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Ann Thorac Surg 1997;64:785-789
© 1997 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Laparoscopic Esophageal Myotomy and Anterior Partial Fundoplication for the Treatment of Achalasia

Division of Thoracic Surgery, Departments of Surgery and Radiology, University of British Columbia, and the Vancouver Hospital Physiology Centre, Vancouver, British Columbia, Canada

	Abstract

Top Footnotes Abstract Introduction Material and Methods Surgical Technique Results Comment Acknowledgments References

 
Background. The purpose of this study was to determine the initial results of laparoscopic esophageal myotomy and anterior fundoplication in the treatment of 26 patients with achalasia.

Methods. Operative time, complications, and length of hospitalization were recorded for each patient. Postoperative outcomes were assessed by a standardized patient questionnaire, 24-hour esophageal pH studies, and esophageal transit studies.

Results. Twenty-six consecutive patients with class IV dysphagia underwent a laparoscopic esophageal myotomy and anterior partial fundoplication, with a single incidence of intraoperative esophageal perforation. The mean operative time was 3.5 hours. The median length of hospitalization was 5 days. Of the 21 patients for whom follow-up was available (median follow-up, 4 months), 19 (90%) were satisfied and 2 (10%) were somewhat satisfied with their surgery. After operation, 14 of the 21 patients (67%) reported no dysphagia (class I), whereas 6 (28%) had class II dysphagia (less than once per week) and only 1 (5%) had class III dysphagia (greater than once per week). Liquid-phase esophageal transit studies (n = 14) revealed a significant improvement in esophageal clearance in the supine position from 18% before operation to 44% after operation (p = 0.006). Distal esophageal acid exposure was normal in 6 of 7 patients.

Conclusions. These early results suggest that laparoscopic esophageal myotomy and anterior partial fundoplication provides efficacious treatment of achalasia.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Surgical Technique Results Comment Acknowledgments References

 
See also page 789.

Achalasia is a primary motility disorder of the esophagus of unknown etiology. Progressive dysphagia to liquids and solids is the primary symptom. Regurgitation and weight loss develop without adequate treatment. The underlying pathophysiology appears to be a loss of ganglion cells in the myenteric plexuses of the esophagus resulting in absence of peristalsis of the esophageal body, failure of the lower esophageal sphincter (LES) to relax with swallowing, and normal or elevated resting LES pressures. A functional obstruction at the level of the LES results.

The primary goal of treatment is palliation of symptoms, because the motor abnormality remains unchanged after all forms of treatment. At present, all forms of treatment are directed at relieving the functional obstruction at the level of the LES by disruption of the LES. The LES is the primary barrier to gastroesophageal reflux, and so its disruption places the patient at risk for pathologic gastroesophageal reflux. The treatment of patients with achalasia must strike a balance between the relief of dysphagia and the potential creation of pathologic gastroesophageal reflux.

Treatment approaches have involved both surgical and nonsurgical techniques. The nonsurgical techniques have consisted of passive esophageal bougienage, pneumatic dilatation of the gastroesophageal junction, and botulinum toxin injection into the LES. Pneumatic dilation is reported to improve about 70% of patients who undergo this form of treatment [1]. Proponents of pneumatic dilation argue that it is safe and less costly than surgical therapy. Critics of pneumatic dilation point out the risk of perforation, the need for repeated dilations (especially in younger patients), and the high incidence of subsequent gastroesophageal reflux [2]. A randomized comparison of esophagomyotomy and pneumatic dilatation suggested that myotomy leads to superior results [3]. Pasricha and colleagues [4] have reported their early results with the use of botulinum toxin. They found that 45% of patients (14 of 31) either did not respond or relapsed within 2 to 3 months. Of those who responded, 68% remained in remission at 1 year. The role of botulinum toxin injection in the treatment of patients with achalasia awaits further investigation.

Esophagomyotomy has been the surgical procedure of choice for the treatment of achalasia since its initial description by Heller [5] in 1914. The surgical approach, transthoracic or transabdominal, and the need for a concomitant fundoplication remain controversial. Good long-term symptomatic improvement has been reported using a left thoracotomy to perform an esophageal myotomy with [6] and without an antireflux procedure [7]. In 1993, Pellegrini and associates [8] reported the successful use of thoracoscopic esophageal myotomy of the LES without fundoplication in the treatment of dysphagia secondary to achalasia. However, 5 of 8 patients tested in his study had abnormal acid exposure in the distal esophagus. In our center, 2 of 7 patients had an inadequate thoracoscopic myotomy because of inability to carry the myotomy on to the stomach. The high incidence of inadequate myotomy and gastroesophageal reflux led us to look at other minimally invasive techniques for the treatment of achalasia.

Bonavina and associates [9] have reported symptomatic long-term improvement in 94% of their patients using a transabdominal Heller myotomy and anterior fundoplication using the Dor technique. As a result of experience gained with laparoscopic antireflux procedures and our disappointing results with the thoracoscopic approach, we began to use a laparoscopic approach to perform a Heller myotomy and anterior fundoplication. The purpose of this study was to determine the initial results of the use of laparoscopically performed esophageal myotomy and anterior partial fundoplication in the treatment of patients with achalasia.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Surgical Technique Results Comment Acknowledgments References

 
Patients
From February 1994 to March 1996, 26 consecutive patients (11 women and 15 men) aged 21 to 77 years (mean, 45 years) underwent a laparoscopic esophageal myotomy and anterior partial fundoplication at Vancouver Hospital and Health Sciences Centre. The diagnosis was made on the basis of clinical history, esophagograms, endoscopy, and manometry. All 26 patients had persistent daily dysphagia (class IV dysphagia). The mean duration of the symptom of dysphagia was 83 months. Nineteen of the patients had weight loss of greater than 2.2 kg. Both heartburn and regurgitation were reported in 77% of patients (16 of 21) preoperatively. In all 16 patients who underwent a barium swallow, a bird's beak deformity was reported. Manometry was attempted in all patients, but was successful in only 22. The mean LES pressure was 39 mm Hg. Twelve patients had undergone a previous pneumatic dilation. None of the patients had received previous treatment with botulinum toxin injection.

	Surgical Technique

Top Footnotes Abstract Introduction Material and Methods Surgical Technique Results Comment Acknowledgments References

 
The objectives of this procedure are (1) to carry out a myotomy down to the mucosa of the lower 6 cm of the esophagus, the esophagogastric junction, and the proximal 2 cm of the stomach, obliterating the dysfunctional LES; and (2) to augment the antireflux barrier by fixing the lower 6 cm of myotomized esophagus below the diaphragm under the influence of positive intraabdominal pressure and wrapping it with a partial anterior gastric fundoplication to compress the esophagus during increases in intragastric pressure, at which time reflux usually occurs. All procedures are done under general anesthesia, taking care to avoid aspiration during induction. A flexible endoscope is placed in the esophagus under direct visualization. With the patient in the lithotomy position, a pneumoperitoneum is produced using either a Verres needle or the Hasson technique. Five ports are used for the procedure. The left lobe of the liver is retracted, exposing the diaphragmatic hiatus. A Babcock retractor placed on the upper stomach is used to retract the esophagogastric junction caudally. The gastrohepatic ligament is divided, exposing the right crus of the diaphragm.

The phrenoesophageal ligament is divided, avoiding injury to the vagus nerves. The left crus of the diaphragm is exposed completely. The retroesophageal space is opened from the right side of the esophagus and the esophagus is encircled with a vascular tape. Six to 8 cm of esophagus is mobilized into the abdominal cavity with careful attention paid to hemostasis.

The flexible endoscope is placed into the stomach under direct visualization. The phrenoesophageal ligament is divided along the line of the myotomy, avoiding injury to the anterior vagus nerve. The esophageal myotomy is started in the thickened esophagus 6 to 8 cm proximal to the phrenoesophageal ligament. The myotomy is carried under the anterior vagus nerve through the esophagogastric junction and on to the stomach for at least 2 cm. The esophageal muscle is swept off the mucosa for 180 degrees. The endoscope then is removed, checking the esophagogastric junction for patency and the mucosa for perforations.

Six centimeters of esophagus is anchored in the abdomen by placing two 2-0 silk sutures between the fundus, the left crus of the diaphragm, and the left myotomized esophageal muscle. The vascular tape is removed. Without dividing the short gastric vessels, the fundus of the stomach then is rolled loosely over the lower esophagus and anchored in place with three sutures between the fundus, the right myotomized muscle, and the right crus of the diaphragm. The patients are given nothing by mouth until the second postoperative day and are discharged home on a dental soft diet for 3 weeks.

Operative time, complications, and length of hospitalization were recorded for each patient. Postoperative outcomes were assessed by a standardized patient questionnaire, esophageal transit studies, esophageal manometry, and 24-hour pH studies. The standardized questionnaire was administered by telephone interview or at a follow-up clinic visit. Postoperative dysphagia was subdivided into four classes as proposed by Vantrappen and Hellemans [10]: class I—no dysphagia; class II—dysphagia occurring less than once weekly; class III—dysphagia occurring more than once weekly; and class IV—persistent dysphagia. Patients also were asked to classify their satisfaction with the procedure as very satisfied, somewhat satisfied, or not satisfied. Patients were questioned to determine the presence of heartburn or regurgitation, the use of acid reduction medication, and the need for further therapy.

Esophageal transit studies were performed with technetium-99m sulfur colloid in liquid using multiple swallow techniques [11]. Imaging was performed for 10 minutes in the supine position, then for 10 minutes in the upright position. Stationary esophageal manometry was performed using a solid-state pressure catheter and the Medtronic Synectics Polygraf system (Medtronic, Shoreview, MN) in the manner described by Castell and Castell [12]. Ambulatory pH monitoring was performed with the Medtronic Synectics Mark III Microdigitrapper using monocrystant antimony dual-sensor catheters [13].

	Results

Top Footnotes Abstract Introduction Material and Methods Surgical Technique Results Comment Acknowledgments References

 
The mean operating time was 3.5 hours (range, 2 to 6.5 hours). The mean duration of the procedure decreased from 3.9 hours for the first 18 patients to 2.7 hours for the most recent 8 patients (p = 0.003). No conversions to open procedures were required. Intraoperative complications occurred only in a single patient who sustained a perforation of the esophageal mucosa; this occurred during repeated passage of the endoscope to assess the patency of the esophagogastric junction after myotomy. The perforation was repaired laparoscopically using intracorporeal sutures and was wrapped with the fundus. The patient had no further complications. In the hospital, postoperative complications included subcutaneous emphysema (n = 4), postoperative atelectasis (n = 3), small pneumothoraces (n = 2), and delayed gastric emptying (n = 1). No deaths occurred. Oral fluids were started on the second postoperative day and the median length of hospitalization was 5 days (mean, 5.23 days). The mean length of hospitalization was 5.8 days for the first 18 patients and 3.9 days for the most recent 8 patients (p = 0.03).

Follow-up was available for 21 of 26 patients (81%). The median follow-up period was 4 months (mean, 7.1 months) after operation. The postoperative dysphagia scores are shown in Table 1. All patients noted improvement in their dysphagia score. Most patients (19 of 21) were satisfied with the procedure. Only 10% of patients (2 of 21) were somewhat satisfied, and no patients were dissatisfied after the procedure. Postoperative regurgitation was absent in 18 patients (86%) and occurred less than once per week in 3. After operation, 4 patients (19%) reported heartburn. Each of these 4 patients reported the frequency of heartburn to be less than weekly. No patients were taking acid reduction medications. A single patient required a postoperative dilatation.

View larger version (18K): [in this window] [in a new window]   Fig 1. . Mean results of supine esophageal transit studies in 14 patients preoperatively and postoperatively. Error bars indicate ±1 standard error of the mean.

	Comment

Top Footnotes Abstract Introduction Material and Methods Surgical Technique Results Comment Acknowledgments References

 
The best therapy for patients with achalasia remains controversial. The purpose of this paper was to examine the initial results of laparoscopically performed esophageal myotomy with anterior fundoplication.

The technique of laparoscopic esophageal myotomy and anterior fundoplication can be performed safely. The operative time is greater than that of traditional open procedures, but it decreases with increasing experience in performing the procedure. Most of the complications are minor, such as atelectasis, subcutaneous emphysema, and small pneumothoraces that resolve with supportive therapy. Our single instance of esophageal mucosal perforation occurred during repeated insertion of the endoscope to examine the repair.

Using laparoscopic esophageal myotomy and anterior fundoplication, the vast majority of patients had symptomatic improvement and were satisfied with the procedure. Although the dysphagia class and satisfaction scores are not validated measurement instruments, they represent the patients' impressions of the procedure. The improvement in dysphagia that occurred with laparoscopic esophageal myotomy was comparable to reports of other minimal access procedures. Pellegrini and associates [8], using a thoracoscopic approach to the myotomy without an antireflux procedure, reported that 89% of their patients were in Vantrappen class I or II after operation. Rosati and colleagues [14], using a laparoscopic myotomy and anterior partial fundoplication, reported that 96% of their patients had either absent or mild dysphagia after operation. Our early results are comparable with those reported for open procedures. Ellis [7] reported that 74% of his patients had no or minimal dysphagia 9 years after a left thoracotomy and myotomy without an antireflux procedure. Malthaner and colleagues [6] reported that 67% of their patients had minimal dysphagia 19 years after a left thoracotomy with partial fundoplication.

Radionuclide esophageal transit studies previously have been reported to provide a quantitative assessment of the response to therapy for achalasia. Both solid and liquid meals have been used. We used a liquid meal in the supine position. We used the supine position because it eliminates the assistance of gravity in clearing the esophagus, providing an assessment of isolated esophageal function. Although esophageal clearance improved significantly, it did not return to within the normal range. Failure to return to the normal range was observed previously by Holloway and associates [15], who demonstrated that patients undergoing dilation or myotomy do not return to normal emptying. The significant improvement seen in esophageal emptying objectively confirms the patients' subjective impressions, but reaffirms that treatment of this disorder is palliative rather than curative.

Dysphagia was not relieved in 1 patient, who reported class III dysphagia after operation. The reason for the failure to relieve dysphagia remains unclear because no technical difficulties were encountered. Potential explanations include the possibility that the fundoplication was constructed too tightly and that the myotomy was inadequate.

The severity of the postoperative symptoms of regurgitation and heartburn appears to be mild because none of the patients required acid reduction medication. Although only a few patients underwent postoperative 24-hour pH studies, only 1 patient had an abnormal result. This patient was asymptomatic. It appears that improvement in dysphagia has been achieved without creation of symptomatic gastroesophageal reflux in most patients in the early postoperative period. Out results compare favorably with those of Pellegrini and associates [8], who reported that 5 of their 8 patients tested had abnormal acid exposure in the distal esophagus. We have not observed the high incidence of postoperative heartburn (67%) reported by Raiser and co-workers [2] that led them to suggest the use of posterior partial fundoplication rather than anterior fundoplication. The ideal choice of type of fundoplication, including the necessity of dividing the short gastric vessels, remains unclear. Further study, preferably in the setting of randomized clinical trials, is required.

Our initial results using laparoscopic esophageal myotomy and anterior partial fundoplication for the treatment of achalasia are consistent with other published reports, and suggest that the technique can be performed effectively and safely. The early outcomes are good as assessed by symptom scores and esophageal emptying studies. The results, however, must be interpreted with caution, because the work of DiSimone and colleagues [16] suggests that up to 10 years of follow-up is required to detect the development of gastroesophageal reflux and recurrent dysphagia.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Surgical Technique Results Comment Acknowledgments References

 
Doctor Andrew J. Graham was supported in part by the George Saxton Research Fellowship, British Columbia Lung Association.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Surgical Technique Results Comment Acknowledgments References

 
Presented at the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3-5, 1997.

Address reprint requests to Dr Finley, Department of Surgery, The University of British Columbia Faculty of Medicine, 910 W 10th Ave, 3rd Fl, Vancouver, BC, Canada V5Z 4E3.

	References

Top Footnotes Abstract Introduction Material and Methods Surgical Technique Results Comment Acknowledgments References

 

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4. Pasricha P, Rai R, Ravich W, Hendrix T, Kalloo A. Botulinum toxin for achalasia: long-term outcome and predictors of response. Gastroenterology 1996;110:1410–5.[Medline]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Andrew J. Graham Richard J. Finley Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Graham, A. J. Articles by Storseth, C. Search for Related Content PubMed PubMed Citation Articles by Graham, A. J. Articles by Storseth, C. Related Collections Related Article