Return of esophageal peristalsis after Heller's myotomy for idiopathic achalasia

Laparoscopic calibrated total vs partial fundoplication following Heller myotomy for oesophageal achalasia

AIM: To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia.

METHODS: Fifty-six patients (26 men, 30 women; mean age 42.8 ± 14.7 years) presenting for minimally invasive surgery for oesophageal achalasia, were enrolled. All patients underwent laparoscopic Heller myotomy followed by a 180° anterior partial fundoplication in 30 cases (group 1) and calibrated Nissen-Rossetti fundoplication in 26 (group 2). Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication. A 6-mo follow-up period with symptomatic evaluation and barium swallow was undertaken. One and two years after surgery, the patients underwent symptom questionnaires, endoscopy, oesophageal manometry and 24 h oesophago-gastric pH monitoring.

RESULTS: At the 2-year follow-up, no significant difference in the median symptom score was observed between the 2 groups (P = 0.66; Mann-Whitney U-test). The median percentage time with oesophageal pH < 4 was significantly higher in the Dor group compared to the Nissen-Rossetti group (2; range 0.8-10 vs 0.35; range 0-2) (P < 0.0001; Mann-Whitney U-test).

CONCLUSION: Laparoscopic Dor and calibrated Nissen-Rossetti fundoplication achieved similar results in the resolution of dysphagia. Nissen-Rossetti fundoplication seems to be more effective in suppressing oesophageal acid exposure.

A pneumatic dilation strategy in achalasia: prospective outcome and effects on oesophageal motor function in the long term

BACKGROUND

Long-term follow-up studies of achalasia after pneumatic dilation, mostly retrospective, have shown variable results.

AIM

To examine the outcome of achalasia after pneumatic dilation using a prospective follow-up programme.

METHODS

One or two dilations (first dilation treatment) in 77 patients to achieve stable (>1 year) remission and patients followed up with yearly clinical and manometric assessments. Endoscopy, pH monitoring and barium swallow were also performed.

RESULTS

A total of 69 patients achieved stable remission and were followed up for 5.6 years (3-10.7) [median (IQ range)], whereas six patients underwent cardiomyotomy and two experienced a perforation. Twelve of the 69 patients relapsed after 2.6 years (1.7-5.1): nine of 12 underwent one to two further dilations. Six-year remission rate (by Kaplan-Meyer estimates) was 82% after first dilation treatment and 96% after all dilations. Continuous antisecretory treatment was clinically needed in 16%, oesophagitis present in 7% and reflux pathological in 28% of the patients. Beneficial effects of dilation on oesophageal motility and on diameter of the oesophageal body at barium swallow were maintained during follow-up.

CONCLUSIONS

A management strategy including sessions of pneumatic dilation until stable remission and a standardized follow-up is highly successful in the long term. Gastro-oesophageal reflux is clinically relevant in a minority of patients.

Return of esophageal function after treatment for achalasia as determined by impedance-manometry

BACKGROUND

Treatment for achalasia is aimed at the lower esophageal sphincter (LES), although little is known about the effect, if any, of these treatments on esophageal body function (peristalsis and clearance). We sought to measure the effect of various treatments using combined manometry (peristalsis) with Multichannel Intraluminal Impedance (MII) (esophageal clearance).

METHODS

We enrolled 56 patients with Achalasia referred to the University of Washington Swallowing Center between January 2003 and January 2006. Each was grouped according to prior treatment: 38 were untreated (untreated achalasia), 10 had undergone botox injection or balloon dilation (endoscopic treatment), and 16 a laparoscopic Heller myotomy. The preoperative studies for 8 of the myotomy patients were included in the untreated achalasia group. Each patient completed a dysphagia severity questionnaire (scale 0-10). Peristalsis was analyzed by manometry and esophageal clearance of liquid and viscous material by MII.

RESULTS

Mean dysphagia severity scores were significantly better in patients after Heller Myotomy than in either of the other groups (2.0 vs. 5.3 in the endoscopic group and 6.5 in untreated achalasia, p < 0.05). Peristaltic contractions were observed in 63% of patients in the Heller myotomy group, compared with 40% in the endoscopic group and 8% in untreated achalasia (p < 0.05 for both treatment groups vs. untreated achalasia). Liquid clearance rates were significantly better in both treatment groups: 28% in Heller myotomy and 16% in endoscopic treatment compared to only 5% in untreated achalasia (p < 0.05). Similarly, viscous clearance rates were 19% in Heller myotomy and 11% in endoscopic treatment, vs. 2% in untreated achalasia (p < 0.05). In the subset of patients who underwent manometry/MII both pre- and postoperatively, peristalsis was observed more frequently postoperatively than in preop studies (63% of patients exhibiting peristalsis vs. 12%), as was complete clearance of liquid (35% of swallows vs. 14%) and viscous boluses (22% of swallows vs. 14%). These differences were not significant, however. In the patients who had a myotomy the return of peristalsis correlates with effective esophageal clearance (liquid bolus: r = 0.46, p = 0.09 and viscous bolus: r = 0.63, p < 0.05). There is no correlation between peristalsis and bolus clearance in the endoscopic treatment group.

CONCLUSIONS

With treatment Achalasia patients exhibit some restoration in peristalsis as well as improved bolus clearance. After Heller Myotomy, the return of peristalsis correlates with esophageal clearance, which may partly explain its superior relief of dysphagia.

Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months

INTRODUCTION

Laparoscopic esophagomyotomy is the preferred approach to patients with achalasia of the esophagus, However, there are very few long-term follow-up studies (>10 years) in these patients.

OBJECTIVE

To perform a very late subjective and objective follow-up in a group of 67 patients submitted to esophagomyotomy plus a partial antireflux surgery (Dor's technique).

MATERIAL AND METHODS

In a prospective study that lasted 30 years, 67 patients submitted to surgery were divided into 3 groups: group I followed for 80 to 119 months (15 patients); group II, with follow-up of 120 to 239 months (35 patients); and group III, with follow-up more than 240 months (17 patients). They were submitted to clinical questionnaire, endoscopic evaluation, histologic analysis, radiologic studies, manometric determinations, and 24-hour pH studies late after surgery.

RESULTS

Three patients developed a squamous cell esophageal carcinoma 5, 7, and 15 years after surgery. At the late follow-up, Visick III and IV were seen in 7%, 23%, and 35%, according to the length of follow-up of each group. Endoscopic examination revealed a progressive nonsignificant deterioration of esophageal mucosa, histologic analysis distal to squamous-columnar junction showed a significant decrease of fundic mucosa in patients of group III, with increase of intestinal metaplasia, although not significant time. Lower esophageal sphincter showed a significant decrease of resting pressure 1 year after surgery, which remained similar at the late control. There was no return to peristaltic activity. Acid reflux measured by 24-hour pH studies revealed a progressive increase, and the follow-up was longer. Nine patients developed Barrett esophagus: 6 of them a short-segment and 3 a long-segment Barrett esophagus. Final clinical results in all 67 patients demonstrated excellent or good results in 73% of the cases, development of epidermoid carcinoma in 4.5%, and failures in 22.4% of the patients, mainly due to reflux esophagitis. Incomplete myotomy was seen in only 1 case.

CONCLUSION

In patients with achalasia submitted to esophagomyotomy and Dor's antireflux procedure, there is a progressive clinical deterioration of initially good results if a very long follow-up is performed (23 years after surgery), mainly due to an increase in pathologic acid reflux disease and the development of short- or long-segment Barrett esophagus.

The effect of esophageal myotomy and myectomy on the lower esophageal sphincter pressure profile: intraoperative computerized manometry study

The surgical treatment of achalasia, based on Heller's myotomy is the procedure of choice to reduce the sphincterial high pressure zone, either by laparotomy or, most recently, by laparoscopy. What is the right length of the myotomy? Many authors have reported 10-15% postoperative residual dysphagia, due to the incomplete gastric myotomy and not to esophageal pouring. The aim of this study is to experimentally determine the modifications induced by Heller's myotomy and myectomy of the esophago-gastric junction on lower esophageal sphincter (LES) pressure profile, using a computerized manometric system. Myotomy of the esophageal portion of the LES (i.e. without dissection of the gastric fibers) has not modified the parameters considered, while the dissection of gastric fibers for at least 2-3 cm on the anterior gastric wall has created a significant modification of the LES pressure profile. Our observations seem to confirm and more clearly demonstrate the important role played by gastric fibers in sustaining the sphincteric HPZ. Moreover, analysis of our data, showed the need to always perform a complete myotomy. This was objectively shown during the intervention by means of intraoperative manometry, in order to significantly reduce the possibility of a dysphagic relapse, caused by inadequate treatment.

Long-term effects of myotomy and partial fundoplication for esophageal achalasia

Controversy persists in the surgical approach to treat esophageal achalasia. This investigation reports the long-term effects of esophageal myotomy and partial fundoplication in treating this disorder. From 1984 to 1998, 32 patients with achalasia underwent myotomy and partial fundoplication (Belsey Mark IV) using a left thoracotomy. The median follow up is 7.2 years. Assessments include clinical evaluation, esophagogram, radionuclide transit, manometry, 24-h pH, and endoscopy. There is no complication and no mortality. Preoperative assessment was compared with that in 0-3, 3-7, and 7-16 postoperative years. Clinically, the prevalence of dysphagia was decreased from 100% to 6%, 12%, and 13%, respectively (P < 0.001). Heartburn remains unchanged (P > 0.25). On radiology, the prevalence of barium stasis was decreased from 97% to 44%, 48%, and 47%, respectively (P=0.001), whereas a pseudo-diverticulum was observed in two-thirds of patients after operation (P=0.001). Percent radionuclide stasis at 2 min was measured as 70%, 17%, 20%, and 20%, respectively (P=0.001). Manometrically, lower esophageal sphincter (LES) gradient was decreased from 29 to 10, 9, and 9 mmHg, respectively (P=0.001). LES relaxation was improved from 41% preoperatively to 100% postoperatively at each postoperative period (P < 0.001). An abnormal acid exposure was observed in four patients after the operation. Endoscopy documented mucosal damage in three patients (P > 0.25). In conclusion, on long-term follow up, myotomy and partial fundoplication for achalasia relieve obstructive symptoms and improve esophageal emptying, and reduce LES gradient and improve LES relaxation. Acid reflux is recorded in 13% of patients and esophageal mucosal damage is identified in 11% of the patient population. A longer myotomy not covered by the fundoplication results in pseudodiverticulum formation and increased esophageal retention.

Normal esophageal function after myotomy in a patient with idiopathic diffuse esophageal spasm

A 52-year-old man with idiopathic diffuse esophageal spasm and hypertensive lower esophageal sphincter presented with dysphagia for several years. After unsuccessful therapy with forceful pneumatic dilation of the cardia, a myotomy of the cardia and distal esophagus was performed. The patient became asymptomatic, lower esophageal sphincter pressure diminished to less than 10 mm Hg, and esophageal body motor activity was normalized. This situation remains unchanged 6 years after the operation.

Chest pain and reappearance of esophageal peristalsis in treated achalasia

BACKGROUND

We wanted to evaluate the clinical significance of the esophageal peristalsis that appears in some achalasia patients after treatment.

METHODS

We prospectively investigated the reappearance of esophageal peristalsis in 106 achalasic patients treated with forceful dilatation under endoscopic control (86 metallic dilatations and 20 pneumatic dilatations) and followed up clinically and manometrically for 1 year. Patients were divided in two groups in accordance with the presence (n = 26) or persistent absence (n = 80) of postdilatation esophageal peristalsis.

RESULTS

Before treatment, clinical data and manometric findings were comparable in both groups except for esophageal wave amplitude, which was higher in patients with postdilatation peristalsis (36 +/- 5 mmHg versus 24 +/- 2 mmHg, P < 0.05). One year after dilatation manometric findings were similar in the two groups, but esophageal wave amplitude remained higher in the group with postdilatation peristalsis (46 +/- 4 mmHg versus 21 +/- 2 mmHg, P < 0.05). The proportion of patients with persistent dysphagia was similar in the two groups (15% versus 12.5%). However, 10 patients with postdilatation peristalsis (38%) complained of chest pain as opposed to only 5 patients (6%) in the group with aperistalsis (P < 0.01).

CONCLUSION

The appearance of esophageal peristalsis after forceful dilatation in achalasic patients is frequently associated with persistent or new chest pain.

Onset of oesophageal peristalsis after surgery for idiopathic achalasia

Twenty-seven patients were treated with a Heller myotomy and Dor fundoplication; some peristaltic contractions occurred in seven after operation. When clinical, radiological and manometric data in the seven patients developing peristalsis were compared with findings in the other 20, there were no differences in symptoms, lower oesophageal sphincter pressures and lengths, relief of dysphagia or oesophageal calibre reduction. Oesophageal resting pressure was lower and oesophageal contraction amplitudes were statistically higher in patients with restored peristalsis, which correlated only with the amplitude of contractions 5 cm above the lower oesophageal sphincter (P < 0.05, 95 percent confidence interval). Peristaltic contractions probably exist before treatment, but are concealed by the dilated oesophagus and the common cavity phenomenon. Achalasia is not necessarily associated with complete aperistalsis. No difference was found in the outcome of surgical treatment, and the return to peristalsis appears to be clinically relevant.

Reversible achalasia-like motor pattern of esophageal body secondary to postoperative stricture of gastroesophageal junction

Two cases are presented of benign stenosis of the cardia secondary to fibrosis following antireflux surgery in which the patients developed a motor alteration in the esophageal body similar to that of achalasia of the cardia. There was a complete absence of contractions in one patient, which had developed over a long period of time, and a vigorous pattern in the other patient, which had evolved over a short period. In both cases, after surgical treatment of the stenosis, normal motility in the esophageal body returned.

Achalasia: current evaluation and therapy

The current evaluation of and therapy for achalasia are reviewed. Esophageal manometry remains the best means for diagnosing achalasia. Initial therapy can include either pneumatic dilation or esophagomyotomy. Symptomatic improvement occurs in 71% of patients after pneumatic dilation, with a risk of perforation of 1.4%. Eight percent of these patients require subsequent esophagomyotomy. Surgical procedures for achalasia can be performed through either an abdominal or a thoracic incision. Nearly all authors favoring an abdominal approach add an antireflux operation to esophagomyotomy, whereas many authors advocating a transthoracic esophagomyotomy believe that an antireflux wrap is unnecessary. Overall results for the various surgical approaches used as initial therapy are excellent, with symptomatic improvement in 89% of patients, a mortality rate of less than 1%, and development of gastroesophageal acid reflux in less than 10%. Factors governing the choice of initial therapy are discussed.

Achalasia, diffuse spasm and non-specific motor disorders

Achalasia is the best understood of the motor disorders described in this chapter. The pathogenesis involves loss of intramural neurones, a process that subsequently results in poor lower sphincter relaxation and atony of the oesophageal body. Treatment is appropriately focused on mechanical or pharmacological alleviation of LOS obstruction. In contrast, the pathophysiology of DOS and the non-specific disorders remains poorly understood. Some of the non-specific disorders, such as the vigorous contraction wave abnormalities (including 'nutcracker oesophagus'), appear closely related to DOS. Treatment for patients with these findings has been based on assumptions about mechanisms of symptom production. The non-specific disorders are common in referred patients with oesophageal symptoms, and the importance of these findings deserves further study. We use a method for categorization of these manometric abnormalities which aids understanding of this difficult area and recommend its more widespread use.

Motility changes in primary achalasia following pneumatic dilatation

The changes in esophageal motility after pneumatic dilatation were evaluated prospectively in 51 patients with achalasia. The patients were evaluated for a median of 14 months. Pneumatic dilatation led to a clinical improvement in 41 patients. On manometric evaluation, a significant decrease in lower esophageal sphincter pressure was observed (28.4 +/- 14.9 mmHg vs. 13.5 +/- 7.2 mmHg; p = 0.001); the resting pressure of the esophageal body dropped from 4.8 +/- 4.2 mmHg above gastric baseline to 0.1 +/- 3.9 mmHg below gastric baseline. After therapy, peristaltic activity was present in 10/51 (20%) patients; in 1 case, complete relaxation of the lower esophageal sphincter was recorded. Treatment-induced motility changes could not be predicted by clinical history or the lower esophageal sphincter pressure before or after therapy. However, the resting pressure of the esophageal body before and after therapy was significantly lower in these patients in whom peristalsis recurred after therapy than in patients with an unchanged motility pattern. The reappearance of peristaltic activity after pneumatic dilatation was unrelated to lower esophageal sphincter pressure. In conclusion, motility disturbances of the esophageal body in patients with achalasia do not simply reflect the functional obstruction of the lower esophageal sphincter. These findings support the hypothesis that achalasia is not a distinct motility disturbance but should be regarded as part of a broad spectrum of different interrelated esophageal motility disorders.

Late results following esophagomyotomy in children with achalasia

Twenty one children with achalasia of the esophagus were treated from 1970 to 1986. There were 11 girls and ten boys (average age, 10.9 years; range, 6 months to 16 years). Diagnosis was established by barium swallow in 21 cases and confirmed by manometrics and motility studies in 14. Four children had unsuccessful dilatation (range, 1 to 16 dilatations/pt). All 21 children underwent modified anterior Heller esophagomyotomy (transabdominal in 15 and transthoracic in six). Concomitant Nissen fundoplication was performed in three. Follow-up from 1 to 14 years (mean, 6.3 years) showed complete relief of obstruction in 18 patients (86%), while three required additional procedures for persistent dysphagia. One child improved after a single dilatation, but two others eventually required a second esophagomyotomy. Three additional patients subsequently developed gastroesophageal reflux (GER), and two were managed with Nissen fundoplication; the third responded to medical management. The mortality for this series was zero. Postoperative complications occurred in nine children (42%) and was due to atelectasis and postoperative fever. Modified Heller esophagomyotomy is safe and effective in children with achalasia (mortality, 0%; relief of obstruction, 86%). Results were similar after a transabdominal or transthoracic approach. Esophageal dilatation was not an effective method of treatment. Although postsurgical barium swallow showed relief of obstruction, abnormal esophageal motility persisted, suggesting that long-term follow-up is important.

Esophageal achalasia syndromes

Esophageal achalasia, characterized by failure of the lower esophageal sphincter to relax normally with swallowing and esophageal aperistalsis, may be primary or secondary to another disorder (in the United States most often cancer). Primary achalasia is of unclear etiology but almost certainly is a disorder of the innervation of the smooth muscle portion of the esophagus. This article reviews the classification and clinical features of achalasia syndromes, as well as current concepts of pathogenesis, diagnosis, complications, and therapy of this group of disorders.