Thoracoscopic
Esophagomyotomy
Initial Experience With a New Approach for the Treatment ofAchalasia
CARLOS PELLEGRINI, M.D.,* L. ALBERT WETTER, M.D.,* MARCO PATTI, M.D.,* RHODA LEICHTER, M.D.,* GIL MUSSAN, M.D.,* TOSHIYUKI MORI, M.D.,* GEOFFREY BERNSTEIN, M.D.,t and LAWRENCE WAY, M.D.* The authors treated 17 patients with achalasia by a thoracoscopic (15 patients) or laparoscopic (2 patients) Heller myotomy. All patients had dysphagia and an upper gastrointestinal series demonstrating a dilated esophagus with a bird-beak deformity at the cardia. Manometry showed a mean lower esophageal sphincter (LES) pressure of 32 ± 4 mmHg, incomplete sphincter relaxation on swallowing, and no primary esophageal peristalsis. After operation, mean LES pressure was 10 ± 2 mmHg. Fifteen patients were fed on the second postoperative day. The average hospital stay was 3 days, and there were no deaths or major complications. In three early patients, the myotomy was not carried far enough onto the stomach, and dysphagia persisted until a second myotomy was performed (laparoscopically in two patients). The authors found that having an endoscope in the esophagus during the operation facilitated exposure and was vital to determine the appropriate length of the myotomy. With regard to dysphagia, final results were excellent in 12 patients (70%), good in two patients (12%), fair in two patients (12%), and poor in one patient (6%). Heller myotomy can be safely and reliably performed with minimally invasive techniques. Dysphagia is relieved, postoperative pain is minimal, hospital stay is short, and the patient can return quickly to normal activity. E
From the Departments of Surgery* and Medicine,t University of California, San Francisco, San Francisco, California
tation is occasionally complicated by esophageal perforation, 13,14 and it too often results in gastroesophageal reflux.2"3 In fact, the evidence suggests that the long-term results of myotomy are better than those of pneumatic dilatation.'5 Despite these findings, dilatation remains the treatment recommended in most cases.'6 Therefore, we thought that if thoracoscopic myotomy were feasible, it would provide the known benefits of myotomy with much less discomfort, combining the advantages of both of the competing forms of treatment. We initially used a technique developed (and demonstrated to us) by Cuschieri,'7 which we modified as we gained experience. This report describes our experience with the procedure, including details of operative technique, and it analyzes the results in our first 17 patients.
XTRAMUCOSAL ESOPHAGOMYOTOMY, FIRST de-
scribed by Heller in 1913,' was for many years the principal therapy for achalasia. Several large series showed that the operation could be performed with few complications and excellent results.2-" A thoracotomy or laparotomy was required, however, which resulted in a 7- to 10-day hospital stay and residual discomfort for 4 to 6 weeks. Therefore, when pressure-controlled balloon dilatation was introduced,'2 it soon became the most popular treatment for this disease, because of its short hospital stay and little time off work. Nevertheless, dilaPresented at the II 2th Annual Meeting of the American Surgical Association, April 6-8, 1992, Palm Desert, California. Address reprint requests to Carlos A. Pellegrini, M.D., University of California, San Francisco, 533 Parnassus, Room U- 122, San Francisco, CA 94143-0788. Accepted for publication April 10, 1992.
291
Patients and Methods From January 1991 to March 1992, 17 patients (10 men, 7 women), aged 28 to 90 years (median, 37 years), underwent a Heller myotomy for achalasia at the University of California, San Francisco, using a thoracoscopic or laparoscopic approach. Previous therapies in nine patients consisted ofthe following: pneumatic dilatation, six patients (three patients had several dilatations); Heller myotomy through the left chest, two patients; and a myotomy through the abdomen, one patient. All of these procedures had been performed elsewhere. Dysphagia was the main preoperative complaint in every patient. In addition, nine patients complained of regurgitation of undigested food; five patients complained of heartburn; six patients complained of chest pain; and five patients had a history of persistent cough or pulmonary aspiration. Seven patients had lost more than 10
292
PELLEGRINI AND OTHERS
pounds, and three patients more than 30 pounds. The duration of symptoms was 54 months, ranging from 6 to 180 months.
average
Preoperative Evaluation
The diagnosis of achalasia was based on radiographic and manometric criteria. Esophagograms showed findings typical of achalasia with esophageal dilatation and a bird beak deformity in all patients. In three patients, the diameter of the esophagus was 6 cm. Two of these last four had a typical sigmoid esophagus. Esophageal manometry was performed in fasting patients with the use of a perfused polyethylene catheter assembly connected to a Polygraph (Synectic Medical, Irving, TX). In four patients, the catheter could not be blindly advanced into the stomach; in two of these four, it was placed under endoscopic guidance. Resting lower esophageal sphincter (LES) pressure, measured by the station pull-through technique, averaged 32 ± 4 mmHg. The overall length of the sphincter was 3.5 ± 0.5 cm. The motor function of the esophageal body was evaluated with 10 swallows of 5 mL water. Primary peristalsis was absent in all 17 patients; seven patients had no motor activity; nine patients had occasional simultaneous nonpropulsive waves of 30 mmHg. Impaired LES relaxation (
Esophagomyotomy
Initial Experience With a New Approach for the Treatment ofAchalasia
CARLOS PELLEGRINI, M.D.,* L. ALBERT WETTER, M.D.,* MARCO PATTI, M.D.,* RHODA LEICHTER, M.D.,* GIL MUSSAN, M.D.,* TOSHIYUKI MORI, M.D.,* GEOFFREY BERNSTEIN, M.D.,t and LAWRENCE WAY, M.D.* The authors treated 17 patients with achalasia by a thoracoscopic (15 patients) or laparoscopic (2 patients) Heller myotomy. All patients had dysphagia and an upper gastrointestinal series demonstrating a dilated esophagus with a bird-beak deformity at the cardia. Manometry showed a mean lower esophageal sphincter (LES) pressure of 32 ± 4 mmHg, incomplete sphincter relaxation on swallowing, and no primary esophageal peristalsis. After operation, mean LES pressure was 10 ± 2 mmHg. Fifteen patients were fed on the second postoperative day. The average hospital stay was 3 days, and there were no deaths or major complications. In three early patients, the myotomy was not carried far enough onto the stomach, and dysphagia persisted until a second myotomy was performed (laparoscopically in two patients). The authors found that having an endoscope in the esophagus during the operation facilitated exposure and was vital to determine the appropriate length of the myotomy. With regard to dysphagia, final results were excellent in 12 patients (70%), good in two patients (12%), fair in two patients (12%), and poor in one patient (6%). Heller myotomy can be safely and reliably performed with minimally invasive techniques. Dysphagia is relieved, postoperative pain is minimal, hospital stay is short, and the patient can return quickly to normal activity. E
From the Departments of Surgery* and Medicine,t University of California, San Francisco, San Francisco, California
tation is occasionally complicated by esophageal perforation, 13,14 and it too often results in gastroesophageal reflux.2"3 In fact, the evidence suggests that the long-term results of myotomy are better than those of pneumatic dilatation.'5 Despite these findings, dilatation remains the treatment recommended in most cases.'6 Therefore, we thought that if thoracoscopic myotomy were feasible, it would provide the known benefits of myotomy with much less discomfort, combining the advantages of both of the competing forms of treatment. We initially used a technique developed (and demonstrated to us) by Cuschieri,'7 which we modified as we gained experience. This report describes our experience with the procedure, including details of operative technique, and it analyzes the results in our first 17 patients.
XTRAMUCOSAL ESOPHAGOMYOTOMY, FIRST de-
scribed by Heller in 1913,' was for many years the principal therapy for achalasia. Several large series showed that the operation could be performed with few complications and excellent results.2-" A thoracotomy or laparotomy was required, however, which resulted in a 7- to 10-day hospital stay and residual discomfort for 4 to 6 weeks. Therefore, when pressure-controlled balloon dilatation was introduced,'2 it soon became the most popular treatment for this disease, because of its short hospital stay and little time off work. Nevertheless, dilaPresented at the II 2th Annual Meeting of the American Surgical Association, April 6-8, 1992, Palm Desert, California. Address reprint requests to Carlos A. Pellegrini, M.D., University of California, San Francisco, 533 Parnassus, Room U- 122, San Francisco, CA 94143-0788. Accepted for publication April 10, 1992.
291
Patients and Methods From January 1991 to March 1992, 17 patients (10 men, 7 women), aged 28 to 90 years (median, 37 years), underwent a Heller myotomy for achalasia at the University of California, San Francisco, using a thoracoscopic or laparoscopic approach. Previous therapies in nine patients consisted ofthe following: pneumatic dilatation, six patients (three patients had several dilatations); Heller myotomy through the left chest, two patients; and a myotomy through the abdomen, one patient. All of these procedures had been performed elsewhere. Dysphagia was the main preoperative complaint in every patient. In addition, nine patients complained of regurgitation of undigested food; five patients complained of heartburn; six patients complained of chest pain; and five patients had a history of persistent cough or pulmonary aspiration. Seven patients had lost more than 10
292
PELLEGRINI AND OTHERS
pounds, and three patients more than 30 pounds. The duration of symptoms was 54 months, ranging from 6 to 180 months.
average
Preoperative Evaluation
The diagnosis of achalasia was based on radiographic and manometric criteria. Esophagograms showed findings typical of achalasia with esophageal dilatation and a bird beak deformity in all patients. In three patients, the diameter of the esophagus was 6 cm. Two of these last four had a typical sigmoid esophagus. Esophageal manometry was performed in fasting patients with the use of a perfused polyethylene catheter assembly connected to a Polygraph (Synectic Medical, Irving, TX). In four patients, the catheter could not be blindly advanced into the stomach; in two of these four, it was placed under endoscopic guidance. Resting lower esophageal sphincter (LES) pressure, measured by the station pull-through technique, averaged 32 ± 4 mmHg. The overall length of the sphincter was 3.5 ± 0.5 cm. The motor function of the esophageal body was evaluated with 10 swallows of 5 mL water. Primary peristalsis was absent in all 17 patients; seven patients had no motor activity; nine patients had occasional simultaneous nonpropulsive waves of 30 mmHg. Impaired LES relaxation (
