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Laparoscopic Heller myotomy with Toupet fundoplication for achalasia straightens the esophagus and relieves dysphagia
The American Journal of Surgery 192 (2006) 1– 8
Clinical surgery–International
Laparoscopic Heller myotomy with Toupet fundoplication for achalasia straightens the esophagus and relieves dysphagia Natsuya Katada, M.D.*, Shinichi Sakuramoto, M.D., Nobuyuki Kobayashi, M.D., Nobue Futawatari, M.D., Shinichi Kuroyama, M.D., Shiro Kikuchi, M.D., Masahiko Watanabe, M.D. Department of Surgery, School of Medicine, Kitasato University, 2-1-1, Asamizodai, Sagamihara, Kanagawa, 228-8520, Japan Manuscript received September 23, 2005; revised manuscript January 15, 2006
Abstract Background: A standard procedure for the treatment of achalasia remains to be established. We assessed the usefulness of a laparoscopic Heller myotomy with a Toupet fundoplication (LHT). Methods: LHT was performed in 30 patients (12 men, 18 women; mean age, 41.8 y) who had esophageal achalasia with severe dysphagia. Caution was exercised when the esophagus was pulled downward and straightened. Symptoms and esophageal function were evaluated before and after surgery. Results: The esophagus was straightened surgically in 22 (88%) of 25 patients with esophageal curvature on preoperative esophagography. The dysphagia score decreased to 1.7 ⫾ 1.2 (mean ⫾ SD) points from a preoperative value of 10. The lower esophageal sphincter pressure decreased significantly. Two patients (7%) had esophageal diverticula as postoperative sequelae. Pathologic acid reflex was noted in 3 patients (12%). Conclusions: LHT is a useful procedure for straightening the esophagus, reducing lower esophageal sphincter pressure, and relieving dysphagia in patients with achalasia. © 2006 Excerpta Medica Inc. All rights reserved. Keywords: Achalasia; Laparoscopic surgery; Heller myotomy; Toupet fundoplication
Esophageal achalasia has been attributed to degeneration of Auerbach’s plexus [1,2], but its cause remains unclear. Achalasia is characterized by impaired relaxation of the lower esophageal sphincter (LES). Secondary characteristics include increased LES pressure and the absence of esophageal body peristalsis [3,4]. Consequently, passage through the gastric cardia is impaired, leading to dysphagia. Medical therapy with drugs such as calcium-channel blockers usually cannot control the dysphagia associated with achalasia [4] or achieve cure. In contrast, procedures such as balloon dilatation and Heller myotomy are somewhat effective for dysphagia caused by impaired LES relaxation and increased LES pressure [5–10]. Dilation typically is performed with the use of a pneumatic dilator under fluoroscopic control [5,6]. At some centers the balloon is introduced directly through an endoscope and the LES is dilated * Corresponding author. Tel.: ⫹1-81-42-748-9111; fax: ⫹1-81-42745-5582. E-mail address: [email protected]
without fluoroscopic control [7]. However, a major drawback of dilation is that relief of dysphagia is transient, with many patients requiring repeated dilation [8]. In contrast, surgical therapy reliably relieves dysphagia and its effect is long lasting. Thus, surgery currently is considered the most effective treatment for achalasia [8,9]. The surgical procedure most commonly used to treat achalasia is the Heller myotomy, in which the muscle layer of the esophagus is incised from the distal esophagus to the proximal stomach [10]. However, 1 study reported that 48% of patients who undergo myotomy alone have gastroesophageal reflux during long-term follow-up evaluation [11]. There is now a general consensus that some type of antireflux procedure should be performed at the time of myotomy to prevent postoperative gastroesophageal reflux. Technically, antireflux procedures are easier to perform via a transabdominal rather than a transthoracic approach. In 1991, Shimi et al [12] introduced the laparoscopic Heller myotomy as a minimally invasive procedure for achalasia. Ancona et al [13] compared a laparoscopic Heller myotomy
0002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.01.027
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plus Dor fundoplication with the same procedure performed by conventional open surgery. They clearly showed that laparoscopic surgery was less invasive. Subsequently, various modified procedures for laparoscopic Heller myotomy have been reported. Many studies have performed laparoscopic Heller myotomy with an anterior partial fundoplication (Dor fundoplication) as an antireflux procedure [14 – 16]. However, others have reported that a posterior partial fundoplication (Toupet fundoplication) more effectively controls postoperative symptoms such as dysphagia [17–19]. A standard surgical procedure for the treatment of achalasia, including the use of open or laparoscopic surgery, thus remains a matter of debate. We performed a laparoscopic Heller myotomy with a Toupet fundoplication (LHT) in a series of patients with achalasia to evaluate the safety and usefulness of this procedure.
Methods Patients The study group comprised 30 patients (12 men, 18 women; mean age, 41.8 y; range, 23– 66 y) with achalasia who underwent LHT at the Department of Surgery at Kitasato University Hospital from October 1997 through October 2003. All patients had severe dysphagia. Achalasia was diagnosed definitively on the basis of impaired relaxation of the LES on esophageal manometry. No patient had a history of surgery, which potentially could cause adhesions in the upper abdomen. Endoscopic dilation was performed before surgery in 20 (67%) of the 30 patients, but symptoms did not resolve or improved only transiently. Surgical treatment thus was performed. The median follow-up period after surgery was 4 years and 3 months (range, 14 – 86 mo). Surgical procedure Patients were given nothing to eat or were given a liquid diet 1 to 2 days before surgery to eliminate solid food residue from the esophagus. Laxatives or enemas were used to promote defecation. Surgery was performed under general anesthesia. As shown in Fig. 1, a total of 5 trocars were placed in the upper abdomen, and pneumoperitoneum was created at a pressure of 8 mm Hg. The region around the abdominal esophagus was stripped to expose the left and right crura of the diaphragm. Then the anterior trunk of the vagal nerve was identified and preserved. Next, the esophagus was raised anteriorly, and a window was made in the posterior aspect of the esophagus to permit passage of the wrap used for fundoplication. The posterior trunk of the vagal nerve was preserved. Two or 3 short gastric vessels were divided with laparoscopic coagulating shears to mobilize the gastric fundus for fundoplication. Next, preparations were made for a Heller myotomy. A piece of cotton tape was passed through the window in the posterior aspect of the esophagus and
Fig. 1. Positions for placement of trocars for a laparoscopic Heller myotomy with a Toupet fundoplication (LHT). A 5-mm trocar and a snakeshaped retractor for retracting the liver (A), a 5-mm trocar and a forceps held in the surgeon’s left hand (B), a 12-mm trocar and a forceps held in the surgeon’s right hand (C), a 5-mm trocar and a forceps held by an assistant (D), and a 12-mm trocar and a laparoscope (oblique-viewing rigid scope) (E).
pulled caudally. First, the lower esophagus was pulled downward and a Heller myotomy was performed. While exercising caution not to damage the mucosa, the myotomy was extended 5 to 6 cm proximally from the gastroesophageal junction with the use of a hook cautery in the incision mode or laparoscopic coagulating shears. The myotomy then was extended 2 cm distally from the gastroesophageal junction (Fig. 2). Second, a Toupet fundoplication was performed as an antireflux procedure. The greater curvature of the gastric fundus was grasped with a grasping forceps that had been passed through the window in the posterior aspect of the esophagus. The stomach was pulled to the right along the dorsal aspect of the esophagus, and preparations were made for wrapping. The wrap was confirmed to be mobile and loose, exerting no tension on the cardia. The abdominal esophagus was confirmed to be stripped adequately toward the mediastinum. Then the esophagus was pulled downward and straightened. The wrap was sutured to the right crus of the diaphragm with two 3-0 polypropylene sutures (Prolene; Ethicon, Inc., Somerville, NJ). The wrap on the right side of the esophagus was sutured to the right cut edge of the muscularis with 3 interrupted sutures. The wrap on the left side of the esophagus was sutured to the left cut edge of the muscularis with 3 interrupted sutures. Finally, the wrap was sutured to the left crus of the diaphragm, completing a 270° posterior partial fundoplication (Toupet
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Esophagography All patients underwent esophagography before surgery and 1 year after surgery. The maximum transverse diameter of the esophagus and the type of esophageal dilatation were evaluated before and after surgery and were compared. Esophageal dilatation was classified into 3 types: spindle type (spindle-like tapering of the lower esophagus or a V-shaped lower esophagus, with no curvature of the esophagus), flask type (a flask- or U-shaped lower esophagus, with mild curvature of the esophagus), and sigmoid type (an S-shaped esophagus with severe curvature). Esophageal manometry Esophageal manometry was performed before surgery and 3 months after surgery in 28 of the 30 patients. Stationary manometry was performed using a 4-channel catheter and a low-compliance, pneumohydraulic capillary infusion system (Arndorfer Medical Specialties, Greendale, WI). The end-expiratory gastric pressure at baseline was regarded as 0. The resting pressure (mm Hg) of the LES was defined as the difference between the gastric pressure at Fig. 2. The Heller myotomy. Myotomy is extended 5 to 6 cm above the gastroesophageal junction and 2 cm below the gastroesophageal junction.
fundoplication) (Fig. 3). Before the completion of surgery an endoscope was inserted into the stomach and rotated 180° to confirm wrapping of the gastric cardia. Next, while withdrawing the endoscope, adequate depressurization of the myotomy site and no damage to the mucosa were confirmed. A drain was inserted near the myotomy and the trocars were removed. The wounds were closed to complete the surgery. Surgical methods We examined intraoperative blood loss, length of hospital stay after surgery, number of days until the start of oral intake after surgery, intraoperative and postoperative complications, and postoperative sequelae. In addition, symptoms and esophageal function were assessed prospectively on the basis of dysphagia score, esophagographic findings, esophageal manometry, and 24-hour esophageal pH as described later. Dysphagia score We assessed the degree of improvement in dysphagia by interviewing patients at the outpatient clinic 1 year after surgery. The patients were asked to evaluate their postoperative dysphagia score globally (encompassing both the intensity and frequency of dysphagia), as compared with a preoperative score of 10.
Fig. 3. Completed LHT. A Toupet fundoplication is performed as an antireflux procedure after a Heller myotomy. After the Heller myotomy, the mucosa at the anterior aspect of the esophagus is exposed to the peritoneal cavity.
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N. Katada et al. / The American Journal of Surgery 192 (2006) 1– 8
baseline and the midexpiration pressure at the highest point in the high-pressure zone. LES pressure was measured 4 times, and the mean value was recorded as the resting pressure of the LES. To determine the LES relaxation rate, a transducer was placed in the LES, and the patient was requested to wet swallow. The percent decrease in resting LES pressure on swallowing as compared with the baseline value was determined 4 times. The mean value was calculated to derive the LES relaxation rate. Esophageal body motility was assessed after placing the transducers 3, 8, 13, and 18 cm above the upper border of the LES. A series of 10 wet swallows were completed while recording pressures 3, 8, 13, and 18 cm above the LES. Monitoring of esophageal pH Three months after surgery, 24-hour monitoring of esophageal pH was performed in 25 of the 30 patients, using an antimony electrode and a portable pH recorder (Synectics Mark III Digitrapper; Medtronics, Minneapolis, MN). The pH probe was inserted transnasally and positioned 5 cm above the upper border of the manometrically defined LES. At the end of the 24-hour period, data from the Digitrapper were loaded into a computer and analyzed with the use of a commercially available software program (Esophagram Software Package; Medtronics). Gastroesophageal reflux was defined as abnormal if the pH was below 4 for more than 4% of the 24-hour period. Statistical analysis Data are expressed as means ⫾ SD. All variables before and after surgery were compared with the use of paired Student t tests. P values less than .05 were considered statistically significant.
Results No patient was converted from laparoscopic surgery to open surgery. Laparoscopic surgery was successful in all patients. The intraoperative blood loss was too small to measure in 20 patients (67%). The maximal blood loss was 60 mL. The median number of days until the start of oral intake after surgery was 2 (range, 1– 49 d). The median number of days in the hospital after surgery was 8.5 (range, 5–73 d). No patient died after surgery. Regarding intraoperative complications, 6 patients (20%) sustained thermal injury, measuring 2 to 5 mm in diameter, of the esophageal mucosa at the time of the Heller myotomy. However, their postoperative course was uneventful, apart from having to fast for 3 to 5 days after surgery. Four patients (13%) had esophageal perforation caused by intraoperative injury to the esophageal mucosa. The site of esophageal mucosal injury was sutured during surgery in 3 of these patients. Fasting was prolonged to 5 days after surgery, and their
Table 1 Maximum diameter of esophagus on esophagography, LES pressure on esophageal manometry, and LES relaxation rate before and after surgery
Maximum diameter of esophagus, cm LES pressure, mm Hg LES relaxation rate, %
Before
After
5.4 ⫾ 1.0 35.2 ⫾ 12.6 62.4 ⫾ 16.2
3.8 ⫾ 1.1* 15.0 ⫾ 6.7* 81.5 ⫾ 9.7*
* P ⬍ .001, preoperative versus postoperative value.
postoperative course was uneventful. In the other patient with esophageal perforation, the esophageal mucosa was injured when the most proximal site of the Heller myotomy was incised with laparoscopic coagulating shears. The esophageal perforation was not identified intraoperatively, and surgery was completed. On postoperative day 2, a left pneumothorax and pleural effusion developed, leading to empyema. Although fasting was required for 49 days after surgery, the patient’s condition improved with conservative treatment. Dysphagia did not worsen after surgery in any patient. The dysphagia score 1 year after surgery decreased significantly to 1.7 ⫾ 1.2 (mean ⫾ SD), as compared with a preoperative score of 10 (P ⬍ .001). The maximum transverse diameter of the esophagus on esophagography decreased significantly 1 year after surgery as compared with that before surgery (Table 1). Esophageal dilatation on preoperative esophagography was classified as spindle type in 5 patients, flask type in 17, and sigmoid type in 8. Of the 25 patients who preoperatively had flask-type or sigmoidtype dilatation with esophageal curvature, 22 (88%) showed spindle-type dilatation with straightening of the esophagus 1 year after surgery. All 17 patients who had flask-type dilatation before surgery showed improvement to spindle-type dilatation after surgery. Of the 8 patients who had sigmoidtype dilatation before surgery, 5 patients showed spindletype dilatation after surgery (Fig. 4); in the other 3 patients, sigmoid-type dilatation remained unchanged. In 2 of the 3 patients who had sigmoid-type dilatation both before and after surgery, the postoperative dysphagia scores were 5 and 6, indicating the persistence of dysphagia. Although curvature of the lower esophagus persisted in the other patient with no sign of straightening, the dysphagia score decreased to 1, suggesting an improvement in dysphagia. Esophageal manometry showed that LES pressure was increased before surgery, but decreased significantly 3 months after surgery (Table 1). The LES relaxation rate was low before surgery, but increased significantly 3 months after surgery (Table 1). The esophageal body peristaltic pressure before surgery decreased uniformly from the upper to the lower esophagus. Peristalsis of the esophageal body was simultaneous in all patients; there was no wave progression. The preoperative peristaltic pressure did not differ significantly from the postoperative pressure, except for the
N. Katada et al. / The American Journal of Surgery 192 (2006) 1– 8
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Fig. 4. A 64-year-old woman with an excellent outcome after LHT. (A) Preoperative esophagography showed that the maximum transverse diameter of the esophagus was 6.5 cm. Esophageal dilatation was sigmoid-type. The LES pressure was 44 mm Hg. (B) Esophagography 2 years after surgery indicated that the maximum esophageal diameter had decreased to 3 cm. The esophagus had nearly straightened. The LES pressure decreased to 13 mm Hg, and the dysphagia score decreased to 1.
value 13 cm above the gastroesophageal junction (Fig. 5). Peristalsis also was simultaneous after surgery, indicating no change. Three months after surgery, 24-hour monitoring of esophageal pH showed that the mean (⫾ SD) percent time with a pH of less than 4 was 1.2% ⫾ 3.1%. In 3 (12%) of the 25 patients who underwent esophageal pH monitoring, the percent times with a pH of less than 4 were 4.5%,
5.8%, and 14.1%, respectively, indicating pathologic acid reflux. The severity of reflux was mild in 2 of these 3 patients. Two patients (7%) had esophageal diverticula as postoperative sequelae. The diverticula occurred above the diaphragm, overlying the anterior aspect of the esophagus, in which myotomy had been performed. The diameter of the
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N. Katada et al. / The American Journal of Surgery 192 (2006) 1– 8
Esophageal body peristaltic pressure (mmHg) 30
*
25 20
Before After
15 10 5 0
18cm
13cm
8cm
3cm Distance from gastroesophageal junction
Fig. 5. Peristaltic pressure of the esophageal body on esophageal manometry before and after surgery. Pressure sensors were placed 3, 8, 13, and 18 cm above the gastroesophageal junction to measure peristaltic pressure. The peristaltic pressure 13 cm above the gastroesophageal junction was significantly lower after surgery than before surgery. However, the peristaltic pressures at the other 3 levels did not differ significantly between before and after surgery.
also is important to confirm the presence or absence of mucosal injury endoscopically before completing surgery. If the mucosa is injured then the site of injury can be sutured, thereby preventing postoperative complications. A successful outcome of surgery for achalasia requires a good balance between 2 factors: relief of dysphagia, achieved by decreasing LES pressure by performing a Heller myotomy, and the prevention of postoperative gastroesophageal reflux, achieved by performing an antireflux procedure. Mattioli et al [20] reported that a 2-cm incision made distally to the gastroesophageal junction after making a 5- to 6-cm proximal incision played the most important role in decreasing the final LES pressure after a Heller myotomy. In our study, esophageal manometry showed that LES pressure was high before surgery, but decreased significantly after surgery. The LES relaxation rate, which was low before surgery, increased significantly after surgery. The decreased LES pressure and the increased LES relaxation rate both are believed to contribute to an improvement in dysphagia, but the mechanism responsible for the postoperative increase in the LES relaxation rate remains unclear. To examine esophageal body motility, peristaltic pres-
diverticulum was 6.7 cm in 1 patient followed-up for 3 years after surgery and 6.5 cm in the other patient, followed-up for 5 years after surgery (Fig. 6). The diverticula did not exacerbate dysphagia in either patient.
Comments LHT was performed successfully in our patients, without having to convert to laparotomy during surgery. The intraoperative blood loss was small. Oral intake could be started early after surgery in all but 1 patient who had postoperative complications. The median hospital stay after surgery was 8.5 days, which was longer than that reported by Ancona et al [13] and Patti et al [16] in similar studies of laparoscopic surgery for achalasia. The introduction of critical path analysis and other improvements are likely to shorten the length of hospital stay further. Apart from the length of hospital stay after surgery, the safety and minimally invasive nature of LHT were consistent with the findings of previous studies of achalasia [13–19]. Avoidance of intraoperative injury to the esophageal mucosa is of paramount importance in surgery for achalasia. In our study, 6 patients (20%) had thermal injury and 4 patients (13%) had esophageal perforation of the esophageal mucosa. All 6 patients with thermal injury and 3 patients with perforation recovered after prolongation of postoperative fasting alone. In the other patient, in whom surgery was completed without intraoperative detection of a perforation, empyema developed after surgery. A Heller myotomy is critical to the success of LHT. The esophageal sphincter and mucosa should be stripped carefully during the myotomy, exercising extreme caution not to damage the mucosa. It
Fig. 6. Esophagogram in a patient in whom an esophageal diverticulum occurred 5 years after LHT. The diverticulum occurred above the diaphragm overlying the anterior aspect of the esophagus, the site of myotomy. The diameter of the diverticulum was 6.5 cm.
N. Katada et al. / The American Journal of Surgery 192 (2006) 1– 8
sure was measured before and after surgery. All patients had low peristaltic pressure from the upper to lower esophagus before surgery. Motility of the esophageal body was nearly negligible. LHT thus improved passage disorders in the gastric cardia, but did not improve esophageal body motility. The mean dysphagia score after surgery decreased to 1.7. Dysphagia thus resolved by about 80% after surgery, suggesting a satisfactory outcome in terms of symptomatic improvement. However, about 20% of dysphagia persisted after surgery, and despite a significant decrease in the maximum transverse diameter of the esophagus on postoperative esophagography, the mean value (3.8 cm) still was larger than that of the normal esophagus. Residual dysphagia thus appeared to be caused by the lack of an improvement in esophageal body motility plus mildly impaired passage through the cardia owing to fundoplication. Whether a Toupet fundoplication or a Dor fundoplication is the antireflux procedure of choice in patients undergoing a laparoscopic Heller myotomy remains controversial. Raiser et al [17] compared the Heller-Dor procedure with the HellerToupet procedure in patients undergoing laparoscopic surgery for achalasia and found that the Heller-Toupet procedure is more useful for improving postoperative dysphagia. In contrast, Patterson et al [21] reported that the Heller-Dor procedure has a lower incidence of postoperative dysphagia than the Heller-Toupet procedure. One advantage of the Heller-Toupet procedure is that the wrap around the posterior aspect of the esophagus pulls the anterior wall of the esophagus to the left and right, thereby opening the myotomy site and resulting in a sustained decrease in LES pressure. Another advantage of the Heller-Toupet procedure is that the Toupet fundoplication is performed after the lower esophagus has been pulled downward and straightened, thus improving passage through the cardia and minimizing postoperative dysphagia. In our study, 88% of the patients who had flask-type or sigmoid-type esophageal dilatation before surgery had a straightened, spindle-type lower esophagus after surgery. In patients with sigmoid-type esophageal dilatation, however, the lower esophagus was not necessarily straightened by the Heller-Toupet procedure, and dysphagia persisted. Our results are consistent with the findings of previous studies showing that the Heller myotomy was ineffective in patients with extreme dilation and curvature of the esophagus; in some patients dysphagia improved only after esophageal resection and reconstruction [22,23]. A rare drawback of the Heller-Toupet procedure is the development of diverticula at the site of the Heller myotomy several years after surgery. In such patients, an inadequate decrease in LES pressure after myotomy may lead to increased intraluminal pressure on the mucosa exposed by the myotomy at the anterior aspect of the esophagus. In our study, 2 patients (7%) had diverticula at the site of myotomy. Videotapes recorded during surgery were reviewed to examine why diverticula developed in these patients. We found that the myotomy may have been inadequate on the
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distal side of the gastroesophageal junction. Neither of these patients had exacerbation of dysphagia after 3 to 5 years of follow-up evaluation, but care is required because enlarged diverticula may lead to food retention, further aggravating dysphagia. Dobashi et al [24] described a giant epiphrenic diverticulum detected 20 years after an open Heller myotomy. The formation of this diverticulum was attributed to inadequate decreasing of LES pressure, caused by an insufficient myotomy. Extension of the myotomy to 2 cm below the gastroesophageal junction therefore is essential to prevent the formation of diverticula after surgery. With the Heller-Dor procedure, the incidence of diverticula is low because the myotomy site is covered with a wrap. Even if the mucosa was injured, leakage of esophageal contents into the peritoneal cavity can be prevented because the site of injury is covered with the wrap. On the other hand, after the Heller-Dor procedure, stress is applied medially to the right border of the myotomy, and fibrosis occurs between the wrap and the mucosa, increasing the risk for residual dysphagia after surgery [17]. In addition, downward traction on the esophagus is weaker with the HellerDor procedure than with the Heller-Toupet procedure, making it more difficult to straighten the esophagus. The persistence of sigmoid-type esophageal dilatation may also heighten the risk for residual dysphagia. As an antireflux procedure combined with myotomy, the Toupet fundoplication has been shown to prevent reflux in patients with gastroesophageal reflux disease [25,26]. In our study, 24-hour monitoring of esophageal pH after surgery showed that the Toupet fundoplication combined with myotomy consistently prevented gastroesophageal reflux. When patients are in a supine position after surgery, the Toupet fundoplication is thought to prevent reflux by acting as a hurdle at the dorsal aspect of the gastroesophageal junction. Dor fundoplication is less effective in preventing reflux because the wrap covers only the anterior wall of the esophagus. Therefore, the Toupet fundoplication generally is considered superior to Dor fundoplication for the prevention of reflux. Large randomized trials comparing LHT with other surgical procedures are needed to confirm our findings. Surgical outcomes with different procedures should be analyzed in detail according to factors such as whether esophageal dilatation was sigmoid type before surgery. Long-term studies also are necessary to evaluate the effectiveness of different surgical procedures in patients followed-up for more than 5 years and to assess the incidences of reflux esophagitis and esophageal cancer. In conclusion, LHT for achalasia is minimally invasive and safe. Adequate improvement in dysphagia was confirmed clinically and by esophageal-motility studies. Our results indicate that a Heller myotomy with a Toupet fundoplication as an antireflux procedure surgically can reduce curvature of the esophagus, decrease LES pressure, and adequately relieve dysphagia. However, caution is required because LHT rarely is associated with the postoperative
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formation of diverticula at the myotomy site. Our results reconfirm that extension of the myotomy 2 cm distal to the gastroesophageal junction plays an important part in adequately decreasing LES pressure in patients undergoing a Heller myotomy.
References [1] Cassella RR, Brown AL Jr, Sayre GP, et al. Achalasia of the esophagus: pathologic and etiologic considerations. Ann Surg 1964;160: 474 – 87. [2] Csendes A, Smok G, Braghetto I, et al. Gastroesophageal sphincter pressure and histological changes in distal esophagus in patients with achalasia of the esophagus. Dig Dis Sci 1985;30:941–5. [3] Clouse RE, Statiano A. Manometric patterns using esophageal body and lower sphincter characteristics. Findings in 1013 patients. Dig Dis Sci 1992;37:289 –96. [4] Ferguson MK. Achalasia: current evaluation and therapy. Ann Thorac Surg 1991;52:336 – 42. [5] Fellows IW, Ogilvie AL, Atkinson M. Pneumatic dilatation in achalasia. Gut 1983;24:1020 –3. [6] Vaezi MF, Richter JE. Current therapy for achalasia. J Clin Gastroenterol 1998;27:21–35. [7] Witzel L. Treatment of achalasia with a pneumatic dilator attached to a gastroscope. Endoscopy 1981;13:176 –7. [8] Spiess AE, Kahrilas PJ. Treating achalasia. From whalebone to laparoscope. JAMA 1998;280:638 – 42. [9] Csendes A, Braghetto I, Henriques A, et al. Late results of a prospective randomized study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut 1989;30:299 –304. [10] Heller E. Extramukose karkioplastik beim chronisken kardiospasmus mit dilatation des oesophagus. Mitt Grenzegeb Med Chir 1914;27: 141–9. [11] Jara FM, Toledo-Pereya LH, Lewis JH, et al. Long term results of esophagomyotomy for achalasia of esophagus. Arch Surg 1979;114: 935– 8. [12] Shimi S, Nathanson LK, Cuschieri A. Laparoscopic cardiomyotomy for achalasia. J R Coll Surg Edinb 1991;36:152– 4.
[13] Ancona E, Anselmino M, Zaninotto G, et al. Esophageal achalasia: laparoscopic versus conventional open Heller-Dor operation. Am J Surg 1995;175:265–70. [14] Ancona E, Peracchia A, Zaninotto G. Heller laparoscopic cardiomyotomy with antireflux anterior fundoplication (Dor) in the treatment of esophageal achalasia. Surg Endosc 1993;7:459 – 61. [15] Rosati R, Fumagalli U, Bonavina L, et al. Laparoscopic approach to esophageal achalasia. Am J Surg 1995;169:424 –7. [16] Patti M, Pellegrini CA, Horgan S, et al. Minimally invasive surgery for achalasia. An 8-year experience with 168 patients. Ann Surg 1999;230:587–94. [17] Raiser F, Perdikis G, Hinder RA, et al. Heller myotomy via minimalaccess surgery. An evaluation of antireflux procedures. Arch Surg 1996;131:593– 8. [18] Vogt D, Curet M, Pitcher D, et al. Successful treatment of esophageal achalasia with laparoscopic Heller myotomy and Toupet fundoplication. Am J Surg 1997;174:709 –14. [19] Hunter JG, Trus TL, Branum GD, et al. Laparoscopic Heller myotomy and fundoplication for achalasia. Ann Surg 1997;225:655– 65. [20] Mattioli S, Pilotti V, Felice V, et al. Intraoperative study on the relationship between the lower esophageal sphincter pressure and the muscular components of the gastro-esophageal junction in achalasia patients. Ann Surg 1993;218:635–9. [21] Patterson EJ, Swanstrom LL, Salky B, et al. Multi-center study of patient outcomes after laparoscopic Heller myotomy with three different anti-reflux procedures. Surg Endosc 2001;15:S95. [22] Banbury MK, Rice TW, Goldblum JR, et al. Esophagectomy with gastric reconstruction for achalasia. J Thorac Cardiovasc Surg 1999; 117:1077– 85. [23] Peters JH, Kauer WKH, Crookers PF, et al. Esophageal resection with colon interposition for end-stage achalasia. Arch Surg 1995;130: 632–7. [24] Dobashi Y, Goseki N, Inutake Y, et al. Giant epiphrenic diverticulum with achalasia occurring 20 years after Heller’s operation. J Gastroenterol 1996;31:844 –7. [25] Thor KBA, Silander T. A long-term randomized prospective trial of the Nissen procedure versus a modified Toupet technique. Ann Surg 1989;210:719 –24. [26] Swanstrom LL. Partial fundoplications for gastroesophageal reflux disease: indications and current status. J Clin Gastroenterol 1999;29: 127–32.
Clinical surgery–International
Laparoscopic Heller myotomy with Toupet fundoplication for achalasia straightens the esophagus and relieves dysphagia Natsuya Katada, M.D.*, Shinichi Sakuramoto, M.D., Nobuyuki Kobayashi, M.D., Nobue Futawatari, M.D., Shinichi Kuroyama, M.D., Shiro Kikuchi, M.D., Masahiko Watanabe, M.D. Department of Surgery, School of Medicine, Kitasato University, 2-1-1, Asamizodai, Sagamihara, Kanagawa, 228-8520, Japan Manuscript received September 23, 2005; revised manuscript January 15, 2006
Abstract Background: A standard procedure for the treatment of achalasia remains to be established. We assessed the usefulness of a laparoscopic Heller myotomy with a Toupet fundoplication (LHT). Methods: LHT was performed in 30 patients (12 men, 18 women; mean age, 41.8 y) who had esophageal achalasia with severe dysphagia. Caution was exercised when the esophagus was pulled downward and straightened. Symptoms and esophageal function were evaluated before and after surgery. Results: The esophagus was straightened surgically in 22 (88%) of 25 patients with esophageal curvature on preoperative esophagography. The dysphagia score decreased to 1.7 ⫾ 1.2 (mean ⫾ SD) points from a preoperative value of 10. The lower esophageal sphincter pressure decreased significantly. Two patients (7%) had esophageal diverticula as postoperative sequelae. Pathologic acid reflex was noted in 3 patients (12%). Conclusions: LHT is a useful procedure for straightening the esophagus, reducing lower esophageal sphincter pressure, and relieving dysphagia in patients with achalasia. © 2006 Excerpta Medica Inc. All rights reserved. Keywords: Achalasia; Laparoscopic surgery; Heller myotomy; Toupet fundoplication
Esophageal achalasia has been attributed to degeneration of Auerbach’s plexus [1,2], but its cause remains unclear. Achalasia is characterized by impaired relaxation of the lower esophageal sphincter (LES). Secondary characteristics include increased LES pressure and the absence of esophageal body peristalsis [3,4]. Consequently, passage through the gastric cardia is impaired, leading to dysphagia. Medical therapy with drugs such as calcium-channel blockers usually cannot control the dysphagia associated with achalasia [4] or achieve cure. In contrast, procedures such as balloon dilatation and Heller myotomy are somewhat effective for dysphagia caused by impaired LES relaxation and increased LES pressure [5–10]. Dilation typically is performed with the use of a pneumatic dilator under fluoroscopic control [5,6]. At some centers the balloon is introduced directly through an endoscope and the LES is dilated * Corresponding author. Tel.: ⫹1-81-42-748-9111; fax: ⫹1-81-42745-5582. E-mail address: [email protected]
without fluoroscopic control [7]. However, a major drawback of dilation is that relief of dysphagia is transient, with many patients requiring repeated dilation [8]. In contrast, surgical therapy reliably relieves dysphagia and its effect is long lasting. Thus, surgery currently is considered the most effective treatment for achalasia [8,9]. The surgical procedure most commonly used to treat achalasia is the Heller myotomy, in which the muscle layer of the esophagus is incised from the distal esophagus to the proximal stomach [10]. However, 1 study reported that 48% of patients who undergo myotomy alone have gastroesophageal reflux during long-term follow-up evaluation [11]. There is now a general consensus that some type of antireflux procedure should be performed at the time of myotomy to prevent postoperative gastroesophageal reflux. Technically, antireflux procedures are easier to perform via a transabdominal rather than a transthoracic approach. In 1991, Shimi et al [12] introduced the laparoscopic Heller myotomy as a minimally invasive procedure for achalasia. Ancona et al [13] compared a laparoscopic Heller myotomy
0002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.01.027
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plus Dor fundoplication with the same procedure performed by conventional open surgery. They clearly showed that laparoscopic surgery was less invasive. Subsequently, various modified procedures for laparoscopic Heller myotomy have been reported. Many studies have performed laparoscopic Heller myotomy with an anterior partial fundoplication (Dor fundoplication) as an antireflux procedure [14 – 16]. However, others have reported that a posterior partial fundoplication (Toupet fundoplication) more effectively controls postoperative symptoms such as dysphagia [17–19]. A standard surgical procedure for the treatment of achalasia, including the use of open or laparoscopic surgery, thus remains a matter of debate. We performed a laparoscopic Heller myotomy with a Toupet fundoplication (LHT) in a series of patients with achalasia to evaluate the safety and usefulness of this procedure.
Methods Patients The study group comprised 30 patients (12 men, 18 women; mean age, 41.8 y; range, 23– 66 y) with achalasia who underwent LHT at the Department of Surgery at Kitasato University Hospital from October 1997 through October 2003. All patients had severe dysphagia. Achalasia was diagnosed definitively on the basis of impaired relaxation of the LES on esophageal manometry. No patient had a history of surgery, which potentially could cause adhesions in the upper abdomen. Endoscopic dilation was performed before surgery in 20 (67%) of the 30 patients, but symptoms did not resolve or improved only transiently. Surgical treatment thus was performed. The median follow-up period after surgery was 4 years and 3 months (range, 14 – 86 mo). Surgical procedure Patients were given nothing to eat or were given a liquid diet 1 to 2 days before surgery to eliminate solid food residue from the esophagus. Laxatives or enemas were used to promote defecation. Surgery was performed under general anesthesia. As shown in Fig. 1, a total of 5 trocars were placed in the upper abdomen, and pneumoperitoneum was created at a pressure of 8 mm Hg. The region around the abdominal esophagus was stripped to expose the left and right crura of the diaphragm. Then the anterior trunk of the vagal nerve was identified and preserved. Next, the esophagus was raised anteriorly, and a window was made in the posterior aspect of the esophagus to permit passage of the wrap used for fundoplication. The posterior trunk of the vagal nerve was preserved. Two or 3 short gastric vessels were divided with laparoscopic coagulating shears to mobilize the gastric fundus for fundoplication. Next, preparations were made for a Heller myotomy. A piece of cotton tape was passed through the window in the posterior aspect of the esophagus and
Fig. 1. Positions for placement of trocars for a laparoscopic Heller myotomy with a Toupet fundoplication (LHT). A 5-mm trocar and a snakeshaped retractor for retracting the liver (A), a 5-mm trocar and a forceps held in the surgeon’s left hand (B), a 12-mm trocar and a forceps held in the surgeon’s right hand (C), a 5-mm trocar and a forceps held by an assistant (D), and a 12-mm trocar and a laparoscope (oblique-viewing rigid scope) (E).
pulled caudally. First, the lower esophagus was pulled downward and a Heller myotomy was performed. While exercising caution not to damage the mucosa, the myotomy was extended 5 to 6 cm proximally from the gastroesophageal junction with the use of a hook cautery in the incision mode or laparoscopic coagulating shears. The myotomy then was extended 2 cm distally from the gastroesophageal junction (Fig. 2). Second, a Toupet fundoplication was performed as an antireflux procedure. The greater curvature of the gastric fundus was grasped with a grasping forceps that had been passed through the window in the posterior aspect of the esophagus. The stomach was pulled to the right along the dorsal aspect of the esophagus, and preparations were made for wrapping. The wrap was confirmed to be mobile and loose, exerting no tension on the cardia. The abdominal esophagus was confirmed to be stripped adequately toward the mediastinum. Then the esophagus was pulled downward and straightened. The wrap was sutured to the right crus of the diaphragm with two 3-0 polypropylene sutures (Prolene; Ethicon, Inc., Somerville, NJ). The wrap on the right side of the esophagus was sutured to the right cut edge of the muscularis with 3 interrupted sutures. The wrap on the left side of the esophagus was sutured to the left cut edge of the muscularis with 3 interrupted sutures. Finally, the wrap was sutured to the left crus of the diaphragm, completing a 270° posterior partial fundoplication (Toupet
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Esophagography All patients underwent esophagography before surgery and 1 year after surgery. The maximum transverse diameter of the esophagus and the type of esophageal dilatation were evaluated before and after surgery and were compared. Esophageal dilatation was classified into 3 types: spindle type (spindle-like tapering of the lower esophagus or a V-shaped lower esophagus, with no curvature of the esophagus), flask type (a flask- or U-shaped lower esophagus, with mild curvature of the esophagus), and sigmoid type (an S-shaped esophagus with severe curvature). Esophageal manometry Esophageal manometry was performed before surgery and 3 months after surgery in 28 of the 30 patients. Stationary manometry was performed using a 4-channel catheter and a low-compliance, pneumohydraulic capillary infusion system (Arndorfer Medical Specialties, Greendale, WI). The end-expiratory gastric pressure at baseline was regarded as 0. The resting pressure (mm Hg) of the LES was defined as the difference between the gastric pressure at Fig. 2. The Heller myotomy. Myotomy is extended 5 to 6 cm above the gastroesophageal junction and 2 cm below the gastroesophageal junction.
fundoplication) (Fig. 3). Before the completion of surgery an endoscope was inserted into the stomach and rotated 180° to confirm wrapping of the gastric cardia. Next, while withdrawing the endoscope, adequate depressurization of the myotomy site and no damage to the mucosa were confirmed. A drain was inserted near the myotomy and the trocars were removed. The wounds were closed to complete the surgery. Surgical methods We examined intraoperative blood loss, length of hospital stay after surgery, number of days until the start of oral intake after surgery, intraoperative and postoperative complications, and postoperative sequelae. In addition, symptoms and esophageal function were assessed prospectively on the basis of dysphagia score, esophagographic findings, esophageal manometry, and 24-hour esophageal pH as described later. Dysphagia score We assessed the degree of improvement in dysphagia by interviewing patients at the outpatient clinic 1 year after surgery. The patients were asked to evaluate their postoperative dysphagia score globally (encompassing both the intensity and frequency of dysphagia), as compared with a preoperative score of 10.
Fig. 3. Completed LHT. A Toupet fundoplication is performed as an antireflux procedure after a Heller myotomy. After the Heller myotomy, the mucosa at the anterior aspect of the esophagus is exposed to the peritoneal cavity.
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baseline and the midexpiration pressure at the highest point in the high-pressure zone. LES pressure was measured 4 times, and the mean value was recorded as the resting pressure of the LES. To determine the LES relaxation rate, a transducer was placed in the LES, and the patient was requested to wet swallow. The percent decrease in resting LES pressure on swallowing as compared with the baseline value was determined 4 times. The mean value was calculated to derive the LES relaxation rate. Esophageal body motility was assessed after placing the transducers 3, 8, 13, and 18 cm above the upper border of the LES. A series of 10 wet swallows were completed while recording pressures 3, 8, 13, and 18 cm above the LES. Monitoring of esophageal pH Three months after surgery, 24-hour monitoring of esophageal pH was performed in 25 of the 30 patients, using an antimony electrode and a portable pH recorder (Synectics Mark III Digitrapper; Medtronics, Minneapolis, MN). The pH probe was inserted transnasally and positioned 5 cm above the upper border of the manometrically defined LES. At the end of the 24-hour period, data from the Digitrapper were loaded into a computer and analyzed with the use of a commercially available software program (Esophagram Software Package; Medtronics). Gastroesophageal reflux was defined as abnormal if the pH was below 4 for more than 4% of the 24-hour period. Statistical analysis Data are expressed as means ⫾ SD. All variables before and after surgery were compared with the use of paired Student t tests. P values less than .05 were considered statistically significant.
Results No patient was converted from laparoscopic surgery to open surgery. Laparoscopic surgery was successful in all patients. The intraoperative blood loss was too small to measure in 20 patients (67%). The maximal blood loss was 60 mL. The median number of days until the start of oral intake after surgery was 2 (range, 1– 49 d). The median number of days in the hospital after surgery was 8.5 (range, 5–73 d). No patient died after surgery. Regarding intraoperative complications, 6 patients (20%) sustained thermal injury, measuring 2 to 5 mm in diameter, of the esophageal mucosa at the time of the Heller myotomy. However, their postoperative course was uneventful, apart from having to fast for 3 to 5 days after surgery. Four patients (13%) had esophageal perforation caused by intraoperative injury to the esophageal mucosa. The site of esophageal mucosal injury was sutured during surgery in 3 of these patients. Fasting was prolonged to 5 days after surgery, and their
Table 1 Maximum diameter of esophagus on esophagography, LES pressure on esophageal manometry, and LES relaxation rate before and after surgery
Maximum diameter of esophagus, cm LES pressure, mm Hg LES relaxation rate, %
Before
After
5.4 ⫾ 1.0 35.2 ⫾ 12.6 62.4 ⫾ 16.2
3.8 ⫾ 1.1* 15.0 ⫾ 6.7* 81.5 ⫾ 9.7*
* P ⬍ .001, preoperative versus postoperative value.
postoperative course was uneventful. In the other patient with esophageal perforation, the esophageal mucosa was injured when the most proximal site of the Heller myotomy was incised with laparoscopic coagulating shears. The esophageal perforation was not identified intraoperatively, and surgery was completed. On postoperative day 2, a left pneumothorax and pleural effusion developed, leading to empyema. Although fasting was required for 49 days after surgery, the patient’s condition improved with conservative treatment. Dysphagia did not worsen after surgery in any patient. The dysphagia score 1 year after surgery decreased significantly to 1.7 ⫾ 1.2 (mean ⫾ SD), as compared with a preoperative score of 10 (P ⬍ .001). The maximum transverse diameter of the esophagus on esophagography decreased significantly 1 year after surgery as compared with that before surgery (Table 1). Esophageal dilatation on preoperative esophagography was classified as spindle type in 5 patients, flask type in 17, and sigmoid type in 8. Of the 25 patients who preoperatively had flask-type or sigmoidtype dilatation with esophageal curvature, 22 (88%) showed spindle-type dilatation with straightening of the esophagus 1 year after surgery. All 17 patients who had flask-type dilatation before surgery showed improvement to spindle-type dilatation after surgery. Of the 8 patients who had sigmoidtype dilatation before surgery, 5 patients showed spindletype dilatation after surgery (Fig. 4); in the other 3 patients, sigmoid-type dilatation remained unchanged. In 2 of the 3 patients who had sigmoid-type dilatation both before and after surgery, the postoperative dysphagia scores were 5 and 6, indicating the persistence of dysphagia. Although curvature of the lower esophagus persisted in the other patient with no sign of straightening, the dysphagia score decreased to 1, suggesting an improvement in dysphagia. Esophageal manometry showed that LES pressure was increased before surgery, but decreased significantly 3 months after surgery (Table 1). The LES relaxation rate was low before surgery, but increased significantly 3 months after surgery (Table 1). The esophageal body peristaltic pressure before surgery decreased uniformly from the upper to the lower esophagus. Peristalsis of the esophageal body was simultaneous in all patients; there was no wave progression. The preoperative peristaltic pressure did not differ significantly from the postoperative pressure, except for the
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Fig. 4. A 64-year-old woman with an excellent outcome after LHT. (A) Preoperative esophagography showed that the maximum transverse diameter of the esophagus was 6.5 cm. Esophageal dilatation was sigmoid-type. The LES pressure was 44 mm Hg. (B) Esophagography 2 years after surgery indicated that the maximum esophageal diameter had decreased to 3 cm. The esophagus had nearly straightened. The LES pressure decreased to 13 mm Hg, and the dysphagia score decreased to 1.
value 13 cm above the gastroesophageal junction (Fig. 5). Peristalsis also was simultaneous after surgery, indicating no change. Three months after surgery, 24-hour monitoring of esophageal pH showed that the mean (⫾ SD) percent time with a pH of less than 4 was 1.2% ⫾ 3.1%. In 3 (12%) of the 25 patients who underwent esophageal pH monitoring, the percent times with a pH of less than 4 were 4.5%,
5.8%, and 14.1%, respectively, indicating pathologic acid reflux. The severity of reflux was mild in 2 of these 3 patients. Two patients (7%) had esophageal diverticula as postoperative sequelae. The diverticula occurred above the diaphragm, overlying the anterior aspect of the esophagus, in which myotomy had been performed. The diameter of the
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Esophageal body peristaltic pressure (mmHg) 30
*
25 20
Before After
15 10 5 0
18cm
13cm
8cm
3cm Distance from gastroesophageal junction
Fig. 5. Peristaltic pressure of the esophageal body on esophageal manometry before and after surgery. Pressure sensors were placed 3, 8, 13, and 18 cm above the gastroesophageal junction to measure peristaltic pressure. The peristaltic pressure 13 cm above the gastroesophageal junction was significantly lower after surgery than before surgery. However, the peristaltic pressures at the other 3 levels did not differ significantly between before and after surgery.
also is important to confirm the presence or absence of mucosal injury endoscopically before completing surgery. If the mucosa is injured then the site of injury can be sutured, thereby preventing postoperative complications. A successful outcome of surgery for achalasia requires a good balance between 2 factors: relief of dysphagia, achieved by decreasing LES pressure by performing a Heller myotomy, and the prevention of postoperative gastroesophageal reflux, achieved by performing an antireflux procedure. Mattioli et al [20] reported that a 2-cm incision made distally to the gastroesophageal junction after making a 5- to 6-cm proximal incision played the most important role in decreasing the final LES pressure after a Heller myotomy. In our study, esophageal manometry showed that LES pressure was high before surgery, but decreased significantly after surgery. The LES relaxation rate, which was low before surgery, increased significantly after surgery. The decreased LES pressure and the increased LES relaxation rate both are believed to contribute to an improvement in dysphagia, but the mechanism responsible for the postoperative increase in the LES relaxation rate remains unclear. To examine esophageal body motility, peristaltic pres-
diverticulum was 6.7 cm in 1 patient followed-up for 3 years after surgery and 6.5 cm in the other patient, followed-up for 5 years after surgery (Fig. 6). The diverticula did not exacerbate dysphagia in either patient.
Comments LHT was performed successfully in our patients, without having to convert to laparotomy during surgery. The intraoperative blood loss was small. Oral intake could be started early after surgery in all but 1 patient who had postoperative complications. The median hospital stay after surgery was 8.5 days, which was longer than that reported by Ancona et al [13] and Patti et al [16] in similar studies of laparoscopic surgery for achalasia. The introduction of critical path analysis and other improvements are likely to shorten the length of hospital stay further. Apart from the length of hospital stay after surgery, the safety and minimally invasive nature of LHT were consistent with the findings of previous studies of achalasia [13–19]. Avoidance of intraoperative injury to the esophageal mucosa is of paramount importance in surgery for achalasia. In our study, 6 patients (20%) had thermal injury and 4 patients (13%) had esophageal perforation of the esophageal mucosa. All 6 patients with thermal injury and 3 patients with perforation recovered after prolongation of postoperative fasting alone. In the other patient, in whom surgery was completed without intraoperative detection of a perforation, empyema developed after surgery. A Heller myotomy is critical to the success of LHT. The esophageal sphincter and mucosa should be stripped carefully during the myotomy, exercising extreme caution not to damage the mucosa. It
Fig. 6. Esophagogram in a patient in whom an esophageal diverticulum occurred 5 years after LHT. The diverticulum occurred above the diaphragm overlying the anterior aspect of the esophagus, the site of myotomy. The diameter of the diverticulum was 6.5 cm.
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sure was measured before and after surgery. All patients had low peristaltic pressure from the upper to lower esophagus before surgery. Motility of the esophageal body was nearly negligible. LHT thus improved passage disorders in the gastric cardia, but did not improve esophageal body motility. The mean dysphagia score after surgery decreased to 1.7. Dysphagia thus resolved by about 80% after surgery, suggesting a satisfactory outcome in terms of symptomatic improvement. However, about 20% of dysphagia persisted after surgery, and despite a significant decrease in the maximum transverse diameter of the esophagus on postoperative esophagography, the mean value (3.8 cm) still was larger than that of the normal esophagus. Residual dysphagia thus appeared to be caused by the lack of an improvement in esophageal body motility plus mildly impaired passage through the cardia owing to fundoplication. Whether a Toupet fundoplication or a Dor fundoplication is the antireflux procedure of choice in patients undergoing a laparoscopic Heller myotomy remains controversial. Raiser et al [17] compared the Heller-Dor procedure with the HellerToupet procedure in patients undergoing laparoscopic surgery for achalasia and found that the Heller-Toupet procedure is more useful for improving postoperative dysphagia. In contrast, Patterson et al [21] reported that the Heller-Dor procedure has a lower incidence of postoperative dysphagia than the Heller-Toupet procedure. One advantage of the Heller-Toupet procedure is that the wrap around the posterior aspect of the esophagus pulls the anterior wall of the esophagus to the left and right, thereby opening the myotomy site and resulting in a sustained decrease in LES pressure. Another advantage of the Heller-Toupet procedure is that the Toupet fundoplication is performed after the lower esophagus has been pulled downward and straightened, thus improving passage through the cardia and minimizing postoperative dysphagia. In our study, 88% of the patients who had flask-type or sigmoid-type esophageal dilatation before surgery had a straightened, spindle-type lower esophagus after surgery. In patients with sigmoid-type esophageal dilatation, however, the lower esophagus was not necessarily straightened by the Heller-Toupet procedure, and dysphagia persisted. Our results are consistent with the findings of previous studies showing that the Heller myotomy was ineffective in patients with extreme dilation and curvature of the esophagus; in some patients dysphagia improved only after esophageal resection and reconstruction [22,23]. A rare drawback of the Heller-Toupet procedure is the development of diverticula at the site of the Heller myotomy several years after surgery. In such patients, an inadequate decrease in LES pressure after myotomy may lead to increased intraluminal pressure on the mucosa exposed by the myotomy at the anterior aspect of the esophagus. In our study, 2 patients (7%) had diverticula at the site of myotomy. Videotapes recorded during surgery were reviewed to examine why diverticula developed in these patients. We found that the myotomy may have been inadequate on the
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distal side of the gastroesophageal junction. Neither of these patients had exacerbation of dysphagia after 3 to 5 years of follow-up evaluation, but care is required because enlarged diverticula may lead to food retention, further aggravating dysphagia. Dobashi et al [24] described a giant epiphrenic diverticulum detected 20 years after an open Heller myotomy. The formation of this diverticulum was attributed to inadequate decreasing of LES pressure, caused by an insufficient myotomy. Extension of the myotomy to 2 cm below the gastroesophageal junction therefore is essential to prevent the formation of diverticula after surgery. With the Heller-Dor procedure, the incidence of diverticula is low because the myotomy site is covered with a wrap. Even if the mucosa was injured, leakage of esophageal contents into the peritoneal cavity can be prevented because the site of injury is covered with the wrap. On the other hand, after the Heller-Dor procedure, stress is applied medially to the right border of the myotomy, and fibrosis occurs between the wrap and the mucosa, increasing the risk for residual dysphagia after surgery [17]. In addition, downward traction on the esophagus is weaker with the HellerDor procedure than with the Heller-Toupet procedure, making it more difficult to straighten the esophagus. The persistence of sigmoid-type esophageal dilatation may also heighten the risk for residual dysphagia. As an antireflux procedure combined with myotomy, the Toupet fundoplication has been shown to prevent reflux in patients with gastroesophageal reflux disease [25,26]. In our study, 24-hour monitoring of esophageal pH after surgery showed that the Toupet fundoplication combined with myotomy consistently prevented gastroesophageal reflux. When patients are in a supine position after surgery, the Toupet fundoplication is thought to prevent reflux by acting as a hurdle at the dorsal aspect of the gastroesophageal junction. Dor fundoplication is less effective in preventing reflux because the wrap covers only the anterior wall of the esophagus. Therefore, the Toupet fundoplication generally is considered superior to Dor fundoplication for the prevention of reflux. Large randomized trials comparing LHT with other surgical procedures are needed to confirm our findings. Surgical outcomes with different procedures should be analyzed in detail according to factors such as whether esophageal dilatation was sigmoid type before surgery. Long-term studies also are necessary to evaluate the effectiveness of different surgical procedures in patients followed-up for more than 5 years and to assess the incidences of reflux esophagitis and esophageal cancer. In conclusion, LHT for achalasia is minimally invasive and safe. Adequate improvement in dysphagia was confirmed clinically and by esophageal-motility studies. Our results indicate that a Heller myotomy with a Toupet fundoplication as an antireflux procedure surgically can reduce curvature of the esophagus, decrease LES pressure, and adequately relieve dysphagia. However, caution is required because LHT rarely is associated with the postoperative
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formation of diverticula at the myotomy site. Our results reconfirm that extension of the myotomy 2 cm distal to the gastroesophageal junction plays an important part in adequately decreasing LES pressure in patients undergoing a Heller myotomy.
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