Nasogastric tube after laparoscopic Heller-Dor myotomy: do you really need it?

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Giuseppe Palomba, Raffaele Basile, Marianna Capuano, Marcella Pesce, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2930409/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Achalasia is a rare esophageal motor disorder. Laparoscopic Heller-Dor myotomy (LHD) is among the most effective treatments. The use of nasogastric tube (NGT) following LHD is still controversial. The aim of our study was to evaluate the role of NGT in achalasia patients undergoing LHD. Methods We prospectively enrolled achalasia patients treated with LHD from January 2019 until June 2022 at our institution and randomly assigned them to two groups: one group with NGT and group without (noNGT). Perioperative outcomes were compared between the two groups. ClinicalTrials.gov Identifier: NCT05729971. Results Seventy-nine patients who underwent LHD myotomy were prospectively enrolled. Patients were divided in two groups: 38 with NGT and 41 noNGT. There were no significant differences between two groups in terms of demographic data, preoperative characteristics, length of stay, start of liquid and solid diet, intraoperative and postoperative complications. First flatus was shorter in the noNGT group (p: 0.03). Conclusion Nasogastric tube placement following LHD myotomy does not reduce nausea, vomiting and chest pain, while it increased patients discomfort and time of first flatus. Achalasia Heller-Dor laparoscopic naso-gastric tube myotomy postoperative nausea and vomiting Figures Figure 1 Introduction Achalasia is a rare disorder of esophageal motility, characterized by absent or impaired peristalsis and incomplete relaxation of the lower esophageal sphincter (LES) [1–2]. This disease is characterized by a partial or total impairment of non-cholinergic inhibitory nerves of the Auerbach plexus [1]. The etiology is unclear but there are multifactorial causes such as autoimmune, infective, neurodegenerative and, genetics factors [3–17]. Although not specific, dysphagia for solids and liquids, regurgitation, weight loss and chest pain represent the most common symptoms, while less frequently patients can complain of nocturnal cough, heartburn, and pulmonary aspiration [18–21]. The Eckardt score is the grading system used to evaluate the severity of symptoms and establish the efficacy of treatment. The score assigns to each of the cardinal symptoms (dysphagia, regurgitation, chest pain and weight loss) a value ranging from zero to 3 points according to the reported severity and frequency. A score of 0–1 corresponds to clinical stage 0; 2–3 to stage I; 4–6 to stage II and a score > 6 to stage III [17, 21, 22]. The gold standard for diagnosis is High resolution manometry (HRM). According to the Chicago classification, there are three subtypes of Achalasia: type I with absent or minimal contractility of esophageal, type II with panesophageal pressurization and type III with spastic contractions [23]. Laparoscopic Heller-Dor (LHD) myotomy is an optimal treatment of choice for type I and type II achalasia [24]. This surgical procedure is safe and effective in reducing symptoms and improving manometric parameters [25]. For this surgery, many surgeons routinely place a nasogastric tube (NGT) during the postoperative period. NGT may allow postoperative gastric decompression, prevention of incisional hernia, reduction of postoperative ileus (POI), mucosal leak, nausea, and vomiting (PONV) [26]. These beliefs prevailed on the degree of discomfort of patients [26]. Recently, the development of minimally invasive surgery, the improvement of the anesthetic prevention of PONV and rehabilitation protocols have opened a debate about the real need of routine placement of a NGT [27]. There are several studies evaluating the use of the NGT in colorectal, hepatic, urologic, thoracic, otorhinolaryngology, gastric and esophageal surgery [28–34]. However, there are no studies about NGT in achalasia patients undergoing LHD. The aim of this study was to value the impact of NGT placement in esophageal surgery for achalasia in terms of postoperative outcomes. Material and methods We prospectively enrolled achalasia patients undergoing LHD at our Surgery Unit from 1 January 2019 to 30 June 2022. Patients with a definitive diagnosis of achalasia were included in our study except pregnant patients, patients with less 18 years, with a history of abdominal surgery, body mass index (BMI) > 40, American Society of Anesthesiology (ASA) score > 4, megaesophagus, type III achalasia and previously treated (e.g., endoscopic dilations, peroral endoscopic myotomy or botulinum toxin injections). Patients were randomized by a random number generator in two groups: the first one underwent NGT and second one without NGT (noNGT). Demographic and clinical data collected were age, sex, BMI, type of Achalasia, comorbidity, Eckardt score and ASA score. The primary endpoint was to establish whether it is safe to remove the NGT at the end of surgery. Secondary endpoints were the following perioperative outcomes: first flatus (in days), conversion rate, length of stay (in days), intraoperative or postoperative complications (based on Clavien-Dindo classification) especially chest pain, nausea, and vomiting [35]. This prospective study was performed according to the Declaration of Helsinki principles and approval was obtained from the Institutional Review Board and Ethics Committee and each patient through specific informed consent. All patients underwent the same preoperative management with esophagogastroduodenoscopy (EGDS), barium X-ray and esophageal high-resolution manometry (HRM). HRM is gold standard for diagnosis. This technique allows to divide achalasia patients in three different subtypes: Type I (absent peristalsis), type II (pan-esophageal high-pressure) and type III (spastic contractions). We performed to all patients a laparoscopic Heller myotomy on the anterior wall of 6–7 cm with Dor fundoplication and an intraoperative EGDS to identify mucosal leaks and to visualize residual muscle fibers [36]. NGT was placed safely and under endoscopic vision during intraoperative EGDS control and was removed at end of surgery only in the noNGT group. NGT is useful intraoperatively for gastric decompression required for fundoplication and as a stent during the gastroplasty. In our protocol each patient was admitted the day before the surgical intervention, only drinking until midnight. In the post-operative course, every patient took liquid infusion, antibiotic, and anticoagulant therapy. No parenteral nutrition was administered. In the first post-operative day (GPO), X-ray with contrast (Gastrografin®) was performed, and, in absence of leak, patients started to drink water. In patients with NGT, the tube was removed after X-ray test in first GPO. On the II GPO, we suggested to all patients a liquid diet and then a semi-solid diet. In our clinical practice, we routinely follow-up patients 1 year following surgery by administering the Eckardt score and routinely performing HRM and a 24-hour ph-impedance monitoring. The sample size was calculated with a confidence interval of 5% and a confidence level of 95% considering the annual number of LHD for achalasia in Campania region. This number is 78 patients. The comparisons between groups were performed using χ2 test with Yates’ correction or the Fisher’s exact test when appropriate. Continuous variables were compared using the two-sided Student’s t test. Statistical analysis was performed using the IBM SPSS Statistics for Windows, version 20.0. Armonk, NY, IBM Corp. IBM SPSS Statistics version 26 (SPSS Inc. Chicago, IL, USA). Results Eighty-three LHD were performed in our unit by an experienced surgeon from 1 January 2019 to 30 June 2022. Four patients were excluded from the study: one with mega-esophagus while three patients were not naïve to treatment (two patients treated with endoscopic myotomy and one with endoscopic dilatation). Seventy-nine patients underwent to LHD were prospectively enrolled. We dived patients in two groups: thirty-eight with NGT and forty-one without NGT (noNGT) (Fig. 1 ). Demographic data and preoperative characteristics were reported in Table 1 and table 2. There were no significant differences between two groups. Only the time of first flatus was significant shorter in noNGT group (p:0.03). In terms of intraoperative and postoperative complications, there were no differences between the two groups. Table 2 shows the postoperative characteristics. Intraoperative complications included three esophageal mucosal leaks (two in group NGT and one in group noNGT) and two minor bleedings. These complications were excellently managed intraoperatively. We observed 5 postoperative complications in the NGT group and 8 in the group without NGT (p:0.39). According to Clavien-Dindo classification, in NGT patients there were 5 grade I complications (2 nausea, 2 vomiting and one chest pain), while 7 complications were recorded in noNGT patients (3 nausea, 2 vomiting, one chest pain and one fever). We observed only one case of grade II in patient noNGT (mucosal leak) diagnosed on the second postoperative day and treated with parenteral nutrition for 6 days (table 3). In terms of length of stay (LOS), start of liquid and solid diet there were no differences (table 3). There was no conversion to open surgery, reoperation, and reintroduction of NGT. After multivariate analysis, we found that grade II postoperative complications were associated with increased LOS and delayed oral feeding. There are no significant long-term differences in terms of Eckardt score, manometry parameters, and gastroesophageal reflux. Discussion In this study, we evaluated the effects of NGT placement in patients undergoing LHD myotomy at our institution. In our experience, we compared the post-operative outcomes of patients undergoing LHD for achalasia in a single center in a period of two years and a half. Several studies focused on NGT in gastric, esophageal, colorectal, otorhinolaryngology, pancreatic, hepatobiliary, urologic, and cardiac surgery [28–34, 37]. The debate on the putative role of NGT is still open. In the past, surgeons thought NGT was able to reduce postoperative gastric decompression, postoperative ileus (POI), mucosal leak, nausea, and vomiting, risk of pulmonary complications and prevention of incisional hernia [26, 38–40]. However, the current evidence shows that routine NGT use does not reduce these complications, but it could actually increase their occurrence [31, 33, 38, 41, 42]. Some authors, indeed, showed a higher rate of respiratory complications, increase of POI and length of stay in patients with NGT [29, 31, 38, 41–43]. Moreover, the NGT increases patients’ discomfort and pain due to the direct irritation of mucosa, sore throat, ear pain, and painful swallowing [38, 42, 44]. Weijs TJ et al performed a systematic literature review and meta-analysis on the effects of the NGT in patients undergoing esophagectomy [31]. These authors showed that early or preoperative removal of NGT is safe and does not increase the risk of complications [31]. Several studies demonstrated no improvement of outcomes with prophylactic use of NGT for gastric surgery [33, 45–52]. Rossetti et al., in their randomized trial concluded that NGT placement in patients treated with laparoscopic sleeve gastrectomy does not reduce the risk of postoperative leak [45]. Wei et al. and Wang D et al, showed that nasogastric decompression does not facilitate the recovery of bowel function or reduce the risk of postoperative complications in gastric cancer surgery, regardless of the type of resection [33, 48]. Interesting is the study of Zhukhovitskaya et al. in surgery for hypopharyngeal diverticula [32]. In this surgery, NGT placement can be associated with higher rates of complications; while several benefits including better compliance, reduced risk of throat pain and vocal cord paralysis have been described in the group without NGT [32]. Furthermore, also nursing assistance in hospital can be associated with lowering costs, improving both healthcare and patients’ satisfaction [32, 53]. The use of NGT for achalasia surgery is still controversial. Many authors routinely place NGT after this surgery, others insert it before, but they say nothing about its removal [54–56]. However, it is not clear if other authors use it [57–63]. Our study attempted to answer this question in consecutive achalasia patients treated with LHD. The result of our study showed that NGT does not improve perioperative outcomes. According to literature data, NGT does not reduce intraoperative and postoperative complications such as mucosal leak, nausea, vomiting and chest pain; furthermore, its use in case of esophageal mucosa leak would seem unnecessary [64]. There was only one patient in noNGT group with mucosal leak treated conservatively without reintroduction of NGT. In our clinical practice, we treated an esophageal leak detected on X-ray with Gastrografin® with parenteral nutrition and intravenous fluids. In several studies the absence of NGT has reduced the time to flatus or first defecation [28, 29, 33, 38, 49, 66]. In other papers, no differences were detected [65]. In our study, the group without NGT displayed a shortened time to flatus. In our opinion, NGT removes gastric juice slowing down peristaltic and interferes with the patients’ activities (walking, drinking, and eating). NGT removal and faster oral refeeding can reduce the LOS in colorectal and upper gastro-intestinal surgery [28, 38, 49, 66]. We didn’t find a difference in terms of LOS because the oral diet started after the Gastrografin® X-ray. To our knowledge, this is the first randomized prospective study evaluating the role of NGT in this type of surgery. Several limitations are present in this study: all patients enrolled were fit for surgery and our data derive from a single center experience. Finally, multicentric randomized, comparative large-scale trials need to be carried out for definitively value the role of NGT although achalasia is a rare disease, and the simple size will never be as large as in other studies. Conclusion According to our results, routine placement of NGT is useless for achalasia patient treated with LHD. It does not reduce nausea, vomiting and chest pain but increases discomfort for patients and time of first flatus. NGT for this surgery, should be used only in specifics cases. Declarations Financial Support and Sponsorship: None Conflict of interest: The authors declare that they have no conflict of interests. Informed consent Informed consent was obtained from each included patient. Research involving human participants and/or animals All the procedures performed in the present study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments. No animal was involved in the present study. 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Laparoscopic Heller myotomy with minimal dissection and Dor anterior valve. J Visc Surg. 2018 Oct;155(5):429–430. doi: 10.1016/j.jviscsurg.2018.06.013. Epub 2018 Jul 24. PMID: 30054201. Salvador, R., Costantini, M., Cavallin, F. et al. Laparoscopic Heller Myotomy Can Be Used As Primary Therapy for Esophageal Achalasia Regardless of Age. J Gastrointest Surg 18, 106–112 (2014). https://doi.org/10.1007/s11605-013-2334-y. Lee JH, Kedia P, Stavropoulos SN, Carr-Locke D. AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review. Clin Gastroenterol Hepatol. 2021 Nov;19(11):2252–2261.e2. doi: 10.1016/j.cgh.2021.06.045. Epub 2021 Jul 2. PMID: 34224876.] Kimura Y, Yano H, Iwazawa T, Fujita J, Fujita S, Yamamoto K, Yasuda T. One-day nasogastric tube decompression after distal gastrectomy: a prospective randomized study. Surg Today. 2017 Sep;47(9):1080–1085. doi: 10.1007/s00595-017-1475-0. Epub 2017 Feb 21. PMID: 28224234. Sun H, Li Y, Liu X, et al. Feasibility of "no tube no fasting" therapy in thoracolaparoscopic oesophagectomy for patients with oesophageal cancer. Zhonghua Wei Chang Wai Ke Za Zhi 2014;17:898–901. Tables Patients Number 79 Sex (M/F) 35/44 Age Onset, years 42 (15 – 82) Age Surgery, years 49 (18 – 83) BMI Preoperative, Kg/m 2 24.7 ± 5.22 Weight Loss, Kg 6 (0 – 29) ASA Score I II III 7 (8.8%) 33 (41.8%) 39 (49.4%) Achalasia Type 1 2 8 (10.1%) 71 (89.9%) Eckardt Score 6.6 ± 3.0 Table 1. Demographic data and preoperative characteristics NGT noNGT p Patients Number 38 41 - Sex (M/F) 18/20 17/24 0.597 BMI, Kg/m 2 25.65 ± 5.32 25.84 ± 5.79 0.789 ASA Score I II III 6 (15,8%) 20 (52.6%) 12 (31.6%) 3 (7.3%) 22 (53.7%) 16 (39%) 0.580 Achalasia Type 1 2 4 (10.5%) 34 (89.5%) 4 (9.8%) 37 (90.2%) >0.999 Eckardt Score 7.5 ± 2.7 6.8 ± 3 0.596 Table 2. Preoperative Patients Characteristics NGT noNGT p Patients Number 38 41 - Length of stay (day) 3.43 (3-7) 3.23 (3-6) 0.2 First flatus (day) 1.31 (1-2) 1.12 (1-2) 0.03 Intake liquid diet (day) 1.2 1.1 0.55 Intake semi-solid diet (day) 2.2 2.23 0.84 Intraoperative complications 3 (7,9%) 2 (4.9%) 0.605 Postoperative complications: Grade I Grade II 5 (13.15%) 5 (100%) 0 8 (19.1%) 7 (87.5%) 1 (12.5%) 0.39 0.67 - Table 3. Intraoperative complications and postoperative variables Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2930409","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":201163085,"identity":"7bb157b4-f4b6-4ff3-a441-5d302085ea8d","order_by":0,"name":"Giuseppe 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06:59:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":317408,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2930409/v1/bdd276b8-f685-484f-b747-0f1dbd4916f3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nasogastric tube after laparoscopic Heller-Dor myotomy: do you really need it?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAchalasia is a rare disorder of esophageal motility, characterized by absent or impaired peristalsis and incomplete relaxation of the lower esophageal sphincter (LES) [1\u0026ndash;2]. This disease is characterized by a partial or total impairment of non-cholinergic inhibitory nerves of the Auerbach plexus [1]. The etiology is unclear but there are multifactorial causes such as autoimmune, infective, neurodegenerative and, genetics factors [3\u0026ndash;17].\u003c/p\u003e \u003cp\u003eAlthough not specific, dysphagia for solids and liquids, regurgitation, weight loss and chest pain represent the most common symptoms, while less frequently patients can complain of nocturnal cough, heartburn, and pulmonary aspiration [18\u0026ndash;21].\u003c/p\u003e \u003cp\u003eThe Eckardt score is the grading system used to evaluate the severity of symptoms and establish the efficacy of treatment. The score assigns to each of the cardinal symptoms (dysphagia, regurgitation, chest pain and weight loss) a value ranging from zero to 3 points according to the reported severity and frequency. A score of 0\u0026ndash;1 corresponds to clinical stage 0; 2\u0026ndash;3 to stage I; 4\u0026ndash;6 to stage II and a score\u0026thinsp;\u0026gt;\u0026thinsp;6 to stage III [17, 21, 22].\u003c/p\u003e \u003cp\u003eThe gold standard for diagnosis is High resolution manometry (HRM). According to the Chicago classification, there are three subtypes of Achalasia: type I with absent or minimal contractility of esophageal, type II with panesophageal pressurization and type III with spastic contractions [23].\u003c/p\u003e \u003cp\u003eLaparoscopic Heller-Dor (LHD) myotomy is an optimal treatment of choice for type I and type II achalasia [24]. This surgical procedure is safe and effective in reducing symptoms and improving manometric parameters [25].\u003c/p\u003e \u003cp\u003eFor this surgery, many surgeons routinely place a nasogastric tube (NGT) during the postoperative period. NGT may allow postoperative gastric decompression, prevention of incisional hernia, reduction of postoperative ileus (POI), mucosal leak, nausea, and vomiting (PONV) [26]. These beliefs prevailed on the degree of discomfort of patients [26].\u003c/p\u003e \u003cp\u003eRecently, the development of minimally invasive surgery, the improvement of the anesthetic prevention of PONV and rehabilitation protocols have opened a debate about the real need of routine placement of a NGT [27]. There are several studies evaluating the use of the NGT in colorectal, hepatic, urologic, thoracic, otorhinolaryngology, gastric and esophageal surgery [28\u0026ndash;34]. However, there are no studies about NGT in achalasia patients undergoing LHD.\u003c/p\u003e \u003cp\u003eThe aim of this study was to value the impact of NGT placement in esophageal surgery for achalasia in terms of postoperative outcomes.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eWe prospectively enrolled achalasia patients undergoing LHD at our Surgery Unit from 1 January 2019 to 30 June 2022. Patients with a definitive diagnosis of achalasia were included in our study except pregnant patients, patients with less 18 years, with a history of abdominal surgery, body mass index (BMI)\u0026thinsp;\u0026gt;\u0026thinsp;40, American Society of Anesthesiology (ASA) score\u0026thinsp;\u0026gt;\u0026thinsp;4, megaesophagus, type III achalasia and previously treated (e.g., endoscopic dilations, peroral endoscopic myotomy or botulinum toxin injections).\u003c/p\u003e \u003cp\u003ePatients were randomized by a random number generator in two groups: the first one underwent NGT and second one without NGT (noNGT). Demographic and clinical data collected were age, sex, BMI, type of Achalasia, comorbidity, Eckardt score and ASA score. The primary endpoint was to establish whether it is safe to remove the NGT at the end of surgery. Secondary endpoints were the following perioperative outcomes: first flatus (in days), conversion rate, length of stay (in days), intraoperative or postoperative complications (based on Clavien-Dindo classification) especially chest pain, nausea, and vomiting [35].\u003c/p\u003e \u003cp\u003e This prospective study was performed according to the Declaration of Helsinki principles and approval was obtained from the Institutional Review Board and Ethics Committee and each patient through specific informed consent.\u003c/p\u003e \u003cp\u003eAll patients underwent the same preoperative management with esophagogastroduodenoscopy (EGDS), barium X-ray and esophageal high-resolution manometry (HRM). HRM is gold standard for diagnosis. This technique allows to divide achalasia patients in three different subtypes: Type I (absent peristalsis), type II (pan-esophageal high-pressure) and type III (spastic contractions).\u003c/p\u003e \u003cp\u003eWe performed to all patients a laparoscopic Heller myotomy on the anterior wall of 6\u0026ndash;7 cm with Dor fundoplication and an intraoperative EGDS to identify mucosal leaks and to visualize residual muscle fibers [36]. NGT was placed safely and under endoscopic vision during intraoperative EGDS control and was removed at end of surgery only in the noNGT group. NGT is useful intraoperatively for gastric decompression required for fundoplication and as a stent during the gastroplasty. In our protocol each patient was admitted the day before the surgical intervention, only drinking until midnight.\u003c/p\u003e \u003cp\u003eIn the post-operative course, every patient took liquid infusion, antibiotic, and anticoagulant therapy. No parenteral nutrition was administered. In the first post-operative day (GPO), X-ray with contrast (Gastrografin\u0026reg;) was performed, and, in absence of leak, patients started to drink water. In patients with NGT, the tube was removed after X-ray test in first GPO. On the II GPO, we suggested to all patients a liquid diet and then a semi-solid diet.\u003c/p\u003e \u003cp\u003eIn our clinical practice, we routinely follow-up patients 1 year following surgery by administering the Eckardt score and routinely performing HRM and a 24-hour ph-impedance monitoring.\u003c/p\u003e \u003cp\u003eThe sample size was calculated with a confidence interval of 5% and a confidence level of 95% considering the annual number of LHD for achalasia in Campania region. This number is 78 patients.\u003c/p\u003e \u003cp\u003eThe comparisons between groups were performed using χ2 test with Yates\u0026rsquo; correction or the Fisher\u0026rsquo;s exact test when appropriate. Continuous variables were compared using the two-sided Student\u0026rsquo;s t test. Statistical analysis was performed using the IBM SPSS Statistics for Windows, version 20.0. Armonk, NY, IBM Corp. IBM SPSS Statistics version 26 (SPSS Inc. Chicago, IL, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eEighty-three LHD were performed in our unit by an experienced surgeon from 1 January 2019 to 30 June 2022. Four patients were excluded from the study: one with mega-esophagus while three patients were not na\u0026iuml;ve to treatment (two patients treated with endoscopic myotomy and one with endoscopic dilatation). Seventy-nine patients underwent to LHD were prospectively enrolled. We dived patients in two groups: thirty-eight with NGT and forty-one without NGT (noNGT) (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Demographic data and preoperative characteristics were reported in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and table 2. There were no significant differences between two groups.\u003c/p\u003e\n\u003cp\u003eOnly the time of first flatus was significant shorter in noNGT group (p:0.03). In terms of intraoperative and postoperative complications, there were no differences between the two groups. Table\u0026nbsp;2 shows the postoperative characteristics.\u003c/p\u003e\n\u003cp\u003eIntraoperative complications included three esophageal mucosal leaks (two in group NGT and one in group noNGT) and two minor bleedings. These complications were excellently managed intraoperatively.\u003c/p\u003e\n\u003cp\u003eWe observed 5 postoperative complications in the NGT group and 8 in the group without NGT (p:0.39). According to Clavien-Dindo classification, in NGT patients there were 5 grade I complications (2 nausea, 2 vomiting and one chest pain), while 7 complications were recorded in noNGT patients (3 nausea, 2 vomiting, one chest pain and one fever). We observed only one case of grade II in patient noNGT (mucosal leak) diagnosed on the second postoperative day and treated with parenteral nutrition for 6 days (table 3).\u003c/p\u003e\n\u003cp\u003eIn terms of length of stay (LOS), start of liquid and solid diet there were no differences (table 3).\u003c/p\u003e\n\u003cp\u003eThere was no conversion to open surgery, reoperation, and reintroduction of NGT.\u003c/p\u003e\n\u003cp\u003eAfter multivariate analysis, we found that grade II postoperative complications were associated with increased LOS and delayed oral feeding.\u003c/p\u003e\n\u003cp\u003eThere are no significant long-term differences in terms of Eckardt score, manometry parameters, and gastroesophageal reflux.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we evaluated the effects of NGT placement in patients undergoing LHD myotomy at our institution. In our experience, we compared the post-operative outcomes of patients undergoing LHD for achalasia in a single center in a period of two years and a half.\u003c/p\u003e \u003cp\u003eSeveral studies focused on NGT in gastric, esophageal, colorectal, otorhinolaryngology, pancreatic, hepatobiliary, urologic, and cardiac surgery [28\u0026ndash;34, 37].\u003c/p\u003e \u003cp\u003eThe debate on the putative role of NGT is still open. In the past, surgeons thought NGT was able to reduce postoperative gastric decompression, postoperative ileus (POI), mucosal leak, nausea, and vomiting, risk of pulmonary complications and prevention of incisional hernia [26, 38\u0026ndash;40].\u003c/p\u003e \u003cp\u003eHowever, the current evidence shows that routine NGT use does not reduce these complications, but it could actually increase their occurrence [31, 33, 38, 41, 42]. Some authors, indeed, showed a higher rate of respiratory complications, increase of POI and length of stay in patients with NGT [29, 31, 38, 41\u0026ndash;43]. Moreover, the NGT increases patients\u0026rsquo; discomfort and pain due to the direct irritation of mucosa, sore throat, ear pain, and painful swallowing [38, 42, 44].\u003c/p\u003e \u003cp\u003eWeijs TJ et al performed a systematic literature review and meta-analysis on the effects of the NGT in patients undergoing esophagectomy [31]. These authors showed that early or preoperative removal of NGT is safe and does not increase the risk of complications [31].\u003c/p\u003e \u003cp\u003eSeveral studies demonstrated no improvement of outcomes with prophylactic use of NGT for gastric surgery [33, 45\u0026ndash;52]. Rossetti et al., in their randomized trial concluded that NGT placement in patients treated with laparoscopic sleeve gastrectomy does not reduce the risk of postoperative leak [45].\u003c/p\u003e \u003cp\u003eWei et al. and Wang D et al, showed that nasogastric decompression does not facilitate the recovery of bowel function or reduce the risk of postoperative complications in gastric cancer surgery, regardless of the type of resection [33, 48].\u003c/p\u003e \u003cp\u003eInteresting is the study of Zhukhovitskaya et al. in surgery for hypopharyngeal diverticula [32]. In this surgery, NGT placement can be associated with higher rates of complications; while several benefits including better compliance, reduced risk of throat pain and vocal cord paralysis have been described in the group without NGT [32]. Furthermore, also nursing assistance in hospital can be associated with lowering costs, improving both healthcare and patients\u0026rsquo; satisfaction [32, 53].\u003c/p\u003e \u003cp\u003eThe use of NGT for achalasia surgery is still controversial. Many authors routinely place NGT after this surgery, others insert it before, but they say nothing about its removal [54\u0026ndash;56]. However, it is not clear if other authors use it [57\u0026ndash;63]. Our study attempted to answer this question in consecutive achalasia patients treated with LHD. The result of our study showed that NGT does not improve perioperative outcomes. According to literature data, NGT does not reduce intraoperative and postoperative complications such as mucosal leak, nausea, vomiting and chest pain; furthermore, its use in case of esophageal mucosa leak would seem unnecessary [64]. There was only one patient in noNGT group with mucosal leak treated conservatively without reintroduction of NGT. In our clinical practice, we treated an esophageal leak detected on X-ray with Gastrografin\u0026reg; with parenteral nutrition and intravenous fluids.\u003c/p\u003e \u003cp\u003eIn several studies the absence of NGT has reduced the time to flatus or first defecation [28, 29, 33, 38, 49, 66]. In other papers, no differences were detected [65]. In our study, the group without NGT displayed a shortened time to flatus. In our opinion, NGT removes gastric juice slowing down peristaltic and interferes with the patients\u0026rsquo; activities (walking, drinking, and eating).\u003c/p\u003e \u003cp\u003eNGT removal and faster oral refeeding can reduce the LOS in colorectal and upper gastro-intestinal surgery [28, 38, 49, 66]. We didn\u0026rsquo;t find a difference in terms of LOS because the oral diet started after the Gastrografin\u0026reg; X-ray.\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the first randomized prospective study evaluating the role of NGT in this type of surgery. Several limitations are present in this study: all patients enrolled were fit for surgery and our data derive from a single center experience. Finally, multicentric randomized, comparative large-scale trials need to be carried out for definitively value the role of NGT although achalasia is a rare disease, and the simple size will never be as large as in other studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAccording to our results, routine placement of NGT is useless for achalasia patient treated with LHD. It does not reduce nausea, vomiting and chest pain but increases discomfort for patients and time of first flatus. NGT for this surgery, should be used only in specifics cases.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFinancial Support and Sponsorship:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e The authors declare that they have no conflict of interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from each included patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch involving human participants and/or animals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the procedures performed in the present study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments. No animal was involved in the present study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026apos;s contribution:\u003c/strong\u003e G.P. conceived, designed, performed the statistical analysis and final approve of the manuscript; G.P. and R.B. wrote the main manuscript text; R.B. prepared figures 1, M.C.; M.P. and S.R. performed data collection; G.A. designed of the manuscript; G.S, G.D.DP. and G.A. critically revised, and final approve of the manuscript. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHoshino M, Omura N, Yano F, et al. Immunohistochemical study of the muscularis externa of the esophagus in achalasia patients. Dis Esophagus 2013;26(1): 14\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eRaymond L, Lach B, Shamji FM. Inflammatory aetiology of primary oesophageal achalasia: an immunohistochemical and ultrastructural study of Auerbach\u0026rsquo;s plexus. Histopathology 1999;35(5):445\u0026ndash;53.\u003c/li\u003e\n\u003cli\u003ePressman A, Behar J, et al. Etiology and Pathogenesis of Idiopathic Achalasia. J Clin Gastroenterology 2017; 195\u0026ndash;202\u003c/li\u003e\n\u003cli\u003eRaymond L, Lach B, Shamji FM. Inflammatory etiology of primary esophageal achalasia: an immunohistochemical and ultrastructural study of Auerbach\u0026rsquo;s plexus. Histopathology.1999;35:445\u0026ndash;453.\u003c/li\u003e\n\u003cli\u003eFuruzawa-Carballeda J, Aguilar-Le\u0026oacute;n D, Gamboa-Dom\u0026iacute;nguez A, Valdovinos MA, Nu\u0026ntilde;ez-\u0026Aacute;lvarez C, Mart\u0026iacute;n-del-Campo LA, Enr\u0026iacute;quez AB, Coss-Adame E, Svarch AE, Flores-N\u0026aacute;jera A, Villa-Ba\u0026ntilde;os A, Ceballos JC, Torres-Villalobos G. Achalasia\u0026ndash;An Autoimmune Inflammatory Disease: A Cross-Sectional Study. J Immunol Res. 2015;2015:729217. doi: 10.1155/2015/729217. Epub 2015 May 20. PMID: 26078981; PMCID: PMC4452860.\u003c/li\u003e\n\u003cli\u003eMoses PL, Ellis LM, Anees MR, et al. Antineuronal antibodies in idiopathic achalasia and gastro-oesophageal reflux disease. Gut. 2003;52:629\u0026ndash;636.\u003c/li\u003e\n\u003cli\u003eLucchinetti CF, Kimmel DW, Lennon VA. Paraneoplastic and oncologic profiles of patients seropositive for type 1 anti-neuronal nuclear autoantibodies. Neurology. 1998;50:652\u0026ndash;657.\u003c/li\u003e\n\u003cli\u003eZ\u0026aacute;rate N, Mearin F, Gil-Vernet JM, Camarasa F, Malagelada JR. Achalasia and Down's syndrome: coincidental association or something else? Am J Gastroenterol. 1999 Jun;94(6):1674-7. doi: 10.1111/j.1572-0241.1999.01161.x. PMID: 10364043.\u003c/li\u003e\n\u003cli\u003eGockel I, Becker J, Wouters MM, et al. Common variants in the HLA-DQ region confer susceptibility to idiopathic achalasia. Nat Genet. 2014;46:901\u0026ndash;904.\u003c/li\u003e\n\u003cli\u003eSara C, Marcella P, Martina C, Marta A, Eleonora E, Giovanni A, Marco M, Paola DV, Domenico PG, Giovanni S. Clinical correlation and disease phenotype in patients with esophageal achalasia and comorbid autoimmune diseases. Dis Esophagus. 2021 Jan 11;34(1):doaa072. doi: 10.1093/dote/doaa072. PMID: 32766709.\u003c/li\u003e\n\u003cli\u003eBoeckxstaens GE. Achalasia: virus-induced euthanasia of neurons? Am J Gastroenterol. 2008;103:1610\u0026ndash;1612.\u003c/li\u003e\n\u003cli\u003eRobertson CS, Martin BA, Atkinson M. Varicella-zoster virus DNAed in the oesophageal myenteric plexus in achalasia. Gut. 1993;34:299\u0026ndash;302.\u003c/li\u003e\n\u003cli\u003eCastagliuolo I, Brun P, Costantini M, et al. Esophageal achalasia: is the herpes simplex virus really innocent? J Gastrointest Surg. 2004;8:24\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eJones DB, Mayberry JF, Rhodes J, et al. Preliminary report of an association between measles virus and achalasia. J Clin Pathol. 1983;36:655.\u003c/li\u003e\n\u003cli\u003eNiwamoto H, Okamoto E, Fujimoto J, et al. Are human herpes viruses or measles virus associated with esophageal achalasia? Dig Dis Sci. 1995;40:859\u0026ndash;864.\u003c/li\u003e\n\u003cli\u003eBirginsson S, Galinski MS, Goldblum JR, et al. Achalasia is not associated with measles, or known herpes or human papilloma viruses. Dig Dis Sci. 1997;42:300\u0026ndash;306.\u003c/li\u003e\n\u003cli\u003eEckardt VF, Stauf B, Bernhard G. Chest pain in achalasia: patient characteristics and clinical course. Gastroenterology 1999;116(6):1300\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eSmart HL, Foster PN, Evans DF, et al. Twenty four hour oesophageal acidity in achalasia before and after pneumatic dilatation. Gut 1987;28(7):883\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eSinan H, Tatum RP, Soares RV, et al. Prevalence of respiratory symptoms in patients with achalasia. Dis Esophagus 2011;24(4):224\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eVaezi MF, Pandolfino JE, Yadlapati RH, et al. ACG clinical guidelines: diagnosis and management of achalasia. Am J Gastroenterol 2020;115(9):1393\u0026ndash;411.\u003c/li\u003e\n\u003cli\u003eLaurino-Neto RM, Herbella F, Schlottmann F, Patti M. Evaluation of Esophageal Achalasia: From Symptoms To The Chicago Classification. Arq Bras Cir Dig. 2018;31(2):e1376..\u003c/li\u003e\n\u003cli\u003eGockel I, Junginger T. The value of scoring achalasia a comparison of current systems and the impact on treatment\u0026ndash;the surgeon's viewpoint. \u003cem\u003eAm Surg.\u003c/em\u003e 2007;73(4):327\u0026ndash;331.\u003c/li\u003e\n\u003cli\u003eKahrilas PJ, Bredenoord AJ, Fox M. International High Resolution Manometry Working Group The Chicago Classification of esophageal motility disorders, v3.0. \u003cem\u003eNeurogastroenterol Motil.\u003c/em\u003e 2015;27(2):160\u0026ndash;174.\u003c/li\u003e\n\u003cli\u003eAndolfi C, Fisichella PM. Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes. Br J Surg 2019;106(4):332\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eHerbella FA, Moura EG, Patti MG. Achalasia 2016: Treatment Alternatives. \u003cem\u003eJ Laparoendosc Adv Surg Tech A.\u003c/em\u003e 2017;27(1):6\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eTanguy M, Seguin P, Mall\u0026eacute;dant Y. Bench-to-bedside review: Routine postoperative use of the nasogastric tube - utility or futility? Crit Care. 2007;11(1):201. doi: 10.1186/cc5118. PMID: 17214909; PMCID: PMC2151862.\u003c/li\u003e\n\u003cli\u003eMen\u0026eacute;ndez-Jim\u0026eacute;nez M, Bruna-Esteban M, Mingol F, Vaqu\u0026eacute; J, Herv\u0026aacute;s D, \u0026Aacute;lvarez-Sarrado E, Navasquillo-Tamarit M, Hurtado-Pardo L, Garc\u0026iacute;a-Granero E. Nasogastric tube utilization after esophagectomy: an unnecessary gesture? Cir Esp (Engl Ed). 2020 Dec;98(10):598\u0026ndash;604. English, Spanish. doi: 10.1016/j.ciresp.2020.04.021. Epub 2020 Jun 3. PMID: 32505557.\u003c/li\u003e\n\u003cli\u003eVenara A, Hamel JF, Cotte E, Meillat H, Sage PY, Slim K; GRACE Group*. Intraoperative nasogastric tube during colorectal surgery may not be mandatory: a propensity score analysis of a prospective database. Surg Endosc. 2020 Dec;34(12):5583\u0026ndash;5592. doi: 10.1007/s00464-019-07359-9. Epub 2020 Jan 13. PMID: 31932940.\u003c/li\u003e\n\u003cli\u003eWen Z, Zhang X, Liu Y, Bian L, Chen J, Wei L. Is routine nasogastric decompression after hepatic surgery necessary? A systematic review and meta-analysis. Int J Nurs Stud. 2019 Dec;100:103406. doi: 10.1016/j.ijnurstu.2019.103406. Epub 2019 Aug 26. PMID: 31629211\u003c/li\u003e\n\u003cli\u003eHsu FS, Huang WY, Chen YF, Wu LY, Wang SM, Huang KH. Nasogastric tube decompression is unnecessary in patients undergoing laparoscopic nephroureterectomy for localized upper tract urothelial carcinoma. J Formos Med Assoc. 2020 Sep;119(9):1353\u0026ndash;1359. doi: 10.1016/j.jfma.2019.11.011. Epub 2019 Dec 5. PMID: 31813657.\u003c/li\u003e\n\u003cli\u003eWeijs TJ, Kumagai K, Berkelmans GH, Nieuwenhuijzen GA, Nilsson M, Luyer MD. Nasogastric decompression following esophagectomy: a systematic literature review and meta-analysis. Dis Esophagus. 2017 Feb 1;30(3):1\u0026ndash;8. doi: 10.1111/dote.12530. PMID: 27627872.\u003c/li\u003e\n\u003cli\u003eZhukhovitskaya A, Weiland DJ, Goshtasbi K, Verma SP. Is nasogastric tube feeding necessary after hypopharyngeal diverticulum surgery? Am J Otolaryngol. 2020 May-Jun;41(3):102453. doi: 10.1016/j.amjoto.2020.102453. Epub 2020 Mar 10. PMID: 32199712.\u003c/li\u003e\n\u003cli\u003eWang D, Li T, Yu J, Hu Y, Liu H, Li G. Is nasogastric or nasojejunal decompression necessary following gastrectomy for gastric cancer? A systematic review and meta-analysis of randomised controlled trials. J Gastrointest Surg. 2015 Jan;19(1):195\u0026ndash;204. doi: 10.1007/s11605-014-2648-4. Epub 2014 Sep 20. PMID: 25238814.\u003c/li\u003e\n\u003cli\u003eHern\u0026aacute;ndez Mateo MM, Mart\u0026iacute;nez-L\u0026oacute;pez I, Hernando-Rydings M, Revuelta-Suero S, Marqu\u0026eacute;s de Marino P, Serrano Hernando FJ. Systematic nasogastric tube in aortic surgery: is it necessary? Ann Vasc Surg. 2015;29(4):786\u0026thinsp;\u0026minus;\u0026thinsp;91. doi: 10.1016/j.avsg.2015.01.002. Epub 2015 Mar 4. PMID: 25749609.\u003c/li\u003e\n\u003cli\u003eDindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205\u0026ndash;213.\u003c/li\u003e\n\u003cli\u003eAncona E, Peracchia A, Zaninotto G, Rossi M, Bonavina L, Segalin A. Heller laparoscopic cardiomyotomy with antireflux anterior fundoplication (Dor) in the treatment of esophageal achalasia. Surg Endosc. 1993 Sep-Oct;7(5):459\u0026thinsp;\u0026minus;\u0026thinsp;61. doi: 10.1007/BF00311744. PMID: 8211631.\u003c/li\u003e\n\u003cli\u003eKunstman JW, Klemen ND, Fonseca AL, Araya DL, Salem RR. Nasogastric drainage may be unnecessary after pancreaticoduodenectomy: a comparison of routine vs selective decompression. J Am Coll Surg. 2013 Sep;217(3):481-8. doi: 10.1016/j.jamcollsurg.2013.04.031. Epub 2013 Jul 25. PMID: 23891073.\u003c/li\u003e\n\u003cli\u003eZhang R, Zhang L. Feasibility of complete nasogastric tube omission in esophagectomy patients. J Thorac Dis. 2019 Apr;11(Suppl 5):S819-S823. doi: 10.21037/jtd.2018.11.98. PMID: 31080664; PMCID: PMC6503281\u003c/li\u003e\n\u003cli\u003eNelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2007;(3):CD004929\u003c/li\u003e\n\u003cli\u003eTsai YF, Luo CF, Illias A, Lin CC, Yu HP. Nasogastric tube insertion in anesthetized and intubated patients: a new and reliable method. BMC Gastroenterol. 2012 Aug 1;12:99. doi: 10.1186/1471-230X-12-99. PMID: 22853453; PMCID: PMC3444911\u003c/li\u003e\n\u003cli\u003eRao, W., Zhang, X., Zhang, J. et al. The role of nasogastric tube in decompression after elective colon and rectum surgery: a meta-analysis. Int J Colorectal Dis 26, 423\u0026ndash;429 (2011). https://doi.org/10.1007/s00384-010-1093-4.\u003c/li\u003e\n\u003cli\u003eDaryaei P, Davari FZ, Mir M, Harirchi I, Salmasian H. Omission of nasogastric tube application in postoperative care for esophagectomy. World J Surg. 2009;33:773\u0026ndash;7. http://dx.doi.org/10.1007/s00268-009-9930-8.21.\u003c/li\u003e\n\u003cli\u003eSchwarz M, Coccetti A, Murdoch A, Cardell E. The impact of aspiration pneumonia and nasogastric feeding on clinical outcomes in stroke patients: A retrospective cohort study. J Clin Nurs. 2018 Jan;27(1\u0026ndash;2):e235-e241. doi: 10.1111/jocn.13922. Epub 2017 Aug 3. PMID: 28618137.\u003c/li\u003e\n\u003cli\u003eSavassi-Rocha PR, Conceicao SA, Ferreira JT (1992) Evaluation of the routine use of the nasogastric tube in digestive operation by a prospective, controlled study. Surg Gynecol Obstet 174:317.\u003c/li\u003e\n\u003cli\u003eRossetti G, Fei L, Docimo L, Del Genio G, Micanti F, Belfiore A, Brusciano L, Moccia F, Cimmino M, Marra T. Is nasogastric decompression useful in prevention of leaks after laparoscopic sleeve gastrectomy? A randomized trial. J Invest Surg. 2014 Aug;27(4):234-9. doi: 10.3109/08941939.2013.875606. Epub 2014 Jan 29. PMID: 24476003.\u003c/li\u003e\n\u003cli\u003eWolff BG, Pembeton JH, van Heerden JA, Beart RW Jr, Nivatvongs S, Devine RM, Dozois RR, Ilstrup DM. Elective colon and rectal surgery without nasogastric decompression. A prospective, randomized trial. Ann Surg. 1989 Jun;209(6):670-3; discussion 673-5. doi: 10.1097/00000658-198906000-00003. PMID: 2658880; PMCID: PMC1494121.\u003c/li\u003e\n\u003cli\u003eHyung WJ, Lee JH, Lah KH, Noh SH. Intraoperative needle decompression: a simple alternative to nasogastric decompression. J Surg Oncol. 2001 Aug;77(4):277-9\u003c/li\u003e\n\u003cli\u003eWei ZW, Li JL, Li ZS, Hao YT, He YL, Chen W, Zhang CH. Systematic review of nasogastric or nasojejunal decompression after gastrectomy for gastric cancer. Eur J Surg Oncol. 2014 Dec;40(12):1763-70.\u003c/li\u003e\n\u003cli\u003eYoo CH, Son BH, Han WK, et al. Nasogastric decompression is not necessary in operations for gastric cancer: prospective randomised trial. Eur J Surg. 2002;168:379\u0026ndash;83.\u003c/li\u003e\n\u003cli\u003eLee JH, Hyung WJ, Noh SH. Comparison of gastric cancer surgery with versus without nasogastric decompression. Yonsei Med J. 2002;43:451\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eCarrere N, Seulin P, Julio CCH, et al. Is nasogastric or nasojejunal decompression necessary after gastrectomy? A prospective randomized trial. World J Surg. 2007;31:122\u0026ndash;7\u003c/li\u003e\n\u003cli\u003eDoglietto GB, Papa V, Tortorelli AP, et al. Naso-jejunal tube placement after total gastrectomy: a multicenter prospective randomized trial. Arch Surg. 2004;139:1309\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eBrousseau VJ, Kost KM. A rare but serious entity: nasogastric tube syndrome. Otolaryngology\u0026mdash;Head and Neck Surgery 2006 Nov;135(5):677\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSanti S, Belluomini MA, D'Imporzano S, Bellomini MG, Solito B, Gianetri D, Giusti P, Pallabazzer G. Robotic Heller-Dor for Idiopathic Achalasia: the Pisa experience. Updates Surg. 2021 Dec;73(6):2247\u0026ndash;2252. doi: 10.1007/s13304-021-01092-6. Epub 2021 May 24. PMID: 34028697.\u003c/li\u003e\n\u003cli\u003eArcerito M, Jamal MM, Perez MG, Kaur H, Sundahl A, Moon JT. Esophageal Achalasia: From Laparoscopic to Robotic Heller Myotomy and Dor Fundoplication. JSLS. 2022 Jul-Sep;26(3):e2022.00027. doi: 10.4293/JSLS.2022.00027. PMID: 35967962; PMCID: PMC9355798.\u003c/li\u003e\n\u003cli\u003eSuman S, Varshney VK, Soni S, Sachdeva S, Hussain S, Bhargava N. Comparative Analysis of Heller Myotomy With Dor Versus Toupet Fundoplication for Achalasia Cardia. Cureus. 2022 Oct 13;14(10):e30243. doi: 10.7759/cureus.30243. PMID: 36381857; PMCID: PMC9652607.\u003c/li\u003e\n\u003cli\u003eAndr\u0026aacute;si L, Paszt A, Simonka Z, \u0026Aacute;brah\u0026aacute;m S, Erdős M, Roszt\u0026oacute;czy A, Oll\u0026eacute; G, L\u0026aacute;z\u0026aacute;r G. Surgical Treatment of Esophageal Achalasia in the Era of Minimally Invasive Surgery. JSLS. 2021 Jan-Mar;25(1):e2020.00099. doi: 10.4293/JSLS.2020.00099. PMID: 33879995; PMCID: PMC8035823.\u003c/li\u003e\n\u003cli\u003eSalvador, R., Nezi, G., Forattini, F. et al. Laparoscopic Heller-Dor is an effective long-term treatment for end-stage achalasia. Surg Endosc (2022). https://doi.org/10.1007/s00464-022-09696-8.\u003c/li\u003e\n\u003cli\u003eSiow SL, Mahendran HA, Najmi WD, Lim SY, Hashimah AR, Voon K, Teoh KH, Boo HS, Chuah JS, Nurazim S, Faqihuddin MH. Laparoscopic Heller myotomy and anterior Dor fundoplication for achalasia cardia in Malaysia: Clinical outcomes and satisfaction from four tertiary centers. Asian J Surg. 2021 Jan;44(1):158\u0026ndash;163. doi: 10.1016/j.asjsur.2020.04.007. Epub 2020 May 15. PMID: 32423838.\u003c/li\u003e\n\u003cli\u003eDoubova M, Gowing S, Robaidi H, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS, Villeneuve PJ, Seely AJE. Long-term Symptom Control After Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia. Ann Thorac Surg. 2021 May;111(5):1717\u0026ndash;1723. doi: 10.1016/j.athoracsur.2020.06.095. Epub 2020 Sep 3. PMID: 32891651.\u003c/li\u003e\n\u003cli\u003eMcCarthy E, Jao SL, Pryor AD. Laparoscopic Heller Myotomy and Dor Fundoplication. World J Surg. 2022 Jul;46(7):1527\u0026ndash;1530. doi: 10.1007/s00268-022-06569-y. Epub 2022 May 21. PMID: 35597821.\u003c/li\u003e\n\u003cli\u003eCahais J, Lupinacci RM, Valverde A. Laparoscopic Heller myotomy with minimal dissection and Dor anterior valve. J Visc Surg. 2018 Oct;155(5):429\u0026ndash;430. doi: 10.1016/j.jviscsurg.2018.06.013. Epub 2018 Jul 24. PMID: 30054201.\u003c/li\u003e\n\u003cli\u003eSalvador, R., Costantini, M., Cavallin, F. et al. Laparoscopic Heller Myotomy Can Be Used As Primary Therapy for Esophageal Achalasia Regardless of Age. J Gastrointest Surg 18, 106\u0026ndash;112 (2014). https://doi.org/10.1007/s11605-013-2334-y.\u003c/li\u003e\n\u003cli\u003eLee JH, Kedia P, Stavropoulos SN, Carr-Locke D. AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review. Clin Gastroenterol Hepatol. 2021 Nov;19(11):2252\u0026ndash;2261.e2. doi: 10.1016/j.cgh.2021.06.045. Epub 2021 Jul 2. PMID: 34224876.]\u003c/li\u003e\n\u003cli\u003eKimura Y, Yano H, Iwazawa T, Fujita J, Fujita S, Yamamoto K, Yasuda T. One-day nasogastric tube decompression after distal gastrectomy: a prospective randomized study. Surg Today. 2017 Sep;47(9):1080\u0026ndash;1085. doi: 10.1007/s00595-017-1475-0. Epub 2017 Feb 21. PMID: 28224234.\u003c/li\u003e\n\u003cli\u003eSun H, Li Y, Liu X, et al. Feasibility of \"no tube no fasting\" therapy in thoracolaparoscopic oesophagectomy for patients with oesophageal cancer. Zhonghua Wei Chang Wai Ke Za Zhi 2014;17:898\u0026ndash;901.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.10280373831776%\" valign=\"top\"\u003e\n \u003cp\u003ePatients Number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.89719626168224%\" valign=\"top\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.10280373831776%\" valign=\"top\"\u003e\n \u003cp\u003eSex (M/F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.89719626168224%\" valign=\"top\"\u003e\n \u003cp\u003e35/44\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.10280373831776%\" valign=\"top\"\u003e\n \u003cp\u003eAge Onset, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.89719626168224%\" valign=\"top\"\u003e\n \u003cp\u003e42 (15 \u0026ndash; 82)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.10280373831776%\" valign=\"top\"\u003e\n \u003cp\u003eAge Surgery, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.89719626168224%\" valign=\"top\"\u003e\n \u003cp\u003e49 (18 \u0026ndash; 83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.10280373831776%\" valign=\"top\"\u003e\n \u003cp\u003eBMI Preoperative, Kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.89719626168224%\" valign=\"top\"\u003e\n \u003cp\u003e24.7 \u0026plusmn; 5.22\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.10280373831776%\" valign=\"top\"\u003e\n \u003cp\u003eWeight Loss, Kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.89719626168224%\" valign=\"top\"\u003e\n \u003cp\u003e6 (0 \u0026ndash; 29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.10280373831776%\" valign=\"top\"\u003e\n \u003cp\u003eASA Score\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; I\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; II\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.89719626168224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (8.8%)\u003c/p\u003e\n \u003cp\u003e33 (41.8%)\u003c/p\u003e\n \u003cp\u003e39 (49.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.10280373831776%\" valign=\"top\"\u003e\n \u003cp\u003eAchalasia Type\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.89719626168224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 8 (10.1%)\u003c/p\u003e\n \u003cp\u003e71 (89.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52.10280373831776%\" valign=\"top\"\u003e\n \u003cp\u003eEckardt Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"47.89719626168224%\" valign=\"top\"\u003e\n \u003cp\u003e6.6 \u0026plusmn; 3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDemographic data and preoperative characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNGT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e\u003cstrong\u003enoNGT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003ePatients Number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003eSex (M/F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e18/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e17/24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003eBMI, Kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e25.65 \u0026plusmn; 5.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e25.84 \u0026plusmn; 5.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e0.789\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003eASA Score\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; I\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; II\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (15,8%)\u003c/p\u003e\n \u003cp\u003e20 (52.6%)\u003c/p\u003e\n \u003cp\u003e12 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (7.3%)\u003c/p\u003e\n \u003cp\u003e22 (53.7%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 16 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e0.580\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003eAchalasia Type\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;2 \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (10.5%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;34 (89.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (9.8%)\u003c/p\u003e\n \u003cp\u003e37 (90.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e\u0026gt;0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003eEckardt Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e7.5 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e6.8 \u0026plusmn; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e0.596\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"86.00311041990669%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Preoperative Patients Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.996889580093313%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNGT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e\u003cstrong\u003enoNGT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003ePatients Number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003eLength of stay (day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e3.43 (3-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e3.23 (3-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003eFirst flatus (day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e1.31 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e1.12 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003eIntake liquid diet (day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003eIntake semi-solid diet (day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e2.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003eIntraoperative complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e3 (7,9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e0.605\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.890965732087224%\"\u003e\n \u003cp\u003ePostoperative complications:\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eGrade I\u003c/li\u003e\n \u003cli\u003eGrade II \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;5 (13.15%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 5 (100%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; 0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.54517133956386%\"\u003e\n \u003cp\u003e8 (19.1%)\u003c/p\u003e\n \u003cp\u003e7 (87.5%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;1 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.018691588785046%\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"86.00311041990669%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. Intraoperative complications and postoperative variables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.996889580093313%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Achalasia, Heller-Dor laparoscopic, naso-gastric tube, myotomy, postoperative nausea and vomiting","lastPublishedDoi":"10.21203/rs.3.rs-2930409/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2930409/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAchalasia is a rare esophageal motor disorder. Laparoscopic Heller-Dor myotomy (LHD) is among the most effective treatments. The use of nasogastric tube (NGT) following LHD is still controversial. The aim of our study was to evaluate the role of NGT in achalasia patients undergoing LHD.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe prospectively enrolled achalasia patients treated with LHD from January 2019 until June 2022 at our institution and randomly assigned them to two groups: one group with NGT and group without (noNGT). Perioperative outcomes were compared between the two groups. ClinicalTrials.gov Identifier: NCT05729971.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSeventy-nine patients who underwent LHD myotomy were prospectively enrolled. Patients were divided in two groups: 38 with NGT and 41 noNGT. There were no significant differences between two groups in terms of demographic data, preoperative characteristics, length of stay, start of liquid and solid diet, intraoperative and postoperative complications. First flatus was shorter in the noNGT group (p: 0.03).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eNasogastric tube placement following LHD myotomy does not reduce nausea, vomiting and chest pain, while it increased patients discomfort and time of first flatus.\u003c/p\u003e","manuscriptTitle":"Nasogastric tube after laparoscopic Heller-Dor myotomy: do you really need it?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-05-19 20:53:02","doi":"10.21203/rs.3.rs-2930409/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9ea40cfc-2aad-46b9-9399-6e1a838468d3","owner":[],"postedDate":"May 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-05-24T02:14:20+00:00","versionOfRecord":[],"versionCreatedAt":"2023-05-19 20:53:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2930409","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2930409","identity":"rs-2930409","version":["v1"]},"buildId":"oE6Zbj460LM0Up2FdVbMZ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}