LAPAROSCOPIC SURGERY 0039-6109/96 $0.00 + .20

LAPAROSCOPIC MANAGEMENT OF ACHALASIA

Margret Oddsdbttir, MD

Achalasia is a primary esophageal motility disorder of unknown etiology. It is characterized by progressive loss of peristalsis in the body of the esophagus and failure of a normal or hypertensive lower esophageal sphincter (LES) to relax in response to swallowing.", I h , 36

No form of therapy returns esophageal peristalsis or LES function to normal. Instead, therapy is aimed at relieving the functional obstruction at the gastro- esophageal junction. Medical efforts to relieve the distal esophageal obstruction have been largely unsatisfactory. Relief can only be achieved by disrupting the lower LES by either forceful dilatation or surgical cardiorny~tomy.~, 11, 13, 16, 32

Surgical cardiomyotomy provides excellent relief of dysphagia in 85% to 90% of patients, with minimal complication^.^, R, 9, 17, 27, 32 However, the necessary thora- cotomy or laparotomy results in significant pain and prolonged recovery period. Therefore, pressure-controlled balloon dilatation has become the primary treat- ment for achalasia, in spite of a success rate of 70% to 80% and a perforation rate of 3% to lo%.', 9,

Laparoscopic cardiomyotomy for achalasia was first reported in 1991 by Shimi et al.34 In 1996, laparoscopic (or thoracoscopic) cardiomyotomy has proven to be safe, effective, and associated with minimal discomfort.2, 3, 5, 7, 10-14, 24, 25,

29-31, 34-36 Laparoscopic cardiomyotomy is an alternative that seems to combine the advantages of balloon dilatation and standard surgical cardiomyotomy, that is, a minimally invasive procedure with a high success rate.

32, 33

PREOPERATIVE EVALUATION AND PREPARATION

Prior to treatment it is important to establish the correct diagnosis because other disorders can present in a similar fashion. These include malignant ob-

From the Department of Surgery, University of Iceland Medical School and University Hospital-Landspitali, Reykjavik, Iceland

SURGICAL CLINICS OF NORTH AMERICA

VOLUME 76 * NUMBER 3 9 JUNE 1996 451

452 ODDSD~TTIR

struction (especially when the sphincter is infiltrated), gastroesophageal reflux with stricture formation, diffuse esophageal spasms, and nutcracker esopha- gus.I3, l6, 23, 36 Diagnostic work-up therefore includes an endoscopic examination with biopsies as necessary, a barium swallow, and esophageal manometry. If a peptic stricture is suspected, a 24-hour pH study is indicated. A CT scan is obtained if a malignant obstruction is suspected.

Patients with proven achalasia who can tolerate general anesthesia are candidates for cardiomyotomy. Prior balloon dilatation is not a contraindication to cardiomyotomy. However, in patients with previous dilatation, the periesoph- ageal dissection and the myotomy may become more difficult because of scar- ring in the

Patients with achalasia frequently retain food and liquids in their esopha- gus. Therefore, preoperative fasting for more than 8 hours is necessary, and many recommend a liquid diet for a few days before the operation. An effective prophylaxis for deep venous thrombosis is recommended. There is no need for perioperative antibiotics. If a mucosal perforation occurs during the procedure, then antibiotics can be given at that time.

THEPROCEDURE

The operating room set-up is similar to that for laparoscopic fundoplication, with a standard endosurgical unit, two monitors, and basic laparoscopic instru- mentation (Fig. 1). A few pieces of special equipment are necessary: forward- oblique viewing telescope, 30 or 45 degree; atraumatic graspers (Glassman type); dissecting scissors, twin-action; expandable liver retractor; hook cautery; right- angle dissector; needle driver; clip applier; suction-irrigation device. All of these instruments are now available as nondisposable instruments, which reduces the cost of the procedure significantly. A bipolar electrocautery or the ultrasonically activated shears, if available, can replace the clip applier and the monopolar electrocautery.2, 36

THE TECHNIQUE

Pneumoperitoneum is established and the first trocar, for the telescope, is placed through the left rectus sheath. The trocar placement is shown in Figure 1. A liver retractor, passed through the right subcostal trocar, elevates the left liver lobe to expose the hiatus.

The hiatal exposure and the mobilization of distal esophagus and cardia are the same as those for laparoscopic fundoplication (see the preceding article).I9, 22

The esophagus is encircled with a one-fourth inch Penrose drain. At least 5 cm of the distal esophagus must be mobilized and be intra-abdominal. The epiphrenic fat pad is dissected off the anterior surface of the gastroesophageal junction and the cardia.

The myotomy is begun on the anterior surface of the esophagus, to the left of the anterior vagus nerve, just proximal to the gastroesophageal junction. Using dissecting scissors and electrocautery, a longitudinal area of the outer coat is cauterized carefully, and the longitudinal fibers separated using the twin action of the scissors. The transverse fibers are separated bluntly from the underlying mucosa. The transverse fibers are then divided with the hook cau- tery. It is important to tent the fibers well away from the mucosa before applying the electrocautery if a monopolar electrocautery is being used. Once in the

LAPAROSCOPIC MANAGEMENT OF ACHALASlA 453

Figure 1. Trocar placement and operating room set-up. The 10-mm supraumbilical trocar and the right subcostal trocar are placed 15 cm from the xiphoid. The left subcostal trocar is placed about 10 cm from the xiphoid. The 5-mm epigastric trocar is placed as high as the liver edge allows and as lateral as the falciform ligament allows. The 5-mm left flank port is about 7 cm lateral to the left subcostal trocar.

submucosal plane, the mucosa bulges up. This is clearly seen in the magnified laparoscopic view. The myotomy is carried proximally for about 5 cm from the gastroesophageal junction (Fig. 2). Distally the myotomy is carried across the gastroesophageal junction and onto the stomach for about 1 cm. On the stomach site, the separation of the muscle layers from the mucosa is more difficult to achieve and there are more bridging vessels than on the esophagus. This can result in more bleeding than encountered during the esophageal myotomy and increased risk of perforation. Once the myotomy is completed, the muscle edges are separated from the underlying mucosa for approximately 40% of the esophageal circumference. The orogastric tube is pulled back into the distal esophagus and about 100 mL of methylene blue solution (one ampule diluted in about 250 mL NaC1) is injected down the tube. This clearly demonstrates any mucosal perforation. If a perforation is encountered, it can be closed with a stitch. Some surgeons prefer to have a flexible endoscope or a dilator in the esophagus as they do their myotomy. I prefer not to place anything but an orogastric tube in the esophagus. With the gastroesophageal junction mobilized as described, one can control the tension and freely move the distal esophagus and the cardia by pulling the Penrose drain. Besides, the mucosa is easily identified as it bulges out, when not stretched by a dilator or an endoscope.

An antireflux procedure, either a Toupet (a posterior fundoplication) or a Dor (an anterior fundoplication), is recommended in conjunction with the myot-

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Figure 2. The myotomy being carried be taken to elevate the muscle fibers is applied.

proximally, using hook electrocautery. Care must away from the mucosa before the electrocautery

omy. Both can be accomplished with the laparoscopic approach?, 5, 7, 22* 31* 35, 36 I prefer a Toupet procedure, for reasons discussed below. For a description of Toupet hemifundoplication, see the preceding article.22, 36 Completed cardiomy- otomy and Toupet fundoplication are shown in Figure 3. Laparoscopic cardio- myotomy takes, on the average, 1.5 to 2 hours to perform. When an hemifun- doplication is done as well, the procedure takes about 2.5 to 3 hours to perform.

POSTOPERATIVE COURSE AND COMPLICATIONS

Postoperative chest films show mediastinal air, but a small pneumothorax is occasionally detected. Rarely is a chest tube required, as the carbon dioxide is rapidly absorbed. Oral liquids can be started once the patient is awake. If a perforation was sutured, liquids are begun the morning after the operation, after an esophagogram shows no leak. The patient is advanced to a soft diet when liquids are tolerated and discharged 2 to 4 days following surgery. There are no postoperative restrictions, except for a soft diet for 2 to 4 weeks.

The most common complication is a small perforation of the mucosa. This is usually easily recognized, if not at once, then during the instillation of methylene blue dye into the esophagus. These lacerations are clean and easily repaired with a stitch. As of today, there are no reports of infection from a small, recognized mucosal laceration during laparoscopic cardiomyotomy. Perforation of the stomach from a retracting grasper, as described in laparoscopic fundoplications, is also a potential complication during laparoscopic cardiomy- otomy. Again, it is of little consequence as long as it is recognized and repaired. A late perforation-from an electrocautery burn, for example-is possible but thus far not described in the literature for laparoscopic cardiomyotomy. If the patient develops fever and is not progressing well, one must obtain an esopha- gram to rule out a perforation.

Bleeding can occur from several sites. Blood loss requiring transfusion has

LAPAROSCOPIC MANAGEMENT OF ACHALASIA 455

not been reported for laparoscopic cardiomyotomy. However, even a small amount of bleeding can be annoying because it absorbs the light and obscures the view. Aspiration may occur, especially if care is not taken during induction of anesthesia, as discussed earlier.

RESULTS

Laparoscopic cardiomyotomy for achalasia was first reported in 1991 by Shimi et a1.= The patient had complete relief of dysphagia and no untoward symptoms. Since then several reports on laparoscopic cardiomyotomy have been published.2, 3, 5, 7, lo, 12, 14, 25, 31, 35, 36 The largest one, with 85 patients and a mean follow-up for 20 months, shows excellent and good results in 82 patients (96.4%), but two required reoperation (laparoscopic) for dy~phagia. '~ In 12 patients fol- lowed for the mean of 16 months, Swanstrom and Pennings had good to excellent relief of dysphagia in all 12 patients.36 Manometry in 11 of these 12 patients showed a mean decrease in the lower esophageal sphincter pressure from 33.4 mm Hg preoperatively to 19.3 mm Hg postoperatively. The longest follow-up in the literature for laparoscopic cardiomyotomy is about 4 years, but most are 1 to 3 years.2, 3, 5, 7, '", 12, 14, 25, 31, 35, 36 Dysphagia is relieved in 91% to 100% of patients in these reports (combined over 100 patients).

Reflux is a common problem after conventional (open) cardiomyotomy. The literature clearly indicates that an antireflux procedure should be added to a conventional abdominal cardiomy~tomy.~, 6, n, y, 20. 27 The same arguments can be applied to the laparoscopic approach. The two most commonly performed

I

Figure 3. Completed abdominal myotomy with Toupet hemifundoplication. ( f rom Swan- strom LL, Pennings J: Laparoscopic esophagomyotomy for achalasia. Surg Endosc 9:286, 1995; with permission.)

456 ODDSDOTTIR

antireflux procedures in conjunction with cardiomyotomy are Dor and Toupet hemifundoplications. The Dor procedure requires less mobilization of the fundus and the gastroesophageal junction and is therefore easier to perform?, 5, 6, 9, 15, 31

However, the Toupet fundoplication is a proven, effective antireflux procedure, and when performed in conjunction with cardiomyotomy it helps keep the edges of the myotomy apart.*, 27, 36* 37 If the gastroesophageal junction is not dissected circumferentially, one can argue that an antireflux procedure is needed only if the patient has a hiatal hernia or if a sutured mucosal perforation needs to be buttressed. However, the minimal dissection is to take down the phrenoesophageal membrane and to mobilize the esophagus for at least 5 cm anterolaterally. In addition, the LES is completely disrupted by the myotomy. By mere disruption of the LES by forceful balloon dilatation, reflux becomes a common problem.32 A partial fundoplication at the time of the myotomy adds 30 to 60 minutes to the procedure but prevents disabling reflux.

Esophageal myotomy for achalasia can be performed via either the chest or the abdomen. Laparoscopic access offers excellent exposure of the distal 5 to 8 cm of the esophagus. With the surgeon standing between the patient’s legs and trocars placed as described above, coaxial alignment with the gastroesophageal junction and the videoendoscope is maintained. The operating instruments enter in line with the esophagus, making dissection and suturing easy. Thoraco- scopic cardiomyotomy does not allow the same alignment between the operating instruments and esophagus as does the laparoscopic approach. The instruments come in almost perpendicular to the esophagus, making dissection and suturing difficult. This is particularly of concern at the distal-most part of the dissection. This is the most difficult part of the dissection and it is not well visualized during thoracoscopic cardiomyotomy. In addition, the thoracoscopic approach requires double-lumen endotracheal intubation and pulmonary collapse for ex- posure of the esophagus?,

For the conventional (open) thoracic cardiomyotomy, the consensus on antireflux procedure is not as clear as that for abdominal cardiomy~tomy.~, 5, l7

A thoracoscopic antireflux procedure has been described but is not a routinely performed procedure.= Finally, should a conversion to an open procedure be necessary, the morbidity of the thoracic incision is significantly higher than that of the abdominal one.

11, 24, 29, 30

SUMMARY

Cardiomyotomy for achalasia is one of the ideal procedures for the video endoscopic approach. Magnification of the operative field during laparoscopic surgery allows precise division of the muscle fibers with excellent results. The number of reports on cardiomyotomy performed with laparoscopic (and thora- coscopic) access is growing2, 5, 7, l c w * 24, ~ 5 , 29,31, 35, 36 They all show the same excellent results as for conventional (open) myotomy, with minimal morbidity, short hospital stay, and early return to routine activity.

References

1. Abid S, Champion G, Richter JE, et al: Treatment of achalasia: The best of both worlds.

2. Amarel J F Laparoscopic myotomies using an ultrasonically activated scalpel. Surg Am J Gastroenterol 89:979, 1994

Endosc 8:463, 1994

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3. Ancona E, Peracchia A, Zaninotto G, et al: Heller laparoscopic cardiomyotomy with antireflux anterior fundoplication (Dor) in the treatment of esophageal achalasia. Surg Endosc 7459, 1993

4. Andreollo NA, Earlam RJ: Heller’s myotomy for achalasia: Is an added anti-reflux procedure necessary? Br J Surg 74:765, 1987

5. Anselmino M, Hinder RA, Filipi CJ, et al: Laparoscopic Heller cardiomyotomy and thoracoscopic esophageal long myotomy for the treatment of primary esophageal motor disorders. Surg Laparosc Endosc 3:437, 1993

6. Bonavina L, Nosadini A, Bardini R, et al: Primary treatment of esophageal achalasia. Arch Surg 127222, 1992

7. Buess G, Cuschieri A, Manneke K, et al: Technique and preliminary results of laparo- scopic cardiomyotomy. Endosc Surg 1:76, 1993

8. Crookes PF, Wilkinson AJ, Johnston GW: Heller’s myotomy with partial fundoplica- tion. Br J Surg 76:98, 1989

9. Csendes A, Braghetto I, Henriquez, et al: Late results of a prospective randomized study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut 30:299, 1989

10. Cuschieri A Endoscopic oesophageal myotomy for specific motility disorders and non-cardiac chest pain. Endosc Surg 1:280, 1993

11. Cuschieri A, Nathanson LK, Shimi SM: Thoracoscopic oesophageal myotomy for motility disorders. In Cuschieri A, Buess G, Perissat J (eds): Operative Manual of Endoscopic Surgery. Berlin, Springer-Verlag, 1992, p 141

12. Cushieri A, Shimi SM, Nathanson L K Laparoscopic cardiomyotomy for achalasia. ln Cuschieri A, Buess G, Perissat J (eds): Operative Manual of Endoscopic Surgery. Berlin, Springer-Verlag, 1992, p 298

13. Dellamagne B: Endoscopic approaches to oesophageal disease. Bailliere’s Clin Gas- troenterol 7795, 1993

14. DePaula AL, Hashiba K, Bafutto M: Laparoscopic approach to esophageal achalasia. Surg Endosc 9:220, 1995

15. Dor J, Humbert P, Paoli JM, et al: Traitement du reflux par la technique dite de Heller- Nissen modifiee. Presse Med 75:2563, 1967

16. Ellis FH: Functional disorders of the esophagus. In Zuidema GD, Orringer MB (eds): Shackelford’s Surgery of Alimentary Tract, ed 3. Philadelphia, WB Saunders, 1991, p 146

17. Ellis FH: Oesophagomyotomy for achalasia: A 22-year experience. Br J Surg 80:882, 1993

18. Ellis FH, Crozier RE, Gibb SP: Reoperative achalasia surgery. J Thorac Cardiovasc Surg 92:859, 1986

19. Hinder RA, Filipi CJ, Wetscher G, et al: Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease. Ann Surg 220:472, 1994

20. Jaakkola A, Ovaska J, Isolauri J: Esophagocardiomyotomy for achalasia. Eur J Surg 157407, 1991

21. Katz P: Achalasia: Two effective treatment options-let the patient decide. Am J Gastroenterol 89:969, 1994

22. McKeman JB, Champion J K Laparoscopic antireflux surgery. Am Surg 61:530, 1995 23. Mercer CD, Hill L Reoperation after failed esophagomyotomy for achalasia. Can J

24. Monson JRT, Darzi A, Carey PD, et al: Thoracoscopic Heller’s cardiomyotomy: A new

25. Mucio M: Achalasia: Laparoscopic treatment. Surg Endosc 8:463, 1994 26. Pai GP, Ellison RG, Rubin JW, et al: Two decades of experience with modified Heller‘s

myotomy for achalasia. Ann Thorac Surg 38:201, 1984 27. Paricio PP, Martinez de Haro L, Oritz A, et al: Achalasia of the cardia: Results of

oesophagomyotomy and posterior partial fundoplication. Br J Surg 771371, 1990 28. Parkman HP, Reynolds JC, Ouyang A, et al: Pneumatic dilatation or esophagomy-

otomy treatment for idiopathic achalasia: Clinical outcomes and cost analysis. Dig Dis Sci 38:75, 1993

Surg 29:177, 1986

approach for achalasia. Surg Laparosc Endosc 4:6, 1994

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29.

30.

31.

32. 33.

34.

35.

36.

37.

38.

Pellegrini CA, Leichter R, Patti M, et al: Thoracoscopic esophageal myotomy in the treatment of achalasia. Ann Thorac Surg 56:680, 1993 Pellegrini C, Wetter LA, Patti M, et al: Thoracoscopic esophagomyotomy. Ann Surg 216:291, 1992 Rosati R, Fumigalli U, Bonavina A, et al: Laparoscopic Heller-Dor procedure with intraoperative balloon dilatation of the cardia. Surg Endosc 8:463, 1994 Sauer L, Pellegrini CA, Way LW The treatment of achalasia. Arch Surg 124:929, 1989 Schwartz HM, Cahow CE, Traube M Outcome after perforation sustained during pneumatic dilatation for achalasia. Dig Dis Sci 38:1409, 1993 Shimi S, Nathanson LK, Cuschieri A: Laparoscopic cardiomyotomy for achalasia. J R Coll Surg Edinb 36:152, 1991 Spencer J: Cardiomyotomy. In Ballantyne GH, Leahy PF, Modlin IM (eds): Laparo- scopic Surgery. Philadelphia, WB Saunders, 1994, p 400 Swanstrom LL, Pennings J: Laparoscopic esophagomyotomy for achalasia. Surg Endosc 9:286, 1995 Toupet A: Technique d'oesophago-gastroplastie avec phreno-gastropexie appliquee dans la cure radicale des hernies hiatales et comme complement de l'operation de Heller dans les caridospasmes. Acad Chir 89:394, 1963 Yang HK, Del Guercio Louis RM, Steichen FM: Thoracoscopic Belsey-Mark IV fun- doplication. Surg Endosc 9:622, 1995

Address reprint requests to Margret Oddsdottir, MD

University of Iceland Medical School University Hospital-Landspitalinn

Department of Surgery 101 Reykjavik, Iceland