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13 Management ofAchalasia: ADisease Hard toSwallow
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anterior myotomy with promising results in eight patients in 1923 [38]. This myotomy was performed via an open approach, either trans-thoracic or trans- abdominal.
The myotomy incision, as described by Ellis etal., extended to only 5mm on the
gastric wall [38]. Through a “short” myotomy on the gastric wall, he was able to
achieve an improvement rate of 89% with marked reux in 5% of patients. Notably,
a trans-abdominal approach resulted in a signicantly higher incidence of postoperative reux, which is attributed to a longer myotomy on the gastric wall, division of
the phrenoesophageal ligament, and greater mobilization of the esophagus. In 1962,
Dor introduced a partial fundoplication to an extended myotomy to decrease postoperative reux. Bonavina etal. supported this technique nding that in 206 patients
who had an anterior myotomy (8cm on the esophagus and 2cm on the stomach) with
Dor fundoplication 93.8% of patients had complete or near-complete resolution of
symptoms [38]. The addition of a Dor fundoplication after a Heller myotomy reduced
pathologic reux demonstrated by Richards et al. nding a 47–9% measurable
decrease in 24-h pH studies without impact on dysphagia [39].
The myotomy with fundoplication remained the tenet of surgical treatment for
achalasia; however, the approach underwent modernization in the 1990s with the
introduction of laparoscopic techniques to esophageal surgery. The rst laparoscopic cardiomyotomy was performed by Dr. Cushieri in 1991 [40]. In 1992, Dr.
Pelligrini described the results of 17 patients who underwent a thoracoscopic 7cm
myotomy on the left side of the esophagus extending only 5mm on the gastric wall.
The goal was to balance dysphagia relief with reux prevention. While the shortand long-term outcomes were excellent in 90% of cases, this approach had drawbacks, including intraoperative lung exclusion, a postoperative chest tube, and high
incidence of reux given the absence of fundoplication [38]. The ability to perform
a myotomy and a partial fundoplication could be achieved with a laparoscopic
approach, making this the standard of care by the late 1990s. Comparisons of these
approaches by Patti etal. found that the laparoscopic group had shorter median
hospital stay (42hours laparoscopic vs. 84 hours thoracoscopic group), better resolution of dysphagia (90% laparoscopic vs. 87% thoracoscopic group), and improved
24h pH testing (10% laparoscopic vs. 60% thoracoscopic group) [38].
Regarding the type of fundoplication, Rawlings etal in 2012 found no signicant
difference in terms of relief of dysphagia and reux control when comparing a Dor
to a Toupet fundoplication. Albeit, Rebecchi, and colleagues found a signicant difference in the dysphagia symptoms when a Nissen wrap was performed [38]. The
advent of robotic surgery has rivaled the previous laparoscopic techniques arguing
the absence of a tremor and 3D magnied view can reduce the incidence of esophageal perforation. In 2005, Horgan etal. demonstrated a perforation incidence of 0%
in the robotic group versus 16% in the laparoscopic group. Huffman etal. supported
these ndings in 2007 with a perforation rate of 0% in the robotic group versus 8%
in the laparoscopic group. The development of cardiomyotomy, as envisioned by
Heller over a century ago, performed minimally invasively with a partial fundoplication, remains the surgical treatment of choice for achalasia today [37].
The key component of selecting patients for surgical management of achalasia is
to differentiate it from other motility disorders such as pseudoachalasia,
146
malignancy, and mechanical obstruction. This should be performed in the preoperative setting by the surgeon reviewing the history of the patient’s symptoms and
review of previous studies, including the results of esophageal manometry, endoscopy, and contrast esophagram. The patient needs to understand that this is a palliative surgery meant to relieve the symptoms and is not a cure. A laparoscopic
myotomy, when combined with an antireux procedure, provides better symptom
relief (90%) than all endoscopic and other surgical approaches and carries a lower
complication rate of 6.3% [40]. This information should be communicated to the
patient during the preoperative clinic visit.
M. Belisle et al.
Heller Myotomy
Operative Steps
Anesthesia Induction andRobot Docking
Patients are advised to stay on a liquid diet preoperatively for 1week, especially if
they have an end-stage esophagus, that is, sigmoid esophagus. During this time,
they are placed on a high-protein shake. Preoperative enoxaparin is given prior to
intubation. Care is taken by anesthesia to minimize the risk of aspiration by performing a rapid sequence intubation and the patient not laying completely at.
After induction of general anesthesia, the patient is placed on the operating table
in supine position, with both arms tucked and a foot board in place. The arm is tucked
to allow the robot to be docked with no interference with the arm board. Having the
arm out is an acceptable practice. The patient is given prophylactic antibiotics, usually a rst-generation cephalosporin, within 1h of the incision. An orogastric tube
and an optional Foley catheter is inserted. Sequential compression devices are turned
on and functioning throughout the case.
The procedure is commenced by making a stab incision in the left upper quadrant at Palmer’s point. A Veress needle is inserted and pneumoperitoneum established to 15mmHg of CO2. The authors use the Davinci Xi platform. All trocars are
lined in a horizontal line that is no more than 15cm below the xiphoid process. The
abdominal cavity is then entered along the right mid-clavicular line using a 30-degree
5-mm laparoscope housed in a robotic 8-mm trocar, using the Optiview technique.
Under direct visualization, an 8-mm trocar is then placed two ngerbreadths to the
left of the umbilicus, approximately 15cm below the xiphoid process. Two additional 8-mm trocars are inserted roughly 8cm apart along the left midclavicular and
left anterior axillary lines. An optional additional 5-mm assistant port is placed in
the right lower quadrant. The patient is then placed in reverse Trendelenburg position. The authors utilize two right hands and one left hand. The Davinci Xi robot is
then docked with a Maryland bipolar in (right midclavicular trocar), camera in arm
two, Vessel sealer/hook/syncroseal in (left midclavicular trocar), and Cardiere
grasper in (left anterior axillary trocar). At this point, the orogastric tube is removed
once the stomach is conrmed to be deated and suction is left on while it is being
withdrawn slowly to suction all esophageal content.
13 Management ofAchalasia: ADisease Hard toSwallow
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Liver Retraction
Next, the left lateral segment of the liver is retracted. This has been described with
a Nathonson retractor or pretzel retractor. Both of which require an additional incisional with an epigastric incision with the former and 5mm trocar in the latter. The
Nathanson retractor should be positioned so it does not interfere with robot arms.
Alternatively, a suture hammock with a #1 V-lock 18-inch suture as described by Dr.
Havaleshko’s, “Dima stitch,” to suspend the left lateral segment of the liver anteriorly in order to expose the hiatus.
Hiatal Dissection
The dissection toward the crus can be initiated with a right-rst approach or a left.
If the surgeon plans to perform a Toupet fundoplication as the choice of partial wrap
or the patient has a hiatal hernia (rare), then a left approach is more logical. This will
allow for the placement of a penrose/umbilical tape for esophageal retraction from
the patient’s left. This can be retrieved from the right side once the retroesophageal
window is created. However, if the plan is to perform a Dor fundoplication or not to
perform a wrap at all (in the case of sigmoid esophagus, i.e., end esophagus), it is
better to start with the right-rst approach. A person may wonder why with a Dor
wrap to start on the right side. When creating a Dor wrap, the retroesophageal
attachment is kept intact. Also, if the fundus is very oppy, the short gastric arteries
do not need to be taken down, although preserving the short gastrics with a Dor
wrap is not the author’s preferred approach as it can create tension at the gastroesophageal junction.
To begin the left-rst approach, the gastrocolic ligament is incised, and dissection is continued toward the left crus, taking down the short gastric vessels and
mobilizing the gastric fundus. This can be performed using the vessel sealer or
Synchroseal. Care is taken to avoid avulsing the splenic capsule or splenic vessels
by aiming the tip of the bipolar device toward the left crus and never toward the
splenic hilum. To expose the left crus, the stomach should be grasped by the posterior wall and retracted toward the patient’s right side, that is, away from the spleen.
This provides better exposure than grasping the anterior wall or the greater curve.
Attention is then carried to incising the pars accida along the lesser curvature,
heading toward the right crus. Care should be taken as sometimes a replaced left
hepatic artery can arise from the left gastric artery. The vessel can be clamped and
the liver observed for color change. If none are observed, the vessel is transected.
The phrenoesophageal membrane and peritoneum overlying the esophagus is
incised, with care to not injure the esophagus or anterior vagus nerve. Then, the pillar of the left crus is separated from the esophagus. Dissection is then carried into
the mediastinum. This is done mostly in a blunt fashion, anteriorly and laterally to
the esophagus, so that at least 9cm of esophagus is exposed for esophageal myotomy later, or dissected roughly to the level of the inferior pulmonary vein. The lateral esophageal dissection can help straighten the esophagus, whether this provides
better emptying or not is unknown.
Next, the fat pad is excised from the anterior surface of the esophagus taking care
not to injure the anterior vagus nerve. It is best to start taking the fat pad starting on
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M. Belisle et al.
the greater curve, heading toward the lesser curve with frequent, gentle pulling of
the fat pad caudally to locate the vagus nerve.
Myotomy
The myotomy can be performed with or without a bougie in place. If utilized, a 56
French or similar-sized lighted Bougie is carefully inserted into the esophagus, to
facilitate the myotomy. The lighted bougie can be seen entering the abdominal
cavity both on white mode and near-infrared mode. The anesthesia team can perform or the surgeon can insert the bougie to avoid the complication of an esophageal perforation. The myotomy can be performed in a blunt fashion (Fig.13.1a),
using scissors, a hook (Fig.13.1b), or bipolar device (vessel sealer or Synchroseal).
The magnication, stability of the robot platform, and 3D magnication allow
this critical portion of surgery to be performed with precision. Initially, the longitudinal outer muscle of the esophagus is bluntly separated (Fig.13.2a). This facilitates exposure of the circular muscle of the esophagus, which is then incised with
the vessel sealer, which is our preferred approach (Fig.13.2b). The esophageal
myotomy is then extended 7–9cm proximally along the esophagus, exposing the
underlying mucosa (Fig.13.3). The lighted bougie helps with the mucosal transillumination to ensure myotomy completion (Fig.13.4). It is important to note there
is currently no consensus on the length of the myotomy. Currently, SAGES recommends a 4cm esophageal myotomy, extended on the stomach for 2cm. The
2018 International Society of Diseases of the Esophagus guidelines recommend at
least 6cm proximal to the gastroesophageal junction, with 2cm distal to the junction [41].
The myotomy is then extended distally along the stomach, for a length of 3cm
(Fig.13.5). Wright etal. compared 52 patients with achalasia undergoing a Heller
myotomy, extending for 1–2cm onto the gastric wall and Dor fundoplication to
63 patients who underwent an extended myotomy (3cm) with Toupet fundoplication, and found that the extended 3cm myotomy gave patients better relief of
dysphagia [42]. This is done with blunt dissection, exposing the underlying
mucosa. The robot, with its articulating instruments, allows this portion of
Fig. 13.1 The myotomy can be performed using various techniques, including blunt dissection
(a), or with the aid of instruments such as scissors, a hook (b), or a bipolar device like the
Synchroseal or a vessel sealer
ab
ab
13 Management ofAchalasia: ADisease Hard toSwallow
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abc
Fig. 13.2 The procedure begins with blunt separation of the longitudinal outer muscle of the
esophagus (a), allowing clear exposure of the underlying circular muscle. The circular muscle is
then incised using the vessel sealer (b and c)
abc
Fig. 13.3 The esophageal myotomy is then extended 7–9cm proximally along the esophagus,
exposing the underlying mucosa. In image “b” an epinephrine-soaked sponge is used to clear the
blood and facilitate visualization. In image “c” you can see the anterior Vagus nerve crossing from
left to become the anterior Vagus nerve in the abdomen. This should be preserved and retracted
during the myotomy
Fig. 13.4 A lighted bougie helps with the mucosal transillumination to ensure myotomy
completion
Fig. 13.5 The myotomy is further extended distally along the stomach, for a length of 3cm
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M. Belisle et al.
surgery, which is the most difcult due to the high risk of perforation on the gastric side due to the insertion of the oblique bers. Unlike during laparoscopy, there
is no tactile feedback and the surgeon relies heavily on visual cues. Also, unlike
laparoscopy, this portion can be performed with a hook in a top-down fashion
from the esophagus toward the stomach because the instruments articulate.
Completion of gastric myotomy should be conrmed by visualizing the cardinal
vein, which can sometimes bleed during this portion of the procedure (Fig.13.6).
Care should be taken not to use energy sources as to avoid gastric mucosal injury
that can result in immediate versus delayed perforation. It is best to control any
bleeding from the myotomy with soaked epinephrine gauze and gentle pressure
(Fig.13.7). The length of both esophageal myotomy and gastric myotomy is measured with a ruler that is inserted intra-abdominally.
The lighted bougie is then removed and intraoperative upper endoscopy is performed. We like to perform a picture-in-picture endoscopy, that is, Tile Pro, where
the surgeon can see both the laparoscopic view of abdomen and the endoscopic
image at the console. The purpose of endoscopy is to
1. Examine the ease by which the scope passes the GE junction prior to and after
the wrap.
2. Conrm the GE junction and, therefore, conrm the length of gastric myotomy
and esophageal myotomy.
3. Examine the completion of myotomy by noticing mucosa bulging.
4. Examine for any bougie injury or mucosal perforation. The latter is performed
by emerging the mucosa underwater and performing a leak test.
Partial Fundoplication
Attention is then paid to the partial fundoplication; the type of partial fundoplication
performed, Dor versus Toupet, is still under debate. Tomasko etal. retrospectively
compared patient outcomes for laparoscopic Heller myotomy with either Dor versus Toupet and found overall patient satisfaction was similar (93.8% vs. 87.5%)
Fig. 13.6 The completion
of the gastric myotomy is
conrmed by visualizing
the cardinal vein
ab
13 Management ofAchalasia: ADisease Hard toSwallow
Fig. 13.7 Bleeding from the gastric myotomy is managed using epinephrine-soaked gauze and
gentle pressure, which helps prevent delayed thermal injury to the mucosa
[43]. They found no difference in regards to the incidence or severity of postoperative heartburn, dysphagia, or bloating. The mean operative time for the Toupet fundoplication was 137.3min while the mean time for the Dor fundoplication was only
111.5 min (p =0.006). Torres etal. had similar ndings with their randomized
control trial comparing laparoscopic Heller myotomy with Dor versus Toupet fundoplication in regards to patient symptom scores and high-resolution manometry
long term [44]. These studies provide support that either option is acceptable.
The goal of surgical intervention of achalasia is to provide an adequate myotomy
while reducing the risk of reux. This lies with an intraoperative assessment of the
LES during the myotomy and fundoplication that can be done with EndoFLIP.Law
etal. were able to report changes in EndoFLIP prior to and after myotomy and after
fundoplication. There was a measurable difference in mean DI from 0.7 mm2/
mmHg prior to myotomy to 3.2mm2/mmHg after (p<0.001). Following fundoplication, the DI decreased to 2.2mm2/mmHg following Dor fundoplication, which is
consistent with previous studies nding a decrease in DI to 3.3 from 4.5mm2/
mmHg. This distensibility has been correlated to an Eckardt score with a DI <3
associated with an Eckardt score of >3, indicating treatment failure. The median
Eckhardt score in this study utilizing intraoperative EndoFLIP after myotomy and
fundoplication was 0 from 4.5 prior to surgery, still with no reported symptoms of
postoperative reux. Therefore, EndoFLIP can be a benecial adjunct during surgery to reduce the risk of reux symptoms and provide optimal patient outcomes
[17]. In cases where the patient has an end-stage esophagus, that is, sigmoid esophagus, no wrap is performed. In these patients, we only reconstitute the angle of His
to reduce reux without compromising the EGJ.Endoip is a great adjunct that is
currently available at some institutions and can help tailor the choice of wrap; however, the authors do not currently use this technology.
Our institution typically performs the Dor procedure. The initial and possibly most
important step is to reapproximate the angle of His, by suturing the medial portion of
the fundus to the left crus with a #2-0 Ethibond suture (Fig.13.8a, b). The fundoplication is then performed by suturing the medial portion of the fundus to the left pillar of
the crus and the left edge of the myotomy. Then, two additional sutures are placed
distally, approximately 1cm apart, securing the medial portion of the fundus to the left
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M. Belisle et al.
edge of the myotomy (Fig.13.8c). The most lateral part of the fundus is then secured
to the right edge of the myotomy and the right pillar of the crus. Two additional sutures
are then placed distally, securing the lateral fundus to the right edge of the myotomy,
ensuring no mucosa is incorporated. Finally, one last stitch is placed between the
upper two stitches and the crus, completing the Dor fundoplication.
After the wrap is completed, repeat upper endoscopy is performed to ensure
patency of the gastroesophageal junction and the scope is retroexed to assess the
wrap (Fig. 13.9). Richards etal. performed a prospective, randomized, doubleblind, control trial comparing surgical outcomes in patients who underwent Heller
myotomy alone versus Heller myotomy plus Dor fundoplication [39]. They enrolled
43 patients and found pathologic reux, dened as distal esophageal acid exposure
abc
Fig. 13.8 Dor fundoplication is performed to re-establish the angle of His. This involves suturing
the medial portion of the fundus to the left crus using a #2-0 Ethibond suture (a and b). Total of
three sutures are placed separated 1 cm apart. The fundoplication is then completed by securing the
the anteriolateral fundus to the right pillar of the crus and the right edge of the myotomy with three
sutures separated 1 cm apart
Fig. 13.9 A repeat upper
endoscopy with
retroexion is performed to
assess the integrity and
positioning of the wrap
after its completion. It’s
important to make sure the
wrap although partial is not
too tight when the scope is
traversing the GE junction.
The latter can lead to
postoperative dysphagia
13 Management ofAchalasia: ADisease Hard toSwallow
153
time of more than 4.2% per 24-hr period 6months postoperatively, was signicantly
reduced in the Heller plus Dor group (47.6% vs. 9.1%). There was no difference
found in postoperative dysphagia. These ndings were investigated for long-term
effects by Broman etal., who contacted the previous cohort 10 years later, and
found the dysphagia scores were slightly worse for Heller alone than Heller plus
Dor, but the ndings were not statistically signicant [45]. Interestingly, 96% of
patients contacted stated they would undergo the operation again.
Intraoperative Complications
Esophageal Perforation
Iatrogenic esophageal perforation can occur while creating the myotomy. This
should be noticed intraoperatively with the assistance of the lighted bougie
(Fig.13.10a) or during upper endoscopy with or without a leak test. This can be
repaired with a 5-0 PDS suture, in a gure-of-eight fashion (Fig.13.10b). A leak test
should be performed after repair (Fig.13.10c).
Gastric Perforation
Gastric mucosal perforation is more common than esophageal mucosal perforation
due to the oblique muscles. This can occur while extending the myotomy into the
cardia of the stomach. This can be repaired with a 5-0 PDS suture, in a gure-ofeight fashion (Fig.13.11). A leak test should be performed after repair.
Vagal Nerve Injury
Care should be taken to identify anterior vagus nerve intraoperatively. If one vagal
nerve is transected, this should be disclosed to the patient after completion of the case
(Fig. 13.12). Unilateral vagal nerve injury can lead to delayed gastric emptying;
abc
Fig. 13.10 An iatrogenic esophageal injury is identied intraoperatively with the assistance of the
lighted bougie (a). The injury is repaired using a 5-0 PDS suture (b), followed by a leak test to
ensure the repair’s integrity (c)
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Fig. 13.11 An iatrogenic gastric perforation is repaired using a 5-0 PDS suture in an interrupted fashion
Fig. 13.12 Unilateral
anterior vagal nerve injury
is noted intraoperatively
M. Belisle et al.
however, Lindeboom et al. have shown that fundoplication itself may signicantly
accelerate gastric emptying [46]. This may be due to alteration in gastric compliance.
Postprandial accommodation of the proximal stomach is impaired, which may lead to
more rapid transport of the meal to the antrum, thereby accelerating gastric emptying.
Oelschlager etal. recently investigated the use of an intentional vagotomy to lengthen
the esophagus during complex esophageal surgery [47]. They found no difference in
the severity of abdominal pain, bloating, diarrhea, or early satiety between the vagotomy and no vagotomy groups. They propose it as an alternative to a Collis gastroplasty
when extensive esophageal mobilization fails to provide adequate esophageal length.
Postoperative Care
Postoperatively, patients are admitted to the surgical team and are started on a clear
liquid diet immediately, even if the patient had a mucosal injury that was repaired
intraoperatively. Scheduled antiemetics are given for 5days postoperatively. Patients
also receive 10mg of Decadron every 8h for 48h. This helps reduce the swelling