Thoracoscopic esophagomyotomy for achalasia in the pediatric population: A retrospective cohort study

Background/Purpose

Achalasia is an extremely rare disease in children (0.1 per 100,000 individuals). Standard treatments for this include pneumatic dilation and esophagomyotomy. Minimally invasive esophagomyotomies have increasingly been used owing to improved postoperative pain and length of stay. We describe our experience with thoracoscopic esophagomyotomy in this population.

Laparoscopic esophagomyotomy for achalasia

Results of an ongoing clinical study treating achalasia patients with a transabdominal laparoscopic Heller myotomy and Toupet partial fundoplication are presented. Twelve patients underwent surgery between January 1992 and October 1993. All patients had barium esophagograms, preoperative endoscopy, esophageal manometry, 24-h pH studies, and extensive GI history preoperatively. Surgical complications included two perforations of the mucosa at the gastroesophageal junction repaired laparoscopically. There were no surgical mortalities and the average hospital stay was 39 h. Postoperatively all patients at follow-up had a repeat GI history, esophagogastroscopy, 24-h pH testing, and esophageal manometry. This follow-up showed good-to-excellent relief of dysphagia in all 12 patients with one patient complaining of heartburn documented to be from reflux postoperatively. Manometry showed a mean decrease in the lower esophageal sphincter pressure from 33.4 mmHg preoperatively to 19.3 mmHg postoperatively; 24-hour pH testing showed no significant reflux in the nine patients who had Heller myotomy plus a Toupet fundoplication. However, two of three patients who had Heller myotomy alone demonstrated abnormal 24-h pH testing. One of these patients was symptomatic and was found to have mild esophagitis by biopsy on postoperative endoscopy. These good results have persisted for mean follow-up of 16 months.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, TN, 18–19 April 1994     

Thoracoscopic esophagomyotomy for achalasia: preoperative patterns of acid reflux and long-term follow-up

BACKGROUND: The best technique for surgical esophagomyotomy to treat achalasia remains contentious. The controversies include the best approach (thoracoscopic or laparoscopic) and the need for an antireflux procedure. Postoperative pH studies have suggested pathologic gastroesophageal reflux (GER) in many cases; however, control studies of reflux patterns are scarce. This study presents pH studies before esophagomyotomy as well as long-term follow-up of patients undergoing esophagomyotomy. METHODS: Forty-nine patients underwent esophagomyotomy (45 thoracoscopically, 4 laparoscopically) for achalasia. Before treatment, 24-hour pH studies were conducted for 38 patients with achalasia. The patients were evaluated postoperatively for dysphagia and reflux. Results were classified as excellent, good, fair, or poor. RESULTS: The findings of the pretreatment pH studies were abnormal in 15 patients (39%). Twelve patients (32%) had GER either with esophageal fermentation (6 patients [16%]) or without fermentation (6 patients [16%]). Eight percent had esophageal fermentation alone. There was no correlation between GER and previous pneumatic dilatation. Twenty-three patients (60%) had normal pH scores; of these, 24% had esophageal fermentation, whereas 29% had neither reflux nor fermentation. Operative results were excellent in 70% of patients, good in 10%, and fair in 20%. All patients considered their conditions improved. Four patients required a subsequent operation because of dysphagia (n = 3) or reflux (n = 1), and their original procedures were classified as failures. Their current status is fair (n = 2), good (n = 1), and excellent (n = 1). GER was documented before the original operation in 3 of the 4 patients in whom the procedure failed. Fifteen patients were eligible for 5-year follow-up. Their results are excellent or good (n = 11) (73%) and fair (n = 4) (27%). CONCLUSIONS: A high percentage of patients with achalasia exhibit pathologic GER before surgical therapy and seem to be at higher risk for failed surgical treatment. Thoracoscopic esophagomyotomy resulted in improvement in 92% of patients, and long-term follow-up indicates that these results are durable.     

Thoracoscopic esophagomyotomy. Initial experience with a new approach for the treatment of achalasia.

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.     

Reoperation after failed esophagomyotomy for achalasia

Of 49 patients with achalasia treated surgically between 1975 and 1985, 12 (8 women, 4 men) had undergone transthoracic esophagomyotomy previously. Four had had concomitant upper gastrointestinal surgery. All 12 patients complained of dysphagia; other symptoms included regurgitation, nocturnal aspiration, heartburn, chest pain, vomiting, upper gastrointestinal bleeding and weight loss. The average time from initial operation to onset of symptoms was 9 months. Preoperative investigations and operative findings identified the cause of dysphagia as inadequate or healed esophagomyotomy with persistent or recurrent achalasia (eight patients--two had partially disrupted fundoplications contributing to their dysphagia), hiatus hernia with reflux esophagitis causing esophageal spasm or peptic esophageal stricture (two patients) and incorrect initial diagnosis and treatment (two patients). Treatment, with the aid of intraoperative manometry, included repeat Heller myotomy (five patients), Hill antireflux repair (four patients), takedown of Nissen fundoplication and extension of myotomy (two patients). The average follow-up was 16 months. Eight patients had good results, two required further operation and one underwent multiple dilatations postoperatively. The causes of recurrent dysphagia following surgery for achalasia are diverse and patients require individualized investigation and treatment. Remedial surgery for achalasia can correct postoperative dysphagia but results are less successful than those following an adequate initial operation.     

Reoperation after esophagomyotomy for achalasia of the esophagus

Eleven patients who required reoperation for persistent or recurrent symptoms after esophagomyotomy are reported on. Failure of the original operation was attributed to inadequate myotomy in three, healed myotomy in four, and reflux esophagitis in four.The myotomy was extended or a new myotomy created in the first two categories of patients. Three of the four patients with reflux esophagitis were treated by antrectomy and Roux-en-Y esophagojejunostomy; one of these also required concomitant excision of the esophagogastric junction because of stricture. The fourth patient with esophagitis ultimately required colonic interposition for relief of symptoms.Ten of the eleven patients were improved after reoperation, but results were less good than those achieved by a properly performed primary esophagomyotomy. This re-emphasizes the need for attention to the technical details of esophagomyotomy if good results are to be achieved.     

Video-assisted thoracoscopic esophagomyotomy for achalasia after pulmonary lobectomy

A 52-year-old man developed achalasia and a lung abscess due to aspiration pneumonia. We conducted a right upper lobectomy by thoracotomy for the abscess and, 2 weeks later, video-assisted thoracoscopic myotomy and fundoplication (modified Belsey Mark IV procedure) though the left thorax for achalasia. Three months after surgery, the patient was free of dysphasia and chest pain and had regained his original weight Esophageal myotomy and fundoplication using video-assisted thoracoscopy appear to be feasible in treating achalasia involving impaired pulmonary function.     

Long-term results of esophagomyotomy for achalasia of esophagus.

Modified Heller's esophagomyotomy for achalasia of the esophagus was done in 145 patients at Henry Ford Hospital, Detroit, from 1951 to 1977. Information on current symptoms was obtained for 121 patients from a detailed questionnaire that was sent to all patients, from personal interviews, or from data obtained from patients' clinical records. Average period of follow-up was 85 months. Actuarial analysis of postoperative symptoms showed an incidence of reflux of 24% after one year and 48% after ten years; incidence of relief of dysphagia was 89% of all patients after one year and 81% after ten years. Continual surveillance of patients after esophagomyotomy must be stressed. Dissatisfaction with the results of this procedure prompted us to recommend that an antireflux operation be performed at the time of the initial procedure.     

Laparoscopic esophagomyotomy for the treatment of achalasia in children

BACKGROUND: Albeit rare in children, achalasia is a disorder with severe symptoms that causes growth impairment. The treatment of choice in children is the esophagomyotomy, although there are variations in the surgical approaches available and differences of opinion regarding the inclusion of an adjunctive antireflux procedure. The recent advent of the laparoscopic approach has had a profound impact on the treatment of achalasia in both adults and children. METHODS: In this report, we describe eight patients with severe achalasia who were treated by laparoscopic Heller's operation associated with a fundoplication according to either Dor's or Toupet's technique. The patients' ages ranged between 2 and 13 years. A five-port technique was used: a 10-mm port placed infraumbilically for the optics and four 5-mm ports. One was placed in the right abdominal quadrant for retraction of the left hepatic lobe, one in the left abdominal quadrant for the first operative instrument, one below the xyphoid appendix for the second operative instrument, and the last one to introduce a 5-mm cannula laterally to the umbilicus to retract the stomach below. A 7-8-cm laparoscopic Heller esophagomyotomy was completed, followed by an anterior Dor fundoplication in six cases and a Toupet in two. The longitudinal division of the anterior esophageal musculature was performed with a scalpel or scissors. The myotomy was made along the stomach, extending for >/=2-3 cm. RESULTS: Mean operating time was 120 mins. Three complications were recorded. There were two perforations of the gastroesophageal mucosa; the first was sutured in laparoscopy and the second required a second operation. The third complication was a case of dysphagia resolved by dismounting a fundoplication that was too tight. At follow-up, which lasted from 6 months to 5 years, the children were all free of symptoms. CONCLUSIONS: Laparoscopic Heller esophagomyotomy appears to be a complex and difficult operation, but it is as safe and effective as laparotomy in children with achalasia. However, complications can be numerous and severe at the beginning of a surgeon's experience.     

Laparoscopic esophagomyotomy for achalasia without a complementary antireflux procedure

BACKGROUND: Achalasia is a progressive motility disorder of the esophagus, without a definitive cure. The principal method of palliation is myotomy of the distal esophagus. We analyzed the 5-year experience at our institution with laparoscopic Heller myotomy without an antireflux procedure to determine its results, particularly regarding postoperative gastroesophageal reflux. MATERIALS AND METHODS: Thirty-three patients, mean age 43 years (range, 29-62 years) with clinical, manometric, x-ray, and endoscopic proof of achalasia were operated on and followed up for 24 months. Prior to being referred to surgery they had all undergone at least one pneumatic balloon dilation. The operative technique was a 7-cm myotomy that included the lower esophageal sphincter but did not exceed 5 mm of the gastric cardia. Follow-up consisted of clinical observation, cineesophagography, and 24-hour pHmetry. RESULTS: All patients reported satisfactory to excellent results regarding dysphagia and no heartburn two years after the operation. The 24-hour pHmetry and the radiographic investigation showed no evidence of gastroesophageal reflux. CONCLUSION: It seems that the risk of gastroesophageal reflux is very low when the cardiomyotomy does not exceed the length of 5 mm. Our results are in accordance with other observational studies as well as larger cohort and meta-analysis studies. Prospective randomized studies are needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.     

Video-assisted thoracoscopic esophagomyotomy for achalasia after pulmonary lobectomy.

A 52-year-old man developed achalasia and a lung abscess due to aspiration pneumonia. We conducted a right upper lobectomy by thoracotomy for the abscess and, 2 weeks later, video-assisted thoracoscopic myotomy and fundoplication (modified Belsey Mark IV procedure) though the left thorax for achalasia. Three months after surgery, the patient was free of dysphasia and chest pain and had regained his original weight. Esophageal myotomy and fundoplication using video-assisted thoracoscopy appear to be feasible in treating achalasia involving impaired pulmonary function.     

Comparison of outcomes following open and laparoscopic esophagomyotomy for achalasia

BACKGROUND: Minimally invasive esophagomyotomy is replacing open surgery for achalasia, but data comparing these procedures performed by the same surgical team are sparse. The purpose of this study was to compare the morbidity and clinical outcome following laparoscopic and open esophagomyotomy. METHODS: Twelve consecutive patients referred for elective surgery between August 1995 and August 1997 underwent laparoscopic myotomy and partial fundoplication. They were compared to a group of 10 patients chosen from a larger pool of 20 patients who had open surgery during the same period performed by our own group. The mean length of follow-up in the laparoscopic group was 16 months; in the open group, it was 60 months. Both groups had similar demographics and clinical features. Each patient had at least one previous pneumatic dilatation. Inpatient records were reviewed. Patients were interviewed using a symptom assessment and patient satisfaction questionnaire. RESULTS: As compared to the open operation, laparoscopic esophagomyotomy with partial fundoplication resulted in significantly (p < 0.05) less blood loss (50 +/- 26 cc versus 220 +/- 127 cc), parenteral narcotic use (2.1 +/- 1.0 days versus 5.3 +/- 1.4 days), time in hospital (2.7 +/- 1.0 days versus 8.8 +/- 2.6 days), and time off work (19 +/- 16 days versus 85 +/- 60 days). There were similar results for the laparoscopic and open groups in the improvement in dysphagia (92% versus 90%) and patient satisfaction with surgery (84% versus 80%). CONCLUSIONS: Laparoscopic esophagomyotomy for achalasia results in symptomatic improvement and high patient satisfaction comparable to the open procedure but with significantly less morbidity.     

Late results following esophagomyotomy in children with achalasia

Twenty one children with achalasia of the esophagus were treated from 1970 to 1986. There were 11 girls and ten boys (average age, 10.9 years; range, 6 months to 16 years). Diagnosis was established by barium swallow in 21 cases and confirmed by manometrics and motility studies in 14. Four children had unsuccessful dilatation (range, 1 to 16 dilatations/pt). All 21 children underwent modified anterior Heller esophagomyotomy (transabdominal in 15 and transthoracic in six). Concomitant Nissen fundoplication was performed in three. Follow-up from 1 to 14 years (mean, 6.3 years) showed complete relief of obstruction in 18 patients (86%), while three required additional procedures for persistent dysphagia. One child improved after a single dilatation, but two others eventually required a second esophagomyotomy. Three additional patients subsequently developed gastroesophageal reflux (GER), and two were managed with Nissen fundoplication; the third responded to medical management. The mortality for this series was zero. Postoperative complications occurred in nine children (42%) and was due to atelectasis and postoperative fever. Modified Heller esophagomyotomy is safe and effective in children with achalasia (mortality, 0%; relief of obstruction, 86%). Results were similar after a transabdominal or transthoracic approach. Esophageal dilatation was not an effective method of treatment. Although postsurgical barium swallow showed relief of obstruction, abnormal esophageal motility persisted, suggesting that long-term follow-up is important.     

Operation for esophageal achalasia. Results of esophagomyotomy without an antireflux operation

Between January, 1970, and January, 1984, 113 patients with esophageal achalasia underwent 115 esophagomyotomies at the Lahey Clinic. Twenty-nine patients had been treated on one or more occasions by forceful dilation, and 18 had been operated upon before. Results are based on follow-up studies of 103 patients operated on 1 to 13.5 years ago (average follow-up period, 6.75 years). Six patients were lost to follow-up study, and six were operated upon less than a year ago. The condition of 94 patients (91%) was improved by operation. The improvement rate was 94% for those who underwent a primary operation and 76% for those who underwent reoperation. Only four of the nine poor results were caused by reflux esophagitis, and these patients are satisfactorily managed medically. Multiple regression analysis of risk factors including age, sex, duration of symptoms, severity of disease, length of follow-up, previous operation, and forceful dilations revealed that only previous operation correlated significantly with poor results (p = 0.0004). Preoperative and postoperative manometric assessment of the lower esophageal sphincter was made on some of these patients. The amplitude of lower esophageal sphincter pressure dropped from 32.5 +/- 1.6 (SEM) to 14.5 +/- 1.4 mm Hg, and the length of the lower esophageal sphincter decreased from 3.7 +/- 0.1 to 2.2 +/- 0.1 cm. These differences were highly significant (p = 0.001). After myotomy a short subhiatal remnant of the lower esophageal sphincter remains with pressure within the normal range, which minimizes the risk of postoperative gastroesophageal reflux. Because of the high success rate of limited esophagomyotomy and the low incidence of significant reflux symptoms after its use, we recommend that it be performed without an associated antireflux procedure.     

Surgical treatment of achalasia: results with esophagomyotomy and Belsey repair

To address the controversy regarding the choice of operation for achalasia, the cases of 57 patients having operation, 38 for the first time (Group 1) and 19 with a previous procedure (Group 2), were reviewed. Surgical emphasis was on hiatal dissection to maximize exposure and use of the Belsey fundoplication to achieve cardiac competence without obstruction. Operative mortality was 1 (1.8%) of 57 patients. In group 1, 21 of the 38 had prior pneumatic dilations. All were treated with esophagomyotomy and a Belsey fundoplication. Clinical results are excellent or good in 30 (88%) of the 34 patients for whom follow-up is available, and are similar in patients with and without prior dilation. Lower esophageal sphincter (LES) pressure decreased from 22.3 to 7.7 mm Hg (p less than 0.001), and pH testing shows no reflux in any of 13 patients. In Group 2, previous operations were esophagomyotomy in 13, esophagomyotomy plus a Nissen fundoplication in 3, and a Nissen fundoplication only in 3. The initial operation failed because of inadequate myotomy in 6 patients, an obstructive Nissen fundoplication in 6, and reflux esophagitis in 7. In these 7 patients, acid reflux testing documented reflux due to cardiac incompetence and delayed clearance. Reoperations included takedown of a Nissen fundoplication in 6, esophagomyotomy and Belsey procedure in 15, Belsey procedure in 1, and resection plus colon interposition in 2. Clinical results are excellent or good in 12 (75%) of the patients with follow-up. These conclusions can be drawn. (1) Esophagomyotomy and Belsey fundoplication lowers LES pressure and provides good results with low risk, even after pneumatic dilation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Laparoscopic esophagomyotomy with dor anterior fundoplication in a child with achalasia

Laparoscopic myotomy with anterior fundoplication was successfully performed on a 12-year-old boy with esophageal achalasia. After completion of a longitudinal esophagocardiomyotomy approximately 6 cm in length, a 180 degrees fundic patch was sutured anteriorly to the myotomized esophagus according to the Dor-Gavriliu technique. The patient showed a rapid and uneventful recovery with complete resolution of his preoperative symptoms. The nonobstructive antireflux procedure can be safely performed concomitantly with another surgery, even in a pediatric patient.     

腹腔镜食管肌层切开加胃底折叠术治疗贲门失弛症的护理

目的总结贲门失弛症在腹腔镜下行食管肌层切开加胃底折叠术的护理经验。方法对7例贲门失弛症患者采用单腔气管插管静吸复合麻醉,人工CO2气腹后腹腔镜下行食管肌层切开加胃底折叠术;术前加强患者的心理护理,改善营养状况,完善各项术前检查和术前准备;术后加强各种引流管的护理,鼓励患者早期活动,进行饮食指导,注重并发症的观察及处理。结果患者手术过程顺利,平均手术时间175.7min;术中平均出血45.7mL;无手术及护理相关的并发症,平均住院时间5.4d。术后随访1～10个月,体质量增长平均5.4kg;手术效果优5例,良2例。结论腹腔镜应用于贲门失弛症的治疗可行及有效,加强围术期护理,是保证手术顺利进行和减少术后并发症的重要环节。     

Thoracoscopic cardiomyotomy for achalasia of the cardia: early results.

A thoracoscopic technique of Heller's procedure for achalasia of the cardia is described. The operation has been performed on five patients with excellent symptomatic results. There were no complications. All patients went home on the 3rd postoperative day and returned to work within 2 weeks of the procedure.