Thorascopic Myotomy

Updated: Feb 6, 2014

Background
Achalasia is an uncommon disorder of the esophagus. The disorder is
characterized by inadequate relaxation of the lower esophageal sphincter and
concomitant loss of peristalsis in the body of the esophagus. Patients are usually
young and often present with dysphagia to both solids and liquids at the same
time. Other symptoms may include regurgitation, chest pain, aspiration, and
weight loss. The disorder is often misdiagnosed for gastroesophageal reflux
disease (GERD) and is a common reason for a delay in diagnosis.
Achalasia is most common between the second and fifth decade of life but has
been reported in people of all ages. In the United States, the incidence is about 1
per 200,000 population.
With achalasia, the essential problem is lack of normal esophageal motility and a
hypertonic lower esophageal sphincter (LE)S which fails to relax. The aim of
surgery is to disrupt the muscle fibers of the LES to relax the esophagus and
allow for passage of food.
Today, many surgeons offer a laparoscopic procedure for the treatment of
achalasia. Current result indicate that this surgery offers durable results with
good short-term benefits. More than 90% of patients have relief of their
symptoms immediately after surgery. In addition, the use of minimally invasive
surgery has also reduced the morbidity associated with open esophageal surgery.
There are many treatments for achalasia. However, over the years, the role of
surgery has become better defined. For mild cases of achalasia, medical
therapies still play a role. Botox and pneumatic dilatation are good choices in
patients who want to wait or would like a nonsurgical alternative. However, the
results of these treatments are not sustained, and the relief from symptoms is
variable. Minimally invasive surgery has now supplanted most medical therapies
for achalasia. The minimally invasive approaches have a far much lower
morbidity and mortality compared to the open technique. More than 90% of
patients find effective relief from dysphagia. For those who have associated
GERD, an antireflux procedure can be combined without any added morbidity.
Etiology
Achalasia has been known to occur for more than 200 years, but its cause still
remains unknown. Biopsy of the mucosa in the affected part of the esophagus
often reveals loss of ganglion cells and fibrosis of myenteric plexus.
This process is likely autoimmune regulated because T-cell lymphocytes
predominate in the inflammatory infiltrate.[1] Additional research has shown that

achalasia patients have decreased nitric oxide synthase in the myenteric plexus,
resulting in reduced nitric oxide production. [2] Because nitric oxide is a key factor
in gastrointestinal smooth muscle relaxation, it at least partly explains the
dysfunction of the LES.
Symptoms
The hallmark symptom of achalasia is progressive dysphagia, often first to solids
and then to liquids. Because the dysphagia usually worsens very gradually, it is
often quite severe upon presentation. Most patients adapt their eating behavior
long before the diagnosis is made. Because stress and cold liquids may
exacerbate the dysphagia, both liquids and solids may be poorly tolerated
simultaneously at presentation.
Chest pain is also a common symptom, and patients often undergo extensive
cardiac evaluation prior to diagnosis. Previously, 10-39% of patients suffered
bronchopulmonary complications from repeated regurgitation and aspiration.
[3]
Now many of these complications are avoided by earlier diagnosis and
treatment. Dyspepsia occurs in about one fourth of cases, although it is usually
caused by fermentation of unevacuated food in the esophagus rather than
gastroesophageal reflux.[4, 5]
Patients often have a long history of symptoms, some greater than 30 years.
Weight loss is common, although usually patients alter their diets enough to
maintain body mass until the disease becomes intolerable and they seek
therapy. Acute onset of symptoms or rapid weight loss should be a red flag for
clinicians to rule out malignancy. Ruling out pseudoachalasia (presence of a
distal esophageal tumor causing dysphagia) in older patients (>55 years) is
crucial, as is ruling it out in those with a shorter duration of symptoms (< 6
months), or more profound, rapid weight loss (>15 lb). Any patient with a
questionable diagnosis should be carefully evaluated, including the use of
endoscopic ultrasound and computed tomography (CT) scan to rule out
pseudoachalasia.[4, 6, 7]
Indications
Sigmoid-Shaped or Megaesophagus
Some patients with achalasia develop a megaesophagus, which is usually the
end stage of achalasia. This disorder is characterized by an aperistaltic
esophagus and failure of the LES to relax. Over time, progressive dilatation and
lengthening of the esophagus occurs. In the past, the only surgical option these
patients had was total esophagectomy because no matter what type of surgery
was performed, the dilated and tortuous esophagus had no motility and
dysphagia persisted.
In the last decade, some surgeons have been offering laparoscopic myotomy to
these patients. The myotomy significantly lowers the morbidity and mortality

that is associated with a total esophagectomy. The few studies done so far reveal
that laparoscopic myotomy is beneficial in these patients and provide moderate
to excellent relief of symptoms. Short-term evaluation of these patients has
revealed no reflux and improvement of dysphagia. However, long-term results
are not available.
Contraindications
To be able to undergo a laparoscopic myotomy under general anesthesia, the
patient must be surgically fit. A relative contraindication may be prior
esophageal or hiatal hernia surgery. Some surgeons feel that a megaesophagus
or grade 1V dilatation (>8 cm) is a contraindication to a myotomy because poor
relief from dysphagia occurs. Instead, these patients may be better served with
an esophagectomy.
In any case, other surgeons feel that a minimally invasive procedure may be
attempted and an esophagectomy can be performed if it fails.
Technical Considerations
Length of the Myotomy
No absolute rule exists regarding the extent of the myotomy. In the past, most
surgeons have elected to perform a myotomy of 3-5 cm. However, numerous
studies have shown a direct correlation between length of myotomy and relief
from dysphagia . Ample evidence shows that a myotomy that is less than 1 cm
on the gastric wall is associated with persistent dysphagia. Most experts
recommend making a myotomy of about 1.5 cm over the gastric wall to ensure
that no residual dysphagia exists. Some surgeons also recommend that
extending a myotomy to about 3 cm has better outcomes, but no long-term
results with this approach are available.
A controversial aspect of laparoscopic myotomy is whether to perform an
antireflux procedure at the same time. Some surgeons recommend this
procedure each and every time, but others say that it depends on the patient
and status of the esophagus.
Outcomes
Long-term outcomes data from the open surgical era suggests successful relief of
dysphagia in 65-70% of patients. However, most of these patients underwent
open thoracotomy with minimal extension of the myotomy onto the stomach.
This lack of sufficient myotomy onto the cardia has been proven to be the cause
of most recurrent dysphagia after thoracoscopic or open myotomy via the chest.
Additionally, many of these late failures are the result of severe, intractable
reflux affecting quality of life and requiring surgical intervention. Since the
advent of the abdominal approach, and because laparoscopic techniques greatly
improve visualization and allow longer transabdominal myotomies, success rates

have improved dramatically. Several authors now support performing the

myotomy with intraoperative endoscopic or manometric guidance to ensure
complete obliteration of the LES. Specifically the sling fibers of Willis (the oblique
component of the LES) must be surgically divided to provide adequate passage
of food.
Transthoracic approaches also make performing an antireflux procedure more
difficult. These problems have been substantially corrected with laparoscopic
techniques.[8] Long-term outcomes for dysphagia in patients undergoing a
laparoscopic Heller myotomy and antireflux procedure range from 80-95% in
large studies.[9] Results for control of reflux may be inferior to results for
dysphagia.
Early Complications
Perforation of the esophagus is known to occur in 1-5% of cases. The vast
majority of perforations are identified in the operating room and easily repaired
with minimal morbidity and no affect on the relief of dysphagia. This is vastly
different from the morbidity associated with esophageal rupture that occurs
following balloon dilatation for achalasia
Other complications of surgery seen in 3% of patients include bleeding,
pneumothorax, wound infection, and ileus. The pneumothorax rarely requires
treatment except for observation with serial chest radiographs. Other rare
complications include splenic injury and injury to the vagus nerve.
Late Complications
Late complications from the surgery include recurrent dysphagia. Other common
complications include incomplete myotomy, scarring in the hiatal region, or
stricture formation.

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