Thoracic Surgery Interesting Case Hadley Wesson February 21, 2013

49 yo female with history of achalasia – Left thoracotomy with Heller myotomy in 1979 – Symptoms resolved until late 1980s – Underwent multiple dilations without improvement – Manometry 3 years ago Aperistalsis Incomplete relaxation of the LES

Taken to OR for redo laparoscopic Heller myotomy and Dor fundoplication

Intra-operatively

5 cm 3 cm

Heller myotomy

3 cm

Dor fundoplication

Surgical Approaches to Achalasia Advances in the field since 1979

Achalasia Motility disorder of the esophagus Diagnosed by manometry – Incomplete relaxation of the LES – Aperistalsis of the esophageal body

Surgical Treatment Directed at obliterating the dysfunctional LES Myotomy of the lower esophagus and GEJ

Surgical Treatment Directed at obliterating the dysfunctional LES Myotomy of the lower esophagus and GEJ – 2 incision approach described by Heller in 1913 – Modified in 1923 into a single incision

Surgical Treatment In 1962, Dor described a partial fundoplication Fundus is anchored to the right myotomized esophagus and right crus

Operative Controversies Role of minimally invasive surgery Addition of a concurrent antireflux procedure The length of the myotomy

Role of Minimally Invasive Surgery Reported Swallowing Results in Long Run

Role of Minimally Invasive Surgery Reported Swallowing Results in Long Run

Role of Minimally Invasive Surgery Effect of Laparoscopic Heller Myotomy Mean esophageal diameterLES pressure

Operative Controversies Role of minimally invasive surgery Addition of a concurrent antireflux procedure The length of the myotomy

Operative Controversies Role of minimally invasive surgery Addition of a concurrent antireflux procedure The length of the myotomy

Concurrent antireflux procedure

Does Dor fundoplication affect incidence of pathologic GER? N=43 patients – 21 Heller – 22 Heller plus Dor – Follow up 3-5 months with pH study and questionnaire

Concurrent antireflux procedure

Pathologic GER – Heller: 48% – Heller + Dor: 9% RR 0.11 (95% CI ; P=0.01)

Concurrent antireflux procedure Distal esophageal acid exposure was lower

Myotomy Length Traditionally, the recommendation was to end the myotomy as it crossed the GEJ (0.5 cm) – Preserved an effective anti-reflex barrier

Myotomy Length Traditionally, the recommendation was to end the myotomy as it crossed the GEJ (0.5 cm) – Preserved an effective anti-reflex barrier In the 1990s, recommended length was 1.5 cm

Myotomy Length Traditionally, the recommendation was to end the myotomy as it crossed the GEJ (0.5 cm) – Preserved an effective anti-reflex barrier In the 1990s, recommended length was 1.5 cm In 1998, University of Washington extended the myotomy 3 cm to further decrease reoccurrence

Myotomy Length N=110 patients – Standard laparoscopic myotomy (1.5 cm in the stomach) plus Dor = 52pts ( ) – Extended laparoscopic myotomy (3 cm) plus Toupet = 58 pts ( )

Myotomy Length Pre-operative characteristics

Myotomy Length Pre-operative characteristics

Myotomy Length

Limitations – Study design Different time intervals Different follow up periods – Standard myotomy: 46 months – Extended myotomy: 16 months Different fundoplications – Extended myotomy group had worse pre-operative dysphasia

Operative Controversies Role of minimally invasive surgery Addition of a concurrent antireflux procedure The length of the myotomy

Operative Controversies Role of minimally invasive surgery Addition of a concurrent antireflux procedure The length of the myotomy Remain