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Laparoscopic Heller myotomy and Dor fundoplication for treatment of achalasia

  • Thomas W. Rice
    Correspondence
    Address reprint requests to Thomas W. Rice, MD, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195 USA
    Affiliations
    Division of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
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      Achalasia is a degenerative esophageal disease culminating in aperistalsis of the esophageal body and abnormal relaxation of the lower esophageal sphincter. The underlying cause of this T-cell mediated destruction and fibrous replacement of the esophageal myenteric neural plexus is unknown.
      • Goldblum J.R.
      • Whyte R.I.
      • Orringer M.B.
      • et al.
      Achalasia. A morphologic study of 42 resected specimens.
      ,
      • Goldblum J.R.
      • Rice T.W.
      • Richter J.E.
      Histopathologic features in esophagomyotomy specimens from patients with achalasia.
      ,
      • Clark S.B.
      • Rice T.W.
      • Tubbs R.R.
      • et al.
      The nature of the myenteric infiltrate in achalasia an immunohistochemical analysis.
      Neural function cannot be restored. Therefore, treatment is palliative and directed toward symptom control and preservation of the esophagus as a passive conduit. The treatment principle requires reduction of lower esophageal sphincter pressure while minimizing gastroesophageal reflux. This can be affected laparoscopically by modified Heller myotomy and Dor (partial anterior) fundoplication.

      Surgical technique

      Figure thumbnail GR3
      1The patient is placed in lithotomy position. The surgeon is positioned between the patient’s legs. The cameraman stands to the patients right and the first assistant to the patient’s left.
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      2Using the Hassan technique, a 10-mm port is placed in the mid-line below the xiphoid process, Math Eq to Math Eq of the distance to the umbilicus. Carbon dioxide is insufflated to produce a pneumoperitoneum with intraabdominal pressure limited to 15-mm Hg. A 10-mm 30-degree laparoscope is passed through this port and the abdominal cavity visually inspected. Three 5-mm ports are placed under laparoscopic view: first, in the right upper quadrant below the costal arch (for liver retraction); next, in the midline just below the xiphoid process (for the surgeon’s left hand instrument); and, finally, along the left axillary line in the left lower quadrant (for gastric retraction). In the left upper quadrant, triangulated between the two-midline ports, the fifth port, a 10-mm port (for the surgeon’s right hand) is placed. The patient is positioned in a reverse Trendelenburg position allowing the bowel and other mobile abdominal contents to occupy the lower portions of the abdomen, providing a degree of “self retraction.” (Color version of figure is available online.)
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      3The left lateral segment of the liver is retracted superiorly. The clear space (pars lucida) in the lesser omentum over the caudate lobe of the liver is opened. Using the harmonic scalpel, the lesser omentum is divided superiorly to the patient’s right of the esophagus. This exposes the right crus of the esophageal hiatus. Dissection may require division of the hepatic branch of the vagus nerve and an arterial branch of the left gastric artery to the left lateral segment of the liver. (Color version of figure is available online.)
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      4The peritoneum overlying the right crus is divided with the harmonic scalpel. Blunt mobilization is performed from the inferior portion of the right crus, where it merges with the left crus, to the apex of the hiatus. The esophagus and posterior vagus nerve are retracted to the patient’s left, facilitating the dissection. (Color version of figure is available online.)
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      6The superior aspect of the left crus is dissected from the apex of the esophageal hiatus inferiorly to meet the mobilization described in .
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      5With the esophagogastric junction retracted superiorly, the inferior and medial portions of the left crus are bluntly dissected. (Color version of figure is available online.)
      This completes the hiatal dissection. These three steps indirectly mobilize the esophagus and may potentially reduce inadvertent esophagogastric injury. The esophagus is encircled with a penrose drain (18 cm long) which aids in retraction, and permits completion of the hiatal dissection.
      Theoretically, since the myotomy is performed on the anterior gastrointestinal wall, the hiatal and esophageal mobilization are not necessary. The mobilization of the esophagus is significant and destroys at least Math Eq of the anchoring phrenoesophageal ligament. However, especially in elderly patients, there frequently is an associated hiatal hernia which will require simultaneous repair. In addition, the stabilization and retraction provided by the penrose drain facilitates myotomy. (Color version of figure is available online.)
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      7A 60 Fr. Maloney bougie is passed to assist myotomy. In the dilated sigmoid esophagus, blind passage of a bougie may not be possible; this requires esophagoscopy and placement of a guide wire over which a guided (Savary) bougie may be passed.
      The harmonic scalpel is used to divide the fat pad in the midline over the esophagogastric junction. The anterior vagus nerve will now lie on the patient’s left in this esophagogastric tissue. The myotomy begins on the anterior wall of the esophagus approximately 2 cm above the esophagogastric junction. The longitudinal layer of the muscularis propria is split. This exposes the circular muscle, which can fractured by distraction between Maryland dissectors. The submucosa is uncovered. The identification of the plane between the muscularis propria and the submucosa is critical for successful myotomy. Although saline injection into the esophageal wall has been proposed as an aid to development of this plane, it is unnecessary and may, in fact, distort the anatomy and foster submucosal injury. The myotomy extends superiorly to the junction of the thoracic and abdominal esophagus and inferiorly to the esophagogastric junction by careful traction and fracture of the muscle layer. Electrocautery can be used in this process; however, care must be taken to avoid thermal injury to the submucosa that may result in a delayed esophageal leak. Usually, direct pressure on the bleeding muscle edge and pinpoint cautery of muscular vessels is sufficient for hemostasis. Since the extent of sonic injury to the submucosa is not appreciated at the time of myotomy the harmonic scalpel should not be used in this portion of the operation.
      Although prior pneumatic dilation or Botulinum toxin injection has not been shown to affect outcome,these treatments may obliterate the plane between the muscularis propria and submucosa.If the initial site chosen for myotomy is at an unappreciated focus of fibrosis from prior treatment then the myotomy should be restarted laterally, in a new location, potentially removed from the site of previous therapy. (Color version of figure is available online.)
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      8The key to relief of esophageal obstruction is the extension of the myotomy onto the stomach for 2 cm to 3 cm. Extending the myotomy here becomes extremely difficult because the muscle thins in this area and develops an oblique orientation. The appearance of transverse submucosal veins confirms that the proximal stomach is being myotomized. If these vessels are inadvertently injured, they should be controlled with vascular clips, not electrocautery. (Color version of figure is available online.)
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      9Esophagogastroscopy verifies adequate length of the myotomy and integrity of the mucosa/submucosa layer. The use of the picture-in-picture function of the video monitor allows simultaneous viewings of the myotomy by esophagoscopy and by laparoscopy. Using this technique, myotomy length can be measured and sufficient gastric extension confirmed. Visual inspection of the mucosa and insufflation of the esophagogastric junction, while the area is immersed in saline will prove, the layer intact and airtight. This step is facilitated if the patient is placed in Trendeleberg position. (Color version of figure is available online.)
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      10The esophageal hiatus is reapproximated by direct closure using nonabsorbable sutures of 0 or 1 size. The ideal suture length is 18 cm. (Color version of figure is available online.)
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      11The construction of the Dor (partial anterior) fundoplication begins with the placement of a nonabsorbable 0 suture (22 cm long). This passes from the greater curve of the stomach to the left crus, close to its superior limit and to the left myotomy edge. This suture is tied with an intracorporeal technique that forms the left edge of the fundoplication. (Color version of figure is available online.)
      Figure thumbnail GR13
      12The right side of the fundoplication is formed by a suture (18 cm long) passed from the gastric fundus (approximately 5 cm to 6 cm medial to the previous suture in the greater curve) to the right myotomy edge and to the right crus, close to its superior limit. A third suture (18 cm long) is placed from the superior aspect of the midportion of the fundoplication to the apex of the esophageal hiatus. (Color version of figure is available online.)
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      13The completed Dor fundoplication. Incorporation of myotomy borders into the fundoplication distracts the myotomy and prevents healing of muscle edges together. The apposition of the gastric wall to the esophageal submucosa in the base of the myotomy provides a “serosal patch” that potentially protects against leak from a microperforation. (Color version of figure is available online.)
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      15Relief of symptoms provides an inaccurate evaluation of treatment.
      • Vaezi M.F.
      • Baker M.E.
      • Richter J.E.
      Assessment of esophageal emptying post-pneumatic dilation Use of the timed barium esophagram.
      ,
      • Torbey C.F.
      • Achkar E.
      • Rice T.W.
      • et al.
      Long-term outcome of achalasia treatment The need for closer follow-up.
      Timed barium esophagram gives a quantifiable assessment of esophageal emptying. In the patient described in ,
      Figure thumbnail GR2
      14Timed barium esophagram is important for both diagnosis of achalasia and therapy assessment.
      • de Oliveira J.M.
      • Birgisson S.
      • Doinoff C.
      • et al.
      Timed barium swallow A simple technique for evaluating esophageal emptying in patients with achalasia.
      ,
      • Kostic S.V.
      • Rice T.W.
      • Baker M.E.
      • et al.
      Timed barium esophagogram A simple physiologic assessment for achalasia.
      ,
      • Vaezi M.F.
      • Baker M.E.
      • Richter J.E.
      Assessment of esophageal emptying post-pneumatic dilation Use of the timed barium esophagram.
      A 39 year-old female with a 2-year history of dysphagia and regurgitation was misdiagnosed as gastroesophageal reflux. Ingestion of 250 mL of barium demonstrated a dilated, poorly emptying esophagus. At 1 minute, the entire extent of barium retention cannot be seen on one standard radiographic film. The height of the barium column is an estimated 18 cm (froth, which is barium coated saliva, is not included in this measurement) and the maximum width of the column is 10 cm. At 5 minutes there has been minimal emptying, with a barium column height of 17 cm and a width of 9 cm. Esophageal manometry confirmed the diagnosis of achalasia.
      eight weeks after laparoscopic Heller myotomy and Dor fundoplication, ingestion of 250 mL of barium demonstrated improved esophageal emptying with a 5 cm by 4 cm column at 1 minute and complete emptying by 5 minutes.
      Figure thumbnail GR16
      1624-hour pH monitoring is necessary to confirm an adequate antireflux barrier. Because esophageal acid clearance is impaired in patients with achalasia, and, because peptic stricture is a potential complication of aggressive myotomy, it is imperative to prove the absence of gastroesophageal reflux. Aggressive acid control with proton-pump inhibitors is indicated for patients with pathologic reflux. In the previous patient, 24-hour pH monitoring 8 weeks postoperatively showed minimal reflux with 0.9% total acid exposure (normal <5.5%), 0.4% upright reflux (normal <8.2%) and 2.1% supine reflux (normal <3.0%).

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