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fast-track
protocols.
Fast-
(e.g.,
the use of drains or tubes). It uses modern intraoperative anesthesia (e.g., fluid restrict
ion)
and analgesia, including new drugs and novel ways of administration (e.g., thoracic ep
idural analgesia)
and surgeons,
the processes involved. The aim of this report was to present the outcome of the
application of ERAS protocols in surgical treatment of achalasia. This report was a
Between
admitted to our clinic for further investigation and treatment. This was a prospective
study of 14 patients undergoing laparoscopic Hellers cardiomyotomy with Dors
fundoplication combined with an enhanced recovery protocol (early oral intake, no
drains or nasogastric tubes, no epidural analgesia, no use of urinary catheter and plan
discharge 12 to 24 hours after surgery). It included 8 women and 5 men ranging from
21 to 67 years of age (mean age 41). Standard preoperative evaluation included the
following ; a. Barium meal b. Manometry function tests c. Endoscopy d. Pneumatic
dilatations were performed in two patients previously. The operation performed was
laparoscopic Heller's cardiomyotomy with Dor's fundoplication. This involves a 5 cm
sero-muscular incision across the lower third of the esophagus and the first 2 cm of
the stomach . The first 1 or 2 short gastric vessels are ligated
in order for the gastric dome to be mobilized 180 degrees onto the
cardiomyotomy.
. All patients received antithrombotic intraoperative prophylaxis ( ). No abdominal drain was used. Liquid diet
initiated immediately after the operation. All patients mobilized as soon as the
recovered the anesthesia. No endoscopy was performed during surgery. No
gastrografin contrast was administered post operatively (unless it was considered
necessary). Postoperative pain control included paracetamol 1 g every 8 h and
tramadol 100 mg PRN.
Results
No conversions to open procedure were recorded. The duration of the operation
ranged between 70 and 120 minutes (mean duration 83 min). No drains were used
and no post operative complications were recorded. The patients were fed the same
afternoon and were discharged from our center the same day.
Discussion
Esophageal achalasia is a primary esophageal motility disorder characterized by lack
of esophageal peristalsis and inability of the lower esophageal sphincter (LES) to
relax properly in response to swallowing. The procedure of choice in the modern
surgical field is laparoscopic Heller's cardiomyotomy and Dor's fundoplication. In
1913, Ernest Heller reported the first successful cardiomyotomy for achalasia. He
used 8 cm parallel myotomies (anterior and posterior). These were considered
extensive, and, in 1918, De Brune Groenveidt and Zaaijer described the single
incision.
Laparoscopic Heller myotomy can safely and durably relieve symptoms of dysphagia while also
reducing symptoms of reflux. Length of stay is short and patient satisfaction is very high with extended follow-up.
Laparoscopic Heller myotomy is strongly encouraged for patients with symptomatic achalasia and is efficacious
even after failures of dilation and/or Botox therapy.
Over the past decade, advances in healthcare with an evolution in peri- and postoperative care have led to a new surgical approach. Enhanced recovery after surgery
(ERAS) protocols, also known as fast-track surgery or multimodal optimisation,
are a combination of evidence based peri-operative strategies which work
synergistically to expedite recovery after surgery. These strategies include..
To the best of our knowledge, there is no previous report on the application of ERAS
protocols in the treatment of achalasia. Laparoscopic Heller myotomy gathers all the
conditions required for the application of fast-track surgery.
Conclusion
Laparoscopic Heller's cardiomyotomy and Dor's fundoplication is the procedure of choice in younger
patients with no co-morbidities. It offers a definitive advantage over pneumatic dilatations which only
give a short term solution the motility disorders of the esophagus.