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Surg Endosc

DOI 10.1007/s00464-009-0508-1

Laparoscopic Heller myotomy for achalasia: results after 10 years


Sarah M. Cowgill Æ Desiree Villadolid Æ
Robert Boyle Æ Sam Al-Saadi Æ Sharona Ross Æ
Alexander S. Rosemurgy II

Received: 15 May 2008 / Accepted: 16 December 2008


Ó Springer Science+Business Media, LLC 2009

Abstract perioperative deaths. One patient required a redo myotomy


Background Laparoscopic Heller myotomy was first after 5 years due to recurrence of symptoms. At this writing,
undertaken in the early 1990s, and appreciable numbers of 33 patients (70%) are still alive. The causes of death after
patients with 10-year follow-up periods are now available. discharge were unrelated to myotomy. The frequency and
This study was undertaken to determine long-term out- severity scores for dysphagia, chest pain, vomiting, regur-
comes after laparoscopic Heller myotomy used to treat gitation, choking, and heartburn all decreased significantly
achalasia. after laparoscopic Heller myotomy (p \ 0.0001 for all).
Methods Of 337 patients who have undergone laparo- Conclusions Laparoscopic Heller myotomy can be
scopic Heller myotomy since 1992, 47 who underwent undertaken with few complications. This procedure sig-
myotomy more than 10 years ago have been followed nificantly decreases the frequency and severity of achalasia
through a prospectively maintained registry. Among many symptoms without promoting heartburn. The symptoms of
symptoms, patients scored dysphagia, chest pain, vomiting, achalasia are durably ameliorated by laparoscopic Heller
regurgitation, choking, and heartburn before and after myotomy during long-term follow-up evaluation, thereby
myotomy using a Likert scale with choices ranging from 0 promoting application of this procedure.
(never/not bothersome) to 10 (always/very bothersome).
Symptom scores before and after myotomy were compared
Keywords Achalasia  Digestive  Esophageal 
using a Wilcoxon matched-pairs test. Data are reported as
Laparoscopic Heller myotomy
median (mean ± standard deviation).
Results The median length of the hospital stay was 2 days
(mean, 3 ± 8.6 days; range, 1–60 days). Notable compli-
cations were infrequent after myotomy. There were no Through the years, various methods used to relieve the
esophageal outlet obstruction of achalasia have included
blunt dilation, injection of the gastroesophageal junction
Presented at the 2007 Society of American Gastrointestinal (GEJ), and operative decompression transthoracically or
Endoscopic Surgeons (SAGES) Scientific Session, 18–22 April 2007, transabdominally. Laparoscopic Heller myotomy, first
Las Vegas, NV, USA.
undertaken in the early 1990s, was described by Shimi
S. M. Cowgill  D. Villadolid  R. Boyle  S. Al-Saadi  et al. [1]. Although patients with achalasia often are
S. Ross  A. S. Rosemurgy II referred to surgeons for a myotomy, sometimes after
Digestive Disorders Center, undergoing years of pneumatic dilation, botulinum toxin
Tampa General Hospital, Tampa, FL, USA
(BoTox) injections, or both, laparoscopic Heller myotomy
S. M. Cowgill  D. Villadolid  R. Boyle  S. Al-Saadi  has gained acceptance as the intervention of choice for
S. Ross  A. S. Rosemurgy II (&) treating achalasia [2–5].
Division of General Surgery, University of South Florida Achalasia is a rare esophageal motility disorder affect-
College of Medicine, Tampa General Hospital,
P.O. Box 1289, Room F145, Tampa, FL 33601, USA
ing an estimated 1 per 100,000 individuals a year [6]. Few
e-mail: arosemur@hsc.usf.edu centers amass significant numbers of patients treated for

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Surg Endosc

achalasia. Treatment in the past has been scattershot, with Operative technique
clinicians providing pneumatic dilations, Botox injections,
or combinations of the two before referral to surgeons. All the patients underwent laparoscopic Heller myotomy.
Laparoscopic Heller myotomy provides a minimally inva- This operation is performed using a five-port technique, as
sive approach to achalasia with durable and effective out- previously described [7]. A 10-mm port is placed at the
comes [2]. umbilicus under direct visualization. A 10-mm port placed
Relieving the esophageal outlet obstruction ameliorates with pneumoperitoneum and videoscopic guidance along
symptoms of achalasia, but symptoms rarely disappear the right anterior axillary line at the subcostal margin is
completely. Patients often continue to have ongoing com- used to insert a fan retractor. This retractor lifts the liver
plaints related to underlying esophageal dysmotility, away from the stomach and gastroesophageal junction.
symptoms not amenable to palliation by myotomy. Since The main working port is a 10-mm port placed near the
1992, laparoscopic Heller myotomies have been offered, right midclavicular line along the subcostal margin.
and appreciable numbers of patients with 10-year follow- Another 10-mm port is placed at the subxyphoid position,
up periods are now available. through which a 0° scope is placed. Finally, a 5-mm port is
This study was undertaken to determine the long-term placed along the left subcostal margin to allow access for
outcomes after laparoscopic Heller myotomy used to treat the assistant.
achalasia. Our hypothesis was that laparoscopic Heller First, the gastrohepatic ligament is opened widely in a
myotomy offers excellent palliation of symptoms related to stellate fashion using an ultrasonic dissector. The dissec-
achalasia with minimal immediate morbidity and durable tion then is carried up and down the right and left crura and
long-term efficacy. into the mediastinum for adequate mobilization of the
esophagus into the peritoneal cavity. It generally is
unnecessary to divide short gastric vessels, but they are
Materials and methods divided if this aids in freeing the esophagus from the
esophageal hiatus and in starting the mediastinal dissection.
Since 1992, 337 patients have undergone laparoscopic Once a sufficient length of esophagus has been mobilized
Heller myotomy and are followed in a prospectively into the abdomen, the dissection is concluded. The gas-
maintained database. Patient data collection and study trohepatic fat pad is routinely excised to expose the GEJ
design were conducted in concordance with a protocol optimally for myotomy. The myotomy is carried cephalad
approved by the Institutional Review Board of the Uni- and then caudad to stomach.
versity of South Florida College of Medicine. To confirm an adequate myotomy, intraoperative
Of the 337 patients, those who underwent laparoscopic endoscopy is routinely undertaken. An adequate myotomy
Heller myotomy 10 years or longer ago were identified. is confirmed when the endoscope passes easily into the
Achalasia was firmly diagnosed for all patients by a timed stomach, the gastroesophageal junction opens easily with
barium esophagram, esophagoscopy, and/or esophageal endoscopic air insufflation, and transillumination of the
manometry. Loss of esophageal peristalsis with failure of myotomized segment confirms muscle division well above
coordinated lower esophageal sphincter (LES) relaxation and below the Z-line [8].
was documented by manometry. Early in our experience, fundoplications were selec-
Preoperatively, patients scored the frequency and tively constructed with Heller myotomies. Selectively, a
severity of their symptoms during their clinic visit using a partial fundoplication was applied only if a patulous hiatal
Likert scale with choices ranging from 0 (never/not both- defect was encountered, a large hiatal hernia was noted, or
ersome) to 10 (always/very bothersome). Many symptoms an esophagotomy occurred [9]. Initially, 270° posterior
were queried. Among symptoms queried were dysphagia, fundoplications were applied selectively except when
heartburn, chest pain, vomiting, choking, and regurgitation. esophagotomy occurred, and then an anterior fundoplica-
In addition, the patients scored the frequency and severity tion was used to buttress the repair. Subsequently, sub-
of their symptoms after operative intervention. At the last jective concerns about dysphagia led to application of
follow-up visit after operative intervention, the patients anterior fundoplications. Later, anterior fundoplications
reported their outcomes as excellent (complete resolution were constructed routinely after publication of a random-
of symptoms), good (symptoms once per month or less ized trial supporting their application [10].
frequently), fair (symptoms weekly or less frequently), or If an anterior fundoplication was used, the anterior
poor (symptoms daily or more often or severe than before fundus was first sutured to the left side of the esophagus,
myotomy). The patients graded their experience from very lateral to the myotomy. Then the anterior fundus was
satisfying to very unsatisfying. Finally, the patients were sutured to the right side of the esophagus, again lateral to
asked whether they still would undergo the operation. the myotomy. In this manner, nearly, but not all the

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Surg Endosc

myotomized esophagus was covered by the anterior fun- with 95% confidence. Where, appropriate, data are pre-
doplication. The esophageal hiatus then was reconstructed sented as median (mean ± standard deviation).
using 0-braided polyester suture. Next, the anterior fundus
was tacked to the right crus to avoid twisting of the
esophagus and to minimize tension on the fundus, which
could cause the fundoplication to come undone. The fascia Results
at each trocar site was closed with monofilament absorb-
able suture, and the skin was closed with paper strips. Of the 337 patients who have undergone laparoscopic
Heller myotomy since 1992, 47 had laparoscopic myotomy
Postoperative management 10 or more years ago. Of these 47 patients, 26 (55%) are
men with a median age of 49 years (mean,
With transfer out of the postanesthesia recovery unit, 52 ± 19.2 years; range, 18–85 years). The median duration
patients underwent esophagography to ensure adequate of symptoms before laparoscopic Heller myotomy was
esophageal emptying and absence of esophagotomy/gas- 4 years (mean, 7 ± 6.3 years).
trotomy. With prompt emptying and no leak, patients were Before laparoscopic Heller myotomy, 38 patients (81%)
started on liquid oral diets. They generally were discharged had endoscopic interventions for achalasia, with 9 under-
the next morning with instructions to continue a liquid diet going pneumatic dilation, 10 undergoing botulinum toxin
until a follow-up visit in 1–2 weeks. At that time, their injection, and 19 undergoing both. One patient had three
diets were advanced to a more textured diet. If the post- Botox injections before referral for a laparoscopic Heller
operative esophagram indicated poor esophageal emptying, myotomy. Another had seven pneumatic dilations before
it usually was due to self-limited postoperative edema that undergoing a laparoscopic Heller myotomy.
resolved within 24–48 h. If evidence of poor emptying did Before laparoscopic Heller myotomy, symptom severity
not resolve quickly, the possibility of an incomplete and frequency were scored by the patients. Preoperatively,
myotomy was considered. the frequency of dysphagia was particularly bothersome to
Patients were seen at the clinic within 2 weeks of dis- patients, but all symptoms were scored high. The preop-
charge, then followed with clinic visits annually as out- erative severity of dysphagia, choking, vomiting, and
patients. The patients determined the frequency and regurgitation were scored high, but, again, preoperative
severity of their symptoms at each encounter, as stated chest pain and heartburn were severe as well (Figs. 1, 2).
previously. All Heller myotomies were attempted and completed
laparoscopically. Nine patients underwent concomitant
Data management and statistical analysis procedures at the time of laparoscopic Heller myotomy
including one anterior fundoplication, four Toupet fundo-
Data were maintained on an Excel spreadsheet (Microsoft, plications, one concomitant diverticulectomy, one para-
Redmond, WA, USA). The data were analyzed by Wilco- thyroidectomy, one umbilical hernia repair, and one
xon matched-pairs test and Mann–Whitney U test when cholecystectomy. The median length of the hospital stay
appropriate, using True Epistat (Epistat Services, Rich- was 2 days (mean, 3 ± 8.6 days; range, 1–60 days).
ardson, TX, USA) or GraphPad InStat (GraphPad Soft- Complications or inadvertent intraoperative events did
ware, San Diego, CA, USA). Significance was accepted occur. One patient required a small tube thoracostomy for a

Fig. 1 The frequencies of all Before Myotomy


achalasia symptoms scored Frequency of Symptoms After Myotomy
were significant, but dysphagia *(p<0.01, Wilcoxon matched pairs test)
was particularly troubling 10
preoperatively. Postoperatively, 9
0 (never) to 10 (always)
Median Likert Score

during an extended follow-up 8


period, the frequency of
7
symptoms continue to be
ameliorated 6
5 *
4
3 * * * * *
2
1
0
Dysphagia Choking Vomiting Regurgitation Chest Pain Heartburn

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Surg Endosc

Fig. 2 Severity levels of Before Myotomy


dysphagia, choking, vomiting, Severity of Symptoms
*(p<0.01, Wilcoxon matched pairs test) After Myotomy
and regurgitation all were
10

0 (not bothersome) to 10 (very


notable preoperatively, and all
improved significantly during 9

Median Likert Score


an extended follow-up period 8

bothersome)
7
6
5
4
3 * *
2 * * *
1 *
0
Dysphagia Choking Vomiting Regurgitation Chest Pain Heartburn

carbon dioxide pneumothorax, and one patient had a pro- Fair Poor
longed hospital stay due to urinary retention. 8% 0%
Seven patients experienced a prolonged stay ([24 h)
secondary to delayed esophageal emptying after myotomy,
seemingly due to postoperative edema at the GEJ docu-
mented on postoperative esophagography. The median
length of stay for these seven patients was 3.7 days, and all Excellent
had resolution of delayed esophageal emptying. 42%
Two patients in this cohort experienced significantly
more complicated hospital courses after laparoscopic Hel-
ler myotomy. The first patient with a significantly pro-
longed stay was a septuagenarian with chronic obstructive
pulmonary disease and coronary artery disease who Good
required extensive lysis of adhesions at the initial opera- 50%
tion. On postoperative day 5, when he failed to progress, an
enterocutaneous fistula was identified at the proximal
jejunum, and he underwent an open repair of the fistula. Fig. 3 Patients were asked to grade their current symptoms com-
Prolonged respiratory failure after this complication led to pared with before their operation as excellent (symptoms completely
tracheostomy placement, but the patient was subsequently resolved), good (symptoms less than once per month), fair (symptoms
less than once per week), or poor (symptoms not improved)
discharged after 60 days in the hospital.
The second patient, an 18-year-old woman, underwent a
laparoscopic Heller myotomy in 1995 but experienced patients undergoing laparoscopic Heller myotomy reported
unexplained acute renal failure and respiratory failure their experience overall to be satisfying or very satisfying
without evidence of a leak on radiologic studies. Ulti- (Fig. 4).
mately, she recovered but had a complicated course, Of the 47 patients, 6 underwent some form of endo-
requiring a ‘‘redo’’ open myotomy. At this writing, she scopic intervention for achalasia postoperatively, with 2
continues to report symptoms related to profound esopha- undergoing pneumatic dilation, 2 undergoing botulinum
geal dysmotility. To date, no patient in this population has toxin injection, and 2 undergoing both.
undergone an esophagectomy for end-stage achalasia. Of the 47 patients, 33 are still alive at this writing. The
Postoperatively, all symptoms uniformly and signifi- 14 patients who died did not experience perioperative
cantly improved in frequency and severity (Figs. 1, 2) deaths. One patient died of complications associated with
(p \ 0.01 for all symptoms, Wilcoxon matched-pairs test). congestive heart failure, and one patient died of pneumo-
The frequency of dysphagia postoperatively continued to nia. The cause of death for the remaining 12 patients is
be scored relatively high. However, it significantly unknown, but it is believed that neither achalasia nor lap-
improved from preoperative scoring. The frequency and aroscopic Heller myotomy played a role in their deaths.
severity of heartburn symptoms, although present, also For nine patients, current contact has been lost, although
significantly improved after laparoscopic Heller myotomy. follow-up evaluation beyond short term was obtained for
Most of the patients (92%) reported symptom control all. The median follow-up period was 10.6 years (mean,
overall to be good or excellent (Fig. 3), and 92% of the 10.9 ± 1.1 years).

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Surg Endosc

Very esophagus to stomach with no extraluminal leak in the


Unsatisfying Unsatisfying postoperative esophagram, patients could tolerate a liquid
8% 0% or soft diet and were discharged within 24 h. The median
Neither length of hospital stay was 2 days. However, early in the
0% experience with laparoscopic Heller myotomy, surgeons
experienced less security in sending the patients home on
postoperative day 1. As experience with the operation
Satisfying increased and hospital discharge issues became more
29%
important in medicine, most patients were discharged
within the first 24 h after laparoscopic Heller myotomy.
Very Satisfying
63%
The most commonly identified cause of prolonged
hospital stay in this cohort was narrowing at the GEJ
secondary to postoperative edema. In all seven patients,
this edema resolved. A repeat esophagram demonstrated
Fig. 4 Patients were asked to grade their overall experience appropriate flow of contrast into the stomach, and the
patients were discharged soon after demonstrating toler-
Discussion ance of an oral diet.
Although no perioperative deaths occurred, 2 of the 47
Surgeons and most clinicians do not have the opportunity patients sustained serious complications. The first patient,
to see significant numbers of patients with a diagnosis of an elderly gentleman, had an extensive lysis of adhesions
achalasia. Often, the failure to recognize and diagnose in association with his myotomy and experienced sepsis
achalasia expediently means the process to definitive and respiratory failure secondary to an enterocutaneous
treatment can be a chronic, vexing problem for both the fistula. He subsequently recovered and at this writing
naı̈ve clinician and the patient experiencing the symptoms. reports amelioration of his achalasia.
Chronicity of the dysmotility integral to achalasia can The second patient, 18 years old when her achalasia was
lead to lifelong complaints from the patient regardless of diagnosed, underwent a laparoscopic Heller myotomy. No
medical or surgical intervention. In the short term, certainly, enteric leak was identified, but the patient became pro-
a Heller myotomy is in the armamentarium of therapy for foundly ill, experienced renal failure, and required moni-
patients with achalasia, but the question is whether the toring in the intensive care unit soon after operative
chronicity of the condition and the palliative nature of the intervention. Continued symptoms after recovery and
operation lead to long-term satisfaction for these patients. radiologic evidence of an incomplete myotomy led to a
Due to the chronicity of achalasia and the very nature of the reoperative myotomy, with increased extension onto the
operation indicated to palliate it (i.e., operating on the gastric cardia. At this writing, 12 years later, the patient
tenuous tissues of the esophagus), evidence of beneficial continues to exhibit profound dysmotility and multiple
symptomatic outcomes might be expected to diminish over obstructive complaints. Esophageal extirpation has been
time. This study documents the course of patients followed described as a last resort for end-stage achalasia, and this
since laparoscopic Heller myotomies were first described in patient may be a candidate for such aggressive measures
1991 and confirms that laparoscopic Heller myotomy is a [11].
safe, durable mode of alleviating the esophageal outlet All patients during an extended follow-up period report
obstruction of achalasia in the long term. excellent control of symptoms after laparoscopic Heller
A relatively gender-equal population of middle-aged myotomy. Frequency of dysphagia still is scored relatively
individuals has been followed after laparoscopic Heller high, but it is significantly improved from preoperative
myotomy. Many had reported symptoms related to acha- levels. Although we now routinely add a concomitant
lasia of more than 4 years duration, and many had under- anterior fundoplication after completing the laparoscopic
gone prior endoscopic attempts to alleviate the esophageal Heller myotomy, the majority of individuals do not have
obstruction of achalasia with little to no long-term relief. any sort of antireflux operation. Scores for symptoms of
All reported significant dysphagia and regurgitation, but heartburn during long-term postoperative follow-up
certainly choking, vomiting, chest pain, and heartburn also assessment are not noted to be particularly higher than
were scored high in this group of patients before laparo- other symptom scores. Patients with ongoing underlying
scopic Heller myotomy. esophageal dysmotility may have a ‘‘burned out’’ esopha-
All the patients underwent a laparoscopic Heller myot- gus, and symptoms of reflux can be unreliable.
omy with no conversions to celiotomy. Generally, after Objective parameters of gastroesophageal reflux were
documentation of contrast promptly flowing from not measured long term. Despite the lack of symptoms

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Surg Endosc

related to reflux in these patients, there is significant evi- cost-utility analysis of a randomized trial. Surg Endosc 20:389–
dence from other groups that the routine addition of a 393
5. Patti MG, Pellegrini CA, Horgan S, Arcerito M, Omelanczuk P,
partial fundoplication confers more benefits than risk [10, Tamburini A, Diener U, Eubanks TR, Way LW (1999) Minimally
12]. invasive surgery for achalasia: an 8-year experience with 168
Laparoscopic Heller myotomy can be undertaken with patients. Ann Surg 230:587–593
few complications. This procedure significantly decreases 6. Mayberry JF (2001) Epidemiology and demographics of achala-
sia. Gastrointest Endosc Clin North Am 11:235–248
the frequency and severity of achalasia symptoms without 7. Bloomston M, Boyce W, Mamel J, Albrink M, Murr M, Durkin
promoting heartburn symptoms. Symptoms of achalasia are A, Rosemurgy A (2000) Videoscopic Heller myotomy for acha-
durably ameliorated by laparoscopic Heller myotomy with lasia: results beyond short-term follow-up. J Surg Res 92:150–
long-term follow-up evaluation, thereby promoting appli- 156
8. Bloomston M, Brady P, Rosemurgy AS (2002) Videoscopic
cation of this procedure. Heller myotomy with intraoperative endoscopy promotes optimal
outcomes. J Soc Laparoendosc Surg 6:133–138
9. Bloomston M, Rosemurgy AS (2002) Selective application of
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