laparoscopic approach to esophageal achalasia

LAPAROSCOPY

Laparoscopic Approach to Esophageal Achalasia Riccardo Rosati, MD, FACS, Uberto Fumagalli, MD, Luigi Bonavina, MD, Andrea Segalin, MD,

Marco Montorsi, MD, Stefano Bona, MD, Albert0 Peracchia, MD, FACS, Milan, Italy

Certain technical details are considered important to ease the laparoscopic performance of a Heller myotomy combined with a Dor antireflux procedure for esophageal achalasia. A special emphasis is given to intraoperative esophagoscopy combined with a mild balloon distension of the esophagogastric junction. These maneuvers prove helpful in identifying the esophagogastric region, easing the myotomy, and controlling its completeness.

E xtramucosal myotomy of the lower esophagus and cardia, as first described by Heller,’ combined with

an antireflux anterior fundoplication according to the Dor technique,2 is in our opinion the procedure of choice in the surgical treatment of achalasia. Having obtained excellent clinical results with this operation in open surgery over a 15year period,3 and having acquired sufficient skill in minimally invasive surgical techniques, we started to per- form the Heller-Dor procedure through laparoscopy and the technique has now been standardized.

As in open surgery, there are some important technical details that must be fulfilled with the laparoscopic approach: identification of the proper submucosal level; complete resection of the circular muscular fibers of the lower esophagus; proper extension of the myotomy on the stomach; performance of an adequate antireflux procedure to prevent gastroesophageal reflux; and delaying the healing of muscular edges of the myotomy. The laparoscopic myotomy can be hazardous due to loss of tactile perception. We have found it extremely helpful to distend the esophagogastric junction using an endoscopic pneumatic dilator. Moreover, endoscopy allows the surgeon to check the length and completeness of the myotomy, as well as the integrity of the mucosa. We describe herein the technique of the laparoscopic Heller-Dor operation.

Surgical Technique The patient is placed on the operating table in the litho-

tomy position with a 20” to 30” reverse Trendelenburg and the surgeon standing between the legs. After creating the pneumoperitoneum, the abdominal cavity is entered through a lo-mm disposable trocar placed in the left upper quadrant approximately at the midclavicular line (initially for the scope, then used as operating port). Four additional ports are then placed under direct vision: a 10-n-m trocar in the midline 4 to 5 cm above the umbilicus (for the scope);

From the Department of General and Oncologic Surgery, University of Milan, Ospedale Maggiore Policlinico IRCCS, Milan, Italy.

Requests for reprints should be addressed to Riccardo Rbsati, MD, Istituto Chirurgia Generale. Padiglione Monte&a, Osoedale Policlinico. Via F. Sforza,hS, -- L 20122 Milan,%aly.

Manuscript submitted December 1, 1993 and accepted in revised form June 7, 1994.

a lo-mm trocar in the right hypochondrium (for liver retraction); a 5-mm trocar in the midline just below the xiphoid (for grasping, dissecting): and a 5-mm trocar in the left upper quadrant along the anterior axillary line (for cardial grasping and retraction). Both a direct and a 30” scope can be used; even if the angled scope can provide a better view of the cardial region, the direct scope always proved suitable in our experience. After trocar placement, a flexi- ble esophagoscope is inserted, and a guide wire is advanced through. the operating channel into the stomach. After in- cision of the phrenoesophageal membrane, dissection is limited to the anterior aspect of the esophagus and the superior part of crura diaphragmatis. Care is taken not to in- jure the anterior vagus nerve, the lesser omentum, and the hepatic branch of the anterior vagus.

Under esophagoscopic control, a low-compliance balloon dilator (Rigiflex; Microvasive, Watertown, Massachusetts) 30-mm O.D. is then introduced over the wire and positioned at the cardia (Figure 1). The correct position of the balloon is constantly verified endoscopically, placing the instrument 2 to 3 cm above the cranial margin of the dilator. A gentle inflation of the balloon, always less than 1 PSI, allows a mild distension of the lower esophagus and cardia.

Myotomy is started with the hook on the anterior aspect of the esophageal wall. Muscular fibers are divided and the submucosal level is reached. Bleeding here is minimal and coagulation should be used at very low voltage. While the right edge of the myotomy is lifted, the muscular layer is dissected from the submucosa, and the myotomy is extended cranially for about 5 to 6 cm (Figure 2). This maneuver is performed with slightly curved endoscopic scissors. Alternate inflation and deflation of the dilator is useful to free the anterior hemicircumference of the submucosa completely, transecting all the circular muscular fibers that are easily identified by distension and transillumination through the endoscope. Myotomy is then extended caudally with the hook for 1.5 to 2 cm below the cardia; driv- ing the myotomy toward the left anterolateral aspect of the esophagogastric junction helps in identifying the proximal oblique muscular fibers of the cardia that must be transected (Figure 3).

All surgical maneuvers are controlled through the esophagoscope. Through the transparency of the inflated balloon, the endoscopist gives useful information on the mucosal aspect and thickness. After completion of the myotomy and removal of the Rigiflex, esophagoscopy allows control of the completeness of the myotomy itself and en- sures mucosal integrity. The anterior fundoplication is then constructed. The anterior fundic wall is sutured first to the left, then to the right muscular edges of the myotomy with three interrupted stitches for each side (we use 2-O Ti-cron, [American Cyanimid Co., Wayne, New Jersey] for intra- corporeal and 2-O Prolene [Ethicon, Inc., Somerville, New Jersey] for extracorporeal knotting techniques); the proximal suture of the right side also includes the superior part

424 THE AMERICAN JOURNAL OF SURGERY” VOLUME 169 APRIL 1995

Figure 2. Lifting the right edge of the myotomy, the muscular layer is dissected from the submucosa to extend the myotomy cranially for about 5 to 6 cm. This maneuver is performed with slightly curved en doscopic scissors.

of the right cm (Figure 4). A rubber drain may be positioned if required. A nasogastric tube is left in place until the second postoperative day, and removed after a radiopa- que (Gastrografin, Bristol-Myers Squibb Co., Princeton, New Jersey) swallow study has shown no leaks.

Clinical Material As of March 1994, 25 patients have been operated on.

There were 14 men and 11 women, with a mean age of 40.8 years (range 16 to 66) suffering from grades I, II, and III achalasia (I, n = 5; II, n = 18; III, n = 2). The preoperative workup of patients included clinical evaluation, barium swallow, esophagoscopy, manometry, and in some cases, esophageal transit-time study with scintigraphy. There were 3 conversions to laparotomy: in 1 case because of a difficult exposure of the hiatal region due to a hyper- trophic left lobe of the liver, and in 2 cases because a mucosal tear occurred at the beginning of the experience when

Figure 3. The myotomy is extended caudally with the hook for 1.5 to 2 cm below the cardia toward the left anterolateral aspect of the esophagogastric junction. This procedure helps in identifying the proximal oblique muscular fibers of the cardia that must be transected.

we performed myotomy without intraoperative cardial distension. Three other mucosal tears were made in patients with previous endoscopic dilations; these were easily repaired laparoscopically with 4-O absorbable interrupted sutures tied intracorporeally.

The postoperative course was uneventful for all but 1 patient who experienced a hemorrhage from a stress gastric ulcer, which healed with conservative treatment. Follow- up of patients consisted of a clinical and radiographic control 1 month after surgery and esophageal manometry. Clinical evaluation was based on comparing preoperative and postoperative dysphagia scores according to the following criteria: for grade, 0 = absent, 1 = mild, 2 = moderate, 3 = severe; for frequency, 1 = occasional, 2 = monthly, 3 = weekly, 4 = twice a week, and 5 = daily. Clinical results are shown in the Table. Functional evaluation was based on the following parameters: for mor- phology, esophageal diameter at barium swallow; for

THE AMERICAN JOURNAL OF SURGERY” VOLUME 169 APRIL 1995 425

LAPAROSCOPY FOR ESOPHAGEAL ACHALASWROSATI ET AIL

.

Figure 4. The anterior fundoplication is constructed: The anterior fundic wall is sutured first to the left, then to the right muscular edges of the myotomy with three interrupted stiches for each side.

manometry, lower esophageal sphincter basal and residual pressure. Functional results are shown in Figure 5. At a mean follow-up of 12 months (range 1.5 to 27..5), the only patient with recurrent dysphagia was successfully submitted to endoscopic dilation.

COMMENTS Performing transabdominal esophagomyotomy accord-

ing to the Heller technique combined with the Dor fundoplication proved to be a safe and effective procedure to treat achalasia. We are satisfied with this operation, which we have been performing in open surgery for more than 15 years.3l4 Our improved skill in minimally invasive techniques also allowed us to approach many diseases of the esophagus using such a technique.5,6 As with gastroesophageal reflux,7-9 in cases of achalasia laparoscopy can also provide good clinical and functional results and has significant advantages in terms of less postoperative pain and early return to work and daily activities.6*‘0

Myotomy is more difficult during laparoscopy than during open surgery, however, due to the absence of tactile perception. This might lead to an increased risk of in- complete myotomy and of mucosal tear. We twice had a perforation of the mucosa during the initial experience when intraoperative esophageal distension was not used. Both patients had to be converted to open surgery in or- der to safely suture the tear. Since then, we have adopted the technique of peroperative cardial distension to ease the myotomy. We had three other perforations of the mucosa in patients with previous endoscopic dilations that com- plicated dissection of the muscular level: however, these were repaired laparoscopically with absorbable sutures and no postoperative complications were observed.

Dissection of the esophagogastric region is limited to the anterior aspect of the esophagus, as we do also in open surgery, because we consider the preservation of the anatomical relationships of the esophagogastric junction of the utmost importance. Endoscopy and balloon cardial distension allow the identification of the residual circular fibers and their complete resection. The distension of the cardia decreases bleeding from the resection of the muscular fibers; thus, the need for cautery, which is always hazardous at this site, is kept to a minimum. A crucial point

TABLE Clinical Evaluation After Laparoscopic Heller-Dor Operation: Dysphagia Score (“V)

Grade Preoperative Postoperative Frequency Preoperative Postoperative 0 Absent 0 (0) 20 (80) 1 Occasional 1 (41 3 (12) 1 Mild 1 (4) 4 (16) 2 Monthly 0 (0) 0 (0) 2 Moderate 10 (40) 1 (4) 3 Weekly 0 (0) 0 10) 3 Severe 14 (56) 0 (0) ; 2;; a week 3 112) 1 (4)

21 (841 1 (41

Pm(n=25) Fbst(ns12)

igure 5. The effect of the laparoscopic Heller-Dor operation on the mean diameter of the thoracic esophagus as measured by barium swaC w and by lower esophageal sphincter pressure.

426 THE AMERICAN JOURNAL OF SURGERY” VOLUME 169 APRIL 1995

LAPAROSCOPY FOR ESOPHAGEAL ACHALASIMtOSATI ET AL

of the technique is the extension of the myotomy onto the stomach. Incompleteness of the myotomy at this site leads to persistent or recurrent achalasia.’ l-l3 Technically this is the most demanding part of the operation. The hook is the most suitable instrument to dissect and coagulate the fibers of the anterior gastric wall. The changing direction of the muscular fibers, from circular in the esophagus to oblique at the cardia, is better visualized because of the esophagoscopic transillumination and the mild pneumatic distension of the cardia. Bleeding is also more evident at this site, and coagulation must be effective. As the myotomy is com- pleted, the endoscopic dilator is removed, allowing further endoscopic control. The construction of an anterior fundoplication according

to the Dor technique helps to protect against reflux. Moreover, the wrap helps to prevent healing of the muscular edges of the myotomy, which could result in a long- term recurrence.

In conclusion, the Heller myotomy combined with the Dor fundoplication is feasible through laparoscopy, pro- vided some technical details are respected. Conversion to open surgery must be considered in case of difficult exposure and in case of mucosal perforation. Intraoperative endoscopic distension of the cardia may facilitate the procedure and increase its safety.

REFERENCES 1. Heller E. Extramukose Cardioplastik beim chronischen Cardio- spasmus mit Dilatation des Oesophagus. Mitr Grenzeg Med Chir. 1913;27:141.

2. Dor J, Humbert P, Dor V, Figarella J..L’int&et de la technique de Nissen modit%e dam la prevention du reflux apres cardiomyotomie extramuqueuse de Heller. Mem Acad Chir. (Paris) 1962;88:877-883. 3. Bonavina L, Nosadini A, Bardini R, et al. Primary treatment’of esophageal achalasia. Long-term results of myotomy and Dor fundoplication. Arch Surg. 1992;127:222-226. 4. Csendes A, Braghetto I, Mascaro J, Henriquez A. Late subjective and objective evaluation of the results of esophagomyotomy in 100 patients with achalasia of the esophagus. Surgery. 1988;104:469-475. 5. Peracchia A, Bonavina L, Bardini R, Ruol A. Attuali possibilha e limiti della chirurgia mininvasiva in patologia esofagea. Arch Atti Sot It Chir. (Rome.) 1992$248-255. 6. Ancona E, Peracchia A, Zaninotto G, et al. Heller laparoscopic cardiomyotomy with antireflux anterior fundoplication (Dor) in the treatment of esophageal achalasia. Surg E&SC. 1993;7:459-461. 7. Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc En&c. 1991;l: 138-143. 8. Weerts JM, Dallemagne B, Hamoir E, et al. Laparoscopic Nissen fundoplication: detailed analysis of 132 patients. Surg Zqarosc Endosc. 1993;3:359-364. 9. Hinder RA, Filipi CJ. The technique of laparoscopic Nissen fundoplication. Surg ilaparosc Endosc. 1992;2:265-272. 10. Ansehuino M, Hinder RA, Filipi CJ, Wilson P. Laparoscopic Heller cardiomyotomy and thoracoscopic esophageal long myotomy for the treatment of primary esophageal motor disorders. Surg kzpa- rose Endosc. 1993;3:43741. 11. Belsey RH. Functional disease of the esophagus. .I Thorac Cardi- ovasc Surg. 1966;52:16&188. 12. Skinner DB. Myotomy and achalasia. Ann Thorac Surg. 1984;37: 183-184. 13. Peracchia A, Bonavina L, Nosadini A, et al. Management of recurrent symptoms after esophagomyotomy for achalasia. Dis Esoph. 1990;3:25-28.

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laparoscopic approach to esophageal achalasia

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