Achalasia surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2], Ahmed Younes M.B.B.CH [3]

Overview

Most effective treatment options for achalasia are pneumatic dilation and laparoscopic myotomy. Pneumatic dilation works by flattening the waist of insufficiently relaxed LES by placing a balloon at LES. Laparoscopic myotomy relaxes LES by dissecting outer muscular layers of the esophagus and sparing the inner mucosal layer.

Pneumatic Dilation

Pneumatic dilation is the most effective non surgical treatment option, however, patients should be a surgical candidate in case an esophageal perforation occurs and immediate surgery is required. Pneumatic dilation is contraindicated in patients who are not surgical candidates such as patients with poor cardiopulmonary status or any other comorbid illness. Nonradiopaque polyethylene balloons (Rigiflex dilators) are the most commonly used dilators for pneumatic dilation.[1]

Procedure

  • Patients are kept on a liquid diet for several days and nil per oral for 12 hours before endoscopy.[2]
  • It is performed as an outpatient procedure.
  • Endoscopy is done under conscious sedation.
  • Rigiflex balloon is passed over the guide-wire, smallest balloon (3 cm) is used first for the initial dilation.
  • Balloon placement is done most commonly using flouroscopy (endoscopic placement can be used too).
  • LES is flattened using 8-15 psi of air, for 15-60 seconds.
  • Post procedure follow up is done for 2-6 hours, and patient is observed for any fever or chest pain.
  • In case of chest pain, Gastrograffin esophagram is done to look for esophageal perforation.
  • In graded dilation protocol, subsequent dilations are done with larger balloons at 2-4 weeks interval after the initial dilation. Serial pneumatic dilation (PD) has been reported to be more successful than single PD. Symptomatic improvement at 6 months occurred in 90% of patients after serial PD compared to 62% patients after single PD.[3]

Complications

  • Esophageal perforation is the most serious complication present in 0-16% patients after pneumatic dilation (2% in experienced hands).[4] 50% of these need surgical treatment. Small perforations can be managed with conservative treatment using antibiotics, parenteral nutrition and stent placement.
    • Patients at high risk for perforation:
    • Elderly patients
    • Patients undergoing pneumatic dilation for the first time
    • Patients in whom 35 mm dilator is used first instead of 30 mm dilator
  • Gastroesophageal reflux disease (GERD) occurs in 15-35% patients, managed with proton pump inhibitors (PPI).
  • Pneumatic dilation causes some scarring which may increase the difficulty of Heller myotomy, if this surgery is needed later.
  • Other minor complications include chest pain, aspiration pneumonia, esophageal hematoma, mucosal tear without perforation, fever and bleeding.

Prognosis

Relapse occurs in one third patients in 4-6 years. Long term remission can be achieved by doing repeated balloon dilation, procedure is performed whenever patient needs it based on the symptoms.[5] Patients older than 40 years of age, female patients and patients with type II achalasia have the best prognosis. Timed barium esophagram is an important tool to predict effectiveness of procedure objectively.[6][7]

Myotomy

Surgical myotomy for the treatment of achalasia was performed by Ernest Heller for the first time in 1913 by laprotomy approach. Minimally invasive approaches for esophageal myotomy, which developed much later in 1990s include thoracoscopic and laproscopic approaches. It has been shown that symptomatic improvement is significantly better with laproscopic approach.[8]

Procedure

The myotomy is a lengthwise cut along the esophagus, starting above the LES and extending down onto the stomach a little way. The esophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner muscosal layer intact. Since myotomy disrupts the anti-reflux function of LES, symptoms of GERD are very common in patients after surgery. Studies have shown significant improvement in reflux symptoms if an anti-reflux procedure such as fundoplication is added to the myotomy.[8][9]Partial fundoplication is used instead of Nissen fundoplication(complete) because symptoms of dysphagia are more common with the later. Partial fundoplication can be either anterior (Dor) or posterior (Toupet), both approaches provide similar control of reflux symptoms. In a Dor (anterior) fundoplication, part of the stomach is laid over the esophagus and stitched in place so whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. After surgery, patients should keep to a soft diet for several weeks to a month, avoiding foods that can aggravate reflux.

Complications

Overall complication rate of Heller myotomy is 6.3 % (0-35%).[2][10]

  • Most common complication of laproscopic myotomy is mucosal perforation. It is usually identified during the procedure and managed immediately.
  • Development of GERD
  • Recurrence of dysphagia (due to scarring of myotomy or tight anti-reflux wrap, managed by pneumodilation)
  • Post-operative chest pain (most difficult to treat)

Success rate

In a metanalysis done by Campos et al, mean success rate of Heller myotomy was found to be 89% at a follow up period of 35 months.[8] Success rate is found to decrease at longer follow up period, being 65-85% at follow up period of 5 years.[2][11][12] Decrease in success rate can be due to progression of disease.

Factors associated with better prognosis after Heller myotomy are[13]:

  • Type II achalasia
  • Young age (<40 years)
  • Lower esophageal sphincter resting pressure > 30 mmHg
  • Straight esophagus (compared to sigmoid esophagus with tortuosities)


Pneumatic Dilation Versus Myotomy

Europian Achalasia Trial a large prospective randomised trial in 2011, compared the success rates of pneumatic dilation (up to 3 subsequent pneumatic dilation) and myotomy. In this trial, both groups were found to have a comparable success rate (86% for dilation and 90% for myotomy).[14]

Per-oral Endoscopic Myotomy (POEM)

Per-oral endoscopic myotomy is a newly developed endoscopic approach for myotomy. In this technique, lower esophageal sphincter is reached through a submucosal tunnel and circular fibers are dissected over a length of 7 cm in esophagus and 2 cm in gastric area. High success rates ranging from 90-100% have been reported with this technique, however, more studies need to be done to compare its effectiveness with laproscopic myotomy and pneumatic dilation.[15] One major limitation of this procedure is inability to perform an anti-reflux procedure which leads to high rates of GERD development (46% in one study).[16]

Esophagectomy

Additional Facts About Surgical Management of Achalasia:

  • Bougienage
  • A mechanical dilation of the LES with a firm rubber hose. This tends to be much more effective for patients with strictures than for achalasia.
  • Balloon Dilation
  • Also depends on ripping the LES.
  • There is a fine line between achieving a good result and causing esophageal perforation (seen in 2-6%).
  • Additionally, there are no guidelines concerning inflation time, number of inflations / session, inflation pressure, and how many sessions a patient should have before moving to another therapeutic modality.
  • Approximately 60 –85 % of patients have good initial results. Unfortunately, 50 % of patients will require further therapy within the next 5 years.
    • There is also data that suggests that repeated attempts are less likely to be successful and are associated with an increased risk of perforation.
  • It appears that better results are associated with age > 45 years, patients with symptoms greater than 5 years, and in those with a mildly dilated esophagus.
  • The other major side effect is the development of reflux esophagitis in ~ 2%.
  • Surgical myotomy was first performed by Heller in 1913. The operation consisted of two myotomies on opposite sides of the esophagus performed through a laparotomy.
  • The modified Heller approach (via left thoracotomy) has a success rate of 70–90%, and a mortality rate of 0.3% (similar to the 0.2% for pneumatic dilation).
  • Reflux occurs in ~ 10%, and can be complicated by ulceration, stricture and the development of Barrett’s esophagus.
  • There is little good data comparing surgery vs. pneumatic dilation, however surgery may have a higher rate of long-term benefit (95% vs. 65% at ~5 years).
  • Surgery is a good option for younger patients (<40 years old) as balloon dilation is only 50% successful with the 1st treatment, and < 70% effective overall in this age group.
    • It is also recommended for patients in whom dilation is especially risky (those with a tortuous distal esophagus, esophageal diverticula or who have had previous surgery of the gastroenterology (GE) junction), and those who have failed Botox.
  • The surgery can also be performed laparoscopically or thoracoscopically, and early data suggests equivalent short-term results when compared with the open procedure.

ACG Clinical Guideline: Diagnosis and Management of Achalasia[1]

Recommendations for the Management of Achalasia

"1. Either graded pneumatic dilation (PD) or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy for the treatment of achalasia in those fit and willing to undergo surgery (strong recommendation, moderate-quality evidence)."
"2. PD and surgical myotomy should be performed in high-volume centers of excellence (strong recommendation, low-quality evidence)."
"3. The choice of initial therapy should be guided by patients’ age, gender, preference, and local institutional expertise (weak recommendation, low-quality evidence)."
"4. Botulinum toxin therapy is recommended in patients who are not good candidates for more defi nitive therapy with PD or surgical myotomy (strong recommendation, moderate quality evidence)."
"5. Pharmacologic therapy for achalasia is recommended for patients who are unwilling or cannot undergo definitive treatment with either PD or surgical myotomy and have failed botulinum toxin therapy (strong recommendation, low-quality evidence)."

References

  1. 1.0 1.1 Vaezi MF, Pandolfino JE, Vela MF (2013). "ACG clinical guideline: diagnosis and management of achalasia". Am J Gastroenterol. 108 (8): 1238–49, quiz 1250. doi:10.1038/ajg.2013.196. PMID 23877351.
  2. 2.0 2.1 2.2 Boeckxstaens GE, Zaninotto G, Richter JE (2014). "Achalasia". Lancet. 383 (9911): 83–93. doi:10.1016/S0140-6736(13)60651-0. PMID 23871090.
  3. Vela MF, Richter JE, Khandwala F, Blackstone EH, Wachsberger D, Baker ME; et al. (2006). "The long-term efficacy of pneumatic dilatation and Heller myotomy for the treatment of achalasia". Clin Gastroenterol Hepatol. 4 (5): 580–7. PMID 16630776.
  4. Katzka DA, Castell DO (2011). "Review article: an analysis of the efficacy, perforation rates and methods used in pneumatic dilation for achalasia". Aliment Pharmacol Ther. 34 (8): 832–9. doi:10.1111/j.1365-2036.2011.04816.x. PMID 21848630.
  5. Zerbib F, Thétiot V, Richy F, Benajah DA, Message L, Lamouliatte H (2006). "Repeated pneumatic dilations as long-term maintenance therapy for esophageal achalasia". Am J Gastroenterol. 101 (4): 692–7. doi:10.1111/j.1572-0241.2006.00385.x. PMID 16635216.
  6. Rohof WO, Salvador R, Annese V, Bruley des Varannes S, Chaussade S, Costantini M; et al. (2013). "Outcomes of treatment for achalasia depend on manometric subtype". Gastroenterology. 144 (4): 718–25, quiz e13-4. doi:10.1053/j.gastro.2012.12.027. PMID 23277105.
  7. Vaezi MF, Baker ME, Achkar E, Richter JE (2002). "Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment". Gut. 50 (6): 765–70. PMC 1773230. PMID 12010876.
  8. 8.0 8.1 8.2 Campos GM, Vittinghoff E, Rabl C, Takata M, Gadenstätter M, Lin F; et al. (2009). "Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis". Ann Surg. 249 (1): 45–57. doi:10.1097/SLA.0b013e31818e43ab. PMID 19106675.
  9. Richards WO, Torquati A, Holzman MD, Khaitan L, Byrne D, Lutfi R; et al. (2004). "Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial". Ann Surg. 240 (3): 405–12, discussion 412-5. PMC 1356431. PMID 15319712.
  10. Perrone JM, Frisella MM, Desai KM, Soper NJ (2004). "Results of laparoscopic Heller-Toupet operation for achalasia". Surg Endosc. 18 (11): 1565–71. doi:10.1007/s00464-004-8912-z. PMID 15931473.
  11. Snyder CW, Burton RC, Brown LE, Kakade MS, Finan KR, Hawn MT (2009). "Multiple preoperative endoscopic interventions are associated with worse outcomes after laparoscopic Heller myotomy for achalasia". J Gastrointest Surg. 13 (12): 2095–103. doi:10.1007/s11605-009-1049-6. PMID 19789928.
  12. Rosemurgy AS, Morton CA, Rosas M, Albrink M, Ross SB (2010). "A single institution's experience with more than 500 laparoscopic Heller myotomies for achalasia". J Am Coll Surg. 210 (5): 637–45, 645–7. doi:10.1016/j.jamcollsurg.2010.01.035. PMID 20421021.
  13. Torquati A, Richards WO, Holzman MD, Sharp KW (2006). "Laparoscopic myotomy for achalasia: predictors of successful outcome after 200 cases". Ann Surg. 243 (5): 587–91, discussion 591-3. doi:10.1097/01.sla.0000216782.10502.47. PMC 1570561. PMID 16632992.
  14. Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A; et al. (2011). "Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia". N Engl J Med. 364 (19): 1807–16. doi:10.1056/NEJMoa1010502. PMID 21561346.
  15. Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M; et al. (2010). "Peroral endoscopic myotomy (POEM) for esophageal achalasia". Endoscopy. 42 (4): 265–71. doi:10.1055/s-0029-1244080. PMID 20354937.
  16. Swanstrom LL, Kurian A, Dunst CM, Sharata A, Bhayani N, Rieder E (2012). "Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure". Ann Surg. 256 (4): 659–67. doi:10.1097/SLA.0b013e31826b5212. PMID 22982946.



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