Ann Thorac Surg 2004;77:385-392
© 2004 The Society of Thoracic Surgeons
Original article: general thoracic
Thoracoscopy-assisted Heller myotomy for the treatment of achalasia: results of a minimally invasive technique
Kenneth A. Kesler, MDa*,
Stacey E. Tarvin, MSa,
Jo Ann Brooks, DNSa,
Karen M. Rieger, MDa,
Glen A. Lehman, MDb,
John W. Brown, MDa
a Department of Surgery, Thoracic Division, Indiana University School of Medicine, Indianapolis, Indiana, USA
b Department of Medicine, Gastroenterology Division, Indiana University School of Medicine, Indianapolis, Indiana, USA
* Address reprint requests to Dr Kesler, Indiana University School of Medicine, Department of Surgery, Thoracic Division, 545 Barnhill Dr, EH 215, Indianapolis, IN 46202, USA
e-mail: kkesler{at}iupui.edu
Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31-Feb 2, 2003.
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Abstract
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BACKGROUND: Several surgical methods have been described to treat achalasia with a recent trend toward utilizing minimally invasive techniques to perform a myotomy. Since 1998 our institution has utilized a minimally invasive thoracoscopy-assisted technique (ThAM) that allows a myotomy to be performed under direct visualization.
METHODS: From 1992 to 2002, 57 patients underwent transthoracic Heller myotomy at our institution. Thirty-eight patients (67%) who underwent ThAM were reviewed and compared with 19 (33%) who previously underwent myotomy through a standard open left thoracotomy (OM).
RESULTS: There were no operative deaths in the ThAM group (n = 38) and 4 patients (11%) experienced minor morbidity. Four ThAM patients required conversion to open thoracotomy and 2 were lost to follow-up. Of the remaining 32 patients, 29 have improved postoperative dysphagia scores after a mean follow-up of 17 months. Only 4 patients have required further endoscopic or surgical intervention. Compared with the OM group, ThAM patients experienced significantly shorter average surgery time (97 versus 139 minutes), less blood loss (80 versus 155 mL), less postoperative narcotic requirement (8 versus 20 days), and shorter recovery to normal activity (20 versus 73 days).
CONCLUSIONS: Thoracoscopy-assisted myotomy results in excellent relief of dysphagia in the short term and would be expected to have long-term results similar to OM. Shorter operating and recovery times as compared with OM without the need for an antireflux procedure makes ThAM an attractive minimally invasive technique.
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Introduction
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The etiology of achalasia remains unknown for the vast majority of patients diagnosed in North America. As there is no effective treatment to correct the absence of esophageal body motility, efforts to palliate the symptoms of dysphagia have therefore involved disruption of hypertonic lower esophageal sphincter (LES) muscle. Several surgical methods have been described to divide the LES with recent trends involving the utilization of minimally invasive techniques. Heller first described a cardiomyotomy through an abdominal approach with both anterior and posterior LES muscle divisions. In 1958 Ellis [1] subsequently popularized a transthoracic approach through left thoracotomy with a single myotomy that extended 1 cm onto the gastric cardia without fundoplication. After the advent of minimally invasive technology, attempts at a pure thoracoscopic approach were problematic and not uncommonly led to incomplete LES division even under endoscopic guidance [2]. More recently, laparoscopic myotomy with partial fundoplication has gained popularity for the treatment of achalasia [3, 4]. Since 1998, our institution has utilized a minimally invasive thoracoscopy-assisted technique in which a myotomy is performed under direct visualization through the interspace without rib retraction or reapproximation. We describe this surgical technique and report the results of our institutional series.
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Material and methods
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Operative technique
From 1992 to 2002, 57 patients with a manometric diagnosis of achalasia underwent a transthoracic Heller myotomy at Indiana University Hospital. Before 1998 a standard low posterior-lateral thoracotomy approach or "open myotomy" (OM) was utilized. Since 1998, we have used a thoracoscopy-assisted approach (ThAM) in all but 1 patient who required left thoracotomy for decortication of an aspiration-induced empyema in addition to the myotomy. Our ThAM procedure has undergone several refinements since 1998 however. The following describes the technique as it has been performed over the last 2 years of this series.
Thoracoscopy-assisted myotomy is performed with the patient in the right lateral decubitus position after double lumen endobronchial tube and epidural catheter placement. The operating table is jack-knifed at the hips, which widens the lower left-sided intercostal spaces, and then the left chest is leveled with reverse Trendelenberg rotation (Fig 1).
The approximate level of the diaphragm dome is drawn on the patient's skin after preparing and draping. An 8- to 10-cm incision is made over the rib superior to the estimated level of the diaphragm dome which usually represents the seventh or eighth rib depending on the patient's body habitus. The soft tissues are divided with electrocautery until the pleural space is entered after left lung deflation. Self-retaining retractors (Weitlander or Beckman; Codman/Johnson & Johnson, New Brunswick, NJ, depending on the patient's body habitus) are used to separate the chest wall soft tissues. The opening through the interspace can be further widened by judicious intercostal muscle retraction with one arm of the self-retaining retractor applied to the superficial fascial layer of the intercostal muscle and the other arm of the retractor applied to the chest wall soft tissues inferiorly. If this retraction technique is utilized, then attention must be given to avoiding placement of the retractor teeth deep near the intercostal neurovascular bundle. Two 10-mm trocar ports are placed through stab incisions inferior to the limited thoracotomy incision immediately cephalad to the diaphragm insertion on the costal margin. An endoscopic fan-type retractor (Autosuture, Norwalk, CT) is deployed through the one trocar port to retract the diaphragm caudally and a rigid thoracoscope is placed through the other trocar port. A second assistant holds both the fan retractor and thoracoscope. The thoracoscope is used to help illuminate the operative field for the primary surgeon, who is working under direct visualization, and provides video-imaging for the assistants from a monitor placed above the patient's head. We also utilize fiber optic headlight illumination and loop magnification to assure complete circular muscle division.
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Fig 1. Planned incision based on estimated level of diaphragm dome and position of primary surgeon with first and second assistants. (Thin dashed line = estimated level of diaphragm; thick dashed line = incision.)
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The vast majority of the procedure is performed by the surgeon without assistance. The inferior pulmonary ligament is divided with an extended electrocautery unit under direct visualization. A laparotomy sponge is packed against the deflated lung to keep it rotated cephalad and out of the operating field. With the primary surgeon standing on the left side of the operating table (assuming right hand dominance), the parietal pleura overlying the esophagus is secured with a forceps then divided with electrocautery from the inferior pulmonary vein to the crus of the diaphragm. The posterior esophageal margin is identified and then secured with a Russian type forceps 2 to 3 cm above the crus (Fig 2, A). Judicious division of the longitudinal and the circular muscle layers at this level is then accomplished with the electrocautery unit until the submucosal layer is identified. A submucosal plane is established with a long right-angle clamp in the cephalad direction (Fig 2, B). The primary surgeon continues to apply downward traction on the posterior margin of the esophagus with the forceps while elevating the muscular wall off the submucosa with the right-angle clamp. The primary surgeon then looks to the video screen and confirms satisfactory clamp position. The first assistant divides the elevated muscle using electrocautery under direct visualization. This dissection technique is continued superiorly to within 1 to 2 cm of the inferior pulmonary vein.
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Fig 2. (A) Initial identification of the submucosal layer by judicious dissection with an extended electrocautery unit. (B) Establishing a submucosal plane toward the inferior pulmonary vein with a right-angle clamp before myotomy. The forceps are used to stabilize and retract the esophagus downward.
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The primary surgeon then moves to the right side of the operating table. Although more cumbersome, we prefer to utilize upward and outward counter traction with forceps held by both the primary surgeon and first assistant who are working under direct visualization and video-assistance respectively, as the plane between the muscular and submucosal layers typically becomes somewhat more difficult to dissect inferiorly onto the cardia. Of equal importance, the upward esophageal retraction along with simultaneous downward retraction on the diaphragm at this point in the procedure makes the gastric cardia easily identified (Fig 3, A).
We therefore do not employ intraoperative endoscopy for verification or guidance. This sequence of right-angle clamp dissection by the primary surgeon then muscular wall division by the first assistant is continued inferiorly 1 cm onto the gastric cardia or until it is deemed that the muscular and submucosal layers are relatively fused and do not allow safe clamp dissection.
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Fig 3. (A) Upward countertraction by the surgeon and first assistant facilitates right angle dissection as the myotomy is carried inferiorly onto the cardia. (B) Any remaining circular muscle fibers around the gastroesophageal junction and cardia are judiciously divided with an extended electrocautery tip.
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The primary surgeon returns to the left side of the operating table and again secures the posterior margin of the divided esophageal muscle wall at the cardia level with forceps. Using freehand dissection with gentle use of the electrocautery tip and application of electrocautery, any remaining circular muscle fibers are disrupted over the proximal cardia (Fig 3, B). A submucosal plane is then developed posteriorly using mainly blunt dissection with the tip of the electrocautery unit for the entire length of the myotomy. A 5- to 7-mm strip of dissected muscle wall is removed longitudinally, carefully avoiding the posterior vagus nerve to prevent an early "scar-over" phenomenon. The pleura overlying the esophagus is closed with a running monofilament suture. Although optional, we prefer to place a nasogastric tube into the stomach with transthoracic guidance if necessary. We also prefer to place two chest tubes into the pleural space which are tunneled through the incisions initially established for the trocar ports and left in place until drainage is less than 100 mL in 24 hours. Only the chest wall soft tissues are closed after lung reinflation. No intercostal sutures are used. Early in this series, we were conservative with nasogastric tube removal, however we now remove the nasogastric tube on the first postoperative day at which time the patient is begun on a clear liquid diet and advanced to a regular diet as tolerated. Open myotomies were performed in a similar manner as described above but using a standard low left thoracotomy approach that allowed both the primary surgeon and first assistant to work under direct visualization.
Data collection and analysis
The medical records department provided a listing of all consecutive patients who underwent a Heller myotomy between 1992 and 2002. One research assistant retrospectively reviewed all hospital charts. Twenty-six preoperative variables including gender, age, race, body mass index (BMI), symptoms, weight loss, manometry pressures, and previous endoscopic (dilation, botox) or medical therapy were recorded (Table 1).
Comorbid surgical risk factors were also recorded including smoking history (> 40 pack-year history), cardiac disease (history of angina, myocardial infarction, coronary artery bypass graft surgery, percutaneous transluminal coronary angioplasty), cerebrovascular disease (history of transient ischemic attack, cerebrovascular accident, carotid bruits), peripheral vascular disease (history of claudication, aortic aneurysm, infradiaphragmatic arterial bypass surgery), hypertension, and diabetes mellitus.
Operative data obtained included duration of surgery, intraoperative complications (estimated blood loss and conversion to open thoracotomy—for ThAM patients only), and postoperative complications including atelectasis requiring bronchoscopy, mechanical ventilation more than 48 hours, pneumonia, and length of hospital stay. Patients were contacted for follow-up information including subjective preoperative and postoperative quality of swallowing and the presence of gastroesophageal reflux disease (GERD) before initiating any medical treatment using a modified six-point quality of life scale (Table 2).
Information regarding requirements for further endoscopic or surgical intervention, duration of postoperative narcotic requirements (
2x/d), length of time until return to normal functional activity, and overall satisfaction of swallowing at the time of last follow-up were also obtained.
Statistical comparisons of OM and ThAM (excluding patients requiring conversion to open thoracotomy) groups were done using standard 
2 tests for nominal variables and Student's t test for continuous variables. A Mann-Whitney U test was used to compare continuous variables between groups if data were determined to be nonparametric in distribution. Paired t tests were employed for comparison of preoperativeversus postoperative dysphagia scores. Freedom from repeat endoscopic or surgical intervention survival was calculated with Kaplan-Meier analysis.
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Results
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A total of 38 patients, 22 male and 16 female, with an average age of 47 ± 17 years underwent ThAM during the study interval. Table 1 demonstrates the patient demographics, comorbid risk factors, symptoms, manometric pressures, and previous therapy. In summary all patients presented with dysphagia and 30 patients (79%) experienced an average weight loss of 15 kg before the time of surgery. A total of 17 patients (45%) had one or more comorbid risk factors. Manometry reports were available for review in 32 patients and demonstrated high relaxation and resting LES pressures with means of 18.6 and 38.3 mm Hg respectively. Twenty-six patients (68%) had undergone previous dilatations or botox injections before surgery.
There was no operative mortality. Four patients (11%) required conversion to open thoracotomy (pleural space adhesions, n = 2; bleeding, n = 1; and esophageal perforation, n = 1). Four patients experienced minor postoperative morbidity (atelectasis, n = 1; mechanical ventilation > 48 hours, n = 2; and atrial tachyarrhythmias, n = 1). Two patients were lost to follow-up. Four patients have required further endoscopic intervention and 2 of these patients have subsequently undergone esophagectomy at 1 and 15 months after ThAM. Freedom from repeat endoscopic or surgical intervention was 84% at 18 months.
The 32 remaining patients who underwent ThAM have been followed up for an average interval of 17 months (range, 2 to 50). Dysphagia scores improved from an average of 4.4 preoperatively to 0.7 postoperatively, with no patients reporting a worsening postoperative dysphagia score (p < 0.01). Of the remaining 32 patients, 24 (75%) reported a score of 0 to 1 for residual dysphagia, 6 (19%) a score of 2, and 2 (6%) reported a score of 3 at the time of follow-up. Thus 94% of patients reported no residual dysphagia to occasional symptoms but not on a daily basis. No patient reported a score of 4 or 5 dysphagia (symptoms troublesome and may impact daily activities) without undergoing endoscopic intervention or esophagectomy. Twenty-seven patients (85%) reported none to occasional symptoms of GERD (score 0 to 1, n = 16; score 2, n = 11). Three patients (9%) reported a score of 3 and 2 patients (6%) reported a score of 4 to 5 regarding symptoms of GERD. Of the 5 patients who reported a score of 3 or more on postoperative GERD, 4 reported being very satisfied or satisfied with their current swallowing and all are symptomatically well controlled on routine medical therapy. Four patients symptomatic with postoperative GERD (score 0 to 1, n = 1; score 2 to 3, n = 3) have undergone endoscopy. All 4 of these patients demonstrated grade I esophagitis only. Overall 27 (84%) of the ThAM patients who have not required further surgical intervention report being very satisfied to satisfied with their current swallowing at time of follow-up.
Table 3
compares operative and postoperative variables between the ThAM and OM groups. Both groups were well matched with respect to sex, mean age, and comorbid risk factors. The ThAM patients experienced shorter operative times by an average of 42 minutes (p < 0.01). As with any new operation, however, our institution demonstrated a typical "learning curve" with the first 17 ThAM cases taking an average of 108 minutes versus an average of 86 minutes for the second 17 cases. The ThAM patients had an average of 75 mL less blood loss as compared with OM patients (p < 0.01). The length of hospitalization did not differ between the two groups, which is directly attributable to our previous conservative policy for resumption of oral nutrition and chest tube removal as opposed to a continued need for intravenous narcotic pain management. However, our ThAM patients are currently experiencing a 3- to 5-day hospitalization, which is due to earlier resumption of oral nutrition, earlier chest tube removal, and less requirement for narcotic pain medications. Finally, the duration of postoperative narcotic requirement and return to full normal activity level was significantly shorter in the ThAM group with an average of 8 and 20 days, respectively (p < 0.01).
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Comment
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There have been several surgical methods described for the treatment of achalasia. More recently there has been a trend toward using minimally invasive techniques. Utilization of minimally invasive techniques have likely resulted in earlier referrals for surgical intervention as opposed to continued endoscopic therapy with dilatation or botox injection that typically only temporize symptoms for short durations. Laparoscopic techniques have been most commonly employed as initial attempts at pure thoracoscopic approaches were fraught with technical difficulties and not infrequent failures due to incomplete myotomy. Thoracoscopic-assisted Heller myotomy is a minimally invasive technique that represents a natural extension of technical expertise for most thoracic surgeons familiar with the performing the myotomy through an open left thoracotomy approach. With minimally invasive techniques we perform a myotomy similar to that originally described by Ellis [5] who additionally dissects half of the esophageal muscle circumference. Although subtotal circumferential dissection can be accomplished with the ThAM approach we favor dissecting only approximately one third of the esophageal circumference and adding a limited longitudinal myomectomy as described. This potentially would also prevent a scar-over phenomenon and at the same time avoids dissection near the vagus nerves.
There was no operative mortality in our series, which would be anticipated regardless of the surgical approach. The morbidity in our series was equally acceptable. We experienced only one esophageal perforation while attempting ThAM, which arguably represents the most serious intraoperative complication and also predisposes a patient to an adverse long-term symptomatic outcome. Luketich and colleagues [6] reported that 6 patients of 62 patients sustained inadvertent perforation during myotomy through a laparoscopic approach; it mainly occurred early in this series and was therefore attributed to a procedural learning curve. The ability to perform the myotomy under direct visualization with this ThAM technique preserves the three-dimensional relationships particularly with respect to instrument position and depth of dissection. This may minimize this complication as compared with either laparoscopic or purely thoracoscopic procedures that currently rely upon two-dimensional fiber optic imaging. Moreover the ability to retract the esophagus cephalad and extend the myotomy onto the cardia under direct visualization with ThAM should minimize the risk of persistent dysphagia secondary to incomplete myotomy. This problem not infrequently complicated the pure thoracoscopic approaches, which therefore have been abandon by most surgeons. The 4 patients who required further endoscopic or surgical intervention possibly represented technical failures that occurred early in our series before procedural refinements.
The addition of an antireflux procedure to LES myotomy is one of the most controversial issues. Postoperative manometric data suggest that LES function is preserved and no antireflux procedure is necessary after a transthoracic approach provided the myotomy is extended no further than 1 cm onto the gastric cardia [7]. Conversely a transabdominal approach requires dissection of the esophageal crus and disruption of the phrenoesophageal membrane, which predisposes to postoperative esophageal reflux. Results from a meta-analysis based on publications between 1970 and 1985 cite a 7.7% overall incidence of reflux after transthoracic myotomy versus 13.2% performed through a transabdominal approach [8]. Any antireflux procedure, even a partial fundoplication, potentially adds resistance to the gravitational flow of ingested food and liquids in achalasia patients thereby reducing the effectiveness of the procedure. Partial fundoplications that do not incorporate the myotomy site have recently been shown to have a potential to develop pseudodiverticuli at the myotomy site if the gastric wrap contracts over time [9]. Partial fundoplications which do incorporate the myotomy site may therefore have a similar propensity to create a scar-over phenomenon. Regardless of the fundoplication technique, performing a partial wrap with a distal myotomy cannot uniformly prevent GERD in all patients. Our incidence of symptomatic reflux after short-term follow-up seems acceptable and moreover has been easily controlled with medical therapy.
The time required for complete functional recovery after any surgical procedure can be directly related to the amount of surgical trauma and the duration of significant postoperative pain. Without additionally having to perform an antireflux procedure, this technique appears to require a significantly shorter operating time as compared with times reported using laparoscopic techniques, which average from 138 to 199 minutes [10–13]. In our series ThAM was performed on average in 97 minutes. We have accomplished ThAM in less than 1 hour using the technique as described in the last 14 patients. It is also well accepted that postoperative pain after any transthoracic procedures is primarily a function of intercostal nerve injury sustained during rib retraction or "pinching" from interspace closure. We have demonstrated a significantly decreased requirement for narcotic pain medication and time interval before returning to a normal functional status after ThAM as compared with OM. This is most likely attributable to not only smaller incisions, but also more importantly, the avoidance intercostal nerve injury. The vast majority of our ThAM patients have minimal narcotic requirements after chest tube removal and have returned to full functional activity within 3 weeks after surgery. Two studies [14, 15] have reported a range of 15 to 19 days until normal activity resumes after laparoscopic myotomy and partial fundoplication, which appears to be comparable with our data after ThAM.
Ellis [16] reported 185 cases of LES myotomy performed through a low left thoracotomy approach with 89% improvement after an average follow-up of 9 years. Okike and colleagues [17] reporting on the Mayo experience of 468 patients found that relief of dysphagia was achieved in 85% of cases using the open transthoracic approach after a mean 6-year follow-up. Luketich and associates [6] reported improved dysphagia in 92% of patients who underwent laparoscopic myotomy and partial fundoplication after an average follow-up of 19 months. Thirty-seven percent of this series complained of residual dysphagia but the dysphagia scores were improved postoperatively in all but 1 patient. Other recent series of patients undergoing laparoscopic myotomy with partial fundoplication have reported 91% success in relieving symptomatology [12, 13]. Although long-term follow-up with laparoscopic and ThAM techniques are lacking, short-term results seem equivalent with respect to freedom from dysphagia. Furthermore, we believe that it is not unreasonable to anticipate long-term results of ThAM to be similar to that reported after OM techniques.
Minimally invasive surgical techniques would seem to be most applicable to treat benign conditions such as esophageal motility disorders. As new technology evolves more minimally invasive approaches can be developed. Our current ThAM technique is similar to OM techniques, which are familiar to most thoracic surgeons. Although long-term results are pending, less blood loss, shorter operating and recovery times as compared with OM techniques, without the need for a concomitant antireflux procedure required with laparoscopic approaches, makes thoracoscopy-assisted myotomy an attractive minimally invasive technique.
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Discussion
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DR FRANCIS C. NICHOLS (Rochester, MN): President Guyton, Secretary Murray, members and guests. First, I would like to thank Dr Kesler for providing me with a copy of his manuscript and presentation well before this meeting.
Early in my surgical career, one of my mentors, Dr Spencer Payne, took me to a Mayo Clinic historical display and showed me the whale bone dilators utilized years ago in the treatment of achalasia. Clearly times have changed. At the beginning of my residency an open transthoracic Heller myotomy was the procedure of choice. With improvements in pneumatic dilatation our gastrointestinal colleagues performed an ever-increasing number of dilatations for achalasia, and we eventually did very few open myotomies. With the advancement of minimally invasive surgical techniques the pendulum in the treatment of achalasia is swinging back toward surgery. Given our rich past experience in the treatment of this disorder we as thoracic surgeons need to avail ourselves of this opportunity.
While my colleagues and I long believed in open transthoracic myotomy without fundoplication, our early, rapidly growing experience and comfort with laparoscopic fundoplication for reflux disease led us to eventually pursue a laparoscopic as opposed to thoracoscopic approach to the treatment of achalasia. We believe advantages of the laparoscopic approach include avoidance of a double-lumen endotracheal tube, ease of exposure of the gastroesophageal junction, a lack of frustration when trying to decide if the myotomy is long enough, ease of repair in the event of mucosal perforation and reinforcement of that repair with an anterior fundoplication, a lack of chest tubes, less pain, and perhaps shorter hospital stay.
Since 1996 we have done more than 150 laparoscopic myotomies with partial fundoplication. Fifty-six percent of our patients had preoperative dilatations or Botox injections or both and this appeared to result in an increased rate of mucosal perforation during the procedure. These perforations were identified and successfully repaired laparoscopically. Our conversion rate to open is 3.6% and functional results have been excellent to good in 92% of patients, fair in 4.5%, and poor in 3.5%. Our results are similar to those of other authors.
Two studies comparing laparoscopic myotomy with partial fundoplication and thoracoscopic myotomy exist. Patti and colleagues found less dysphagia, greater postoperative comfort, and a shorter hospital stay in the laparoscopic group. Most importantly, 60% of their patients in the thoracoscopic group had positive postoperative 24-hour pH studies compared with only 10% in the laparoscopic group. Most of these patients with documented reflux were clinically asymptomatic.
Finally, Ellis and colleagues found a 29% incidence of gastroesophageal reflux in a group of their patients who underwent postoperative pH monitoring after transthoracic open myotomy without fundoplication.
What about this current report by Dr Kesler and his colleagues? First, as the authors have honestly told us, this is not a pure thoracoscopic approach. In addition to two small thoracoscopic incisions, an 8- to 10-cm incision is utilized. The authors must be commended as 68% of their patients had prior dilatations or Botox injections and their mucosal perforation rate was only 3%. This is a rate far lower than most minimally invasive series. Their overall conversion rate to a full open procedure was 11%. While their current follow-up was only a mean of 17 months, this is a shortcoming shared with most minimally invasive esophageal myotomy series. Fifteen percent of their patients were bothered by daily reflux and an additional 34% had noticeable and bothersome reflux on less than a daily basis. Overall their patients seemed satisfied with their improved swallowing ability. Postoperative narcotic usage averaged almost 22 days, which seems long compared with our laparoscopic experience.
Doctor Kesler, I would like to ask you four questions. Have you noticed increased technical difficulty with the myotomy because of prior dilatations or Botox injections?
Perforations are likely to remain a problem in these patients. Intraoperative recognition is key. Do you perform any maneuvers upon completion of the myotomy to assess for leak, and how do you manage a perforation if identified?
Two patients in your series eventually required esophagectomy. What were the indications?
Finally do you plan on performing any objective studies such as 24-hour pH monitoring to more objectively assess postoperative gastroesophageal reflux?
I would like to thank the Society for the opportunity to discuss this stimulating paper in an area where objective long-term follow-up data are still necessary and also an area where thoracic surgeons can again flourish.
DR KESLER: Thank you for your comments, Dr Nichols. We have not seen significant scarring from previous dilitations or botox injections between muscular and submucosal layers. None of our patients had more than very transient benefit from dilatation suggesting that no significant muscle injury was incurred during dilatation efforts however. In addition with only short-term benefits our GI physicians have seen with endoscopic therapy from either dilatation or botox injections, there has been a definite trend toward early referral for this minimally invasive myotomy technique with few patients now undergoing multiple attempts at endoscopic therapy prior to thoracic surgery referral.
As this procedure is done under direct visualization with loop magnification, the isolated esophageal perforation which occurred in our first 38 patients was easily identified without the need for any maneuvers such as air or fluid insufflation within the esophageal lumen. This perforation was repaired through an open thoracotomy. We recently have encountered another inadvertent perforation out of 44 ThAM procedures we have now performed at our institution for a perforation rate of 4%. Of note, both of these perforations occurred during right-angle clamp dissection onto the cardia where the muscular and submucosa layers can be more difficult to separate. This underscores caution during dissection at this level and we tend to use more judicious free hand muscular division with an extended cautery tip and fine forceps to avoid this complication. This more recent perforation, not included in this series, was repaired through the interspace without performing a thoracotomy. We used the myomectomy specimen as tissue "pledgets" on either side of the submuscosal rent, which was closed with a running monofiliment suture. This closure technique left the myotomy site widely open without the need for stomach wrap or closure of the esophageal muscular wall and contralateral myotomy. Routine closure of the parietal pleural layer, which is done in all our ThAM cases, also provided tissue coverage over the repair site in this patient who has no residual dysphagia and who recovered rapidly without having undergone thoracotomy for perforation repair.
Both patients who ultimately underwent esophageal resection in our series had recurrent dysphagia after ThAM and were also subsequently refractory to endoscopic therapy. Both of these patients underwent ThAM early in our series. The technique of ThAM we presented today represents a refinement and what we believe to be an improvement over the ThAM procedure we used 3 years ago. Using our current ThAM technique we have not had any patients with recurrent or persistent dysphagia over the past 18 months.
The vast majority of our patients are very satisfied with their results after ThAM including minimal if any symptoms of GERD. For this reason as well as other issues related to obtaining invasive tests without absolute indications we unfortunately have not been able to study patients with pH probes postoperatively.
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References
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- Ellis F.H., Jr, Olsen A.M., Holman C.B., et al. Surgical treatment of cardiospasm: consideration of aspects of esophagomyotomy. JAMA 1958;166:29.
- Stewart K.C., Finley R.J., Clifton J.C., Graham A.J., Storseth C., Inculet R. Thoracoscopic versus laparoscopic modified Heller myotomy for achalasia efficacy and safety in 87 patients. J Am Coll Surg 1999;189:164-170.[Medline]
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- Patti M.G., Molena D., Fisichella P.M., et al. Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures. Arch Surg 2001;136:870-877.[Abstract/Free Full Text]
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- Ancona E., Anselmino M., Zaninotto G., et al. Esophageal achalasia: laparoscopic versus conventional open Heller-Dor operation. Am J Surg 1995;170:265-270.[Medline]
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- Okike N., Payne W.S., Neufeld D.M., Bernatz P.E., Pairolero P.C., Sanderson P.R. Esophagomyotomy versus forceful dilation for achalasia of the esophagus: results in 899 patients. Ann Thorac Surg 1979;28:119-125.[Abstract]
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Abstract
Introduction
