Laparoscopic myotomy in achalasia: intraoperative evidence for myotomy of the gastric cardia *

Abstract

The myotomy performed for achalasia of the esophagus should divide all of the constricting, diseased muscular elements that obstruct the esophagogastric junction (EGJ). Whether the disease process includes proximal gastric as well as esophageal components is as yet unclear, but anatomic evidence complemented by clinical data suggest that the disease process does not end at the evanescent and poorly defined EGJ. Clinical reports from enthusiastic proponents of a particular operative approach for achalasia have not been illuminating in this regard, because all patients are improved to some degree post-operatively, and there are no objective parametric standards for the evaluation of swallowing function. This study reports a series of patients in whom endoscopic viewing was used to judge the adequacy of myotomy after 'esophageal' myotomy. The question posed by this study was, 'Does esophageal myotomy remove all constricting elements at the gastroesophageal junction?' Laparoscopic myotomy was performed in 48 patients with a diagnosis of achalasia; these patients are the most recent in a total cohort of 72 patients operated upon for achalasia during the past 20 years. Myotomy was begun on the esophagus, and extended to the esophagogastric junction; anatomic landmarks, including the appearance of submucosal veins, guided the initial dissection. Intraoperative endoscopy was then performed to determine whether there was residual constriction of the channel between the esophagus and stomach; if so, myotomy was extended onto the gastric cardia until visual evidence of obstruction had disappeared. All patients had either Toupet fundoplication or Dor fundoplication after myotomy. There were obvious constricting elements distal to the gastroesophageal junction in 90% of the patients. These patients required extension of the myotomy onto the stomach for an average of 15 mm. All but one patient had improved swallowing post-operatively. Eight patients required 'stretch' of the distal esophagus/cardia within the first year post-operatively; one patient was reoperated for fibrous scar obstruction of the distal esophagus. Esophageal myotomy limited to the esophageal muscle does not remove all constricting elements at the gastroesophageal junction; as a result, the extended myotomy must be complemented by an antireflux procedure during operations for achalasia.

Revisional Surgery after Heller Myotomy for Treatment of Achalasia: A Comparative Analysis Focusing on Operative Approach

“…Redo myotomy at the same site was performed in majority of these patients (65.2%). A fresh myotomy was performed in 34.8% of patients [12,23,32]. In our review new onset of reflux disorder after undergoing Heller myotomy was seen in 32% cases that required a revisional surgery.…”

“…Interestingly, this study showed that surgeons performing Heller myotomy as a primary procedure have also performed an additional procedure at the same time, the most likely reason being to prevent postoperative reflux. Procedures such as truncal vagotomy [10,11], pyloroplasty [10,11,16], cardioplasty [10], antrectomy [11,12,21,27], Belsey repair [14,26,27,32], and roux-en-Y gastrojejunostomy [12,21,23,27,30] have been documented.…”

“…Postoperative complications such as pnemothorax [19,32,33], pulmonary atelectasis [19,32,33], esophageal fistula [10], esophageal perforation [31,33], gastric perforation [33], deep venous thrombosis [10], paraesophageal hernia [19], splenic injury [31], and adhesions [31] were reported after primary Heller myotomy procedure. Complications were comparatively less after revisional surgeries and the overall mortality rate was 0.63%.…”

Achalasia: What is the best treatment?

“…14 Manometry on the other hand gives a more functional assessment of the myotomy and can be use to locate areas of residual high pressure zone. 48 The role of antireflux procedure following esophagomyotomy remains controversial. Opponents of antireflux procedure argue that a good postoperative LES pressure with low incidence of reflux symptoms can be achieved without fundoplication by avoiding excessive posterior dissection and limiting the myotomy to 0.5 to 1cm onto the stomach.…”

“…11,12 The methods of assessing completeness of division of the LES fibers during myotomy are intra operative endoscopy and manometry. 14,48 Endoscopic view allows precise identification of the squamocolumnar junction and guides the proximal and distal extent of the myotomy and also detects perforations that can be repaired immediately. 14 Manometry on the other hand gives a more functional assessment of the myotomy and can be use to locate areas of residual high pressure zone.…”