Laparoscopic Heller Myotomy with Toupet Fundoplication Outcomes Predictors in 121 Consecutive Patients

PAPER Laparoscopic Heller Myotomy With Toupet Fundoplication Outcomes Predictors in 121 Consecutive Patients

Yashodhan S. Khajanchee, MD; Shalini Kanneganti, MD; Amy E. B. Leatherwood, NP; Paul D. Hansen, MD; Lee L. Swanström, MD

Hypothesis: This study was performed to assess the in- Results: Preoperatively, 89 patients (73.6%) had se- termediate-term outcomes after laparoscopic Heller my- vere dysphagia (dysphagia score, 3 or 4) and 32 patients otomy and posterior Toupet fundoplication in a single- (26.4%) had mild or moderate dysphagia (dysphagia score, surgeon series with the expectation of identifying patient 1 or 2). After a median follow-up period of 9 months, and disease factors associated with poor outcomes. 102 patients (84.3%) (PϽ.001) had excellent relief of dysphagia (dysphagia score, 0 or 1). Eight additional pa- Design: Retrospective analysis of prospectively col- tients (6.6%) demonstrated a significant (25%-75% lected data. [P=.01]) improvement in dysphagia scores. Only 11 patients (9.0%) had either no change or worse dysphagia. Setting: Tertiary care teaching hospital with a compre- Postoperatively, all patients with manometry had a nor- hensive esophageal physiology laboratory. mal lower esophageal sphincter pressure (mean±SD, 14.7±6.6 mm Hg; PϽ.001) and good lower esophageal Patients: A total of 121 patients undergoing laparo- sphincter relaxation. Odds of failure were greatest for scopic Heller myotomy with Toupet fundoplication (be- patients with severe preoperative dysphagia, male pa- tween December 1, 1996, and December 31, 2004) for tients, and patients with classic amotile achalasia. Of achalasia were included. the 60 patients having heartburnlike symptoms preop- Interventions: All patients had preoperative objective eratively (mean±SD score, 2.52±1.00), 19 (31.7%) con- documentation of achalasia. A 5- to 6-cm-long my- tinued to have similar symptoms after surgery. Sixteen otomy was performed on the distal esophagus. The my- (33.3%) of the 48 patients having postoperative pH stud- otomy incision was extended 2 cm onto the stomach. A ies demonstrated objective reflux (DeMeester score, Ͼ partial (270°) posterior Toupet fundoplication was per- 14.7). Five (31.2%) of these patients had symptoms of formed as an antireflux mechanism in all patients. their reflux.

Main Outcome Measures: Data on preoperative and Conclusions: Dysphagia improves in most patients af- postoperative symptoms, manometry, and 24-hour am- ter laparoscopic Heller myotomy with partial fundopli- bulatory pH were prospectively collected. Symptoms were cation. Patients with severe preoperative dysphagia, esoph- recorded with a standardized assessment tool. Patients ageal dilation, or amotile achalasia may have greater with postoperative dysphagia scores of 2 or greater were chances of a poor outcome. considered treatment failure. Logistic regression modeling was performed to identify variables significant for poor outcomes. Arch Surg. 2005;140:827-834

CHALASIA IS AN IDIOPATHIC directed toward relieving dysphagia and primary motility disorder preventing stasis-related complications, but characterized manometri- do not restore normal esophageal motil- cally by a poorly relaxing ity.2-4 Surgical myotomy, endoscopic pneu- lower esophageal sphinc- matic dilation, and botulinum toxin injec- terA (LES) and complete loss of primary peri- tions of the LES are the most commonly stalsis, which leads to a compromise of the used techniques for the treatment of acha- primary function of the esophagus.1 Un- lasia at present, all of which seem to pro- Author Affiliations: Minimally treated, it leads to an extremely poor qual- vide excellent symptomatic relief at least ini- Invasive Surgery Department, ity of life because of progressive dyspha- tially. Although most studies indicate that Legacy Health System, gia, esophageal dilation, and stasis. All surgical myotomy is superior to endo- Portland, Ore. current treatments are palliative, as they are scopic approaches in providing long-term

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 etry, and 24-hour ambulatory pH were prospectively collected Table 1. Scale for Assessment of GER on standardized data collection forms, which were main- and Dysphagia Symptoms tained in an electronic database system (Microsoft Access 97; Microsoft Corp, Redmond, Wash). Symptoms were recorded Score GER Symptoms Dysphagia with a symptom assessment tool using a scale of 0 to 4, with 0 Never Never higher ordinal values representing greater frequency of symp- 1 Occurs once or twice a Rarely (once or twice a toms (Table 1). Baseline demographics and preoperative clini- month but not weekly month but not weekly) to cal data were obtained at the time of the first office visit. Acha- bread or meat lasia was defined manometrically by the complete absence of 2 Occurs once or twice a week Occasionally (once or twice primary peristalsis of the esophageal body. Other manometric but not daily a week but not daily) to characteristics of achalasia, such as failure of the LES to relax thick food to gastric baseline with swallowing or the presence of a hyper- 3 Occurs daily but not To thin liquids tensive LES, were also recorded. Esophageal dilation was de- continuously termined by the maximum esophageal diameter on review of 4 Occurs daily and Cannot swallow oral upright barium swallow radiographs. Minimal dilation was de- continuously (all the time) secretions scribed as less than 2.5 cm, moderate as 2.5 to 5 cm, and severe as greater than 5 cm. Data on operative time and intraop- Abbreviation: GER, gastroesophageal reflux. erative complications were acquired at the time of surgery. The primary symptom outcomes for this study were dysphagia and

5-9 sensation of gastroesophageal reflux. relief of dysphagia, many physicians still favor endo- Patients were followed up at 1 to 2 weeks after surgery, and scopic treatment because of the relatively higher morbid- again at 6 weeks if indicated. At 3 months, patients were asked ity associated with laparotomy or thoracotomy.10-13 Sur- to complete a symptom assessment form. After a postopera- gical myotomy, however, has regained primacy since the tive period of 6 months, all of the patients were recalled and introduction of a minimally invasive laparoscopic ap- encouraged to undergo esophageal manometry and 24-hour am- proach in 1991.14 This is because of the obvious advan- bulatory pH testing at no charge. Symptom assessment forms tages associated with this approach, including less post- were administered at each visit. Long-term follow-up of all pa- operative pain, a shorter hospital stay, and an earlier return tients was done by telephone interview every year, and symp- to work.15 Current data suggest that, in experienced hands, tomatic patients were brought back for further testing. Pa- tients with a postoperative dysphagia score of 2 or higher were results of laparoscopic Heller myotomy (LHM) are excel- considered to represent treatment failures. lent and are comparable with those of open surgery.8,16-20 Even so, the symptoms of achalasia may recur in 6% to 23% of patients, and little is known, at present, about the INTERVENTIONS factors that may lead to failure after myotomy. The aim of this study was to evaluate intermediate-term outcomes af- All surgical procedures were performed under the supervision ter LHM with a posterior 270° Toupet fundoplication and of 1 of us (L.L.S.). Surgery residents or fellows were involved to identify patient, technical, and disease factors associ- in most of the cases. A posterior 270° wrap (Toupet fundopli- ated with or predictive of poor outcomes. cation) was the primary antireflux surgery used after an LHM. Dor fundoplications or no wrap were used occasionally for spe- cific anatomic reasons or because of a failed Toupet proce- METHODS dure; these patients were excluded from the present study to achieve uniform data. PATIENTS Five trocars were placed in the upper part of the abdomen. The gastroesophageal junction and lower mediastinal esopha- Patients were selected from a prospective database of patients gus were widely mobilized while both vagus nerves were pre- undergoing esophageal procedures at our institution. Patients served. The short gastric vessels were routinely divided. A 54F were included only if they had a preoperative diagnosis of acha- to 56F bougie was used in all cases. A myotomy to the level of lasia, underwent LHM with 270° posterior Toupet fundopli- submucosa was started on the anterior gastric cardia, 2 cm be- cation, and had a postoperative follow-up of at least 6 months’ low the gastroesophageal junction, and was extended 5 to 6 cm duration. Patients undergoing LHM with no antireflux proce- proximal to it on the anterior esophageal wall. Adequacy of the dure and those undergoing Dor fundoplication were excluded myotomy was assessed by noting mucosal bulging without any from the study, as were patients who had surgery before 1996, visible crossing fibers and by performing endoscopy if indi- when a different symptom assessment tool was in use. A total cated. Both crura were loosely approximated posterior to the of 158 LHMs were performed by one of us (L.L.S.) between De- esophagus, and a 270° posterior Toupet fundoplication was com- cember 1, 1996, and December 31, 2004. One hundred forty pleted by suturing the wrapped fundus to the edges of the my- patients with achalasia satisfied the selection criteria for this otomy as well as to the right and left crura. A closed suction study. Nineteen of these patients were eliminated because of drain was placed adjacent to the myotomy, and a water- incomplete follow-up, resulting in a study population of 121 soluble contrast study was performed before the drain was re- patients. Forty-five of the patients had had previous endo- moved and oral feeding was started the following day. scopic interventions (bougienage, 35; balloon dilation, 10; and/or Manometry was performed with an 8-channel water-per- botulinum toxin injections, 8), and 7 patients had a previous fused catheter. The LES was located by means of the station- myotomy. ary pull-through technique, and the resting LES pressure (LESP), LES relaxation, and esophageal body contractility OUTCOME MEASURES were determined for a minimum of 10 wet swallows. A com- mercial software program (Medtronics, Inc, Stockholm, Swe- Baseline demographics and data on preoperative and postop- den) was used for the interpretation of manometry tracings erative symptoms, upper gastrointestinal tract studies, manom- and data analysis.

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 STATISTICAL ANALYSIS A total of 43 patients underwent postoperative manometry.MeanpostoperativerestingLESPwas14.7±6.6mmHg. The means of all continuous variables were compared by ap- This was significantly (PϽ.001) lower than preoperative propriate parametric or nonparametric tests. Categorical vari- values (Figure 2). All patients had improved apparent ables and proportions were compared with the ␹2 test or the LES relaxation after LHM (average nadir, 90.2%±27.6%; Fisher exact test. Logistic regression modeling was performed interquartile range, 70.1%-108.8%), and/or with a relaxation to identify variables significant for the prediction of a poor out- pressure less than 6 mm Hg. There was, however, no res- come. Factors included in the model were age, sex, weight, se- toration of primary esophageal peristalsis in any patient. verity of preoperative dysphagia (mild to moderate [grade 1 or Preoperative upper gastrointestinal tract studies with 2] vs severe [grade 3 or 4]), amotile vs vigorous achalasia, resting LESP (hypertensive vs normotensive), preoperative endo- contrast were available for 94 patients (77.7%). Of 15 patients who continued to have postoperative dysphagia, scopic interventions, previous myotomy, preoperative esoph- Ͼ ageal dilation, and postoperative resting LESP (Ͼ20 mm Hg 8 (53.4%) had severe (maximum diameter, 5 cm) esoph- vs Յ20 mm Hg). PՅ.05 was considered to be significant. All ageal dilation as compared with 26 (32.9%) of the 79 pa- data are reported as proportions, mean±SD, or median (range). tients who had a favorable outcome. Odds of having preoperative esophageal dilation were 2.3 (95% confidence interval, 0.7-7.1; P=.22) in patients having postopera- RESULTS tive failure as compared with patients with no postoperative dysphagia. Of the 121 patients, 48 (39.7%) were male and 73 (60.3%) Of the 60 patients who had heartburnlike symptoms were female. The mean age of the patients was 46.4±14.1 preoperatively, 19 (31.7%) continued to complain of years; mean weight was 76.9±20.0 kg. Preoperatively, heartburn after surgery (mean score, 2.2±1.0). Twelve 89 patients (73.6%) had severe dysphagia (dysphagia patients (19.7%) demonstrated new-onset reflux symp- score, 3 or 4) and 32 patients (26.4%) had mild or mod- toms after surgery (mean score, 2.0±0.9). A total of 48 erate dysphagia (dysphagia score, 1 or 2). Sixty patients patients had postoperative pH studies; of these, 12 (25.0%) (49.6%) had heartburnlike symptoms preoperatively. The were complaining of reflux symptoms. Of the 73 pa- mean preoperative score for these reflux symptoms was tients who did not undergo postoperative objective test- 2.52±1.00. ing, 18 (24.7%) complained of heartburn (P=.86). Six- All patients included in this study had preoperative teen (33.3%) of the 48 patients having postoperative pH documentation of complete absence of primary peristal- studies demonstrated objective reflux (DeMeester score sis on manometry. In 51 patients who underwent pre- Ͼ14.7). Only 5 (31.2%) of these 16 patients, however, operative manometry outside of our facility, either the had any symptoms of reflux. original tracings were obtained or the physician who per- Results of regression modeling are summarized in formed the study was contacted to ensure the diagnosis Table 2. None of the factors included in the regression of achalasia; otherwise, the study was repeated in our labo- modeling was identified as being a statistically signifi- ratory. Immediate preoperative manometry was per- cant predictor of a poor outcome. However, the odds of formed in our esophageal laboratory in 70 of the 121 pa- failure were higher among patients with severe preop- tients. All manometry and radiographic studies were erative dysphagia, in male patients, in patients with the interpreted by one of us (L.L.S.). The diagnosis of acha- amotile variety of achalasia, and in patients having pre- lasia was based on manometric criteria (completely aperi- operative esophageal dilation. staltic esophageal body and a poorly relaxing LES [Ͻ50% Intraoperatively there were no conversions to open pro- relaxation, or relaxation pressure Ͼ6 mm Hg]) and barium cedures in the series. Mean±SD operative time was 2 hours swallow study findings showing delayed transit and/or 18 minutes±2 hours. Mean blood loss was 65.0±54.5 mL. dilation of the esophageal body. Sixty-five patients (53.7%) Intraoperative and immediate postoperative complica- demonstrated an amotile variety of achalasia. Mean pre- tions are summarized in Table 3. Of the 8 esophageal operative resting LESP was 38.3±23.9 mm Hg and mean mucosal tears that occurred, 7 were identified and re- LES relaxation was 62.9%±28.7%. Sixteen patients paired at the time of surgery and patients had no se- (13.2%) demonstrated nearly normal LES relaxation quelae. In 1 patient an esophageal leak was identified at (Ͼ90%) but had radiographs typical of achalasia and clas- the time of routine postoperative upper gastrointestinal sic symptoms, and 46 (38.0%) had a hypertensive LES tract study. The perforation was successfully repaired tho- (mean resting LESP, 58.6±24.2 mm Hg). racoscopically; however, the patient had an extended hos- After a median postoperative 9-month follow-up pital stay of 3 weeks because of a postoperative myocar- (range, 6-48 months), 102 patients (84.3%; PϽ.001) had dial infarction. An additional patient had a postoperative relief of dysphagia after surgery (dysphagia score, 0 or myocardial infarction and was discharged on postopera- 1), 8 patients (6.6%) demonstrated a 25% to 50% im- tive day 12. Mean hospital stay for the remaining pa- provement in their dysphagia (P=.01), and 11 patients tients was 1.7±1.3 days. One patient (0.8%) in this se- (9.0%) had either no change or a worsening of their dys- ries died on postoperative day 11 of aspiration pneumonia. phagia (Figure 1). Eighteen (94.7%) of 19 patients with postoperative failure had severe preoperative dysphagia, while 71 (69.7%) COMMENT of 102 patients with a favorable outcome had grade 3 or 4 dysphagia before surgery (odds ratio, 11.31; 95% con- Laparoscopic Heller myotomy has become the standard fidence interval, 1.45-88.22; P=.01). surgical treatment for patients with achalasia during the

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0 % Change in Dysphagia Score –25

–50

–75

–100

Figure 1. Improvement in dysphagia score after surgery in individual patients. Positive values represent improvement; negative values demonstrate worsening dysphagia.

Patients who fail to have good outcomes after cardiomy- 10 70 otomy generally have a poor quality of life and may require invasive endoscopic interventions,21 revision of 22 23 60 myotomy, or even esophagectomy to relieve their symptoms. In addition to determining the outcomes of LHM with 270° posterior Toupet fundoplication, one of the pri- 50 mary goals of the present study was to analyze the influence of various preoperative and postoperative factors on 40 outcomes, particularly dysphagia and reflux symptoms. Technical factors such as inadequate myotomy and tight 30 fundoplication are thought to be the most important cause

Mean LESP, mm Hg Mean LESP, of persistent dysphagia after myotomy.24,25 In a review of 20 100 consecutive Heller myotomies without fundoplication, Sharp et al17 reported that an inadequate myotomy, 10 as judged by a residual LESP greater than 18 mm Hg, was associated with a significantly higher incidence of post- 0 operative dysphagia. In the present series, we had 11 pa- Preoperative Postoperative tients with postoperative LESPs greater than 20 mm Hg but less than 30 mm Hg. None of these patients had post- Figure 2. Mean±SD preoperative and postoperative resting lower operative dysphagia. This is most likely because of the in- esophageal sphincter pressure (LESP). teresting phenomenon we noted of an apparent return of receptive relaxation after myotomy. All patients under- past decade. Most patients have good to excellent relief going postoperative manometry and no dysphagia had a of dysphagia with this treatment; however, about 6% to decrease in resting pressure to less than 6 mm Hg in re- 23% of patients may continue to have dysphagia.8,16-20 sponse to an induced swallow. It is not clear whether this

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Adjusted 95% Confidence Predictor Odds Ratio Interval ␤ Coefficient P Value Preoperative dysphagia severity 3.54 0.26-46.82 1.266 .33 Sex 2.90 0.16-51.88 1.065 .46 Preoperative distal esophageal amplitude 2.24 0.23-21.67 0.808 .48 Preoperative esophageal dilation 1.79 0.06-45.41 0.547 .76 Postoperative resting LES pressure 1.18 0.08-17.85 0.230 .86 Weight 1.00 0.96-1.03 0.002 .93 Age 0.99 0.92-1.06 −0.007 .86 Preoperative hypertensive LES 0.72 0.06-7.60 −0.325 .78 Preoperative endoscopic intervention 0.65 0.21-2.05 −0.419 .47 Previous myotomy 0.25 0.20-3.32 −1.36 .29

Abbreviation: LES, lower esophageal sphincter.

response is a true neurologically mediated one or merely a physiologic reaction to the presence of a swallowed bo- Table 3. Intraoperative and In-Hospital Complications* lus. Regardless, this basal pressure may be a very important factor in minimizing postoperative dysphagia. One pa- No. of Complication Patients Comment tient did have a high postoperative LESP of 33.4 mm Hg and also had grade 2 dysphagia. Intraoperative 7 All identified and repaired during 16 esophageal surgery with no sequelae; Among the various preoperative factors, LESP and mucosal tears 2 in reoperative cases, 26,27 esophageal dilation have been shown to have some 2 in patients with previous correlation with postoperative outcomes. Arain et al16 re- endoscopic treatments ported that a higher preoperative resting LESP was a strong Intraoperative gastric 2 Both identified and repaired predictor of resolution of dysphagia; however, in an- serosal tears during surgery with no sequelae other study, preoperative LESP was not found to have Blood loss Ͼ300 mL 2 One had liver retraction injury; 28 any influence on outcomes. Our data seem to support other was reoperative case the findings of the latter study, as results of both uni- Postoperative gastric 1 None variate and multiple regression modeling did not find in- leak creased odds of failure for patients having normoten- Postoperative 1 Also had myocardial infarction esophageal leak after repair of esophageal leak sive preoperative LES. We did find higher odds of failure Cardiac complications 2 None in patients with marked preoperative dilation of the Aspiration pneumonia 1 Died of aspiration pneumonia on esophagus; however, it was not statistically significant. postoperative day 11 In the present study we also analyzed the influence Urinary retention 1 None of several other important preoperative factors, includ- Cellulitis around 1 None ing the severity of dysphagia, amotile vs vigorous forms trocar site of achalasia, a history of endoscopic intervention, and pre- *There were 18 complications in 15 patients (12%). vious myotomy. Univariate analysis of these factors showed that severe preoperative dysphagia is the only factor that is significantly associated with poor outcomes patients are also urged to return for a pH and motility (odds ratio, 11.3; P=.01). Patients with preoperative study at no charge as part of routine follow-up. Patients esophageal dilation, previous myotomy, or endoscopic with normal study results are asked to return if they de- intervention had marginally higher odds of failure after velop recurrent symptoms or heartburn. Patients with ab- surgery. When adjustment for confounding variables was normal study results are seen more regularly, and 5 pa- performed by multiple logistic regression, none of the fac- tients in this series eventually had revision of their surgery tors included in our model was found to be a statisti- during follow-up. It has been our experience that the vast cally significant predictor of poor outcome. The odds of majority of failures are apparent at 1 year, and, after a failure were still greatest among patients with severe pre- year, it is almost impossible to get asymptomatic pa- operative dysphagia and those with the amotile variety tients back for studies. of achalasia (Table 2). Interestingly, the predictors male The need for an antireflux procedure after myotomy patients and a postoperative LESP greater than 20 mm Hg remains one of the most controversial issues surround- were found to have marginally increased odds of poor ing LHM. It is widely accepted that a complete 360° wrap outcome. should not be used in achalasia, but even the use of a par- A possible criticism of the current report is the rela- tial wrap is controversial. Opponents of using an antire- tive shortness of the follow-up (9 months). Our routine flux procedure argue that a good postoperative LESP (14 follow-up includes office visits at 1 to 2 weeks, 6 weeks mm Hg) with low incidence of reflux symptoms can be (if indicated), and 6 months. Symptom assessment forms achieved without partial fundoplication by avoiding ex- are completed at each visit. Between 6 months and 1 year, cessive posterior dissection and any closure of the crura.17

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Such techniques, however, need careful long-term evalu- no medication for dysphagia, and progressive dyspha- ation for potential paraesophageal herniation or other gia and esophageal dilation often culminate in esopha- problems. gectomy. Patients with severe preoperative dysphagia, In our series, the mean postoperative resting LESP of the amotile variety of achalasia, and severe esophageal 14.7 mm Hg (Figure 2) was similar to that observed by dilation should be warned that there may be a greater previous authors. Only a small proportion (20.1%) of pa- likelihood of a poor outcome. tients had postoperative LESPs greater than 20 mm Hg, and this did not increase the chances of a poor outcome. Our observations suggest that a modest postoperative Accepted for Publication: May 19, 2005. LESP can be achieved by performing a carefully fash- Correspondence: Lee L. Swanström, MD, 1040 NW 22nd ioned Toupet repair in combination with an adequate ex- Ave, Suite 560, Portland, OR 97210 (lswanstrom@aol tension of the myotomy onto the anterior gastric wall, .com). and that this also achieves a secure closure of the hiatus. Previous Presentation: This paper was presented at the Most important, it does not lead to an increased barrier 76th Annual Meeting of the Pacific Coast Surgical Asso- to the passage of food. Oelschlager et al18 also demon- ciation; February 19, 2005; Dana Point, Calif; and is pub- strated that, with adequate extension of the myotomy onto lished after peer review and revision. The discussions that the gastric cardia and with a Toupet fundoplication, a low follow this article are based on the originally submitted LESP can be achieved without increasing the incidence manuscript and not the revised manuscript. of postoperative reflux. The postoperative rate of reflux detected by pH test- REFERENCES ing was 33.3% in our study, which is somewhat higher than is frequently reported by other authors. This may 1. Spechler SJ, Castell DO. Classification of oesophageal motility abnormalities. Gut. be owing to our aggressive myotomy technique or an ar- 2001;49:145-151. 2. Achkar E. Achalasia. Gastroenterologist. 1995;3:273-288. tifact from the aggressive use of postoperative pH stud- 3. Csendes A, Braghetto I, Mascaro J, Henriquez A. Late subjective and objective ies. We advocate postoperative pH studies for all pa- evaluation of the results of esophagomyotomy in 100 patients with achalasia of tients with achalasia irrespective of their symptom status. the esophagus. Surgery. 1988;104:469-475. If a patient is found to have significant acid reflux after 4. Parrilla P, Martinez de Haro LF, Ortiz A, Morales G, Garay V, Aguilar J. Factors achalasia surgery, we prescribe acid suppression therapy involved in the return of peristalsis in patients with achalasia of the cardia after Heller’s myotomy. Am J Gastroenterol. 1995;90:713-717. regardless of whether the patient has heartburn symp- 5. Okike N, Payne WS, Neufeld DM, Bernatz PE, Pairolero PC, Sanderson DR. toms. We do this in the hope of preventing recurrent dys- Esophagomyotomy versus forceful dilatation for achalasia of the oesophagus: phagia secondary to peptic stricture. In the current study, results in 899 patients. Ann Thorac Surg. 1979;28:119-125. one might suspect that more patients would follow 6. Csendes A, Valasco N, Braghetto I, Henriquez A. A prospective randomized study comparing forceful dilatation and esophagomyotomy in patients with achalasia through with postoperative testing if they were having of the esophagus. Gastroenterology. 1981;80:789-795. problems, which might negatively bias our results. How- 7. Csendes A, Braghetto I, Henriquez A, Cortes C. Late results of a prospective ran- ever, the proportions of symptomatic patients among those domized study comparing forceful dilatation and oesophagomyotomy in pa- undertaking pH studies and those who did not undergo tients with achalasia. Gut. 1989;30:299-304. postoperative pH studies were the same (25%). This would 8. Ali A, Pellegrini CA. Laparoscopic myotomy: technique and efficacy in treating achalasia. Gastrointest Endosc Clin N Am. 2001;11:347-358. seem to reduce any sampling bias with regard to pH out- 9. Karamanolis G, Sgorous S, Karatzias G, et al. Long-term outcome of pneumatic come. We showed as well that postoperative symptoms dilatation in the treatment of achalasia. Am J Gastroenterol. 2005;100:270- are an unreliable indicator of objective reflux, as only 274. 6 of the 12 patients who developed new-onset reflux 10. Meshkinpour H, Haghighat P, Meshkinpour A. Quality of life among patients treated for achalasia. Dig Dis Sci. 1996;41:352-356. symptoms had an abnormal pH study. On the basis of 11. Parkman HP, Reynolds JC, Ouyang A, Rosato EF, Eisenberg JM, Cohen S. Pneu- these data and our previous experience with the poor cor- matic dilatation or esophagomyotomy treatment for idiopathic achalasia: clini- relation between postoperative symptoms and objective cal outcomes and cost analysis. Dig Dis Sci. 1993;38:75-85. reflux in patients with gastroesophageal reflux dis- 12. Abid S, Champion G, Richter JE, McElvein R, Slaughter RL, Koehler RE. Treat- ease,21 we believe that routine 24-hour pH monitoring ment of achalasia: the best of both worlds. Am J Gastroenterol. 1994;89:979- 985. is optimally performed to detect reflux in all patients un- 13. Dobrucali A, Erzin Y, Tuncer M, Dirican A. Long-term results of graded pneu- dergoing Heller myotomy. Similar observations have been matic dilatation under endoscopic guidance in patients with primary esophageal made by other authors.29 achalasia. World J Gastroenterol. 2004;10:3322-3327. 14. Shimi S, Nathanson LK, Cuschieri A. Laparoscopic cardiomyotomy for achalasia. J R Coll Surg Edinb. 1991;36:152-154. CONCLUSIONS 15. Douard R, Gaudric M, Chaussade S, Couturier D, Houssin D, Dousset B. Func- tional results after laparoscopic Heller myotomy for achalasia: a comparative study to open surgery. Surgery. 2004;136:16-24. Our results indicate that in most patients with achala- 16. Arain MA, Peters JH, Tamhankar AP, et al. Preoperative lower esophageal sphinc- sia, LHM with 270° posterior Toupet fundoplication pro- ter pressure affects outcome of laparoscopic esophageal myotomy for achalasia. J Gastrointest Surg. 2004;8:328-334. vides excellent relief of dysphagia with low intraopera- 17. Sharp KW, Khaitan L, Scholz S, Holzman MD, Richard WO. 100 consecutive mini- tive and perioperative morbidity and mortality. mally invasive Heller myotomies: lessons learned. Ann Surg. 2002;235:631- Postoperative reflux remains a problem in 33.3% of pa- 639. tients, and these patients should be closely monitored for 18. Oelschlager BK, Chang L, Pellegrini CA. Improved outcomes after extended gastric myotomy for achalasia. Arch Surg. 2003;138:490-497. esophageal mucosal damage and should probably be 19. Patti MG, Fisichella PM, Galvani C, Gorodner MV, Robinson T, Way LW. Impact treated with antipeptic medications. Nonetheless, we pre- of minimally invasive surgery on the treatment of esophageal achalasia: a de- fer good dysphagia relief to low reflux rates, as there is cade of change. J Am Coll Surg. 2003;196:698-705.

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 20. Finley RJ, Clifton JC, Stewart KC, Graham AJ, Worsley DF. Laparoscopic Heller ment. As we tried that, we have seen that very rarely do we have myotomy improves esophageal emptying and the symptoms of achalasia. Arch to go to an esophagectomy in a patient with a sigmoid esopha- Surg. 2001;136:892-896. gus. So are you suggesting that we review or revise this strategy? 21. Annese V, Basciani M, Lombardi G. Perendoscopic injection of botulinum toxin is effective in achalasia after failure of myotomy or pneumatic dilatation. Gas- You had a number of perforations, and I was surprised that trointest Endosc. 1996;44:461-465. those patients were repaired and had a Toupet fundoplication. 22. Kiss J, Voros A, Sziranyi E, Altorjay A, Bohak A. Management of failed Heller’s Our advice has been that when there is a perforation, that it be operations. Surg Today. 1996;26:541-545. repaired laparoscopically and that a Dor fundoplication be done 23. Miller DL, Allen MS, Traste VF, Deschamps C, Pairolero PC. Esophageal resec- to buttress the closure with gastric wall. I noted that you had tion for recurrent achalasia. Ann Thorac Surg. 1995;60:922-925. 2 postoperative leaks, and I am wondering if you could give the 24. Zaninotto G, Costantino M, Portale G, et al. Etiology, diagnosis, and treatment of audience advice with regard to how to treat the perforation and failures after laparoscopic Heller myotomy for achalasia. Ann Surg. 2002;235: whether to use a Toupet or a Dor? Finally, could you tell us what 186-192. is the role of the Dor procedure in the treatment of achalasia? 25. Ellis FH Jr. Failure after esophagomyotomy for esophageal motor disorders: causes, prevention and management. Chest Surg Clin N Am. 1997;7:477-488. Marco G. Patti, MD, San Francisco, Calif: Congratula- 26. Pechlivanides G, Chrysos E, Athanasakis E, Tsiaoussis J, Vassilakis JS, Xynos tions on an excellent study. I echo Dr Pellegrini’s comments. E. Laparoscopic Heller cardiomyotomy and Dor fundoplication for esophageal I would like it if the authors could comment on the 7 patients achalasia. Arch Surg. 2001;136:1240-1243. with a failed myotomy. Specifically, I have 2 questions: (1) what 27. Mineo TC, Pompeo E. Long-term outcome of Heller myotomy in achalasic sig- do they think was the cause of the failed myotomy; and (2) do moid esophagus. J Thorac Cardiovasc Surg. 2004;128:402-407. they have any tips on how to approach these patients? 28. Gorodner MV, Galvani C, Fisichella PM, Patti MG. Preoperative lower esopha- C. Daniel Smith, MD, Atlanta, Ga: As a guest physician, geal sphincter pressure has little influence on the outcome of laparoscopic Heller thank you for the opportunity to ask the authors a question. myotomy for achalasia. Surg Endosc. 2004;18:774-778. 29. Patti MG, Arcerto M, Tong J, et al. Importance of preoperative and postopera- Along the same lines of the dilated esophagus, I wonder if Dr tive pH monitoring in patients with esophageal achalasia. J Gastrointest Surg. Swanström could comment whether they have data on dura- 1997;1:505-510. tion of symptoms. In our series of a little over 200 patients, an- ecdotally those patients who have had severe dysphagia for longer periods of time seem to not do quite as well. It may also DISCUSSION relate to the dilation question. My second question has to do with your reflux rate. As I Carlos A. Pellegrini, MD, Seattle, Wash: What the authors have understood it, 30% of patients who are objectively assessed had shown today is that in a selective group of patients with acha- reflux and, of those, 30% were asymptomatic. My question would lasia, Heller myotomy when combined with a Toupet fundo- be, are you doing anything differently with your patients in terms plication completely reverses dysphagia in 85% of the patients of PPI [proton pump inhibitor] therapy, especially in the asymp- and alleviates it in an additional 8%. They have also shown that, tomatic patient, particularly since more and more of these pain those who underwent postoperative studies (about one third tients are young and there is a little bit of concern about asymp- of the population), the operation reduced the lower esopha- tomatic reflux. Finally, a couple of patients had over 90% LES geal sphincter (LES) pressure to approximately 15 mm Hg and relaxation. Tell us a little bit more about this because by clas- that abnormal reflux occurs in 30% of those individuals. Fur- sic criteria, that would not fall into achalasia. With that degree thermore, they suggested (although I don’t think the numbers of relaxation and any degree of peristalsis, how would you de- prove it) that among those patients who have severe dyspha- cide in that case to go ahead and do a myotomy? gia or a dilated esophagus preoperatively, the outcome of the Dr Swanström: Thank you, Mr President. I would very much operation tends to be worse than among those who don’t have like to thank the Association for the privilege of presenting our those features preoperatively. work. I have to also thank Yash Khajanchee, who has worked We have performed this operation in a manner similar to with me for several years and has really been a trailblazer in that reported, except that we prefer to extend our myotomy fur- understanding this very interesting disease. He’s done a great ther into the stomach, which presumably accounts for our lower job, as you can all see from this presentation. LES pressure postoperatively. Using the Toupet procedure we Dr Pellegrini, thanks so much for your comments; you are have seen the same incidence of abnormal reflux but have noted the ideal discussant and certainly somebody whom we all look that this reflux is rarely symptomatic. Unlike the authors, how- to as a leader in minimally invasive treatments of achalasia. You ever, we have not been able to achieve complete relief of dys- asked us about the complete relief of dysphagia, and as we all phagia in 85% of the patients long-term. Unlike the authors, know from our experience in antireflux surgery, the answer al- we have not noticed a difference among the patients with di- ways depends on how you ask the patient and what you are lated and nondilated esophagi. Our different results may be ac- asking. We use a numeric scoring system for dysphagia. For counted in part by the follow-up period, which is longer in our this study, any patient who scored grade 1 or 0 we put down series. I noted with surprise that your follow-up is only 9 months. as “complete relief” of dysphagia because we have found when Why is this the case? You included patients operated on over establishing our “norms” for this that many asymptomatic vol- an 8-year period and excluded those who had less than 6 months’ unteers will say on occasion that they have some dysphagia. follow-up. If all patients were followed to date, your average Since achalasia patients will remain without motility after sur- follow-up should be longer. Could you comment on that? And gery, it would be very rare to find one who didn’t on rare oc- could you tell us if you have looked separately, perhaps, at the casions have some dysphagia. I ascribe our good results to a subgroup that has had a 5-year or longer follow-up, and, if so, very aggressive approach with our myotomies, extending them do you still see an 85% complete relief of dysphagia? well onto the stomach, as you have advocated, and always mak- With respect to the dilated esophagus, could you tell us how ing a point of aggressively separating the fibers, peeling the my- you define it? Are you including or excluding patients with the otomized walls back a long way to really open up the distal sigmoid shape, which are the most difficult to treat since their esophagus, and perhaps that partly explains our low dyspha- esophagi can’t empty quite easily? And, now that you know these gia rates. patients may not respond as well, would you recommend some- A question about the 9-month follow-up in what is essen- thing different for them? tially a 14-year experience: we did exclude patients from our We recommend a myotomy for all patients with achalasia, in- early experience, 1996 and earlier. At that time we used a dif- cluding those with a sigmoid esophagus, as a first line of treat- ferent symptom-scoring tool and probably were in our learn-

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 ing curve as well. The shorter follow-up is also due to our de- creation of the angle of His. Results for reoperative myotomies sire to correlate our objective data, which we routinely obtain are not great. There is a 50% success rate, at the most. We don’t between 6 and 12 months, with symptoms. We do have late try a third myotomy. We would instead proceed to a vagal- outcomes data, which is symptomatic only. The objective data sparing laparoscopic esophagectomy in that group. that we have more than a year out is for patients who are fail- Dr Smith, it is great to see you, although you are a long way ing and who come back years later and are retested. from home. Duration of symptoms: no, we didn’t specifically There was a question about the dilated esophagus. We used look at that. Achalasia patients come with so many odd symp- a simple measurement of the maximum diameter and didn’t toms. Some of them present with chest pain; a lot of them pre- really look at sigmoidization as there is no real way to quantify sent as reflux patients. Because it was difficult to pinpoint, we it. Anything less than 5 cm we called minimal dilation; any- didn’t record duration of symptoms. We use, and I think it is a thing over 5 cm we listed as a large degree of dilation; and fair surrogate, dilation of the esophagus as an indicator of dis- I think our results support the intuitive sense that greater di- ease progression, and perhaps our results also support the pro- lation represents more end-stage organ failure and therefore gression of achalasia from vigorous (early) to amotile (late); worse outcomes. a long-standing theory. You question the use of the Toupet with perforations. You Our 30% reflux rate: I think that it is a little bit higher than are correct to assume that many of the Dor repairs that were most in the literature. I think we are very aggressive, once again, excluded from this study group were done to reinforce muco- at relieving dysphagia and will not compromise that in an ef- sal perforations. On the other hand, I have not found a small fort to stop reflux. I think some more recent data have shown plastic closure of the mucosa to be especially threatening; in reflux rates much higher if you don’t do a fundoplication, up this series, none of the patients with postoperative problems to 60%, so I think we are doing something to control it. You were those who had a repaired mucosal perforation. If I feel also refer to the growing awareness, supported again by our data, that the Toupet repair is a better “fit” for a patient, I will sim- that patients who complain of heartburn symptoms after sur- ply do a nice repair, perhaps place some fibrin glue on it, and gery most often don’t have reflux as measured by 24-hour pH watch the patient closely. testing. Should we then put all patients on PPIs after surgery? How about the role of the Dor? I personally favor the Tou- It’s a valid question because recurrent dysphagia following treat- pet, mostly because it holds the myotomy open. Once again, ment because of peptic stricture is almost an automatic esoph- our philosophy is to attempt to minimize dysphagia. I am not agectomy. Perhaps we should be treating all postoperative acha- that concerned about reflux. Almost everyone in the world is lasia patients with prophylactic medications. on Prilosec or Nexium anyway. Our goal is a more aggressive Then, finally, you made a comment on the traditional defi- opening of the lower esophageal sphincter and a little better nition of achalasia as an amotile esophagus. I think we all agree antireflux repair, and I feel that the Toupet achieves this. That with this as the key criteria. Of course, the definition used to being said, for the last 2½ years we have been involved with a also require a hypertensive LES and then a nonrelaxing LES. randomized prospective study comparing the Dor and Toupet Dr Patti has produced data from his Swallowing Center that repairs, and those patients, of course, were excluded from this the LES criteria is no longer necessary, finding as we did that study as well. the LES can be hypertensive, normotensive, or even hypoten- Dr Patti, thank you very much for your comments. Failed sive. It can also show a wide spectrum of relaxation, ranging myotomies are a fascinating clinical puzzle. What do you do from no relaxation to complete. When we looked very care- with these unfortunate patients? It’s a tough problem, espe- fully, however, at that group of patients with normal LES pres- cially patients who actually get worse with a myotomy, of which sures and what appeared to be relaxation, we noted that the we had 2 in this series. It’s been our philosophy to go ahead relaxation often is transient or poorly timed, and I believe Dr and try a second myotomy, 180° from the first, and to take down Patti has found the same thing. I believe that the actual 2005 the fundoplication. I strongly advise not adding another fun- definition of achalasia is an aperistaltic esophagus that is pro- doplication on these patients or, at most, adding a little 90° re- gressively dilating.

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