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Laparoscopic Heller Cardiomyotomy and Dor Fundoplication for Esophageal Achalasia Possible Factors Predicting Outcome

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Laparoscopic Heller Cardiomyotomy and Dor Fundoplication for Esophageal Achalasia Possible Factors Predicting Outcome ORIGINAL ARTICLE Laparoscopic Heller Cardiomyotomy and Dor Fundoplication for Esophageal Achalasia Possible Factors Predicting Outcome George Pechlivanides, MD, PhD; Emmanuel Chrysos, MD, PhD; Elias Athanasakis, MD; John Tsiaoussis, MD, PhD; John Sophocles Vassilakis, MD, PhD; Evaghelos Xynos, MD, PhD, FACS Hypothesis: Laparoscopic Heller myotomy with ante- stage II, 12 had stage III, and 4 had stage IV at preop- rior hemifundoplication is the surgical procedure of choice erative radiologic examination. At surgery, there were for the treatment of esophageal achalasia. Specific fac- no conversions to open procedures, and 2 mucosal per- tors, eg, severity of esophageal body deformity, might forations were immediately identified and sutured. affect postoperative outcome. Good or excellent results were seen in 26 patients. All patients with stage I or II disease had excellent func- Design: Prospective case-control study. tional results. Of patients with stage III disease, results were excellent in 7, good in 4, and bad in 1. Of patients Setting: Academic referral center for gastrointestinal tract with stage IV disease, 2 had good results and 2 had bad motility disorders. results. After surgery, lower esophageal sphincter pres- sure was reduced significantly (from 46.1±12.1 to Patients: Twenty-nine patients with esophageal acha- 5.4±1.8 mm Hg; PϽ.001), as was esophageal diameter lasia who underwent 1 to 3 sessions of failed pneumatic (from 61±17 to 35±19 mm; PϽ.001) (data are given as dilation each. mean±SD). However, an excellent result occurred only in patients with a postoperative esophageal diameter Intervention: Laparoscopic Heller myotomy with an- less than 40 mm. terior (Dor) hemifundoplication. Conclusion: Functional outcome of laparoscopic Heller- Main Outcome Measures: Preoperative and postop- Dor procedure for achalasia is related to the preopera- erative symptomatic evaluation, esophagoscopy, esopha- tive stage of the disease on the esophagogram and to the gography, stationary and ambulatory esophageal ma- extent of reduction in esophageal width after surgery. nometry, and pH monitoring. Results: Three patients had stage I disease, 10 had Arch Surg. 2001;136:1240-1243 HEN pneumatic dila- scopic approach is associated with signifi- tion of the lower cantly less blood loss, parenteral narcotic esophageal sphinc- use, hospitalization time, and time off ter (LES) is contra- work.7,8 However, little has been reported indicated or poor re- about any predictors of outcome after sur- Wsults are anticipated or the procedure fails gery. It has been suggested that a signifi- to relieve the patient’s symptoms, surgery cant reduction in esophageal body diam- should be considered for the treatment of eter on an esophagogram after surgery is esophageal achalasia.1-4 Transabdominal car- associated with good postoperative func- diomyotomy, first described by Heller in tional results, whereas the patient with a 1914,5 offers satisfactory results in approxi- dilated and tortuous esophagus is un- mately 95% of patients with achalasia.6 likely to respond to cardiomyotomy.9 More recently, minimally invasive In the present study, we analyzed esophagomyotomy by laparoscopy is re- data from 29 patients who underwent placing open surgery for achalasia, but data laparoscopic Heller myotomy and ante- comparing these 2 different approaches are rior hemifundoplication for achalasia and From the Laboratory of 7 Gastrointestinal Motility and sparse. Data from small series show simi- who completed 1-year follow-up. Empha- the Department of General lar results concerning relief of dysphagia sis was given to documentation of the Surgery, University Hospital of and satisfaction of the patient with the out- results and to definition of any predictors Heraklion, Crete, Greece. come after either approach. The laparo- of outcome. (REPRINTED) ARCH SURG/ VOL 136, NOV 2001 WWW.ARCHSURG.COM 1240 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 PATIENTS AND METHODS instilling 50 mL of diluted methylene blue through a nasal tube into the esophageal lumen. The operation was com- pleted with an anterior hemifundoplication of the Dor type, Between January 1, 1995, and June 30, 1998, 29 patients un- which was accomplished by suturing the anterior gastric fun- derwent laparoscopic treatment for esophageal achalasia. Pre- dus first to the left cut edge of the myotomy and the left pil- operative workup included clinical assessment, esophagog- lar of the crus and then to the right cut edge of the my- raphy, upper alimentary endoscopy, esophageal manometry, otomy and the right pillar of the crus.12 24-hour ambulatory esophageal manometry, and pH moni- The nasogastric tube was left in place for 24 to 48 hours toring. Severity of dysphagia, regurgitation, and heartburn was and was removed after a meglumine diatrizoate (Gastro- assessed separately according to a scoring system similar to grafin) swallow showed easy passage through the lumen of that described by Johnson and DeMeester10 (0 indicates ab- the gastroesophageal junction and no leaks. A liquid diet was sence; 1, occasional episodes; 2, frequent episodes; and 3, daily then resumed. On the second postoperative day and con- episodes). On the esophagogram, the diameter of the esopha- tinuing for 6 to 8 weeks, a soft diet was recommended. Un- gus 8 cm proximal to the gastroesophageal junction was mea- less other complications occurred, patients were discharged sured and the disease was graded as follows: stage I, diameter from the hospital on the second to third postoperative day. less than 40 mm; stage II, diameter of 40 to 60 mm; stage III, diameter greater than 60 mm; and stage IV, diameter of any POSTOPERATIVE ASSESSMENT size with sigmoid configuration of the distal esophagus. Am- bulatory esophageal manometric and pH monitoring data were Patients were clinically assessed 2 weeks, 3 months, and 1 assessed according to standard definitions.11 year after surgery. Clinical outcome was classified as ex- cellent (symptomatic score of 0-1), good/satisfactory (symp- OPERATIVE TECHNIQUE AND tomatic score of 2-4), or bad (symptomatic score of Ն5). POSTOPERATIVE MANAGEMENT Nine months to 1 year after surgery, all patients under- went esophagography, standard stationary manometry, and Dissection was limited to the anterior aspect of the abdomi- 24-hour ambulatory esophageal pH monitoring. nal esophagus and the diaphragmatic crura. The anterior va- gal trunk was dissected and preserved, as was the hepatic STATISTICAL ANALYSIS branch of the anterior vagus. After dissecting and excising the fatty pad of the gastroesophageal junction, the my- Unless otherwise stated, all values are expressed as otomy was started from the junction and was extended proxi- mean±SD. Comparisons between preoperative and post- mally on the esophagus up to 5 cm by dividing the circular operative values of the various variables were made by ap- muscular layer and distally on the stomach up to 1.0 to 1.5 plying the Mann-Whitney test for paired values and the ␹2 cm by dividing the oblique muscular fibers. Division of the test with the Yates correction, as appropriate. Regression muscular fibers was achieved using a hook device and mini- analysis was also used to identify any correlation between mal electrocautery. The cut muscular edges were dissected the preoperative stage of the disease and the clinical and laterally to fully expose the anterior aspect of the submu- laboratory outcomes after surgery. PϽ.05 was considered cosa. The integrity of the submucosal layer was tested by statistically significant. RESULTS incomplete in 6. At standard esophageal manometry, esophageal peristalsis was absent in all patients. Ambu- PREOPERATIVE ASSESSMENT latory manometry showed aperistalsis in 26 patients, failed peristalsis in 2, and dropped peristalsis in 1. An abnor- There were 12 men and 17 women aged 47.5±18.9 years mal DeMeester score (51±22) on esophageal pH moni- (range, 18-74 years). Duration of symptoms was 5.2±4.5 toring was found in 9 patients, 7 of whom reported heart- years (range, 1-19 years). Twelve patients underwent 1 ses- burn. In these 9 patients, the pattern of reflux was sion, 10 underwent 2 sessions, and 4 underwent 3 ses- characterized by a few long-duration reflux episodes (total sions of LES pneumatic dilation before surgery, with tem- reflux time, 18%±7%), with a pH just less than 4. porary or no relief of dysphagia. In only 3 patients with stage IV disease on esophagography (dilated sigmoid shape OPERATIVE AND POSTOPERATIVE COURSE of the distal esophagus) was pneumatic dilation not at- tempted immediately before surgery, although they had Operative time was 73±18 minutes (range, 45-105 1 to 2 attempts at earlier stages of disease. All patients had minutes). Blood loss was minimal. The location of the constant dysphagia and regurgitation. Twelve patients re- gastroesophageal junction with use of the endoscope as ported weight loss, 10 experienced recurrent respiratory the Z-line was usually 0.5 to 1.0 cm more proximal than tract symptoms, and 7 had heartburn. Two young pa- that found using the laparoscope as the proximal border tients reported spontaneous or postdeglutition chest pain. of the oblique muscle fibers of the stomach. In most According to the preoperative esophagogram, pa- patients, there was considerable difficulty in detaching tients were classified as follows: stage I, 3 patients; stage the cut edges of the circular muscle fibers away from the II, 10; stage III, 12; and stage IV, 4. Mean esophageal di- underlying esophageal submucosa. Two intraoperative ameter was 61±17 mm. Mean LES pressure was mucosal perforations occurred, both at the level of the 46.1±12.1 mm Hg (range, 29-69 mm Hg). Lower esoph- gastroesophageal junction: one using the transesopha- ageal sphincter relaxation was absent in 23 patients and geal endoscope and the other using the hook device dur- (REPRINTED) ARCH SURG/ VOL 136, NOV 2001 WWW.ARCHSURG.COM 1241 ©2001 American Medical Association. All rights reserved.
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