surgical myotomy for achalasia

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Offi cial reprint from UpToDatewww.uptodate.com ©2016 UpToDate

AuthorsBrant K Oelschlager, MDRebecca P Petersen, MD, MSc

Section Editor Joseph S Friedberg, MD

Deputy Editor Wenliang Chen, MD, PhD

Surgical myotomy for achalasia

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Feb 2016. | This topic last updated: Feb 06, 2015.

INTRODUCTION — Heller described a surgical approach for the treatment of achalasia in 1913 [1,2]. The Heller

myotomy with a fundoplication is the optimal surgical treatment of achalasia, with effective symptom control in 90

to 97 percent of patients [3,4]. The muscle fibers of the lower esophageal sphincter are incised without disrupting

the mucosal lining of the esophagus and can be performed as a laparoscopic or open procedure. With the

advancement of laparoscopic surgery, the open technique is rarely used.

The indications for surgery, surgical technical insights, and postoperative results of the Heller myotomy will be

reviewed here. The pathophysiology and etiology, clinical manifestations and diagnosis, and medical treatment of

achalasia are discussed elsewhere. (See "Overview of the treatment of achalasia" and "Pathophysiology and

etiology of achalasia" and "Clinical manifestations and diagnosis of achalasia" and "Pneumatic dilation andbotulinum toxin injection for achalasia".)

PATIENT SELECTION CRITERIA — The key component for selecting appropriate patients for surgical

management is to differentiate achalasia from other motility disorders and from pseudoachalasia, malignancy, and

mechanical obstruction. The preoperative evaluation by the surgeon includes a history of patient symptoms as well

as a review of previous studies and the results of medical therapies to alleviate symptoms. As an example,

patients who are older than 50 years, with symptoms less than six months duration, and/o r who have lost more

than 10 pounds (4.5 kg) must be evaluated for esophageal cancer.

Pertinent details of the preoperative assessment include:

Medical therapies, which are nonspecific and have inconsistent results and side effects, have a limited role in the

treatment of achalasia [5,6]. While some controversy exists as to whether endoscopic or surgical therapy should

be initiated first [7], most specialists agree that it is no longer necessary or even preferred that patients first

undergo a trial of medical therapy or dilatation.

Pneumatic dilatation is used in centers with significant experience with its use and for patients who prefer to avoid

surgery, have undergone multiple prior abdominal operations, or who would be unable to tolerate the

pneumoperitoneum required to perform the procedure laparoscopically (eg, restrictive pulmonary disease, chronic

heart failure). However, a network meta-analysis that included 16 studies and 590 patients found that patients

®

®

Age●

History of weight loss●

Quality of symptoms (dysphagia, regurgitation, chest pain, etc.)●

Duration of symptoms●

Physiologic studies of esophageal function●

Radiographic imaging studies●

Results of dilatations●

Botulinum toxin injections●

Biopsy results●

Previous intra-abdominal and intra-thoracic surgery●

Comorbid illnesses●

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undergoing laparoscopic Heller myotomy had superior short- and long-term efficacy compared with patients

undergoing endoscopic balloon dilatation (odds ratio [OR] 2.2 95%, CI 1.2-4.19, p = 0.01 at 12 months and OR

29.8, 34.0-224.7, p = 0.001 at 60 months) [8].

Peroral endoscopic myotomy is an investigative procedure for the management of achalasia. (See "Overview of

the treatment of achalasia", section on 'Peroral endoscopic myotomy' .)

REVIEW OF DIAGNOSTIC EVALUATION — The diagnosis of achalasia is based upon the clinical history,

barium swallow, and esophageal manometry. Esophageal manometry, endoscopy, and a barium swallow study are

essential to confirming the diagnosis of achalasia, and the studies should be personally reviewed by the surgeonbefore proceeding with an operation. (See "Clinical manifestations and diagnosis of achalasia", section on

'Evaluation'.)

The key diagnostic studies that a surgeon must review or perform to evaluate a patient for the operation are

reviewed below.

SURGICAL MYOTOMY — Surgical myotomy, in which the lower esophageal sphincter (LES) is weakened by

incising the muscle fibers, is the primary alternative to pneumatic dilatation for achalasia. The advantages of

surgical myotomy are high initial success rates and, compared with pneumatic dilation, lower rates of symptom

recurrence. The main disadvantages of surgery are the high initial cost, the protracted recovery period, and the

frequent development of gastroesophageal reflux disease postoperatively, especially if a fundoplication is not part

of the procedure [10].

The primary goal of the operative treatment is to relieve the functional obstruction of the LES while preventing

reflux. The surgical principles include:

Manometry – Manometry is the measurement of muscular function of the esophagus and includes three

zones: lower esophageal sphincter (LES), esophageal body, and upper esophageal sphincter (UES). High-

resolution manometry (HRM) provides for a more accurate characterization of esophageal function compared

with standard manometry (figure 1 and picture 1) [9]. HRM permits continuous recording of motor activity

along the entire length of the esophagus and yields a more complete and detailed picture of esophageal

motility. Manometry systems include a catheter with multiple pressure sensor channels, pressure

transducers, and a recording device with a computer for analysis. The technique and the interpretation of the

results are discussed elsewhere. (See "Clinical manifestations and diagnosis of achalasia", section on 'High

resolution manometry' and "Motility testing: When does it help?", section on 'Esophageal manometry' and

"Oropharyngeal dysphagia: Clinical features, diagnosis, and management", section on 'Manometry' and

"Clinical manifestations and diagnosis of achalasia", section on 'Manometry' .)

●

Endoscopy – Most patients undergo endoscopy to establish a diagnosis well in advance of consideration for

surgery. It is important that the surgeon review the results to exclude other etiologies of the symptoms. It is

not necessary to routinely repeat the endoscopy before every operative procedure, but the surgeon must

have a low threshold to repeat endoscopy if concomitant or alternative upper gastrointestinal disease remains

a consideration. (See "Clinical manifestations and diagnosis of achalasia", section on 'Upper endoscopy' .)

●

Radiographic imaging – The barium swallow is the preferred initial study to define the esophageal anatomy

(image 1). This study will show the extent of esophageal dilation, shape, and gastroesophageal junction

(GEJ) obstruction. Absence of obstruction at the GEJ, which is characterized by a column of barium with air-

fluid levels, should make one question the diagnosis. Routine CT scans of the chest and abdomen are not

necessary, but if pseudoachalasia is suspected based on the clinical history, a CT scan or endoscopic

ultrasound should be performed to ensure accuracy of diagnosis. A sigmoid esophagus is a complication of

long standing achalasia. The surgical approach to a sigmoid esophagus may be to limit the procedure to

myotomy without fundoplication or an esophagectomy for patients with prior attempts at myotomy or mega-

esophagus.

●

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Surgical myotomy was first described in 1913 by Ernest Heller, who performed both anterior and posterior

incisions at the gastroesophageal junction [1]. His technique was modified to include only the anterior myotomy.

The modified Heller myotomy is the most common operative procedure used to treat achalasia [11]. The operation

can be performed using an open or a minimally invasive technique, and the esophagus can be approached throughthe abdomen or thorax [7,12-18]. With advances in minimally invasive surgery in the early 1990s, the

thoracoscopic approach and later the laparoscopic approach became popular [14-17,19]. There are advantages and

disadvantages to each approach. The main disadvantages of a thoracoscopic approach compared with a

laparoscopic esophageal myotomy include limited exposure of the distal lower esophageal sphincter (LES) and

stomach and the technical challenges of performing a fundoplication. With regards to clinical outcomes, the

thoracoscopic approach is associated with a higher rate of residual or recurrent dysphagia, more postoperative

pain, and a longer hospital stay [20]. Outcomes for the laparoscopic and open techniques are discussed

elsewhere. (See "Overview of the treatment of achalasia", section on 'Surgical myotomy'.)

Laparoscopic technique — The following is a description of the key technical elements of performing a

laparoscopic esophageal myotomy [10,14]. General issues related to laparoscopic abdominal surgery arediscussed elsewhere. (See "Abdominal access techniques used in laparoscopic surgery".)

Patient position — Patients are placed in a supine, split leg, or lithotomy position with padding, such as a

surgical bean bag. We prefer the lithotomy position for optimal ergonomics and access to the hiatus. The patient is

positioned in a steep reverse Trendelenburg position, which allows the stomach and other organs to fall away from

the esophageal hiatus.

Abdominal access and port placement — Abdominal access is obtained at the left upper quadrant just

inferior to the costal margin by inserting a Veress needle followed by placement of an optical trocar after

establishing pneumoperitoneum according to standard laparoscopic techniques. Four operative ports (two for the

surgeon, one for the assistant, and one for the scope) are then placed under direct vision, and liver retraction is

then achieved by any number of such devices on the market via an additional port site (figure 2). Other port

placements can also be used. (See "Abdominal access techniques used in laparoscopic surgery", section on

'Foregut surgery'.)

Mobilization of the gastric fundus — Based on the surgeon’s preference, the initial dissection can begin on

the right or the left side of the esophageal hiatus. The steps to mobilize the gastric fundus include:

Minimal dissection of the cardia●

Adequate distal myotomy to release the pressure of the LES●

Prevention of postoperative gastroesophageal reflux●

Prevention of scarred closure of the myotomy site●

Dividing the left phrenogastric ligaments by dividing the short gastric arteries, starting at the inferior pole of

the spleen to the exposed left crus of the diaphragm

●

Incising the gastrohepatic ligament in an avascular plane●

Preserving the nerve of Latarjet and avoiding injury to an accessory or replaced hepatic artery●

Dividing the right anterior phrenoesophageal ligament and the peritoneum overlying the anterior abdominal

esophagus

●

Preserving the anterior vagus nerve, which lies immediately posterior to the right anterior phrenoesophageal

ligament

●

At this point, if a posterior partial (Toupet) fundoplication is performed, a posterior esophageal window is

created. In performing this window, the posterior vagus nerve is identified and protected. If an anterior

fundoplication (Dor) technique is used, a posterior esophageal window is unnecessary unless a hiatal hernia

and/or and a relatively short esophagus is encountered and there is a need for further mobilization to allow

●

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Mobilization of the mediastinal esophagus — The distal portion of the mediastinal esophagus is mobilized

to achieve sufficient length to perform a myotomy incision that divides the entire length of the LES and permits a

tension-free fundoplication. A Penrose drain may be placed around the gastroesophageal junction to facilitate

retraction of the esophagus, but is not essential, especially if an anterior fundoplication is to be performed.

Myotomy — It is critical when performing the myotomy that visualization and exposure are adequate to

prevent inadvertent mucosal injuries. The cardioesophageal fat pad and the anterior vagus nerve must be clearedfrom the esophagus and the gastroesophageal junction. A continuous myotomy is performed for 6 cm on the

esophagus and 3 cm onto the stomach.

The following principles are important when performing the myotomy:

The use of electrocautery should be avoided unless critical when creating the myotomy. If bleeding is

encountered, it should be controlled with pressure and patience since thermal injury can lead to an unrecognized

perforation of the esophagus.

Fundoplication — If a fundoplication procedure is performed, it is typically a partial (eg, Toupet or Dor) and

not a circumferential (Nissen) wrap (see 'Addition of a fundoplication' below). A Toupet fundoplication is a 270

degree posterior wrap of the fundus around the esophagus, while the Dor fundoplication is a 180 degree anterior

wrap.

more intra-abdominal length in order to construct a proper fundoplication. (See 'Fundoplication' below and

'Addition of a fundoplication' below.)

A suitable and stable platform is useful. Our preference is a lighted bougie dilator (50 Fr), which illuminates

the esophagus and stretches the muscle fibers around the gastroesophageal junction, facilitating their

division. An endoscope may be used instead of the lighted bougie dilator. The anterior surface of the

esophagus is completely exposed and slight tension is created by retracting caudally with a Babcock

retractor or similar instrument.

●

The incision may be started on either the stomach or the esophagus. We prefer starting on the stomach;while this is a more difficult submucosal plane to identify, we find it easier to proceed in a cephalad than

caudal direction.

●

The myotomy is performed by individually dividing the esophageal and gastric muscle fibers.●

The longitudinal muscles are divided first, which exposes the underlying circular muscles.•

Division of the circular layer reveals a bulging mucosal plane that should appear smooth and white(picture 2).

•

The most critical and challenging factor is to create a 3 cm myotomy caudal to the gastroesophageal

junction, where the t issue plane becomes less readily identifiable. An intervening sling of muscle fibers

may blur the dissection, and the stomach mucosa is thinner and more prone to perforation (figure 3).

•

The portion of the myotomy on the esophagus should be approximately 6 cm in length. Thus, the total

length of the entire myotomy is 9 cm.

•

Endoscopic inspection of the mucosa and the myotomy is performed prior to proceeding to the next steps to

identify and repair any mucosal perforations.

●

If a Toupet (posterior) fundoplication is being performed, a retroesophageal window is established along the

lines of dissection (figure 4 and picture 3). The following is a brief description of the technique:

●

The fundus is mobilized by dividing the short gastric vessels and all fundal attachments starting

approximately at the inferior pole of the spleen, approximately 10 to 15 cm inferior to the angle of His.

•

The retroesophageal window is developed by further dissection along the base of the left crus.•

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Open technique — There are no differences in surgical technique or principles when performing a myotomy with

or without a fundoplication between a laparoscopic or open (laparotomy or thoracotomy) approach except for a few

technical variations that are discussed below. Although in theory an open approach might be more appropriate for

patients with severe pulmonary disease who will not tolerate pneumoperitoneum, such a patient most likely would

not be considered a surgical candidate at all. Another indication for an open approach might be less inexperience

with advanced laparoscopy; however, given that this disease is rare, and almost always can be managed

electively, there is ample time for the patient to be referred to a center with experienced surgeons [ 21].

Intraoperative technical risks — The major intraoperative risks include an unrecognized perforation of the

esophageal or gastric mucosa, division or injury to the anterior vagus nerve, and splenic injury.

OPERATIVE CONSIDERATIONS — There are several technical variations for performing a laparoscopic or open

Following mobilization of the mediastinal esophagus, the gastroesophageal hiatus is closed posteriorly

with interrupted sutures if a large defect is present, but our preference is to leave laxity of the hiatus.

•

The posterior aspect of the gastric fundus is passed through the retroesophageal window and secured

to the right edge of the myotomy and right crus of the diaphragm with a coronal suture. Another

interrupted suture is placed to secure the posterior fundus to the base of the right crus.

•

The leading posterior edge of the fundus is secured to the right edge of the myotomy with interrupted

sutures.

•

Any redundancy of the fundus is removed from behind the esophagus and the proximal, anterior aspect

of the fundus is secured to the left side in a similar fashion.

•

A Dor (anterior) fundoplication may be particularly useful to buttress the repair of an esophageal perforation

that may occur. The greater curve of the fundus is grasped and placed anteriorly to the right side of the

gastroesophageal hiatus. The following is a brief description of the technique:

●

An inner row of interrupted sutures are used to secure the medial aspect of the fundus to the left side of

the myotomy, which begins to recreate the angle of His.

•

The anterior fundus is folded over the esophagus, and a coronal suture to the right crus and right side of

the esophagus is performed.

•

A second row of interrupted sutures is placed to fix the leading edge to the right side of the myotomy

(picture 4). A final suture from the apex of the gastroesophageal hiatus to the fundus completes the

fundoplication.

•

Esophageal or gastric perforation — The risk of an esophageal or gastric perforation during surgical myotomy

ranges from 10 to 16 percent [3,22]. Mucosal perforations are repaired with fine 4-0 and 5-0 absorbable

monofilament suture. An advantage of the anterior (Dor) fundoplication is that it will buttress the repair.

●

Division of vagus nerve — Using careful dissection and attention to detail, injury to the vagus nerves is rare.

The anterior vagus nerve is at risk of injury during several technical steps of the operation including the

initial dissection of the esophagus, mobilizing the gastroesophageal fat pad, performing the myotomy, and

performing the fundoplication [23]. The posterior vagus nerve is less likely to be injured. If an injury to only

the anterior or posterior vagus nerve occurs, it is not repaired as postvagotomy diarrhea, bloating, early

satiety, and/or dumping syndrome rarely occur with a unilateral vagotomy [24]. Nevertheless, extra care

should be taken to identify and preserve both nerves.

●

Splenic injury — The risk of injury to the spleen ranges from < 1 to 5 percent [25-27]. The higher rates are

from reports when laparoscopic surgery was in the early stages of use. Management of an intraoperative

splenic injury is discussed elsewhere. (See "Management of intraabdominal, pelvic, and genitourinary

complications of colorectal surgery", section on 'Splenic injury'.)

●

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Heller myotomy, reflecting areas of controversy. These include length of the gastric component of the myotomy

incision, optimal type of antireflux procedure [10], management of a sigmoid megaesophagus, and the role of

robotic surgery.

Extended gastric myotomy — An extended gastric myotomy, which is defined as a 3 cm myotomy incision onto

the cardia of the stomach, is an important technical component for reducing recurrence of symptoms of achalasia.

The standard esophageal myotomy includes a 1.5 to 2.0 cm extension of the incision onto the cardia of the

stomach [28-30]. A 3 cm extension of the esophageal myotomy incision onto the stomach provides long-term

durable dysphagia relief due to disruption of the gastric sling, which consists of short transverse muscle fibers on

the lesser curve of the stomach [28,29]. The importance of the gastric sling fibers in the lower esophageal

sphincter (LES) mechanism was recognized when transitioning from the thoracoscopic to laparoscopic approach

(figure 3) [19].

The following studies illustrate the outcomes of performing a standard or an extended myotomy:

Addition of a fundoplication — The rationale for performing an anti-reflux fundoplication is to reduce the risk of

symptomatic gastroesophageal reflux that may result from obliterating the LES mechanism. The indications for

addition of a fundoplication vary, in part, with the approach to the myotomy. A fundoplication is included in most

patients in whom a laparoscopic myotomy is performed. A randomized trial of 43 patients undergoing a myotomy

for achalasia found that patients treated with the addition of an anterior (Dor) fundoplication had significantly fewer

gastroesophageal reflux symptoms (9 versus 48 percent) and a lower acid exposure time to the distal esophagus

compared with patients treated with a myotomy alone [10]. There was no difference in the frequency of dysphagia.

Both anterior (Dor) and posterior (Toupet) partial fundoplication techniques are used, and currently there is no

consensus on which procedure is superior:

Unfortunately, a randomized trial comparing the Dor (n = 36) and Toupet (n = 24) fundoplication techniques in

patients undergoing laparoscopic Heller myotomy was inconclusive due to small sample size and incomplete

follow-up [32]. No differences in esophageal symptoms were found between the two groups at 6 to 12 months.

A case series from a prospective database found that symptoms following the laparoscopic Heller myotomy

were improved with an extended gastric myotomy [28]. Patients treated with a 3 cm extended gastric

myotomy (n = 58) and a Toupet fundoplication had a significantly lower LES pressure (9.5 versus 15.8

mmHg), less frequent dysphagia (1.2 versus 2.1 percent), less severe dysphagia on VAS pain score (3.2

versus 5.3), and fewer recurrences requiring dilatation (2 versus 9 patients) compared with patients treated

with a standard 1.5 cm gastric myotomy and a Dor fundoplication (n = 52). Patients treated with theextended gastric myotomy had similar rates of heartburn (1.3 versus 1.7 percent), regurgitation (0.3 versus

0.8 percent), chest pain (0.3 versus 0.6 percent), and proximal (1.7 versus 2.3 percent) and distal (6.0 versus

5.9 percent) esophageal acid exposure.

●

A retrospective review of 113 patients undergoing a laparoscopic Heller myotomy reported good or excellent

results in 90 percent [31]. Ten patients (8.7 percent) were considered surgical failures, including two who

reported no relief of symptoms. The reasons for recurrence of or persistent symptoms included an incomplete

myotomy, sclerosis of the myotomy, and a sigmoid megaesophagus. Patients who were symptomatic

following surgery had a significantly larger esophageal diameter identified on a postoperative barium swallow

(25.5 versus 20 mm), and a significantly longer intact LES overall (42.5 versus 37.5 mm), longer intact length

of the gastric component of the LES (32 verus 27 mm), and a higher amplitude of contraction above the LES(32 versus 18 mmHg).

●

The Dor procedure avoids mobilization of the stomach during the initial dissection and is technically easier to

perform. In addition, it is a useful technique to buttress the repair of an inadvertent esophageal perforation.

●

The Toupet fundoplication splays the edges of the myotomy, which may decrease fibrosis at the incision site

and reduce recurrence of dysphagia.

●

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The Dor group had a higher percentage of patients with abnormal 24-hour pH results compared with the Toupet

group, but the difference was not significant (42 versus 21 percent) [ 32]. A circumferential complete fundoplication

(Nissen) is usually not performed to avoid excessive constriction at the gastroesophageal junction. Our preference

is to perform a Toupet partial fundoplication as we believe it reduces the risk of recurrent dysphagia by splaying

open the edges of the myotomy, thus preventing scarring. We perform a Dor fundoplication to provide coverage of

the primary repair only when there is an esophageal perforation [33].

While a fundoplication is routinely performed with a laparoscopic myotomy, there are several instances when a

fundoplication is not performed. These settings include:

Sigmoid megaesophagus — Sigmoid megaesophagus is an enlarged and atonic esophagus that results from

long standing increased LES pressure. Traditionally, a standard Heller myotomy was not performed on patientswith a sigmoid megaesophagus, as the degree of esophageal dilation and relief of symptoms were not thought to

improve with myotomy [35]. Hence, patients with a sigmoid esophagus were typically treated with an

esophagectomy prior to the laparoscopic era [36].

The results of an esophageal myotomy with a fundoplication for patients with a sigmoid megaesophagus are

illustrated in the following retrospective studies:

Currently, the majority of surgeons will initially offer patients with a sigmoid megaesophagus a laparoscopic Heller

myotomy, and if this fails, a subsequent esophagectomy. If a Heller myotomy is performed in patients with a

sigmoid megaesophagus, one should be careful if adding a concomitant partial fundoplication, which is more likely

to cause angulation and/or resistance in a megaesophagus. An alternative to an esophagectomy or a myotomy

with a fundoplication may be a laparoscopic esophagogastrectomy [38]. However, there are no short-term or long-

term studies on the efficacy of this procedure to improve symptoms and no high quality data from randomized

trials to suggest the best operative approach for management of sigmoid megaesophagus.

Robotic surgery — An evolving surgical modality for treatment of achalasia is robot-assisted minimally invasive

surgery. Theoretical advantages for the surgeon over standard laparoscopic surgery include increased range of

The myotomy is performed with a left video-assisted thorascopic surgery (VATS) approach without disruption

of the phrenoesophageal ligament [3].

●

Late stage disease manifested by the presence of a sigmoid megaesophagus on the preoperative

esophagogram. (See 'Sigmoid megaesophagus' below.)

●

Patients who are morbidly obese. Although achalasia is rarely seen in obese patients, we believe that the

optimal procedure for these patients is a laparoscopic Heller myotomy with a concomitant Roux-en-Y gastric

bypass, which we have performed with success in a small series of patients [34].

●

A review of 113 consecutive patients with achalasia who were treated with a laparoscopic Heller myotomy

and Dor fundoplication [35]. The twelve patients with a sigmoid megaesophagus had an equivalent operating

time, length of hospital stay, rate of postoperative complications, and relief of symptoms compared with

patients without esophageal dilatation.

●

A review of 51 patients with achalasia treated with a Heller myotomy and Dor fundoplication by laparoscopy

or laparotomy found that the 14 patients with a sigmoid megaesophagus had equivalent postoperative

changes in esophageal width, LES pressure, dysphagia score, and regurgitation score as the 37 patients

without a megaesophagus [37].

●

In contrast to the previous two studies, a retrospective review of 394 patients with achalasia undergoing a

laparoscopic Heller myotomy found that sigmoid megaesophagus was an independent predictor for failure of

a laparoscopic myotomy as the primary or secondary treatment of achalasia [ 4]. There were 13 patients with

a megaesophagus in this study: five had a good outcome and eight patients were considered a surgical

failure.

●

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motion, decreased tremor, improved visibility with respect to depth perception, and improved ability to perform finer

movements in a smaller, confined space [39]. The largest prospective series included 104 patients with achalasia

treated with a robot-assisted Heller myotomy with partial fundoplication [40]. There were no esophageal

perforations, eight minor complications, and two conversions to an open procedure because of bleeding and

computer system failure. Almost two-thirds of patients were discharged on the first postoperative day. A symptom

survey was completed in 79 patients (76 percent); all had a significant improvement in postoperative symptom

score compared with a preoperative score (0.5 versus 5.0), and none required a reoperation to control symptoms.

POSTOPERATIVE MANAGEMENT — The principle components of postoperative care for laparoscopic and/or

open myotomy include advancement of diet and control of nausea. The following is a summary of the major

issues:

POSTOPERATIVE COMPLICATIONS — The most common complications following laparoscopic and open

myotomy with a fundoplication include perforation, recurrent dysphagia, and gastroesophageal reflux. Following

laparoscopic Heller myotomy, the morbidity rate ranges between 1 and 10 percent and the mortality rate is


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Other potential reasons for recurrent dysphagia include:

The approach to the patient with recurrent dysphagia is to identify the cause and to rule out significant pathology,

such as a malignancy, stricture, or hernia. The diagnostic evaluation typically begins with upper endoscopy or, if

endoscopy is not available, a barium swallow. Manometry may be performed if achalasia is a possible cause of

the dysphagia. (See "Overview of dysphagia in adults" and "Clinical manifestations and diagnosis of achalasia",

section on 'Evaluation'.)

Gastroesophageal reflux — The rate of gastroesophageal reflux (GER) developing in patients undergoing

myotomy with a partial fundoplication (Dor or Toupet) ranges from 2 to 26 percent in different series [10,29,46-48].

The rate of GER for patients undergoing myotomy alone is much higher. This was demonstrated in a prospective

randomized trial of 43 patients with achalasia in which patients undergoing a Heller myotomy with a Dor

fundoplication had a significantly lower rate of pathologic GER at 6 months after surgery compared with patients

undergoing a Heller myotomy without a fundoplication (9 versus 48 percent) [10].

Patients who develop GER should have pH monitoring performed three to six months after myotomy and repeatedwith any change in symptoms that could suggest GER, especially heartburn and regurgitation. Patients with

abnormal esophageal acid exposure are treated medically. Incomplete myotomy with stasis in the distal

esophagus can mimic GER. (See "Medical management of gastroesophageal reflux disease in adults".)

Other complications — Pneumothorax, bleeding, inadvertent vagal injury, and infection are uncommon

complications, with at least one occurring in approximately 3 percent of cases [49]. A pneumothorax can be

caused from inadvertent injury to the pleura during mobilization of the mediastinal esophagus. If this occurs, the

defect can be repaired with a primary suture closure if the patient develops intraoperative hypotension or hypoxia.

Otherwise, neither a primary repair nor a chest tube is necessary in most patients.

RISK OF ESOPHAGEAL CANCER — Untreated achalasia is associated with an increased risk of squamous

cell esophageal cancer. There is a paucity of long-term data on the development of esophageal cancer following a

myotomy. In a retrospective review of 226 patients surgically treated for achalasia, four (1.8 percent) developed a

squamous cell carcinoma at 2, 8, 13, and 18 years after the operation [ 48]. The risk of esophageal cancer in

patients with achalasia and the possible role of screening are discussed separately. (See "Clinical manifestations

and diagnosis of achalasia", section on 'Natural history and prognosis'.)

SUMMARY AND RECOMMENDATIONS — The laparoscopic Heller myotomy with a partial fundoplication is the

optimal surgical treatment of achalasia, with effective control of symptoms in 90 to 97 percent of patients. The

primary goal of the operative treatment is to relieve the functional obstruction of the lower esophageal sphincter

(LES) while preventing reflux.

Herniated fundoplication●

Peri-hiatal scarring●

Peptic stricture●

Obstructing tumors●

A laparoscopic Heller myotomy is the first line of surgical therapy for patients with a confirmed diagnosis of achalasia and who are operative candidates. An open approach (laparotomy) to the Heller myotomy is rarely

performed as the initial treatment, and is reserved for patients who have had multiple prior abdominal

operations or who cannot tolerate a pneumoperitoneum because of cardiac or pulmonary disease (see

'Patient selection criteria' above). For those patients, or those who prefer a nonoperative approach,

pneumatic dilatation is performed.

●

The surgeon must review the results of the manometry, endoscopy, and pathology if not personally

performing the tests. (See 'Review of diagnostic evaluation' above.)

●

It is critical when performing the myotomy that visualization and exposure are adequate to prevent

inadvertent mucosal injuries. The cardioesophageal fat pad and the anterior vagus nerve must be cleared

●

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esophagus and 3 cm onto the stomach as measured from the gastroesophageal junction. (See 'Surgical

myotomy' above and 'Operative considerations' above.)

We recommend a partial fundoplication when performing a laparoscopic myotomy for achalasia (Grade 1B)

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repair only when there is an esophageal perforation.

●

The major intraoperative risks include an unrecognized perforation of the esophageal or gastric mucosa,

division or injury to the anterior vagus nerve and splenic injury. (See 'Intraoperative technical risks' above.)

●

If a Heller myotomy is performed in patients with a sigmoid megaesophagus, one should be careful if adding

a concomitant partial fundoplication, as this is more likely to cause angulation and/or resistance to a very

abnormal esophagus. (See 'Sigmoid megaesophagus' above.)

●

The most common complications following laparoscopic and open myotomy with a fundoplication include

esophageal or gastric perforation (1 to 7 percent), recurrent dysphagia (3 to 10 percent), and

gastroesophageal reflux (2 to 26 percent). (See 'Postoperative complications' above.)

●

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Topic 15060 Version 10.0

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GRAPHICS

High-resolution manometry achalasia

This high-resolution manometry depicts the findings of achalasia.

Graphic 67060 Version 2.0


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High-resolution manometry - Vigorous achalasia

This picture depicts the high amplitude simultaneous contractions and no lower

esophageal sphincter (LES) contractions of vigorous achalasia.



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Achalasia

Barium swallow showing a dilated esophagus and bird's beak

appearance typical of achalasia. Retained food is also visible.

Courtesy of Ram Dickman, MD.



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Heller myotomy performed laparoscopically

This is an intraoperative photograph of the laparoscopic performance

of the myotomy on the esophagus.



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Gastric component of the LES

The proximal margin of the lower esophageal sphincter (LES) extends

up to and a short distance proximal to the squamocolumnar junction

(not shown). The distal margin of the LES is more difficult to define

but careful anatomic studies suggest that it is composed of elements

of the gastric musculature, the opposing clasp and sling fibers of the

gastric cardia.

Adapted from: L iebermann-Meffert D, Allgöwer M, Schmid P, Blum AL. Muscular

equivalent of the lower esophageal sphincter. Gastroenterology 1979; 76:31.



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Laparoscopic Heller myotomy with Toupet

fundoplication

This is an intraopertive photograph showing the edge of the Toupet

fundoplication sutures to the edge of the myotomy. The procedure

was performed laparoscopically.



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Heller myotomy and fundoplication

This is an intraoperative photograph of the anterior fundus of the

stomach folded over the esophageal myotomy.



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Disclosures: Brant K Oelschlager, MD Nothing to disclose. Rebecca P Petersen, MD, MSc Nothing to disclose. Joseph S Friedberg,MD Nothing to disclose. Wenliang Chen, MD, PhD Nothing to disclose.

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