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      Laparoscopic Heller's cardiomyotomy in cirrhosis with oesophageal varices

      case-report

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          Abstract

          Surgical intervention in cirrhosis of liver with portal hypertension is associated with increased morbidity and mortality. This is attributed to liver decompensation, intra-operative bleeding, prolonged operative time, wound related and anaesthesia complications. Laparoscopic surgery in cirrhosis is advantageous but is associated with technical challenges. We report one such case of hepatitis C cirrhosis with oesophageal varices and symptomatic achalasia cardia, who was successfully treated by laparoscopic cardiomyotomy after thorough preoperative workup and planning. In the review of literature on pubmed, no such case is reported.

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          Most cited references15

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          Current therapies for achalasia: comparison and efficacy.

          M F Vaezi, J Richter (1998)
          Achalasia is a primary esophageal motor disorder of unknown etiology producing complaints of dysphagia, regurgitation, and chest pain. The current treatments for achalasia involve the reduction of lower esophageal sphincter (LES) pressure resulting in improved esophageal emptying. Calcium channel blockers and nitrates, once used as initial treatment strategy for early achalasia, are now only used in patients who are not candidates for pneumatic dilation or surgery and those not responding to botulinum toxin injections. By virtue of the more rigid balloons, the current pneumatic dilators are more effective and have better efficacy than the older more compliant balloons. The graded approach to pneumatic dilation using the Rigiflex balloons (3.0, 3.5, and 4.0 cm) are now the most commonly used nonsurgical means of treating patients with achalasia, resulting in symptom improvement in up to 90% of patients. Surgical myotomy, once with high morbidity and long hospital stay, can now be performed laparoscopically with similar efficacy to the open surgical approach (94% vs. 84%, respectively), reduced morbidity, and hospitalization time. Given the advances in both balloon dilation and laparoscopic myotomy, most patients with achalasia can now choose between these two equally efficacious treatment options. Botulinum toxin injection of the LES should be reserved for patients who cannot undergo balloon dilation and are not surgical candidates.
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            Risk factors for nonhepatic surgery in patients with cirrhosis.

            B Flor-Lorente, Ilia A. Serra, Salvador Lledo … (2003)
            Cirrhosis of the liver appears to have an unfavorable prognosis in the surgical patient. The aim of this study was to determine risk factors for morbidity and mortality in patients with cirrhosis undergoing nonhepatic surgery. We studied 135 patients with liver cirrhosis undergoing nonhepatic procedures and 86 controls matched by age, sex, and preoperative diagnosis. Preoperative, intraoperative, and postoperative variables associated with 30-day mortality and morbidity were assessed by univariate and multivariate analyses. Patients with cirrhosis showed higher blood transfusion requirements, longer length of hospital stay, and a higher number of complications than controls. The mortality rate was 16.3% in cirrhotics and 3.5% in controls. By univariate analysis, the need for transfusions, prothrombin time, and Child-Pugh score were significantly associated with postoperative liver decompensation, whereas duration of surgery, prothrombin time, Child-Pugh score, cirrhosis-related complications, and general complications were significantly associated with mortality. In the multivariate analysis, Child-Pugh score (odds ratio [OR] 24.4; 95% confidence interval [CI] 5.5 to 106); duration of surgery (OR 5; 95% CI 1.2 to 15.6), and postoperative general complications (OR 3.7; 95% CI 3.4 to 6.4) were independent predictors of mortality. Patients with cirrhosis undergoing nonhepatic operations are at significant risk of perioperative complications leading to death. Independent variables associated with perioperative mortality include preoperative Child-Pugh score, the duration of surgery, and the presence of postoperative general complications.
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              Long-term outcome of pneumatic dilation in the treatment of achalasia.

              Georgios Karamanolis, Spiros N Sgouros, Georgios Karatzias … (2005)
              Achalasia is a well-defined esophageal motor disorder for which pneumatic dilation is an established therapeutic method. Even though it has been used for several years, there are limited data on the long-term outcomes of patients treated with this procedure. Hence, we aimed to evaluate the long-term efficacy of pneumatic dilation to control the symptoms of achalasia. The medical records of all patients treated in our unit for achalasia with pneumatic dilation were reviewed. We identified the long-term result of the initial procedure, the date of the first dilation, and the time interval between dilation and retreatment. Of 260 patients who were treated with pneumatic dilation, 153 (67 men, 86 women) were followed up for more than 5 yr. The mean follow-up period was 11.09 +/- 3.91 yr, and the success rate of the dilation was 75.8%. Among these patients, 35 (19 men, 16 women) had follow-up periods of more than 15 yr. The mean follow-up time of those patients was 16.56 +/- 1.09 yr, and the success rate was 51.4%. Kaplan-Meier survival analysis showed that, overall, 50% of patients develop recurring symptoms after 10.92 yr. Although 51.4% of patients continued to be in clinical remission more than 15 yr after the initial pneumatic dilation, the long-term success rate of pneumatic dilation seems to drop progressively with time.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Minim Access Surg
                Journal ID (publisher-id): JMAS
                Title: Journal of Minimal Access Surgery
                Publisher: Medknow Publications (India )
                ISSN (Print): 0972-9941
                ISSN (Electronic): 1998-3921
                Publication date (Print): Apr-Jun 2010
                Volume: 6
                Issue: 2
                Pages: 46-49
                Affiliations
                Department of Minimal Invasive Surgery, Jupiter Hospital, Thane, Maharashtra, India
                [1 ]Department of Gastroenterology, Jupiter Hospital, Thane, Maharashtra, India
                Author notes
                Address for correspondence: Dr. Abhay N Dalvi, 257 Walkeshwar Road, Mumbai-400 006, India. E-mail: abhaydalvi@ 123456hotmail.com
                Article
                Publisher ID: JMAS-6-46
                DOI: 10.4103/0972-9941.65164
                PMC ID: 2924548
                PubMed ID: 20814511
                SO-VID: 2a6b401d-b4f0-4dcc-b2e1-b76b5288acb2
                Copyright © © Journal of Minimal Access Surgery
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 09 December 2009
                Date accepted : 29 January 2010
                Categories
                Subject: Unusual Case

                ScienceOpen disciplines: Surgery
                Keywords: esophageal varices,laparoscopic cardiomyotomy,cirrhosis,achalasia
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: esophageal varices, laparoscopic cardiomyotomy, cirrhosis, achalasia

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