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Heller myotomy with esophageal diverticulectomy: an operation in need of improvement

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Abstract

Background

This study was undertaken to evaluate the outcomes after laparoscopic Heller myotomy with anterior fundoplication and diverticulectomy for patients with achalasia and esophageal diverticula.

Methods

634 patients undergoing laparoscopic Heller myotomy and anterior fundoplication from 1992 to 2015 are prospectively followed up; patients were stratified for those undergoing concomitant diverticulectomy. Patients graded symptom frequency and severity before and after myotomy, using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Median data are presented (mean ± SD).

Results

Forty-four patients, age 70 years (65 ± 14.2), underwent laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy. Operative time was 182 min (183 ± 54.6). Fifty percentage of patients had a postoperative complication: Most notable were leaks at the diverticulectomy site (n = 8) and pulmonary complications (n = 11; 10 effusion, 1 empyema). Length of stay (LOS) was 3 days (5 ± 8.3). All leaks occurred after discharge and resolved without sequelae using transthoracic catheter drainage and parenteral nutrition; two patients received endoscopic esophageal stents. Median follow-up is 39 months. Symptoms amelioration was significant postoperatively, including severity of dysphagia [6 (6 ± 3.9) to 2(4 ± 3.6)]. Seventy-six percentage of patients rated their symptoms at last follow-up as satisfying/very satisfying. Seventy-seven percentage of patients had symptoms once per week or less. Eighty-one percentage would have the operation again knowing what they know now.

Conclusions

Laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy well palliate the symptoms of achalasia with accompanying esophageal diverticulum. The operations are generally longer than those without diverticulectomy and are accompanied by a relatively longer LOS. Complications are relatively frequent and severe (e.g., leaks and pneumonia). In particular, leaks at the diverticulectomy site are unpredictable, occur after discharge, and remain vexing. Nevertheless, for this advanced form of achalasia, long-term symptom relief and patient satisfaction are high after anterior fundoplication with concomitant diverticulectomy. New and innovative techniques are needed to decrease the frequency of leaks at the diverticulectomy site.

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Authors and Affiliations

  1. Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, 3000 Medical Park Drive, Suite 310, Tampa, FL, 33613, USA

    Ty A. Bowman, Benjamin D. Sadowitz, Sharona B. Ross, Andrew Boland, Kenneth Luberice & Alexander S. Rosemurgy

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  1. Ty A. Bowman
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  2. Benjamin D. Sadowitz
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  3. Sharona B. Ross
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  4. Andrew Boland
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  5. Kenneth Luberice
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  6. Alexander S. Rosemurgy
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Corresponding author

Correspondence to Sharona B. Ross.

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Disclosures

Dr. Alexander Rosemurgy has an educational relationship with Olympus and serves as a consultant for the Modeling Electronic Reporting Project (NCPR-MERP). Dr. Sharona Ross has an educational relationship with Olympus. Mr. Ty Bowman, Andrew Boland, Kenneth Luberice, and Dr. Benjamin Sadowitz have no conflict of interest or financial ties to disclose.

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Bowman, T.A., Sadowitz, B.D., Ross, S.B. et al. Heller myotomy with esophageal diverticulectomy: an operation in need of improvement. Surg Endosc 30, 3279–3288 (2016). https://doi.org/10.1007/s00464-015-4655-2

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  • DOI: https://doi.org/10.1007/s00464-015-4655-2

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