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Ann Thorac Surg 2008;85:S743-S746. doi:10.1016/j.athoracsur.2007.12.004
© 2008 The Society of Thoracic Surgeons
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Supplement: The Minimally Invasive Thoracic Surgery Summit

Laparoscopic Heller Myotomy for Achalasia: A Review of the Controversies

Virginia R. Litle, MD*

Division of Thoracic Surgery, Department of Cardiothoracic Surgery, The Mount Sinai Medical Center, New York, New York

* Address correspondence to Dr Litle, Division of Thoracic Surgery, The Mount Sinai Medical Center, 1190 Fifth Ave, Box 1028, New York, NY 10029-6574 (Email: virginia.litle{at}mountsinai.org).

Presented at the Minimally Invasive Thoracic Surgery Summit, New York, NY, June 8–9, 2007.


   Abstract
Top
 Abstract
Introduction
 Minimally Invasive Approach
 Summary
 References
 
Achalasia is a rare primary motility disorder of the esophagus with a United States prevalence of less than 0.001%. Laparoscopic modified Heller myotomy has become the standard of care for palliation of this incurable but benign disease. The role of a fundoplication with the myotomy continues to be controversial. This report summarizes the current laparoscopic management of achalasia with a review of the medical literature on the outcome of combining a fundoplication with a laparoscopic myotomy. The optimal length of myotomy as suggested in the literature is also summarized. To complete the goal, peer-reviewed publications were identified in PubMed by search terms achalasia, myotomy, fundoplication, Nissen, Dor, and Toupet.


   Introduction
Top
 Abstract
 Introduction
Minimally Invasive Approach
 Summary
 References
 
Achalasia is an uncommon primary motility disorder of the esophagus, with a prevalence or less than 0.001% in the United States [1]. Progressive dysphagia to solids and liquids and chest pain are the predominant symptoms in more than 80% of patients, and regurgitation occurs in two-thirds [2, 3]. Aperistalsis and incomplete relaxation of the lower esophageal sphincter (LES) by esophageal manometry are the sine qua non findings for diagnosing the disease. In addition, approximately 60% of the patients have elevated resting LES pressure [4]. Not infrequently the diagnosis is initially suggested by an upper endoscopy performed for dysphagia. This essentially rules out a diagnosis of pseudoachalasia from malignancy but does not eliminate the need for manometry. A barium swallow is helpful for identifying a megaesophagus or sigmoid esophagus from end-stage achalasia because these patients may be offered immediate surgical resection vs dilation or myotomy.

Until the past 10 years, pneumatic esophageal dilation was most commonly used to treat achalasia because it was the least invasive therapy and provided long-term relief for a subset of patients. Treatment with injection of botulinum toxin A (Botox; Allergan Inc, Irvine, CA) in the LES has not been associated with perforation similar to dilation but has a shorter and temporary therapeutic efficacy. The effect averages from 3 to 6 months, and duration is not clearly operator- or patient-dependent. Injection of botulinum toxin probably should be reserved for poor operative candidates who classically are elderly patients with recurrent aspiration pneumonia.


   Minimally Invasive Approach
Top
 Abstract
 Introduction
 Minimally Invasive Approach
Summary
 References
 
Within the past 15 years, the increased competence of surgeons to perform minimally invasive surgery has resulted in the laparoscopic, modified Heller myotomy becoming in the gold standard treatment for achalasia. A left video-assisted thoracoscopic surgery (VATS) approach may still be performed at some centers or when a concurrent intrathoracic esophageal diverticulum is excised. The original Heller myotomy described in 1913 involved creating an anterior and posterior cardiomyotomy, but the current technique was modified in 1923 to simply an anterior myotomy [5, 6]. The operative controversies have most recently included the length of myotomy and the addition of a concurrent antireflux procedure.

When a modified Heller myotomy is performed with a left VATS and the phrenoesophageal ligament remains intact, an antireflux procedure should not be necessary. With a transabdominal Heller myotomy, however, a hiatal hernia is essentially created and reflux can occur. A routine antireflux procedure is controversial because of the concomitant aperistaltic esophagus and because the long-term outcomes may not be better with a fundoplication. A review of the role of fundoplication and other controversies in achalasia will be addressed separately below as ascertained from peer-reviewed publications in PubMed.

Laparoscopic Heller and Nissen Fundoplication
In several early series in the minimally invasive era and against conventional wisdom in an aperistaltic esophagus, a complete 360° (Nissen) fundoplication was performed with a laparoscopic Heller myotomy. In one review of 42 patients treated with various approaches, 9 patients underwent a Heller and a "floppy" Nissen over a 40F bougie. At a mean follow-up of 8.5 years in this small group of patients, 22% (2 of 9) of patients complained of dysphagia to meat or bread and 30% complained of reflux, although there was no objective evidence of this with 24-hour pH monitoring [7].

Another study in Australia included 49 patients who underwent a laparoscopic myotomy and Nissen fundoplication and 13 who had a myotomy and partial anterior fundoplication [8]. The dysphagia score at 3 years and then at 5 years for these two groups of patients trended toward statistically significantly less dysphagia in the partial fundoplication group at 5 years (dysphagia score difference at 5 years, p = 0.08). The authors concluded that although partial fundoplication results in less dysphagia and chest pain than a complete wrap, there is no evidence to suggest a total fundoplication resulted in a worse outcome overall. The authors recommended a controlled randomized trial to answer the controversy [8].

The third report of a "floppy" Nissen combined with myotomy was a review by Frantzides and colleagues [5] of their 10-year experience that began in 1992. In this retrospective study of 53 patients, 48 (90%) had a concomitant Nissen fundoplication with the laparoscopic myotomy. After completing a long myotomy with up to 7 cm on the cardia, a 50F bougie was placed and the 360° wrap completed. The laxity of the wrap was assessed by placing a 1-cm instrument next to the esophagus. At a median 3-year follow-up, 2 of the 48 Nissen patients (4%) had dysphagia as determined by a modified Visick scoring system. The dysphagia was attributed to an incomplete myotomy in one case and an excessively tight wrap in the other. The authors attribute their success with a low postoperative dysphagia rate after a Nissen fundoplication to the use of a lighted bougie that allows performance of a complete myotomy with improved visualization and hence division of intact muscle fibers.

Laparoscopic Heller and Dor Fundoplication
Several series have evaluated Heller myotomy with and without partial fundoplication, and most of the reports involve an anterior or Dor fundoplication (Table 1) [5, 9–12]. One study that looked at quality of life (QOL) and dysphagia after myotomy used a Medical Outcomes Study Short-Form 36 (SF-36) Health Survey QOL and a dysphagia scoring system [13]. These authors did not report the incidence of postoperative dysphagia with and without a Dor, but they found that at an average follow-up of 3.3 years, the mean dysphagia score was not statistically worse when a Dor was performed. They also found that the mean SF-36 scores in the two groups at 3 years were similar, as the 100 total respondents who underwent a Heller or a Heller and Dor had an equal satisfaction rate of 92%. Although the authors did not report rates of gastroesophageal reflux disease (GERD) in their cohort, we can at least conclude from this large series of patients that dysphagia may not be a long-term complication after the addition of a partial anterior fundoplication.


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  		Table 1 Frequency of Dysphagia After Modified Heller Myotomy and Partial (Dor, Toupet) or Complete (Nissen) Fundoplication
 
Intraoperative esophageal perforation has been reported to occur in at least 10% to 14% of laparoscopic myotomy cases [13, 14], but is likely underreported and may not even be considered a complication by some. Again, the surgeon should be proficient at or have immediate access to a gastroenterologist to perform intraoperative endoscopy so the perforation can be identified and repaired immediately. Several sutures usually can be placed laparoscopically, but conversion to a laparotomy may be necessary. Only the minimal number of sutures (1 to 2) needed to reapproximate the mucosa should be placed, because the injury can be easily extended during suturing. If intraoperative perforation does occur by the myotomy, the endoscope or a bougie, then an anterior (Dor) would provide both an antireflux component and additional security that the perforation and postoperative leak risk has been minimized.

Because of the controversy of performing an antireflux procedure with the myotomy, a prospective randomized clinical trial of myotomy with and without Dor was completed at Vanderbilt University and reported in 2004 [15]. This study randomized 43 patients undergoing laparoscopic myotomy for achalasia to Dor vs no Dor. Patients underwent manometry and 24-hour pH monitoring at 3 to 5 months postoperatively. Pathologic reflux was significantly less in the Dor group (9% vs 48% in patients without the Dor); in addition, distal esophageal acid exposure was significantly higher in the Heller-only group. Again, dysphagia was not a long-term complication as judged by similar dysphagia scores between the two groups.

The other studies looking at Dor fundoplication and rates of postoperative dysphagia did not separate Dor from Toupet, Nissen, or even Belsey patients, so we may only conclude that rates of dysphagia after partial fundoplication are 2% to 38% (Table 1). In the University of Pittsburgh cohort, any patient who complained of some dysphagia at a mean follow-up of 19 months contributed to the 38% rate of dysphagia. More important though, the dysphagia severity score was significantly improved in more than 95% of patients, and similarly, more than 92% of patients were satisfied with the operation [11].

Although the goal of an antireflux procedure with the myotomy is to prevent postoperative symptomatic and objective reflux and associated complications of esophagitis, the randomized study by Richards and colleagues [15] provides the best evidence that the heartburn rates improved with a Dor fundoplication. The rates of heartburn with fundoplication were 8% to 26% in all series (Table 2) [5, 10, 11, 13–16], and at least one patient (2%) in a moderate-sized series had Barrett’s esophagus [14].


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  		Table 2 Incidence of Heartburn or Symptomatic Gastroesophageal Reflux after Heller Myotomy With and Without a Fundoplication (Wrap)
 
Laparoscopic Heller and Toupet Fundoplication
There are fewer total patients in the reports of the use of a partial posterior, or Toupet, fundoplication as an antireflux procedure after the myotomy. The only published report directly comparing Dor and Toupet was from Wright and colleagues [9] at the University of Washington. These authors compared two groups of achalasia patients treated with two different procedures: from 1994 to 1998, a standard myotomy (1 to 2 cm on the cardia) and a Dor fundoplication was done; whereas from 1998 to 2003, an extended myotomy (more than 3 cm on the cardia) and a Toupet fundoplication was done. Using telephone surveys, they determined that dysphagia severity was lower in the extended myotomy and Toupet group, although frequency of dysphagia was similar. In this study, postoperative heartburn and regurgitation frequencies were the similar after the two different approaches.

The Myotomy
A method for assessing completeness of myotomy is to perform intraoperative manometry to measure any residual high pressure across the gastroesophageal junction [17]. In this series of 132 patients, 34% had persistently elevated pressures allowing immediate revision of their myotomy, with a short postoperative success rate of 93% at 1 month. This technique of intraoperative manometry is a good educational tool but is not typically available to surgeons. Probably a more common way of assessing the completeness of myotomy is with intraoperative endoscopy and the ease with which the operator passes it across the gastroesophageal junction after the myotomy. Of course this assessment must be done carefully, because this may provide the greatest risk of perforation during the entire operation.

Extent of myotomy on the gastric cardia (2 to 3 cm) appears to reduce postoperative dysphagia and minimize "recurrent" achalasia. Patti and colleagues [12] concluded that an inadequate cardiomyotomy accounted for at least two failed Heller myotomies, with intraoperative video demonstrating impaired visualization of the gastroesophageal junction [12]. The extended myotomy recently endorsed by Dr Pellegrini’s group involves more than 3 cm of cardiomyotomy [9]. The important technical message is elevation of the anterior esophageal fat pad to provide accurate identification of the gastroesophageal junction and completion of at least 2 cm of cardiomyotomy.

Secondary Achalasia After Complete Fundoplication for Gastroesophageal Reflux Disease
Two reports of achalasia developing after antireflux surgery have recently been published. One report from Toronto involved two such cases, one of which occurred 12 years after the initial fundoplication. Both patients in this report were then treated successfully with myotomies [18]. The message in this article was an endorsement of preoperative manometry before antireflux surgery. Esophageal motility studies can be beneficial before routine fundoplication to reduce the risk of postoperative dysphagia, but because the study cannot always be completed, an accurate history and a barium swallow should prevent—or at least minimize—a misdiagnosis of GERD in a patient with achalasia.

The other recent article on secondary achalasia after fundoplication supports the routine use of manometry before antireflux surgery [19]. In this review of 250 patients who underwent laparoscopic Nissen fundoplication by one surgeon, late-onset postoperative dysphagia and manometric aperistalsis developed in 7 patients. Only 2 patients had failure of LES relaxation, but all 7 were given a diagnosis of secondary achalasia. All the patients were treated with dilation, but 3 also responded to botulinum toxin injection, and 1 patient underwent a Heller myotomy. The incidence of achalasia after fundoplication in the series is less than 1%, with 2 patients having standard manometry consistent with achalasia. Although fewer than 20 patients with post-Nissen achalasia have been reported in the literature, this may provide evidence against choosing a Nissen as an antireflux procedure with a myotomy for achalasia.


   Summary
Top
 Abstract
 Introduction
 Minimally Invasive Approach
 Summary
References
 
Laparoscopic-modified Heller esophagocardiomyotomy is the standard treatment for patients with achalasia but without prohibitive comorbidities. Perioperative mortality should approach 0%, and long-term patient satisfaction exceeds 90%. An antireflux procedure can reduce postoperative heartburn rates by 80% and reduce risk of esophagitis and peptic stricture. A Dor or Toupet fundoplication reduces reflux as well as a Nissen, but the partial wraps trend toward less dysphagia. The dysphagia rates attributed to fundoplication range from 0% to 8%. Failure of improvement with dilation suggests incomplete myotomy and requires repeat manometry. Optimal length of the cardiomyotomy is at least 2 cm. Although a Dor fundoplication is more commonly reported, the choice of Toupet vs Dor depends on surgeon preference.


   References
Top
 Abstract
 Introduction
 Minimally Invasive Approach
 Summary
 References
 

  1. Mayberry JF. Epidemiology and demographics of achalasia Gastrointest Clin N Am 2001;11:235-248.
  2. Bedgood R, Sadurski R, Schade RR. The use of the internet in data assimilation in rare diseases Dig Dis Sci 2007;52:307-312.[Medline]
  3. Spiess AE, Kahrilas PJ. Treating achalasia: from whalebone to laparoscope JAMA 1998;280:638-642.[Medline]
  4. Kraichely RE, Farrugia G. Achalasia: physiology and etiopathogenesis Dis Esophagus 2006;19:213-223.[Medline]
  5. Frantzides CT, Moore RE, Carlson MA, et al. Minimally invasive surgery for achalasia: a 10-year experience J Gastrointest Surg 2004;8:18-23.[Medline]
  6. Payne WS. Heller’s contribution to the surgical treatment of achalasia of the esophagus. 1914 Ann Thorac Surg 1989;48:876-881.[Abstract/Free Full Text]
  7. Jordan PH. Longterm results of esophageal myotomy for achalasia J Am Coll Surg 2001;193:137-145.[Medline]
  8. Wills VL, Hunt DR. Functional outcome after Heller myotomy and fundoplication for achalasia J Gastrointest Surg 2001;5:408-413.[Medline]
  9. Wright AS, Williams CW, Pellegrini CA, Oelschlager BK. Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia Surg Endosc 2007;21:713-718.[Medline]
  10. Lyass S, Thoman D, Steiner JP, et al. Current status of an antireflux procedure in laparoscopic Heller myotomy Surg Endosc 2003;17:554-558.[Medline]
  11. Luketich JD, Fernando HC, Christie NA, et al. Outcomes after minimally invasive esophagomyotomy Ann Thor Surg 2001;72:1909-1913.[Abstract/Free Full Text]
  12. Patti MG, Molena D, Fisichella PM, et al. Laparoscopic Heller myotomy and Dor fundoplication for achalasia Arch Surg 2001;136:870-877.[Medline]
  13. Youssef Y, Richards WO, Sharp, et al. Relief of dysphagia after laparoscopic Heller myotomy improves long-term quality of life J Gastrointest Surg 2007;11:309-313.[Medline]
  14. Donahue PE, Horgan S, Liu KJ-M, et al. Floppy Dor fundoplication after esophagocardiomyotomy for achalasia Surgery 2002;132:716-723.[Medline]
  15. Richards WO, Torquati A, Holzman, MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: A prospective randomized double-blind clinical trial Ann Surg 2004;240:405-415.[Medline]
  16. Burpee SE, Mamazza J, Schlachta CM, et al. Objective analysis of gastroesophageal reflux after laparoscopic heller myotomy: An anti-reflux procedure is required Surg Endosc 2005;19:9-14.[Medline]
  17. Chapman JR, Joehl RJ, Murayama KM, et al. Achalasia treatment: improved outcome of laparoscopic myotomy with operative manometry Arch Surg 2004;139:508-513.[Medline]
  18. Poulin EC, Diamant NE, Kortan P, et al. Achalasia developing years after surgery for reflux disease: case reports, laparoscopic treatment, and a review of achalasia syndromes following antireflux surgery J Gastrointest Surg 2000;4:626-631.[Medline]
  19. Stylopoulos N, Bunker CJ, Rattner DW. Development of achalasia secondary to laparoscopic Nissen fundoplication J Gastrointest Surg 2002;6:368-378.[Medline]



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