World J Surg DOI 10.1007/s00268-014-2940-1
SURGICAL SYMPOSIUM CONTRIBUTION
Laparoscopic Heller Myotomy and Fundoplication in Patients with End-Stage Achalasia Fernando A. M. Herbella • Marco G. Patti
Ó Socie´te´ Internationale de Chirurgie 2015
Abstract Achalasia may present in a non-advanced or advanced (end stage) stage. The latter is characterized by massive esophageal dilatation and/or the loss of the esophageal straight axis (sigmoid-shaped esophagus). The treatment for non-advanced cases of achalasia is well defined while the therapy for end-stage disease is still debatable. Laparoscopic Heller’s myotomy is an option in patients with end-stage achalasia. Dysphagia is relieved in a significant number of patients, it is a simpler operation to be used in frail patients, and it does not preclude a latter esophagectomy if necessary.
Introduction Achalasia is a rare neurodegenerative disorder of the esophagus with an estimated prevalence of 8 cases per 100,000 inhabitants and an incidence of 1 case per 100,000 inhabitants/year [1]. The etiology of the disease is still speculative [2] except for cases found in Chagas’ disease [3]. Achalasia may present in a non-advanced or advanced (end stage) stage. The latter is characterized by massive esophageal dilatation and/or the loss of the esophageal straight axis (sigmoid-shaped esophagus). The boundary to define the end stage of achalasia is variable. While some adopt the esophageal diameter of 6 cm as the cut-off [4], others adopt 7 cm [5]. Brazilian surgeons classify esophageal dilatation into 4 different grades (grade I \4 cm; grade II 4–7 cm; grade III 7–10 cm; and grade IV[10 cm) F. A. M. Herbella (&) Department of Surgery, Escola Paulista de Medicina, Federal University of Sa˜o Paulo, Rua Diogo de Faria 1087 cj 301, Sa˜o Paulo, SP 04037-003, Brazil e-mail: [email protected] M. G. Patti Department of Surgery, University of Chicago, Chicago, IL, USA
and defined advanced cases as grade IV only [6] (Fig. 1). Esophageal dilatation seems to be more pronounced in Chagas’ disease [7]. Massively dilated esophagus is reported in no more than 5 % in idiopathic achalasia series, while over 15 % of the Chagas’s disease series have an esophageal diameter [10 cm. The ideal treatment for end-stage achalasia is still debatable. The treatment for non-advanced cases of achalasia is well defined Endoscopic forceful pneumatic dilatation of the cardia has long been the therapy for achalasia. Even though several authors still adopt this procedure as the first treatment for non-advanced achalasia [8], current evidence show better and long-standing results for laparoscopic Heller’s myotomy [9]. The procedure has very low rate of complications and excellent and good outcomes in over 85 % of the cases [6]. This leads to a shift in the paradigm for the treatment of non-advanced achalasia toward the surgical approach [10]. Although the procedure can also be performed endoscopically [11], long-term follow-up is still not available to prove that the operation is time resisting especially that a fundoplication is not added to the
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World J Surg Fig. 1 Radiologic classification of achalasia according to the degree of esophageal dilatation on the barium esophagram (grade I \4 cm; grade II 4–7 cm; grade III 7–10 cm; and grade IV [10 cm)
Table 1 Outcomes of Heller’s myotomy and fundoplication in the treatment of end-stage achalasia Author
N
Mean follow-up (months)
Mortality (%)
Excellent/good outcomes (%)
Notes
Herbella et al. [19]
12
40
0
97.6
Esophageal diameter [10 cm
Faccani et al. [20]
33
89
0
69.7
Esophageal diameter [6 cm
Mineo and Pompeo [21]
14
85
0
72
Esophageal diameter [6 cm
Gaissert et al. [22]
12
154
0
54
Sigmoid esophagus Outcomes not different from non-advanced cases
Sweet et al. [23]
12
45
0
91
Esophageal diameter [6 cm
Scott et al. [24] Shuchert et al. [25]
4 24
NR 30.5
0 0
100 62.5
Esophageal diameter [10 cm
Pantanali et al. [26]
11
31.5
0
72.8
Esophageal diameter [10 cm
procedure in order to prevent reflux and the reapproximation of the borders of the myotomy.
The treatment for advanced cases of achalasia is not well defined As previously mentioned, although South American surgeons are more used to the end-stage disease, rendering the name megaesophagus as achalasia is known in these countries, a massive dilated esophagi is a rare finding in idiopathic achalasia. Thus, international literature is scarce in studies dealing with this problem. Endoscopic treatment (either balloon dilatation or botulinum toxin injection) is rarely tried in end-stage achalasia. Data are limited to case reports or small series [12, 13]. The procedure is technically demanding and outcomes do not seem to be good ones. The experience with endoscopic myotomy (POEM) is still incipient [14]. Esophagectomy is a well-established procedure for this condition. Its advantages and disadvantages will be discussed in other review in this Symposium on achalasia. Different non-conventional techniques have been tried for the treatment of end-stage achalasia. Cardioplasty ?
123
gastrectomy, distal esophagectomy ? gastrectomy, sleeve esophagectomy ? myotomy, and Merendino’s procedure are examples [6, 15]. None acquired good reputation and reports are limited to small series. Some studies associated a poor outcome after Heller myotomy to the degree of esophageal dilatation [16–18]. These studies, however, even though showed a mathematical inferiority for advanced degrees of esophageal dilatation in comparison to non-advanced grades, do not show specific outcomes in the subgroup of patients with advanced disease. Grade III megaesophagus (7–10 cm) is not considered an end-stage disease in Brazil and has been historically treated with a Heller myotomy with good outcomes [6]. Moreover, different studies also showed significant improvement in dysphagia with low morbidity and null mortality after Heller’s myotomy in end-stage disease (Table 1). Excellent and good outcomes were obtained in average in 79 % of the cases (range 54–100 %). In opposition to other techniques, Heller’s myotomy in patients with advanced disease is not technically different or more difficult compared to initial disease. A more extensive dissection of the mediastinal esophagus in order to straighten its axis and the addition of a hiatoplasty if the hiatus is too enlarged are recommended by some [23].
World J Surg
Conclusion A laparoscopic Heller’s myotomy is an option in patients with end-stage achalasia. Dysphagia is relieved in a significant number of patients, it is a simpler operation to be used in frail patients and it does not preclude a latter esophagectomy if necessary. Conflict of interest
There are no conflicts of interest.
References 1. Farrokhi F, Vaezi MF (2007) Idiopathic (primary) achalasia. Orphanet J Rare Dis 2:38–45 2. Petersen RP, Martin AV, Pellegrini CA, Oelschlager BK (2012) Synopsis of investigations into proposed theories on the etiology of achalasia. Dis Esophagus 25:305–310 3. Vicentine FP, Herbella FA, Allaix ME, Silva LC, Patti MG (2014) Comparison of idiopathic achalasia and Chagas’ disease esophagopathy at the light of high-resolution manometry. Dis Esophagus 27(2):128–133 4. Patti MG, Feo CV, Diener U, Tamburini A, Arcerito M, Safadi B, Way LW (1999) Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated. Surg Endosc 13(9):843–847 5. Onopriev VI, Durleshter VM, Ryabchun VV (2005) Comparative pre and postoperative results analysis of functional state of the esophagus assessment in patients with various stages of achalasia. Eur J Cardiothorac Surg 28(1):1–6 6. Herbella FA, Aquino JL, Stefani-Nakano S, Artifon EL, Sakai P, Crema E, Andreollo NA, Lopes LR, de Castro Pochini C, Corsi PR, Gagliardi D, Del Grande JC (2008) Treatment of achalasia: lessons learned with Chagas’ disease. Dis Esophagus 21(5): 461–467 7. Herbella FA, Oliveira DR, Del Grande JC (2004) Are idiopathic and chagasic achalasia two different diseases? Dig Dis Sci 49(3):353–360 8. Spechler SJ (2011) Pneumatic dilation and laparoscopic Heller’s myotomy equally effective for achalasia. N Engl J Med 364(19):1868–1870. doi:10.1056/NEJMe1100693 9. Campos GM, Vittinghoff E, Rabl C, Takata M, Gadensta¨tter M, Lin F, Ciovica R (2009) Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 249(1):45–57. doi:10.1097/SLA.0b013e31818e43ab 10. Allaix ME, Herbella FA, Patti MG (2012) The evolution of the treatment of esophageal achalasia: a look at the last two decades. Updates Surg 64(3):161–165. doi:10.1007/s13304-012-0169-9 11. Minami H, Inoue H, Haji A, Isomoto H, Urabe S, Hashiguchi K, Matsushima K, Akazawa Y, Yamaguchi N, Ohnita K, Takeshima F, Nakao K (2014) Per-oral endoscopic myotomy: emerging indications and evolving techniques. Dig Endosc. doi:10.1111/ den.12328 12. Holloway RH, McCallum RW (1982) Technique for pneumatic dilatation in achalasia complicated by ‘‘sigmoid’’ esophagus. J Clin Gastroenterol 4(2):123–125
13. Bernstein D, Barkin JS (1993) Pneumatic dilation of a sigmoid esophagus in achalasia using an overtube. Gastrointest Endosc 39(4):549–550 14. Inoue H, Tianle KM, Ikeda H, Hosoya T, Onimaru M, Yoshida A, Minami H, Kudo SE (2011) Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes. Thorac Surg Clin. 21:519–525 15. Duranceau A, Liberman M, Martin J, Ferraro P (2012) End-stage achalasia. Dis Esophagus 25(4):319–330. doi:10.1111/j.14422050.2010.01157.x 16. Gutschow CA, To¨x U, Leers J, Scha¨fer H, Prenzel KL, Ho¨lscher AH (2010) Botox, dilation, or myotomy? Clinical outcome of interventional and surgical therapies for achalasia. Langenbecks Arch Surg. 395(8):1093–1099 17. Mattioli S, Ruffato A, Lugaresi M, Pilotti V, Aramini B, D’Ovidio F (2010) Long-term results of the Heller-Dor operation with intraoperative manometry for the treatment of esophageal achalasia. J Thorac Cardiovasc Surg 140(5):962–969 18. Zaninotto G, Costantini M, Rizzetto C, Zanatta L, Guirroli E, Portale G, Nicoletti L, Cavallin F, Battaglia G, Ruol A, Ancona E (2008) Four hundred laparoscopic myotomies for esophageal achalasia: a single centre experience. Ann Surg 248(6):986–993 19. Herbella FA, Del Grande JC, Lourenco LG, Mansur NS, Haddad CM (1999) Resultados tardios da operac¸a˜o de Heller associada a` fundoplicatura no tratamento do megaesoˆfago: ana´lise de 83 casos. Rev Ass Med Brasil 45(4):317–322 20. Faccani E, Mattioli S, Lugaresi ML, Di Simone MP, Bartalena T, Pilotti V (2007) Improving the surgery for sigmoid achalasia: long-term results of a technical detail. Eur J Cardiothorac Surg 32(6):827–833 21. Mineo TC, Pompeo E (2004) Long-term outcome of Heller myotomy in achalasic sigmoid esophagus. J Thorac Cardiovasc Surg 128(3):402–407 22. Gaissert HA, Lin N, Wain JC, Fankhauser G, Wright CD, Mathisen DJ (2006) Transthoracic Heller myotomy for esophageal achalasia: analysis of long-term results. Ann Thorac Surg 81(6):2044–2049 23. Sweet MP, Nipomnick I, Gasper WJ, Bagatelos K, Ostroff JW, Fisichella PM, Way LW, Patti MG (2008) The outcome of laparoscopic Heller myotomy for achalasia is not influenced by the degree of esophageal dilatation. J Gastrointest Surg. 12(1): 159–165 24. Scott PD, Harold KL, Heniford BT, Jaroszewski DE (2009) Results of laparoscopic Heller myotomy for extreme megaesophagus: an alternative to esophagectomy. Surg Laparosc Endosc Percutan Tech. 19(3):198–200 25. Schuchert MJ, Luketich JD, Landreneau RJ, Kilic A, Wang Y, Alvelo-Rivera M, Christie NA, Gilbert S, Pennathur A (2009) Minimally invasive surgical treatment of sigmoidal esophagus in achalasia. J Gastrointest Surg. 13(6):1029–1036 26. Pantanali CA, Herbella FA, Henry MA, Mattos Farah JF, Patti MG (2013) Laparoscopic Heller myotomy and fundoplication in patients with Chagas’ disease achalasia and massively dilated esophagus. Am Surg 79(1):72–75
123
SURGICAL SYMPOSIUM CONTRIBUTION
Laparoscopic Heller Myotomy and Fundoplication in Patients with End-Stage Achalasia Fernando A. M. Herbella • Marco G. Patti
Ó Socie´te´ Internationale de Chirurgie 2015
Abstract Achalasia may present in a non-advanced or advanced (end stage) stage. The latter is characterized by massive esophageal dilatation and/or the loss of the esophageal straight axis (sigmoid-shaped esophagus). The treatment for non-advanced cases of achalasia is well defined while the therapy for end-stage disease is still debatable. Laparoscopic Heller’s myotomy is an option in patients with end-stage achalasia. Dysphagia is relieved in a significant number of patients, it is a simpler operation to be used in frail patients, and it does not preclude a latter esophagectomy if necessary.
Introduction Achalasia is a rare neurodegenerative disorder of the esophagus with an estimated prevalence of 8 cases per 100,000 inhabitants and an incidence of 1 case per 100,000 inhabitants/year [1]. The etiology of the disease is still speculative [2] except for cases found in Chagas’ disease [3]. Achalasia may present in a non-advanced or advanced (end stage) stage. The latter is characterized by massive esophageal dilatation and/or the loss of the esophageal straight axis (sigmoid-shaped esophagus). The boundary to define the end stage of achalasia is variable. While some adopt the esophageal diameter of 6 cm as the cut-off [4], others adopt 7 cm [5]. Brazilian surgeons classify esophageal dilatation into 4 different grades (grade I \4 cm; grade II 4–7 cm; grade III 7–10 cm; and grade IV[10 cm) F. A. M. Herbella (&) Department of Surgery, Escola Paulista de Medicina, Federal University of Sa˜o Paulo, Rua Diogo de Faria 1087 cj 301, Sa˜o Paulo, SP 04037-003, Brazil e-mail: [email protected] M. G. Patti Department of Surgery, University of Chicago, Chicago, IL, USA
and defined advanced cases as grade IV only [6] (Fig. 1). Esophageal dilatation seems to be more pronounced in Chagas’ disease [7]. Massively dilated esophagus is reported in no more than 5 % in idiopathic achalasia series, while over 15 % of the Chagas’s disease series have an esophageal diameter [10 cm. The ideal treatment for end-stage achalasia is still debatable. The treatment for non-advanced cases of achalasia is well defined Endoscopic forceful pneumatic dilatation of the cardia has long been the therapy for achalasia. Even though several authors still adopt this procedure as the first treatment for non-advanced achalasia [8], current evidence show better and long-standing results for laparoscopic Heller’s myotomy [9]. The procedure has very low rate of complications and excellent and good outcomes in over 85 % of the cases [6]. This leads to a shift in the paradigm for the treatment of non-advanced achalasia toward the surgical approach [10]. Although the procedure can also be performed endoscopically [11], long-term follow-up is still not available to prove that the operation is time resisting especially that a fundoplication is not added to the
123
World J Surg Fig. 1 Radiologic classification of achalasia according to the degree of esophageal dilatation on the barium esophagram (grade I \4 cm; grade II 4–7 cm; grade III 7–10 cm; and grade IV [10 cm)
Table 1 Outcomes of Heller’s myotomy and fundoplication in the treatment of end-stage achalasia Author
N
Mean follow-up (months)
Mortality (%)
Excellent/good outcomes (%)
Notes
Herbella et al. [19]
12
40
0
97.6
Esophageal diameter [10 cm
Faccani et al. [20]
33
89
0
69.7
Esophageal diameter [6 cm
Mineo and Pompeo [21]
14
85
0
72
Esophageal diameter [6 cm
Gaissert et al. [22]
12
154
0
54
Sigmoid esophagus Outcomes not different from non-advanced cases
Sweet et al. [23]
12
45
0
91
Esophageal diameter [6 cm
Scott et al. [24] Shuchert et al. [25]
4 24
NR 30.5
0 0
100 62.5
Esophageal diameter [10 cm
Pantanali et al. [26]
11
31.5
0
72.8
Esophageal diameter [10 cm
procedure in order to prevent reflux and the reapproximation of the borders of the myotomy.
The treatment for advanced cases of achalasia is not well defined As previously mentioned, although South American surgeons are more used to the end-stage disease, rendering the name megaesophagus as achalasia is known in these countries, a massive dilated esophagi is a rare finding in idiopathic achalasia. Thus, international literature is scarce in studies dealing with this problem. Endoscopic treatment (either balloon dilatation or botulinum toxin injection) is rarely tried in end-stage achalasia. Data are limited to case reports or small series [12, 13]. The procedure is technically demanding and outcomes do not seem to be good ones. The experience with endoscopic myotomy (POEM) is still incipient [14]. Esophagectomy is a well-established procedure for this condition. Its advantages and disadvantages will be discussed in other review in this Symposium on achalasia. Different non-conventional techniques have been tried for the treatment of end-stage achalasia. Cardioplasty ?
123
gastrectomy, distal esophagectomy ? gastrectomy, sleeve esophagectomy ? myotomy, and Merendino’s procedure are examples [6, 15]. None acquired good reputation and reports are limited to small series. Some studies associated a poor outcome after Heller myotomy to the degree of esophageal dilatation [16–18]. These studies, however, even though showed a mathematical inferiority for advanced degrees of esophageal dilatation in comparison to non-advanced grades, do not show specific outcomes in the subgroup of patients with advanced disease. Grade III megaesophagus (7–10 cm) is not considered an end-stage disease in Brazil and has been historically treated with a Heller myotomy with good outcomes [6]. Moreover, different studies also showed significant improvement in dysphagia with low morbidity and null mortality after Heller’s myotomy in end-stage disease (Table 1). Excellent and good outcomes were obtained in average in 79 % of the cases (range 54–100 %). In opposition to other techniques, Heller’s myotomy in patients with advanced disease is not technically different or more difficult compared to initial disease. A more extensive dissection of the mediastinal esophagus in order to straighten its axis and the addition of a hiatoplasty if the hiatus is too enlarged are recommended by some [23].
World J Surg
Conclusion A laparoscopic Heller’s myotomy is an option in patients with end-stage achalasia. Dysphagia is relieved in a significant number of patients, it is a simpler operation to be used in frail patients and it does not preclude a latter esophagectomy if necessary. Conflict of interest
There are no conflicts of interest.
References 1. Farrokhi F, Vaezi MF (2007) Idiopathic (primary) achalasia. Orphanet J Rare Dis 2:38–45 2. Petersen RP, Martin AV, Pellegrini CA, Oelschlager BK (2012) Synopsis of investigations into proposed theories on the etiology of achalasia. Dis Esophagus 25:305–310 3. Vicentine FP, Herbella FA, Allaix ME, Silva LC, Patti MG (2014) Comparison of idiopathic achalasia and Chagas’ disease esophagopathy at the light of high-resolution manometry. Dis Esophagus 27(2):128–133 4. Patti MG, Feo CV, Diener U, Tamburini A, Arcerito M, Safadi B, Way LW (1999) Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated. Surg Endosc 13(9):843–847 5. Onopriev VI, Durleshter VM, Ryabchun VV (2005) Comparative pre and postoperative results analysis of functional state of the esophagus assessment in patients with various stages of achalasia. Eur J Cardiothorac Surg 28(1):1–6 6. Herbella FA, Aquino JL, Stefani-Nakano S, Artifon EL, Sakai P, Crema E, Andreollo NA, Lopes LR, de Castro Pochini C, Corsi PR, Gagliardi D, Del Grande JC (2008) Treatment of achalasia: lessons learned with Chagas’ disease. Dis Esophagus 21(5): 461–467 7. Herbella FA, Oliveira DR, Del Grande JC (2004) Are idiopathic and chagasic achalasia two different diseases? Dig Dis Sci 49(3):353–360 8. Spechler SJ (2011) Pneumatic dilation and laparoscopic Heller’s myotomy equally effective for achalasia. N Engl J Med 364(19):1868–1870. doi:10.1056/NEJMe1100693 9. Campos GM, Vittinghoff E, Rabl C, Takata M, Gadensta¨tter M, Lin F, Ciovica R (2009) Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 249(1):45–57. doi:10.1097/SLA.0b013e31818e43ab 10. Allaix ME, Herbella FA, Patti MG (2012) The evolution of the treatment of esophageal achalasia: a look at the last two decades. Updates Surg 64(3):161–165. doi:10.1007/s13304-012-0169-9 11. Minami H, Inoue H, Haji A, Isomoto H, Urabe S, Hashiguchi K, Matsushima K, Akazawa Y, Yamaguchi N, Ohnita K, Takeshima F, Nakao K (2014) Per-oral endoscopic myotomy: emerging indications and evolving techniques. Dig Endosc. doi:10.1111/ den.12328 12. Holloway RH, McCallum RW (1982) Technique for pneumatic dilatation in achalasia complicated by ‘‘sigmoid’’ esophagus. J Clin Gastroenterol 4(2):123–125
13. Bernstein D, Barkin JS (1993) Pneumatic dilation of a sigmoid esophagus in achalasia using an overtube. Gastrointest Endosc 39(4):549–550 14. Inoue H, Tianle KM, Ikeda H, Hosoya T, Onimaru M, Yoshida A, Minami H, Kudo SE (2011) Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes. Thorac Surg Clin. 21:519–525 15. Duranceau A, Liberman M, Martin J, Ferraro P (2012) End-stage achalasia. Dis Esophagus 25(4):319–330. doi:10.1111/j.14422050.2010.01157.x 16. Gutschow CA, To¨x U, Leers J, Scha¨fer H, Prenzel KL, Ho¨lscher AH (2010) Botox, dilation, or myotomy? Clinical outcome of interventional and surgical therapies for achalasia. Langenbecks Arch Surg. 395(8):1093–1099 17. Mattioli S, Ruffato A, Lugaresi M, Pilotti V, Aramini B, D’Ovidio F (2010) Long-term results of the Heller-Dor operation with intraoperative manometry for the treatment of esophageal achalasia. J Thorac Cardiovasc Surg 140(5):962–969 18. Zaninotto G, Costantini M, Rizzetto C, Zanatta L, Guirroli E, Portale G, Nicoletti L, Cavallin F, Battaglia G, Ruol A, Ancona E (2008) Four hundred laparoscopic myotomies for esophageal achalasia: a single centre experience. Ann Surg 248(6):986–993 19. Herbella FA, Del Grande JC, Lourenco LG, Mansur NS, Haddad CM (1999) Resultados tardios da operac¸a˜o de Heller associada a` fundoplicatura no tratamento do megaesoˆfago: ana´lise de 83 casos. Rev Ass Med Brasil 45(4):317–322 20. Faccani E, Mattioli S, Lugaresi ML, Di Simone MP, Bartalena T, Pilotti V (2007) Improving the surgery for sigmoid achalasia: long-term results of a technical detail. Eur J Cardiothorac Surg 32(6):827–833 21. Mineo TC, Pompeo E (2004) Long-term outcome of Heller myotomy in achalasic sigmoid esophagus. J Thorac Cardiovasc Surg 128(3):402–407 22. Gaissert HA, Lin N, Wain JC, Fankhauser G, Wright CD, Mathisen DJ (2006) Transthoracic Heller myotomy for esophageal achalasia: analysis of long-term results. Ann Thorac Surg 81(6):2044–2049 23. Sweet MP, Nipomnick I, Gasper WJ, Bagatelos K, Ostroff JW, Fisichella PM, Way LW, Patti MG (2008) The outcome of laparoscopic Heller myotomy for achalasia is not influenced by the degree of esophageal dilatation. J Gastrointest Surg. 12(1): 159–165 24. Scott PD, Harold KL, Heniford BT, Jaroszewski DE (2009) Results of laparoscopic Heller myotomy for extreme megaesophagus: an alternative to esophagectomy. Surg Laparosc Endosc Percutan Tech. 19(3):198–200 25. Schuchert MJ, Luketich JD, Landreneau RJ, Kilic A, Wang Y, Alvelo-Rivera M, Christie NA, Gilbert S, Pennathur A (2009) Minimally invasive surgical treatment of sigmoidal esophagus in achalasia. J Gastrointest Surg. 13(6):1029–1036 26. Pantanali CA, Herbella FA, Henry MA, Mattos Farah JF, Patti MG (2013) Laparoscopic Heller myotomy and fundoplication in patients with Chagas’ disease achalasia and massively dilated esophagus. Am Surg 79(1):72–75
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