Minimally Invasive Esophageal Procedures

Marco G. Patti, MD, FACS

Disclosures

August 30, 2005

Laparoscopic Heller Myotomy with Partial Fundoplication

Minimally invasive surgical procedures for primary esophageal motility disorders (achalasia, diffuse esophageal spasm, and nutcracker esophagus) yield results that are comparable to those of open procedures but are associated with less postoperative pain and with a shorter recovery time.[26] Today, laparoscopic Heller myotomy with partial fundoplication has supplanted left thoracoscopic myotomy as the procedure of choice for esophageal achalasia.[4,5,6,7] Long-term studies demonstrated that even though left thoracoscopic myotomy led to resolution of dysphagia in about 85% to 90% of patients, it had the following four drawbacks.

  1. Gastroesophageal reflux developed postoperatively in about 60% of patients because no fundoplication was performed in conjunction with the myotomy.[4] With the laparoscopic approach, in contrast, a partial fundoplication can easily be performed, which prevents reflux in the majority of patients[4,5] and corrects many instances of preexisting reflux arising from pneumatic dilatation.[4] A prospective, randomized, double-blind clinical trial that compared Heller myotomy alone with Heller myotomy and Dor fundoplication clearly demonstrated that the addition of a fundoplication is essential: the incidence of postoperative reflux (as measured by pH monitoring) was 47.6% in patients who underwent myotomy alone but only 9.1% in those who underwent myotomy and Dor fundoplication.[27]

  2. The extension of the myotomy onto the gastric wall (clearly the most critical and challenging part of the operation) proved difficult because of poor exposure, with the consequent risk of a short myotomy and persistent dysphagia. With the laparoscopic approach, in contrast, excellent exposure of the esophagogastric junction is easily achieved, and the myotomy can be extended onto the gastric wall for about 2 to 2.5 cm.[4]

  3. Double-lumen endotracheal intubation and single-lung ventilation were required, with the patient in the right lateral decubitus position. In contrast, the setting for a laparoscopic myotomy (the same as that for a laparoscopic fundoplication) is much easier for the patient, the anesthesiologist, and the OR personnel. In addition, most surgeons have by now acquired substantial experience with laparoscopic antireflux procedures and thus are more familiar and comfortable with laparoscopic exposure of the distal esophagus and the esophagogastric junction.

  4. The average postoperative hospital stay was about 3 days because of the chest tube left in place at the time of the operation and the discomfort arising from the thoracic incisions. After a laparoscopic Heller myotomy, the hospital stay is only 1 or 2 days; there is no need for a chest tube, and patients are more comfortable.

Because of these drawbacks, left thoracoscopic myotomy is now largely reserved for patients with achalasia who have undergone multiple abdominal operations (which may rule out a laparoscopic approach). A laparoscopic Heller myotomy and Dor fundoplication is considered the procedure of choice for achalasia.

All candidates for a laparoscopic Heller myotomy should undergo a thorough and careful evaluation to establish the diagnosis and characterize the disease.[28]

An upper GI series is useful. A characteristic so-called bird's beak is usually seen in patients with achalasia. A dilated, sigmoid esophagus may be present in patients with long-standing achalasia. A corkscrew esophagus is often seen in patients with diffuse esophageal spasm. Endoscopy is performed to rule out a tumor of the esophagogastric junction and gastroduodenal pathologic conditions.

Esophageal manometry is the key test for establishing the diagnosis of esophageal achalasia. The classic manometric findings are (1) absence of esophageal peristalsis and (2) a hypertensive LES that fails to relax appropriately in response to swallowing.

Ambulatory pH monitoring should always be done in patients who have undergone pneumatic dilatation to rule out abnormal gastroesophageal reflux. In addition, pH monitoring should be performed postoperatively to detect abnormal reflux, which, if present, should be treated with acid-reducing medications.[28]

In patients older than 60 years who have experienced the recent onset of dysphagia and excessive weight loss, secondary achalasia or pseudoachalasia from cancer of the esophagogastric junction should be ruled out. Endoscopic ultrasonography or computed tomography can help establish the diagnosis.[29]

Patient preparation (i.e., anesthesia, positioning, and instrumentation) is identical to that for laparoscopic fundoplication.

Many of the steps in a laparoscopic Heller myotomy are the same as the corresponding steps in a laparoscopic fundoplication. The ensuing description focuses on those steps that differ significantly.

Either a Dor or a Guarner fundoplication (see "Laparoscopic Partial (Guarner) Fundoplication") may be performed in conjunction with a Heller myotomy. The Dor fundoplication is an anterior 180º wrap. Its advantages are that (1) it does not require posterior dissection and the creation of a window between the esophagus, the stomach, and the left pillar of the crus; (2) it covers the exposed esophageal mucosa after completion of the myotomy; and (3) it is effective even in patients with GERD.[30] Its main disadvantage is that achieving the proper geometry can be difficult, and a wrong configuration can lead to dysphagia even after a properly performed myotomy.[31] The advantages of the Guarner fundoplication are that (1) it is easier to perform; (2) it keeps the edges of the myotomy well separated; and (3) it might be more effective than a Dor procedure in preventing reflux. Its main disadvantages are that (1) it requires more dissection for the creation of a posterior window and (2) it leaves the esophageal mucosa exposed.

Steps 1 through 6

Steps 1, 2, 3, 4, 5, and 6 of a laparoscopic Heller myotomy are essentially identical to the first six steps of a laparoscopic fundoplication. Steps 4 and 6, however, are necessary only if a posterior partial fundoplication is to be performed. Care must be taken not to narrow the esophageal hiatus too much and push the esophagus anteriorly.

Step 7: Intraoperative Endoscopy

The esophageal stethoscope and the orogastric tube are removed, and an endoscope is inserted. The endoscopic view allows easy identification of the squamocolumnar junction, so that the myotomy can be extended downward onto the gastric wall for about 2 cm distal to this point. In addition, if possible mucosal perforation is a concern, the esophagus can be covered with water from outside while air is insufflated from inside; bubbling will be observed over the site of any perforation present.

At the beginning of a surgeon's experience with laparoscopic Heller myotomy, intraoperative endoscopy is a very important and helpful step; however, once the surgeon has gained adequate experience with this procedure and has become familiar with the relevant anatomy from a laparoscopic perspective, it may be omitted.

Troubleshooting. The most worrisome complication during intraoperative endoscopy is perforation of the esophagus. This complication can be prevented by having the procedure done by an experienced endoscopist who is familiar with achalasia.

Step 8: Initiation of Myotomy and Entry into Submucosal Plane at Single Point

The fat pad is removed with the ultrasonic coagulating shears to provide clear exposure of the esophagogastric junction. A Babcock clamp is then applied over the junction, and the esophagus is pulled downward and to the left to expose the right side of the esophagus. The myotomy is performed at the 11 o'clock position. It is helpful to mark the surface of the esophagus along the line through which the myotomy will be carried out (see Figure 2). The myotomy is started about 3 cm above the esophagogastric junction. Before it is extended upward and downward, the proper submucosal plane should be reached at a single point; in this way, the likelihood of subsequent mucosal perforation can be reduced.

Laparoscopic Heller myotomy with partial fundoplication. The proposed myotomy line is marked on the surface of the esophagus.

Troubleshooting. The myotomy should not be started close to the esophagogastric junction, because at this level the layers often are poorly defined, particularly if multiple dilatations or injections of botulinum toxin have been performed. At the preferred starting point, about 3 cm above the esophagogastric junction, the esophageal wall is usually normal. As a rule, I do not open the entire longitudinal layer first and then the circular layer; I find it easier and safer to try to reach the submucosal plane at one point and then move upward and downward from there. In the course of the myotomy, there is always some bleeding from the cut muscle fibers, particularly if the esophagus is dilated and the wall is very thick. After the source of the bleeding is identified, the electrocautery must be used with caution. The most troublesome bleeding comes from the submucosal veins encountered at the esophagogastric junction (which are usually large). In most instances, gentle compression is preferable to electrocautery. A sponge introduced through one of the ports facilitates the application of direct pressure.

Step 9: Proximal and Distal Extension of Myotomy

Once the mucosa has been exposed, the myotomy can safely be extended (see Figure 3). Distally, it is extended for about 2 to 2.5 cm onto the gastric wall; proximally, it is extended for about 6 cm above the esophagogastric junction. Thus, the total length of the myotomy is typically about 8 cm (see Figure 4).

Laparoscopic Heller myotomy with partial fundoplication. The myotomy is extended proximally and distally.

Laparoscopic Heller myotomy with partial fundoplication. The myotomy is approximately 8 cm long, extending distally for about 2 to 2.5 cm onto the gastric wall and proximally for about 6 cm above the esophagogastric junction.

Troubleshooting. The course of the anterior vagus nerve must be identified before the myotomy is started. If this nerve crosses the line of the myotomy, it must be lifted away from the esophageal wall, and the muscle layers must then be cut under it. In addition, care must be taken not to injure the anterior vagus nerve while removing the fat pad. Treatment with botulinum toxin occasionally results in fibrosis with scarring and loss of the normal anatomic planes; this occurs more frequently at the level of the esophagogastric junction.

If a perforation seems possible or likely, it should be sought as described earlier (see "Step 7"). Any perforation found should be repaired with 5-0 absorbable suture material, with interrupted sutures employed for a small perforation and a continuous suture for a larger one. When a perforation has occurred, an anterior fundoplication is usually chosen in preference to a posterior one because the stomach will offer further protection against a leak.

Step 10 (Dor Procedure): Anterior Partial Fundoplication

Two rows of sutures are placed. The first row (on the left side) comprises three stitches: the uppermost stitch incorporates the gastric fundus, the esophageal wall, and the left pillar of the crus (see Figure 5), and the other two incorporate only the gastric fundus and the left side of the esophageal wall (see Figure 6). The gastric fundus is then folded over the myotomy, and the second row (also comprising three stitches) is placed on the right side between the fundus and the right side of the esophageal wall, with only the uppermost stitch incorporating the right crus (see Figures 7 and 8). Finally, two additional stitches are placed between the anterior rim of the hiatus and the superior aspect of the fundoplication (see Figure 9). These stitches remove any tension from the second row of sutures.

Laparoscopic Heller myotomy with anterior partial fundoplication (Dor procedure). The uppermost stitch in the first row incorporates the fundus, the esophageal wall, and the left pillar of the crus.

Laparoscopic Heller myotomy with anterior partial fundoplication (Dor procedure). The second and third stitches in the first row incorporate only the fundus and the left side of the esophageal wall.

Laparoscopic Heller myotomy with anterior partial fundoplication (Dor procedure). The uppermost stitch in the second row incorporates the fundus, the esophageal wall, and the right crus.

Laparoscopic Heller myotomy with anterior partial fundoplication (Dor procedure). The second and third stitches in the second row incorporate only the fundus and the right side of the esophageal wall.

Laparoscopic Heller myotomy with anterior partial fundoplication (Dor procedure). Two final stitches are placed between the superior portion of the wrap and the anterior rim of the hiatus.

Troubleshooting. Efforts must be made to ensure that the fundoplication does not become a cause of postoperative dysphagia. Accordingly, I always take down the short gastric vessels, even though some authorities suggest that this step can be omitted.[5,29] In addition, the gastric fundus rather than the body of the stomach should be used for the wrap, and only the uppermost stitch of the right row of sutures should incorporate the right pillar of the crus.[30]

Step 10 (Guarner Procedure): Posterior Partial Fundoplication

Alternatively, a posterior 220º fundoplication may be performed. The gastric fundus is delivered under the esophagus, and each side of the wrap (right and left) is attached to the esophageal wall, lateral to the myotomy, with three sutures (see Figure 10).

Laparoscopic Heller myotomy with posterior partial fundoplication (Guarner procedure). Each side of the posterior 220º wrap is attached to the esophageal wall with three sutures.

Step 11: Final Inspection and Removal of Instruments and Ports from Abdomen

Step 11 of a laparoscopic Heller myotomy is identical to step 9 of a laparoscopic Nissen fundoplication.

Delayed esophageal leakage, usually resulting from an electrocautery burn to the esophageal mucosa, may occur during the first 24 to 36 hours after operation. The characteristic signals are chest pain, fever, and a pleural effusion on the chest x-ray. The diagnosis is confirmed by an esophagogram. Treatment options depend on the time of diagnosis and on the size and location of the leak. Early, small leaks can be repaired directly. If the site of the leak is high in the chest, a thoracotomy is recommended; if the site is at the level of the esophagogastric junction, a laparotomy is preferable, and the stomach can be used to reinforce the repair. If the damage to the esophagus is too extensive to permit repair, a transhiatal esophagectomy is indicated.

Dysphagia may either persist after the operation or recur after a symptom-free interval. In either case, a complete workup is necessary, and treatment is individualized on the basis of the specific cause of dysphagia. Reoperation may be indicated (see "Reoperation for Esophageal Achalasia").

Abnormal gastroesophageal reflux occurs in 7% to 20% of patients after operation.[4,5] Because most patients are asymptomatic, it is essential to try to evaluate all patients postoperatively with manometry and prolonged pH monitoring. Reflux should be treated with acid-reducing medications.

I do not routinely obtain an esophagogram before initiating feeding. Patients are started on a soft mechanical diet on the morning of postoperative day 1, and this diet is continued for the rest of the first week. Patients are discharged after 24 to 48 hours and are able to resume regular activities in 7 to 14 days.

The results obtained to date with laparoscopic Heller myotomy and partial fundoplication are excellent and are generally comparable to those obtained with the corresponding open surgical procedures: dysphagia is reduced or eliminated in more than 90% of patients.[4,5,6,7] Laparoscopic treatment clearly outperforms balloon dilatation and botulinum toxin injection in the treatment of achalasia. Its high success rate has caused a shift in practice, to the point where most referring physicians currently regard surgery as the preferred treatment.[32]

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