Asian Cardiovasc Thorac Ann 2008;16:459-462
© 2008 Asia Publishing EXchange Ltd
Minimally Invasive Thoracoscope-Assisted Heller Myotomy for Achalasia
Nan Ma, MD,
Hong Zhong, MD,
Chuanzhong Ye, MD1,
Genfa Shan, MD,
Fuxian Zhang, MD,
Ju Mei, MD
Department of Cardiothoracic Surgery
1 Department of Urology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
For reprint information contact: Hong Zhong, MD, Tel: 86 21 6579 0000 Ext 7755, Fax 86 21 6515 3984, Email: zhonghongyyy{at}163.com, Department of Cardiothoracic Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, No. 1665 Kong Jiang Road, Shanghai 200092, P.R. China.
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ABSTRACT
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Forty-five patients (20 men and 25 women) with a median age of 46.5 years, who were diagnosed with esophageal achalasia by clinical history, esophagoscopy, and barium esophagogram, underwent thoracoscope-assisted Heller myotomy with a minimal incision. Esophageal pressure and pH were monitored. Two patients were excluded because of mucosal perforation during the operation, requiring conversion to an open procedure. There was no postoperative esophageal leakage or hospital death. All patients resumed a normal diet as soon as gastrointestinal function recovered, and their symptoms disappeared completely. The mean operative time was 1.2 hours (range, 0.5–3.8 hours). After 2.1 years of follow-up, the outcome was rated excellent in 33 (77%) patients, good in 7 (16%), and fair in 3 (7%). Esophageal dilation was required in 3 patients because of relapsing dysphagia within 3 months after the operation. Four (9%) patients had some regurgitation but no further surgical or medical treatment was needed. Esophageal pressure and pH correlated with the clinical manifestations. Our modified Heller myotomy with the assistance of thoracoscopy is effective for achalasia.
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INTRODUCTION
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Clinical evidence has suggested that thoracoscope- or laparoscope-assisted esophagomyotomy achieves better short- and long-term outcomes than pneumatic dilatation and botulinum toxin injection.1 With the advent of minimally invasive surgery, esophagomyotomy can now be safely performed with thoracoscopy or laparoscopy. We report our experience of achalasia treatment using a thoracoscope with a small incision.
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PATIENTS AND METHODS
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The investigation was approved by the ethics committee of Xinhua Hospital, and individual informed consent was obtained from the patients. From January 1999 to June 2005, 45 patients with esophageal achalasia underwent the modified Heller myotomy through a minimal incision with the assistance of thoracoscopy at Xinhua Hospital. There were 20 men and 25 women, aged 16 to 68 years (mean, 46.5 years). No patient had previously undergone surgery for achalasia. The mean duration of symptoms was 4.9 years (range, 1 week to 20 years). All patients had some degree of dysphagia; the severity was assessed using a dysphagia grading scale:1 grade I, able to eat normally (0 patients); grade II, requires liquids with meals (3 patients); grade III, able to take only semisolid food (19 patients); grade IV, able to take only liquids (17 patients); grade V, able to swallow saliva but not liquids (4 patients); and grade VI, complete dysphagia (2 patients). Symptoms included severe regurgitation (> 3 times per week) in 27 (60%) patients, heartburn in 21 (47%), and chest pain in 18 (40%); 5 (11%) reported weight loss. The diagnosis of achalasia was made on the basis of clinical history, esophagoscopy, esophageal pressure measurement, and barium esophagogram. Esophagrams showed typical achalasia with narrowing of the distal esophagus ("bird-beak" deformity) and esophageal dilatation. The diameter of the esophagus was measured in all patients: 10 (22%) had grade 1 dilatation (< 4 cm in diameter), 27 (60%) had grade 2 (4–6 cm in diameter), and 8 (18%) had grade 3 (> 6 cm in diameter). The mean preoperative resting pressure of the lower esophageal sphincter was 4.65 ± 0.87 kPa. Preoperative esophagoscopy was performed to exclude malignant stricture, gastroduodenal disease, or esophagitis.
General anesthesia was induced with the patient in the supine position. Contralateral single-lung ventilation was accomplished with double-lumen endotracheal intubation, to allow ipsilateral lung collapse and optimal visualization of the esophagus. The patient was placed in the right lateral position. An esophagoscope was inserted into the distal esophagogastric junction to identify the esophagus and retract it from the mediastinum to visualize the surgical field intraoperatively. A trocar was placed through the left chest wall at the 5th interspace on the midaxillary line. A 0° thoracoscope was inserted after collapsing the lung, and the lower esophagus was exposed. Under thoracoscopic guidance, a 5–6-cm incision was made in the 7th interspace on the midaxillary line for the modified Heller myotomy. The left inferior pulmonary ligament was divided beneath the left pulmonary vein. The visceral pleura was divided down to the level of the crus, with hook cautery. A longitudinal esophageal incision was made from the upper level of the left inferior pulmonary ligament down to 1 cm distal to the esophagogastric junction, using curved scissors under esophagoscope guidance. The muscle was swept off the mucosa for 120°–180°. No reflux procedure was performed. Water was perfused into the esophagus through the esophagoscope to confirm the integrity of the mucosa and the adequacy of the myotomy. If the mucosa was perforated, a routine thoracotomy was performed to close the perforation with absorbable sutures. The esophagoscope was removed, and a gastric tube was inserted into the stomach. A chest tube was left. Finally, the lung was inflated, and the operation was completed. After respiration recovered, the patient was extubated and sent to the intensive care unit for observation. When gastrointestinal function recovered, the gastric tube was removed, and the patient began normal oral intake.
All 45 patients were followed up at 1 and 6 months and then annually. The effects of the modified Heller myotomy were graded by questionnaire using the self-completed modified scoring system of Abid and colleagues,2 based on regurgitation, dysphagia, heartburn, chest pain, and weight loss. In patients rated excellent, symptoms disappeared, weight was gained, and they resumed work. In patients rated good, the symptoms almost disappeared, weight was gained, and they were able to work but had occasional dysphagia when swallowing cooked rice quickly. In patients rated fair, the symptoms did not disappear or worsened, weight remained unchanged, and they could not work normally. All patients underwent a postoperative esophagogram that was compared with the baseline findings.
Six months after the operation, esophageal pressure and pH were monitored for 24 hours in all 45 patients. All acid-suppressing medications were stopped more than 1 month before this test. Any medication that might affect esophageal kinetics was avoided for 3 days before the measurements. The examination began after fasting for 4 hours. A PC Polygraf HR pressure meter (Synectics Medical A/B, Stockholm, Sweden) was calibrated and zeroed in vitro. With the patient seated, the probe was inserted into the gastric lumen via the nasal cavity. Using the fixed point drag technique, lower esophageal sphincter resting pressure (high-pressure area for standard) was detected. A Digitrapper MK III pH meter (Synectics) was used to monitor pH for 24 hours. The microelectrode probe was set 5 cm above the inferior esophageal sphincter high-pressure level. The stomach-esophagus regurgitation data were analyzed by a recorder.
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RESULTS
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Except for the 2 patients who were converted to a traditional thoracotomy intraoperatively, the minimal incision thoracoscope-assisted modified Heller myotomy was completed successfully in a mean time of 1.2 hours (range 0.5–3.8 hours). The drainage tube was kept in situ for 24–72 hours. The mean drainage volume was 150 mL (range, 40–600 mL). The mean hospital stay was 5 days (range, 3–11 days). There was no postoperative esophageal leakage or mortality in any of the 45 patients. In all except the 2 patients who suffered esophageal perforation, symptoms disappeared and a normal diet was resumed when gastrointestinal function recovered. The mean follow-up period was 2.1 years (range, 3 months to 5 years). According to the dysphagia grading system, 30 patients reached grade I, 10 were grade II, and 3 (7%) had recurrent dysphagia of grade III or IV and pneumatic balloon dilation was therefore required. Dysphagia scores before and after the operation are shown in Table 1
. Four patients had some regurgitation at 3 months after the minimal-incision thoracoscopic surgery, but no reoperation or medication was needed. At the end of the follow-up period, the outcome was rated excellent in 33 (77%) patients, good in 7 (16%), and fair in 3 (7%). On pH monitoring, stomach-esophagus regurgitation was observed in 4 patients with > 7% regurgitation time (pH < 4) and lower esophageal sphincter resting pressure < 0.667 kPa. Regurgitation time of 4%–7% was observed in 5 patients. In 34 patients, the regurgitation time was 
4% with lower esophageal sphincter resting pressure of 1.33–2.66 kPa. The mean lower esophageal sphincter resting pressure decreased to 2.1 ± 0.64 kPa (p < 0.05).
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DISCUSSION
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Primary options for the treatment of esophageal achalasia include pneumatic dilatation and botulinum toxin injection, but the effects of these treatments are unsatisfactory, and most patients eventually require surgical management.3 The modified Heller myotomy is the operation of choice for achalasia.4 It has been suggested that myotomy offers a better long-term outcome than pneumatic dilatation for achalasia.5 Ramacciato and colleagues6 suggested that esophagomyotomy, together with a form of anti-reflux procedure, resulted in functional improvement.
In recent years, thoracoscopy or laparoscopy has been used frequently in modified Heller myotomy for achalasia. The technique has proved to be safe and effective for palliation of symptoms. However, whether a thoracoscopic or laparoscopic approach is the best choice for a modified Heller myotomy is still controversial. Stewart and colleagues7 compared the efficacy and safety of both procedures. Their results showed that laparoscopic modified Heller myotomies were associated with shorter operating time, less chance of conversion to an open procedure, and shorter postoperative hospitalization than the thoracoscopic procedure. Follow-up revealed no or very little dysphagia in 90% of patients after a laparoscopic modified Heller myotomy. In cases of thoracoscopic modified Heller myotomy, this effective rate decreased to 31%. However, Maher and colleagues8 reported better results with thoracoscopic modified Heller myotomy in 21 patients compared with the laparoscopic procedure; 16 (80%) patients had excellent relief and 2 (10%) had good relief. Our results showed 35 (78%) patients had excellent relief of symptoms and 7 (16%) had good relief. Therefore, we concluded that the thoracoscopic and laparoscopic modified Heller myotomy may have similar efficacy for achalasia. The major difference is that general surgeons tend to like the abdominal approach with laparoscopy, while thoracic surgeons tend to prefer an approach with thoracoscopy. When the surgery is performed with thoracoscopy, a 5–6-cm incision is made in the 7th interspace at the midaxillary line. This additional incision produces good exposure of the esophagus, and the myotomy can be performed from the upper level of the left inferior pulmonary ligament down to 1 cm distal to the esophagogastric junction, without difficulty; this decreases operation time markedly. On the other hand, esophagoscopy plays a guiding role in the operation, allowing easy identification of the esophagus and the ability to move it from the mediastinum into a more visible orientation to check the integrity of the mucosa and the adequacy of myotomy.
Whether an anti-reflux procedure following the myotomy is needed is still controversial.9,10 One report clearly demonstrated that a short transthoracic myotomy extending 1 cm distal to the esophagogastric junction could relief dysphagia without producing clinically significant reflux.1 We dissected the esophagus from the upper level of the left inferior pulmonary ligament down to 1 cm distal to the esophagogastric junction. The success of this approach is probably attributable to the clasp fibers of the lower esophageal sphincter being divided, eliminating esophageal obstruction without dividing the gastric sling fibers that contribute to the control of reflux.11
Monitoring 24-hour pH and pressure in the esophagus is an objective and effective method to evaluate esophageal function.12 No dysphagia developed when the inferior esophageal sphincter resting pressure was < 2.4 kPa. The reason for postoperative dysphagia following esophagomyotomy without a reflux procedure is incomplete myotomy. The reason for postoperative dysphagia with esophagomyotomy followed by a reflux procedure is that the anti-reflux procedure was performed inappropriately. When a reoperation is required, the pressure measurement technique can help to detect the cause of the previous failed surgery and aid in completing the operation. The fact that our monitoring results matched the patient’s clinical situation indicates the significance of the monitoring technique in assessing operative efficacy.
In our study, the esophageal mucosa was perforated in 2 patients. This happened at an early stage of the procedure when biopsy by esophagoscopy was employed to eliminate malignant disease. We recommend biopsy before the operation, by a surgeon well versed in the technique. All patients resumed a normal diet during hospitalization, and their symptoms disappeared. Only 3 patients required esophageal dilation for recurrent dysphagia. Our results imply the efficacy of the thoracoscope-assisted Heller myotomy with a small skin incision in treating achalasia.
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ACKNOWLEDGMENTS
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We thank Laura R Hendershot for technical assistance in the preparation of this article, and all of the study participants for their support.
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REFERENCES
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ABSTRACT
INTRODUCTION
