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Ann Thorac Surg 2001;72:1909-1913
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Outcomes after minimally invasive esophagomyotomy

^a University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA

* Address reprint requests to Dr Luketich, Section of Thoracic Surgery, UPMC Presbyterian, 200 Lothrop St, Suite C-800, Pittsburgh, PA 15213, USA
e-mail: luketichjd{at}msx.upmc.edu

Presented at the Thirty-seventh Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 29–31, 2001.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Background. Thoracic surgeons traditionally performed thoracotomy and myotomy for achalasia. Recently minimally invasive approaches have been reported with good success. This report summarizes our single-institution experience using video-assisted thoracoscopy (VATS) or laparoscopy (LAP) for the treatment of achalasia.

Methods. A review of 62 patients undergoing minimally invasive myotomy for achalasia was performed. There were 27 male and 35 female patients. Mean age was 53 years (range 14 to 86). Thirty-seven (59.7%) had failed prior treatments (balloon dilation, botulinim toxin injection, or prior surgery). Outcomes studied were dysphagia score (1 = none, 5 = severe), Short-Form 36 quality of life (SF36 QOL) score, and heartburn-related QOL index (HRQOL).

Results. Surgery included myotomy and partial fundoplication (5 VATS and 57 LAP). Mortality was zero, and complications occurred in 9 (14.5%) patients. There were 6 perforations (4 repaired by LAP and 2 open). Median length of stay was 2 days, time to oral intake was 1 day. At a mean of 19 months follow-up, 92.5% of patients were satisfied with outcome. Dysphagia scores improved from 3.6 to 1.5 (p < 0.01) but 3 patients ultimately required esophagectomy for recurrent dysphagia. HRQOL scores for heartburn and SF-36 QOL scores were comparable with control populations.

Conclusions. Minimally invasive myotomy and partial fundoplication for achalasia improved dysphagia in 92.5% of patients with heartburn and QOL scores were comparable with normal values at 19-month follow-up. The laparoscopic approach offers excellent results and was the preferred approach by our thoracic group for treating achalasia. Thoracic residency training should strive to include laparoscopic esophageal experience.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Achalasia is a rare disorder with an incidence of approximately 1 per 100,000 [1]. This is an acquired disease with increasing frequency throughout adult life, with patients over the age of 70 years being at the most risk of becoming symptomatic [2]. The disease is characterized by the manometric findings of esophageal body aperistalsis and a lower esophageal sphincter (LES) that fails to relax in response to swallowing.

No therapy is successful in reversing or curing the underlying pathology. Both operative and nonoperative treatments are aimed at decreasing the LES pressure to facilitate esophageal emptying. The hallmark of surgical therapy is cardiomyotomy. This was originally developed by Heller [3] in 1913 and included both an anterior and posterior myotomy of the esophagus. In 1923 the procedure was modified by Zaaijer [4] to a single anterior myotomy.

Recently, minimally invasive approaches to treat achalasia have been introduced. The first report of laparoscopic myotomy was by Cushieri and colleagues [5] from Scotland in 1991. That was followed in 1992 by a report of a VATS approach to myotomy by Pelligrini and associates [6]. Since these initial reports, minimally invasive esophageal myotomy for achalasia has become the standard operative approach in many centers. Thoracic surgeons have traditionally performed myotomy using a thoracotomy approach. With the expansion of minimally invasive surgery, myotomy is primarily being performed by general surgeons using a laparoscopic approach in many centers. Thoracic surgeons are finding that they are treating a dwindling proportion of these patients with benign esophageal disorders such as achalasia.

At the University of Pittsburgh Medical Center, a minimally invasive surgery center has been developed jointly by both thoracic and general surgeons. Minimally invasive myotomy is routinely performed and included in the training of our cardiothoracic residents. The aims of this study were to review our experience and examine our treatment outcomes after minimally invasive myotomy.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
A retrospective analysis was performed of patients who underwent minimally invasive esophageal myotomy at the University of Pittsburgh. This included 62 operations performed over an 8-year period from 1992 to 2000. There were 27 male and 35 female patients with a mean age of 53 years (range 14 to 86). All operations were performed for achalasia (n = 58) or achalasia in association with an epiphrenic diverticulum (n = 4).

The most common presenting symptom in the 62 patients was dysphagia, which was seen in 59 (95.2%) patients. Two patients had aspiration pneumonia and 1 patient had bleeding from an esophageal diverticulum. Symptoms had been present for at least 12 months in 52 (84%) patients. Thirty-seven (59.7%) patients had failed prior nonoperative therapies. These included dilation in 32 (51.6%) patients. Most of these patients had only one (n = 9) or two (n = 8) dilatations but 1 patient had this performed 40 times. Eleven (17.7%) patients had botulinim toxin injections and 3 (4.8%) had been treated with calcium channel antagonists. Previous myotomy had been performed in 4 (6.4%) patients.

Preoperative workup included barium swallow in all patients. Manometry was performed in all patients and attempted unsuccessfully in 3 patients. Operations were performed by 7 surgeons; however, one surgeon (JDL) performed 49 (79%) of the operations. Initially a left VATS approach (n = 5) was used to perform the myotomy, but our current preference is a laparoscopic approach (n = 57) to the myotomy. We have found that the laparoscopic approach allows excellent exposure of the hiatus and distal esophagus and avoids the need for single lung ventilation and chest tube drainage after surgery. We still use a VATS approach for the rare patient with a motor disorder requiring a long myotomy or patients requiring a myotomy to remove an esophageal leiomyoma. In this series of 62 achalasia patients myotomy alone was used in 2 (3.2%) patients. In the remaining 60 patients a partial fundoplication was performed. In 45 (72.6%) this was a posterior Toupet fundoplication. An advantage of this approach is that the edges of the wrap are sutured to the edges of the myotomized esophageal muscle to help keep the myotomy open. An anterior (Dor) wrap was performed in 8 (12.9%) and a Belsey fundoplication performed in 3 (4.8%) patients using a VATS approach.

Our operative technique includes an initial esophagoscopy. The endoscope is left in place during the procedure; the patient is supine, the surgeon is on the patient’s right side, and one assistant is on the left. Five laparoscopic ports are used with one 10-mm port and four 5-mm ports. Our preference is to use ultrasonic coagulating shears (US Surgical, Norwalk, CT) for the major portion of the dissection. Crural dissection is performed. Limited division of the short gastric vessels is performed so that there is adequate mobility of the gastric fundus to allow creation of a tension-free fundoplication. The fat pad is dissected from the gastroesophageal junction to clearly identify this area for the myotomy. Epinephrine (1 mL of 1:1000 in 20 mL normal saline) is then injected into the muscular layers of the anterior esophagus and stomach. That helps minimize bleeding and also aids in performing the myotomy by lifting the muscle layer of the mucosa. The myotomy is performed along the distal 8 to 10 cm of esophagus onto the first 1 to 2 cm of the stomach using ultrasonic shears and blunt dissection with "Endo-Peanut" dissector (US Surgical, Norwalk, CT). The endoscope is used to assess the completeness of the myotomy and also to check for mucosal perforations. Because a myotomy performed in this manner will require division of the phrenoesophageal membrane and exposure of the distal esophagus in the mediastinum, we include a partial fundoplication as described above.

We do not routinely place a nasogastric tube. Barium swallow imaging is obtained on the first postoperative day and a clear liquid diet started if the barium swallow is satisfactory.

Detailed follow-up included the measurement of dysphagia using a scale from 1 (no dysphagia) to 5 (severe dysphagia). In addition the Short-Form 36 (SF36) was also used. This is a global quality-of-life (QOL) instrument that has been extensively validated and US normal values defined [7]. Because heartburn can occur after myotomy, heartburn severity was recorded using the gastroesophageal reflux disease (GERD) Health-Related Quality of Life scale (HRQOL). This is a disease-specific instrument designed by Velanovich and coworkers [8] that consists of 10 questions. Nine questions relate to aspects of GERD with each response scored from 0 (no symptoms) to 5 (severe symptoms). The best possible score is 0 and the worst possible score is 45. The tenth question relates to an overall assessment of satisfaction. In the initial reports describing the use of the HRQOL, mean scores of 28 were reported for patients with severe reflux before antireflux operation [8]. In this retrospective study, QOL and HRQOL scores were not obtained before operation. SF36 scores were compared with US normal values. Dysphagia scores were collected before operation and at follow-up. Raw outcome data were entered and scored using an outcome analyzer software package (Assist Technology, Arizona) and statistics were performed on SPSS software (version 10; SPSS, Inc, Chicago, IL) and included paired and one-sample t-test analysis.

	Results

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
There were no operative deaths. Complications occurred in 9 (14.5%) patients and are outlined in Table 1. There were no differences in complications between the VATS and laparoscopic approaches. There were 5 patients who had esophageal perforations and 1 patient with a gastric perforation. In 2 cases this required conversion to open operation to repair the perforation and in the other 4 patients the perforation was repaired endoscopically without further sequela. Analysis of factors leading to mucosal perforation during the myotomy revealed that 5 (83%) of the 6 occurred within the first 10 procedures performed by the surgeons involved in the study. All but 1 of these patients gave a history of prior esophageal dilation. The sixth mucosal perforation occurred in a patient who had undergone open myotomy 18 years previously. Botulinim toxin had not been used in any of these 6 patients.

Detailed outcome follow-up was available in 53 patients at a mean of 19 months (range 1 to 96). Twenty patients (37.7%) complained of some dysphagia. However the dysphagia severity was improved in all but 1 patient, with the mean dysphagia score decreasing significantly (p < 0.001) from 3.5 before operation to 1.3 after operation. Forty-nine (92.5%) of patients were satisfied and 4 (7.5%) were neither satisfied nor dissatisfied with their treatment results. None of the patients were dissatisfied. SF36 scores are shown in Table 2. All eight of the domain scores that make up the SF36 were the same or better than US normal value scores.

	Comment

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
The treatment of achalasia remains controversial. Many patients are elderly with significant comorbid disease so there is some reluctance to refer these patients for operation. Currently there is only one randomized study comparing dilation and open esophageal myotomy [9]. In this study, at a median follow-up of 6 years 95% of the surgical patients had excellent results compared with only 65% of the patients who underwent pneumatic dilation. A problem with interpretation of this study is that treatment methods have changed with better techniques of pneumatic dilation [10] and the prevalence of minimally invasive approaches to myotomy.

Another issue frequently debated in the literature is the best approach to performing esophageal myotomy. The open transthoracic approach, which utilizes a myotomy extending approximately 0.5 to 1 cm onto the stomach, has been the preferred technique in many North American institutions. Ellis [11] reported on 185 patients using this approach with an 89% improvement rate at 9 years. The open transabdominal approach requires a wider dissection of the hiatus and disruption of the phrenoesophageal membrane. The myotomy usually extends about 1 to 2 cm onto the stomach so the incidence of reflux appears to be higher [10]. A partial fundoplication is therefore usually added to minimize reflux. Bonavina and colleagues [12] reported on 193 patients who had undergone laparotomy with Heller myotomy and Dor fundoplication with good to excellent results in 94.5% at 64.5 months.

With the advent of minimally invasive myotomy, the issues of approach to the esophagus and whether to add an antireflux procedure continue, although the laparoscopic approach appears to offer some advantages. The laparoscopic approach may provide better visualization of the gastroesophageal junction and anesthetic requirement is simplified without the use of a double-lumen endotracheal tube and single-lung ventilation. In a retrospective comparison [13] of 24 patients who had a VATS approach and 63 who had a laparoscopic approach, laparoscopy was associated with decreased conversion rate, shortened hospital stay, and better relief of dysphagia. Patti and associates [14] recently reported the largest series of minimally invasive myotomy from two institutions. Although these authors were the first to report on VATS myotomy [6], their preferred approach is now laparoscopy. Hospital stay was longer for the VATS group (72 versus 48 hours), relief of dysphagia was better by laparoscopy (93% versus 85%), and less reflux was also seen in the laparoscopic group (17% versus 60%). Our experience with minimally invasive myotomy is one of the largest reported from a single institution. We have preferred the laparoscopic approach for the reasons outlined above and in fact only 5 of the 62 operations in our report were VATS myotomies.

Another controversial issue is how to manage the patient with end-stage achalasia and a sigmoid esophagus. Patti and colleagues [15] recently reported good to excellent results in 7 patients with megaesophagus who underwent myotomy. These patients demonstrated similar morbidity and hospital stay after operation as patients without a dilated esophagus. Although esophagectomy has been advocated by some based on the degree of esophageal dilation and tortuosity, we believe that an initial attempt at laparoscopic myotomy is reasonable. Ultimately only 3 (4.8%) of our patients required esophagectomy after minimally invasive myotomy.

In summary, we have demonstrated that minimally invasive esophageal myotomy can be performed safely with excellent perioperative outcomes. Quality-of-life scores were the same as that seen in a control group without achalasia and heartburn control was excellent, with low heartburn severity scores in most patients. Dysphagia was significantly improved and 92.5% of our patients were satisfied. Thoracic surgeons can perform these operations effectively. Thoracic residency training should strive to include laparoscopic esophageal surgery experience.

	Discussion

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
DR MARK S. ALLEN (Rochester, MN): I would like to thank Dr Fernando and his colleagues for allowing me to comment on this paper and providing me with a manuscript a few days ago so I could peruse it. Since the introduction of whalebone dilation for achalasia, the treatment of achalasia has varied immensely. In the beginning, the open Heller myotomy was the standard of care. This was pretty much true in the 1970s and surgeons performed most of the therapeutic interventions for patients with achalasia. When pneumatic dilatation was developed, surgical treatment waned and medical therapy predominated. Thus, in my residency we rarely saw patients for surgical therapy of achalasia because pneumatic dilatation was the treatment of choice. Recently, with the invention of minimally invasive techniques, surgical therapy is coming back to the forefront, and it is good to see because I think surgical treatment is better than pneumatic dilatation. I am concerned that the surgical specialty that is caring for patients with achalasia is becoming general surgery and not thoracic surgery. It seems that esophageal surgery is being lost by the general thoracic surgeons. I would encourage all thoracic surgeons to examine these minimally invasive techniques, try to learn them and use them in their practice, because I think we have a better education and a better background in esophageal disease and are able to offer the patients better treatment.

We too have been performing laparoscopic esophageal myotomies with a partial fundoplication as our primary treatment for achalasia. I have been impressed by the short-term success of this operation and very hopeful that these good outcomes will continue as we follow up these patients in the future. I have several questions for the authors.

Do you think that the operation is made more difficult when patients have had previous therapy such botulism toxin or balloon dilatation? I noticed in your manuscript you had a fair number of these treatments done on your patients. Did that make the outcomes any worse, was the operation any harder?

In the manuscript you had a fairly high perforation rate, 6 of 62 patients, for about 10%. I wonder if you could describe the technical aspects of what happened in these patients and what you did about these patients. I have been pretty impressed about how easy it is just to pry the muscles apart, sometimes with a dissector, without directly cutting it. Our perforation rate has been pretty low with that technique. Do you think the use of the ultrasonic knife has contributed to this perforation, as others have described?

I am also surprised in the manuscript by the number of esophagectomies that had to be done in these patients, it was about 5%, which seems a bit high although I am not exactly sure what our rate is. I wonder if you have ever tried to redo a myotomy in one of these patients after a laparoscopic myotomy?

Finally, most of the follow-up you have presented is pretty much subjective and I have always thought that subjective measurements are almost always good because patients generally want to feel good that they had an operation. I think it would be better if we used some sort of objective measurement such as a barium swallow with measurement of the esophageal diameter, measurement of esophageal emptying as Tom Rice’s group at the Cleveland Clinic has mentioned or a manometry postoperatively so we could see what the pressure of the LES is. I would ask you what objective measures are you using to continue to follow these patients?

DR MARK B. ORRINGER (Ann Arbor, MI): With a 21-month follow-up, 3 patients requiring a redo myotomy and 3 patients requiring an esophagectomy result in a 10% "failure rate" of the operation in less than 2 years of follow-up. Are you concerned at all about that? It is a relatively short-term follow-up and the results in the people who did well are great, but is that adequate?

DR FERNANDO: Well, first of all, of the 3 patients who had esophagectomy, 2 of these patients had a redo myotomy performed by us prior to proceeding with esophagectomy. Dr Orringer’s group presented a paper yesterday on esophagectomy for end-stage achalasia. An important question that this raises is when should an esophagectomy be performed as initial treatment for achalasia or should a myotomy always be undertaken before proceeding with esophagectomy. Our own preference is to perform a myotomy as an initial approach although we recognize that there are arguments to proceed directly to an esophagectomy based on esophageal diameter and on whether an esophagus is sigmoid or not. Perhaps we selected these patients incorrectly for myotomy and then redo myotomy and perhaps our results would have been better if we had offered these patients esophagectomy right from the beginning. I think that future outcome studies will help us to select the appropriate treatment a little better.

As far as the mucosal perforations that we had, these occurred mostly early on in our experience, particularly in patients who had multiple previous dilations. We do feel that multiple botox injections make the plane between muscle and mucosa more difficult to define at operation and increase the chances of a mucosal injury. However most of these injuries can be repaired very easily using an Endo-stitch.

Regarding the comment about ultrasonic shears, there is a risk with using these as it is possible to pass-point with the tip as you are doing the myotomy and so injure the mucosa. As long as attention is paid to avoid this kind of an injury, I feel that this is a good instrument for this procedure. I would also like to stress that much of the dissection is performed with the instrument closed and used as a blunt dissector to pry the muscles apart as Dr Allen described.

We routinely perform a barium swallow after operation but do not perform manometry. Although I acknowledge the comments about subjective measures I do feel that patient derived measures of outcome such as the SF36 are excellent instruments to use in a disease that primarily affects quality of life. These instruments have been validated by others and allow a way to quantify subjective outcome. This is better than the subjective measures often reported in earlier surgical series where the results are simply presented as good or excellent.

	References

Top Abstract Introduction Patients and methods Results Comment Discussion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James D. Luketich Hiran C. Fernando Neil A. Christie Robert J. Keenan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Luketich, J. D. Articles by Schauer, P. R. Search for Related Content PubMed PubMed Citation Articles by Luketich, J. D. Articles by Schauer, P. R. Related Collections Esophagus - other