Minimally Invasive Esophageal Procedures

Marco G. Patti, MD, FACS

Disclosures

August 30, 2005

Reoperation for Esophageal Achalasia

Laparoscopic Heller myotomy improves swallowing in more than 90% of patients. What causes the relatively few failures reported is still incompletely understood. Typically, a failed Heller myotomy is signaled either by persistent dysphagia or by recurrent dysphagia that develops after a variable symptom-free interval following the original operation.

A complete workup (routinely including barium swallow, endoscopy, manometry, and pH monitoring) is required before treatment is planned. In addition, it is my practice to review the video of the first operation to search for technical errors that might have been responsible for the poor outcome. Such errors typically fall into one of the following three categories.

  1. A myotomy that is too short either distally or proximally. If the myotomy is too short distally, a barium swallow shows persistent distal esophageal narrowing and manometry shows a residual high-pressure zone. If the myotomy is too short proximally, it will be apparent from the barium swallow.

  2. A constricting Dor fundoplication. Often, manometry and pH monitoring yield normal results, but a barium swallow shows slow passage of contrast media from the esophagus into the stomach. In one study from UCSF,[31] problems with Dor fundoplications occurred in four (4%) of 102 patients. Analysis of the video records of the first operations showed that in three of the four patients, all the stitches in the right suture row had incorporated the esophagus, the right pillar of the crus, and the stomach, thereby constricting the myotomy. In one patient, the short gastric vessels had not been taken down, and the body of the stomach rather than the fundus had been used for the fundoplication.

  3. Transmural scarring caused by previous treatment. In patients treated with intrasphincteric injection of botulinum toxin, transmural fibrosis can sometimes be found at the level of the esophagogastric junction. This unwelcome finding makes the myotomy more difficult and the results less reliable.

There are two treatment options for persistent or recurrent dysphagia after Heller myotomy: (1) pneumatic dilatation and (2) a second operation tailored to the results of preoperative evaluation. In a 2002 study,[36] pneumatic dilatation was successfully used to treat seven of 10 patients who experienced dysphagia postoperatively; of the remaining three patients, two required a second operation and one refused any treatment.

In the UCSF study just cited,[31] however, pneumatic dilatation was effective in only one of the eight patients in whom it was tried. That patient was the one with a short distal myotomy; none of the four patients with dysphagia resulting from a poorly constructed Dor fundoplication derived any benefit. In two patients who had a short proximal myotomy, the myotomy was successfully extended to the inferior pulmonary vein through a left thoracoscopic approach. Of the four patients with a constricting Dor fundoplication, two underwent a second operation during which the Dor was taken down, and one of these two had a second myotomy. Currently, both patients are free of dysphagia; however, they experience abnormal reflux and are being treated with acid-reducing medications.

Reoperation for achalasia is a technically challenging procedure. It is of paramount importance to avoid perforating the exposed esophageal mucosa during the dissection. A small hole can be repaired, but a larger laceration might necessitate an esophagectomy. This option should always be discussed with the patient before the operation.

Overall, about 10% of patients have some degree of dysphagia after a Heller myotomy. Pneumatic dilatation, a second operation, or both should always be tried before a radical procedure such as esophagectomy is decided on.

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to ACS Surgery: Principles and Practice.

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