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Laparoscopic Heller's Cardiomyotomy in Cirrhosis with Oesophageal Varices

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Unusual Case

Laparoscopic Heller’s cardiomyotomy in cirrhosis with oesophageal varices

Abhay N Dalvi, Pinky M Thapar, Nitin M Narawane1, Rippan N Shukla

Departments of Minimal Invasive Surgery and 1Gastroenterology, Jupiter Hospital, Thane, Maharashtra, India.

Address for correspondence: Dr. Abhay N Dalvi, 257 Walkeshwar Road, Mumbai-400 006, India. E-mail: [email protected]

Abstract

in the presence of varices is technically challenging. Bleeding obscuring the vision is one of the obstacles of this procedure that can lead to complication of oesophageal mucosal perforation. Thorough pre-operative investigations, planning, meticulous dissection are required to tackle this problem by a laparoscopic approach. PUBMED search shows no reported case of laparoscopic cardiomyotomy in patient of cirrhosis with oesophageal varices.

Surgical intervention in cirrhosis of liver with portal hypertension is associated with increased morbidity and mortality. This is attributed to

liver decompensation, intra-operative bleeding, prolonged operative time, wound related and

anaesthesia complications. Laparoscopic surgery in cirrhosis is advantageous but is associated with technical challenges. We report one such case of hepatitis C cirrhosis with oesophageal varices

and symptomatic achalasia cardia, who was

successfully treated by laparoscopic cardiomyotomy after thorough preoperative workup and planning.

In the review of literature on pubmed, no such case

is reported..

CASE REPORT

A 53-year-old lady was referred to us for surgical management of achalasia cardia. In the past, she had sustained severe gastroenteritis (30 years ago) for which she was transfused 2 units of blood. She developed jaundice 25 years ago which responded to medical management. Since 6 years, she had progressive dysphagia to liquids and solids associated with weight loss and nocturnal cough. She underwent oesophageal manometry and upper GI endoscopy 2 years ago and was diagnosed to have achalasia cardia. Apart from classical findings of dilated oesophagus and narrowing at the gastro-oesophageal (GE) junction, endoscopy revealed the presence of three columns of grade I-II varices. She had no history of GI bleed. During the same time, she was also detected to have hepatitis C with high viral load and was treated with interferon decreasing her viral load.

Key words: Achalasia, cirrhosis, esophageal varices, laparoscopic cardiomyotomy.

DOI: 10.4103/0972-9941.65164

INTRODUCTION

Cirrhosis of liver with portal hypertension is associated with high risk for any surgical intervention.[1] Laparoscopic surgery offers advantages of decreased tissue trauma and surgical stress in cirrhosis.[2] Combination of Hepatitis C cirrhosis with oesophageal varices and symptomatic achalasia cardia is rare. Laparoscopic cardiomyotomy is a well-established technique to treat achalasia. Surgery involves separation of oesophageal and gastric musculature from underlying mucosa to release the high pressure zone of lower oesophageal sphincter (LES)[3] However, dissection in the submucosal plane
She received botulinum toxin injection for treatment of achalasia cardia, but had recurrence of symptoms of dysphagia within few months of the injection. Nocturnal dry cough progressed to a distressing level and fear of endoscopic dilatation inducing variceal bleed, led for a referral for a surgical option.

  • Journal of Minimal Access Surgery | April-June 2010 | Volume 6 | Issue 2
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Dalvi et al.: Laparoscopic Heller’s cardiomyotomy

On examination, she had mild hepatomegaly, but no evidence of splenomegaly or ascitis. bleeding from varices. At 18 months’ follow up, patient was on full diet with no complaints.

Repeat endoscopy revealed grade II oesophageal varix on the right wall, grade I column to the left of midline and grade II on posterior wall. A CT angiography was done, which showed dilated left gastric vessel, collaterals around the oesophago-gastric junction and lower oesophageal varices [Figure 1]. Her Liver function tests were normal and she was categorized as child A cirrhosis.

DISCUSSION

Cirrhosis of liver with documented varices on endoscopy involves development of dilatation of submucosal and paraoesophageal venous channels specially in the lower oesophagus and upper stomach. Surgery on or around these regions in patients with varices is challenging, and prone to bleeding. Achalasia cardia is a primary oesophageal motility disorder characterized by failure of relaxation of hypertensive LES on swallowing and aperistalsis of the body of the oesophagus.[4,5] Progressive dysphagia more to liquids than solids, regurgitation, retrosternal burning, weight loss are the common symptoms. Nocturnal coughing with
Laparoscopic attempt at cardiomyotomy was planned. Standard ports for laparoscopic cardiomyotomy were made. Findings included an enlarged cirrhotic liver, large left gastric vessels and collaterals in the left gastrohepatic ligament. Left lobe was retracted using a 5 mm instrument grasping the right crus. Staying in midline, anterior myotomy was done using harmonic shear and extended for 7 cm, with 1 cm extension over anterior wall of stomach [Figure 2]. Thickening of oesophageal wall with fibrosis was encountered. There was the presence of sub-mucous varix, which was controlled with harmonic shear. Intra-operative endoscopy was done to confirm the adequacy of myotomy. After satisfactory findings, anterior Dor fundoplication was done [Figure 3]. The procedure was completed in 80 min with minimum blood loss of 50 ml. She had good post-operative recovery.

Conray gram done on day 1 documented free flow of dye across the GE junction. Her nocturnal cough and dysphagia disappeared since the day of surgery. She was on primary prophylaxis, tab propanolol to prevent

Figure 2: Completed cadiomyotomy showing cirrhotic liver, cardiomyotomy and endoscopic illumination.

Figure 3: Completed fundoplication showing dilated collaterals and liver retraction.
Figure 1: CT angiogram showing collaterals marked with arrows.

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  • Journal of Minimal Access Surgery | April-June 2010 | Volume 6 | Issue 2

Dalvi et al.: Laparoscopic Heller’s cardiomyotomy

pulmonary infiltrates that was one of the presenting complaint in our patient is rare but indicates severe disorder.[6] collaterals, manipulation of non-pliable nodular left liver lobe, fibrosis due to botulinum toxin injection were the technical challenges. Discussion and review of the investigations had revealed a relatively “risk free” window at 12 O Clock position where the dissection had to be done to keep bleeding to minimum and tackle the 1 O’clock submucosal varix with caution. The same was achieved with use of harmonic scalpel. Submucosal fibrosis and scarring due to history of botulinum toxin injection is known[12] and was encountered in the present case. Intraoperative endoscopy helped to confirm accurate completion of myotomy across the GE junction.
Modification in diet and lifestyle, pharmacotherapy,[7] botulinum toxin injection[8] balloon dilatation[9,10] and surgery[11] are the treatment options available in patients with achalasia cardia. Botulinum toxin injection was tried in our case as patient was high risk for surgery due to varices. It acts by inhibiting calcium-dependent release of acetylcholine from nerve terminals, but 50% patients develop recurrence within 6 months,[11,12] While nocturnal cough never improved, symptoms of dysphagia had recurred in a short time. Balloon dilatation is an established therapy involving forceful stretching and disruption of LES, but was deferred due to the presence of varices. Fear of developing pulmonary infiltrates due to persistent and increasing nocturnal cough, recurrence of symptoms of dysphagia after conservative treatment modalities led to a surgical referral.
Post-operative instant relief from nocturnal cough and dysphagia is the aim of cardiomyotomy in patients with achalasia cardia, and the same was achieved using the laparoscopic technique with uneventful post-operative recovery.

The literature search on Medline (Pubmed) does not reveal any case of laparoscopic myotomy for achalasia cardia in patient of oesophageal varices.
Cardiomyotomy with or without an anti-reflux procedure is well established and effective modality for treatment of achalasia cardia. Advantages of decreased pain, in-hospital stay, less tissue trauma and early recovery has given laparoscopic approach an absolute advantage over open surgery.[13]

CONCLUSION

Technical challenges in laparoscopic surgery like cirrhosis can be overcome with thorough preoperative planning, precise and meticulous dissection.
In our patient, there was this unreported problem of associated cirrhosis and oesophageal varices, and advice of laparoscopic or open approach had to be guarded. The surgery had to be meticulously planned and knowledge of venous channels in and around the lower oesophagus and upper stomach was absolutely mandatory. This was managed by CT angiography and endoscopy. Co-ordination between the endoscopist, radiologist and the surgical team allowed us to proceed with the laparoscopic approach. Further, recent reports documenting feasibility of laparoscopic surgery in cirrhotics for bleeding varices with emphasis on technological advancements and surgical expertise[14] encouraged us to push for a laparoscopic over open approach with background of 22 laparoscopic cardiomyotomies in non-cirrhotics.

ACKNOWLEDGMENT

We thank Dr. Ajay Thakker, Chief Executive Officer, Jupiter Hospital, Thane, Maharashtra, for allowing us to publish the hospital data.

REFERENCES

  • 1.
  • Del Olmo JA, Flor-Lorente B, Flor-Civera B, Serra MA, Escudero A, Lledo

S, et al. Risk factors for nonhepatic surgery in patients with cirrhosis. World J Surg 2003;27:647-52.

  • 3.
  • Fernandes NF, Schwesinger WH, Hilsenbeck SG, Gross GW, Bay MK,

Sirinek KR, et al. Laparoscopic cholecystectomy and cirrhosis: A casecontrol study of outcomes. Liver Transpl 2000;6:340-4. Kuster GG, Innocenti FA. Laparoscopic anatomy of the region of the esophageal hiatus. Surg Endosc 1997;11:883-93. Cohen S, Lipshutz W. Lower esophageal sphincter dysfunction in achalasia. Gastroenterology 1971;61:814-20. Castell DO. Achalasia and diffuse esophageal spasm. Arch Intern Med 1976;136:571-9
4. 5. 6

Risk of bleeding due to the presence of varices in the plane of dissection, dilated para-oesophagogastric

  • 7
  • Feldman M, Sleisenger MH, Scharschmidt BF. Sleisenger and Fordtrans

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Dalvi et al.: Laparoscopic Heller’s cardiomyotomy

gastrointestinal and liver disease: Pathophysiology, diagnosis and management. 6th ed. Philadelphia; London: WB Saunders; 1998. Massey BT. Esophageal Motility and sensory disorders: Presentations, evaluation and treatment. Gastroenterol Clin N Am 2007;36:553-75. Bansal R, Nostrant TT, Scheiman JM, Koshy S, Barnett JL, Elta GH, et al. Intrasphincteric botulinum toxin versus pneumatic balloon dilation for treatment of primary achalasia. J Clin Gastroenterol 2003;36:209-14.
13 Vaezi MF, Richter JE. Current therapies for achalasia: Comparison and efficacy. J Clin Gastroenterol 1998;27:21-35.
14 Patti MG, Pellegrini CA, Horgan S, Arcerito M, Omelanczuk P, Tamburini
A, et al. Minimally invasive surgery for achalasia: An 8-year experience with 168 patients. Ann Surg 1999;230:587-94.
15 Wang YD, Ye H, Ye ZY, Zhu YW, Xie ZJ, Zhu JH, et al. Laparoscopic splenectomy and azygoportal disconnection for bleeding varices with hypersplenism. J Laparoendosc Adv Surg Tech A 2008;18:37-41
89

10 West RL, Hirsch DP, Bartelsman JF, de Borst J, Ferwerda G, Tytgat GN, et al. Long term results of pneumatic dilation in achalasia followed for more than 5 years. Am J Gastroenterol 2002;97:1346-51.
11 Karamanolis G, Sqouros S, Karatzias G, Papadopoulou E, Vasiliadis K,
Stefanidis G et al. Long-term outcome of pneumatic dilation in the treatment of achalasia. Am J Gastroenterol 2005;100:270-4.
12 Woltman TA, Pellegrini CA, Oelschlager BK. Achalasia. Surg Clin N Am
2005;85:483-93.

Cite this article as: Dalvi AN, Thapar PM, Narawane NM, Shukla RN. Laparoscopic Heller’s cardiomyotomy in cirrhosis with oesophageal varices.

J Min Access Surg 2010;6:46‑49.

Date of submission: 09/12/09, Date of acceptance: 29/01/2010

Source of Support: Nil, Conflict of Interest: None declared.

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  • Progression of Jackhammer Esophagus to Type II Achalasia

    Progression of Jackhammer Esophagus to Type II Achalasia

    J Neurogastroenterol Motil, Vol. 22 No. 1 January, 2016 pISSN: 2093-0879 eISSN: 2093-0887 http://dx.doi.org/10.5056/jnm15162 JNM Journal of Neurogastroenterology and Motility Case Report Progression of Jackhammer Esophagus to Type II Achalasia Jason Abdallah and Ronnie Fass* The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA It has been suggested that patients with certain motility disorders may progress overtime to develop achalasia. We describe a 66 year-old woman who presented with dysphagia for solids and liquids for a period of 18 months. Her initial workup showed normal endoscopy and non-specific esophageal motility disorder on conventional manometry. Six months later, due to persistence of symptoms, the patient underwent a high resolution esophageal manometry (HREM) demonstrating jackhammer esophagus. The patient was treated with a high dose proton pump inhibitor but without resolution of her symptoms. During the last year, the patient reported repeated episodes of food regurgitation and a significant weight loss. A repeat HREM revealed type II achalasia. Multiple case reports, and only a few prospective studies have demonstrated progression from certain esophageal motility disorders to achalasia. However, this report is the first to describe a case of jackhammer esophagus progressing to type II achalasia. (J Neurogastroenterol Motil 2016;22:153-156) Key Words Esophageal achalasia; Esophageal motility disorders; Esophagus; Manometry reflux disease (GERD) progressing to achalasia.4-9 Although no causal relationship has been identified, these reports suggest that the Introduction different esophageal motor disorders represent a spectrum rather Achalasia is a primary esophageal motor disorder of unknown than unique and stable disorders.
  • Case Studies and Review of Jackhammer Esophagus

    Case Studies and Review of Jackhammer Esophagus

    Review articles Case Studies and Review of Jackhammer Esophagus Robin Germán Prieto Ortiz, MD1, Álvaro Andrés Gómez Venegas, MD2, Albis Cecilia Hani de Ardila, MD3 1 General Surgeon and Resident in Gastroenterology at Abstract the Fundación Universitaria Sanitas 2 Internist and Gastroenterologist at Gastroclínico Jackhammer esophagus is a peristaltic hypercontractile disorder. According to the second version of the Chicago Institute in Medellín, Colombia Classification of esophageal motility, jackhammer esophagus is defined manometrically by distal contractile in- 3 Internist and Gastroenterologist, Director of the Unit tegrals greater than 8000 mm Hg/cm/s which indicates very high amplitude and velocity. We present a series of of Gastroenterology and Digestive Physiology of the Hospital Universitario San Ignacio in Bogotá, five patients with jackhammer esophagus who underwent high-resolution esophageal manometry (HREM) from Colombia which clinical and manometric data were collected. There were three men and two women whose ages ranged from 41 to 73. Three of them had been diagnosed with gastroesophageal reflux disease, and showed symptoms This work was presented as a poster at the 2015 ACADI Convention. of dysphagia, heartburn and regurgitation. The main endoscopic finding was the presence of hiatal hernia and presbyesophagus in two patients. HREM showed waves of up to 4 mm Hg greater than 8000 mm Hg/cm/s. In three of the five patients there were multiple waves. Although, the new third version of the Chicago classification ......................................... Received: 24-09-15 of requires two waves with DCIs over 8000 mm Hg/cm/s to confirm a diagnosis of jackhammer esophagus, it Accepted: 25-07-16 should be noted that we do not yet have available equipment to interpret MAR and allow classifying esophageal disorders by Chicago v.3, and that is why in our physiology unit we still report the MAR with presorting.