Ann Thorac Surg 2007;83:2235-2238
© 2007 The Society of Thoracic Surgeons
How To Do It
Laparoscopic Cardioplasty to Avoid Esophageal Resection in Patient Not Responsive to Heller Myotomy
Gianmattia del Genio, MD*,
Alberto del Genio, MD, PhD,
Luigi Brusciano, MD,
Gianluca Russo, MD,
Francesco Pizza, MD,
Federica del Genio, MD, PhD,
Gianluca Rossetti, MD, PhD
First Division of General and Gastrointestinal Surgery, Second University of Naples, Naples, Italy
Accepted for publication July 10, 2006.
* Address correspondence to Dr del Genio, Via Strettola a Chiaia, 7, Napoli, I-80122, Italy. (Email: gdg{at}doctor.com).
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Abstract
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Some achalasia patients do not ameliorate dysphagia after Heller myotomy. If stenosis does not respond to endoscopic dilatations and persists after a second extended myotomy, an esophageal resection is considered unavoidable. This article describes an original technique of treating this type of persistent stenosis with an esophageal stricturoplasty. The procedure was completed under laparoscopy. The postoperative course was uneventful. Resolution of all preoperative symptoms was achieved at the first year follow-up. Control of gastroesophageal reflux was documented by 24-hour pH-impedance. If confirmed by further cases, laparoscopic esophageal stricturoplasty could become a valid option for a conservative treatment of these patients.
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Introduction
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Achalasia is a degenerative disease characterized by a defective peristaltic activity of the esophageal body and impaired relaxation of the lower esophageal sphincter, which leads to a difficult progression of bolus into the stomach. Surgical therapy of achalasia relies on relieving the functional obstruction to facilitate this transit. Among different techniques described, the Heller’s extended extramucosal esophagogastromyotomy followed by an antireflux procedure seems to have gained a spread acceptance as the first line of treatment [1]. However, patients with a residual upper achalasia in the thorax or a stenosis at the esophagogastric junction not responsive to dilations necessitate a more aggressive surgical therapy. This may vary from a transthoracic second look to extend the myotomy up in the chest to an esophageal resection, such as the transhiatal subtotal esophagectomy (with gastric or colon replacement) or the distal esophagectomy (with intrathoracic esophagogastrostomy or Merendino’s jejunal loop interposition) [2].
We report the case of 1 patient with esophageal stenosis at the esophagogastric junction after Heller’s myotomy and Nissen fundoplication was not responsive to endoscopic dilations. The patient was treated by laparoscopic extension of the original myotomy associated to a stricturoplasty. Preoperative assessment, surgical technique, and outcomes will be discussed.
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Technique
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Medical History
A 40-year-old Caucasian woman was admitted to our institution with complaints of severe dysphagia for liquids and solids and for regurgitation. In 1990 she had undergone a laparoscopic Heller myotomy followed by a Nissen fundoplication with an initial amelioration of the odynophagia at another institution. During the preceding 3 years, the pre-existing symptoms (ie, dysphagia, sialorrhea, and cough) became progressively worse, and despite the medical therapy (ie, vasodilative drugs, proton pump inhibitor, and procinetics) and repeated endoscopic dilations the dysphagia did not ameliorate leading to an unintentional 8 kg weight loss.
At admission, a barium esophagogram identified a residual mega-esophagus with a maximum diameter of 5.5 cm and a stenosis at the distal segment of the esophagus. Upper endoscopy confirmed the dilated esophagus and a cardial zone was not overstepped. At manometry, the lower esophageal sphincter resting pressure was 30 mm Hg; relaxation during swallowing was absent in 70% of the cases and incomplete in the remaining 30%, with a lower esophageal sphincter residual pressure of 14 mm Hg. Absence of esophageal body peristalsis was noted in 100% of the swallows. The 24-hour pH monitoring (Digitrapper Proxima [Synetics Medical, Stockholm, Sweden]) showed a long acidification (percentage with pH <4: total, 56.4; upright, 38.1; and supine, 100.0), but without any drop of pH <3.5 (Fig 1).
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Fig 1. Preoperative 24-hour pH monitoring showed mild esophageal acidification without gastroesophageal acid reflux episodes, as suggested by the absence of pH-line dropping.
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On the basis of the preoperative assessment, a mechanical stenosis due to an inadequate myotomy, a too tight or not relaxing wrap, or a peptic stenosis was suspected, and the patient was referred for a reoperation.
Surgical Technique
The position of the patient and trocars were identical to those we adopted for a primary Heller myotomy [1]. The abdominal portion of the esophagus was identified with the help of the transillumination provided by the endoscope. The first step consisted in the liberation of the adherences of the wrap with the left liver and the crura. The fundoplication was disrupted with a gentle blunt dissection, taking extra care to visualize and avoid injury to the vagal nerves. The crura were well exposed, the esophagus was completely encircled to allow a downward traction, and an adequate posterior window for the wrap was obtained. The dissection continued beyond the diaphragm toward the lower mediastinum to eliminate all the attachments and achieve a wide mobilization of the esophagus.
The redo-esophagogastromyotomy stage of the procedure was accomplished by a close collaboration between an expert endoscopist and the surgeon to avoid mucosal perforation. Thanks to the insufflation and transillumination properties of the endoscope, it was constantly possible to identify all the residual circular muscle fibers and extend the myotomy upward 3 to 4 cm more than the previous myotomy and downward onto the stomach for at least 2 cm. Although the endoscopic transillumination confirmed that no residual muscular fibers were left over the mucosal layer, the esophageal lumen did not dilate, and a 3-cm long stenosis persisted so that the gastroscope (9-mm diameter) could not to overpass into the stomach (Fig 2).
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Fig 2. Extended redo-esophagogastromyotomy evidenced a 3-cm long segmental mucosal stenosis at the esophagogastric junction.
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Esophageal stricturoplasty and re-fundoplication were used to avoid an esophageal resection, and a distal esophageal stricturoplasty was realized. The esophageal mucosal was longitudinally opened for approximately 5 cm across the stenotic segment. The mucosal margins were sutured transversally with five extracorporeal interrupted stitches (Fig 3). The suture line was submerged under saline, and the endoscopy was performed under air insufflation to check air leaks, bleeding, and the caliber of the esophageal lumen. Intraoperative pull-through manometry confirmed no residual pressure in the stricturoplasty zone (<4 mm Hg). The procedure was completed with a Nissen-Rossetti antireflux wrap using our routinely adopted technique [1] (Fig 4). The reverse endoscopic vision confirmed the correct geometry of the fundoplication. The new high-pressure zone value was in the suitable range (25–35 mm Hg).
Postoperative Course
Operative time was 135 minutes. Blood loss was not relevant. The patient did not require admission to the intensive care unit. No blood transfusion was necessary. On postoperative day 5, after a normal medical prescription swallow with gastrographin, a semi-liquid diet was started. The patient was discharged home on postoperative day 8.
The patient returned to normal feeding in 4 weeks. Two months afterward the medical prescription swallow confirmed good functioning of the esophageal stricturoplasty. Endoscopy confirmed a large esophageal lumen and a normal fundoplication at the 180-degree inversion.
During the first postoperative year at three outpatient controls, she reported complete resolution of her dysphagia with a weight gain of 5 kg. At 8 months, multichannel intraluminal impedance-pH showed a normalization of the esophageal exposure to acid (percentage of time pH <4: total, 2.3; upright, 6.7; supine 0.4; DeMeester’s score, 8.6); nonacid reflux was absent (one episode in recumbent position); the symptom index correlation to reflux was not quantifiable, being that the symptoms were absent during the recording (Fig 5).
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Fig 5. Postoperative multichannel intraluminal impedance-pH. Noteworthy is the complete normalization of the pH channel (lowest track).
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Comment
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Persisting or recurrent dysphagia after an attempted Heller myotomy is commonly the result of inadequate, incomplete, or refused myotomy. The obstacle to esophageal emptying of these patients may be also caused by a too tight or poorly relaxing fundoplication. In these cases, treatment consists of repeating a correctly sited myotomy of adequate length or a correctly refashioned fundoplication, or both. This conservative approach is not possible in patients who have undergone previous surgery without relief with a diagnosis of end-stage achalasia (ie, sigmoid-shaped esophagus), or a nondilatable peptic stricture. There is substantial agreement that in these cases an esophageal resection is considered unavoidable. It may be carried out under laparoscopy with undoubted advantage [3], but it still represents a major operation that exposes the patient to mortality risk. Moreover, the long-term exposition of the esophagus to acid and bile after transposition of the stomach up to the neck may affect the long-term quality of life for these patients.
To find an alternative procedure in patients with a segmental stenosis not responsive to Heller myotomy and endoscopic dilation could be of great advantage. Some other techniques have been reported. The Thal-Hatafuku surgical technique consists of suturing the gastric fundus to the opened distal esophagus [4]. The Serra-Doria combined a long latero-lateral anastomosis extended through the esophagus onto the gastric fundus with a Roux-en-Y distal gastrectomy to prevent bile reflux [5]. Recently, Braghetto and colleagues [6] reported an interesting technique consisting of a long gastroesophageal reverse "Y" cardioplasty associated to the Roux-en-Y antrectomy and bi-troncular vagotomy to reduce the risk of either bile or acid reflux [6].
Our proposed stricturoplasty, by means of a longitudinal incision in the segmental stenosis tract followed by a transversal suture, is a simpler procedure that does not require resection or anastomosis and seems to be feasible under laparoscopic approach. By means of single stitches, it transposes the same principles of the Heineke-Mikulicz [7] stricturoplasty for Crohn’s disease.
The stricturoplasty was completed by a total fundoplication that buttressed the suture line, which constituted only the esophageal mucosal. In contrast with the great majority of authors that support the use of the partial antireflux wrap in achalasic patients to prevent a postoperative dysphagia [8], we prefer to associate a total fundoplication with the rationale of offering a superior protection to the reflux in such patients with a lack of esophageal clearance [1]. Once an adequate enlargement of the cardia was obtained with the stricturoplasty, the total fundoplication did not impair the esophageal emptying and the dysphagia disappeared. Perfect control of gastroesophageal reflux was confirmed by the use of multichannel intraluminal impedance-pH. In any case, the original aspect of the technique lays on the type of stricturoplasty fashioned and not on the antireflux procedure associated, which may be modified by the preferences of the surgeon (eg, Dor fundoplication).
If validated by additional cases, this laparoscopic esophageal stricturoplasty could represent an alternative to the esophageal resection in the rare but challenging condition of a patient with a segmental distal stenosis of the esophagus not responsive to disruption of the fundoplication and redo extended Heller myotomy.
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References
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- Rossetti G, Brusciano L, Amato G, et al. A total fundoplication is not an obstacle to esophageal emptying after Heller myotomy for achalasia: results of a long-term follow up Ann Surg 2005;241:614-621.[Medline]
- Devaney EJ, Lannettoni, MD, Orringer MB, Marshall B. Esophagectomy for achalasia: patient selection and clinical experience Ann Thorac Surg 2001;72:854-858.[Abstract/Free Full Text]
- Crema E, Ribeiro LBP, Terra Jr JA, Silva AA. Laparoscopic transhiatal subtotal esophagectomy for the treatment of advanced megaesophagus Ann Thorac Surg 2005;80:1196-1201.[Abstract/Free Full Text]
- Thal AP, Hatafuku T. Improved operation for esophageal rupture JAMA 1964;188:826.[Abstract/Free Full Text]
- Serra-Dória OB. Trattamento cirúrgico do megaesôfago operaçâo de Serra Dória Rev Poiana Med 1973;19:185-193.
- Braghetto I, Korn O, Csendes A, Frias JC. Esophagocardioplasty, vagotomy-antrectomy and Roux-en-Y gastrojejunostomy: indication in cases with severe esophageal motor disfunction Dis Esophagus 1998;11:58-61.[Medline]
- Fazio VW, Galandiuk S, Jagelman DG, Lavery IC. Strictureplasty in Crohn’s disease Ann Surg 1989;210:621-625.[Medline]
- Deb S, Deschamps C, Allen MS, et al. Laparoscopic esophageal myotomy for achalasia: factors affecting functional results Ann Thorac Surg 2005;80:1191-1194discussion 1194–5.[Abstract/Free Full Text]
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Abstract
Introduction
