Urs Diener

Minimally invasive surgery for achalasia: an 8-year experience with 168 patients.

BACKGROUND Seven years ago, the authors reported on the feasibility and short-term results of minimally invasive surgical methods to treat esophageal achalasia. In this report, they describe the evolution of the surgical technique and the clinical results in a large group of patients with long follow-up. PATIENTS AND METHODS Between January 1991 and October 1998, 168 patients (96 men, 72 women; mean age 45 years, median duration of symptoms 48 months), who fulfilled the clinical, radiographic, endoscopic, and manometric criteria for a diagnosis of achalasia, underwent esophagomyotomy by minimally invasive techniques. Forty-eight patients had marked esophageal dilatation (diameter >6.0 cm). Thirty-five patients had a left thoracoscopic myotomy, and 133 patients had a laparoscopic myotomy plus a partial fundoplication. Follow-up to October 1998 was complete in 145 patients (86%). RESULTS Median hospital stay was 72 hours for the thoracoscopic group and 48 hours for the laparoscopic group. Eight patients required a second operation for recurrent or persistent dysphagia, and two patients required an esophagectomy. There were no deaths. Good or excellent relief of dysphagia was obtained in 90% of patients (85% after thoracoscopic and 93% after laparoscopic myotomy). Gastroesophageal reflux developed in 60% of tested patients after thoracoscopic myotomy and in 17% after laparoscopic myotomy plus fundoplication. Laparoscopic myotomy plus fundoplication corrected reflux present before surgery in five of seven patients. Patients with a dilated esophagus had excellent relief of dysphagia after laparoscopic myotomy; none required an esophagectomy. CONCLUSIONS Minimally invasive techniques provided effective and long-lasting relief of dysphagia in patients with achalasia. The authors prefer the laparoscopic approach for three reasons: it more effectively relieved dysphagia, it was associated with a shorter hospital stay, and it was associated with less postoperative reflux. Laparoscopic Heller myotomy and partial fundoplication should be considered the primary treatment for esophageal achalasia.

Effects of Previous Treatment on Results of Laparoscopic Heller Myotomy for Achalasia

Until recently, pneumatic dilatation andintrasphincteric injection of botulinum toxin (Botox)have been used as initial treatments for achalasia, withmyotomy reserved for patients with residual dysphagia. It is unknown, however, whether thesenonsurgical treatments affect the performance of asubsequent myotomy. We compared the results oflaparoscopic Heller myotomy and Dor fundoplication in 44patients with achalasia who had been treated withmedications (group A, 16 patients), pneumatic dilatation(group B, 18 patients), or botulinum toxin (group C, 10patients). The last group was further subdivided according to whether there was (C2, 4 patients)or was not (C1, 6 patients) a response to the treatment.Results for groups A, B, C1, and C2, respectively, were:anatomic planes identified at surgery (% of patients) — 100%, 89%, 100%, and 25%;esophageal perforation (% of patients) — 0%, 5%,0%, and 50%; hospital stay (hrs)-26 ± 8, 38± 25, 26 ± 11, and 72 ± 65; andexcellent/good results (% of patients) — 87%, 95%, 100%, and50%. These results show that: (1) previous pneumaticdilatation did not affect the results of myotomy; (2) inpatients who did not respond to botulinum toxin, the myotomy was technically straightforward and theoutcome was excellent; (3) in patients who responded tobotulinum toxin, the LES muscle had become fibrotic(perforation occurred more often in this setting, and dysphagia was less predictably improved);and (4) myotomy relieved dysphagia in 91% of patientswho had not been treated with botulinum toxin. Thesedata support a strategy of reserving botulinum toxin for patients who are not candidates forpneumatic dilatation or laparoscopic Hellermyotomy.

Esophageal dysmotility and gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) produces a spectrum of symptoms ranging from mild to severe. While the role of the lower esophageal sphincter in the pathogenesis of GERD has been studied extensively, less attention has been paid to esophageal peristalsis, even though peristalsis governs esophageal acid clearance. The aim of this study was to evaluate the following in patients with GERD: (1) the nature of esophageal peristalsis and (2) the relationship between esophageal peristalsis and gastroesophageal reflux, mucosal injury, and symptoms. One thousand six consecutive patients with GERD confirmed by 24-hour pH monitoring were divided into three groups based on the character of esophageal peristalsis as shown by esophageal manometry: (1) normal peristalsis (normal amplitude, duration, and velocity of peristaltic waves); (2) ineffective esophageal motility (IEM; distal esophageal amplitude <30 mm Hg or >30% simultaneous waves); and (3) nonspecific esophageal motility disorder (NSEMD; motor dysfunction intermediate between the other two groups). Peristalsis was classified as normal in 563 patients (56%), IEM in 216 patients (2l%), and NSEMD in 227 patients (23%). Patients with abnormal peristalsis had worse reflux and slower esophageal acid clearance. Heartburn, respiratory symptoms, and mucosal injury were all more severe in patients with IEM. These data show that esophageal peristalsis was severely impaired (IEM) in 21 % of patients with GERD, and this group had more severe reflux, slower acid clearance, worse mucosal injury, and more frequent respiratory symptoms. We conclude that esophageal manometry and pH monitoring can be used to stage the severity of GERD, and this, in turn, should help identify those who would benefit most from surgical treatment.

Role of esophageal function tests in diagnosis of gastroesophageal reflux disease

Clinicians typically make the diagnosis of gastroesophageal reflux disease (GERD) from the clinical findings and then prescribe acid-suppressing drugs. Endoscopy is usually done for persistent or severe symptoms. Esophageal function tests (EFTs: esophageal manometry and 24-hr pH monitoring) are generally reserved for patients who have the most severe disease, including those being considered for surgery. We hypothesized that EFTs are more accurate than symptoms and endoscopy in the diagnosis of GERD. This was a retrospective study undertaken in a university tertiary care center. Between October 1989 and November 1998, 822 patients with a clinical diagnosis of GERD (based on symptoms and endoscopic findings) were referred for EFTs. The patients were divided into two groups depending on whether the 24-hr pH monitoring score showed GERD (group A, GERD−; group B, GERD+). The groups were compared with respect to the incidence and severity of symptoms, presence of a hiatal hernia on barium x-rays, presence and severity of esophagitis on endoscopy, and esophageal motility. In all, 247 patients (30%) had normal reflux scores (group A, GERD−), and 575 patients (70%) had abnormal scores (Group B, GERD+). Eighty percent of group A and 88% of group B had been treated with acid-suppressing medications. The incidence of heartburn and regurgitation was similar in the two groups. Grade I–II esophagitis was diagnosed by endoscopy in 25% of group A and 35% of group B, and grade III esophagitis in 4% of group A and 11% of group B. Esophageal manometry showed that group B more often had esophageal dysmotility, consisting of a hypotensive lower esophageal sphincter and abnormal esophageal peristalsis. These data show that: (1) symptoms were unreliable for diagnosing GERD; (2) endoscopic evidence of grade I–II esophagitis was diagnostically nonspecific, and grade III was much less certain than claimed in other reports; and (3) pH monitoring identified patients with GERD and stratified them according to the severity of the disease. We conclude that esophageal manometry and pH monitoring are important in diagnosing GERD accurately. More liberal use of these tests early in patient management would avoid much improper and costly medical therapy and would help single out for special attention the patients with GERD who have the most severe disease.

Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated.

AbstractBackground: It has been said that a Heller myotomy cannot improve dysphagia in achalasia when the esophagus is markedly dilated or sigmoid shaped. Those who hold this belief recommend esophagectomy as the primary treatment in such cases. This study aimed to compare the results of laparoscopic Heller myotomy combined with Dor fundoplication in 66 patients with and without esophageal dilatation, all of whom had achalasia. Methods: On the basis of the maximal diameter of the esophageal lumen and the shape of the esophagus, the patients were placed into four groups: group A (esophageal diameter <4.0 cm; 26 patients), group B (diameter 4.0–6.0 cm; 21 patients), group C1 (diameter >6.0 cm and straight esophageal axis; 12 patients), and group C2 (diameter >6.0 cm and sigmoid-shaped esophagus; 7 patients). All patients underwent a laparoscopic Heller myotomy and Dor fundoplication. Results: The duration of the operation and the length of hospital stay were similar among the four groups. Excellent or good results were obtained in 88% of group A, 100% of group B, 83% of group C1, and 100% of group C2. No patient in this consecutive series ultimately required an esophagectomy. Conclusions: In patients with achalasia who have esophageal dilation, a laparoscopic Heller myotomy and Dor fundoplication (a) took no longer and was no more difficult, (b) was associated with no more postoperative complications, and (c) gave just as good relief of dysphagia. We conclude that esophageal dilation by itself should rarely serve as an indication for esophagectomy rather than myotomy as the initial surgical treatment.

Laparoscopic Heller myotomy relieves dysphagia in patients with achalasia and low LES pressure following pneumatic dilatation

Background: Although pneumatic dilatation is said to relieve dysphagia in achalasia if it decreases lower esophageal sphincter (LES) pressure to <10 mmHg, dysphagia persists in some cases. Performing a Heller myotomy in this setting has been challenged on the assumption that everything possible has already been done to eliminate the barrier posed by the malfunctioning sphincter. Therefore, we set out to assess the results of laparoscopic Heller myotomy and Dor fundoplication in achalasia in relation to LES pressure. Methods: Fifty-seven patients with achalasia were divided into the following three groups, based on the LES pressure and previous treatment: group A, previous balloon dilatation and LES pressure ?10 mmHg (n = 9); group B, previous balloon dilatation and LES pressure >10 mmHg (n = 23); group C, no previous balloon dilatation and LES pressure >10 mmHg (n = 25). All patients underwent a laparoscopic Heller myotomy and Dor fundoplication. The severity of dysphagia was gauged on a scale of 0-4. Results: In group A, LES pressure was 7 ± 2 mmHg preoperatively and 8 ± 3 mmHg postoperatively; the dysphagia score was 3.3 ± 0.7 preoperatively and 0.9 ± 1.1 postoperatively. Eighty-nine percent of patients had excellent or good results. In group B, LES pressure was 23 ± 8 mmHg preoperatively and 10 ± 1 mmHg postoperatively; the dysphagia score was 3.3 ± 0.7 preoperatively and 0.3 ± 0.5 postoperatively. All patients had excellent or good results. In group C, LES pressure was 23 ± 11 mmHg preoperatively and 14 ± 12 mmHg postoperatively; the dysphagia score was 3.6 ± 0.6 preoperatively and 0.2 ± 0.5 postoperatively. All patients had excellent or good results. Conclusions: These results show that (a) a LES pressure of <10 mmHg after pneumatic dilatation does not guarantee relief of dysphagia, and (b) laparoscopic Heller myotomy relieves dysphagia in most patients with a postdilatation LES pressure <10 mmHg. Thus, a laparoscopic Heller myotomy is indicated if dilatation does not relieve dysphagia, even if LES pressure has been decreased to <10 mmHg. Esophagectomy should be reserved for the occasional failure of this simpler operation.

Esophageal achalasia: Preoperative assessment and postoperative follow-up

ConclusionsA complete preoperative evaluation is a key element of a successful operation. With experience, the number of patients with persistent dysphagia due to technical factors decreases. In our experience, the incidence of postoperative dysphagia was 2 3 % among 43 patients operated on between 1991 and 1994 but only 3% among 12.5 patients who had a laparoscopic Heller myotomy and Dor fundoplication between 1995 and 1998. Close follow-up is of paramount importance to identify and treat appropriately patients with recurrent dysphagia.

Laparoscopic Esophageal Myotomy

The past 10 years have seen a tremendous evolution in the treatment of esophageal achalasia. We believe that the results obtained by minimally invasive surgery have convincingly put to rest the controversy between pneumatic dilatation and Heller myotomy. A laparoscopic Heller myotomy and partial fundoplication should be considered today the first line of treatment for patients with achalasia, relegating pneumatic dilatation to a secondary role for failures of surgery or when adequate surgical expertise is not available.