Laparoscopic myotomy for oesophageal achalasia - adding an antireflux procedure is not always necessary

Abstract

Laparoscopy is the access of choice for functional surgery of the gastroesophageal junction, and oesophagocardiomyotomy, as the conventional surgical treatment of achalasia, is one of the favourable indications for laparoscopic surgery. Laparoscopic anterior myotomy technique is highly effective and secure for relieving dysphagia with minimal risk of gastroesophageal reflux. Fifteen patients with the diagnosis of achalasia were treated with laparoscopic anterior face oesophagocardiomyotomy without a concomitant antireflux procedure. There was not any perioperative complication and no procedure was converted to open operation. Oesophageal cineradiography, manometry and 24-h pH monitoring were repeated postoperatively. Manometry showed a significant reduction of the resting tone (48-34.4 to 18-3.2 mmHg), and patients were free of symptoms for reflux and dysphagia at the follow-up between 8 and 96 (median 42) months. Only one patient needed pneumatic dilation, 1 year after the operation for mild dysphagia, and one patient had moderate reflux, which was managed by medication. Thanks to minimal invasive technique of laparoscopic surgery and intraoperative endoscopy, oesophagocardiomyotomy can safely be performed in a length needed without dividing lateral and posterior phrenoesophageal ligamentous attachments. Consequently, adding an antireflux procedure routinely is not necessary. We advocate laparoscopic anterior oesophagocardiomyotomy alone as the first-line treatment for achalasia.

Long-term outcome after laparoscopic myotomy for achalasia

“…Complications in several other series vary from 0 to 16%. 9,17 The overall complication rate in the review by Campos and colleagues 2 was 6.3%. Most complications in our series were of minor nature except 2 patients who had bowel perforation and needed subsequent surgery.…”

“…Rate of intraoperative esophageal perforation during laparoscopic myotomy varies from 0% to 33% in several series. 2,4,[9][10][11][12][13][14][15][16][17] Only 1 patient had a delayed presentation of a mucosal perforation and required a subsequent operation to repair the leak. When mucosal perforations do occur, our current treatment recommendation is that they should be repaired laparoscopically with fine sutures with the addition of a Dor-type fundoplication to buttress the repair.…”

24‐h pH monitoring patterns and clinical response after achalasia treatment with pneumatic dilation or laparoscopic Heller myotomy

“…The need for and efficacy of antireflux procedures continue to be debated in surgical circles 12, 31–37 . At our institution, partial Fp is performed routinely in all patients who underwent myotomy.…”

“…21 The need for and efficacy of antireflux procedures continue to be debated in surgical circles. 12,[31][32][33][34][35][36][37] At our institution, partial Fp is performed routinely in all patients who underwent myotomy. Many studies reporting on the incidence of post-operative GER used different surgical techniques.…”

Surgical treatment for achalasia: when should it be performed, and for which patients?

“…A procedure without dividing lateral and posterior phrenoesophageal ligamentous attachments has been reported to decrease postoperative GER after HM without an antirefl ux procedure. 48,49 Simic et al evaluated the effectiveness of limited hiatal dissection. 50 This prospective randomized study revealed that HM with limited hiatal dissection led to better refl ux control, regardless of Dor's fundoplication.…”