Surgical Treatment of Achalasia: Current Status and Controversies

Abstract

Objective: To review the current management of achalasia, and the controversies regarding the different treatment options. Methods: A review of the literature was performed. The key words used were esophageal achalasia, Heller myotomy, endoscopic balloon dilatation, laparoscopic Heller myotomy, and fundoplication. Results: Patients who fail medical therapy (e.g. pharmacologic therapy, botulinum toxin, balloon dilatation) should be considered for surgical therapy for the management of achalasia. Currently, numerous surgical procedures exist for the treatment of achalasia (transabdominal cardiomyotomy, thoracoscopic or open transthoracic cardiomyotomy, and laparoscopic Heller myotomy with an antireflux procedure). Conclusions: Laparoscopic Heller myotomy is generally accepted as the operative procedure of choice for achalasia. However, controversy exists as to whether a concomitant antireflux procedure is necessary, and if so, what type should be performed. Given the deleterious effects of postoperative reflux, and the facility of including an antireflux procedure at the time of the myotomy, there is merit in undertaking an antireflux procedure at the time of the laparoscopic Heller myotomy.

Laparoscopic Heller Myotomy for Achalasia Cardia—Initial Experience in a Teaching Institute

“…As was reported before, the most frequent cause of failure or recurrence after this operation is an incomplete myotomy, both on the mediastinal and gastric sides [8]. The open approach entails a perioperative mortality of 1.2 %, and the laparoscopic approach consistently achieves a zero mortality rate [9]. In our series, all 25 patients had minimal morbidity of surgery and excellent outcome in terms of relief of dysphagia and weight gain.…”

Surgical Treatment of Achalasia: Transabdominal Versus Transthoracic Cardiomyotomy

“…This technique is known as the heller technique and is the surgical treatment of achalasia for the past 85 years. 17) Many surgeons choose an abdominal approach. A study by Abir and Colleagues was performed on 2680 patient with this approach.…”

“…The only complication was a small perforation in the esophagus during cardiomyotomy and post operative Gastro esophageal reflux. 17) Although, today, many surgeons perform this procedure laparoscopically as the first step, but all of them believe that in spite of all benefits of this method including minor tissue trauma and the lower rate of post operative reflux, the risk of microperforation was higher, and surgeon expertise is so important. Passing the learning curve is essential for a correct and non complicated procedure.…”

“…19) But in a comparison by Abir and colligued about the success rate of these two techniques (transthoracic or transabdominal) they conclude that there is no difference in these approaches, but morbidity was higher in abdominal procedure. 17) The other point that is controversial between surgeons is the length of myotomy on the esophagus. Many investigators emphasize that the greater the lengh of myotomy, the more chance there is to control the dysphagis.…”

Minimal Access Surgery (Laparoscopic Cardiomyotomy) for Achalasia Cardia

“…Laparoscopic Heller's myotomy has comparable success to open Heller's myotomy and causes less early detriment in the quality of life and should be the primary treatment in all fit patients was the conclusion of the study by Katillus M, Velanonvich V 4 62 patients underwent minimal access esophagomyotomy in a study done by Luketich el al 5 at their institute also proved that laparoscopic approach offers very good results. Abir et al 6 in their review of current status and controversies of management for achalasia stated that laparoscopic Heller's myotomy is generally accepted as the procedure of choice for esophageal achalasia.…”