Surgical myotomy for achalasia
- Brant K Oelschlager, MD
Brant K Oelschlager, MD
- Professor, Department of Surgery
- University of Washington
- Rebecca P Petersen, MD, MSc
Rebecca P Petersen, MD, MSc
- Assistant Professor, Department of Surgery
- University of Washington
Heller described a surgical approach for the treatment of achalasia in 1913 [1,2]. The Heller myotomy with a fundoplication is the optimal surgical treatment of achalasia, with effective symptom control in 90 to 97 percent of patients [3,4]. The muscle fibers of the lower esophageal sphincter are incised without disrupting the mucosal lining of the esophagus and can be performed as a laparoscopic or open procedure. With the advancement of laparoscopic surgery, the open technique is rarely used.
Alternatively, esophageal and gastric myotomy can be accomplished endoscopically with the per oral endoscopic myotomy (POEM) procedure at select centers as an alternative to Heller myotomy. (See "Peroral endoscopic myotomy (POEM)".)
The indications for surgery, surgical technical insights, and postoperative results of the Heller myotomy will be reviewed here. The pathophysiology and etiology, clinical manifestations and diagnosis, and medical treatment of achalasia, and details of the POEM procedure, are discussed elsewhere. (See "Overview of the treatment of achalasia" and "Pathophysiology and etiology of achalasia" and "Achalasia: Pathogenesis, clinical manifestations, and diagnosis" and "Pneumatic dilation and botulinum toxin injection for achalasia" and "Peroral endoscopic myotomy (POEM)".)
PATIENT SELECTION CRITERIA
The key component for selecting appropriate patients for surgical management is to differentiate achalasia from other motility disorders and from pseudoachalasia, malignancy, and mechanical obstruction. The preoperative evaluation by the surgeon includes a history of patient symptoms as well as a review of previous studies and the results of medical therapies to alleviate symptoms. As an example, patients who are older than 50 years, with symptoms less than six months duration, and/or who have lost more than 10 pounds (4.5 kg) must be evaluated for esophageal cancer.
Pertinent details of the preoperative assessment include:
- Heller E. Extra mucous cardioplasty in chronic cardiospasm with dilatation of the esophagus (Extramukose Cardiaplastik mit dilatation des oesophagus). Mitt Grenzgels Med Chir 1913; 27:141.
- Payne WS. Heller's contribution to the surgical treatment of achalasia of the esophagus. 1914. Ann Thorac Surg 1989; 48:876.
- Litle VR. Laparoscopic Heller myotomy for achalasia: a review of the controversies. Ann Thorac Surg 2008; 85:S743.
- Zaninotto G, Costantini M, Rizzetto C, et al. Four hundred laparoscopic myotomies for esophageal achalasia: a single centre experience. Ann Surg 2008; 248:986.
- Traube M, Dubovik S, Lange RC, McCallum RW. The role of nifedipine therapy in achalasia: results of a randomized, double-blind, placebo-controlled study. Am J Gastroenterol 1989; 84:1259.
- Abir F, Modlin I, Kidd M, Bell R. Surgical treatment of achalasia: current status and controversies. Dig Surg 2004; 21:165.
- Campos GM, Vittinghoff E, Rabl C, et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 2009; 249:45.
- Schoenberg MB, Marx S, Kersten JF, et al. Laparoscopic Heller myotomy versus endoscopic balloon dilatation for the treatment of achalasia: a network meta-analysis. Ann Surg 2013; 258:943.
- Rohof WO, Boeckxstaens GE, Hirsch DP. High-resolution esophageal pressure topography is superior to conventional sleeve manometry for the detection of transient lower esophageal sphincter relaxations associated with a reflux event. Neurogastroenterol Motil 2011; 23:427.
- Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004; 240:405.
- Spiess AE, Kahrilas PJ. Treating achalasia: from whalebone to laparoscope. JAMA 1998; 280:638.
- Ellis FH Jr, Gibb SP, Crozier RE. Esophagomyotomy for achalasia of the esophagus. Ann Surg 1980; 192:157.
- Pai GP, Ellison RG, Rubin JW, Moore HV. Two decades of experience with modified Heller's myotomy for achalasia. Ann Thorac Surg 1984; 38:201.
- Hunter JG, Trus TL, Branum GD, Waring JP. Laparoscopic Heller myotomy and fundoplication for achalasia. Ann Surg 1997; 225:655.
- 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.
- Ancona E, Anselmino M, Zaninotto G, et al. Esophageal achalasia: laparoscopic versus conventional open Heller-Dor operation. Am J Surg 1995; 170:265.
- Holzman MD, Sharp KW, Ladipo JK, et al. Laparoscopic surgical treatment of achalasia. Am J Surg 1997; 173:308.
- Arreola-Risa C, Sinanan M, Pellegrini CA. Thoracoscopic Heller's myotomy. Treatment of achalasia by the videoendoscopic approach. Chest Surg Clin N Am 1995; 5:459.
- Pellegrini C, Wetter LA, Patti M, et al. Thoracoscopic esophagomyotomy. Initial experience with a new approach for the treatment of achalasia. Ann Surg 1992; 216:291.
- Patti MG, Pellegrini CA, Horgan S, et al. Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg 1999; 230:587.
- Patti MG, Arcerito M, De Pinto M, et al. Comparison of thoracoscopic and laparoscopic Heller myotomy for achalasia. J Gastrointest Surg 1998; 2:561.
- Omura N, Kashiwagi H, Ishibashi Y, et al. Laparoscopic Heller myotomy and Dor fundoplication for the treatment of achalasia. Assessment in relation to morphologic type. Surg Endosc 2006; 20:210.
- Wohlers A, Evans SRT. Section III: Gastrointestinal surgery. Chapter 18: Laparoscopic esophagomyotomy with Dor fundoplication. In: Surgical pitfalls: Prevention and management, Evans SRT (Ed), Saunders Elsevier, 2009. p.187.
- Oelschlager BK, Yamamoto K, Woltman T, Pellegrini C. Vagotomy during hiatal hernia repair: a benign esophageal lengthening procedure. J Gastrointest Surg 2008; 12:1155.
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- 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.
- Oelschlager BK, Chang L, Pellegrini CA. Improved outcome after extended gastric myotomy for achalasia. Arch Surg 2003; 138:490.
- Wright AS, Williams CW, Pellegrini CA, Oelschlager BK. Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia. Surg Endosc 2007; 21:713.
- Patti MG, Molena D, Fisichella PM, et al. Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures. Arch Surg 2001; 136:870.
- Zaninotto G, Costantini M, Portale G, et al. Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg 2002; 235:186.
- Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc 2012; 26:18.
- Tatum RP, Pellegrini CA. How I do it: laparoscopic Heller myotomy with Toupet fundoplication for achalasia. J Gastrointest Surg 2009; 13:1120.
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- Sweet MP, Nipomnick I, Gasper WJ, et al. The outcome of laparoscopic Heller myotomy for achalasia is not influenced by the degree of esophageal dilatation. J Gastrointest Surg 2008; 12:159.
- Patti MG, Feo CV, Diener U, et al. Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated. Surg Endosc 1999; 13:843.
- Mineo TC, Pompeo E. Long-term outcome of Heller myotomy in achalasic sigmoid esophagus. J Thorac Cardiovasc Surg 2004; 128:402.
- Ablassmaier B, Jacobi CA, Stoesslein R, et al. Laparoscopic esophagogastrostomy: an alternative minimally invasive treatment for achalasia stage III. Surg Endosc 2002; 16:216.
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- Melvin WS, Dundon JM, Talamini M, Horgan S. Computer-enhanced robotic telesurgery minimizes esophageal perforation during Heller myotomy. Surgery 2005; 138:553.
- Teitelbaum EN, Soper NJ, Santos BF, et al. Symptomatic and physiologic outcomes one year after peroral esophageal myotomy (POEM) for treatment of achalasia. Surg Endosc 2014; 28:3359.
- Bhayani NH, Kurian AA, Dunst CM, et al. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg 2014; 259:1098.
- Ujiki MB, Yetasook AK, Zapf M, et al. Peroral endoscopic myotomy: A short-term comparison with the standard laparoscopic approach. Surgery 2013; 154:893.
- Swanstrom LL, Kurian A, Dunst CM, et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg 2012; 256:659.
- Rosemurgy AS, Morton CA, Rosas M, et al. A single institution's experience with more than 500 laparoscopic Heller myotomies for achalasia. J Am Coll Surg 2010; 210:637.
- Schuchert MJ, Luketich JD, Landreneau RJ, et al. Minimally-invasive esophagomyotomy in 200 consecutive patients: factors influencing postoperative outcomes. Ann Thorac Surg 2008; 85:1729.
- Torquati A, Richards WO, Holzman MD, Sharp KW. Laparoscopic myotomy for achalasia: predictors of successful outcome after 200 cases. Ann Surg 2006; 243:587.
- Vaziri K, Soper NJ. Laparoscopic Heller myotomy: technical aspects and operative pitfalls. J Gastrointest Surg 2008; 12:1586.
- Petersen RP, Pellegrini CA. Revisional surgery after Heller myotomy for esophageal achalasia. Surg Laparosc Endosc Percutan Tech 2010; 20:321.
- Donahue PE, Horgan S, Liu KJ, Madura JA. Floppy Dor fundoplication after esophagocardiomyotomy for achalasia. Surgery 2002; 132:716.
- Luketich JD, Fernando HC, Christie NA, et al. Outcomes after minimally invasive esophagomyotomy. Ann Thorac Surg 2001; 72:1909.
- Zaninotto G, Rizzetto C, Zambon P, et al. Long-term outcome and risk of oesophageal cancer after surgery for achalasia. Br J Surg 2008; 95:1488.
- Ludemann R, Krysztopik R, Jamieson GG, Watson DI. Pneumothorax during laparoscopy. Surg Endosc 2003; 17:1985.
- PATIENT SELECTION CRITERIA
- REVIEW OF DIAGNOSTIC EVALUATION
- SURGICAL MYOTOMY
- Laparoscopic technique
- - Patient position
- - Abdominal access and port placement
- - Mobilization of the gastric fundus
- - Mobilization of the mediastinal esophagus
- - Myotomy
- - Fundoplication
- Open technique
- Intraoperative technical risks
- OPERATIVE CONSIDERATIONS
- Extended gastric myotomy
- Addition of a fundoplication
- Sigmoid megaesophagus
- Alternatives to laparoscopic or open surgical myotomy
- - Robotic surgery
- - Peroral endoscopic myotomy (POEM)
- POSTOPERATIVE MANAGEMENT
- POSTOPERATIVE COMPLICATIONS
- Recurrent dysphagia
- Gastroesophageal reflux
- Other complications
- RISK OF ESOPHAGEAL CANCER
- SUMMARY AND RECOMMENDATIONS