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Eur J Cardiothorac Surg 2008;34:423-426. doi:10.1016/j.ejcts.2008.04.003
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Long-term clinical results of thoracoscopic Heller's myotomy in the treatment of achalasia

Dharmendra Agrawala,*, Lynne Meekisonb, William S. Walkera

a Department of Cardio thoracic Surgery, New Royal Infirmary, Dalkeith Road, Edinburgh EH16 4SA, UK
b Department of Gastro enterology, New Royal Infirmary, Dalkeith Road, Edinburgh EH16 4SA, UK

Received 27 October 2007; received in revised form 29 March 2008; accepted 2 April 2008.

* Corresponding author. Tel.: +44 131 6674515; fax: +44 131 2423929. (Email: adharmendra{at}hotmail.com).


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Summary
 Appendix A
 References
 
Objective: The aim of this study is to review the immediate and long-term results of video-imaged thoracoscopic Heller's myotomy (THM). Methods: All patients undergoing THM by a single surgeon at one institution were analysed. Follow-up was conducted using a structured questionnaire and oesophageal manometry and/or 24 h pH monitoring were undertaken when clinically indicated. Results: Fifty-six consecutive patients (32 males, 24 females, mean age 45 ± 18.7 years) suffering from grade 4 dysphagia underwent THM between January 1992 and March 2006. Preoperative mean lower oesophageal sphincter (LOS) pressure was 38.4 ± 10.6 mmHg. Eighteen patients (32.1%) had undergone previous pneumatic dilatations. There were no hospital deaths. Oesophageal perforation occurred in two patients; one repaired thoracoscopically and one at thoracotomy. Mean hospital stay was 4 ± 1.37 days. At mean follow-up of 5.9 ± 4.66 years, freedom from any reintervention was 87% (49/56). Twenty-nine patients (52%) were asymptomatic. In patients with residual or recurrent symptoms (n = 27), their severity was significantly reduced from the preoperative period (dysphagia score 1.37 ± 0.77 vs 4.00 ± 0; p < 0.001). Seven patients (12.5%) with troublesome residual or recurrent grade 3–4 dysphagia underwent repeat oesophageal manometric study, showing a mean reduction in LOS pressure from their baseline values of 46.8 ± 6.1–30.0 ± 5.4 mmHg (p < 0.001). Of these patients, three patients with grade 4 dysphagia were reoperated: one open Heller's myotomy and two by cardia resection. Eleven patients complained of troublesome postoperative heartburn; distal oesophageal acid exposure was shown to be abnormal in nine patients (16.9%) and all were successfully managed with medical therapy. Conclusion: The results of thoracoscopic treatment for achalasia are at least equivalent to historical outcomes obtained with open surgery but the patient is spared major thoracotomy or the acid reflux associated with a laparoscopic approach.

Key Words: Achalasia • Minimally invasive • Thoracoscopic • Heller's myotomy


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Summary
 Appendix A
 References
 
Achalasia is an oesophageal motility disorder characterised by failure of lower oesophageal sphincter (LES) to relax with swallowing and the absence of oesophageal peristalsis. No therapy is successful in reversing or curing the underlying pathology. Both operative and nonoperative treatment is aimed at decreasing the LES pressure to facilitate oesophageal emptying. The surgical therapy is myotomy. This was first described by Heller in 1913 [1] and included both anterior and posterior myotomy by abdominal approach. This was modified in 1923 by Zaaijer [2] to a single anterior myotomy. Subsequently in 1958 Ellis et al. [3] popularised a transthoracic approach via left thoracotomy.

Recently, minimally invasive approaches to treat achalasia have been introduced. The video-assisted thoracoscopic approach was first reported by Pelligrini and associates [4] in 1992. It is a safe and efficacious method [5–7] however, to date, there is a paucity of long-term results after thoracoscopic Heller's myotomy (THM).

The aim of this study is to review the immediate and long-term results of video-imaged thoracoscopic Heller's myotomy. In 2002, we published our results in the same journal and this paper is an extension of our previous study [9].


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Summary
 Appendix A
 References
 
A retrospective analysis was performed; patients who underwent minimally invasive thoracoscopic oesophageal myotomy by a single surgeon at Royal Infirmary of Edinburgh, UK between January 1992 and March 2006.

Our operative technique has been described previously [9]. Data about the patients who underwent thoracoscopic myotomy between 1992 and 2006 were collected from unit records. Follow-up was conducted using a structured questionnaire and symptoms of dysphagia, regurgitation and heartburn were graded as described in Table 1 . Patients who reported recurrent or residual symptoms of sufficient severity to warrant further investigations underwent oesophageal manometry; 24 h pH study and/or barium swallow as indicated by the presence of dysphagia, heartburn and/or regurgitation. All patients (98%, 55/56) returned their questionnaires except one who died 3 years after surgery from unrelated cause.


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  		Table 1 Symptom classification for heartburn and dysphagia
 
Demographic pre-, intra- and postoperative data were entered into an electronic spreadsheet and analysed using commercially available statistical software (StatView Version 5, SAS Institute Inc.). The statistical analyses presented use standard descriptive statistics and conventional tests of significance for comparisons, principally Student's t-test for paired and Mann–Whitney test for unpaired comparisons. Statistical significance was set at the 5% level. Unless otherwise stated, data are presented as mean ± standard deviation. Cumulative probability values of freedom from symptoms were estimated by Kaplan–Meier method, reported as mean ± SEM. Nonparametric Wilcox signed rank test were used to compare preoperative and postoperative dysphagia score [9] (Fig. 1 ).


Figure 1
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  		Fig. 1. Preoperative vs postoperative dysphagia score (see Table 1 for definitions); mean values 4.00 ± 0 vs 1.37 ± 0.77, p < 0.001.

 

   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Summary
 Appendix A
 References
 
From 1992 to 2006, 56 consecutive patients (32 males, 24 females), mean age 45.0 ± 18.7 years, (range 17–74 years) with a manometric diagnosis of achalasia underwent a thoracoscopic Heller's myotomy. All 56 patients were suffering from grade 4 dysphagia. Eighteen patients (32.1%) had undergone a mean of 2.3 ± 1 previous pneumatic dilatations, whereas no patients received botulinum toxin injection. Preoperative mean lower oesophageal sphincter (LOS) pressure was 38.4 ± 10.6 mmHg. There were no hospital deaths. Oesophageal perforation occurred in two patients; one perforation was repaired thoracoscopically and the other required open thoracotomy. One female patient suffered from persistent vomiting and developed a hiatus hernia, which prompted surgical re-exploration. Via a left thoracotomy, the herniated stomach was reduced into the abdominal cavity and the oesophageal hiatus repaired with interrupted sutures. Her further recovery was uncomplicated. The mean duration of surgery was 97 ± 8 min for the whole cohort (105 ± 12 for the first 25 patients and 82 ± 8 for the last 31 patients, p < 0.0001). The intercostal drain was removed on the first postoperative day. Length of total hospital stay from admission to discharge was 4.3 ± 1.8 days in previous 25 patients and 4 ± 1.37 days in the last 31 patients (p = 0.36). The median postoperative hospital stay was 3.15 days. The minimum narcotic analgesics were required on first postoperative day and none on the following days. One patient died 3 years after surgery from an unrelated cause.

At mean follow-up of 5.9 ± 4.66 years (range 2–14.6 years), freedom from any reintervention was 87% (49/56). Twenty-nine patients (52%) were asymptomatic. In patients with residual or recurrent symptoms (n = 27), their severity was significantly reduced from the preoperative period (dysphagia score 1.37 ± 0.77 vs 4.00 ± 0; p < 0.001). Seven patients (12.5%) with troublesome residual or recurrent grade 3–4 dysphagia but no chest pain or regurgitation (four patients with grade 3 and three patient with grade 4) underwent repeat oesophageal manometric study, showing a mean reduction in LOS pressure from their baseline values of 46.8 ± 6.1–30 ± 5.4 mmHg (p < 0.001). Of these patients, three with grade 4 dysphagia were reoperated: one required open Heller's myotomy and other two required cardia resection. Eleven patients complained of postoperative heartburn; distal oesophageal acid exposure was shown to be abnormal in nine patients (16.9%) and all were successfully managed with medical therapy.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Summary
 Appendix A
 References
 
Oesophageal achalasia remains a disorder of unknown aetiology and with no definitive cure. The major pathophysiological changes of achalasia are incomplete relaxation of lower oesophageal sphincter and impaired peristalsis of oesophageal muscle with swallowing. Neuroanatomic data suggests that the ganglion cells are degenerate in the oesophageal myenteric plexus. The treatment of achalasia remains controversial. Several therapeutic options have been described for the treatment [11]. Surgical myotomy has shown better results than nonsurgical techniques [12,13]. More recently there has been a trend towards using minimally invasive techniques and this has resulted in earlier referral for surgical interventions as opposed to continued endoscopic therapy with dilatation or Botox injection. Although the relative advantages and disadvantages of both laparoscopic and thoracoscopic approaches have been described [14,15] there is little data concerning the long-term results of Heller's myotomy via either of these approaches.

This study of thoracoscopic Heller's myotomy is one of the largest reported series from a single institute. It shows that both the LES resting pressure and clinical symptom score were significantly decreased after thoracoscopic Heller's myotomy, and 87.5% of patients had a good or excellent relief of dysphagia. This figure was consistent with other reports [16,17]. This study confirms the excellent safety and efficacy profile of thoracoscopic surgical myotomy and demonstrates that THM confers long-term relief [mean follow up 5.9 ± 4.66 years] from symptoms of achalasia without the morbidity associated with the open approach.

The aim of this study was to review the immediate and long-term results of THM rather than comparison of different surgical techniques and approaches. Heller's myotomy is very effective in treating achalasia, but significant dysphagia or chest pain has been reported to persist or recur in 10–40% of patients treated by THM. However, a review of these series [5–8,18] indicates a very short mean follow-up time (0.8 years [range 0.1–4 years]). In this study with a much longer follow-up period of 5.9 years (range 2–14.6 years), persistent or recurrent dysphagia (grade 3–4) was present in seven patients (12.5%). This compares favourably to the typical figure of 16% reported in the literature. We believe that this is due to the excellent exposure achieved by retracting the oesophagus superiorly and cephalad so that extension of the myotomy on to the cardia (an essential part of the Heller's procedure) can be carefully performed under magnified vision thereby reducing the risk of incomplete myotomy [19].

Seven patients in our series developed recurrent symptoms. One who required repeat Heller's myotomy had undergone three pneumatic dilatations and had a sigmoid appearance of the oesophagus prior to the first procedure. This patient continues to enjoy symptomatic relief two years from last surgery. Two patients had residual or recurrent obstruction at the level of the gastric portion of the cardia on oesophageal manometry and required cardia resection. In the remaining four patients repeat oesophageal manometric study showed a mean reduction in LOS pressure from their baseline values of 46.8 ± 6.1–30 ± 5.4 mmHg. No further intervention has been required in this group.

Postoperative heartburn after THM is reported at 18–60% in the literature [5–8]. In our patients, we observed an incidence of heartburn in nine patients (16.9%) and all improved on recommencing or increasing anti-acid and pro-kinetic medical treatment, thereby not requiring an anti-reflux procedure.

A laparoscopic approach provides the opportunity to add an anti-reflux procedure. However, it is important to recognise that published series of laparoscopic Heller's myotomy report an incidence of gastro-oesophageal reflux of 17–27.3% despite the addition of a wrap. Without an anti-reflux procedure this figure rises to 65% [18,20].

We believe that the excellent exposure and visualisation obtained at THM, enables the surgeon to perform the myotomy with precision and within a narrow operative zone thereby reducing disruption of the phreno-oesophageal ligament. This may account for the reported low incidence of gastro-oesophageal reflux in this series and in previous reports [6,21]. The addition of an anti-reflux procedure, with its attendant morbidity, is not therefore necessary with THM provided that the myotomy is not extended more than 1 cm onto cardia of stomach [22]. Conversely, a transabdominal approach requires dissection of the crurae and disruption of the phreno-oesophageal ligament, which may account for postoperative reflux [19]. Also, it may be argued that the addition of a wrap in a condition characterised by impaired peristalsis is potentially prejudicial to a good long-term functional result.

Our postoperative hospital stay to median of 4 days is comparable with mean hospital stays of 2.65–4 days reported following after laparoscopic myotomy [23,24].

In this series approximately half of the patients had undergone prior pneumatic dilatation which is known to make dissection of oesophageal layers difficult and to increase the risk of perforation or incomplete myotomy [8,25]. We experienced two patients with intraoperative oesophageal perforation. Both of these had previous pneumatic dilatations. One perforation was repaired thoracoscopically and the other required open thoracotomy.


   5. Summary
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Summary
Appendix A
 References
 
Thoracoscopic Heller's myotomy for achalasia is safe and effective as either first line treatment or after pneumatic dilatation. The results are at least equivalent to outcomes obtained with open surgery. Thus, the patient is spared a major thoracotomy. Also, the results of THM equal those obtained using a laparoscopic approach while the need for an anti-reflux procedure is avoided.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Summary
 Appendix A
References
 
Conference discussion

Dr M. Orringer (Ann Arbor, Michigan, USA): Going back to the days when Ronald Belsey and Henry Ellis would argue at our national meetings about whether you did a myotomy with or without an anti-reflux operation, if there were ever a need for outcomes research and a randomised study, that hasn’t changed a bit! I enjoyed this paper, but I’m afraid it doesn’t help answer this question. From what I heard you say, about 12% of the patients who had grade 3 or 4 dysphagia were studied postoperatively with manometry and acid reflux testing.

When I was trying to decide in my own mind about the need to add a Belsey anti-reflux operation after a transthoracic esophagomyotomy for achalasia, many years ago, I took 10 consecutive patients and did a myotomy as carefully as I could using Ellis’ dictum of not carrying the myotomy too far down onto the stomach. Within 7 days of the operation, we did standard acid reflux testing with an intra-oesophageal pH electrode, and 85% of these patients had wide open, gross gastro-oesophageal reflux even in the absence of reflux symptoms. And we returned them to the operating room immediately and did Belsey Mark IV procedures. I’ve been convinced since that an anti-reflux procedure is an integral part of the operation for achalasia. Now I believe that a laparoscopic myotomy and the ease with which an abdominal partial fundoplication, a Dor fundoplasty is added, has made this the procedure of choice.

I don’t think that the upward extent the myotomy makes a thoracic approach any better. I would like you to explain how you can carry the cardiomyotomy incision onto the stomach for a centimetre and a half, thereby by definition disrupting the lower sphincter, and say that the lower sphincter is not disrupted! It is. And you haven’t proven your case with this report, have you? Have you got postoperative pH studies on the majority of these patients?

Dr Agrawal: Yes. We have done pH studies and there was symptom reduction from grade 3 to grade 1,which were improved with just proton pump inhibitors.

Mr P.B. Rajesh (Birmingham, UK): Bill, can you respond to that question?

Dr Walker: A couple of points. I guess the series of patients you described, Dr Orringer, would have been through open thoracotomies, so I would submit that that's perhaps not the same procedure as what we do here, simply because of the very minimal amount of manipulation around the area of the cardia.

Second, going for 1 cm onto the gastric surface I don’t think really does go through the whole cardiomechanism at all. And if you look back with your endoscope from the gastric view at the end of the procedure and look for the transillumination effect, it's remarkable how well preserved from the internal aspect the sling seems to be.

We don’t have detailed reflux data on every patient, you’re quite right in observing that. We have a bit of an ethical problem in putting patients through that unless they have a symptomatic problem. But of this series, from a clinical perspective, 16% I think had some degree of reflux. And I would submit that to put 84% of other patients through a further surgery when that's not going to be needful for them seems to me unnecessary. That's the philosophical approach we’ve come from.

I completely concur with your view on the need for randomised studies.

Dr D. Wood (Seattle, Washington, USA): I have two questions for you. One relates to the length of hospitalisation with your minimally invasive approach. When we look at these patients in Seattle, they’re usually overnight stays, which has been the big advantage of going to a minimally invasive approach, and I don’t see a significant difference in your hospital length of stay between what I think you were showing with 4.3 days prior to the thoracoscopic approach to 4 days with a thoracoscopic approach. So is there some methodological reason in how you’re managing these patients that have them in the hospital for 4 days rather than out sooner?

And my second question relates to your decision to maintain the thoracoscopic approach while, I believe, the vast majority of the rest of centres now doing myotomies are doing them transabdominally, that is, they have gone from doing a thoracoscopic myotomy back to doing a transabdominal laparoscopic myotomy. So what do you feel that the advantages are of maintaining that the thoracic approach? It seems at odds with most other experiences.

Dr Walker: The time in hospital I think is a cultural issue. Four days would be better than what we would achieve normally with an open thoracotomy and that would have been the alternative to compare with. So it's a reasonable length of time in terms of our expected occupancies. I accept it doesn’t translate across to North American practice.

We offer the thoracoscopic approach and the upper GI surgeons offer a laparoscopic approach, and the patients are coming our way from the upper GI physicians who I presume aren’t satisfied with the outcome. So at least in our centre it seems to give a good result.

Dr A. Lerut (Leuven, Belgium): Nevertheless I think that it's still a difficult issue and we haven’t reached the perfection that we all want to reach when 16% of patients require treatment for reflux and another 12% suffer from troublesome dysphasia, in your abstract it says even 17%. Basically it altogether totals up to about one in three of the patients without a completely satisfactory result.


   Footnotes
 
{star} Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Summary
 Appendix A
 References
 

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