title: Mucosal perforation during laparoscopic surgery for achalasia: impact of preoperative pneumatic balloon dilation.
abstract: Controversy remains whether preoperative pneumatic balloon dilation (PBD) influences the surgical outcome of laparoscopic esophagocardiomyotomy in patients with esophageal achalasia. The aim of this study was to evaluate whether preoperative PBD represents a risk factor for surgical complications and affects the symptomatic and/or functional outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD).
  
  
  
  A retrospective chart review was conducted on a prospectively compiled surgical database of 103 consecutive patients with esophageal achalasia who underwent LHD from November 1994 to September 2014. The following data were compared between the patients with preoperative PBD (PBD group; n = 26) and without PBD (non-PBD group; n = 77): (1) patients' demographics: age, gender, body mass index, duration of symptoms, maximum transverse diameter of esophagus; (2) operative findings: operating time, blood loss, intraoperative complications; (3) postoperative course: complications, clinical symptoms, postoperative treatment; and (4) esophageal functional tests: preoperative and postoperative manometric data and postoperative profile of 24-h esophageal pH monitoring.
  
  
  
  (1) No significant differences were observed in the patients' demographics. (2) Operative findings were similar between the two groups; however, the incidence of mucosal perforation was significantly higher in the PBD group (n = 8; 30.7 %) compared to the non-PBD group (n = 6; 7.7 %) (p = 0.005). (3) Postoperative complications were not encountered in either group. The differences were not significant for postoperative clinical symptoms, the incidence of gastroesophageal reflux disease, or necessity of postoperative treatments. (4) Lower esophageal sphincter pressure was effectively reduced in both groups, and no differences were observed in manometric data or 24-h pH monitoring profiles between the two groups. Multivariate logistic regression analysis showed that preoperative PBD and the maximum transverse diameter of esophagus were significantly associated with intraoperative mucosal perforation.
  
  
  
  Although postoperative outcomes were not affected, additional caution is recommended in identifying intraoperative mucosal perforation in patients with preoperative PBD when performing LHD.
authors: Department of Surgery, Osaka Central Hospital, 3-3-30, Umeda, Kita-ku, Osaka, 530-0001, Japan.
authors: Yoshihito
authors: 0000-0002-2944-513X
authors: Y
authors: Souma
authors: Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan. knakajima@gesurg.med.osaka-u.ac.jp.|Division of Next Generation Endoscopic Intervention, Global Center for Medical Engineering and Informatics, Osaka University, 2-2, E-2, Yamadaoka, Suita, Osaka, 565-0871, Japan. knakajima@gesurg.med.osaka-u.ac.jp.
authors: Kiyokazu
authors: K
authors: Nakajima
authors: Department of surgery, Otemae Hospital, Osaka, Japan.
authors: Eiji
authors: E
authors: Taniguchi
authors: Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors: Tsuyoshi
authors: T
authors: Takahashi
authors: Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors: Yukinori
authors: Y
authors: Kurokawa
authors: Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors: Makoto
authors: M
authors: Yamasaki
authors: Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors: Yasuhiro
authors: Y
authors: Miyazaki
authors: Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors: Tomoki
authors: T
authors: Makino
authors: Department of Surgery, Osaka Central Hospital, 3-3-30, Umeda, Kita-ku, Osaka, 530-0001, Japan.
authors: Tetsuhiro
authors: T
authors: Hamada
authors: Department of Surgery, Osaka Central Hospital, 3-3-30, Umeda, Kita-ku, Osaka, 530-0001, Japan.
authors: Jun
authors: J
authors: Yasuda
authors: Department of Surgery, Osaka Central Hospital, 3-3-30, Umeda, Kita-ku, Osaka, 530-0001, Japan.
authors: Takeyoshi
authors: T
authors: Yumiba
authors: Department of Surgery, Osaka Central Hospital, 3-3-30, Umeda, Kita-ku, Osaka, 530-0001, Japan.
authors: Shuichi
authors: S
authors: Ohashi
authors: Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors: Shuji
authors: S
authors: Takiguchi
authors: Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors: Masaki
authors: M
authors: Mori
authors: Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors: Yuichiro
authors: Y
authors: Doki
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D013505:Digestive System Surgical Procedures / Q000379:methods*; D004106:Dilatation / Q000379:methods*; D004931:Esophageal Achalasia / Q000601:surgery*; D004939:Esophageal Perforation / Q000453:epidemiology*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D050782:Esophageal pH Monitoring; D005260:Female; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000453:epidemiology; D006801:Humans; D007431:Intraoperative Complications / Q000453:epidemiology*; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008365:Manometry; D008875:Middle Aged; D009092:Mucous Membrane / Q000293:injuries; D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
keywords: Esophageal achalasia; Functional outcome; Intraoperative mucosal perforation; Laparoscopic Heller myotomy with Dor fundoplication; Pneumatic balloon dilation; Symptomatic outcome