Review

Br. J. Surg. 1987, Vol. 74, September,765-769 Heller's myotomy for achalasia: is

an added anti-reflux procedurenecessary?

N. A. Andreollo andR. J. Earlam

The London Hospital,Whitechapel, London El IBB, UK

Correspondence to:Mr R. J. Earlam

Literature review (1970-85) indicates excellent or good results followingHeller's operation in 89 per cent of 5002 patients. The overall mortalitywas 2-8 per cent with a reoperation rate of 2-8 per cent. When theoperation was done through an abdominal incision, gastro-oesophagealreflux was almost twice as common as when it was done through athoracic incision, regardless of whether an anti-reflux procedure wasperformed.Keywords: Achalasia, Heller's myotomy

Achalasia is due to decreased numbers or absence of ganglioncells in Auerbach's plexus between the inner circular and outerlongitudinal muscle layers. In the normal oesophagus there arealmost no nerve cells in the submucous Meissner's plexus sothat a mucosal biopsy is useless for diagnosis. The physiologicalabnormalities are: absent peristalsis in the body of theoesophagus and abnormal relaxation in the gastro-oesophagealsphincter, which never amounts to a total absence ofrelaxation—achalasia—but only to incomplete relaxation andnot always in response to every swallow. The oesophagus fills upwith food and fluid leaving the contents to trickle into thestomach under the influence of simultaneous contraction wavesand gravity. The air that accompanies a normal bolus does notenter the stomach and an absent gastric air bubble is diagnostic.The resting pressure in the smooth muscle sphincter is eithernormal, as measured by non-perfused open tip manometry, orabove normal if perfused. This perfused pressure is the preferredmethodology now and represents a squeeze response to pressureincrements caused by the perfused fluid in the sphincter. It is themanometric equivalent to cardiospasm which is often used as asynonym for achalasia—the Greek word for failure to relax1.

The treatment for achalasia is based on the principle thatthere is an abnormal sphincter which causes obstruction, andthat weakening, but not destroying it completely, improvesoesphageal emptying even though the underlying pathologyitself cannot be changed. Dilatation of the lower oesophagusand its treatment by a whalebone probang were described byWillis in 16722'3. The first successful surgical procedure wasperformed by a German surgeon, Ernest Heller, on 14 April 1913through a laparotomy and consisted of a double myotomy4.Zaaijer, a Dutch surgeon, modified this by using a singlemyotomy incision in 19235. The weakening of thegastro-oesophageal sphincter by a single incision approachthrough the abdomen or chest is the present surgical procedureof choice. There are two main complications: recurrentdysphagia due to an incomplete myotomy and gastro-oesophageal reflux. In the last 15 years there has been anincreased number of reports of reflux after a Heller's myotomyand many authors have advocated the routine addition of ananti-reflux procedure. In spite of this, the majority still do asimple myotomy and obtain good results. The purpose of thisarticle is to review the recent literature to see whether there wasany reason to add the anti-reflux procedure, whether itsnecessity was due to a different technique of making the cut inthe muscle which destroyed rather than weakened the sphincter,and why some surgeons have good results with a simplemyotomy and very little subsequent gastro-oesophageal reflux.

Review of the literature

A review in 1980 reported 4500 patients6, whereas previouslythe situation was summed up by Ellis and Olsen in their classic1969 monograph based on 1906 patients2. The present paper isbased on 5002 patients reported in 75 papers7"81 (Table J).Some papers with incomplete data have been excluded but thenumber cited represents some 90 per cent of all the citedliterature from 1970 to 1985.

Diagnosis

The diagnosis of achalasia may be made by analysing clinicalsymptoms, radiology, cineradiography and oesophagealmanometry82. Although manometry and oesophageal pressurestudies are important and essential according to some22 '26 '28 '56,they have been employed in only 5 per cent of the seriesreported13-23-26-28-30-33-45 '55-56-58-60 '62 '76. Oesophagoscopywas used in I2percent10 '13-14-17-18-21-28 '33-46 '51 '60-71-75-81.Other tests such as acid perfusion and pH measure-ments13-15 '19-30-62, cineradiography51 and pharmacologicaltests (mecholyl)34 were rarely used. Of specific relevance to thepresent study, the associated abnormalities of hiatus hernia(0-5 per cent)14-57 and peptic ulcer (<0-3 per cent) were rarelyfound pre-operatively. Approximately 43 per cent of the patientsreported had been dilated before being submitted to definitivesurgery 10.13,27,28.34.51,58

Surgery

Since the first Heller's myotomy in 1913 and Zaaijer'smodification in 1923, both by the abdominal approach,numerous different procedures have been introduced. In thisreview 56 per cent of the patients had the myotomy donethrough a thoracotomy. Some authors employed both thethoracic and abdominal approach37-73. The different anti-refluxprocedures with reference to the authors using either a thoracicor abdominal approach are listed in Table 2.

Associated procedures such as proximal gastric vagotomy30,truncal vagotomy63 and pyloroplasty17-31-37-54-63 have alsobeen used. Other authors have proposed a complete incisionthrough the oesophageal wall and reconstitution of theoesophagogastric junction with the gastric fundus37-63-70-83 orY-V cardioplasty37. Approximately 50 per cent of the patientshad an added anti-reflux operation. The mark IV Belsey repairwas the most widely used anti-reflux procedure by thoracicsurgeons (21 per cent) and the anterior fundoplication wasmostly employed by abdominal surgeons (36 per cent).

0007-1323/87/090765-05$3.00 CO 1987 Butterworth & Co (Publishers) Ltd 765

Heller's myotomy: N. A. Andreollo and R. J. Earlam

Table 1 Collected data from 75 papers (1970-85)

.

Patients

First author

Adebo7

Akuamoa8

Anyanwu9

Arvanitakis10

Barker1 'Belsey12

Bjorck13

Black14

Borgeskov15

Boulez16

Cabrero-Gomez17

Caminiti18

Castrini19

Coan20

Coloni21

Csendes22

De La F. Perucho23

Dotsenko24

Dotsenko25

Duranceau26

Effler27

Ellis28

Fekete29

Gallone30

Gavriliu31

Giovinetto32

Goulbourne33

Grimes34

Harley35

Heil36

Hirashima37

Hollender38

Jamieson39

Jara40

Jezioro41

Kessler42

Kinoshita43

Lagache44

Lens45

Mabogunje46

Maillet47

Mansour48

Mehta49

Menguy50

Menzies-Gow51

Moreno G-Bueno52

Mullard53

Muralidharam54

Murray55

Nelems56

Nemir57

Okike58

Orringer59

Pai60

Petrovsky61

Peyton62

Rees63

Ribet64

Rossetti65

Ruland66

Sariyannis67

Schomacher68

Sery69

Shevchuk70

Stein71

Stipa72

Tomlinson73

Uchida74

Veiga-Fernandes75

Viard76

Vossschulte77

Yon78

Year

198019711982197519711972198219761970198119821975198219711975197519771973198419821971198419771982197519781985197019761980197819771984197919771980198119701980198319731976197419711978198119721978198419801971197919761984197219741971197519781981197519781982198319851976198119811981198319721975

Country

NigeriaDenmarkNigeriaUSAEnglandEnglandSwedenEnglandDenmarkFranceSpainItalyItalyItalyItalyChileSpainEthiopiaRussiaCanadaUSAUSAFranceItalyRomaniaItalyScotlandUSAWalesGermanyJapanFranceCanadaUSAPolandGermanyJapanFranceHollandNigeriaFranceUSAIndiaUSAEnglandSpainEnglandIndiaUSACanadaUSAUSAUSAUSARussiaUSAUSAFranceSwitzerlandGermanyEnglandGermanyPolandRussiaZimbabweItalyAustraliaJapanPortugalFranceFranceUSA

n

36101302330

14963

10852

10350274021

1242045175212

100113370

14256

2465506513212236

1452149195312207238756

10264

10090213274

4683

36113

14847563574825

2043125

162742015901924

Sex

Male

2561211415

295624

19

2710

1120

186

3549

8

33

1857

811

42

5130

6012

220

18

850

1712

29

40

Female

1140

99

15

345228

31

1311

925

346

6564

6

32

1888

49

33

5134

309

248

18

634

3113

45

50

Meanage(years)

34-54036-654-441

4347-542

40584435

45-232-830

4412-7445

45

4047

40-60

20-40

45

8-7446

51

43

48-4

50-742

48

40-50

Anti-refluxApproach* procedure

TATTTT +TA +TAA +TTT +TA +A +T +T +T +T +TA +A +A +A +TTTA +AA +T +TA +A +A +

—T +AA +TT -A +TA +jTT +T +TTT +T +T +T +T +A +A +

TA +A +A +

AT +T +A +A +AT -

Results (%)Deaths (excellent(%)

2-8————1-3———

—

———

———

——

———

——

—

2——————1-3————1-1——1-35

—2-8

———

——————1-4

——

and good)

9491-596-391909088

65-5759586-488959087-69578-59095958794859584-187-5807896-5

1008090958990907390

10080968086-7

1008094-29692-395907594

1009479-7809079959095-8958595908591-495

10087-6

10085

Reflux( °/1

68-500

16-6

12-618-51517-567-42-7

6-40

5033-5

0

12-54-66

35-2

102-7

249-50

5-605

23-68

13-75-873-10

12-517-53

11-17-1

298-3

14

9-88-3

6-4

228-5

011

20-8

Reoperations

2

316

43

5

2

4

55

49

5

14113

4

6

3

4

766 Br. J. Surg., Vol. 74, No. 9, September 1987

Heller's myotomy: N. A. Andreollo and R. J. Earlam

Table 1 Collected data from 75 papers (1970-85) (continued)

Patients

Sex Mean

First author

Yu Yong-Xian79

Wenzel80

Wingfield81

Year

198319721972

Country

ChinaGermanyEngland

n

443627

Male

18

11

Female (years)

26

16 37

A n f i rpfln\ Dpath

Approach* procedure (%)

T +A 2-8T

Results (%)

and good)

909080

Reflux( %) Reoperations

11-1 5

: T, thoracic; A, abdominal

Table 2 Anti-reflux procedures with reference to authors using either athoracic or abdominal approach

Mark IV Bdsey repajrl"9,45,48,55,56,60,62.72,74,75.76

Nissen fundoplication26'42'60'65'68'75

Lateral fundoplication'7•32-52•76

Anterior fundoplication22 '25 '30-31 '37

Diaphragmatic pedicled graft—Petrovsky24"26 '61 '79

Hiatal diaphragmatic reconstitution14 '27 '54 '81

Collis repair14'20'38-56-59

Allison repair60

Hill repair75

Others17'20<31'36'41'43-59-69-70

Results

Relief of dysphagia is the aim of a Heller's myotomy and this wasachieved with 'excellent' or 'good' results in 89 per cent ±7-2(mean + s.d.) (range 65-5-100 per cent) (Table 1). The terms'excellent' or 'good' were taken from the published data andshould mean that the patients could swallow solid food withoutdifficulty. It was a totally subjective assessment in the majorityand there was no practical and agreed difference between thewords excellent and good. These represented early results butlate review in 65 per cent of these patients gave a range ofbetween 60 and 94 per cent excellent and good results. The term'late' meant review at between 1 and 36 years. The overallmortality rate, calculated from the papers in Table 7, was0-2 per cent. Higher mortality rates occurred in small series ofpatients7'42'60'80. Other reported rates from large series in theliterature were 1-4 per cent from 1906 cases collected before19692, 0-7 per cent from 1669 cases collected from 1968 to197584 and 1-1 percent from 611 cases collected between 1967and 197538. The most important early complication wasperforation of the mucosa during myotomy, usually closedimmediately with careful suture of the mucosa. Thiscomplication was found in 1-1 percent of the patients in thisreview. Perforation of the mucosa led to an oesophageal fistulaand pleural empyema in 0-4 per cent. Other postoperativeproblems occurred such as pneumonia and atelectasis(1-8 per cent), wound infection (0-8 per cent) and phlebitis(0-5 per cent).

Gastro-oesophageal reflux was the most frequent latecomplication. The true incidence is difficult to establish becauseit depends on surgical approach, length of myotomy, associatedpathologies, length of follow-up and methods of assessingpostoperative reflux1 '28 '82 '85. A range of between 0 per cent and29 per cent was discovered in this review during the earlypostoperative period with an average of 8-6 per cent + 7-0(mean + s.d.). Table 3 shows the incidence of reflux afterthoracotomy and laparotomy with and without an additionalanti-reflux procedure, calculated from those papers withcomplete data (65 per cent). All four groups had the samepercentage of patients (about 90 per cent) with excellent orgood results. The terms 'excellent' and 'good' were used in mostpapers even though reflux occurred, so obviously all reflux wasnot considered equal. Diagnosis of reflux was not equallyaccurate either, with the method being variously symptomanalysis, radiology and pH measurement. Oesophagitis was not

Table 3 Incidence of postoperative reflux

ThoracotomyLaparotomy

Heller's myotomyalone

7-7%13-2%

Heller's myotomy andanti-reflux procedure

7-3%7'4%

a term used accurately and was taken to mean oesophagitisdiagnosed by visual appearance or that seen by micro-scopy. There were not sufficient data to calculate whetherany specific anti-reflux procedure prevented reflux more thananother, although the single commonest procedure wasfundoplication followed by the mark IV Belsey procedure. Norwas it possible to state that a specific procedure would be morelikely to be followed by dysphagia. About twice the number(13-2 per cent) had reflux with a Heller's myotomy done througha laparotomy than through a thoracotomy (7-7 per cent) andthis percentage became lower (7-4 per cent) when an anti-refluxprocedure was added to the abdominal approach. Statisticalanalysis showed that the difference between the laparotomygroup without an anti-reflux procedure and the others wassignificant (x2 = 26-573, P<0-05).

Reoperations were performed in 146 out of the 5002 patients(2-9 per cent), but this figure must be an underestimate becausemost series did not include this information in their follow-updata. Eight reoperations were done for an incompletemyotomy, five for relief of dysphagia due to the anti-refluxprocedure, three for leakage and the remainder, the majority, forreflux or peptic stricture. There was not enough information toassess the incidence of postoperative dilatation necessaryeither for an incomplete myotomy or a peptic stricture. Simpledilatation to FG 50 with a bougie relieved dysphagia due to anincomplete myotomy on the gastric side2 so that most re-operations were done for uncontrollable reflux86.

Peptic stricture, a late complication of oesophagitis due togastro-oesophageal reflux, was found in about 3 per cent of thepatients with complete data. Re-operations to treat pepticstricture were performed with various techniques: oesophago-gastrostomy17'57'60, oesophagogastrectomy29'40'51'76, cardio-plasty14'27'29'40'57'63'81, jejunal or colon inter-position17 '57 '60-67 and subtotal gastrectomy57.

Discussion

It was not the purpose of this review to discover whether aHeller's myotomy is better than various methods ofoesophageal dilatation. This has been discussed in otherpapers6'11'58'66'85'87, although the matter is still controversial.The main purpose was to discover why some surgeons add ananti-reflux procedure to their routine myotomy. Manyauthorities perform a Heller's myotomy through the thoracicapproach with one myotomy cut, and no added procedure andproduce good results2. It would appear that those who advocateadditional anti-reflux procedures obtain too much refluxfollowing a routine myotomy and seek to reduce it to acceptablelevels. But is their myotomy performed properly, is theapproach correct, is the phreno-oesophageal ligament

Br. J. Surg., Vol. 74, No. 9, September 1987 767

Heller's myotomy: N. A. Andreollo and R. J. Earlam

preserved, and would they be better advised to do the myotomycorrectly in the first instance?

In the abdominal approach the phreno-oesophagealligament has to be divided to expose enough of the loweroesophagus to do an adequate myotomy proximally. Theincision through a laparotomy is usually anterior whereas it ismore lateral through the thoracic approach. Some authors,believing in the gastric sling fibres which run obliquely round thelower oesophagus, state that their preservation is important andthat their destruction is the cause of reflux. The experimentalevidence refuting this theory is discussed in Ellis and Olsen'smonograph2. With an abdominal incision the distal cut usuallyextends further onto the stomach than with a thoracic approachwhereas Ellis2'28'86 recommends only cutting 0-5 cm distal tothe mucosal gastro-oesophageal junction. This can be done inthe thoracic approach with minimal disruption of the phreno-oesophageal ligament through a longitudinal incision. In thechest there is no need for full mobilization of the oesophagus bycutting the ligament circumferentially. The authors are fullyaware of the controversy about this phreno-oesophagealligament and whether it exists or not. Its destruction probablyleads to reflux; respecting and preserving it is more likely toleave the normal anti-reflux mechanism intact while at the sametime achieving the weakening, not the total destruction, of thezone of elevated pressure. This weakened sphincter in its correctposition can prevent reflux, without an added anti-refluxprocedure. Do those who use these additional proceduresbelieve that the flap valve effect produced is more importantthan the low pressure sphincter?

It is appreciated that the poor secondary clearing of thelower oesophagus after a myotomy occurs because lack ofperistalsis is a feature of the disease and is not altered by surgery.This reflex emptying after gastro-oesophageal reflux is slow,weak and inefficient; it results in pooling of acid in the loweroesophagus and that is why procedures such as fundoplicationcan cause dysphagia when done at the same time as a myotomy.It seems odd to do a Heller's myotomy which weakens thesphincter and then add a procedure that is said to increasesphincteric pressure.

In summary, the abdominal approach for a Heller's myotomyresults in more reflux than a thoracic approach. There isabundant experimental evidence to show that extending theincision onto the stomach increases reflux2'28'40'84'815. This isdiscussed in great detail by Ellis and Olsen2 and no recentresearch has challenged the experimental results. The sphincteris only 4 cm long physiologically and it would seem logical toweaken it by a limited incision both proximally and distally;extending the cut 7-8 cm proximally is unnecessary and mayweaken lower oesophageal clearing. Incomplete distal myotomyor a myotomy that had reunited were rare. The technique ofburrowing laterally between the muscle and mucosa for 180° toallow mucosa to pout through and prevent the muscle joiningup is well accepted. Extension of the muscle cut to only 0-5 cmdistal to the gastro-oesophageal mucosal junction is sufficient toperform an adequate myotomy yet prevent reflux. Thisepithelial junction can be seen when the mucosa has beenmobilized and is the only accurate way of limiting the distalincision. Since good results can be obtained by a correctly doneHeller's myotomy through the left chest, the conclusion to bedrawn from this review is that additional anti-reflux proceduresare only needed to compensate for an incorrectly done myotomyor are unnecessary.

AcknowledgementsDr Nelson A. Andreollo is a Brazilian research fellow in receipt of ascholarship from the Brazilian National Council of Scientific andTechnological Development (CNPq).

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Paper accepted 13 May 1987

Br. J. Surg., Vol. 74, No. 9, September 1987 769