Laparoscopic Heller-Dor operation for patients with achalasia

Achalasia is a primary motor disorder characterized by aperistalsis of the esophageal body and the absence of relaxation of the lower esophageal sphincter (LES), which often has a high resting pressure.¹ The incidence of achalasia is about 0.3－11/10⁶per year, and the etiology is still not completely understood.² The basic principle of treatment has been established since the early decades of the 20th century, and consist of disruption of the unrelaxing LES either by myotomy or by forceful dilation, with success rates ranging from 70% to 95%.³ With the advent and subsequent refinement of minimally invasive surgery, laparoscopic esophageal cardiomyotomy rapidly replaced the open techniques (thoracotomy or laparotomy). Laparoscopic Heller-Dor procedure is now the treatment of choice for this disease with good results in an average of 90% patients.⁴ However, the laparoscopic approach is seldom utilized in China and rarely reported in Chinese literature. We began to perform laparoscopic Heller-Dor operation in October 2003. The aim of this study was to analyze the clinical outcome of our initial experience in 25 patients.

Patients
Between October 2003 and January 2006, 25 consecutive patients with achalasia underwent laparoscopic Heller-Dor operation in our department. Among them, 9 were male and 16 were female with an average age of (41.5±5.1) years (21－66). The Symptom duration was (5.3±1.8) years (range, 1－18). All the patients experienced dysphagia before operation, many of them also complained of regurgitation (19/25) and chest pain (21/25), and only few patients had heartburn (4/25). About half of the patients (12/25) had undergone previous endoscopic treatment either by pneumatic dilatation and/or by botulinum toxin. With increasing experience, we observed a significant increase in the number of patients referred for treatment by laparoscopic Heller-Dor operation.

Examinations
Preoperative evaluation included barium esophago- gram, endoscopy, and manometry in all the patients to establish the diagnosis of achalasia and to rule out esophageal malignancy. Preoperative 24-hour pH monitoring was performed in all the patients except for 4 due to technical difficulty.

Surgical technique
All the patients were operated by laparoscopic modified Heller's myotomy with Dor fundoplication using harmonic shears. In addition, 2 patients had combined cholecystectomy+excision of hepatic hemangioma, and cholecystectomy, respectively.

Under general anesthesia, the patients were placed in the French position, with the operator standing between the legs. A pneumoperitoneum with a constant 12 mmHg intra-abdominal pressure was created through a 10 mm supraumbilical incision using a Veress needle. Four or five trocars were inserted in the upper abdomen. The left hepatic lobe was lifted up by a fan retractor with three arms covered with rubber tubes (Fig. 1), inserted through the right upper quadrant port to expose the esophageal hiatus. After the gastroesophageal junction was identified, a longitudinal dissection was performed with the Harmonic Scalpel. The myotomy was started in the middle third of the exposed esophagus, lateral to the anterior vagus nerve. The longitudinal fibers were divided by using harmonic shears until the circular muscle fibers were identified. The myotomy was extended upward 4－5 cm on the esophageal side and downward 1－2 cm on the gastric side across the sling muscles of the gastroesophageal junction. The length of the myotomy was measured by the marks on the irrigation/suction tube. Intraoperative endoscopy was performed before and after the cardiomyotomy to confirm completion of the myotomy and to inspect the potential mucosa perforation. In the event of mucosa perforation, it was sutured with absorbable sutures laparoscopically. Then the anterior partial fundoplication was fashioned using the gastric fundus fixed to the edges of the myotomy with 3－5 stitches for each side. Abdominal drainage tube was placed under the left liver when required.

Follow-up
The patients were followed up in outpatient department and/or by telephone. The postoperative evaluation included clinical questionnaire and esophageal barium radiography routinely. The results were stratified as follows: no improvement (persistent or recurrent dysphagia), minor improvement (interrupted dysphagia within weeks), good improvement (mild dysphagia within months), and excellent response (no dysphagia and reflux) to treatment.

RESULTS

All the patients were treated by laparoscopic modified Heller's myotomy with Dor fundoplication without conversion. In addition, the first patient had combined laparoscopic cholecystectomy and excision of hepatic hemangioma and the last patient also had a laparoscopic cholecystectomy. The operative time averaged (110.6±12.9) minutes (range, 60－180), and decreased with experience (Fig. 2). The operative blood loss on average was (18.6±7.1) ml (5－50), the median time to oral feeding was (1.6±0.4) days (1－4), and the median hospital stay was (12.6±1.2) days (10－20). Intraoperative mucosal perforation occurred in six patients and was repaired by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication. After a median follow-up of (10.6±7.2) months (1－27)，24 patients were asymptomatic and 1 had mild postoperative dysphagia. The rates of excellent response and good improvement were 96% (24/25), and 4% (1/25), respectively. The body weight increased one month after operation in 21 patients by 5－15 kg with an average of (7.2±1.2) kg.

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Fig.2. Operating time decreased with our increased experience (Case 1 and case 25 were treated by laparoscopic Heller-Dor operation combined with other laparoscopic surgeries).

DISCUSSION

Prior to the advent of minimally invasive surgery, most patients with esophageal achalasia opted for less effective medical treatments, such as medication, bougie or balloon dilation, and endoscopic injection of botulinum toxin into the LES. However, the results have been highly disappointing; therefore, these therapeutic modalities have been largely abandoned and are now recommended only for patients who refuse surgery or cannot tolerate an invasive procedure.⁵ These unsuccessful endoscopic treatment may make the surgery more difficult, causing a high risk of mucosa perforation and jeopardizing the outcome. On the regression analysis of long-term outcome in 248 patients with laparoscopic Heller-Dor procedure, Portale et al⁶ reported that prior treatment with two botulinum toxin injection combined with dilation was associated with poor outcome.

Surgical cardiomyotomy was first introduced for the treatment of this disease by Ernest Heller in 1913. The operation initially included an anterior and a posterior myotomy, and it was subsequently modified by Zaajier to include a single incision over the anterior aspect of the esophagus.⁷ The immediate results were spectacular, with complete relief of patients' dysphagia. However, the postoperative course was often marked by reflux disease and recurrence of dysphagia due to peptic stricture. Over the intervening years, many surgeons have attempted with this procedure with variable success. Dor reported an anterior partial fundoplication in 1962, and Andre Toupet reported a posterior partial fundoplication in 1963.^7,8 Unfortunately, these modifications did little to modify the associated morbidity, hence surgery was often not chosen by patients or their primary care physicians. The main reason was that the myotomy required a thoracotomy or laparotomy, and these open surgical approach with large incision caused considerable pain, significant postoperative complications and long hospital stays. This was also the main reason for about half of the patients had to be treated repeatedly by less effective medical treatments before operation.

In the late 1980's, advances in video and computer technology allowed Sir Alfred Cuschieri and his colleagues to perform one of the first laparoscopic Heller myotomies, and furthermore to find a decrease in postoperative morbidity and convale- scent time. The first laparoscopic cardiomyotomy was carried out in 1991 and it soon became the preferred surgical technique with most surgeons.⁹ In China, the first laparoscopic Heller-Toupet operation was reported in 2003.¹⁰

On the basis of our initial practice on laparoscopic Heller-Dor operation, we strongly agree that the minimally invasive procedures can offer many other advantages over conventional thoracotomy and laparotomy in addition to decreased pain, morbidity, and hospital stay. First, surgeons can operate with greater accuracy in identifying the muscle layers and other important structures (vagus nerve, blood vessels, etc.) due to the magnification of the operative field provided by videoendoscopy. Second, the minimally invasive approach minimizes the operative trauma because no requirement for detachment of the esophagus from its bed, and furthermore, it decreases postoperative morbidity associated with the open surgical approach. In addition, the laparoscopic approach facilitates the execution and precision of the operation especially when combined with intraoperative endoscopy. Last, minimally invasive myotomy and fundoplication can restore an optimal quality of life, and significantly improves the social function of the patients.¹¹

Although there is still some controversy regarding the execution of minimally invasive myotomy with respect to the thoracoscopic or laparoscopic approach, more and more surgeons nowadays prefer the laparoscopic approach because it requires simpler anesthesia and provides excellent exposure for the performance of an antireflux procedure, thus reducing the risk of late dysphagia from peptic stricture. Furthermore, it reduces the risk of perforation or disease recurrence due to incomplete myotomy in the distal part of esophagus and at the gastric junction, which is difficult to access by the thoracoscopic approach.¹² Among the 84 cases of minimally invasive myotomy reported in Chinese literature, only 30 cases were preformed by laparoscopic approach.^10,13 This was mainly because the majority of patients with achalasia were refered to the thoracic surgeons by gastroen- terologists in China.

Another controversy relates to the type of fundoplication in conjunction with the Heller myotomy. Most surgeons feel that Nissen fundoplication may ultimately lead to dysphagia and recommend partial wraps in association with the myotomy.¹¹ The Toupet posterior fundoplication has the theoretical advantage of preventing closure of the myotomy by fixing the gastric fundus to both edges of the myotomy, and also provides good protection against postoperative reflux in 93%－100% of patients.¹⁴ Comparatively, the Dor anterior fundoplication may leave the posterior esophageal attachments and the short gastric vessels in place, and it is easier to construct with less operative time. On the basis of selected publications of laparoscopic Heller myotomy for achalasia, the mean operative time of Heller-Dor operation is 30 to 60 minutes shorter thanthat of Heller-Toupet operation.¹¹ The mean operative time of our initial 25 patients was only 110 minutes, while it was 180 minutes in the initial 20 patients reported by Tello et al.¹⁵ In addition, the laparoscopic approach may protect against potential leaks that could result from unrecognized injuries to the mucosa, and may also provides good protection against postoperative gastroesophageal reflux in 85%－95% of patients.^16-18 These were also the main reasons for us to select laparoscopic Heller- Dor operation as our minimally invasive approach for patients with achalasia.

In conclusion, the results of our initial series of 25 patients clearly show that laparoscopic Heller myotomy combined with Dor fundoplication provides many advantages, including reduced compromise of the cardiopulmonary function, less disruption of the supporting structures (phrenoesophageal membrane) of the antireflux mechanism, requiring simpler general anesthesia and excellent exposure for the execution of the fundoplication, less pain and reduced morbidity, shorter hospitalization and faster convalescence.

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