Minimally Invasive "3-Stitch" Modification of the Dor Fundoplication: Simple and Effective

Heller myotomy in patients with prior endoscopic interventions vs the treatment-naïve

BACKGROUND

Definitive palliation for achalasia is surgical myotomy; however, patients frequently undergo endoscopic treatments prior to myotomy. Surgeons may perceive myotomy to be more challenging after prior treatments, due to scarring and fusion of dissection planes, but outcomes compared to the treatment-naïve remain unclear. Hence, we compared institutional Heller myotomy outcomes in patients who underwent pre-myotomy endoscopic treatments to those who did not.

METHODS

From 1/1/2010 to 1/1/2020, 436 patients underwent Heller myotomy for achalasia at Cleveland Clinic, 101 (23%) of whom had prior endoscopic intervention(s): 39 (39%) pneumatic dilation, 57 (56%) botulinum toxin injection, and 5 (4.9%) both (Prior group). Propensity score matching generated two groups of 101 pairs. Short-term outcomes and longitudinal postoperative symptom palliation (Eckardt score ≤ 3), esophageal emptying at five minutes, and reintervention were assessed and compared with the treatment-naïve (Naïve group).

RESULTS

There were no statistically significant differences in operative time, mucosal perforation, or length of stay between Prior and Naïve groups (P > .12). At 5 years, the probability of symptom palliation was 83% in the Prior Group vs 81% in the Naïve Group (P = .63) and complete esophageal emptying 23% vs 32% (P = .095). The cumulative number of reinterventions per 100 patients at 10 years was 7.9 in the Prior Group and 4.8 in the Naïve Group (P = .13).

CONCLUSION

The perception of increased complexity of Heller myotomy in patients with prior endoscopic interventions does not translate to stastically significant differences in short- or long-term outcomes when compared to the treatment-naïve. A subtle longitudinal pattern of suboptimal esophageal emptying and increased reintervention for patients with prior intervention(s), suggests that, when possible, up-front myotomy may be preferred.

Esophageal tortuosity in achalasia: increased length-to-height ratio predicts inferior symptom relief and esophageal emptying following myotomy

BACKGROUND

Current classification of achalasia does not account for variability in esophageal tortuosity. The esophageal length-to-height ratio (LHR) was developed to objectively quantify tortuosity, based on the premise that the esophagus must elongate to become tortuous. Hence, we assess the relationship of esophageal tortuosity, measured by LHR, to preoperative patient characteristics and post-myotomy outcomes, including longitudinal symptom relief and esophageal emptying.

METHODS

From 01/2014 to 01/2020, 420 eligible adult patients underwent myotomy for achalasia at our institution, 216 (51%) Heller myotomy and 204 (49%) per-oral endoscopic myotomy. LHR was measured on pre- and first postoperative timed barium esophagram (TBE), with larger values signifying greater tortuosity. Variable predictiveness and risk-adjusted longitudinal estimates of symptom relief (Eckardt score ≤ 3) and complete emptying, in relation to LHR and manometric subtype, were estimated.

RESULTS

Median [15th, 85th percentile] preoperative LHR was 1.04 [1.01, 1.10]. Preoperative esophageal width > 3 cm and age > 68 years were most predictive of increased LHR. Increased LHR corresponded with decreases in longitudinal postoperative symptom relief and complete esophageal emptying, with a 4% difference in symptom relief and 20% difference in complete emptying, as LHR increased from 1.0 to 1.16. After adjusting for patient factors, including LHR, manometric subtype was less predictive of symptom relief, with estimated symptom relief occurring in 4% fewer patients with Type III achalasia, compared to Types I and II. Overall, LHR decreased following myotomy in patients with an initially tortuous esophagus.

CONCLUSION

Length-to-height ratio was the only variable highly predictive of both longitudinal post-myotomy symptom relief and complete esophageal emptying, whereas manometric subtype was less predictive. These findings highlight the importance of tortuosity in the treatment of patients with achalasia, suggesting that inclusion of esophageal morphology in future iterations of achalasia classification is warranted.

State-of-the-Art Surgery in Achalasia

Background

Achalasia is a motility disorder of the esophagus and depending on its type, esophageal tubular hypo- or hypermotility can cause typical symptoms, such as dysphagia, chest pain, weight loss, or regurgitation. Clinical symptoms during initial diagnosis as well as over the course of therapy can be measured by the Eckardt score. Diagnostics include high-resolution manometry (HR manometry), (timed barium) esophagogram, upper gastrointestinal endoscopy, multiple rapid swallow response, and Endo-FLIP measurement. In this work, we provide a review of the recent literature on surgical treatment of achalasia.

Summary

Besides pharmacological and endoscopic interventions, surgical procedures of laparoscopic/robotic Heller myotomy (LHM/RHM) and 180° anterior Dor's semifundoplication versus 270° dorsal Toupet's fundoplication are primary therapeutic options, especially for type I and II achalasia. Both surgical procedures display little morbidity and mortality. Postsurgical results are comparable between LHM and RHM. RHM allows better angulation during myotomy, lower rates of intraoperative mucosal laceration, and better visualization of the muscles in the lower esophageal sphincter area. Surgery can also be performed safely after failed endoscopic treatments.

Key Messages

Surgery in achalasia is especially indicated in patients ≤40 years and also recommended after repeated unsuccessful or complicated endoscopic interventions. In selected patients with end-stage achalasia and sigmoid-shaped megaesophagus, esophagectomy is a reasonable option in order to improve quality of life.

The Value of Fundoplication in the Treatment of Type I Achalasia

BACKGROUND

Type I achalasia comprises 20% of achalasia and has nearly absent esophageal motor activity. Concerns that fundoplication decreases the effectiveness of Heller myotomy in these patients has increased adoption of peroral endoscopic myotomy (POEM). Hence, we compared outcomes after Heller myotomy with Dor fundoplication vs POEM.

METHODS

From 2005 to 2020, 150 patients with type I achalasia underwent primary surgical myotomy (117 Heller myotomy, 33 POEM). Patient demographics, prior treatments, timed barium esophagrams, Eckardt scores, and reinterventions were assessed between the 2 groups. Median follow-up was 5 years for Heller myotomy and 2.5 years for POEM.

RESULTS

The Heller myotomy group was younger, had fewer comorbidities, and lower body mass index vs POEM. Risk-adjusted models demonstrated clinical success (Eckardt ≤3) in 83% of Heller myotomies and 87% of POEMs at 3 years; longitudinal complete timed barium esophagram emptying and reintervention were also similar. An abnormal pH test result was documented in 10% (6 of 60) after Heller myotomy and in 45% (10 of 22) after POEM (P < .001).

CONCLUSIONS

Despite nearly absent esophageal contractility, Heller myotomy with Dor fundoplication and POEM result in similar long-term symptom relief, esophageal emptying, and occurrence of reintervention in patients with type I achalasia. There is decreased esophageal acid exposure with the addition of a fundoplication, without compromised esophageal drainage, allaying fears of a detrimental effect of a fundoplication. Hence, choice of procedure may be personalized based on patient characteristics and esophageal morphology and not solely on manometric subtype.