, 2017
Sheraz Markar, Giovanni Zaninotto
In cases of decompensated achalasia and sigmoid megaesophagus, the success of laparoscopic Heller myotomy is lower than in less advanced cases. In these patients, however, the alternative is an esophagectomy, so before embarking on such an invasive and aggressive approach, it is still worth performing a simpler laparoscopic Heller myotomy. The surgical technique is slightly modified and the distal esophagus is posteriorly dissected, encircled, and straightened. The myotomy and fundoplication are then performed as previously described.
Upper GI
Published in Stephen Brennan, FRCS General Surgery Viva Topics and Revision Notes, 2017
Heller myotomy helps 90% of achalasia patients. The myotomy is a lengthwise cut along the oesophagus, starting above the LOS and extending down onto the stomach a little way. A partial fundoplication or ‘wrap’ is generally added in order to prevent excessive reflux, which can cause serious damage to the oesophagus over time. After surgery, patients should keep to a soft diet for several weeks to a month, avoiding foods that can aggravate reflux.
Application of botulinum toxin in pregnancy and its impact on female reproductive health
Published in Expert Opinion on Drug Safety, 2020
Treatment options for achalasia include dietary regulation, calcium channel blocker administration, total parenteral nutrition, and Heller myotomy. Minimally invasive surgery and procedures (e.g., pneumatic dilation, laparoscopic myotomy, and topical injections of BoNT into the sphincter) provide relatively long-term relief until full-term delivery. Notably, the rate of remission of pneumatic augmentation treatment is 50–75%, but its long-term treatment efficacy is low. The most serious potential complication is esophageal rupture (incidence of 55%), which is resolved through surgical treatment [52]. However, laparoscopic surgery during pregnancy, which requires general anesthesia and establishment of pneumoperitoneum, may cause physical damage to pregnant women and can impede fetal development
Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae
Published in Expert Review of Medical Devices, 2019
Shirin Siddiqi, Dean P. Schraufnagel, Hafiz Umair Siddiqui, Michael J. Javorski, Adam Mace, Abdulrhman S. Elnaggar, Haytham Elgharably, Patrick R. Vargo, Robert Steffen, Saad M. Hasan, Siva Raja
Any surgical procedure which involves the esophagus can be complicated by a postoperative leak. The most common surgeries where this can occur are esophagectomy, Heller myotomy, and per-oral endoscopic myotomy (POEM). Leaks after esophagectomy are defined as discontinuity of tissue apposition in the immediate postoperative period, and these remain a challenge due to both a high incidence (5–40%) and associated mortality (2–12%) [8,63–66]. An esophageal anastomosis is located either inside the thoracic cavity or the neck. The incidence of anastomotic leak is higher in the cervical region (10–25%) but has a lower mortality rate due to its extra-thoracic location. Meanwhile, the incidence of thoracic anastomotic leak is comparatively lower (5–10%) but the mortality rate is higher (30–60%) [67,68] due to the relative difficulty with sterilization of the intrathoracic space in comparison with the cervical space.
Challenges of peroral endoscopic myotomy in the treatment of distal esophageal spasm
Published in Scandinavian Journal of Gastroenterology, 2018
Fraukje Anna-Marie Ponds, André J.P.M. Smout, Paul Fockens, Albert J. Bredenoord
The premature and rapidly propagated contractions in DES are caused by the impairment of esophageal inhibitory neural function. Treatment is challenging and in many patients medical treatment is insufficient. POEM has been introduced for achalasia treatment as a less invasive alternative to Heller myotomy [6,7]. For DES, POEM has the advantage over laparoscopic Heller myotomy that the myotomy can be more extended, also cleaving the circular muscles in the mid and proximal esophagus [8–10]. However, this case shows that POEM for DES can be challenging and we have learned two lessons. First, reactive spastic contractions during and after the procedure may complicate execution of the technique and lengthen the procedure, increase post-operative pain and prolong hospital admission. Nitroglycerin during the procedure can be helpful. Second, the myotomy should start more proximally than usual, at least several centimeters above the proximal border of the spastic region. Otherwise a remnant of spastic contractions proximal to the myotomy will remain, causing persistent symptoms. HRM can be helpful for guidance. A recent systematic review and meta-analysis on POEM for spastic esophageal disorders which included achalasia type III, distal esophageal spasm and hypercontractile (Jackhammer) esophagus, revealed that POEM is a safe and highly effective treatment for this type of disorders [11]. The tailored procedure with an extended myotomy is a major advantage over other therapeutic options for DES. Based on the literature and our experience we conclude that POEM is a promising treatment for patients with therapy-refractory DES, however the above described caveats should be taken into account.