Jara Hernandez Gutierrez, Aurelio Aranzana, Beatriz Muñoz Jimenez, Juan S Malo Corral. CH Toledo
Introduction: Achalasia is a type of motor disorder of the esophagus due to degeneration of ganglion cells in the myenteric plexus, leading to failure of relaxation of the lower esophageal sphincter, accompanied by a loss of peristalsis in the distal esophagus.
The association of a long-term achalasia and a large size hiatus hernia is an infrequent entity, making it difficult not only to diagnose it but also to treat it. Among the therapeutic options is medical treatment, endoscopic treatment either dilatation or POEM, and surgical treatment associated with an antireflux procedure, with the laparoscopic approach being the more indicated due to its better results in terms of morbidity, mortality and recurrences.
The objective of this VIDEO is to show the effectiveness and safety of the laparoscopic approach in this infrequent pathology, pointing out the importance of performing a standardized procedure.
Methods and Procedures: 73-year-old male patient, with personal history of chronic ischemic heart disease and obesity, diagnosed with long-term achalasia with moderate dilatation of the esophagus associated with giant hiatus hernia. The complementary explorations and iconography of interest are exposed, highlighting esophageal manometry.
Results: Preoperative optimization with respiratory and cardiological prehabilitation.
Intervention: complete endoscopic approach, 5 trocars. Reduction of hernial content into the abdominal cavity, dissection of the hernial sac and esophageal lipoma. Extended mediastinal esophageal dissection. Complete resection of both the sac and lipoma, respecting the posterior vagus. Heller's myotomy of 10 cm, including 3 cm distal to the UEG, perforation of 3 mm of the mucosa at the UEG level, suture and blue methylene verification of the sealing of the same. Hiatorraphy and Dor-type anterior fundoplication as antireflux technique. Correct postoperative, with EGD control on the 3rd PO day and discharge on the 6th. Asymptomatic at 12 months after surgery.
Conclusion: For patients who are at low surgical risk laparoscopic Heller myotomy with a partial fundoplication should be the treatment of choice to treat achalasia. The length of the myotomy, especially distal to UEG is one of the most important aspects of the surgery, most authors recommend that the myotomy extend 1-2 cm in the stomach, even up to 3 cm below the UEG to achieve an effective disruption of the LES. The presence of a giant hiatus hernia makes the procedure difficult, increasing the risk of complications, as in this case of perforation. Standardization is essential to increase safety and efficacy in these more complex cases.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93972
Program Number: V241
Presentation Session: Video Loop Day 2
Presentation Type: VideoLoop
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