ORIGINAL ARTICLE
Are Contrast Swallows Necessary Immediately Postlaparoscopic Heller Cardiomyotomy? Anantha Madhavan, MBChB, MRCS,* Alexander W. Phillips, MA, BSc, MBBS, MRCSEd, FHEA,w William R. J. Carr, MBBS, MRCS,w and Yirupaiahgari Krishnaiah Setty Viswanath, MBBS, MS, FRCSz
Abstract: Laparoscopic cardiomyotomy is an effective treatment for achalasia. Intraoperative leak tests are carried out to exclude mucosal perforations, additionally some surgeon perform postoperative contrast swallows. The aim of the study was to identify whether postoperative contrast swallows were necessary in all patients who undergo laparoscopic cardiomyotomy. All patients who underwent a laparoscopic cardiomyotomy at a single center between 2004 and 2011 were identified. Median age was 55 (18 to 79), median body mass index 26 (17 to 37), and median length of stay was 1 day (1 to 4). A total of 54% of patients had previous pneumatic dilatations. One intraoperative mucosal perforation was identified and repaired. No leaks were seen on the postoperative swallow; however, 1 patient was readmitted with a contained leak, 8 days after surgery. Postoperative contrast swallow did not have any clinical impact. We suggest that they are only indicated if there is a clinical concern and that laparoscopic cardiomyotomy can be safely carried out as a day case procedure. Key Words: achalasia, pneumatic dilatation, Heller cardiomyotomy, laparoscopic cardiomyotomy, contrast swallow, esophageal perforation
(Surg Laparosc Endosc Percutan Tech 2014;24:e167–e169)
A
chalasia is an esophageal dysmotility disorder characterized by incomplete relaxation of the lower esophageal sphincter (LOS) and lack of peristalsis.1 Patients classically present with progressive dysphagia. Incidence of the disease in the United Kingdom is 1 per 100,000.2 There are a number of treatment options available that include pharmacological, pneumatic dilatation, botulinum toxin injection, per-oral endoscopic myotomy, and cardiomyotomy.3–5 The main aim of pharmacological and botulinum toxin is to decrease the LOS pressure and although they are shown to provide immediate clinical response, their long-term efficacy remains in question.5 Endoscopic pneumatic dilatation works in the principle of stretching and therefore rupturing the LOS. A recent randomized clinical trial has reported that there is no significant difference in efficacy between pneumatic dilatation and laparoscopic cardiomyotomy, with a reported therapeutic success rate of 90% over a follow-up of 1 year. Received for publication January 19, 2013; accepted February 27, 2013. From the *James Cook University Hospital; wGeneral Surgery, James Cook University Hospital; and zUpper GI surgery, James Cook University Hospital, Marton Road, Middlesbrough, UK. The authors declare no conflicts of interest. Reprints: Yirupaiahgari Krishnaiah Setty Viswanath, MBBS, MS, FRCS, Upper GI Surgeon, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK (e-mail: yks. [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
However, it was also noted that all patients routinely received at least 2 dilatations and some patients underwent further “on-demand” pneumatic dilatation based upon their symptom score.6 The requirement of further endoscopic intervention increases the inherent risk of iatrogenic esophageal perforation. End-stage disease may even necessitate esophagectomy. Heller cardiomyotomy accompanied by an anti-reflux “wrap” is the most frequently performed surgical procedure for this disease and is usually undertaken laparoscopically.7,8 The laparoscopic approach offers the benefit of lower morbidity and shorter recovery time when compared with the open procedure. Further, success rates after the procedure have been stated to be 85% to 93%.8 Intraoperative leak tests are often performed to try and confirm no mucosal injury has occurred. This can be done with methelyne blue or as an air leak test performed with intraoperative endoscopy.9,10 In addition, there is wide spread use of postoperative check swallows before commencement of oral feed to determine whether there is any mucosal injury and thus risk of leak.11 This usually necessitates a hospital inpatient stay that can lead to a delayed discharge and subsequent increase in the cost of the procedure.9 The aim of this study was to determine whether these radiographic studies alter patient management.
METHODS A retrospective review of laparoscopic cardiomyotomy performed by a single surgeon in a single center over a 7year period was performed. A case note review was carried after production of an initial proforma. All patients underwent a water contrast swallow and esophageal studies preoperatively.
Surgical Technique All patients underwent a standard laparoscopic cardiomyotomy under general anesthetic. A pneumoperitoneum was created using an open Hassan technique with the introduction of a 12-mm port. A further two 10mm ports and a 5-mm port was introduced. The myotomy was extended 2 to 3 cm across the proximal stomach to cut the gastric sling fibers and extended cranially 8 cm. An anterior Dor wrap was carried out to complete the procedure. An intraoperative air leak test was carried out in all patients with the use of endoscopy and used to identify whether there had been any mucosal breach before the completion of the wrap. Postoperatively, all patients had a water-soluble contrast swallow, which was scheduled to be done on the first postoperative day before commencement of oral feeding.
Volume 24, Number 5, October 2014
www.surgical-laparoscopy.com |
e167
Surg Laparosc Endosc Percutan Tech
Madhavan et al
TABLE 1. Demographics of the Patients in the Study Male:female Median age (range) Median BMI (range) Median length of hospital stay (range) (d) ASA I ASA II ASA III
15:9 50 (18-79) 28 (17-37) 1 (1-4) 6 15 3
ASA indicates American Society of Anesthesiologists; BMI, body mass index.
Patients were discharged if the swallow was satisfactory. Patients were followed up over a 6-month period and the postoperative outcome was assessed with the use of a verbal analog scale. The verbal analog scale was used to assess the satisfaction with regard to their ability to swallow; the range was 0 to 10. This was compared with the score obtained in the first consultation before surgery. Patients were subsequently discharged if they had no problems.
RESULTS Twenty-four patients underwent laparoscopic cardiomyotomy for achalasia during the 7 years reviewed (Table 1). Twenty-one patients (88%) had previous interventions to treat their achalasia (Table 2). Only 1 mucosal perforation was identified intraoperatively that was repaired at the time. There was no radiologic evidence of leaks identified on all the postoperative contrast swallows that were performed. One patient was admitted 8 days after surgery with chest pain and raised inflammatory markers. Subsequent investigations revealed the presence of a mediastinal infection secondary to a mucosal perforation. The patient was managed conservatively with intravenous antibiotics and parenteral feeding. A subsequent swallow performed 2 weeks after admission showed resolution of the leak. The median length of stay was 1 day.1–4 Four patients had delayed discharge due to timing of the postoperative swallow. All patients had preoperative and postoperative swallow satisfaction assessed with a verbal analog score. The median preoperative swallow score was 2. At 6-month follow-up, the median score was 10.
DISCUSSION Laparoscopic cardiomyotomy has been demonstrated to be a safe method in the treatment of achalasia.7–9 It has been to shown to be superior as a single intervention in
TABLE 2. Previous Interventions Patients Underwent Before Surgery for Laparoscopic Cardiomytomy
Previous Interventions None Botox alone Dilatation 1 Dilatation 2 Dilatation 3
e168 | www.surgical-laparoscopy.com
No. Patients 3 8 9 2 2
Volume 24, Number 5, October 2014
the treatment, when compared with pneumatic dilatation and botulinum toxin.8,9 The incidence of mucosal perforation is 5% to 33%.12,13 Furthermore preoperative endoscopic therapies did not increase the risk of perforation or intraoperative complications in our patient complications.9 There is little evidence to suggest that patients who have had previous therapeutic interventions such as pneumatic dilatation have worse results after surgery. Indeed, 54% of the patients in this cohort had undergone at least 1 pneumatic dilatation and all of these patients had an excellent clinical outcome. The sole patient in our study who sustained a mucosal perforation in the postoperative period had no previous therapeutic intervention before their surgery. Interestingly, the intraoperative leak test and the initial postoperative swallow revealed no radiologic evidence of a leak. The initial insult was attributed to the thermal injury intraoperatively at the site of the leak. Subsequent necrosis at the site of the injury during the postoperative period resulted in the delayed leak, thus was not recognized in the immediate postoperative swallow. Many surgeons carry out an intraoperative leak test and subsequent postoperative swallow to exclude any mucosal perforation after surgery.10 Postoperative swallows have also been advocated in assessing clinical outcome based on the degrees of esophageal dilatation and other radiologic parameters.14 However, there are little data about clinical outcome and the relationship to postoperative contrast studies and they are not used routinely at our institution to gauge results, but only to identify possible perforations. The main limitation of this study is the small number of patients, but it is interesting to note that the early postoperative swallow in our cohort had no impact on clinical outcome. We would suggest that postoperative contrast swallows are not required routinely in the immediate postoperative period. Instead, they should be reserved for situations where intraoperative surgical concerns may have arisen. Therefore, laparoscopic cardiomyotomy may be carried out safely as a day-case procedure. Delaying discharge for a contrast swallow is therefore not necessary and thus supports the use of day-case cardiomyotomy.
REFERENCES 1. Tsuboi K, Omura N, Yano F, et al. Preoperative dilatation does not affect the surgical outcome of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia. Surg Laparosc Endosc Percutan Tech. 2009;19:98–100. 2. Mayberry JF, Atkinson M. Variations in the prevalence of achalasia in Great Britain and Ireland: an epidemiological study based on hospital admissions. Q J Med. 1987;62: 67–74. 3. Abir F, Modlin I, Kidd M, et al. Surgical treatment of achalasia: current status and controversies. Dig Surg. 2004;21: 165–176. 4. Pohl D, Tutuian R. Achalasia: an overview of diagnosis and treatment. J Gastrointest Liver Dis. 2007;16:297–303. 5. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010; 42:265–271. 6. Wu JCY. Pneumatic Dilation versus Laparoscopic Heller’s Myotomy for Idiopathic Achalasia (N Engl J Med 2011;364: 1807-1816). N Engl J Med. 2011;17:324–326. r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 5, October 2014
7. Sharp KW, Khaitan L, Scholz S, et al. 100 consecutive minimally invasive Heller myotomies: lessons learned. Ann Surg. 2002;235:631–639. 8. Rossetti G, Brusciano L, Amato G, et al. A total fundoplication is not an obstacle to esophageal emptying after Heller myotomy for achalasia. Ann Surg. 2005;241: 614–621. 9. Finan KR, Renton D, Vick CC, et al. Prevention of postoperative leak following laparoscopic Heller myotomy. J Gastrointest Surg. 2009;13:200–205. 10. Vaziri K, Soper NJ. Laparoscopic Heller myotomy: technical aspects and operative pitfalls. J Gastrointest Surg. 2008;12: 1586–1591.
r
2014 Lippincott Williams & Wilkins
Is Contrast Swallow Necessary Post Cardiomyotomy?
11. Iqbal A, Haider M, Desai K, et al. Technique and follow-up of minimally invasive Heller myotomy for achalasia. Surg Endosc. 2006;20:394–401. 12. Morino M, Rebecchi F, Festa V, et al. Preoperative pneumatic dilatation represents a risk factor for laparoscopic Heller myotomy. Surg Endosc. 1997;11:359–361. 13. Beckingham IJ, Callanan M, Louw JA, et al. Laparoscopic cardiomyotomy for achalasia after failed balloon dilatation. Surg Endosc. 1999;13:493–496. 14. Yoo C, Levine MS, Redfern RO, et al. Laparoscopic Heller myotomy and fundoplication: findings and predictive value of early postoperative radiographic studies. Abdom Imaging. 2004;29:643–647.
www.surgical-laparoscopy.com |
e169
Are Contrast Swallows Necessary Immediately Postlaparoscopic Heller Cardiomyotomy? Anantha Madhavan, MBChB, MRCS,* Alexander W. Phillips, MA, BSc, MBBS, MRCSEd, FHEA,w William R. J. Carr, MBBS, MRCS,w and Yirupaiahgari Krishnaiah Setty Viswanath, MBBS, MS, FRCSz
Abstract: Laparoscopic cardiomyotomy is an effective treatment for achalasia. Intraoperative leak tests are carried out to exclude mucosal perforations, additionally some surgeon perform postoperative contrast swallows. The aim of the study was to identify whether postoperative contrast swallows were necessary in all patients who undergo laparoscopic cardiomyotomy. All patients who underwent a laparoscopic cardiomyotomy at a single center between 2004 and 2011 were identified. Median age was 55 (18 to 79), median body mass index 26 (17 to 37), and median length of stay was 1 day (1 to 4). A total of 54% of patients had previous pneumatic dilatations. One intraoperative mucosal perforation was identified and repaired. No leaks were seen on the postoperative swallow; however, 1 patient was readmitted with a contained leak, 8 days after surgery. Postoperative contrast swallow did not have any clinical impact. We suggest that they are only indicated if there is a clinical concern and that laparoscopic cardiomyotomy can be safely carried out as a day case procedure. Key Words: achalasia, pneumatic dilatation, Heller cardiomyotomy, laparoscopic cardiomyotomy, contrast swallow, esophageal perforation
(Surg Laparosc Endosc Percutan Tech 2014;24:e167–e169)
A
chalasia is an esophageal dysmotility disorder characterized by incomplete relaxation of the lower esophageal sphincter (LOS) and lack of peristalsis.1 Patients classically present with progressive dysphagia. Incidence of the disease in the United Kingdom is 1 per 100,000.2 There are a number of treatment options available that include pharmacological, pneumatic dilatation, botulinum toxin injection, per-oral endoscopic myotomy, and cardiomyotomy.3–5 The main aim of pharmacological and botulinum toxin is to decrease the LOS pressure and although they are shown to provide immediate clinical response, their long-term efficacy remains in question.5 Endoscopic pneumatic dilatation works in the principle of stretching and therefore rupturing the LOS. A recent randomized clinical trial has reported that there is no significant difference in efficacy between pneumatic dilatation and laparoscopic cardiomyotomy, with a reported therapeutic success rate of 90% over a follow-up of 1 year. Received for publication January 19, 2013; accepted February 27, 2013. From the *James Cook University Hospital; wGeneral Surgery, James Cook University Hospital; and zUpper GI surgery, James Cook University Hospital, Marton Road, Middlesbrough, UK. The authors declare no conflicts of interest. Reprints: Yirupaiahgari Krishnaiah Setty Viswanath, MBBS, MS, FRCS, Upper GI Surgeon, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK (e-mail: yks. [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
However, it was also noted that all patients routinely received at least 2 dilatations and some patients underwent further “on-demand” pneumatic dilatation based upon their symptom score.6 The requirement of further endoscopic intervention increases the inherent risk of iatrogenic esophageal perforation. End-stage disease may even necessitate esophagectomy. Heller cardiomyotomy accompanied by an anti-reflux “wrap” is the most frequently performed surgical procedure for this disease and is usually undertaken laparoscopically.7,8 The laparoscopic approach offers the benefit of lower morbidity and shorter recovery time when compared with the open procedure. Further, success rates after the procedure have been stated to be 85% to 93%.8 Intraoperative leak tests are often performed to try and confirm no mucosal injury has occurred. This can be done with methelyne blue or as an air leak test performed with intraoperative endoscopy.9,10 In addition, there is wide spread use of postoperative check swallows before commencement of oral feed to determine whether there is any mucosal injury and thus risk of leak.11 This usually necessitates a hospital inpatient stay that can lead to a delayed discharge and subsequent increase in the cost of the procedure.9 The aim of this study was to determine whether these radiographic studies alter patient management.
METHODS A retrospective review of laparoscopic cardiomyotomy performed by a single surgeon in a single center over a 7year period was performed. A case note review was carried after production of an initial proforma. All patients underwent a water contrast swallow and esophageal studies preoperatively.
Surgical Technique All patients underwent a standard laparoscopic cardiomyotomy under general anesthetic. A pneumoperitoneum was created using an open Hassan technique with the introduction of a 12-mm port. A further two 10mm ports and a 5-mm port was introduced. The myotomy was extended 2 to 3 cm across the proximal stomach to cut the gastric sling fibers and extended cranially 8 cm. An anterior Dor wrap was carried out to complete the procedure. An intraoperative air leak test was carried out in all patients with the use of endoscopy and used to identify whether there had been any mucosal breach before the completion of the wrap. Postoperatively, all patients had a water-soluble contrast swallow, which was scheduled to be done on the first postoperative day before commencement of oral feeding.
Volume 24, Number 5, October 2014
www.surgical-laparoscopy.com |
e167
Surg Laparosc Endosc Percutan Tech
Madhavan et al
TABLE 1. Demographics of the Patients in the Study Male:female Median age (range) Median BMI (range) Median length of hospital stay (range) (d) ASA I ASA II ASA III
15:9 50 (18-79) 28 (17-37) 1 (1-4) 6 15 3
ASA indicates American Society of Anesthesiologists; BMI, body mass index.
Patients were discharged if the swallow was satisfactory. Patients were followed up over a 6-month period and the postoperative outcome was assessed with the use of a verbal analog scale. The verbal analog scale was used to assess the satisfaction with regard to their ability to swallow; the range was 0 to 10. This was compared with the score obtained in the first consultation before surgery. Patients were subsequently discharged if they had no problems.
RESULTS Twenty-four patients underwent laparoscopic cardiomyotomy for achalasia during the 7 years reviewed (Table 1). Twenty-one patients (88%) had previous interventions to treat their achalasia (Table 2). Only 1 mucosal perforation was identified intraoperatively that was repaired at the time. There was no radiologic evidence of leaks identified on all the postoperative contrast swallows that were performed. One patient was admitted 8 days after surgery with chest pain and raised inflammatory markers. Subsequent investigations revealed the presence of a mediastinal infection secondary to a mucosal perforation. The patient was managed conservatively with intravenous antibiotics and parenteral feeding. A subsequent swallow performed 2 weeks after admission showed resolution of the leak. The median length of stay was 1 day.1–4 Four patients had delayed discharge due to timing of the postoperative swallow. All patients had preoperative and postoperative swallow satisfaction assessed with a verbal analog score. The median preoperative swallow score was 2. At 6-month follow-up, the median score was 10.
DISCUSSION Laparoscopic cardiomyotomy has been demonstrated to be a safe method in the treatment of achalasia.7–9 It has been to shown to be superior as a single intervention in
TABLE 2. Previous Interventions Patients Underwent Before Surgery for Laparoscopic Cardiomytomy
Previous Interventions None Botox alone Dilatation 1 Dilatation 2 Dilatation 3
e168 | www.surgical-laparoscopy.com
No. Patients 3 8 9 2 2
Volume 24, Number 5, October 2014
the treatment, when compared with pneumatic dilatation and botulinum toxin.8,9 The incidence of mucosal perforation is 5% to 33%.12,13 Furthermore preoperative endoscopic therapies did not increase the risk of perforation or intraoperative complications in our patient complications.9 There is little evidence to suggest that patients who have had previous therapeutic interventions such as pneumatic dilatation have worse results after surgery. Indeed, 54% of the patients in this cohort had undergone at least 1 pneumatic dilatation and all of these patients had an excellent clinical outcome. The sole patient in our study who sustained a mucosal perforation in the postoperative period had no previous therapeutic intervention before their surgery. Interestingly, the intraoperative leak test and the initial postoperative swallow revealed no radiologic evidence of a leak. The initial insult was attributed to the thermal injury intraoperatively at the site of the leak. Subsequent necrosis at the site of the injury during the postoperative period resulted in the delayed leak, thus was not recognized in the immediate postoperative swallow. Many surgeons carry out an intraoperative leak test and subsequent postoperative swallow to exclude any mucosal perforation after surgery.10 Postoperative swallows have also been advocated in assessing clinical outcome based on the degrees of esophageal dilatation and other radiologic parameters.14 However, there are little data about clinical outcome and the relationship to postoperative contrast studies and they are not used routinely at our institution to gauge results, but only to identify possible perforations. The main limitation of this study is the small number of patients, but it is interesting to note that the early postoperative swallow in our cohort had no impact on clinical outcome. We would suggest that postoperative contrast swallows are not required routinely in the immediate postoperative period. Instead, they should be reserved for situations where intraoperative surgical concerns may have arisen. Therefore, laparoscopic cardiomyotomy may be carried out safely as a day-case procedure. Delaying discharge for a contrast swallow is therefore not necessary and thus supports the use of day-case cardiomyotomy.
REFERENCES 1. Tsuboi K, Omura N, Yano F, et al. Preoperative dilatation does not affect the surgical outcome of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia. Surg Laparosc Endosc Percutan Tech. 2009;19:98–100. 2. Mayberry JF, Atkinson M. Variations in the prevalence of achalasia in Great Britain and Ireland: an epidemiological study based on hospital admissions. Q J Med. 1987;62: 67–74. 3. Abir F, Modlin I, Kidd M, et al. Surgical treatment of achalasia: current status and controversies. Dig Surg. 2004;21: 165–176. 4. Pohl D, Tutuian R. Achalasia: an overview of diagnosis and treatment. J Gastrointest Liver Dis. 2007;16:297–303. 5. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010; 42:265–271. 6. Wu JCY. Pneumatic Dilation versus Laparoscopic Heller’s Myotomy for Idiopathic Achalasia (N Engl J Med 2011;364: 1807-1816). N Engl J Med. 2011;17:324–326. r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 5, October 2014
7. Sharp KW, Khaitan L, Scholz S, et al. 100 consecutive minimally invasive Heller myotomies: lessons learned. Ann Surg. 2002;235:631–639. 8. Rossetti G, Brusciano L, Amato G, et al. A total fundoplication is not an obstacle to esophageal emptying after Heller myotomy for achalasia. Ann Surg. 2005;241: 614–621. 9. Finan KR, Renton D, Vick CC, et al. Prevention of postoperative leak following laparoscopic Heller myotomy. J Gastrointest Surg. 2009;13:200–205. 10. Vaziri K, Soper NJ. Laparoscopic Heller myotomy: technical aspects and operative pitfalls. J Gastrointest Surg. 2008;12: 1586–1591.
r
2014 Lippincott Williams & Wilkins
Is Contrast Swallow Necessary Post Cardiomyotomy?
11. Iqbal A, Haider M, Desai K, et al. Technique and follow-up of minimally invasive Heller myotomy for achalasia. Surg Endosc. 2006;20:394–401. 12. Morino M, Rebecchi F, Festa V, et al. Preoperative pneumatic dilatation represents a risk factor for laparoscopic Heller myotomy. Surg Endosc. 1997;11:359–361. 13. Beckingham IJ, Callanan M, Louw JA, et al. Laparoscopic cardiomyotomy for achalasia after failed balloon dilatation. Surg Endosc. 1999;13:493–496. 14. Yoo C, Levine MS, Redfern RO, et al. Laparoscopic Heller myotomy and fundoplication: findings and predictive value of early postoperative radiographic studies. Abdom Imaging. 2004;29:643–647.
www.surgical-laparoscopy.com |
e169
