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Results of laparoscopic Heller myotomy without anti-reflux procedure in achalasia. Monocentric prospective study of 106 cases

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Abstract

Background

Heller myotomy (HM) combined with an anti-reflux procedure has been shown to be effective for the treatment of achalasia, as postoperative gastro-esophageal reflux (GER) is observed in about 10% of the cases. Laparoscopy has brought an undeniable benefit in providing excellent visualisation of the gastro-esophageal junction (GEJ) without lateral and posterior dissection. Respecting the anatomical fixation of the GEJ seems to permit the performing of HM without an anti-reflux procedure, the need for which is therefore debatable. The purpose of this study was to analyse the results of this controversial procedure.

Methods

A monocentric prospective study was carried out on 106 patients who underwent HM without an anti-reflux procedure. The postoperative assessment consisted of a manometry and a 24-hour pH study two months after surgery, and a yearly clinical examination for a minimum of five years. The data capture was done using a statistical analysis.

Results

There was no mortality, one conversion to an open procedure, and four mucosal perforations. Postoperative morbidity was 2%. The average follow-up period was 55 months (range, 2 to 166), with 10 patients lost to follow-up. Good functional results were observed in 91.4% of patients at one year, and 78.6% at five years. Two months after surgery, a 9.4% prevalence of GER was detected in the pH study, and the lower esophageal sphincter pressure had significantly decreased. After a long term follow-up we observed an 11.3% global rate of GER. No repeat surgery was necessary to control postoperative GER.

Conclusions

Laparoscopic HM without anti-reflux procedure gives good functional results provided the anatomical fixation of the GOJ is respected.

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References

  1. Gholoum S, Feldman LS, Andrew CG, Bergman S, Demyttenaere S, Mayrand S, Stanbridge DD, Fried GM (2006) Relationship between subjective and objective outcome measures after Heller myotomy and Dor fundoplication for achalasia. Surg Endosc 20:214–219

    Article  PubMed  CAS  Google Scholar 

  2. Mattioli G, Esposito C, Pini Prato A, Doldo P, Castagnetti M, Barabino A, Gandullia P, Staiano AM, Settimi A, Cucchiara S, Montobbio G, Jasonni V (2003) Results of the laparoscopic Heller-Dor procedure for pediatric esophageal achalasia. Surg Endosc 17:1650–1652

    Article  PubMed  CAS  Google Scholar 

  3. Frantzides CT, Moore RE, Carlson MA, Madan AK, Zografakis JG, Keshavarzhian A, Smith C (2004) Minimally invasive surgery for achalasia: a 10-year experience. J Gastrointest Surg 8:18–23

    Article  PubMed  Google Scholar 

  4. Ho KY, Tay HH, Kang JY (1999) A prospective study of the clinical features, manometric findings, incidence and prevalence of achalasia in Singapore. J Gastroenterol Hepatol 14:791–795

    Article  PubMed  CAS  Google Scholar 

  5. Moreno Gonzalez E, Garcia Alvarez A, Landa Garcia I, Gomez Gutierrez M, Rico Selas P, Garcia Garcia I, Jover Navalon JM, Arias Diaz J (1988) Results of surgical treatment of esophageal achalasia. Multicenter retrospective study of 1,856 cases. GEEMO (Groupe Europeen Etude Maladies Oesophageennes) Multicentric Retrospective Study. Int Surg 73:69–77

    PubMed  CAS  Google Scholar 

  6. Bonavina L, Nosadini A, Bardini R, Baessato M, Peracchia A (1992) Primary treatment of esophageal achalasia. Long-term results of myotomy and Dor fundoplication. Arch Surg 127:222–226

    PubMed  CAS  Google Scholar 

  7. Rosemurgy A, Villadolid D, Thometz D, Kalipersad C, Rakita S, Albrink M, Johnson M, Boyce W (2005) Laparoscopic Heller myotomy provides durable relief from achalasia and salvages failures after botox or dilation. Ann Surg 241:725–733

    Article  PubMed  Google Scholar 

  8. Patti MG, Pellegrini CA, Horgan S, Arcerito M, OMelanczuk P, Tamburini A, Diener U, Eubanks TR, Way LW (1999) Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg 230:587–593

    Article  PubMed  CAS  Google Scholar 

  9. Douard R, Gaudric M, Chaussade S, Couturier D, Houssin D, Dousset B (2004) Functional results after laparoscopic Heller myotomy for achalasia: A comparative study to open surgery. Surgery 136:16–24

    Article  PubMed  Google Scholar 

  10. Patti MG, Fisichella PM, Peretta S, Galvani C, Gorodner MV, Robinson T, Way LW (2003) Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change. J Am Coll Surg 196:698–703

    Article  PubMed  Google Scholar 

  11. Zaninotto G, Costantini M, Molena D, Buin F, Carta A, Nicoletti L, Ancona E (2000) Treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor partial anterior fundoplication: prospective evaluation of 100 consecutive patients. J Gastrointest Surg 4:282–289

    Article  PubMed  CAS  Google Scholar 

  12. Costantini M, Zaninotto G, Guirroli E, Rizzetto C, Portale G, Ruol A, Nicoletti L, Ancona E (2005) The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up. Surg Endosc 19:345–351

    Article  PubMed  CAS  Google Scholar 

  13. Lyass S, Thoman D, Steiner JP, Phillips E (2003) Current status of an antireflux procedure in laparoscopic Heller myotomy. Surg Endosc 17:554–558

    Article  PubMed  CAS  Google Scholar 

  14. Richards WO, Sharp KW, Holzman MD (2001) An antireflux procedure should not routinely be added to a Heller myotomy. J Gastrointest Surg 5:13–16

    Article  PubMed  CAS  Google Scholar 

  15. Cortesini C, Cianchi F, Pucciani F (2002) Long-term results of Heller myotomy without an antireflux procedure in achalasic patients. Chir Ital 54:581–586

    PubMed  Google Scholar 

  16. Vela MF, Richter JE, Wachsberger D, Connor J, Rice TW (2004) Complexities of managing achalasia at a tertiary referral center: use of pneumatic dilatation, Heller myotomy, and botulinum toxin injection. Am J Gastroenterol 99:1029–1036

    Article  PubMed  Google Scholar 

  17. West RL, Hirsch DP, Bartelsman JF, De Borst J, Ferwerda G, Tytgat GN, Boeckxstaens GE (2002) Long term results of pneumatic dilation in achalasia followed for more than 5 years. Am J Gastroenterol 97:1346–1351

    Article  PubMed  CAS  Google Scholar 

  18. Gockel I, Junginger T, Bernhard G, Eckardt VF (2004) Heller myotomy for failed pneumatic dilation in achalasia: how effective is it? Ann Surg 239:371–377

    Article  PubMed  Google Scholar 

  19. Bloomston M, Fraiji E, Boyce HW Jr, Gonzalvo A, Johnson M, Rosemurgy AS (2003) Preoperative intervention does not affect esophageal muscle histology or patient outcomes in patients undergoing laparoscopic Heller myotomy. J Gastrointest Surg 7:181–188

    Article  PubMed  Google Scholar 

  20. Zaninotto G, Annese V, Costantini M, Del Genio A, Costantino M, Epifani M, Gatto G, D’Onofrio V, Benini L, Contini S, Molena D, Battaglia G, Tardio B, Andriulli A, Ancona E (2004) Randomized controlled trial of botulinum toxin versus laparoscopic Heller myotomy for esophageal achalasia. Ann Surg 239:364–370

    Article  PubMed  Google Scholar 

  21. Horgan S, Hudda K, Eubanks T, McAllister J, Pellegrini CA (1999) Does botulinum toxin injection make esophagomyotomy a more difficult operation? Surg Endosc 13:576–579

    Article  PubMed  CAS  Google Scholar 

  22. Patti MG, Albanese CT, Holcomb GW, Molena D, Fisichella PM, Peretta S, Way LW (2001) Laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children. J Pediatr Surg 36:1248–1251

    Article  PubMed  CAS  Google Scholar 

  23. Patti MG, Arcerito M, Tong J, De Pinto M, De Bellis M, Wang A, Feo CV, Mulvihill SJ, Way LW (1997) Importance of preoperative and postoperative pH monitoring in patients with esophageal achalasia. J Gastrointest Surg 1:505–510

    Article  PubMed  CAS  Google Scholar 

  24. Maher JW, Conklin J, Heitshusen DS (2001) Thoracoscopic esophagomyotomy for achalasia: preoperative patterns of acid reflux and long-term follow-up. Surgery 130:570–576

    Article  PubMed  CAS  Google Scholar 

  25. Patti MG, Diener U, Molena D (2001) Esophageal achalasia: preoperative assessment and postoperative follow-up. J Gastrointest Surg 5:11–12

    Article  PubMed  CAS  Google Scholar 

  26. Benini L, Sembenini C, Castellani G, Bardelli E, Brentegani MT, Giorgetti P, Vantini I (1996) Pathological esophageal acidification and pneumatic dilitation in achalasic patients. Too much or not enough? Dig Dis Sci 41:365–371

    Article  PubMed  CAS  Google Scholar 

  27. Ramacciato G, Mercantini P, Amodio PM, Stipa F, Corigliano N, Ziparo V (2003) Minimally invasive surgical treatment of esophageal achalasia. JSLS 7:219–225

    PubMed  Google Scholar 

  28. Ramacciato G, Mercantini P, Amodio PM, Corigliano N, Barreca M, Stipa F, Ziparo V (2002) The laparoscopic approach with antireflux surgery is superior to the thoracoscopic approach for the treatment of esophageal achalasia. Experience of a single surgical unit. Surg Endosc 16:1431–1437

    Article  PubMed  CAS  Google Scholar 

  29. Boulez J, Meeus P, Espalieu P (1997) Heller’s esocardiomyotomy without anti-reflux procedure by the laparoscopic approach. Analysis of a series of 27 cases. Ann Chir 51:232–236

    PubMed  CAS  Google Scholar 

  30. Oelschlager BK, Chang L, Pellegrini CA (2003) Improved outcome after extended gastric myotomy for achalasia. Arch Surg 138:490–495

    Article  PubMed  Google Scholar 

  31. Falkenback D, Johansson J, Oberg S, Kjellin A, Wenner J, Zilling T, Johnsson F, Von Holstein CS, Walther B (2003) Heller’s esophagomyotomy with or without a 360 degrees floppy Nissen fundoplication for achalasia. Long-term results from a prospective randomized study. Dis Esophagus 16:284–290

    Article  PubMed  CAS  Google Scholar 

  32. Chapman JR, Joehl RJ, Murayama KM, Tatum RP, Shi G, Hirano I, Jones MP, Pandolfino JE, Kahrilas PJ (2004) Achalasia treatment: improved outcome of laparoscopic myotomy with operative manometry. Arch Surg 139:508–513

    Article  PubMed  Google Scholar 

  33. Zaninotto G, Costantini M, Portale G, Battaglia G, Molena D, Carta A, Costantino M, Nicoletti L, Ancona E (2002) Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg 235:186–192

    Article  PubMed  Google Scholar 

  34. Bloomston M, Durkin A, Boyce HW, Johnson M, Rosemurgy AS (2004) Early results of laparoscopic Heller myotomy do not necessarily predict long-term outcome. Am J Surg 187:403–407

    Article  PubMed  Google Scholar 

  35. Ellis FH Jr (1993) Oesophagomyotomy for achalasia: a 22-year experience. Br J Surg 80:882–885

    Article  PubMed  Google Scholar 

  36. Peters JH (2001) An antireflux procedure is critical to the long-term outcome of esophageal myotomy for achalasia. J Gastrointest Surg 5:17–20

    Article  PubMed  CAS  Google Scholar 

  37. Gallez JF, Berger F, Moulinier B, Partensky C (1987) Esophageal adenocarcinoma following Heller myotomy for achalasia. Endoscopy 19:76–78

    Article  PubMed  CAS  Google Scholar 

  38. Galvani C, Gorodner MV, Moser F, Baptista M, Donahue P, Horgan S (2006) Laparoscopic Heller myotomy for achalasia facilitated by robotic assistance. Surg Endosc 20(7):1105–12

    Article  PubMed  CAS  Google Scholar 

  39. Richards WO, Clements RH, Wang PC, Lind CD, Mertz H, Ladipo JK, Holzman MD, Sharp KW (1999) Prevalence of gastroesophageal reflux after laparoscopic Heller myotomy. Surg Endosc 13:1010–1014

    Article  PubMed  CAS  Google Scholar 

  40. Donahue PE, Horgan S, Liu KJ, Madura JA (2002) Floppy Dor fundoplication after esophagocardiomyotomy for achalasia. Surgery 132:716–722

    Article  PubMed  Google Scholar 

  41. Robertson GS, Lloyd DM, Wicks AC, De Caestecker J, Veitch PS (1995) Laparoscopic Heller’s cardiomyotomy without an antireflux procedure. Br J Surg 82:957–959

    Article  PubMed  CAS  Google Scholar 

  42. Dempsey DT, Delano M, Bradley K, Kolff J, Fisher C (2004) Laparoscopic esophagomyotomy for achalasia: does anterior hemifundoplication affect clinical outcome? Ann Surg 239:779–785

    Article  PubMed  Google Scholar 

  43. Baigrie RJ, Cullis SN, Ndhluni AJ, Cariem A (2005) Randomized double-blind trial of laparoscopic Nissen fundoplication versus anterior partial fundoplication. Br J Surg 92:819–823

    Article  PubMed  CAS  Google Scholar 

  44. Limpert PA, Naunheim KS (2005) Partial versus complete fundoplication: is there a correct answer? Surg Clin North Am 85:399–410

    Article  PubMed  Google Scholar 

  45. Topart P, Deschamps C, Taillefer R, Duranceau A (1992) Long-term effect of total fundoplication on the myotomized esophagus. Ann Thorac Surg 54:1046–1051

    Article  PubMed  CAS  Google Scholar 

  46. Ponce M, Ortiz V, Juan M, Garrigues V, Castellanos C, Ponce J (2003) Gastroesophageal reflux, quality of life, and satisfaction in patients with achalasia treated with open cardiomyotomy and partial fundoplication. Am J Surg 185:560–564

    Article  PubMed  Google Scholar 

  47. Richards WO, Torquati A, Holzman MD, Khaitan L, Byrne D, Lutfi R, Sharp KW (2004) Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 240:405–412

    Article  PubMed  Google Scholar 

  48. Boulez J, Baulieux J, Mayer B, Peix JL, Donne R, Maillet P (1981) Résultats éloignés de la myotomie de Heller dans le traitement de l’achalasie oesophagienne. A propos de 103 cas. Ann Gastroenterol Hepatol 17:321–328

    Google Scholar 

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Authors and Affiliations

  1. Department of Digestive Surgery, Edouard Herriot Hospital, Pavillon D, Pr Boulez unit, Place d’Arsonval, Lyon, France

    M. Robert, G. Poncet & J. Boulez

  2. Department of Gastroenterology, Edouard Herriot Hospital, Pavillon H, Lyon, France

    F. Mion

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  1. M. Robert
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  2. G. Poncet
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Correspondence to M. Robert.

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Robert, M., Poncet, G., Mion, F. et al. Results of laparoscopic Heller myotomy without anti-reflux procedure in achalasia. Monocentric prospective study of 106 cases. Surg Endosc 22, 866–874 (2008). https://doi.org/10.1007/s00464-007-9600-6

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  • DOI: https://doi.org/10.1007/s00464-007-9600-6

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