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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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Minimally Invasive Treatment ofAchalasia
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4.3 Surgical Therapy
The Heller myotomy was rst described by Ernst Heller in 1913 who performed
laparotomy and esophagomyotomies on either side of the esophagus. The procedure
was later revised to a single anterior myotomy and it has been performed for over
100years in that manner. Today, it is standard of care to perform the operation with
a minimally invasive approach as it shows similar symptom improvement to an
open approach with reduced morbidity [18]. In fact, with the advent of the laparoscopic approach, it is not abnormal for patients to bypass medical or endoscopic
therapies (PD or Botox injection) and go straight to surgical treatment because it is
more durable and need for repeat interventions is reduced.
Outcomes of a laparoscopic or robotic Heller myotomy with or without Dor
fundoplication are consistently impressive. Clinical success rates dened by subjective measures—either by a decrease in Eckardt Score or dysphagia improvement,
range from 85% to 95% [16, 19, 20]. A partial fundoplication has been shown to
reduce GERD symptoms and esophageal acid exposure [21], but even with a concomitant anti-reux procedure such as a Dor or Toupet fundoplication the rate of
post-Heller symptomatic GERD is around 15–20% [20]. Endoscopic evidence of
pathologic reux post-Heller with fundoplication can be up to 20–30%. Rarely do
patients need to return to the operating room for an additional or more aggressive
fundoplication for reux symptoms, but it is important to educate prior to intervention on these risks.
4.3.1 Patient Positioning andPreparation
The patient should be in the supine position, arms out, on a split leg table.
Communication between the surgeon and anesthesia team should include possible
rapid sequence induction and cricoid pressure due to high risk of aspiration of
retained esophageal contents. The patient should receive antibiotics and subcutaneous heparin prior to the procedure. The patient is secured to the table via the arms,
legs, and waist strap as they will be in steep reverse Trendelenburg for the majority
of the case. An endoscopy cart should be available in the room. The abdomen is
prepped in the usual sterile fashion and draped, ensuring the xiphoid process is
exposed.
The surgeon is positioned between the legs of the patient while the assistant is on
the patient’s left side. It is the preference of this author to use a hook electrocautery
device and an Ultrasonic Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, OH)
along with standard laparoscopic equipment. It is usual but not mandatory to perform an endoscopy intraoperatively to assess for mucosal injury and to inspect the
fundoplication, so an adult endoscope should be available.
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Fig. 5 This author’s
preferred port placement
for laparoscopic Heller
myotomy, with patient in
the supine, split-leg
position and using a
Nathanson liver retractor
12 mm
K. A. Wong
Liver
Retractor
5 mm
5 mm
5 mm
4.3.2 Port Placement
The abdomen is entered via surgeon’s preference, either open cut down technique,
Veress insufation followed by optical trocar placement, or optical trocar placement
alone. The camera port should be positioned approximately 13cm inferior to the
xiphoid and 2cm towards the patient’s left. After the table has been put into steep
reverse Trendelenburg, a laparoscopic liver retractor (Nathanson or Snake) is placed
to elevate the left lobe of the liver up and away from the hiatus. 12 and 5mm working ports are placed in the right and left upper abdomen, superior to the camera port,
to be used by the surgeon standing between the legs. An additional 5mm assistant’s
port is placed in the left lateral abdomen (Fig.5). In the split leg position, the assistant is able to be seated on a stool to patient’s left or they may straddle the patient’s
left leg.
4.3.3 Mobilization oftheEsophagus
The pars accida is entered just above the hepatic branch of the vagus nerve and the
plane between the esophagus and right crus is developed (Fig.6). A replaced left
hepatic artery can reside in this area, and should be preserved if possible. Once into
the mediastinum, the dissection is carried anteriorly to the left crus, making sure to
identify and protect the anterior vagus nerve. Much of the hiatal dissection (in a
primary operation) can be performed bluntly, using one grasper to retract the left or
right crus and the other to sweep the esophagus and anterior vagus away (Fig.7).
Next, the proximal short gastric vessels are transected starting at the level of the
inferior pole of the spleen, staying close to the stomach (Fig.8). This is in preparation for a fundoplication but additionally aids in exposing the left crus. One does not
need to perform a retroesophageal dissection, in the majority of cases the anterior
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Fig. 6 After opening the
pars accida, the right crus
is identied. A plane
between the right crus and
esophagus is developed to
enter the mediastinum and
begin the esophageal
mobilization
Fig. 7 As the dissection
moves in a clockwise
direction from the right to
left crus, the
gastroesophageal fat pad
should be used for caudal
retraction during the
mediastinal dissection
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Fig. 8 Transection of the
gastrosplenic ligament
containing the short gastric
vessels, starting from
approximately the level of
inferior pole of the spleen
and moving towards the
left crus
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Fig. 9 Removal of the
Gastroesophageal fat pad
in preparation for the
myotomy
K. A. Wong
dissection will allow enough esophageal exposure to perform an adequate myotomy. If a posterior cruroplasty is required or if a posterior fundoplication is preferred, then the esophagus must be circumferentially dissected.
4.3.4 Myotomy
To aid in identication of the mucosa during myotomy, a bougie (36–40 Fr) or an
endoscope is passed with the distal tip in the stomach and left in place. This will
emphasize the “bulging” of the mucosa from underneath the circular muscle bers.
The anterior vagus nerve is again identied. The esophagus is retracted caudally
using an atraumatic grasper on the gastroesophageal fat pad. The portion of fat pad
in the trajectory of the myotomy should be dissected free to expose the esophagogastric junction (Fig.9). The full thickness myotomy is begun on the distal esophagus just proximal to the gastroesophageal junction and to the left of the vagus nerve.
The muscle is retracted using atraumatic gaspers on either side of the vertical line of
the myotomy. The longitudinal muscles are bluntly split, and the circular muscles
divided using blunt dissection with a Maryland dissector and hook or electrocautery
(Fig.10). If thermal energy is used, the surgeon must take care to pull away from the
back of the mucosa. It is important to nd the correct plane underneath the circular
muscle bers, and retracting both edges of the myotomy to peel it off of the submucosa and to create adequate tension with atraumatic graspers makes this easier
(Fig.11). The myotomy is carried proximally on the esophagus for at least 6cm.
Often times the myotomy trajectory will carry you underneath the vagus nerve as it
crosses over from the left side of the chest so care will be required to create space
underneath the nerve (Fig.12). It is helpful to place a Kittner roll gauze into the
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Fig. 10 The longitudinal
muscle bers are split
using blunt dissection,
revealing the circular
muscle bers. The circular
muscle bers can be
bluntly separated with
tearing, or they can be
taken with electrocautery.
This author prefers a
laparoscopic hook for both
tearing and electrocautery
dissection
Fig. 11 Adequate
retraction on the edges of
the cut muscle, along with
placement of a bougie/
EGD across the GE
junction assist in staying in
the correct plane and
avoiding damage to the
back of the mucosa
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abdomen to assist with hemostasis of the muscle edges and submucosal vessels
(Fig.13). Once the myotomy is nished on the esophagus it can be carried distally
onto the gastric side. The gastroesophageal junction is the most difcult area of dissection due to brosis and from previous interventions such as dilations/Botox
injections. It is the most likely location of a mucosal perforation. Great attention
needs to be given to the direction of the circular muscles as they change course to
form the sling bers of the stomach. The myotomy is carried a minimum of 2–3cm
onto the stomach. An air leak or upper endoscopy can be performed, if the latter is
done it can also be used to ensure adequate myotomy.
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Fig. 12 The cranial
trajectory of the myotomy
usually courses underneath
the anterior vagus nerve as
it courses from the left side
of the chest onto the
stomach
Fig. 13 A Kittner roll
gauze is helpful for
hemostasis and
visualization during
myotomy
K. A. Wong
4.3.5 Fundoplication
A fundoplication is considered after myotomy reduce the risk of acid reux and
esophagitis. No consensus has been reached regarding what the ideal fundoplication
is following a Heller myotomy. Several small, randomized-controlled trials [22, 23]
have shown no difference in pathologic acid exposure, quality of life scores, or rates
of dysphagia up to 24months post-surgery with a Dor fundoplication or Toupet
fundoplication. The majority of surgeons continue to prefer the Dor fundoplication,
as it is a gentler wrap compared to the Toupet in theory and it buttresses the myotomy in case of perforation. Here we will describe the steps of Dor fundoplication
creation after the Heller myotomy is performed.
After the gastrosplenic ligament has been taken down as described with the
esophageal mobilization, the fundus is pulled anterior in a 180° fashion and xed to
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both edges of the myotomy in a length of approximately 3cm with non-absorbable,
interrupted stitches. The rst stitch is taken from the edge of the edge of the fundus
to the proximal, left side of the myotomy and the left crus (Fig.14). The second
stitch secures the stomach near the angle of His to the left side of the myotomy,
distal to the rst stitch. The stomach is folded over the myotomy anteriorly, and the
third stitch is taken at the edge of the stomach at the proximal greater curve, to the
right side of the myotomy, and to the hiatus at the 9–10 o’clock position. Two additional stitches are placed tacking the greater curvature to the right side of the myotomy and right crus. Great care must be taken during the wrap creation not to disrupt
the angle of His and to avoid twisting the gastroesophageal junction, a consequence
of inadequate length of gastrosplenic ligament ligation (Fig.15).
Fig. 14 The rst
non-absorbable,
interrupted stitch is placed
just proximal to the tip of
the fundus, and goes
through stomach, edge of
myotomy, and left crus
Fig. 15 The completed
Dor fundoplication
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4.3.6 Postoperative Care
In general, patients are admitted to a oor bed. It is the preference of this author to
start clear liquid diet on POD 0, followed by a full liquid/puree diet with discharge
on POD1. Alternatively, some prefer to obtain a gastrogran study on POD 1 to rule
out leak, then start a liquid diet if negative. Patients will stay on a full liquid/puree
diet for 2weeks and advance to softs followed by solids as tolerated. Medications
are crushed/liquid form for 2weeks or until solid food is started. Breads, meats,
leafy vegetables should especially be avoided in the postoperative period.
4.3.7 Pitfalls andComplications
Postoperative complication rates are around 2% and include intraoperative mucosal
perforation, leak, bleeding requiring transfusion, surgical site infection, mycocardial infarction, pneumonia, etc. Mortality rate is low at 0.3% [24]. Esophageal perforation is the most feared complication. If a mucosal injury is seen intraoperatively,
it may be repaired using ne sutures. A Dor fundoplication is considered to buttress
the repair as opposed to a Toupet or no fundoplication. Missed mucosal perforations
can lead to mediastinitis, peritonitis, sepsis, and death. If this occur, treatment is
emergent reoperation, washout, repair, wide drainage and post pyloric feeding
access placement. If the perforation is unable to be repaired primarily, then diversion or esophagectomy is performed. Of note, redo Heller myotomies come with a
high risk of perforation and leak due to adhesions and already exposed mucosa so
an alternative route to the rst operation should be considered (should consider
posterior POEM, or if prior abdominal approach, then proceed with thoracic and
vice versa).
Recurrent dysphagia and/or regurgitation after Heller myotomy is not uncommon. This can be due to inadequate myotomy, progression of esophageal body dysmotility and dilation, diverticulum, or development of GERD. It is important to
repeat workup in these patients, including EGD, timed barium esophagram, high
resolution manometry, and Endoip™. Each of these tests can give an idea whether
the LES is open versus fails to relax with high resting pressure. If it is the latter, than
a re-intervention on the LES is appropriate and usually achieves satisfactory
outcomes.
K. A. Wong
5 Conclusion
Multiple treatments exist for achalasia, but a minimally invasive laparoscopic Heller
myotomy remains the most successful and durable option. Most surgeons will
encounter only a handful of these patients during their career. Here we have
described the critical steps of the operation, where attention to technical detail is key
in a successful outcome.
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