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Eur J Cardiothorac Surg 2005;27:357-360
© 2005 Elsevier Science NL
a Department of Surgery, Division of Thoracic- and Hyperbaric Surgery, University Medical School Graz, Auenbruggerplatz 29, 8036 Graz, Austria
b Department of Internal Medicine, University Medical School, Graz, Austria
c Department of Dermatology, University Medical School, Graz, Austria
Received 20 October 2004; received in revised form 17 December 2004; accepted 21 December 2004.
* Corresponding author. Tel.: +43 316 385 3302; fax: +43 316 385 4679. (E-mail: jo.lindenmann{at}meduni-graz.at).
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Abstract |
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 Top Abstract 1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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Key Words: Esophagus • Achalasia • Surgery
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1. Introduction |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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Achalasia is characterized by an incomplete relaxation of the lower esophageal sphincter (LES) after deglutition and an elevated LES resting pressure. In time, prestenotic dilatation and failure of the esophageal body peristalsis develop. Patients complain of dysphagia for solids and liquids, regurgitation, chest pain and weight loss. Respiratory symptoms such as coughing or episodes of pneumonia are due to aspiration.
The so far unclear etiology of achalasia results in controversial therapeutic strategies. In general, the concept is focused on the reduction of lower esophageal sphincter (LES) resting pressure, resulting in improved esophageal emptying and symptomatic relief of functional LES obstruction. This may be achieved by medication using nitrates and calcium channel blockers, endoscopic injections of botulinum toxin which need to be repeated every 6 months at least, or repetitive endoscopic balloon dilation of the sphincter [1,2].
When the above mentioned options have failed the transverse fibres of the esophageal sphincter are dissected by esophagocardio-myotomy. This is either done over laparotomy or by the transthoracic route. Recently, both laparoscopy and thoracoscopy, respectively, using minimally invasive techniques have been applied successfully in this indication [2].
Though the postoperative relief from dysphagia is usually immediate, the resulting decrease in sphincter pressure implies the risk of gastroesophageal reflux and associated symptoms. This is, why fundoplication in combination with esophago-cardio-myotomy has been advocated as the option of choice. Since the propulsive function of the esophagus, however, is impaired in most patients with achalasia, fundoplication carries the risk of creating yet another mechanical obstacle. This is why fundoplication has not been adopted by all surgeons [3].
We did a long term evaluation of patients who underwent transthoracic esophago-cardio-myotomy without fundoplication. The primary objectives were the objective evaluation of the therapeutic effect of achalasia, and the postoperative incidence and clinical relevance of gastroesophageal reflux. The secondary objectives were the assessment of patient health related quality of life, and satisfactory of surgical treatment.
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2. Materials and methods |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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All patients were followed up for at least 3 years, the follow-up assessment was complete for all patients.
After signed informed consent, the follow-up procedure was started with a structured clinical questionnaire to evaluate symptoms of persistent achalasia and to record the presence or severity of gastroesophagel reflux and associated morbidity i.e. heartburn, odynophagia, and regurgitation of gastric fluid (Table 1). The objective assessment was based on esophagogastroscopy with biopsies of the distal esophageal mucosa for morphological and histological evaluation, 24h pH-measurement [4,5], esophago-manometry, and esophagogram.
Patient satisfaction after surgery was determined by a 5-point Likert scale (none, little, medium, much and total). Quality of life assessment was done using the EORTC-QLC-C30 (version 3.0, 2001) [6]. The EORTC quality of life questionnaire (QLQ) is an integrated system for assessing the health-related quality of life (QoL) of patients. The QLQ-C30 version 3.0 is composed of both multi-item scales and single-item measures. These include five functional scales, nine symptom scales, a global health status/QoL scale and six single items. Each of the multi-item scales includes a different set of items—no item occurs in more than one scale. All of the scales and single-item measures range in score from 0 to 100. A high scale score represents a higher response level.
Quantitative variables are expressed as the mean and standard deviation (SD) and/ or maximum and minimum values. The Student t-test was used to compare quantitative variables. Statistical significance was considered for P less than 0.05.
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3. Results |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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Thirty-eight patients out of 40 reported no clinical symptoms of gastroesophageal reflux, two patients complained about heartburn.
Esophagogram with reflux-provocation showed signs of reflux in the two patients with clinical symptoms, in all other cases there were no findings of gastroesophageal reflux also in Trendelenburg position. In all patients a mild dilation of the thoracic esophagus could be demonstrated on esophagogram.
The clinical symptoms and the radiological findings corresponded to the endoscopic findings which showed no signs of esophagitis in those 37 patients who did not complain about reflux. The remaining 3 cases showed signs of gastroesophageal reflux disease stage I (2 cases) and one case of candida-esophagitis (1 case). The latter had no subjective symptoms either. The histological findings showed a mild chronic inflammation without any typical signs of reflux disease in 21 cases and a normal esophageal mucosa in 19 cases. The two patients with clinical signs of reflux were among those with mild chronic inflammation. Histologically, none of those patients who underwent preoperative endoscopic injections of botulinum toxin and/or balloon dilation showed any substantial fibrosis in the lower esophagus.
Despite the lack of endoscopic findings of typical morphological mucosal changes, and the lack of clinical symptoms, the 24-h pH-monitoring was positive in 18/40 patients with a mean De-Meester Score (normal range: <14.72) of 73.0±47.09 (range: 22.1–177.7). The presence of clinical symptoms of reflux had a highly significant correlation with a pathological De-Meester Score (P<0.01, Table 2).
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Dysphagia for solids and liquids, as well as regurgitation of undigested food was reported preoperatively in the majority of all cases. Postoperatively, only four patients complained about dysphagia, corresponding to grade I (solids) in three and grade III (liquids) in one case. A persistence of mild regurgitation was noticed by six patients. The patient with persisting dysphagia grade III in whom also the prestenotic dilation worsened proceeded to esophageal resection and reconstruction by gastric pull-up [7].
Patients scored their satisfaction with surgical treatment as total in 12 cases, much in 24, medium in three and none in one case. Both patients with clinical symptoms of gastroesophageal reflux scored there satisfaction as much. Dysphagia, on the other hand, was much more related to poor satisfaction. All four patients who scored medium or no satisfaction suffered from postoperative dysphagia. These patients had postoperative weight loss ranging from 0–7kg (mean: 0.45kg).
Quality of life assessment using the EORTC QLQ-C30 (Version 3.0; 2001) showed a mean score of 70.7±22.0. In 8/40 the QLQ-C30 Score was 100. Patients with a positive De-Meester Score showed 67.9±25.2 compared to those with a negative De-Meester Score who showed 71.2±20.2 (not significant, Table 2). The four patients complaining about dysphagia after surgery showed a QLQ-C30 Score of 25.0, 33.3, 41.7 and 50.0.
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4. Discussion |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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There is a controversy between surgeons and gastroenterologists whether extramucosal myotomy or balloon dilation should be the primary treatment in case of achalasia. However, several studies have shown that extramucosal myotomy is the best method to achieve relief from dysphagia at a low risk of complications [3]. Nevertheless, balloon dilation has been extensively used as primary option, because it entails a shorter hospital stay and less discomfort than an abdominal or thoracic incision. Yet, with pneumatic dilation disruption of esophageal muscle is uncontrolled, healing is unpredictable: Some authors found substantial fibrosis in the lower esophagus of patients who had previous balloon dilation [8]. This fibrosis might even impair the result of later surgery. Moreover, reflux is common if dysphagia has been completely relieved. Pneumatic dilation also carries a serious risk of perforation [9].
Controversy within the surgical society persists about the best approach for esophagocardio-myotomy and regarding the need for fundoplication [10–12]. Many authors advocate esophago-cardiomyotomy using the transabdominal way (laparoscopy or laparotomy). If this approach is chosen, the esophageal attachments to the diaphragm need to be dissected at least in part, which might be the reason for a high incidence of reflux symptoms following this intervention, if funcoplication is not done.
The disadvantages of a myotomy extending far on the stomach have been well documented both experimentally [13] and clinically [14]. When the incision was carried 2cm or more onto the stomach, the incidence of reflux after the operation was found to be 100% [14]. It was also observed, that the incidence of reflux was increasing the longer the patients were followed up.
In transabdomial esophago-cardio-myotomy the addition of a fundoplication has been reported to reduce the indicence of symptomatic gastroesophageal reflux to rates between 5 and 30% [15–17] but on the other hand, postoperative dysphagia was noticed in more than 50% [15]. Though dysphagia persisting postoperatively, may be due to an incomplete transection of the lower esophageal sphincter, it seems likely, that in these cases yet another obstacle for an already impaired esophageal peristalsis was created by fundoplication.
The mainstay of the surgical technique used in our series is that the hiatal attachments of the esophagus, i.e the Leimer's membrane, are not dissected, the incision at the stomach being limited to the level of the cross veins. Preoperative balloon dilation caused no problems concerning the performed surgical technique. In the present study the transthoracic approach without fundoplication was used with a success rate of 90% and an incidence of clinical symptoms of gastroesophageal reflux of 5%. Postoperative GERD stage one, represented by the clinical symptom of heartburn, occurred in two of 40 patients and could be successfully managed by proton pump inhibitors (Table 1).
It is fact, that by objective measurements reflux episodes exceeding the healthy norm were observed in 45% of all cases, but there was no correspondence whatever, neither in manometry, endoscopical or histopathological findings, nor in subjective symptoms.
On the other hand, in the two patients who complained about reflux, the diagnosis was clearly confirmed by manometry, endoscopical findings, pH-measurements and radiological reflux provocation.
The long- term results of these series support the use of the transthoracic approach without any type of fundoplication for the treatment of achalasia. If symptoms of achalasia persist after this procedure salvage by esophageal resection and reconstruction by gastric pull-up can be done conveniently [7].
In conclusion, the transthoracic esophagocardiomyotomy without additional fundoplication can provide excellent long term relief of dysphagia, good quality of life, less risk of postoperative GERD and carries a low risk of postoperative iatrogenous problems.
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References |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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  T. W. Rice, A. A. McKelvey, J. E. Richter, M. E. Baker, M. F. Vaezi, J. Feng, S. C. Murthy, D. P. Mason, and E. H. Blackstone A physiologic clinical study of achalasia: Should Dor fundoplication be added to Heller myotomy? J. Thorac. Cardiovasc. Surg., December 1, 2005; 130(6): 1593 - 1600. [Abstract] [Full Text] [PDF]
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