Surgery as the most effective option for minimally invasive treatment of achalasia

Evelyn Astrid Dorado A., MD. (1)

(1) General and Minimally Invasive Surgeon at the Universidad CES and Hospital Universitario San Ignacio. Assistant Professor of undergraduate and graduate studies in the Faculty of Medicine at the Pontificia Universidad Javeriana.

Received: 29-02-12 Accepted: 15-05-12

Abstract

Management of achalasia is controversial and various options have been proposed ranging from medical management to endoscopic and eventually to surgical management. After the advent of laparoscopy and all of its advantages, Cushieri became the first to perform a minimally invasive Heller myotomy in the 1990's.

Numerous articles and meta-analyses have compared available techniques for improvement of symptoms and improved quality of life. The surgical option has been rated highest in all cases.

To treat achalasia, the minimally invasive surgical service at San Ignacio Hospital performs laparoscopic cardiomyotomy and intraoperative endoscopy to evaluate and determine whether there are perforations in the esophageal mucosa, Finally, a Toupet partial fundoplication is performed with 50F calibration.

Key words

Achalasia, laparoscopic myotomy, pneumatic balloon dilatation.

INTRODUCTION

In our environment achalasia occurs infrequently: its incidence is 1/100,000. It is characterized by a neurovegetative disorder that affects the mesenteric plexus of the lower esophageal sphincter which results in hypertonia and motor disorder of the esophageal body (1). It presents most commonly among patients who are between 20 and 40 years old.

Different treatments for this disease have been reported including endoscopic treatment using botulinum toxin, endoscopic treatment using balloon dilatation, medical treatment using nitrates and the calcium, and finally surgical treatment consisting of myotomy of the lower esophageal sphincter combined with an antireflux procedure.

Surgical treatment has been shown to be the most effective treatment with up to 90% of all symptoms improving (2) and positive impact on patient quality of life from the antireflux procedure.

Various techniques for performance of this procedure have been described. They range from traditional open surgery to minimally invasive thoracoscopic or laparoscopic surgery.

A metaanalysis of 39 articles with 3086 patients with 35.4 months follow up has shown the superiority of the laparoscopic approach over the thoracoscopic approach (89.3% vs. 77.6%; OR 1.9: 95% IC 0.8-2.9; P=0.3) (3). These approaches were accompanied either by prior fundoplication type DOR or posterior Toupet type to partially treat reflux. The gastroesophageal reflux index in laparoscopic procedures was lower than that in thoracoscopic procedures (2).

The European Achalasia Trial Investigators Group which groups together 15 centers in 5 European countries compared endoscopic balloon dilation and surgical treatment. The Eckardt Score was used to determine therapeutic success during first year follow-up. A score of less than 3 was required for therapeutic success (3). 201 patients were randomized and followed up for 43 months. Endoscopic balloon dilation showed a great therapeutic success with 90% success rate in the first year and 86% after two years. The surgical approach showed a 93% success rate in the first year and 90% in second year. Both procedures presented adverse. Endoscopic balloon dilation had a 4% incidence of perforation, while surgical treatment resulted in a 12% perforation rate.

Ellis has described the factors which predispose to failure of cardiomyotomy. They include: longstanding disease, megaesophagus with diameters greater than 4 cm, gastroesophageal reflux, overly tight fundoplication and inappropriate myotomies (4).

DISCUSSION

Achalasia is a rare neurodegenerative disease. The purpose of treatment is to ameliorate dysphagia and regurgitation, improve esophageal emptying and prevent development of megaesophagus and reflux disease (5).

A Heller myotomy with partial antireflux procedure has demonstrated to be the most effective long-term treatment for resolution of symptoms and long-term relief. Tested for 5 years, the persistence the symptomatic improvement has been from 80% to 90%. Over 10 years the rate has been shown to be 70 % (6).

The advantage of the surgical procedure is that lower esophageal sphincter hypertonia is corrected with the cardiomyotomy while simultaneously surgery to prevent pathological reflux secondary to myotomy can be performed. The success of laparoscopic treatment demonstrated by improvement of symptoms with minimal complications is due to advanced training that allows the best patient safety. It should be clarified that this surgery does not ease esophageal motility disorder. We look forward to better understanding of the mechanism of this disease that will allow development of treatment to restore esophageal functioning and provide a cure for these patients.

REFERENCES

1. Campos GM, Vittinghoff E, Rabl C, Takata M, Gadenstätter M, Lin F, et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. An Surg 2009; 249(1): 45-57.

2. Zaninotto G, Rizzetto C. Endoscopic and surgical management of achalasia. Eur Surg 2008; 40(4): 146-53.

3. Gockel I, Sgourakis G, Dreschser D, Lang H. Impact of minimally invasive surgery in the spectrum of current achalasia treatment options. Scand J Surg 2011; 100(2): 72-7.

4. Eckardt VF, Gockel I, Bernard G. Pneumatic dilation for achalasia: late results of prospective follow up investigation. Gut 2004; 53(5): 629-33.

5. Ellis FH Jr. Oesophagomyotomy for achalasia: a 22-year experience. Br J Surg 1993; 80(7): 882-5.

6. Richter JE. Achalasia - an update. J Neurogastroenterol Motil 2010; 16(3): 232-42.

7. Howard JM, Mongan AM, Manning BJ, Byrne P, Lawler P, Ravin N, et al. Outcomes in achalasia from a surgical unit where pneumatic dilatation is first-line therapy. Dis Esophagus 2010; 23(6): 465-72.

8. Wu J. Pneumatic Dilatation versus Laparoscopic Heller´s Myotomy for Idiopathic Achalasia. J Neurogastroenterol Motil 2011; 17(3): 324-6.

9. Lesquereux L, Parada P, Puñal J. Papel del tratamiento quirúrgico por vía laparoscópica de la acalasia del cardias: análisis de 50 casos. Cir Esp 2011; 89(10): 657-62.

10. Yu L, Li J, Wang T, Zhang Y, Krasna MJ. Functional analysis of long-term outcome after Heller´s myotomy for achalasia. Dis Esophagus 2010; 23(4): 277-83.

11. Di Martino N, Brillantino A, Monaco L, Marano L, Schettino M, Porfidia R, et al. Laparoscopic calibrated total vs partial fundoplication following Heller myotomy for oesophageal achalasia. World J Gastroenrol 2011; 17(29): 3431-40.

12. Eckardt AJ, Eckardt VF. Current clinical approach to achalasia. World J Gastroenterol 2009; 15(32): 3969-75.

13. Wright AS, Williams CW, Pellegrini CA, Oelschlager B. Long term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia. Surg Endosc 2007; 21(5): 713-8.

14. Little VR. Laparoscopic Heller myotomy for achalasia: a review of the controversies. Ann Thorac Surg 2008; 85(2): 743-6.

15. Kostic S, Johnsson E, Kjellin A, Ruth M, Lönroth H, Andersson M, et al. Health economic evaluation of therapeutic strategies in patients with idiopathic achalasia: result of a randomized trial comparing pneumatic dilatation with laparoscopic cardiomyotomy. Surg Endosc 2007; 21(7): 1184-9.

16. Balaji NS, Peters JH. Minimally invasive surgery for esophageal motility disorders. Surg Clin North Am 2002; 82(4): 763-82.

17. Richards WO, Torquati A, Lutfi R. The current treatment of achalasia. Adv Surg 2005; 39: 285-314.

18. Ritcher JE. Update on the management of achalasia: balloons, surgery and drugs. Expert Rev Gastroenterol Hepatol 2008; 2(3): 435-45.

19. Finley R, Rattenberry J, Cliffon JC, Finley CJ, Yee J. Practical approaches to the management of achalasia. Am Surg 2008; 74(2): 97-102.

20. Torquati A, Richards WO, Holzman M, Sharp KW. Laparoscopic myotomy for achalasia: predictors of successful outcome after 200 cases. Ann Surg 2006; 243(5): 587-91.

21. Francis DL, Katzka DA. Achalasia: update on the disease and its treatment. Gastroenterology 2010; 139(2): 369-74.

22. Boeckxstaens GE, Annese V, des Varannese SB, Chaussade S, Constantini M, Cuttitta A, et al. Pneumatic dilatation versus Laparoscopic Heller´s myotomy for idiopathic achalasia. N Engl J Med 2011; 364: 1807-16.

23. Eckardt VF, Hoischen T, Bernhard G. Life expectancy, complications, and causes of death in patients with achalasia: results of a 33 years follow-up investigation. Eur J Gastroenterol Hepatol 2008; 20(10): 956-60.

24. Oelschlager B, Chang L, Pellegrini CA. Improved outcomes after extended gastric myotomy for achalasia. Arch Surg 2003;138(5): 490-5.