Journal of Surgery (ISSN: 2575-9760)

Article / Brief Report

"Long Term Follow Up for Patients Post Laparoscopic Heller Dor Myotomy for Achalasia"

Georges Khalifeh, Dany Lichaa, Samer Dbouk, Riad Saheli, Louai S. Chalaby, Salam Abou Rafeh, Hussein Mcheimech*
Department of General Surgery and Laparoscopic Bariatric surgery, Faculty of Medical Science, Al-Zahraa University hospital, Lebanon
*Corresponding author: Hussein Mcheimech, Department of General Surgery and Laparoscopic Bariatric Surgery Faculty of Medical Science, Al-Zahraa University hospital, Lebanon. Tel: +961-3329271; Email:
Received Date: 16 June, 2018; Accepted Date: 20 June, 2018; Published Date: 28 June, 2018

1.       Abstract 
1.1.  Background: Achalasia is a rare primary esophageal motility disorder, characterized by failure of relaxation of the lower esophageal sphincter and aperistalsis of the distal esophagus. Clinical presentation features include progressive swallowing difficulty for liquids and solids, chest pain, and regurgitation. Medical, endoscopic and surgical treatment options exist for treatment of Achalasia, but Heller myotomy remains the gold standard procedure in the management of this disease, although it is not devoted of complications, and gastro-esophageal reflux is reported to occur in 8-10% of cases.
1.2.  Objective: Some modifications of Heller myotomy technique should take place, in aim to decrease the rate of GERD post-Heller myotomy. In this article, we demonstrate that closure of the diaphgramtic crura, could be the needed modification. Regularly at our institute, when performing Heller procedure, esophageal myotomy is followed by a cruroplasty and an anti-reflux procedure. Significantly lower rate of GERD post heller myotomy and recurrence were obtained. 
1.3.  Methods and results: Between 2009 and 2018, 36 patients, with a median age of 44 years, were diagnosed to have achalasia after undergoing gastroscopy and manometry. All patients were treated surgically, using the same technique. The myotomy is extended, at least 8-10 cm over the esophagus and 3-4 cm below the GEJ. It was followed by a cruroplasty consisting of 2 stitches between both crura and an anterior Dor fundoplication. All patients underwent an upper GI series on day 1 post-op, and were discharged on liquid diet for 14 days and PPI for 1 month. GERD was evident only in 1 case, which decreased the rate of GERD post Heller to 2,7%. Another patient complained of dysphagia, but he was successfully treated by endoscopic dilatation. No other complications were noted.
1.4.  Conclusion: Cruroplasty, when added to the esophageal myotomy during a Heller procedure reduces significantly the rate of GERD post Heller myotomy, and should be considered when performing Heller myotomy in aim to offer the best outcome for the patients. 

2.       Introduction 
2.1.  Background 
The esophagus is a tube like- simple structure, spans the distance from the neck to the stomach and it is actually a complex and relatively durable organ. It functions between two extremes of pressures, atmospheric and vacuum; makes us swallow without effort and pain until it is diseased, severe and chronic malady may occur. Until today, we do not have the perfect solution for each esophageal dysfunction, and this leaves the opportunity for future esophagologists and researchers to come up with more effective treatments and innovations; hopefully this paper will highlight some important options for improvement in treating esophageal dysfunctions, especially Achalasia. All esophageal motility disorders present approximately the same (dysphagia, chest pain, heartburn, regurgitation, weight loss), their underlying causes remain poorly understood. By definition, they are diagnosed when manometric findings exceed two standard deviations from normal. Because of their vague presentations, one must rule out other pathologies that may cause similar symptoms, hence a complete workup is crucial (cardiac, respiratory, peptic ulcer disease, pancreaticobiliary disease). In addition, systemic symptoms of connective tissue disorders (scleroderma, Chagas disease, myasthenia gravis...) should raise attention in this aspect. Esophageal motility workup starts with a barium esophagram which guides further workup, followed by upper endoscopy to rule out mucosal abnormalities and better see defects in question (stricture, hernia, diverticulum, esophagitis, masses). Then a CT scan may be performed if extrinsic cause is thought to be the reason for the presenting symptoms. 
Addition of pH testing is only needed when the motility disorder is thought to be the result of end-stage Gastroesophageal Reflux Disease (GERD) as a means of documenting this. Esophageal motility disorders are classified into primary and secondary causes; primary causes include: achalasia, Diffuse Esophageal Spasm (DES), nutcracker (jackhammer) esophagus, hypertensive Lower Esophageal Sphincter (LES), and Ineffective Esophageal Motility (IEM); secondary causes are due to collagen, vascular or neuromuscular disorder and include: scleroderma, dermatomyositis, polymyositis, lupus erythematosus, Chagas disease, and myasthenia gravis. However, this classification is not helpful as a guide to treatment strategies, so a newer classification was adopted depending on the anatomic involvement of the motility disorder, whether affecting the esophageal body or the LES or both and it forms the basis for understanding basic esophageal manometry and often the key to guide surgical therapy. Those involving the esophageal body: diffuse esophageal spasm, Nutcracker esophagus. While those involving the LES: Hypertensive Lower Esophageal Sphincter. And those affecting both include: Achalasia, Ineffective Esophageal Motility.
2.2.  Literature Review
Talking about Achalasia, the literal meaning of the term is “failure to relax” from the Greek word Khalasis or loosening. First described in 1672 by Sir Thomas Willis and he used to treat it with dilation using a whale sponge attached to whale bone. Achalasia is the best understood esophageal motility disorder, occurs in 6/100,000 persons/ year, more common in young women. Its pathogenesis is presumed to be idiopathic or infectious neurogenic degeneration as well as emotional stress, trauma, drastic weight reduction and Chagas disease (parasitic infection with Trypanosoma cruzi). The most known theory states that the destruction of the nerves to the LES is the primary pathology followed by degeneration of neuromuscular function of the body of the esophagus. Achalasia is also known to be a premalignant condition, where long standing retained undigested fermenting food in the body of the esophagus causes mucosal irritation and squamous cell carcinoma is the most common, and this can occur in up to 8% of patients in a 20-year period. Based on high resolution manometry, we are now able to discern three main types of achalasia. Type I (classic) occurs in 25-40 % of patients, characterized by low pressure contractions and minimal esophageal function often appearing as a dilated esophagus on esophagram. Type II (achalasia with esophageal compression), is the most common type, occurring in 50% to 65% of patients, and is characterized as more normal amplitude propulsion waves with maintenance of esophageal body function. It typically appears as a bird’s beak appearance on esophagram. Type III (spastic) is the least common type, representing approximately 10% of patients; it is noted by uncoordinated spastic activity in the distal two thirds of the esophagus without relaxation of the LES, resulting in a corkscrew appearance on esophagram. 
Achalasia treatment whether medical, endoscopic or surgical, is considered palliative because it doesn’t identify the cause, it just reliefs the obstruction and decreases the LES pressure for ingested food to pass [1,2]. Choice of treatment depends on the patient himself; if he is a low surgical risk, then either graded pneumatic dilation, Per Oral Endoscopic Myotomy (POEM) or laparoscopic surgical myotomy with a partial fundoplication should be done. However, if he is a high surgical risk patient, then botulinum toxin injection and pharmacological therapy are possible options. Pharmacologic therapy did not prove good cost-effective outcomes over several year of follow-up, and most of the patients experienced same symptoms after therapy. Thus, surgical therapy has been the standard of treatment over the last decades. Laparoscopic surgical myotomy has shown its superiority over graded pneumatic dilation in several studies. A meta-analysis that compared PD with LHM included three randomized trials with 346 patients published between 2007 and 2011, surgical myotomy was more effective than PD (86 versus 77 percent) and was associated with fewer adverse events (0.6 versus 5 percent) after 1 year of follow up. Four randomized controlled trials comparing PD and SM have shown better response to myotomy and low failure rate as seen in (Table 1).
Another meta-analysis, included 201 patients treated with either pneumatic dilation or laparoscopic Heller myotomy, with a 43 month of follow up, lower esophageal sphincter pressure, esophageal emptying, quality of life, or esophageal acid exposure were less with surgical myotomy. Thus, surgical treatment is considered to be a more definitive treatment for achalasia than other treatment modalities. It carries high initial cost, protracted recovery but provides higher success rates and relieves symptoms in about 90 percent of people 10 years, and in about 65 percent of people 20 years after the surgery. The current technique is a modification of the Heller myotomy that was described originally through a laparotomy in 1913. It is the addition of a partial antireflux procedure, such as a Toupet or Dor fundoplication, which will restore a barrier to reflux and decrease postoperative symptoms since GER is the most common complication. Heller Dor Myotomy is an anterior 180° wrap, and Toupet is a posterior 270° wrap of the stomach across the gastroesophageal junction Richards and colleagues reported in their study in 2004 comparing laparoscopic myotomy alone rate of abnormal reflux on postop pH monitoring when a Dor was added (48 % to 9 % respectively) with no increase in the risk of esophageal emptying impairement. 
In addition to GER post LHDM, several post-operative complications can occur including death, perforation, pneumothorax, bleeding, vagal injury and infection. Regardless of the decrease in GER rates post LHM with Dor fundoplication, it remains the most common complication post-surgery ranging from 10-40% in several series. There have been several modification trials to the regular myotomy plus Dor Fundoplication including extended gastric myotomy up to 3cm in the cardia of the stomach, which improved achalasia symptoms, but unfortunately this has increased post- operative GER symptoms. 
2.3.  Objectives 
Having in mind all of this and for the purpose of controlling post-operative GER rates after LHDM, we are introducing a modification to the regular technique; hopefully will be the main stay of treatment for Achalasia. We are talking about modified LHDM, which we performed on patients diagnosed with achalasia at our institute and planned for surgical treatment. Patients undergoing this modified LHD procedure between January 2009 and January 2017 were included in a retrospective study in aim to assess its efficacy in relieving the symptoms of Achalasia, and the determination of the complication rate of postop GERD and dysphagia. 
2.4.  Operative Technique 
Abdominal approach was used with 5 trocars, diaphragmatic attachments were opened anteriorly and the anterior esophagus cleaned and anterior vagus nerve identified. An 8cm myotomy was then done at 12 o’clock, 5-6 cm on the esophagus and 2-2.5 cm on the gastric side. Then posterior cruroplasty was done with 2 figure of eight sutures using ethibon 3-0 sutures. Dor fundoplication was then done on the anterior side of the fundus and fixed to the edge of the myotomy with 3 sutures on each side. The more proximal suture contained the ipsilateral pillar of the hiatus. 
3.       Materials and methods 
3.1.  Study Design 
It is an observational retrospective study 
3.2.  Population Studied 
All consecutive patients with a definitive diagnosis of achalasia who underwent modified laparoscopic Heller-Dor from January 2009 to January 2018 in three different hospitals Al zahraa, Bahman and Rasoul al aazam 
3.3.  Exclusion Criteria
Patients who don't have a real diagnosis of achalasia patients who were operated with other surgical or non-surgical technique 
3.4.  Outcome Measures 
After a median follow up period of 9 years, all patients were assessed for any complaints denoting evidence of achalasia recurrence or new onset of GERD The following variables will be included: patient’s data (age, gender, and comorbidities), preoperative symptoms (dysphagia to solids, dysphagia to liquids, dysphagia to both solids and liquids, and complete obstruction), depending on manometry, patients were classified into different types of achalasia (classic achalasia, achalasia with compression, and spastic achalasia), postoperative follow-up (Reflux and dysphagia) 
4.       Results 
4.1.  Baseline Characteristics 
Our study was conducted on 36 patients distributed randomly between both gender, with a mean age of 43 years, diagnosed with achalasia using clinical symptoms and manometry and undergone modified LHD myotomy who were followed up over a period of 8 years (2009-2017) Out of a total of 36 patients diagnosed with achalasia, 17 (47.2%) of them were found to be males and 19 (52.8%) were females (Table 2).
Symptoms of achalasia were different between patients, whereby 3 (8.3%) of them had dysphagia to liquids, 4 (11.1%) had dysphagia to solids, 16 (44.4%) had dysphagia to both solids and liquids, and 13 (36.1%) had complete obstruction 
Accordingly, manometry was done for each, and for the sake of making things clearer, patients were classified into having classic achalasia 26 (72.2%), achalasia with compression 8(22.2%) and spastic achalasia 2 (5.6%)               
4.2.  Post-Operative Outcomes 
We followed our patients over a period of approximately 8 years, and we found that 34 patients (94.4%) had no reflux post op, 1 (2.8%) patient had mild reflux and 1 patient (2.8%) had severe reflux on the other hand, 35 patients (97.2%) did not have dysphagia post op, and only 1 patient (2.8%) had dysphagia to solids and liquids. 
5.       Discussion 
The aim of surgical (or endoscopic) therapy for achalasia is to reduce the LES basal and residual pressure to facilitate esophageal emptying and that could result in reflux of gastric contents. In fact, gastroesophageal reflux is the most common complication of LHD for esophageal achalasia (6–34 %). In 25 years of laparoscopic surgery, many studies have reported that the rate of postoperative reflux improves if a partial wrap is associated with myotomy. Two partial fundoplications are commonly performed in achalasia patients after myotomy: the Dor (anterior) and the Toupet (posterior). Some groups, like our own, prefer the Dor because it enables the supporting periesophageal ligaments to be preserved, it covers the exposed submucosa, and it is less complicated to perform. Other authors have suggested that a Toupet may provide better antireflux control and keep the edges of the myotomy separate. A recent randomized multicenter study by Rawlings found no difference between the additional Dor or Toupet fundoplications after myotomy in terms of postoperative LES basal pressure, symptoms, DeMeester score, or percentage of patients with pathological acid exposure.27 In this study, the incidence of objective acid reflux after modified LHD was less than 6%, a figure similar to those reported by other experienced centers. The real incidence and severity of GERD in patients who undergo surgical or endoscopic treatment for achalasia is probably overestimated because many studies judged the presence of reflux only from patients’ symptoms or signs of esophagitis on posttreatment endoscopy. Very few groups used 24-h pH monitoring to objectively establish any presence of GERD after treatment with surgical or endoscopic myotomy, with or without pneumatic dilations. 
Novais and Lemme analyzed 24-h pH patterns after LHD and pneumatic dilations in their randomized trial, showing- after a careful review of false positive results due to fermentation- that the incidence of genuine posttreatment reflux was higher after dilation (31 %) than after LHD (4.7 %). A different result emerged from the European achalasia randomized trial comparing pneumatic dilations with LHD: after a 5-year follow-up [3-7], the incidence of posttreatment GERD did not differ statistically, being 15 % after dilation and 23%after LHD. The reasons for these discrepant results may relate to different methods being used to ascertain abnormal acid exposure; in fact, the latter authors defined as pathological acid exposure when patients had a pH of <4 for more than 4.5 % of the time, not using the DeMeester score. Another reason for differences in the reported incidence of post-myotomy GERD could relate to the expertise with achalasia of the surgeons at the different centers taking part in the trials [8-11]. Multicenter studies are useful for demonstrating the reproducibility of a technique or method, but the end results may differ greatly from one center to another due to different levels of local expertise, especially when a relatively new or particular procedure is involved. 
To date, no randomized studies in the literature have estimated the rate of GERD after surgical or endoscopic myotomy for achalasia and the real prevalence of GERD after POEM remains to be clearly documented. Many studies considered the incidence of GERD after POEM merely by assessing GERD symptoms, and they described percentages between 20 and 40 %. Very few studies rated the incidence of GERD after POEM by means of a complete objective and comprehensive assessment, including endoscopy and pH monitoring. In a recent review, Patel and colleagues analyzed the five studies published in the literature so far that employed pH monitoring, finding abnormal acid exposure in 43 % of patients after POEM. Familiari and colleagues described an altered esophageal acid exposure after POEM in 50.5 % of cases, though only 20 % of their patients had heartburn or esophagitis. These authors also showed that the overall incidence of clinically relevant GERD due to abnormal acid exposure associated with symptoms or esophagitis was only 29 %. The incidence of pathological acid reflux after different treatments is an important parameter that has to be considered when offering a therapy for a functional disease, such as achalasia, especially in young patients, in whom any postoperative reflux may warrant chronic therapy with PPI or antacids. The risk of developing esophageal cancer in achalasia is linked more to the disease itself than to any related GERD, because food and saliva retained in the gullet can cause bacterial overgrowth and an increased production of nitrosamine, leading to mucosal inflammation, dysplasia, and (eventually) squamous cell cancer. Some authors have reported the onset of Barrett’s esophagus and adenocarcinoma. A protective therapy with antireflux drugs is therefore necessary, especially in young patients, to reduce these risks. In the present study, the incidence of post-LHM pathological acid exposure was less than 6%, and we would like to emphasize that our assessment was not only conducted 6 months after surgery but also repeated during the follow up if patients complained of GERD symptoms or esophagitis. Moreover, around the 40%of our patients did not accept to perform the posttreatment pH monitoring (group NP) probably because they were asymptomatic and then the incidence of postoperative reflux could be sensibly lower. The main limitation of the present study is that, as in other studies on the same subject, not all the patients underwent the functional studies. It may be that many asymptomatic patients refused to undergo postoperative manometry and 24-h pH. 
6.       Conclusion 
To sum up, this study demonstrated that, in experienced hands, modified LHD is associated with a very low incidence of true postoperative GERD. The incidence of this posttreatment complication should be assessed only by means of pH monitoring because endoscopic findings and symptoms reported by patients may be misleading. The correct identification of any abnormal esophageal acid exposure is essential in order to prevent the possible complications of untreated GERD. Cruroplasty, when added to the esophageal myotomy during a Heller procedure reduces significantly the rate of GERD post Heller myotomy, and should be considered when performing Heller myotomy in aim to offer the best outcome for the patients.


Table 1: Randomized controlled trials comparing pneumatic dilation with surgical myotomy in the treatment of achalasia.













Table 2: They had a mean age of 43 years at diagnosis.

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Citation: Khalifeh G, Lichaa D, Dbouk S, Saheli R, Chalaby L, et al. (2018) Long Term Follow Up for Patients Post Laparoscopic Heller Dor Myotomy for Achalasia. J Surg: JSUR-1146. DOI: 10.29011/2575-9760. 001146