Laparoscopic Esophagomyotomy for Achalasia

ORIGINAL ARTICLE

Laparoscopic Esophagomyotomy for Achalasia Does Anterior Hemifundoplication Affect Clinical Outcome? Daniel T. Dempsey, MD,* Matthew Delano, MD,* Kevin Bradley, MD,* Jeffrey Kolff, MD,* Carol Fisher, BS,* Dina Caroline, MD,† John Gaughan, PhD,‡ John E Meilahn, MD,* and John M. Daly, MD*

Objective: To determine whether the addition of anterior hemifundoplication to laparoscopic esophagomyotomy for achalasia yields better clinical outcomes than laparoscopic esophagomyotomy alone. Summary Background Data: Although hemifundoplication may prevent gastroesophageal reflux after esophagomyotomy for achalasia, it may also lead to persistent dysphagia in these patients with esophageal aperistalsis. Methods: This is a retrospective study of 51 consecutive patients (mean age 47.5 ⫾ 12.6 years) who had laparoscopic esophagomyotomy for achalasia by our group between August 1995 and January 2001. In 29 patients (57%) an anterior hemifundoplication was added to the esophagomyotomy. In 22 patients (43%), no wrap was added. Patients scored (0 ⫽ none; 1 ⫽ mild; 2 ⫽ moderate; 3 ⫽ severe) symptom severity (dysphagia, regurgitation, heartburn, chest pain) preoperatively and postoperatively. Weight gain, use of gastrointestinal (GI) medication, tolerance to food, and patient satisfaction were also assessed. Results: Mean patient follow-up was 33 months, and there were no operative deaths. Four patients were converted to open operation (8%). The wrap and no wrap groups were similar in terms of esophageal dilation, preoperative symptom severity and duration (5.7 ⫾ 7.1 versus 6.1 ⫾ 7.0 years), and preoperative weight loss (18 ⫾ 15 versus 20 ⫾ 20 pounds). Both groups had similar improvement in symptom grade postoperatively and equivalent satisfaction rates (86%). Postoperative weight gain, GI medication use, and food intolerance was also similar. Postoperatively, patients in the wrap group did not have higher dysphagia scores or lower heartburn scores than the no wrap group. Conclusion: The addition of anterior hemifundoplication to esophagomyotomy for achalasia does not improve or worsen clinical results. (Ann Surg 2004;239: 779 –787)

From the *Departments of Surgery, †Radiology, and ‡Biostatistics, Temple University School of Medicine, Philadelphia, Pennsylavania. Reprints: Daniel T. Dempsey, MD, FACS, Department of Surgery, Temple University School of Medicine, 3401 North Broad St., Philadelphia, PA 19140. E-mail: [email protected]. Copyright © 2004 by Lippincott Williams & Wilkins ISSN: 0003-4932/04/23906-0779 DOI: 10.1097/01.sla.0000128683.61539.9f

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A

chalasia is an idiopathic esophageal motor disorder characterized by incomplete lower esophageal sphincter relaxation and aperistalsis of the smooth muscle lined esophageal body.1 It is thought to be caused by immune-mediated destruction of the ganglion cells in Auerbach’s myenteric plexus, but it is unclear why or how.1,2 Treatment is palliative and consists of temporary inhibition of excitatory cholinergic input to the LES smooth muscle (botulinum toxin),3 forceful tearing of the LES smooth muscle (pneumatic dilation),4 or surgical esophagomyotomy. Over the last decade, laparoscopic esophagomyotomy has become the treatment of choice for most patients with symptomatic achalasia, certainly among surgeons5 and even among gastroenterologists.6 The results with the laparoscopic approach are at least as good as those obtained with open esophagomyotomy, and the morbidity is less.7 Many surgeons add a hemifundoplication to the laparoscopic esophagomyotomy for protection against problematic postoperative reflux. This problem can be difficult to diagnose clinically in achalasia patients because heartburn symptoms correlate poorly with measured esophageal acid exposure8,9 and because the patient with achalasia may not perceive abnormal reflux if it is present.10 Although hemifundoplication may prevent gastroesophageal reflux after esophagomyotomy, it may also lead to persistent dysphagia in this group of patients with esophageal aperistalsis. These issues have been well described by Patti et al in their large series.11 Recently, Sharp et al9 presented a series of 100 patients with achalasia treated with laparoscopic esophagomyotomy. The results were very good, and most of the patients were treated without the addition of hemifundoplication. Thus the routine addition of hemifundoplication to laparoscopic esophagomyotomy for achalasia remains somewhat controversial. The purpose of this retrospective study was to evaluate whether esophagomyotomy with anterior hemifundoplication yields better clinical outcomes than esophagomyotomy alone in patients with achalasia.

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METHODS Fifty-one consecutive patients who had a laparoscopic esophagomyotomy for achalasia between August 1995 (when we started doing the operation) and January 2001 were retrospectively reviewed. This represents our entire experience with minimally invasive esophagomyotomy for achalasia over this 5.5-year period, except for 3 excluded patients (2 who had a thoracoscopic operation and 1 laparoscopic patient who was lost to follow-up). Of the 51 patients studied, 29 patients had an esophagomyotomy and anterior hemifundoplication, and 22 patients had esophagomyotomy alone. The decision to add a hemifundoplication was partly based on an informed preoperative discussion among the surgeon, patient, and referring gastroenterologist and partly on surgeon preference at the time of operation. Patients were maintained on clear liquids for a minimum of 2 days preoperatively, longer if megaesophagus was present. The myotomy technique was identical in all patients and is identical to our open technique. As much as possible, the esophagus is left undisturbed in its bed. Unlike in the Nissen fundoplication procedure, the gastroesophageal junction is not encircled, and most of the esophageal circumference (including most of the hiatal attachments and posterior vagus) is left undisturbed. Dividing some of the phrenoesophageal ligament anterolaterally on the right exposes the right anterolateral surface of the esophagus, and the gastroesophageal fat pad is removed. The anterior vagus is preserved. The myotomy is started just above the highest lesser gastric curvature vessel (usually just below the inferior border of the fat pad) and continued up onto the esophagus for a total length of 7 to 8 cm. Endoscopy is not used routinely. In patients having anterior hemifundoplication, the short gastric vessels were not routinely divided. The first row of sutures was placed between the medial anterior fundus and the left edge of the divided gastroesophageal muscle. The second row of sutures folded the fundus over the lower part of the myotomy and attached it to the anterior aspect of the right crural pillar and the right edge of the divided esophageal muscle. Before hospital discharge, all patients had an upper GI series on postoperative day 1 or 2. All these contrast studies were reviewed by a GI radiologist who did not know whether the patient had a hemifundoplication or not. The degree of chronic esophageal dilation was estimated by calculating the ratio of the greatest esophageal body width to the height of the closest normal vertebral body. Patients are advised to remain on an evening dose of famotidine (20 to 40 mg) indefinitely. All patients were interviewed in the office or by telephone using the same questionnaire and a standardized introductory script. They were asked to grade preoperative and postoperative symptoms (dysphagia, regurgitation, chest pain, and heartburn) and were graded on a scale of 0 (none, asymp-

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tomatic), 1 (mild), 2 (moderate), or 3 (severe, worst ever). Preoperative and postoperative weight loss or gain was recorded, as was preoperative and postoperative medication use and food intolerance. Patients were asked whether they were satisfied with the surgical result and whether they would recommend the operation to a friend or relative with achalasia. Data were compared between the wrap and no wrap group using unpaired t test, Mann-Whitney rank sum test, and ␹2 test. Data were compared within groups using the Wilcoxon signed rank test.

RESULTS Only 5 patients had intraoperative endoscopy. There were no operative deaths. There were 4 intraoperative mucosal perforations, 2 of which had an anterior wrap and 2 of which had no wrap. Four patients required conversion from laparoscopic to open operation, 2 for repair of perforation and 2 because of dense adhesions from previous upper abdominal operation. Patients were followed postoperatively for a mean of 33 months (range, 6 to 72 months). There were 27 men and 24 women. The mean age was 47.5 ⫾ 12.6 (mean ⫾ SD). Patients were symptomatic for 5.9 ⫾ 7.0 years before operation, and the average preoperative weight loss was 19 ⫾ 18 pounds. Preoperatively, patients had an average of 1.6 ⫾ 2.6 pneumatic dilations, and 1.5 ⫾ 1.6 Botox injections. Only 11 of 51 patients (22%) had neither a Botox injection nor a pneumatic dilation. Comparison of the wrap and no wrap groups revealed that they were nearly identical in terms of age, preoperative weight loss, and duration of preoperative symptoms. (Table 1) Also, the degree of chronic esophageal dilatation was similar between the 2 groups; the ratios of widest esophageal diameter to vertebral body height measured on the perioperative upper GI series were the same. Postoperative follow-up was significantly longer in the wrap group (39 ⫾ 22 versus 26 ⫾ 19 months), probably because of the tendency to perform more wraps earlier in our experience (Fig. 1).

TABLE 1. Achalasia Study Population (mean ⫾ SD)

Age (yr) Wt. Loss (lbs) Symptoms (yr) Esdm/Vrtbd Follow-up (mo)

No Wrap (n ⴝ 22)

Wrap (n ⴝ 29)

50 (14) 20 (20) 6.1 (7.0) 1.3 (0.4) 26 (19)

46 (12) 18 (15) 5.7 (7.1) 1.4 (0.5) 39 (22)*

*P ⫽ 0.04, Mann-Whitney, rank sum test. The no wrap and wrap groups were similar in most factors assesed. Follow-up was significantly longer in the wrap group.

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FIGURE 1. Early in the series (cases 1 to 26), most patients were treated with laparoscopic esophagomyotomy with anterior hemifundoplication; later in the series (cases 27 to 51), most patients were treated without a hemifundoplication.

There was significant postoperative improvement in all 4 symptoms graded in the study population (Fig. 2). Preoperatively, the mean symptom grade for dysphagia and regurgitation was higher than the mean grade for chest pain and heartburn. There were no differences in preoperative symptom scores for dysphagia, regurgitation, chest pain, or heartburn between the wrap and no wrap groups (Fig. 3a). Postoperative symptom scores were also nearly identical in the 2 groups (Fig. 3b). Specifically the hemifundoplication group did not have higher postoperative dysphagia scores (0.6 ⫾ 1.0) or lower heartburn scores (0.9 ⫾ 1.0) than the group that did not have a hemifundoplication (dysphagia 0.6 ⫾ 0.7; heartburn

FIGURE 3. (A) The preoperative symptom severity was similar in the no hemifundoplication and hemifundoplication groups. (B) The postoperative symptom severity was similar in the no hemifundoplication and hemifundoplication groups.

FIGURE 2. In the entire study population, preoperative symptoms improve significantly after operation. Also, patients graded the severity of preoperative dysphagia and regurgitation higher than preoperative chest pain and heartburn.

0.9 ⫾ 1.2). Postoperative scores for dysphagia, regurgitation, and chest pain were significantly improved in both the wrap and no wrap group when compared with the preoperative symptom score. The postoperative heartburn score in the wrap group was also significantly better than the preoperative score, but the improvement did not quite reach statistical significance in the no wrap group (P ⫽ 0.064). Postoperative use of GI medications was similar in the wrap and no wrap group (Table 2). Also similar between the groups were postoperative weight gain (Fig. 4) and postoperative solid and liquid food intolerance (Fig. 5). Overall patient satisfaction in the entire study population was 86%, and all but 2 patients said they would recommend the operation (96%). Patient satisfaction was identical in the wrap and no wrap groups (86%). On multivariate analysis, the only symptom that significantly correlated with patient satisfaction was the postoperative regurgitation score (Fig. 6).

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TABLE 2. Postoperative Medications

No meds PPIs and/or H2RAs Other

No Wrap

Wrap

41% 50% 9%

34% 61% 4%

Fisher Exact Test, P ⫽ 0.617. Postoperative medication use was similar in the no wrap and wrap groups. Despite our recommendation that the patients remain on long-term acid suppression, over one third of the patients were noncompliant with this recommendation.

DISCUSSION On the basis of the results of this study, we cannot accept the hypothesis that the addition of hemifundoplication to laparoscopic esophagomyotomy for achalasia leads to better clinical results. We failed to find a significant difference in clinical outcomes between 29 patients with achalasia treated by laparoscopic esophagomyotomy and anterior hemifundoplication and 22 patients treated by esophagomyotomy alone. These results suggest that achalasia patients treated with laparoscopic esophagomyotomy with or without anterior hemifundoplication do equally well. It must be emphasized that this is not a randomized prospective study. Furthermore, there is certainly the potential for type 2 error. It would be unwise to reject the hypothesis under consideration without a larger randomized clinical trial. The routine addition of fundoplication to myotomy for achalasia is a relatively recent development. The concept of esophagomyotomy to treat achalasia was developed by Heller, who described a short double myotomy without fundoplication in 1914.12 Multiple subsequent authors described variations of this technique, most of which employed a single

FIGURE 4. Most patients gained weight postoperatively. The proportion gaining weight in the no wrap and wrap groups was similar.

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FIGURE 5. (A) Postoperatively, about half the patients in both the wrap and no wrap groups continued to have intolerance for some types of solid food. (B) Postoperative intolerance to liquids was uncommon in both groups.

esophagomyotomy done transabdominally without a fundoplication.13,14 Ellis popularized the left chest approach to esophagomyotomy, arguing that a fundoplication was not necessary because the hiatus was minimally disturbed and because the distal extent of the myotomy onto the stomach was limited.13–15 The argument expounded in favor of routine hemifundoplication with esophagomyotomy for achalasia is a good one. It holds that aggressive distal esophagomyotomy is usually necessary to optimize palliation of dysphagia. This obliterates intrinsic LES function, and a significant number of patients will have harmful gastroesophageal reflux following esophagomyotomy if a fundic wrap is not added. Complete fundoplication may create too much outflow resistance for the aperistaltic esophagus and lead to persistent dysphagia; hemifundoplication is thought to create the appropriate amount of resistance and provide good reflux protection. © 2004 Lippincott Williams & Wilkins

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FIGURE 6. A postoperative regurgitation score of 2 or 3 predicted a dissatisfied patient.

An interesting study in this regard is by Oelschlager et al,16 who found a 17% persistent/recurrent dysphagia rate in 52 patients treated by esophagomyotomy (extended 1 to 1.5 cm onto stomach) and Dor fundoplication, but only a 3% postoperative dysphagia rate in the next 58 patients treated with an extended myotomy (3 cm onto stomach) and Toupet fundoplication. The authors concluded from this prospective study that a more aggressive distal myotomy gives better clinical results. However, the study was not randomized but was sequential, and the fundoplication was changed at the same time that the length of myotomy was changed. Of particular note, in 3 of the 4 patients reoperated for dysphagia in the Dor group, the surgeon had the impression that the obstruction may have been due to the wrap. This was also described in series of Patti et al.17 Furthermore, although the hemifundoplication was added to prevent reflux, Oelschlager et al found abnormally high reflux scores (DeMeester scores) in 32% of patients treated by the myotomy/Dor and in 54% of patients treated by the extended myotomy/Toupet. In another study, Ponce et al noted objective evidence of reflux in 8 of 28 patients (29%) following esophagomyotomy and hemifundoplication.18 It is clear that a hemifundoplication can lead to dysphagia and may not protect against reflux. Other authors have noted occasional problems with persistent dysphagia when hemifundoplication is added to esophagomyotomy. Raiser et al reported excellent results with myotomy and hemifundoplication (only 1 of 39 patients dissatisfied), but 3 of 39 patients required reoperation for postoperative dysphagia.19 In 1 patient, the Dor wrap was obstructing; in another, the wrap had herniated into the mediastinum resulting in dysphagia. Although none of the 18 patients studied with 24 hours pHmetry postoperatively had abnormal esophageal acid exposure, the majority of the 39 patients had postoperative heartburn-like symptoms, illustrat© 2004 Lippincott Williams & Wilkins

Laparoscopic Esophagomyotomy for Achalasia

ing the unreliability of heartburn symptoms in diagnosing abnormal gastroesophageal reflux. Vogt et al had a 90% success rate in 20 patients treated with laparoscopic esophagomyotomy and Toupet fundoplication, but 1 patient required reoperation and wrap takedown for persistent dysphagia.20 Zaninotto et al had 10 surgical failures in a series of 113 achalasia patients treated with laparoscopic esophagomyotomy and Dor fundoplication.21 The authors claimed that most failures were due to incomplete extension of the myotomy onto the stomach. But there are no data given to refute the argument that the postoperative dysphagia was due to the wrap. There are other widely quoted series with good results that recommend the addition of hemifundoplication to esophagomyotomy for achalasia. Patti et al had an 89% success rate in 102 patients treated with laparoscopic esophagomyotomy and anterior hemifundoplication. Five patients required reoperation: 3 for incomplete myotomy and 2 because of an obstructing wrap. In another report, Patti et al found a 93% satisfaction in 133 patients treated with myotomy and hemifundoplication. In a report of 62 consecutive patients treated with esophagomyotomy and hemifundoplication, Luketich et al reported a 92% satisfaction rate at a mean 19-month follow-up.22 Finley et al reported a 91% satisfaction rate in 98 patients treated with laparoscopic myotomy, 91 of whom had anterior fundoplication.23 Ben-Meir et al found a 75% patient satisfaction rate in 16 patients followed a mean of 21 months.24 Yamamura et al followed 21 patients for a mean of 16 months after myotomy and hemifundoplication and reported an 88% satisfaction rate.25 In one of the earliest series of laparoscopic esophagomyotomy, Hunter et al reported excellent relief of dysphagia in 36 of 40 patients followed for a mean of 12.5 months. Thirty-two of the 40 patients had the addition of a posterior hemifundoplication (Toupet), and 7 had the addition of an anterior wrap (Dor).26 There are no studies of complete (Nissen) fundoplication with laparoscopic myotomy, but good results have been reported with open abdominal esophagomyotomy and loose floppy Nissen fundoplication27,28 We can see that most patients with achalasia do well with laparoscopic esophagomyotomy and hemifundoplication. Although adequate extension of the myotomy distally is important, the addition of hemifundoplication does not universally prevent reflux and clinical symptoms are notoriously unreliable in assessing the presence or absence of postoperative reflux. Although unusual, clearly hemifundoplication can cause obstruction and may herniate. The argument against the routine addition of hemifundoplication to esophagomyotomy suggests that limited hiatal dissection preserves most of the extraesophageal antireflux mechanism, obviating the need for a wrap. It also holds that there are potential problems with a wrap, such as persistent dysphagia and wrap herniation. Finally, if a patient has

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excessive reflux after an esophagomyotomy without wrap, there are very effective medications to treat this. Interestingly, Ponce et al recently pointed out that patient satisfaction after operation for achalasia is most closely linked to the absence of dysphagia rather than to the presence of reflux. They found the latter symptom relatively easily managed with medication.18 Similarly, postoperative heartburn symptoms were not related to patient satisfaction in our study. It appeared from preoperative symptom scores that patients considered dysphagia and regurgitation the most bothersome symptoms. There is substantial published experience with esophagomyotomy without wrap for achalasia. For many years, this was the open operation of choice used by Ellis and his disciples, performed through a left chest approach.13,15 Ellis’ excellent results were attributed in part to limiting the distal extent of the myotomy, which minimized reflux. His group suggested that the addition of a wrap to short esophagomyotomy could be detrimental if it inhibited esophageal clearance of refluxate. It must also be pointed out that the transthoracic approach to myotomy probably disrupts the hiatal mechanism less extensively than the abdominal or laparoscopic approach used by many surgeons, regardless of the distal extent of the myotomy. Although Pellegrini et al began to use minimally invasive techniques for achalasia via a thoracoscopic approach without fundoplication,29 they found the abdominal approach more user-friendly and recommended the addition of a hemifundoplication to abdominal esophagomyotomy.17 Maher et al continue to recommend a thoracoscopic approach without the addition of a wrap, reporting 80% good to excellent results in 49 patients, 45 of whom were treated thoracoscopically.30 Robertson et al reported good to excellent results in 9 patients treated with laparoscopic myotomy without fundoplication.31 Postoperative pH studies performed in 5 of the 9 patients showed no conclusive evidence of abnormal acid reflux. All patients were operated with intraoperative endoscopy. Scott et al had good results in 27 of 30 patients with achalasia treated with open abdominal esophagomyotomy;32 only 14 of the 30 patients had a concomitant antireflux procedure. Recently, Sharp et al from the same institution reported a 93% patient satisfaction rate at a mean follow-up of 10 months in a consecutive series of 100 patients treated by minimally invasive esophagomyotomy, only 15 of whom had hemifundoplication.9 Routine intraoperative endoscopy was recommended to help determine the extent of the myotomy. Thirty-one patients who had esophagomyotomy without wrap were studied with postoperative 24-hour pH monitoring and only 4 (13%) of 31 had abnormal acid exposure. In these 31 patients, postoperative GERD score did not correlate with esophageal acid exposure as measured by 24-hour pH monitoring.

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Although our study is small and retrospective, our patient follow-up is high (98%) and our length of follow-up (33 months) substantial. It is the only study comparing 2 groups of achalasia patients within a single practice treated concurrently with a standardized laparoscopic esophagomyotomy, with and without fundoplication. None of our patients who had esophagomyotomy without hemifundoplication (some of whom were operated more than 5 years ago) have evidence of reflux-induced problems (stricture, aspiration), but it is clear that reflux stricture may take many years to develop in postoperative achalasia patients.33 Interestingly, despite our urging all patients (wrap or no wrap) to take famotidine with the evening meal, more than a third of the patients were noncompliant with this recommendation. We feel that a prudent use of our data, along with the excellent studies cited, is to enlighten preoperative and intraoperative decision-making regarding the addition of an anterior wrap to laparoscopic esophagomyotomy for achalasia. A more dogmatic approach will have to await a randomized clinical trial, longer follow-up, and/or consistent and repeated postoperative pH monitoring. Our current operation for achalasia is laparoscopic esophagomyotomy without wrap. We add an anterior fundoplication if the patient or gastroenterologist is very concerned with the possible sequelae of gastroesophageal reflux or if the patient cannot or will not take postoperative antisecretory medications. REFERENCES 1. Kahrilas PJ, Pandolfino JE. Motility disorders of the esophagus. In: Yamada, et al. Textbook of Gastroenterology, 4th ed. Philadelphia: Lippincott, Williams, and Wilkins; 2003. 2. Goldblum JR, Rice TW, Richter JE. Histopathologic features in esophagomyotomy specimens from patients with achalasia. Gastroenterology. 1996;111:648 – 654. 3. Pasricha PJ, Ravich WJ, Hendrix TR, et al. Intrasphincteric injection of botulinum toxin for the treatment of achalasia. N Engl J Med. 1995;322: 774 –778. 4. Parkman HP, Reynolds JC, Ouyang A, et al. Pneumatic dilatation or esophagomyotomy treatment for idiopathic achalasia: clinical outcomes and cost analysis. Dig Dis Sci. 1993;38:75– 85. 5. Patti MG, Fisichella PM, Perretta S, et al. Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change. J Am Coll Surg. 2003;196:698 –705. 6. Spiess AE, Kahrilas PJ. Treating achalasia: from whalebone to laparoscope. JAMA. 1998;280:638 – 642. 7. Dempsey DT, Kalan MM, Gerson RS, et al. Comparison of outcomes following open and laparoscopic esophagomyotomy for achalasia. Surg Endoscop. 1999;13:747–750. 8. Hunter JG, Richardson WS. Surgical management of achalasia. Surg Clin North Am. 1997;77:993–1015. 9. Sharp KW, Khaitan L, Scholz S, et al. 100 consecutive minimally invasive Heller myotomies: lessons learned. Ann Surg. 2002;235:631– 639. 10. Brackbill SP, Guoxiang S, Hirano I. Impaired esophageal mechanosensitivity and chemosensitivity in achalasia (abstract). Gastroenterology. 2001;120(suppl):644. 11. Patti MG, Molena D, Fisichella PM, et al. Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures. Arch Surg. 2001;136:870 – 877. 12. Heller E. Extramukose kardiaplastic beim chronischen kardiospasmus mit dilatation des oesophagus. Mitt Grenzgeb Med Chir. 1914;27:141– 149.

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13. Ellis FH. Achalasia. In: Schwartz S, Ellis H: Maingot’s Abdominal Operations. Norwalk CT: Appleton, Century, Crofts; 1985:573:–588. 14. Shackelford RT. Surgery of the Alimentary Tract: Esophagus, 2nd ed. Philadelphia: Saunders; 1978, pp. 121–170. 15. Streitz JM Jr, Ellis FH Jr, Williamson WA, et al. Objective assessment of gastroesophageal reflux after short esophagomyotomy for achalasia with the use of manometry and pH monitoring. J Thorac Cardiovasc Surg. 1996;111:107–113. 16. Oelschlager BK, Chang L, Pellegrini CA. Improved outcome after extended gastric myotomy for achalasia. Arch Surg. 2003;138:490 – 497. 17. Patti MG, Pellegrini CA, Horgan S, et al. Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg. 1999;230: 587–594. 18. Ponce M, Ortiz V, Juan M, et al. Gastroesophageal reflux, quality of life, and satisfaction in patients with achalasia treated with open cardiomyotomy and partial fundoplication. Am J Surg. 2003;185:560 –564. 19. Raiser F, Perdikis G, Hinder RA, et al. Heller myotomy via minimalaccess surgery. An evaluation of antireflux procedures. Arch Surg. 1996;131:593–598. 20. Vogt D, Curet M, Pitcher D, et al. Successful treatment of esophageal achalasia with laparoscopic Heller myotomy and Toupet fundoplication. Am J Surg. 1997;174:709 –714. 21. Zaninotto G, Costantini M, Portale G, et al. Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg. 2002;235:186 –192. 22. Luketich JD, Fernando HC, Christie NA, et al. Outcomes after minimally invasive esophagomyotomy. Ann Thorac Surg. 2001;72:1909 – 1913. 23. Finley RJ, Clifton JC, Stewart KC, et al. Laparoscopic Heller myotomy improves esophageal emptying and the symptoms of achalasia. Arch Surg. 2001;136:892– 896. 24. Ben-Meir A, Urbach DR, Khajanchee YS, et al. Quality of life before and after laparoscopic Heller myotomy for achalasia. Am J Surg. 2001;181:471– 474. 25. Yamamura MS, Gilster JC, Myers BS, et al. Laparoscopic Heller myotomy and anterior fundoplication for achalasia results in a high degree of patient satisfaction. Arch Surg. 2000;135:902–906. 26. Hunter JG, Trus T, Branum G, et al. Laparoscopic Heller myotomy and fundoplication for achalasia. Ann Surg. 1997;225:655– 665. 27. Donahue PE, Schlesinger PK, Sluss KF, et al. Esophagocardiomyotomy–floppy Nissen fundoplication effectively treats achalasia without causing esophageal obstruction. Surgery. 1994;116:719 –725. 28. Duranceau A, LaFontaine ER, Vallieres B. Effects of total fundoplication on function of the esophagus after myotomy for achalasia. Am J Surg. 1982;143:22–28. 29. Pellegrini C, Wetter LA, Patti M, et al. Thoracoscopic esophagomyotomy. Initial experience with a new approach for the treatment of achalasia. Ann Surg. 1992;216:291–299. 30. Maher JW, Conklin J, Heitshusen DS. Thoracoscopic esophagomyotomy for achalasia: preoperative patterns of acid reflux and long-term follow-up. Surgery. 2001;130:570 –576. 31. Robertson GS, Lloyd DM, Wicks AC, et al. Laparoscopic Heller’s cardiomyotomy without an antireflux procedure. Br J Surg. 1995;82: 957–959. 32. Scott HW Jr, DeLozier JB 3rd. , Sawyers JL, et al. Surgical management of esophageal achalasia. Southern Med J. 1985;78:1309 –1313. 33. DiSimone MP, Felice V, D’Errico A, et al. Onset timing of delayed complications and criteria of follow-up after operation for esophageal achalasia. Ann Thorac Surg 1996;61:1106 –1111.

Discussions DR. MARK J. KORUDA (CHAPEL HILL, NORTH CAROLINA): I would like to compliment Drs. Daly, Dempsey, and the Temple group not only for presenting this study but also for succeeding in further muddying the waters concerning the © 2004 Lippincott Williams & Wilkins

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uncertainty of the technical aspects associated with the surgical management of achalasia. It became apparent to me as I was doing more and more of these operations that we could get adequate exposure of the distal esophagus and the hiatus by doing a minimal dissection of the intralateral portion of the hiatus, as these authors describe. By leaving two thirds or so of the native phrenoesophageal mechanism attachments intact, the risk for postoperative reflux should at least in theory be lessened. Since I perform intraoperative endoscopy during the course of this operation, I have been able to observe rather graphically the function of lower esophageal sphincter during this operation. As you are performing the endoscopy, the stomach naturally insufflates with air, and even with a complete myotomy the stomach remains insufflated with the endoscopes in the esophagus and you actually need to aspirate and decompress the stomach either with a tube or with a scope. Granted, this observation is not a true assessment of postoperative reflux, but it does offer some consolation for the potential function of the lower esophageal sphincter after myotomy. With that said, I still, however, do perform an anterior fundoplication very similar to what the authors presented today. And I do it more for insurance, so to speak, because I have not had any wrap-related complications in the more than 60 operations that I have done in this manner. I have several questions for the authors. First, can you comment on how the diagnosis of achalasia was made? Specifically, did these patients have preoperative pH probes or manometry performed; if they did, what role these studies played in the decision that the surgeon made and whether or not to preform a wrap? Were any of these patients characterized as having vigorous achalasia? If so, how did their outcome differ from the rest of the cohort? I am curious about the decision not to perform intraoperative endoscopy. I find it valuable not only to examine the mucosa during the course of the myotomy but also to determine how far the myotomy is extending onto the stomach, since I think this is a critical aspect or component of this procedure. I still have a devil of a time making that determination based on the external gastric anatomy. An 8% conversion rate seems high, and I was wondering if you can comment on the chronological time frame when conversions were performed. We have only had 1 conversion in over 100 cases at UNC. I was wondering also if you could comment on the symptom severity questionnaire. Was the questionnaire sent out periodically over time or once in order to perform this study? Additionally, how were your patients instructed or counseled on how to answer these questions? It seems that there is a wide range for a patient to interpret the scale. For example, if someone has mild reflux symptoms on a daily basis, would they report this as severe? On the other hand, if

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the patient is relatively symptom-free but if they do have an episode of pain or reflex and it is awful, will they present that as severe? You note in your paper that you place all of your patients on H-2 blocker indefinitely. I was wondering what your rationale for this is. And in looking at your data, where 50⫹ percent of your patients are on some anti-acid medication after surgery, perhaps this may be a reflection of your practice rather than on the need for these patients. Do you have any indication whether these medications are over-thecounter or prescribed? Finally, a rhetorical question or 2. Many will criticize the study for lack of objective follow-up data to support your conclusions. And that may be valid. But I think that studies like this are very valuable because the bottom line in most instances is how patients are doing, and that is what you attempt to do with this study. So what should our end point be, considering whether we should wrap or not wrap these patients? Does it matter that someone has an abnormal pH probe study but is asymptomatic and doing well? On the other hand, is it acceptable to approach this problem with the attitude that if someone does get reflux after surgery and they didn’t have a wrap, we can just go ahead and treat them with PPIs indefinitely. I am afraid that, short of a prospective randomized study to address this, only time will tell. And we need to be persistent in our follow-up with these parents to try to answer these questions. DR. WILLIAM C. MEYERS (PHILADELPHIA, PENNSYLVANIA): This truly enlightened paper by Dempsey et al casts new light on a long-asked question concerning surgery for achalasia: Should we add or not an antireflux operation to an already curative esophagomyotomy? To make sure we understand the new light that has been shed, let us summarize again the principle arguments pro and con with respect to this age-old question. The primary argument for adding a wrap is that a small number of patients will have harmful gastroesophageal reflux if a wrap is not added. The primary argument against adding a wrap is to question why we had an operation that might recreate a dysphagia problem for which the myotomy was done in the first place. To consider what Dr. Dempsey is saying, let us now examine what the pro-wrappers are now actually doing when they add an antireflux procedure. The pro-wrappers are also concerned with the possibility of post-op dysphasia, so they do a “minimal” input antireflux operation. Often that operation is done with a single figure 8 stitch that increases the anterior lateral esophageal angle. So the new argument is often not whether or not to add a wrap; instead, the argument is whether or not to add a stitch or 2.

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The new light that Dempsey et al shed is the following. Virtually every past series addressing this question has so few patients with postoperative dysphagia that the data can be interpreted either way, as a pro- or an anti-wrap paper, depending on one’s own bias. It would take so huge a prospective randomized study that the true answer to this question will never be revealed. Dr. Dempsey’s study clearly shows you can do a successful Heller myotomy with or without a wrap. Certainly Dr. Dempsey is now providing us with the right answer to this long-asked question. The answer is: Why worry? Do whatever your bias tells to you do. Do what the patient wants— or occasionally what the referring gastroenterologist wants. Dr. Dempsey, thank you for this beautiful paper. Your paper should finally put to rest this question. In reality, the question will likely rest only until the spring, when the GI societies meet again. But we in the Southern Surgical Association will still know the right answer. DR. J. DAVID RICHARDSON (LOUISVILLE, KENTUCKY): I have 2 questions. Do you think that an anterior fundoplication really has any real antireflux properties? Are you currently adding an antireflux procedure or not? DR. DANIEL T. DEMPSEY (PHILADELPHIA, PENNSYLVANIA): Dr. Koruda, I think, alluded to the fact, and it was certainly pointed out by Ellis with the thoracic approach, that, if you did minimal dissection around the hiatus, there probably would be some extra esophageal component left to the LES. As you know, there is an important diaphragmatic component to that. Dr. Koruda asked how the diagnosis was made. All of these patients had preoperative manometry. The manometry results were not used to decide whether or not a wrap was used. It was pretty much surgeon preference, together with a long discussion preoperatively with the patient and the gastroenterologist, about the potential problems with reflux or persistent dysphagia. As you know, if you have a patient with persistent dysphagia and a wrap, it is fairly hard to figure out whether that is the wrap or inadequate myotomy. We had 5 patients who we did intraoperative endoscopy on and in none of those did we find that the distal extent of the myotomy was inadequate. As you know, Dr. Pellegrini’s group recently published a paper suggesting that an extensive distal myotomy, a 3-cm myotomy, gives better results with a hemifundoplication. We had 4 conversions out of 51 patients. They were all early in the series. Two of them were because we had fairly big holes in the mucosa with big dilated esophagi that were in retrospect inadequately cleaned out. We had all this stuff running into the field, and that made us very uncomfortable. So we felt we better get in there and control the contamina© 2004 Lippincott Williams & Wilkins

Annals of Surgery • Volume 239, Number 6, June 2004

tion quickly. The other 2 conversions were in patients who had previous open upper abdominal procedures. One lady had a radical left nephrectomy; another patient had a vagotomy and distal gastrectomy, and we just couldn’t do the operation laparoscopically. The Symptom Severity Questionnaire was done either in the office or on the phone, with 1 medical student and 1 resident working on this project. We had pretty strict criteria as to how they should rate it based upon how frequently their symptoms were and how severe they were. Why do we use an H-2 blocker? Well, half the patients don’t listen to us anyway. But you know the data are quite good that the reflux is silent or can be silent after this operation. And I think Marco Patti and Carlos Pellegrini have some pretty good data that a hemifundoplication doesn’t prevent all the reflux. In fact, many patients can have abnormal Demeester scores after they have had a myotomy and a hemifundoplication. I think that the way that you take these data depends somewhat on your bias. Those who are biased toward a wrap will say, “Well, it doesn’t seem to hurt, so why not do it?”

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Laparoscopic Esophagomyotomy for Achalasia

Those who are biased against a wrap will say, “Well, it doesn’t make a difference so why bother doing it?” I think probably the best way to use the data is to enlighten the discussion, the informed consent, with the patient and with the gastroenterologist and not worry too much if you don’t add a wrap; but be reassured that if you do add an anterior wrap, which we did in over half these patients, that you are probably not going to hurt the patient in terms of persistent dysphagia. There will never be a prospective randomized study that is powerful enough to answer this question, because it is an unusual disease. I think those of us fortunate enough to accumulate these patients have to try to get as close to 100% follow-up as we can for a long time. Reflux strictures can occur 5, 7, 10 years out, and we need to get good (and repeated) endoscopic and pH data. I would say about two thirds of the time now we don’t do a wrap. About a third of the time, in the patient who is very concerned about reflux or with a gastroenterologist who is very concerned about that, we would add an anterior hemifundoplication.

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