292
36
Fundoplication after Laparoscopic Myotomy for Achalasia
Fernando A. Herbella and Marco G. Patti
only 5mm onto the gastric wall.2 The rationale for this approach (followed by most surgeons in North America) was to make the myotomy long enough to relieve dysphagia but short enough to avoid refl ux and therefore the need for a fundo- plication. The results published by Ellis seemed to confi rm the soundness of this approach: in a review of his 22-year experience with 197 patients he documented symptomatic refl ux in only 9 (5%) of them.2 The problem with his analysis, however, was that it was based on symptom eval- uation only (presence of heartburn) rather than objective evaluation of the refl ux status by pH monitoring. Many studies have, in fact, shown that most patients who develop refl ux after a Heller myotomy do not experience heartburn, so that the symptomatic evaluation usually under- estimates the real incidence of refl ux.6,7 As a matter of fact, when the same author used manometry and pH monitoring to objectively assess gastroesophageal refl ux after short myo- tomy, he found abnormal esophageal acid expo- sure in 29% of patients.8
Contrary to the trans-thoracic approach used in North America, surgeons in Europe9 and South America10 traditionally used a transabdominal approach, performing a longer myotomy onto the gastric wall in combination with an anti-refl ux procedure. For instance, in 1992 Bonavina and colleagues reported the long-term results of myotomy and Dor fundoplication in 206 patients with achalasia operated between 1976 and 1989.
Excellent or good results were obtained in 94% of patients while the rate of postoperative refl ux measured by pH monitoring was 8.6% only.9 Esophageal achalasia is a primary esophageal
motility disorder of unknown origin character- ized by lack of esophageal peristalsis and inabil- ity of the lower esophageal sphincter (LES) to relax properly in response to swallowing. The goal of treatment is to relieve the functional obstruction caused by the LES, therefore allow- ing emptying of food into the stomach by gravity.
However, the elimination of the LES may be fol- lowed by refl ux of gastric contents into the aperi- staltic esophagus, with slow clearance of the refl uxate and the risk of developing esophag- itis, strictures, Barrett’s esophagus, and even adenocarcinoma.1–4
The following chapter reviews the results of surgery for achalasia, describing what is consid- ered today the best procedure to achieve the goal of relieving dysphagia while avoiding develop- ment of refl ux.
36.1. Treatment of Esophageal Achalasia: The Open Era
During the 1970s and 1980s, pneumatic balloon dilatation was considered the primary form of treatment for achalasia. During that period, only an average 1.5 Heller myotomies were performed each year in our tertiary care hospital as well as in other centers, mostly for patients whose dys- phagia did not improve with balloon dilatation or whose esophagus was perforated during a balloon dilation.5 We followed Ellis’ technique and used a left trans-thoracic approach to perform a Heller myotomy which extended for
36.2. Treatment of Esophageal Achalasia: The Minimally Invasive Surgery Era
Shimi and Cuschieri fi rst reported in 1991 the performance of a Heller myotomy for esophageal achalasia by minimally invasive techniques.11 In 1992 we described our initial experience with a thoracoscopic Heller myotomy.12 We initially used the technique developed by Cuschieri,11 which we modifi ed as we gained experience, and performed a left thoracoscopic myotomy (with the guidance of intraoperative endoscopy) which extended for only 5mm onto the gastric wall. The long-term follow-up in the fi rst 30 patients who underwent a left thoracoscopic Heller myotomy confi rmed the excellent outcome of the initial report: almost 90% of patients had relief of dys- phagia, the hospital stay was short, the postop- erative discomfort was minimal, and the recovery was fast. However, some shortcomings of the tho- racoscopic technique soon became apparent, particularly when compared to the laparoscopic approach13:
• Poor exposure of the gastroesophageal junc- tion, particularly important when trying to extend the myotomy onto the gastric wall for 5mm only. Excellent exposure by the laparo- scopic approach.
• Cumbersome intraoperative management (double lumen endotracheal tube, right lateral decubitus position, intraoperative endoscopy).
Very simple for the laparoscopic approach.
• Postoperative discomfort due to the chest tube.
• High incidence of postoperative refl ux and inability to correct preexisting refl ux from pneumatic dilatation. We found that a thoraco- scopic myotomy was associated to refl ux in 60% of patients studied postoperatively by pH monitoring. We also encountered patients who already had abnormal refl ux secondary to dila- tation even though they still experienced dys- phagia. Some of these patients had very low LES pressure.14
These were probably the key reasons that made us switch to a laparoscopic myotomy and Dor fundoplication as suggested by Ancona and col-
leagues,15 in the attempt to fi nd a balance between relieving dysphagia and avoiding postopera- tive refl ux. Similar fi ndings about postoperative refl ux after transthoracic myotomy and the deci- sion to switch to a laparoscopic myotomy and fundoplication were reported by others.16,17
36.3. Laparoscopic Heller Myotomy:
Is a Fundoplication Necessary?
It is generally accepted that a fundoplication is necessary to prevent refl ux after a laparoscopic Heller myotomy, by either performing a Dor fun- doplication,18–24 a Toupet fundoplication,25–28 or a Nissen fundoplication.29–31
This approach is based on some retrospective studies and two prospective, randomized trials comparing laparoscopic myotomy alone versus myotomy and fundoplication. Kjellin and col- leagues found abnormal refl ux by pH monitor- ing in 8 of 14 (57%) patients after laparoscopic myotomy without fundoplication.32 Five of the 8 patients (62%) were asymptomatic. Similarly, Burpee and colleagues documented refl ux (by pH monitoring or endoscopy) in 18 of 30 patients (60%) after laparoscopic Heller myotomy without fundoplication.33 Thirty-nine percent of patients with refl ux were asymptomatic. Gupta and col- leagues reported heartburn after laparoscopic myotomy in 80% of their patients. They felt that it was not a problem as symptoms were well con- trolled with medications.34
The observation of a very high incidence of refl ux after laparoscopic myotomy alone has also been confi rmed by two prospective and random- ized trials. In 2003, Kalkenback and colleagues reported the results of a prospective, randomized trial comparing myotomy alone versus myotomy and Nissen fundoplication.29 Postoperative refl ux was present in 25% of patients who had a myotomy and fundoplication but in 100% of patients who had a myotomy alone. Twenty percent of the patients in the latter group developed Barrett’s esophagus. In 2004, Richards and colleagues reported the results of a prospective, randomized trial comparing laparoscopic myotomy alone versus laparoscopic myotomy and Dor fundopli- cation.24 Postoperative ambulatory pH monitor- ing showed refl ux in 48% of patients after
myotomy alone but in only 9% of patients when a Dor fundoplication was added to the myotomy.
The incidence and the score of postoperative dys- phagia were similar in the two groups.
These data can be summarized as follows:
• Myotomy alone is followed by a high incidence of postoperative refl ux, which is asymptomatic in most cases.
• A fundoplication prevents refl ux in the major- ity of patients.
• It is dangerous to claim that postoperative refl ux does not matter and that nothing should be done to prevent it. Today we are operating on many young patients35 who may develop severe esophageal damage if exposed to years of refl ux.1–4
Based on these data we feel that a fundoplica- tion should be performed after a laparoscopic Heller myotomy (level of evidence 1+ to 3; recom- mendation grade B).
tion. This decision was based on the results of long-term studies which showed that esophageal decompensation and recurrence of symptoms eventually occurs in most patients.37–41 For instance, Duranceau and colleagues initially reported excellent results with a Heller myotomy and total fundoplication.39 Ten years later, however, they noted that symptoms had recurred in 14 of 17 patients (82%), fi ve of whom required a second operation.40 They felt that over time the total fundoplication determines a progressive increase in esophageal retention with poor emp- tying and recurrence of symptoms. They were able to correct this problem by switching to a partial fundoplication.41
Today a laparoscopic Heller myotomy with partial fundoplication is considered the proce- dure of choice for esophageal achalasia, as it attains the best balance between relief of dyspha- gia and prevention of refl ux.42
Based on these data we feel that a partial rather than a total fundoplication should be performed after a laparoscopic Heller myotomy (level of evi- dence 2++ to 4; recommendation grade C).
A fundoplication should be performed after a laparoscopic Heller myotomy (level of evi- dence 1+ to 3; recommendation grade B).
36.4. Which Fundoplication? Partial Versus Total Fundoplication
It has been shown that a laparoscopic total (360º) fundoplication is the procedure of choice in patients with gastroesophageal refl ux disease.
When compared to a partial fundoplication, a total fundoplication determines a better control of refl ux without a higher incidence of postopera- tive dysphagia, even when esophageal peristalsis is weak.36 In esophageal achalasia, however, the pump action of the esophageal body is completely missed, as there is no peristalsis. Therefore, a total fundoplication might determine too much of a resistance at the level of the gastroesophageal junction, impeding the emptying of food from the esophagus into the stomach by gravity, and eventually causing persistent or recurrent dysphagia. Albeit some groups still claim good results adding a total fundoplication after a myotomy,29–31 others have abandoned this approach and switched to a partial fundoplica-
A partial fundoplication is superior to a total fundoplication after a laparoscopic Heller myotomy (level of evidence 2++ to 4; recom- mendation grade C).
36.5. Partial Fundoplication: Anterior Versus Posterior
There are no published prospective, randomized trials comparing a partial posterior (Toupet) versus an anterior (Dor) fundoplication in asso- ciation to a Heller myotomy in patients with achalasia. Some groups feel that a posterior fun- doplication is better as it keeps the edges of the myotomy separated and it is a more effective anti-refl ux operation.25–28 Others, however, feel that a Dor fundoplication is simpler to perform as it does not need posterior dissection, and it adds the advantage of covering the exposed mucosa.18–24
Our philosophy at the University of California, San Francisco during the last 12 years has been to perform a laparoscopic Heller myotomy and
Dor fundoplication.43 The myotomy is about 9cm in length and extends for about 2cm onto the gastric wall. Intraoperative endoscopy is helpful at the beginning of a surgeon’s experience to gauge the extent of the myotomy onto the gastric wall in respect to the squamous–columnar junc- tion, as seen by endoscopy. However, once the surgeon has gained experience with the anatomy from a laparoscopic perspective, it can be omitted.
After the short gastric vessels are divided, an anterior 180º fundoplication (Dor) is performed.
There are two rows of sutures, one right and one left. The left row has three stitches: the fi rst stitch incorporates the stomach, the esophagus, and the left pillar of the crus. The second and the third stitch incorporate only the stomach and the esophageal wall. Subsequently, the fundus is folded over the exposed mucosa, so that the greater curvature of the stomach is next to right pillar of the crus. Similar to the left the row, the right row has three stitches and only the upper- most stitch incorporates the fundus, the esopha- gus, and the right pillar of the crus. Finally, two additional stitches (apical stitches) are placed between the anterior rim of the esophageal hiatus and the superior aspect of the fundoplication.
After laparoscopic Heller myotomy and Dor fun- doplication, excellent or good results for dyspha- gia were obtained in 91% of patients, with a 15%
incidence of postoperative refl ux.43
Based on the available data, it is not possible to give a recommendation regarding the type of partial fundoplication (anterior vs. posterior) to be added after a laparoscopic Heller myotomy for achalasia.
has brought a radical shift in practice, as surgery has become the preferred treatment modality of most gastroenterologists and other referring phy- sicians. During the last 5 years, we have noted a 15-fold increase in the number of patients referred for surgery every year. In addition, the gradual increase in the number of referred patients has been paralleled by an increase in the number of patients referred without previous treatment.44 This remarkable change has followed docu- mentation that laparoscopic myotomy outper- forms balloon dilatation and botulinum toxin injection.45,46
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