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■Esophagealinjurywhiledeveloping

theretroesophagealplane.

■Minimizetheuseoftheultrasonic

dissectorneartheesophagus.

■Tominimizebleedingnearthe

posteriorvagaltrunk,whichmay obscuretheretroesophagealplane, carefullyandbluntlydissectwitha Marylandorbluntgrasper.

■Postoperativedysphagiadueto

excessiverestrictionfromthe device

■Ensurethatthereisnotensionon

thesizerwhenmeasuringthe circumferencearoundtheGE junction.

■Devicemigration ■Whendevelopingthe

retroesophagealplane,minimize theamountofdissectionposterior totheGEjunction.Thedissection onlyneedstobewideenoughto permitpassageofthesizer.

POSTOPERATIVECARE

■ TIF—Patientsareadmittedpostoperativelyforovernightobservation.Aliquid dietisinitiatedfollowingtheprocedureandadvancedtoasoftsoliddiet withinthenextseveralweeks.Antiemeticsareadministeredliberallyto minimizepostoperativeretching.Routinepostoperativeimagingisnot obtained.

■ Radiofrequencyenergyapplication—Patientsaredischargedhomeonthedayof theprocedure.Theyarekeptonaliquiddietforthefirstseveralweeksand aresubsequentlyadvancedtoasoftsoliddiet.Routinepostoperativeimaging isnotobtained.

■ LESaugmentationsurgery—Patientsareadmittedtothehospitalovernight.

Duringourearlyexperience,aspartofaclinicaltrial,allpatientsunderwenta routinechestx-rayandbariumesophagramtoverifycorrectpositionofthe device.Routineimagingisnotcurrentlyobtained.Thepatientmayresumea normaldietimmediatelyaftertheprocedure.

OUTCOMES

■ TIF—Withtheearliestcaseseriesbeingpublishedin2008,5trulylong-termdata regardingTIFarelacking.In2012,Tradandcolleagues6publishedtheirdata whichinvolved28patientsandamedianfollow-upof14months.Eighty-two percentofpatientsremainedofftheirdailyantirefluxmedications,whereas 68%weresatisfiedwiththeresultsoftheprocedure.6Heartburnand regurgitationsymptomswereeliminatedin65%and80%ofpatients, respectively.

■ Radiofrequencyenergyapplication—Intheearliestmulticentertrialconducted intheUnitedStates(involving47patients),87%ofpatientshaddiscontinued theirantirefluxmedicationsat6monthswhilequalityoflifeimprovedand esophagealexposuretoacid(pH<4.0)decreasedbyover50%(11.7%to

4.8%ofthetotaltime).7Four-yearfollow-updatafromastudypublishedin 2007foundthat,alongwithsustainedimprovementsinqualityoflifescores, 85%ofpatientsremainedoffprotonpumpinhibitorsorhaddecreasedtheir usebyhalf.

■ Loweresophagealaugmentationsurgery—InFebruary2013,theresultsofa nonrandomizedmulticentertrialwerepublishedintheNewEnglandJournal ofMedicine.9Sixty-fourpercentofpatientshadeithernormalizedor significantlyreducedtheiresophagealacidexposureat1year.Ninety-three percentofpatientshadsignificantlyreducedtheirantirefluxmedication regimen,whereas92%experiencedasubstantialimprovementinqualityof life.

COMPLICATIONS

■ TIF

■

Esophageallaceration/perforation

■

Postoperativebleeding

■

Gastricleak,mediastinalabscess

■

Earlyfundoplicationfailure

■ Radiofrequencyenergyapplication

■

Bloating,dyspepsia

■

Esophagealulceration/bleeding

■

Esophagealperforation

■ LESaugmentationsurgery

■

Bloating,dysphagia

■ Devicemigrationand/orerosionintotheGItract(todate,nonehavebeen reportedorpublishedintheliterature)

■ Allergicreactiontothedevice(patientswithtitanium,stainlesssteel,nickel, orferrousallergies)

REFERENCES

1.HerbellaAM,PetersJH.Anatomicandphysiologictestsofesophagealfunction.In:SoperNJ, SwanströmLL,EubanksWS,eds.MasteryofEndoscopicandLaparoscopicSurgery.Philadelphia, PA:LippincottWilliams&Wilkins;2009:68–82.

2.HowardD,RichardsR.Endoluminaltherapyforgastroesophagealrefluxdisease.In:Murayama

KM,ChandB,KothariSN,etal,eds.Evidence-BasedApproachtoMinimallyInvasiveSurgery. Woodbury,CT:Cine-Med;2012:29–38.

3.BellRC,CadièreGB.Transoralrotationalesophagogastricfundoplication:technical,anatomical, andsafetyconsiderations.SurgEndosc.2011;25:2387–2399.

4.NikfarjamM,PonskyJL.Endoluminalapproachestogastroesophagealrefluxdisease.In: CameronJL,CameronAM.CurrentSurgicalTherapy.10thed.Philadelphia,PA:Elsevier;2010:19–

21.

5.BergmanS,MikamiDJ,HazeyJW,etal.EndolumenalfundoplicationwithEsophyX:theinitial NorthAmericanexperience.SurgInnov.2008:15(3):166–170.

6.TradKS,TurgeonDG,DeljkichE.Long-termoutcomesaftertransoralincisionless fundoplicationinpatientswithGERDandLPRsymptoms.SurgEndosc.2012;26:650–660.

7.TriadafilopoulosG,DibaiseJK,NostrantTT,etal.Radiofrequencyenergydeliverytothe gastroesophagealjunctionforthetreatmentofGERD.GastrointestEndosc.2001;53(4):407–415.

8.NoarMD,Lotfi-EmranS.SustainedimprovementinsymptomsofGERDandantisecretorydrug use:4-yearfollow-upoftheStrettaprocedure.GastrointestEndosc.2007;65(3):367–372.

9.GanzRA,PetersJH,HorganS,etal.Esophagealsphincterdeviceforgastroesophagealreflux disease.NEnglJMed.2013;368(8):719–727.

Chapter9

LaparoscopicHeller MyotomyandAnterior Fundoplicationfor EsophagealAchalasia



MarcoE.AllaixMarcoG.Patti

DEFINITION

■ Esophagealachalasiaisaprimarymotilitydisordercharacterizedbylackof esophagealperistalsisandfailureoftheloweresophagealsphincter(LES)to relaxproperlyinresponsetoswallowing.

DIFFERENTIALDIAGNOSIS

■ Benignstricturessecondarytogastroesophagealrefluxdisease(GERD)and esophagealneoplasmsmaymimictheclinicalpresentationofachalasia.

■ Aninfiltratingtumorofthegastroesophagealjunctioncanmimicnotonlythe clinicalandradiologicfindingsofachalasiabutalsothemanometricprofile. Thiscondition,definedas“secondaryachalasia”or“pseudoachalasia,”should besuspectedandruledoutinpatientsolderthan60yearsofage,withrecent onsetofdysphagia(lessthan6months),andwithexcessiveweightloss.

PATIENTHISTORYANDPHYSICALFINDINGS

■

Dysphagiaisthemaincomplaint,beingreportedbyabout95%ofpatients.Itis oftenforbothsolidsandliquids.Mostpatientsareabletomaintainastable weightduetochangesmadeintheirdiet.

■ About60%ofpatientsexperienceregurgitationofundigestedfood.Itoccurs morefrequentlyinthesupinepositionandmayleadtoaspirationthatinturn cancauserespiratorysymptoms,suchascough,hoarseness,wheezing,and episodesofpneumonia.

■ Heartburnispresentinabout40%ofpatients:Itisduetostasisandfermentation ofundigestedfoodinthedistalesophagusratherthanduetogastroesophageal reflux(GER).

■ Esophagealdistentioncancausechestpaininupto40%ofpatients,anditis usuallyexperiencedatthetimeofameal.

IMAGINGANDOTHERDIAGNOSTICSTUDIES

■ Athoroughevaluationtoestablishthediagnosisshouldbeperformedinall patientswithsymptomssuggestiveforachalasia.3Itconsistsofthefollowing studies:

■ Upperendoscopyisusuallythefirsttestthatisperformedtoruleoutthe presenceofamechanicalobstructionsecondarytoapepticstrictureor cancer.

■ Bariumswallowshowsanarrowingatthelevelofthegastroesophageal junction(theso-calledbird’sbeak),slowesophagealemptyingwithanair– fluidlevel,andeitherabsenceofortertiarycontractionsoftheesophageal wall(FIG1).Italsodefinesthediameterandtheaxisoftheesophagus (dilatedandsigmoidinlong-standingachalasia)andassociatedpathologic findings,includinganepiphrenicdiverticulum.Thegastricairbubbleis usuallyabsent.

■ Esophagealmanometryisthegoldstandardforthediagnosisofachalasia. LackofperistalsisandabsentorincompleteLESrelaxationinresponseto swallowingarethekeycriteriaforthediagnosis.TheLESishypertensive inonlyabout50%ofpatients.3Recently,anewclassificationof esophagealachalasiahasbeenproposedbasedonhigh-resolution manometry(HRM):typeI,classic,withminimalesophageal pressurization;typeII,achalasiawithpanesophagealpressurization;and typeIII,achalasiawithspasm(FIG2).

■ AmbulatorypHmonitoringisimportantinuntreatedpatientswhenthe diagnosisisuncertaininordertodistinguishbetweenGERDandachalasia. Postoperatively,ambulatorypHmonitoringcanbeperformedtoruleout

GERthatispresentinabout30%to40%ofcasesafterHellermyotomy andisoftenasymptomatic.

SURGICALMANAGEMENT

PreoperativePlanning

■ Acarefulsystematicevaluationandthetestsdescribedbeforeshouldbe performedineverypatientbeforetreatment.

Positioning

■ Afterinductionofgeneralendotrachealanesthesia,thepatientispositioned supineinlowlithotomypositionwiththelowerextremitiesextendedon stirrups,withkneesflexed20to30degreesorstraightifusingasplit-leg table.

■ ToavoidslidingasaconsequenceofthesteepreverseTrendelenburgposition usedduringtheprocedure,abeanbagisinflatedtocreatea“saddle”underthe perineum.

■ Becauseincreasedabdominalpressurefrompneumoperitoneumandthesteep reverseTrendelenburgpositiondecreasevenousreturn,pneumatic compressionstockingsarealwaysusedasprophylaxisagainstdeepvenous thrombosis.

■ Anorogastrictubeisplacedtokeepthestomachdecompressedduringthe procedureanditisremovedbeforestartingthemyotomy.

■ AFoleycatheterisinsertedatthebeginningoftheoperationandremovedatthe end.

■ Thesurgeonstandsbetweenthepatient’slegs.Thefirstandsecondassistants

standontherightandleftsideoftheoperatingtable(FIG3).

TECHNIQUES

PLACEMENTOFPORTS

■ Five10-mmtrocarsareusedfortheprocedure(FIG4).

■ Thefirstincisionismadeinthemidline14cmdistaltothexiphoidprocess andaVeressneedleisintroducedintotheperitonealcavity.Theperitoneal cavityisinsufflatedtoapressureof15mmHg.Subsequently,underdirect vision,anopticalportwitha0-degreescope(port1)isplaced.Oncethis portisplaced,the0-degreescopeisreplacedwitha30-degreescopeand theothertrocarsareinsertedunderlaparoscopicvision.

■ Port2isplacedintheleftmidclavicularlineatthesamelevelofport1.Itis usedbytheassistantfortractiononthegastroesophagealjunctionandas aninstrumenttotakedowntheshortgastricvessels.

■

Port3isplacedintherightmidclavicularlineatthesameleveloftheother twoports.Aretractorisusedthroughthisporttolifttheleftlateral segmentofthelivertoexposethegastroesophagealjunction.Theretractor isheldinplacebyaself-retainingsystemfixedtotheoperatingtable.

■ Ports4and5areplacedundertherightandleftcostalmarginssothattheir axesandthecameraformanangleofabout120degrees.Theseportsare usedbytheoperatingsurgeon.

■ TheinstrumentationnecessaryforthelaparoscopicmyotomyisreportedinTable

DISSECTION

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