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 pressure 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- sultsW 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.

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©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 completed 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 excellent (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 underwent 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-

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 otomy. That particular patient had had esophageal pneu- Clinical Presentation and Radiological, Manometric, matic dilation on 3 occasions before surgery. and Esophageal pH Monitoring Findings Before and After Myotomy and Anterior Hemifundoplication* LONG-TERM FOLLOW-UP Before After Surgery Surgery P Value At 1-year follow-up, excellent or good results were reported by 26 patients (90%). Twenty-one patients (72%) reported Clinical presentation Dysphagia scoring 2.62 ± 0.49 0.48 ± 0.91 Ͻ.001 total relief of dysphagia and absence of regurgitation events Regurgitation scoring 2.52 ± 0.78 0.41 ± 0.78 Ͻ.001 (score of 0 for both symptoms in all patients), and another Esophageal diameter, mm 61 ± 17 35 ± 19 Ͻ.001 5 patients (17%) were satisfied with the final outcome, re- Lower esophageal sphincter 46.1 ± 12.1 5.4 ± 1.8 Ͻ.001 porting considerable improvement of dysphagia (a score resting pressure, mm Hg of 1 in 4 patients and a score of 2 in 1 patient) and occa- Esophageal pH monitoring, 25±21 16±11 .02 sional episodes of regurgitation (a score of 1 in all patients). DeMeester score The remaining 3 patients (10%) did not show any improve- *Data are given as mean ± SD. ment in dysphagia (a score of 2 in 1 patient and a score of 3 in 2 patients) and complained of frequent episodes of

100 regurgitation (a score of 2 in 2 patients and a score of 3 in 1 patient). In addition, 3 patients had severe heartburn (a score of 2 in 1 patient and a score of 3 in 2 patients), and they all had stage IV disease at preoperative classification. All patients with stage I or II disease at preoperative as- 80 Stage III sessment reported excellent results. Of 12 patients with stage III disease, 7 had excellent results, 4 had good results, and 1 reported a bad outcome. Of 4 patients with stage IV disease, the procedure failed to relieve the symptoms in 2 60 and the remaining 2 showed improvement but not complete dissolution of dysphagia. Conceivably, postoperative

Stage II outcome was significantly related to the preoperative radiologic stage of the disease (r=0.66; PϽ.001). An advanced radiologic stage at preoperative assessment was usually as- 40 sociated with a nonsatisfactory clinical outcome.

Diameter of Distal Esophagus, mm The esophagogram showed a significant overall decrease in the diameter of the lower esophagus after myotomy (Table and Figure). However, an excellent result 20 Stage I (total relief of symptoms) occurred only when the postoperative esophageal diameter was less than 40 mm. Fur- thermore, the 5 patients with fair or satisfactory clinical outcomes had a significantly narrower esophagus after surgery

0 than did the 3 patients with bad outcomes (P=.03). Before Surgery After Surgery The increased preoperative LES pressure was low- After myotomy, there was an overall decrease in esophageal width. Patients ered significantly after myotomy (Table). The fact that with postoperative esophageal diameters of less than 40 mm had excellent postoperative LES resting pressure decreased invariably functional results. The 8 patients with postoperative esophageal diameters of below 10 mm Hg signified a complete myotomy. There greater than 40 mm had either partial symptomatic improvement (n=5) or was no correlation between preoperative LES pressure no improvement at all (n=3). or the extent of the postoperative decline in LES pressure and the clinical results. Ambulatory esophageal ma- ing division of the muscle fibers. These perforations nometry did not reveal evidence of even partial restora- were repaired using 4-0 absorbable stitches. There were tion of esophageal peristalsis in any patient. no conversions to open surgery. There was an overall significant decrease in No leaks were evident on the immediate postopera- DeMeester reflux scores to almost normal levels (Table). tive esophagogram, and the nasogastric tube was re- In particular, reflux scores were overall significantly de- moved and an oral diet was resumed by all patients. Four creased in the 9 patients with increased preoperative re- patients developed atelectasis that was promptly resolved flux (DeMeester score, 26±21; P=.01, and total reflux time with chest physiotherapy and antibiotic treatment. Post- of pH Ͻ4, 10%±10%; P=.03), However, 2 of these 9 pa- operative hospital stay was 2.2±0.9 days (range, 1-8 days). tients continued to present with abnormal scores after sur- The third patient in succession in the series was readmit- gery. Only 1 patient without reflux before surgery showed ted because of epigastric pain on the fifth postoperative day. abnormally increased reflux scores after surgery. He developed an esophageal leak and a small collection of fluid below the left hepatic lobe that was treated with per- COMMENT cutaneous drainage. He was discharged from the hospital 6 days later. The late leak was attributed to desloughing of Although the number of series reported in the literature an esophageal mucosal burn at the upper site of my- and the overall number of patients included is rather small,

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©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 laparoscopic surgery for esophageal achalasia offers sat- esophageal acidity, as detected on pH monitoring, is dif- isfactory functional results with minimal morbidity and ferent in the case of true esophageal reflux than in that almost no mortality.2-4,7-9,12,13 In a large series by Patti et caused by delayed esophageal emptying. In the latter case, al,14 100 of 112 patients who underwent laparoscopic there is usually a constant decrease in esophageal pH to Heller myotomy and partial fundoplication had good or just less than 4. In the former case, sharp declines to pH excellent results. At postoperative functional evaluation less than 2 are observed. in 35 of those patients, reflux was present in 17%, and In conclusion, laparoscopic Heller myotomy with Dor the mean LES pressure decreased from 28 mm Hg be- fundoplication is effective in relieving dysphagia in most fore surgery to 10 mm Hg after surgery. In even the most patients with achalasia, preventing simultaneous gastro- recent series by Yamamura et al,15 85% to 90% of pa- esophageal reflux. A good postoperative result is ex- tients who underwent laparoscopic Heller myotomy and pected when the length of myotomy is adequate, LES pres- anterior fundoplication for achalasia were relieved of dys- sure declines substantially, preoperative esophageal dilation phagia, but laboratory documentation is insufficient. is not excessive, and distortion of the distal esophagus is In the present series, in which 4 patients had stage IV absent. Patients with stage IV disease can be treated with disease on the preoperative esophagogram, excellent or good myotomy provided that the postoperative width of the results were obtained in 26 patients with laparoscopic my- esophagus decreases to less than 40 mm. Increased esoph- otomy at 1-year follow-up. These results are similar to those ageal acidity and heartburn in patients after myotomy is reported by other researchers,3,4,7-9,13 although patients with attributed to delayed esophageal emptying. stage IV were usually excluded from these series. It is widely accepted that advanced disease does not respond to my- Corresponding author and reprints: Evaghelos Xynos, MD, otomy, and that esophagectomy should be offered to these PhD, FACS, Department of General Surgery, University Hos- 4 patients first. However, 2 of 4 patients in the present se- pital of Heraklion, Heraklion, Crete, GR-71110, Greece (e- ries with a very dilated and tortuous distal esophagus re- mail: [email protected]). ported satisfactory functional results, with occasional dysphagia or regurgitation. Furthermore, 83% of patients with a dilated and straight distal esophagus and all patients with REFERENCES a dilated and sigmoid-shaped esophagus had a satisfactory functional outcome in a series reported by Patti et al.16 1. Sauer L, Pellegrini CA, Way LW. The treatment of achalasia: a current perspec- tive. Arch Surg. 1989;79:144-154. Taking into account the minimal morbidity of the laparo- 2. Patti MG, Pellegrini CA, Arcerito M, et al. Comparison of medical and minimally scopic approach, we believe that all patients with stage IV invasive surgical therapy for primary esophageal motility disorders. Arch Surg. disease should be offered laparoscopic myotomy first, re- 1995;130:609-615. 3. 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