Operation for Achalasia
Luigi Bonavina, Alberto Peracchia
Introduction
In 1913 Heller reported the first esophageal myotomy for achalasia through a left thoracotomy. Over the years, the transabdominal approach has been extensively adopted, especially in Europe. More recently, laparoscopy has emerged as the initial intervention of choice in several institutions throughout the world.
The operation consists of complete division of the two layers of esophageal muscle (longitudinal and circular fibers) and of the oblique fibers at the esophagogastric junction. A further step of the transabdominal procedure is the construction of an antireflux valve, most commonly an anterior fundoplication according to Dor.
Indications and Contraindications
Indications
■In patients with documented esophageal achalasia, regardless of the disease’s stage
Contraindications
■Not deemed fit for general anesthesia and in those with:
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Significant co-morbidity
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Short life expectancy in whom pneumatic dilation or botulinum toxin injection represent a more reasonable therapeutic option
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Extensive intra-abdominal adhesions from previous upper abdominal surgery can make the laparoscopic approach hazardous
Preoperative Investigation/Preparation for the Procedure
History and clinical evaluation: Duration of dysphagia, nutritional status Chest X-ray: Atelectasis, fibrosis (s/p aspiration pneumonia) Barium swallow study: Degree of esophageal dilatation and lengthening Esophageal manometry: Non-relaxing lower esophageal sphincter,
lack of peristalsis
Endoscopy: Rule out esophageal mucosal lesions, Candida colonization, associated gastroduodenal disease CT scan and/or endoscopic
ultrasound (EUS) in selected
patients: Rule out pseudoachalasia (malignancy-induced) Insert a double-lumen nasogastric tube 12h before surgery to wash and clean the esophageal lumen from food debris
Short-term antibiotic and antithrombotic prophylaxis
Laparoscopic Procedure
For details on access, see chapter “Laparoscopic Gastrectomy.”
STEP 1 Exposure
Incision of the phrenoesophageal membrane. Dissection is limited to the anterior surface of the esophagus and of the diaphragmatic crura to prevent postoperative reflux by preserving the anatomical relationships of the cardia. The cardia is mobilized only in patients with sigmoid esophagus; in such circumstances, it is preferable to reduce the redundancy in the abdomen and to close the crura posteriorly.
STEP 2 Heller myotomy
The Heller myotomy is started on the distal esophagus using an L-shaped hook until identification of the submucosal plane.
The myotomy is extended on the proximal esophagus for about 6cm using insulated scissors, a Harmonic Scalpel, or Ligasure device.
The myotomy is extended on the gastric side including the oblique fibers for about 2cm using the L-shaped hook.
140 SECTION 2 Esophagus, Stomach and Duodenum
STEP 3 Intraoperative endoscopy
Intraoperative endoscopy aids in evaluating the length of the myotomy, dividing residual muscle fibers, and checking the patency of the esophagogastric junction. This is most helpful in patients previously treated by pneumatic dilation or botulinum toxin injec- tion.
STEP 4 Construction of the Dor fundoplication
The anterior fundic wall is sutured with three interrupted stitches (Prolene for extracor- poreal knots, Ethibond for intracorporeal knots) to the adjacent left muscle edge of the myotomy. The most cranial stitch incorporates the diaphragmatic crus.
STEP 5 Security of the fundic wall
A more lateral portion of the anterior fundic wall is secured with three interrupted stitches to the right muscle edge of the myotomy and to the left diaphragmatic crus.
Operation for Achalasia 141
Standard Postoperative Investigations
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Gastrografin swallow on postoperative day 1 to check for esophagogastric transit and absence of leaks
Postoperative Complications
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Persistent dysphagia
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Delayed esophageal emptying
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Recurrent dysphagia
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Esophagectomy may be required in patients with decompensated sigmoid megaesophagus
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Gastroesophageal reflux
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Evidence of stricture may require mechanical dilatation followed by vagotomy and total duodenal diversion
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Leak after undetected perforation
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Consider endoscopic stenting and percutaneous CT-guided drainage
Tricks of the Senior Surgeon
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Once the submucosal plane has been identified, use a pledget swab to create a tunnel before cutting the muscle upward.
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Bleeding from the muscle edges of the myotomy is self-limiting; it is wise to avoid excessive electrocoagulation and to compress with a warm gauze for a few minutes.
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