During the 1970s and the 1980s, operations for benign esophagealdisorders were often withheld or delayed in favor of less effectiveforms of treatment in an effort to prevent the postoperative dis-comfort, the long hospital stay, and the recovery time associatedwith open surgical procedures. For instance, pneumatic dilatationbecame first-line therapy for achalasia, even though surgical man-agement had been shown to be clearly superior.1
In the first part of the 1990s, it became clear that treatment ofbenign esophageal disorders with minimally invasive proceduresyielded results comparable to those of treatment with traditionaloperations while causing minimal postoperative discomfort,reducing the duration of hospitalization, shortening recovery time,and permitting earlier return to work.2,3 Consequently, minimallyinvasive surgery was increasingly considered as first-line treatmentfor achalasia, and laparoscopic fundoplication was consideredmore readily and at an earlier stage in the management of gas-troesophageal reflux disease (GERD).
Since then, minimally invasive esophageal procedures have con-tinued to evolve, thanks to better instrumentation and improvedsurgical expertise. In addition, with greater experience and longerfollow-up periods, it has become possible to analyze techniquesand their results more rigorously. For instance, whereas a fewyears ago a left thoracoscopic Heller myotomy was considered theprocedure of choice for achalasia, the current procedure of choiceis a laparoscopic Heller myotomy with partial fundoplication,which has proved to be better at relieving dysphagia and control-ling postoperative reflux.4-7 Similarly, whereas total fundoplicationand partial fundoplication were initially considered equally effec-tive in treating GERD,8 total fundoplication is now viewed asclearly superior for this purpose and should be used whenever feasible.9
In this chapter, I focus on minimally invasive approaches to thetreatment of abnormal gastroesophageal reflux and esophagealmotility disorders.The standard open counterparts of these opera-tions are described elsewhere [see 4:7 Open Esophageal Procedures].
Laparoscopic Nissen Fundoplication
PREOPERATIVE EVALUATION
All patients who are candidates for a laparoscopic fundoplica-tion should undergo a preoperative evaluation that includes thefollowing: (1) symptomatic evaluation, (2) an upper GI series, (3)endoscopy, (4) esophageal manometry, and (5) ambulatory pHmonitoring.
Symptomatic Evaluation
The presence of both typical symptoms (heartburn, regurgita-tion, and dysphagia) and atypical symptoms of GERD (cough,wheezing, chest pain, and hoarseness) should be investigated, and
symptoms should be graded with respect to their intensity bothbefore and after operation. Nonetheless, a diagnosis of GERDshould never be based solely on symptomatic evaluation. Manyauthorities assert that the diagnosis can be made reliably from theclinical history,10 so that a complaint of heartburn should lead tothe presumption that acid reflux is present; however, testing of thisdiagnostic strategy demonstrates that symptoms are far less sensi-tive and specific than is usually believed.11 For instance, a studyfrom the University of California, San Francisco (UCSF), foundthat of 822 consecutive patients referred for esophageal functiontests with a clinical diagnosis of GERD (based on symptoms andendoscopic findings), only 70% had abnormal reflux on pH mon-itoring.12 Heartburn and regurgitation were no more frequent inpatients who had genuine reflux than in those who did not; thus,symptomatic evaluation, by itself, could not distinguish betweenthe two groups.
The response to proton pump inhibitors (PPIs) is a better pre-dictor of abnormal reflux. For example, in the UCSF study justcited, 75% of patients with GERD reported a good or excellentresponse to PPIs, compared with only 26% of patients withoutGERD.12 Similarly, a study involving multivariate analysis of fac-tors predicting outcome after laparoscopic fundoplication con-cluded that a clinical response to acid suppression therapy was oneof three factors predictive of a successful outcome, the other twobeing an abnormal 24-hour pH score and the presence of a typi-cal primary symptom (e.g., heartburn).13
Upper Gastrointestinal Series
An upper GI series is useful for diagnosing and characterizingan existing hiatal hernia.The size of the hiatal hernia helps predicthow difficult it will be to reduce the esophagogastric junctionbelow the diaphragm. In addition, large hiatal hernias are associ-ated with more severe disturbances of esophageal peristalsis andesophageal acid clearance.14 Esophagograms are also useful fordetermining the location, shape, and size of a stricture and detect-ing a short esophagus.
Endoscopy
Endoscopy is typically the first test performed to confirm asymptom-based diagnosis of GERD. This approach has two pit-falls, however. First, even though the goal of endoscopy is to assessthe mucosal damage caused by reflux, mucosal changes are absentin about 50% of GERD patients.12 Second, major interobservervariations have been reported with esophageal endoscopy, partic-ularly for low-grade esophagitis.15 In one study, for instance, 60(24%) of 247 patients with negative results on pH monitoring hadbeen diagnosed as having grade I or II esophagitis.12 Accordingly,I believe that endoscopy is most valuable for excluding gastric andduodenal pathologic conditions and detecting the presence ofBarrett’s esophagus.
Esophageal manometry provides useful information about themotor function of the esophagus by determining the length andresting pressure of the lower esophageal sphincter (LES) andassessing the quality (i.e., the amplitude and propagation) ofesophageal peristalsis. In addition, it allows proper placement ofthe pH probe for ambulatory pH monitoring (5 cm above theupper border of the LES).
Ambulatory pH Monitoring
Ambulatory pH monitoring is the most reliable test for thediagnosis of GERD, with a sensitivity and specificity of about92%.16 It is of key importance in the workup for the following fourreasons.
1. It determines whether abnormal reflux is present. In the UCSFstudy mentioned earlier,12 pH monitoring yielded normalresults in 30% of patients with a clinical diagnosis of GERD,thereby obviating the continuation of inappropriate and expen-sive drugs (e.g., PPIs) or the performance of a fundoplication.In addition, pH monitoring prompted further investigation thatin a number of cases pointed to other diseases (e.g., cholelithi-asis and irritable bowel syndrome).
2. It establishes a temporal correlation between symptoms andepisodes of reflux. Such a correlation is particularly importantwhen atypical GERD symptoms are present because 50% ofthese patients experience no heartburn and 50% do not haveesophagitis on endoscopy.17
3. It allows staging on the basis of disease severity. Specifically, pHmonitoring identifies a subgroup of patients characterized byworse esophageal motor function (manifested by a defectiveLES or by abnormal esophageal peristalsis), more acid reflux inthe distal and proximal esophagus, and slower acid clearance.These patients more frequently experience stricture formationand Barrett metaplasia and thus might benefit from earlyantireflux surgery.18
4. It provides baseline data that may prove useful postoperativelyif symptoms do not respond to the procedure.
OPERATIVE PLANNING
The patient is placed under general anesthesia and intubatedwith a single-lumen endotracheal tube.Abdominal wall relaxation
is ensured by the administration of a nondepolarizing musclerelaxant, the action of which is rapidly reversed at the end of theoperation. Adequate muscle relaxation is essential becauseincreased abdominal wall compliance allows increased pneu-moperitoneum, which yields better exposure. An orogastric tubeis inserted at the beginning of the operation to keep the stomachdecompressed; it is removed at the end of the procedure.
The patient is placed in a steep reverse Trendelenburg position,with the legs extended on stirrups. The surgeon stands betweenthe patient’s legs.To keep the patient from sliding as a result of thesteep position used during the operation, a bean bag is inflatedunder the patient, and the knees are flexed only 20° to 30°. AFoley catheter is inserted at the beginning of the procedure andusually is removed in the postoperative period. Because increasedabdominal pressure from pneumoperitoneum and the steepreverse Trendelenburg position decrease venous return, pneumat-ic compression stockings are always used as prophylaxis againstdeep vein thrombosis.
The equipment required for a laparoscopic Nissen fundoplica-tion includes five 10 mm trocars, a 30° laparoscope, a hook cau-tery, and various other instruments [see Table 1]. In addition, we usea three-chip camera system that is separate from the laparoscope.
OPERATIVE TECHNIQUE
In all patients except those with very poor esophageal motili-ty—for whom partial fundoplication [see Laparoscopic Partial(Guarner) Fundoplication, below] is preferable—we advocate per-forming a 360° wrap of the gastric fundus around the loweresophagus as described by Nissen, but we always take down theshort gastric vessels to achieve what is called a floppy fundoplica-tion.This type of wrap is very effective in controlling gastroesoph-ageal reflux.19,20 The operation can be divided into nine key stepsas follows.
Step 1: Placement of Trocars
Five 10 mm trocars are used for the operation [see Figure 1].Port A is placed about 14 cm below the xiphoid process; it canalso be placed slightly (2 to 3 cm) to the left of the midline to bein line with the hiatus.This port is used for insertion of the scope.Port B is placed at the same level as port A but in the left mid-clavicular line. It is used for insertion of the Babcock clamp; inser-tion of a grasper to hold the Penrose drain once it is in place sur-rounding the esophagus; or insertion of the clip applier, the ultra-sonic coagulating shears, or both to take down the short gastricvessels. Port C is placed at the same level as the previous two portsbut in the right midclavicular line. It is used for insertion of thefan retractor, the purpose of which is to lift the lateral segment ofthe left lobe of the liver and expose the esophagogastric junction.I do not divide the left triangular ligament.The fan retractor canbe held in place by a self-retaining system fixed to the operatingtable. Ports D and E are placed as high as possible under thecostal margin and about 5 to 6 cm to the right and the left of themidline so that they are about 15 cm from the esophageal hiatus;in addition, they should be placed so that their axes form an angleof 60° to 120°.These ports are used for insertion of the graspers,the electrocautery, and the suturing instruments.
Troubleshooting If the ports are placed too low in theabdomen, the operation is made more difficult. If port C is toolow, the fan retractor will not retract the lateral segment of the leftlobe of the liver well, and the esophagogastric junction will not beexposed. If port B is too low, the Babcock clamp will not reach theesophagogastric junction, and when the ultrasonic coagulating
Table 1—Instrumentation for LaparoscopicNissen Fundoplication
Five 10 mm trocars
30° scope
Graspers
Babcock clamp
L-shaped hook cautery with suction-irrigation capacity
shears or the clip applier is placed through the same port, it willnot reach the upper short gastric vessels. If ports D and E are toolow, the dissection at the beginning of the case and the suturing atthe end are problematic.
Other mistakes of positioning must be avoided as well. Port Cmust not be placed too medially, because the fan retractor mayclash with the left-hand instrument; the gallbladder fossa is a goodlandmark for positioning this port. Port A must be placed withextreme caution in the supraumbilical area: its insertion site is justabove the aorta, before its bifurcation. Accordingly, I recommendinitially inflating the abdomen to a pressure of 18 mm Hg just forplacement of port A; increasing the distance between the abdom-inal wall and the aorta reduces the risk of aortic injury. I also rec-ommend directing the port toward the coccyx. Once port A is inplace, the intraperitoneal pressure is reduced to 15 mm Hg. AHasson cannula can be used in this location, particularly if thepatient has already had one or more midline incisions. Main-taining the proper angle (60° to 120°) between the axes of the twosuturing instruments inserted through ports D and E is alsoimportant: if the angle is smaller, the instruments will cover partof the operating field, whereas if it is larger, depth perception maybe impaired. Finally, if a trocar is not in the ideal position, it is bet-ter to insert another one than to operate through an inconve-niently placed port.
If the surgeon spears the epigastric vessels with a trocar, bleed-ing will occur, in which case there are two options.The first optionis to pull the port out, insert a 24 French Foley catheter with a 30ml balloon through the site, inflate the balloon, and apply tractionwith a clamp. The advantage of this maneuver is that the vessel
need not be sutured; the disadvantage is that the surgeon mustthen choose another insertion site. At the end of the case, the bal-loon is deflated. If some bleeding is still present, it must be con-trolled with sutures placed from outside under direct vision. Thesecond option is to use a long needle with a suture, with which onecan rapidly place two U-shaped stitches, one above the clamp andone below. The suture is tied outside over a sponge and left inplace for 2 or 3 days.
Step 2: Division of Gastrohepatic Ligament; Identification ofRight Crus of Diaphragm and Posterior Vagus Nerve
Once the ports are in place, the gastrohepatic ligament is divid-ed. Dissection begins above the caudate lobe of the liver, wherethis ligament usually is very thin, and continues toward the dia-phragm until the right crus is identified.The crus is then separat-ed from the right side of the esophagus by blunt dissection, andthe posterior vagus nerve is identified.The right crus is dissectedinferiorly toward the junction with the left crus.
Troubleshooting An accessory left hepatic artery originatingfrom the left gastric artery is frequently encountered in the gas-trohepatic ligament. If this vessel creates problems of exposure, itmay be divided; in my experience, doing so has not caused prob-lems.When dissecting the right crus from the esophagus, the elec-trocautery should be used with particular caution. Because themonopolar current tends to spread laterally, the posterior vagusnerve may sustain damage simply from being in proximity to thedevice, even when there is no direct contact. The risk of neuro-praxia can be reduced by using the cut mode rather than the coag-ulation mode when the electrocautery is close to the nerve. Thecut mode has problems of its own, however, and is not recom-mended in most laparoscopic procedures.A better alternative is touse the ultrasonic coagulating shears.
Step 3: Division of Peritoneum and PhrenoesophagealMembrane above Esophagus; Identification of Left Crus ofDiaphragm and Anterior Vagus Nerve
The peritoneum and the phrenoesophageal membrane abovethe esophagus are divided with the electrocautery, and the anteri-or vagus nerve is identified.The left crus of the diaphragm is dis-sected downward toward the junction with the right crus.
Troubleshooting Care must be taken not to damage theanterior vagus nerve or the esophageal wall.To this end, the nerveshould be left attached to the esophageal wall, and the peritoneumand the phrenoesophageal membrane should be lifted from thewall by blunt dissection before they are divided.
Step 4: Creation of Window between Gastric Fundus,Esophagus, and Diaphragmatic Crura; Placement of PenroseDrain around Esophagus
The esophagus is retracted upward with a Babcock clampapplied at the level of the esophagogastric junction. Via blunt and sharp dissection, a window is created under the esophagus be-tween the gastric fundus, the esophagus, and the diaphragmaticcrura. The window is enlarged with the ultrasonic coagulatingshears, and a Penrose drain is passed around the esophagus.Thisdrain is then used for traction instead of the Babcock clamp toreduce the risk of damage to the gastric wall.
Troubleshooting The two main problems to watch for dur-ing this part of the procedure are (1) creation of a left pneumo-thorax and (2) perforation of the gastric fundus.
AssistingPort
Babcock Clamp
30˚ ScopeLiver Retractor
DissectingPort
DE
BAC
Figure 1 Laparoscopic Nissen fundoplication. Illustrated isthe recommended placement of the trocars.
A left pneumothorax is usually caused by dissection done abovethe left crus in the mediastinum rather than between the crus andthe gastric fundus.This problem can be avoided by properly dis-secting and identifying the left crus.
Perforation of the gastric fundus is usually caused by pushing ablunt instrument under the esophagus and below the left cruswithout having done enough dissection. Care must be exercised intaking down small vessels from the fundus when the area behindthe esophagus is approached from the right: the anatomy is not asclear from this viewpoint, and perforation can easily occur.Sometimes, perforation is caused by the use of a monopolar elec-trocautery for dissection. An electrocautery burn can go unrecog-nized during dissection and manifest itself in the form of a leakduring the first 48 hours after operation.
Step 5: Division of Short Gastric Vessels
The ultrasonic coagulating shears or the clip applier is intro-duced through port B. A grasper is introduced by the surgeonthrough port D, and an assistant applies traction on the greatercurvature of the stomach through port E. Dissection begins at thelevel of the middle portion of the gastric body and continuesupward until the most proximal short gastric vessel is divided andthe Penrose drain is reached.
Troubleshooting Again, there are two main problems towatch for during this part of the procedure: (1) bleeding, eitherfrom the gastric vessels or from the spleen, and (2) damage to thegastric wall.
Bleeding from the gastric vessels is usually caused by excessivetraction or by division of a vessel that is not completely occludingwith clips on both sides. Vessels up to 5 mm in diameter can betaken down with the ultrasonic coagulating shears; this processrequires about half of the amount of time needed when only clipsare used.The lower blade has a sharp, oscillating inferior edge thatmust always be kept in view to prevent damage to other structures(e.g., the pancreas, the splenic artery and vein, and the spleen).Damage to the gastric wall can be caused by a burn from the elec-trocautery used to dissect between vessels or by traction appliedvia the graspers or the Babcock clamp.
Step 6: Closure of Crura
The diaphragmatic crura are closed with interrupted 2-0 silksutures on a curved needle; the sutures are tied intracorporeally.Exposure is provided by retracting the esophagus upward andtoward the patient’s left with the Penrose drain.The lens of the 30°laparoscope is angled slightly to the left by moving the light cableof the scope to the patient’s right.The first stitch should be placedjust above the junction of the two crura. Additional stitches areplaced 1 cm apart, and a space of about 1 cm is left between theuppermost stitch and the esophagus.
Troubleshooting Care must be taken not to spear the poste-rior wall of the esophagus with either the tip or the back of the needle. So as not to limit the space available for suturing, thebougie is not placed inside the esophagus during this part of theprocedure.
Step 7: Insertion of Bougie into Esophagus and throughEsophagogastric Junction
The esophageal stethoscope and the orogastric tube areremoved, and a 56 French bougie is inserted by the anesthesiolo-gist and passed through the esophagogastric junction underlaparoscopic vision. The crura must be snug around the esopha-
gus but not too tight: a closed grasper should slide easily betweenthe esophagus and the crura.
Troubleshooting The most worrisome complication duringthis step is perforation of the esophagus.This can be prevented bylubricating the bougie and instructing the anesthesiologist toadvance the bougie slowly and to stop if any resistance is encoun-tered. In addition, it is essential to remove any instruments fromthe esophagogastric junction and to open the Penrose drain; thesemeasures prevent the creation of an angle between the stomachand the esophagus, which can increase the likelihood of perfora-tion.The position of the bougie can be confirmed by pressing witha grasper over the esophagus, which will feel full when the bougieis in place.
Step 8:Wrapping of Gastric Fundus around Lower Esophagus
The gastric fundus is gently pulled under the esophagus withthe graspers. The left and right sides of the fundus are wrappedabove the fat pad (which lies above the esophagogastric junction)and held together in place with a Babcock clamp introducedthrough port B. (The Penrose drain should be removed at thispoint because it is in the way.) Usually, three 2-0 silk sutures areused to secure the two ends of the wrap to each other. The firststitch does not include the esophagus and is used for traction; thesecond and the third include a bite of the esophageal muscle.Thebougie is passed into the stomach after the first stitch to assess thesize of the wrap. If the wrap seems at all tight, the stitch is removedand repositioned more laterally. Two coronal stitches are thenplaced between the top of the wrap and the esophagus, one on theright and one on the left. Finally, one additional suture is placedbetween the right side of the wrap and the closed crura.
To avoid the risk of injuring the inferior vena cava at the begin-ning of the dissection, some surgeons use a different method—theso-called left crus approach.19 In this approach, the operationbegins with identification of the left crus of the diaphragm anddivision of the peritoneum and the phrenoesophageal membraneoverlying it. The next step is division of the short gastric vessels,starting midway along the greater curvature of the stomach andcontinuing upward to join the area of the previous dissection.When the fundus has been thoroughly mobilized, the peritoneumis divided from the left to the right crus, and the right crus is dis-sected downward to expose the junction of the right and left crura.With this technique, the vena cava is never at risk. In addition, thebranches of the anterior vagus nerve and the left gastric artery areless exposed to danger.This technique can be very useful, partic-ularly for management of very large paraesophageal hernias andfor second antireflux operations [see Reoperation for GERD,below].
Troubleshooting To determine whether the wrap is going tobe floppy, the surgeon must deliver the fundus under the esopha-gus, making sure that the origins of the short gastric vessels thathave been transected are visible. Essentially, the posterior wall ofthe fundus is being used for the wrap. If the wrap remains to theright of the esophagus without retracting back to the left, then it isfloppy, and suturing can proceed. If not, the surgeon must makesure that the upper short gastric vessels have been transected. Iftension is still present after these maneuvers, it is probably best toperform a partial wrap [see Laparoscopic Partial (Guarner) Fun-doplication, below].
Damage to the gastric wall may occur during the delivery of thefundus. Atraumatic graspers must be used, and the gastric fundusmust be pulled gently and passed from one grasper to the other.
Sometimes, it is helpful to push the gastric fundus under theesophagus from the left.The wrap should measure no more than2 to 2.5 cm in length and, as noted, should be done with no morethan three sutures.The first stitch is usually the lowest one; it mustbe placed just above the fat pad where the esophagogastric junc-tion is thought to be.
If the anesthesiologist observes that peak airway pressure hasincreased (because of a pneumothorax) or that neck emphysemais present (because of pneumomediastinum), the pneumoperi-toneum should be reduced from 15 mm Hg to 8 or 10 mm Hguntil the end of the procedure. Pneumomediastinum tends toresolve without intervention within a few hours of the end of theprocedure. Small pneumothoraces (usually on the left side) tendto resolve spontaneously, rendering insertion of a chest tubeunnecessary. Larger pneumothoraces (> 20%), however, call forthe insertion of a small (18 to 20 French) chest tube.
Step 9: Final Inspection and Removal of Instruments and Portsfrom Abdomen
After hemostasis is obtained, the instruments and the ports areremoved from the abdomen under direct vision.
Troubleshooting If any areas of oozing were observed, theyshould be irrigated and dried with sponges rolled into a cigarette-like shape before the ports are removed. In addition, if somegrounds for concern remain, the oozing areas should be examinedafter the pneumoperitoneum is decreased to 7 to 8 mm Hg toabolish the tamponading effect exerted by the high intra-abdomi-nal pressure.
All the ports should be removed from the abdomen underdirect vision so that any bleeding from the abdominal wall can bereadily detected. Such bleeding is easily controlled, either frominside or from outside.
COMPLICATIONS
A feared complication of laparoscopic Nissen fundoplication isesophageal or gastric perforation, which may result either fromtraction applied with the Babcock clamp or a grasper to the esoph-agus or the stomach (particularly when the stomach is pulledunder the esophagus) or from inadvertent electrocautery burnsduring any part of the dissection. A leak will manifest itself duringthe first 48 hours. Peritoneal signs will be noted if the spillage islimited to the abdomen; shortness of breath and a pleural effusionwill be noted if spillage also occurs in the chest.The site of the leakshould always be confirmed by a contrast study with barium or awater-soluble contrast agent. Optimal management consists oflaparotomy and direct repair. If a perforation is detected intra-operatively, it may be closed laparoscopically.
About 50% of patients experience mild dysphagia postopera-tively. This problem usually resolves after 4 to 6 weeks, duringwhich period patients receive pain medications in an elixir formand are advised to avoid eating meat and bread. If, however, dys-phagia persists beyond this period, one or more of the followingcauses is responsible.
1. A wrap that is too tight or too long (i.e., > 2.5 cm).21
2. Lateral torsion with corkscrew effect. If the wrap rotates to theright (because of tension from intact short gastric vessels orbecause the fundus is small), a corkscrew effect is created.
3. A wrap made with the body of the stomach rather than the fun-dus. The relaxation of the LES and the gastric fundus is con-trolled by vasoactive intestinal polypeptide and nitric oxide22,23;after fundoplication, the two structures relax simultaneously
with swallowing. If part of the body of the stomach rather thanthe fundus is used for the wrap, it will not relax as the LES doeson arrival of the food bolus.
4. Choice of the wrong procedure. In patients who have severelyabnormal esophageal peristalsis (as in end-stage connective tis-sue disorders), a partial wrap is preferable. A 360° wrap maycause postoperative dysphagia and gas bloat syndrome.
If the wrap slips into the chest, the patient becomes unable toeat and prone to vomiting.A chest radiograph shows a gastric bub-ble above the diaphragm, and the diagnosis is confirmed by meansof a barium swallow.This problem can be prevented by using coro-nal sutures and by ensuring that the crura are closed securely.
Paraesophageal hernia may occur if the crura have not beenclosed or if the closure is too loose. In my opinion, closure of thecrura not only is essential for preventing paraesophageal herniabut also is important from a physiologic point of view, in that itacts synergistically with the LES against stress reflux. Sometimes,it is possible to reduce the stomach and close the crura laparo-scopically. More often, however, because the crural opening is verytight and the gastric wall is edematous, laparoscopic repair isimpossible and laparotomy is preferable.
POSTOPERATIVE CARE AND OUTCOME EVALUATION
Postoperative care and outcome evaluation of laparoscopicNissen fundoplication are considered elsewhere in conjunctionwith the discussion of partial fundoplication [see LaparoscopicPartial (Guarner) Fundoplication, Postoperative Care and Out-come Evaluation, below].
Laparoscopic Partial (Guarner) Fundoplication
PREOPERATIVE EVALUATION AND OPERATIVE PLANNING
Preoperative evaluation and operative planning are essentiallythe same for partial (Guarner) fundoplication as for Nissen fun-doplication. This operation should be performed only in patientswith the most severe abnormalities of esophageal peristalsis: it isless effective than a 360° wrap for long-term control of reflux.9 Inaddition, laparoscopic partial fundoplication may be performedafter laparoscopic Heller myotomy for achalasia [see LaparoscopicHeller Myotomy with Partial Fundoplication, below].24
OPERATIVE TECHNIQUE
The first seven steps in a Guarner fundoplication are identicalto the first seven in a Nissen fundoplication. The wrap, however,differs in that it extends around only 240° to 280° of the esoph-ageal circumference. Once the gastric fundus is delivered underthe esophagus, the two sides are not approximated over the esoph-agus. Instead, 80° to 120° of the anterior esophagus is left uncov-ered, and each of the two sides of the wrap (right and left) is sep-arately affixed to the esophagus with three 2-0 silk sutures, witheach stitch including the muscle layer of the esophageal wall.Theremaining stitches (i.e., the coronal stitches and the stitch betweenthe right side of the wrap and the closed crura) are identical tothose placed in a Nissen fundoplication.
POSTOPERATIVE CARE
Currently, my average operating time for a laparoscopic fun-doplication is approximately 2 hours. I start patients on a softmechanical diet on the morning of postoperative day 1 and usual-ly discharge them after 23 to 48 hours.The recovery time usuallyranges from 10 to 14 days.
OUTCOME EVALUATION
The initial results of laparoscopic fundoplication obtained inthe early 1990s indicated that the operation was effective in con-trolling reflux but that postoperative dysphagia occurred moreoften than had been anticipated.8 Many experts thought that thisproblem could be avoided by tailoring the fundoplication to thestrength of esophageal peristalsis as measured by esophagealmanometry.8 Accordingly, partial fundoplication (240°) was rec-ommended for patients with impaired peristalsis, and total fundo-plication (360°) was recommended for those with normal peri-stalsis. The short-term results of this tailored approach werepromising.8 Gradually, however, it became evident that partialfundoplication was not as durable as total fundoplication9 and thattotal fundoplication did not pose a special problem for patientswith weak peristalsis.25
Long-term follow-up of patients operated on in accordancewith the tailored approach at UCSF between October 1992 andDecember 1999 indicated that the promising short-term resultsreported earlier8 were not maintained over time.20 After a meanfollow-up period of 70 months, 56% of the patients who under-went partial fundoplication had recurrent reflux as documentedby pH monitoring, compared with only 28% of those who under-went total fundoplication. (These figures probably overestimatethe real incidence of postoperative reflux, in that most of thepatients studied had heartburn and very few were asymptomatic.)In addition, more of the patients in the partial fundoplicationgroup needed acid-suppressing medication (25% versus 8%) or asecond operation (9% versus 3%).The incidence of postoperativedysphagia, however, was the same in the two groups, which indi-cated that the completeness of the wrap played no role in causingthis largely transient complication.These findings suggest that theinitial problems with postoperative dysphagia were primarilyattributable to unknown technical factors that were largely elimi-nated from the procedure as surgeons garnered more experiencewith it. As a result, total fundoplication is currently considered theprocedure of choice for patients with GERD, regardless of thestrength of their esophageal peristalsis.
Laparoscopic Heller Myotomy with Partial Fundoplication
Minimally invasive surgical procedures for primary esophagealmotility disorders (achalasia, diffuse esophageal spasm, and nut-cracker esophagus) yield results that are comparable to those ofopen procedures but are associated with less postoperative painand with a shorter recovery time.26 Today, laparoscopic Hellermyotomy with partial fundoplication has supplanted left thoraco-scopic myotomy as the procedure of choice for esophageal achala-sia.4-7 Long-term studies demonstrated that even though left tho-racoscopic myotomy led to resolution of dysphagia in about 85%to 90% of patients, it had the following four drawbacks.
1. Gastroesophageal reflux developed postoperatively in about60% of patients because no fundoplication was performed inconjunction with the myotomy.4 With the laparoscopicapproach, in contrast, a partial fundoplication can easily be per-formed, which prevents reflux in the majority of patients4,5 andcorrects many instances of preexisting reflux arising from pneu-matic dilatation.4 A prospective, randomized, double-blind clin-ical trial that compared Heller myotomy alone with Hellermyotomy and Dor fundoplication clearly demonstrated that theaddition of a fundoplication is essential: the incidence of post-operative reflux (as measured by pH monitoring) was 47.6% inpatients who underwent myotomy alone but only 9.1% in those
who underwent myotomy and Dor fundoplication.27
2. The extension of the myotomy onto the gastric wall (clearly themost critical and challenging part of the operation) proved dif-ficult because of poor exposure, with the consequent risk of ashort myotomy and persistent dysphagia.With the laparoscop-ic approach, in contrast, excellent exposure of the esophagogas-tric junction is easily achieved, and the myotomy can be extend-ed onto the gastric wall for about 2 to 2.5 cm.4
3. Double-lumen endotracheal intubation and single-lung ventila-tion were required, with the patient in the right lateral decubi-tus position. In contrast, the setting for a laparoscopic myotomy(the same as that for a laparoscopic fundoplication) is mucheasier for the patient, the anesthesiologist, and the OR person-nel. In addition, most surgeons have by now acquired substan-tial experience with laparoscopic antireflux procedures and thusare more familiar and comfortable with laparoscopic exposureof the distal esophagus and the esophagogastric junction.
4. The average postoperative hospital stay was about 3 daysbecause of the chest tube left in place at the time of the opera-tion and the discomfort arising from the thoracic incisions.After a laparoscopic Heller myotomy, the hospital stay is only 1or 2 days; there is no need for a chest tube, and patients aremore comfortable.
Because of these drawbacks, left thoracoscopic myotomy is nowlargely reserved for patients with achalasia who have undergonemultiple abdominal operations (which may rule out a laparoscop-ic approach). A laparoscopic Heller myotomy and Dor fundopli-cation is considered the procedure of choice for achalasia.
PREOPERATIVE EVALUATION
All candidates for a laparoscopic Heller myotomy shouldundergo a thorough and careful evaluation to establish the diag-nosis and characterize the disease.28
An upper GI series is useful. A characteristic so-called bird’sbeak is usually seen in patients with achalasia. A dilated, sigmoidesophagus may be present in patients with long-standing achala-sia. A corkscrew esophagus is often seen in patients with diffuseesophageal spasm. Endoscopy is performed to rule out a tumorof the esophagogastric junction and gastroduodenal pathologicconditions.
Esophageal manometry is the key test for establishing the diag-nosis of esophageal achalasia.The classic manometric findings are(1) absence of esophageal peristalsis and (2) a hypertensive LESthat fails to relax appropriately in response to swallowing.
Ambulatory pH monitoring should always be done in patientswho have undergone pneumatic dilatation to rule out abnormalgastroesophageal reflux. In addition, pH monitoring should beperformed postoperatively to detect abnormal reflux, which, ifpresent, should be treated with acid-reducing medications.28
In patients older than 60 years who have experienced the recentonset of dysphagia and excessive weight loss, secondary achalasiaor pseudoachalasia from cancer of the esophagogastric junctionshould be ruled out. Endoscopic ultrasonography or computedtomography can help establish the diagnosis.29
OPERATIVE PLANNING
Patient preparation (i.e., anesthesia, positioning, and instru-mentation) is identical to that for laparoscopic fundoplication.
OPERATIVE TECHNIQUE
Many of the steps in a laparoscopic Heller myotomy are the sameas the corresponding steps in a laparoscopic fundoplication. The
ensuing description focuses on those steps that differ significantly.Either a Dor or a Guarner fundoplication [see Laparoscopic
Partial (Guarner) Fundoplication, above] may be performed inconjunction with a Heller myotomy.The Dor fundoplication is ananterior 180° wrap. Its advantages are that (1) it does not requireposterior dissection and the creation of a window between theesophagus, the stomach, and the left pillar of the crus; (2) it coversthe exposed esophageal mucosa after completion of the myotomy;and (3) it is effective even in patients with GERD.30 Its main dis-advantage is that achieving the proper geometry can be difficult,and a wrong configuration can lead to dysphagia even after a prop-erly performed myotomy.31 The advantages of the Guarner fundo-plication are that (1) it is easier to perform; (2) it keeps the edgesof the myotomy well separated; and (3) it might be more effectivethan a Dor procedure in preventing reflux. Its main disadvantagesare that (1) it requires more dissection for the creation of a poste-rior window and (2) it leaves the esophageal mucosa exposed.
Steps 1 through 6
Steps 1, 2, 3, 4, 5, and 6 of a laparoscopic Heller myotomy areessentially identical to the first six steps of a laparoscopic fundo-plication. Steps 4 and 6, however, are necessary only if a posteriorpartial fundoplication is to be performed. Care must be taken notto narrow the esophageal hiatus too much and push the esopha-gus anteriorly.
Step 7: Intraoperative Endoscopy
The esophageal stethoscope and the orogastric tube areremoved, and an endoscope is inserted. The endoscopic viewallows easy identification of the squamocolumnar junction, so thatthe myotomy can be extended downward onto the gastric wall forabout 2 cm distal to this point. In addition, if possible mucosal
perforation is a concern, the esophagus can be covered with waterfrom outside while air is insufflated from inside; bubbling will beobserved over the site of any perforation present.
At the beginning of a surgeon’s experience with laparoscopicHeller myotomy, intraoperative endoscopy is a very importantand helpful step; however, once the surgeon has gained adequateexperience with this procedure and has become familiar with therelevant anatomy from a laparoscopic perspective, it may beomitted.
Troubleshooting The most worrisome complication duringintraoperative endoscopy is perforation of the esophagus. Thiscomplication can be prevented by having the procedure done byan experienced endoscopist who is familiar with achalasia.
Step 8: Initiation of Myotomy and Entry into SubmucosalPlane at Single Point
The fat pad is removed with the ultrasonic coagulating shearsto provide clear exposure of the esophagogastric junction. ABabcock clamp is then applied over the junction, and the esoph-agus is pulled downward and to the left to expose the right sideof the esophagus. The myotomy is performed at the 11 o’clockposition. It is helpful to mark the surface of the esophagus alongthe line through which the myotomy will be carried out [see Figure2].The myotomy is started about 3 cm above the esophagogastricjunction. Before it is extended upward and downward, the prop-er submucosal plane should be reached at a single point; in thisway, the likelihood of subsequent mucosal perforation can bereduced.
Troubleshooting The myotomy should not be started closeto the esophagogastric junction, because at this level the layersoften are poorly defined, particularly if multiple dilatations orinjections of botulinum toxin have been performed. At the pre-ferred starting point, about 3 cm above the esophagogastric junc-tion, the esophageal wall is usually normal.As a rule, I do not openthe entire longitudinal layer first and then the circular layer; I findit easier and safer to try to reach the submucosal plane at one pointand then move upward and downward from there. In the courseof the myotomy, there is always some bleeding from the cut mus-cle fibers, particularly if the esophagus is dilated and the wall isvery thick. After the source of the bleeding is identified, the elec-trocautery must be used with caution. The most troublesomebleeding comes from the submucosal veins encountered at theesophagogastric junction (which are usually large). In mostinstances, gentle compression is preferable to electrocautery. Asponge introduced through one of the ports facilitates the applica-tion of direct pressure.
Step 9: Proximal and Distal Extension of Myotomy
Once the mucosa has been exposed, the myotomy can safely beextended [see Figure 3]. Distally, it is extended for about 2 to 2.5cm onto the gastric wall; proximally, it is extended for about 6 cmabove the esophagogastric junction. Thus, the total length of themyotomy is typically about 8 cm [see Figure 4].
Troubleshooting The course of the anterior vagus nervemust be identified before the myotomy is started. If this nervecrosses the line of the myotomy, it must be lifted away from theesophageal wall, and the muscle layers must then be cut under it.In addition, care must be taken not to injure the anterior vagusnerve while removing the fat pad.Treatment with botulinum toxinoccasionally results in fibrosis with scarring and loss of the normal
Figure 2 Laparoscopic Heller myotomy with partial fundoplica-tion. The proposed myotomy line is marked on the surface of theesophagus.
anatomic planes; this occurs more frequently at the level of theesophagogastric junction.
If a perforation seems possible or likely, it should be sought asdescribed earlier [see Step 7, above]. Any perforation foundshould be repaired with 5-0 absorbable suture material, withinterrupted sutures employed for a small perforation and a con-tinuous suture for a larger one.When a perforation has occurred,an anterior fundoplication is usually chosen in preference to aposterior one because the stomach will offer further protectionagainst a leak.
Two rows of sutures are placed.The first row (on the left side)comprises three stitches: the uppermost stitch incorporates thegastric fundus, the esophageal wall, and the left pillar of the crus[see Figure 5], and the other two incorporate only the gastric fun-dus and the left side of the esophageal wall [see Figure 6].The gas-tric fundus is then folded over the myotomy, and the second row(also comprising three stitches) is placed on the right side betweenthe fundus and the right side of the esophageal wall, with only theuppermost stitch incorporating the right crus [see Figures 7 and 8].Finally, two additional stitches are placed between the anterior rimof the hiatus and the superior aspect of the fundoplication [seeFigure 9].These stitches remove any tension from the second rowof sutures.
Troubleshooting Efforts must be made to ensure that thefundoplication does not become a cause of postoperative dyspha-gia.Accordingly, I always take down the short gastric vessels, eventhough some authorities suggest that this step can be omitted.5,29
In addition, the gastric fundus rather than the body of the stom-ach should be used for the wrap, and only the uppermost stitchof the right row of sutures should incorporate the right pillar ofthe crus.30
Alternatively, a posterior 220° fundoplication may be per-formed.The gastric fundus is delivered under the esophagus, andeach side of the wrap (right and left) is attached to the esophagealwall, lateral to the myotomy, with three sutures [see Figure 10].
Figure 3 Laparoscopic Heller myotomy with partial fundoplica-tion. The myotomy is extended proximally and distally.
2 to 2.5 cm
EsophagogastricJunction
Figure 4 Laparoscopic Heller myotomy with partial fundopli-cation. The myotomy is approximately 8 cm long, extending dis-tally for about 2 to 2.5 cm onto the gastric wall and proximallyfor about 6 cm above the esophagogastric junction.
Figure 5 Laparoscopic Heller myotomy with anterior partialfundoplication (Dor procedure). The uppermost stitch in thefirst row incorporates the fundus, the esophageal wall, and theleft pillar of the crus.
Step 11: Final Inspection and Removal of Instruments andPorts from Abdomen
Step 11 of a laparoscopic Heller myotomy is identical to step 9of a laparoscopic Nissen fundoplication.
COMPLICATIONS
Delayed esophageal leakage, usually resulting from an electro-cautery burn to the esophageal mucosa, may occur during the first24 to 36 hours after operation.The characteristic signals are chestpain, fever, and a pleural effusion on the chest x-ray.The diagno-
sis is confirmed by an esophagogram.Treatment options dependon the time of diagnosis and on the size and location of the leak.Early, small leaks can be repaired directly. If the site of the leak ishigh in the chest, a thoracotomy is recommended; if the site is atthe level of the esophagogastric junction, a laparotomy is prefer-able, and the stomach can be used to reinforce the repair. If thedamage to the esophagus is too extensive to permit repair, a trans-hiatal esophagectomy [see 4:7 Open Esophageal Procedures] is indicated.
Dysphagia may either persist after the operation or recur after asymptom-free interval. In either case, a complete workup is neces-sary, and treatment is individualized on the basis of the specificcause of dysphagia. Reoperation may be indicated [see Reopera-tion for Esophageal Achalasia, below].
Abnormal gastroesophageal reflux occurs in 7% to 20% ofpatients after operation.4,5 Because most patients are asympto-matic, it is essential to try to evaluate all patients postoperativelywith manometry and prolonged pH monitoring. Reflux should betreated with acid-reducing medications.
POSTOPERATIVE CARE
I do not routinely obtain an esophagogram before initiatingfeeding. Patients are started on a soft mechanical diet on themorning of postoperative day 1, and this diet is continued for therest of the first week. Patients are discharged after 24 to 48 hoursand are able to resume regular activities in 7 to 14 days.
OUTCOME EVALUATION
The results obtained to date with laparoscopic Heller myotomyand partial fundoplication are excellent and are generally compa-rable to those obtained with the corresponding open surgical pro-cedures: dysphagia is reduced or eliminated in more than 90% ofpatients.4-7 Laparoscopic treatment clearly outperforms balloondilatation and botulinum toxin injection in the treatment of acha-lasia. Its high success rate has caused a shift in practice, to the
Figure 6 Laparoscopic Heller myotomy with anterior partialfundoplication (Dor procedure). The second and third stitches inthe first row incorporate only the fundus and the left side of theesophageal wall.
Figure 7 Laparoscopic Heller myotomy with anterior partial fun-doplication (Dor procedure).The uppermost stitch in the secondrow incorporates the fundus, the esophageal wall, and the right crus.
Figure 8 Laparoscopic Heller myotomy with anterior partialfundoplication (Dor procedure). The second and third stitches inthe second row incorporate only the fundus and the right side ofthe esophageal wall.
point where most referring physicians currently regard surgery asthe preferred treatment.32
Left Thoracoscopic Myotomy
PREOPERATIVE EVALUATION
Preoperative evaluation is essentially the same as that for laparo-scopic Heller myotomy.
OPERATIVE PLANNING
The patient is placed under general anesthesia and intubatedwith a double-lumen endotracheal tube so that the left lung can bedeflated during the procedure. As for a left thoracotomy, thepatient is placed in the right lateral decubitus position over aninflated bean bag. The instrumentation is similar to that for alaparoscopic Nissen or Guarner fundoplication. Instead of con-ventional trocars, four or five thoracoports with blunt obturatorsare employed, because insufflation of the thoracic cavity is notrequired.The myotomy can be performed with a monopolar hookcautery, bipolar scissors, or an ultrasonic scalpel. A 30° scope anda 45° scope are essential for thoracoscopic procedures. In addi-tion, an endoscope is used for intraoperative endoscopy.
OPERATIVE TECHNIQUE
Step 1: Placement of Thoracoports
Five ports are usually placed [see Figure 11]. Port A, used for the30° scope, is inserted in the sixth intercostal space about 3.5 to 5cm behind the posterior axillary line. Port B, used for the lungretractor, is placed in the third intercostal space about 1.25 to 2.5cm anterior to the posterior axillary line. Port C, used for insertionof a grasper, is placed in the sixth intercostal space in the anterioraxillary line. Port D, used for insertion of the instrument employedfor the myotomy, is placed in the seventh intercostal space in themidaxillary line. Port E is placed in the eighth intercostal spacebetween the anterior axillary line and the midaxillary line. This
port is optional: it is needed in about 30% of cases to allow the sur-geon to obtain further exposure of the esophagogastric junctionthrough retraction of the diaphragm.
Troubleshooting A common mistake is to insert port A tooanteriorly.This port must be placed well beyond the posterior axil-lary line to provide the best angle for the 30° scope. Often, theother ports are placed one or two intercostal spaces too high.Thismistake hampers the performance of the most delicate portion ofthe operation, the myotomy of the distal portion of the esophagusand the stomach.
Sometimes, chest wall bleeding occurs as a consequence of portinsertion.This bleeding will obscure the operating field and there-fore must be stopped before the intrathoracic portion of the pro-cedure is begun.This is accomplished either by using the cauteryfrom the inside or by applying a stitch from the outside if an inter-costal vessel has been damaged.
Step 2: Retraction of Left Lung and Division of InferiorPulmonary Ligament
Once the ports are in place, the deflated left lung is retractedcephalad with a fan retractor introduced through port B. Thismaneuver places tension on the inferior pulmonary ligament, whichis then divided.After the ligament is divided, the fan retractor can beheld in place by a self-retaining system fixed to the operating table.
Troubleshooting Before the inferior pulmonary ligament isdivided, the inferior pulmonary vein must be identified to preventa life-threatening injury to this vessel. If oxygen saturation decreas-es, particularly in patients with lung disease, the retractor shouldbe removed and the lung inflated intermittently.
Step 3: Division of Mediastinal Pleura and Dissection ofPeriesophageal Tissues
The mediastinal pleura is divided, and the tissues overlying theesophageal wall are dissected until the wall of the esophagus is vis-
Figure 9 Laparoscopic Heller myotomy with anterior partialfundoplication (Dor procedure). Two final stitches are placedbetween the superior portion of the wrap and the anterior rim ofthe hiatus.
Figure 10 Laparoscopic Heller myotomy with posterior partialfundoplication (Guarner procedure). Each side of the posterior220º wrap is attached to the esophageal wall with three sutures.
ible.This maneuver varies in difficulty depending on the width ofthe space between the aorta and the pericardium (which some-times is very small) and on the size and shape of the esophagus.Large (sigmoid) esophagi tend to curve to the right, which makesidentification of the wall difficult. If the esophagus is not immedi-ately apparent, it can be easily identified in the groove between theheart and the aorta by means of transillumination provided by anendoscope [see Figure 12].
Troubleshooting The endoscope placed inside the esophagusat the beginning of the procedure plays an important role. In theearly stages of the procedure, it allows identification of the esopha-gus via transillumination.When the light intensity of the 30° scopeis turned down, the esophagus appears as a bright structure. Inaddition, tilting the tip of the endoscope brings the esophagus intoview as it is lifted from the groove between the aorta and the heart.
Step 4: Initiation of Myotomy and Entry into SubmucosalPlane at Single Point
As in a laparoscopic Heller myotomy, it is helpful to mark thesurface of the esophagus along the line through which the myoto-my will be carried out. The myotomy is started halfway betweenthe diaphragm and the inferior pulmonary vein. Again, the prop-er submucosal plane should be reached at a single point before themyotomy is extended upward and downward.
Troubleshooting Troubleshooting for this step is essentiallythe same as that for step 8 of a laparoscopic Heller myotomy, withthe exception that here the myotomy is started 4 to 5 cm (ratherthan 3 cm) above the esophagogastric junction.
Step 5: Proximal and Distal Extension of Myotomy
Once the mucosa has been exposed, the myotomy can safely beextended proximally and distally [see Figure 13]. I usually extendthe myotomy for about 5 mm onto the gastric wall, withoutadding an antireflux procedure.3,4 Typically, the total length of themyotomy is about 6 cm for patients with achalasia.
Troubleshooting Proximally, the myotomy is extended allthe way to the inferior pulmonary vein only in cases of vigorousachalasia (high-amplitude simultaneous contractions associated
with chest pain in addition to dysphagia) or diffuse esophagealspasm; otherwise, it is limited to the distal 5 to 6 cm of the esoph-agus. If a longer myotomy is needed, the lung is displaced anteri-orly and the myotomy extended to the aortic arch.
Distally, the myotomy is continued for 5 mm past the esopha-gogastric junction. The endoluminal view provided by the endo-scope is useful for assessing the location of the esophagogastricjunction. Often, the stomach is distended by the air insufflated bythe endoscope and pushes the diaphragm upward, thereby limit-ing the view of the esophagogastric junction. If sucking air out ofthe stomach does not resolve this problem, an additional port (i.e.,port E) may be placed in the eighth intercostal space, and a fanretractor may be introduced through this port to push the dia-phragm down.
Because the myotomy of the gastric wall is the most challeng-ing part of the operation, good exposure is essential. It is at thislevel that an esophageal perforation is most likely to occur. The
risk is particularly high in patients who have undergone pneumat-ic dilatation or injection of botulinum toxin, both of which maylead to the replacement of muscle layers by scar tissue and the con-sequent loss of the regular planes. Perforations recognized in theOR can be repaired by thoracoscopic intracorporeal suturing or, ifthis fails, by thoracotomy and open repair.The gastric fundus canbe used to buttress the repair. If it is unclear whether a perforationhas occurred, the esophagus should be covered with water and airinsufflated through the endoscope as described earlier [see Lapa-roscopic Heller Myotomy with Partial Fundoplication, OperativeTechnique, Step 7, above].
Step 6: Insertion of Chest Tube and Removal of Thoracoports
A 24 French angled chest tube is inserted under direct visionthrough port D or port E. The ports are removed under directvision, and the thoracic wall is inspected for bleeding.
COMPLICATIONS
As with laparoscopic Heller myotomy, delayed esophageal leak-age is a common postoperative complication, and treatment op-tions are similar.
If the myotomy is not extended far enough onto the gastric wall,residual dysphagia occurs. To prevent this problem, the distalextent of the myotomy should be assessed by means of endoscopywith the goal of including 5 mm of the gastric wall. Patients withresidual dysphagia must be evaluated by means of esophagealmanometry, which will document the extent of the residual high-pressure zone and the pressure within it.The myotomy can be eas-ily extended by a laparoscopic approach, and a Dor fundoplicationcan be added.
If, on the other hand, the myotomy is extended too far onto thegastric wall, abnormal gastroesophageal reflux occurs. Somepatients present with heartburn; others are asymptomatic. It isessential to evaluate patients postoperatively with manometry andprolonged pH monitoring. Mild reflux can be treated with acid-reducing medications, particularly in elderly patients. In youngerpatients, abnormal reflux should be corrected with a laparoscopicpartial fundoplication (e.g., Dor fundoplication).
POSTOPERATIVE CARE
Patients are started on a liquid diet the morning of postoperativeday 1; on postoperative day 2, they are started on a soft mechani-cal diet, which is continued for the rest of the first week. I do notroutinely obtain an esophagogram before starting feedings. Thechest tube is removed after 24 hours if the lung is fully expandedand there is no air leak. Patients are discharged after 48 to 72 hoursand are able to resume regular activities in 7 to 10 days.
OUTCOME EVALUATION
The results obtained with thoracoscopic myotomy are generallycomparable to those obtained with open surgical procedures. In a1999 study from UCSF,4 26 (87%) of the first 30 patients withachalasia who were treated in this fashion experienced good orexcellent results [see Table 2]. Currently, however, this procedure israrely used to treat esophageal achalasia: laparoscopic Hellermyotomy and Dor fundoplication is now the treatment of choice.32
Right Thoracoscopic Myotomy
A right thoracoscopic myotomy extending from the diaphragmto the thoracic inlet is the preferred procedure for patients whohave nutcracker esophagus or diffuse esophageal spasm involvingthe entire length of the esophagus but whose LES function is nor-
mal. On the whole, this procedure is technically simpler than a leftthoracoscopic myotomy: because there is no need to go throughthe esophagogastric junction, perforation, postoperative dysphagia,and abnormal gastroesophageal reflux are largely prevented.
PREOPERATIVE EVALUATION
Preoperative evaluation of patients being considered for rightthoracoscopic myotomy is essentially the same as that of patientsbeing considered for left thoracoscopic myotomy.
OPERATIVE PLANNING
Operative planning is similar to that for a left thoracoscopicmyotomy.The double-lumen tube is used to deflate the right lungrather than the left, and the patient is placed in the left lateral decu-bitus position over an inflated bean bag, as for a right thoracoto-my. The instrumentation is identical except for the endovascular30 mm stapler used to transect the azygos vein. A thoracot-omy tray should be kept ready in case an emergency thoracotomyis necessary to control bleeding.
OPERATIVE TECHNIQUE
Step 1: Insertion of Thoracoports
Only port B is inserted where it would be for a left thoracoscopicmyotomy. All the other ports are inserted one intercostal spacehigher because the myotomy need not be extended all the way tothe stomach but must be extended to the thoracic inlet. Usually,only four ports are placed; however, an additional port may beplaced in the fourth intercostal space in the anterior axillary line tofacilitate the proximal extension of the myotomy.
Step 2: Dissection of Periesophageal Tissues and Division ofAzygos Vein
The periesophageal tissues above and below the azygos vein aredissected away from the esophagus. A tunnel is created betweenthe azygos and the esophagus with a dissector or a right-angleclamp. The vein is then transected with an endovascular 30 mmstapler. (Alternatively, the azygos is spared and simply lifted off theesophagus with umbilical tape.)
Troubleshooting Dissection of the azygos vein is the mostcritical part of this procedure. I find it easier to transect the azygosvein than to keep the vein lifted away from the esophagus and per-form the myotomy under it.
Steps 3, 4, and 5
Steps 3, 4, and 5 of a right thoracoscopic myotomy are virtual-ly identical to steps 4, 5, and 6 of a left thoracoscopic myotomy,with a few minor exceptions. Once the submucosal plane isreached, the myotomy is extended distally to the diaphragm and
Table 2—Results of Thoracoscopic Myotomyin 30 Patients with Achalasia4
proximally to the thoracic inlet.The endoscope plays a less criticalrole than in a left thoracoscopic myotomy because the esophagusis easily identified and because the myotomy is not extendedthrough the esophagogastric junction. Instead, a 52 to 56 Frenchbougie is placed inside the esophagus; this facilitates division of thecircular fibers and separates the edges of the myotomy nicely.
COMPLICATIONS
A delayed esophageal leak is the most common postoperativecomplication. It should be handled as described earlier [seeLaparoscopic Heller Myotomy with Partial Fundoplication,Complications, above].
POSTOPERATIVE CARE
The postoperative course of patients who have undergone thisprocedure is usually identical to that of patients operated on forachalasia.
OUTCOME EVALUATION
Long-term follow-up has confirmed the excellent results initial-ly obtained for diffuse esophageal spasm with either a thoraco-scopic or a laparoscopic approach.26,33 The results for nutcrackeresophagus, however, have been disappointing: a number ofpatients have experienced postoperative dysphagia and recurrentchest pain. In my view, the optimal treatment of nutcracker esoph-agus remains uncertain.The results of operative management areless predictable with nutcracker esophagus than with otheresophageal disorders, and chest pain often is not alleviated.33
Reoperation for GERD
At the UCSF Swallowing Center, an increasing number ofpatients are being seen for evaluation and treatment of foregutsymptoms after laparoscopic antireflux surgery.These patients aretreated as follows.
PREOPERATIVE EVALUATION
Some degree of dysphagia, bloating, and abdominal discomfortis common during the first 6 to 8 weeks after a fundoplication. Ifthese symptoms persist or heartburn and regurgitation occur, athorough evaluation (with barium swallow, endoscopy, esophagealmanometry, and pH monitoring) is carried out with the aim ofanswering the following three questions:
1. Are the symptoms attributable to persistent gastroesophagealreflux?
2. Are the symptoms attributable to the fundoplication itself?3. Can the cause of the failure of the first operation be identified
and corrected by a second operation?
Many patients report heartburn after a fundoplication. It is oftenassumed that this symptom must be the result of a failed operationand that acid-reducing medications should be restarted. In mostcases, however, this assumption is mistaken: postoperative pHmonitoring yields abnormal results in only about 20% of patients.34
The value of manometry lies in its ability to document the changescaused by the operation at the level of the LES and the esophagealbody.The pH monitoring assesses the reflux status and determineswhether there is a correlation between symptoms and actualepisodes of reflux. If abnormal reflux is in fact present, the thera-peutic choice is between medical therapy and a second operation.
Other patients complain of dysphagia arising de novo after theoperation. This symptom is usually attributable to the operationitself and may occur in the absence of abnormal reflux. In addition
to manometry and pH monitoring, a barium swallow is essentialto define the anatomy of the esophagogastric junction. A studyfrom the University of Washington35 found that the anatomic con-figurations observed could be divided into three main types: (1)type I hernia, in which the esophagogastric junction was above thediaphragm (subdivided into type IA, with both the esophagogas-tric junction and the wrap above the diaphragm, and type IB, withonly the esophagogastric junction above the diaphragm); (2) typeII hernia, a paraesophageal configuration; and (3) type III hernia,in which the esophagogastric junction was below the diaphragmand there was no evidence of hernia but in which the body of thestomach rather than the fundus was used for the wrap. In 10% ofpatients, however, the cause of the failure could not be identifiedpreoperatively.33
Some patients present with a mix of postprandial bloating, nau-sea, and diarrhea.These symptoms may be the result of damage tothe vagus nerves. Radionuclide evaluation of gastric emptyingoften helps quantify the problem.
OPERATIVE PLANNING
Patient preparation (i.e., anesthesia, positioning, and instru-mentation) for a reoperation for reflux is identical to that for theinitial laparoscopic fundoplication.
OPERATIVE TECHNIQUE
I routinely attempt a second antireflux operation laparoscopi-cally, but if the dissection does not proceed smoothly, I convert toa laparotomy. To provide a stepwise technical description thatwould be suitable for all reoperations for reflux is impossiblebecause the optimal procedure depends on the original approach(open versus laparoscopic), the severity of the adhesions, and thespecific technique used for the first operation (total or partial fun-doplication).The key goals of reoperation for reflux are as follows.
1. To dissect the wrap and the esophagus away from the crura.This is the most difficult part of the operation.The major com-plications seen during this part of the procedure are damage tothe vagus nerves and perforation of the esophagus and the gas-tric fundus.
2. To take down the previous repair. The earlier repair must becompletely undone and the gastric fundus returned to its natur-al position. If the short gastric vessels were not taken down dur-ing the first procedure, they must be taken down during the second.
3. To dissect the esophagus in the posterior mediastinum so as tohave enough esophageal length below the diaphragm and avoidplacing tension on the repair.
4. To reconstruct the cardia. The same steps are followed as for afirst-time repair. If, after extensive esophageal mobilization, theesophagogastric junction remains above the diaphragm (shortesophagus), esophageal lengthening can be accomplished byadding a thoracoscopic Collis gastroplasty to the fundoplication.To date, however, I have never found this step to be necessary.
COMPLICATIONS
Because the risk of gastric or esophageal perforation or damageto the vagus nerves is much higher during a second antireflux oper-ation, the surgeon must be ready to convert to a laparotomy if thedissection is too cumbersome or the structures are not properlyidentified. Most perforations are recognized and repaired intraop-eratively. Leaks manifest themselves during the first 48 hours.Peritoneal signs are noted if the spillage is limited to the abdomen;shortness of breath and a pleural effusion are noted if spillage also
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8. Patti MG, Arcerito M, Feo CV, et al: An analysisof operations for gastroesophageal reflux disease:identifying the important technical elements. ArchSurg 133:600, 1998
9. Horvath KD, Jobe BA, Herron DM, et al:Laparoscopic Toupet fundoplication is an inade-quate procedure for patients with severe reflux dis-ease. J Gastrointest Surg 3:583, 1999
10. Sonnenberg A, Delco F, El-Serag HB: Empiricaltherapy versus diagnostic tests in gastroesophagealreflux disease: a medical decision analysis. Dig DisSci 43:1001, 1998
11. Johnsson F, Joelsson B, Gudmundsson K, et al:Symptoms and endoscopic findings in the diagno-sis of gastroesophageal reflux disease. Scand JGastroenterol 22:714, 1987
12. Patti MG, Diener U, Tamburini A, et al: Role of
esophageal function tests in the diagnosis of gas-troesophageal reflux disease. Dig Dis Sci 46:597,2001
14. Patti MG, Goldberg HI, Arcerito M, et al: Hiatalhernia size affects the lower esophageal sphincterfunction, esophageal acid exposure, and the degreeof mucosal injury. Am J Surg 171:182, 1996
15. Bytzer P, Havelund T, Moller Hansen J: Inter-observer variation in the endoscopic diagnosis ofreflux esophagitis. Scand J Gastroenterol 28:119,1993
16. Fuchs KH, DeMeester TR, Albertucci M:Specificity and sensitivity of objective diagnosis ofgastroesophageal reflux disease. Surgery 102:575,1987
17. Patti MG, Arcerito M,Tamburini A, et al: Effect oflaparoscopic fundoplication on gastroesophagealreflux disease–induced respiratory symptoms. JGastrointest Surg 4:143, 2000
occurs in the chest.The site of the leak should always be confirmedby means of a contrast study with barium or a water-soluble agent.Perforation is best handled with laparotomy and direct repair of theleak.
OUTCOME EVALUATION
Whereas the success rate is around 80% to 90% for a firstantireflux operation, it falls to 70% to 80% for a second suchoperation. In my view, a second operation should be attempted byan expert team only if medical management fails to control heart-burn or pneumatic dilatation has not relieved dysphagia.
Reoperation for Esophageal Achalasia
Laparoscopic Heller myotomy improves swallowing in morethan 90% of patients. What causes the relatively few failuresreported is still incompletely understood.Typically, a failed Hellermyotomy is signaled either by persistent dysphagia or by recurrentdysphagia that develops after a variable symptom-free interval fol-lowing the original operation.
A complete workup (routinely including barium swallow,endoscopy, manometry, and pH monitoring) is required beforetreatment is planned. In addition, it is my practice to review thevideo of the first operation to search for technical errors that mighthave been responsible for the poor outcome. Such errors typicallyfall into one of the following three categories.
1. A myotomy that is too short either distally or proximally. If themyotomy is too short distally, a barium swallow shows persis-tent distal esophageal narrowing and manometry shows a resid-ual high-pressure zone. If the myotomy is too short proximally,it will be apparent from the barium swallow.
2. A constricting Dor fundoplication. Often, manometry and pHmonitoring yield normal results, but a barium swallow showsslow passage of contrast media from the esophagus into thestomach. In one study from UCSF,31 problems with Dor fun-doplications occurred in four (4%) of 102 patients. Analysis ofthe video records of the first operations showed that in three ofthe four patients, all the stitches in the right suture row hadincorporated the esophagus, the right pillar of the crus, and the
stomach, thereby constricting the myotomy. In one patient, theshort gastric vessels had not been taken down, and the body of the stomach rather than the fundus had been used for thefundoplication.
3. Transmural scarring caused by previous treatment. In patientstreated with intrasphincteric injection of botulinum toxin, trans-mural fibrosis can sometimes be found at the level of the esoph-agogastric junction.This unwelcome finding makes the myoto-my more difficult and the results less reliable.
There are two treatment options for persistent or recurrent dys-phagia after Heller myotomy: (1) pneumatic dilatation and (2) asecond operation tailored to the results of preoperative evaluation.In a 2002 study,36 pneumatic dilatation was successfully used totreat seven of 10 patients who experienced dysphagia postopera-tively; of the remaining three patients, two required a second oper-ation and one refused any treatment.
In the UCSF study just cited,31 however, pneumatic dilatationwas effective in only one of the eight patients in whom it was tried.That patient was the one with a short distal myotomy; none of thefour patients with dysphagia resulting from a poorly constructedDor fundoplication derived any benefit. In two patients who hada short proximal myotomy, the myotomy was successfully extend-ed to the inferior pulmonary vein through a left thoracoscopicapproach. Of the four patients with a constricting Dor fundopli-cation, two underwent a second operation during which the Dorwas taken down, and one of these two had a second myotomy.Currently, both patients are free of dysphagia; however, they expe-rience abnormal reflux and are being treated with acid-reducingmedications.
Reoperation for achalasia is a technically challenging proce-dure. It is of paramount importance to avoid perforating theexposed esophageal mucosa during the dissection. A small holecan be repaired, but a larger laceration might necessitate anesophagectomy. This option should always be discussed with thepatient before the operation.
Overall, about 10% of patients have some degree of dysphagiaafter a Heller myotomy. Pneumatic dilatation, a second operation,or both should always be tried before a radical procedure such asesophagectomy is decided on.
20. Patti MG, Robinson T, Galvani C, et al:Total fun-doplication is superior to partial fundoplicationeven when esophageal peristalsis is weak. J AmColl Surg 198:863, 2004
21. Patterson EJ, Herron DM, Hansen PD, et al:Effect of an esophageal bougie on the incidence ofdysphagia following Nissen fundoplication: aprospective, blinded, randomized clinical trial.Arch Surg 135:1055, 2000
22. Guelrud M, Rossiter A, Souney PF, et al: Theeffect of vasoactive intestinal polypeptide on thelower esophageal sphincter in achalasia. Gas-troenterology 103:377, 1992
23. Tottrup A, Svane D, Forman A: Nitric oxide medi-ating NANC inhibition in opossum lower esoph-ageal sphincter. Am J Physiol 260:G385, 1991
24. Champion JK, Delisle N, Hunt T: Laparoscopicesophagomyotomy with posterior partial fundopli-cation for primary esophageal motility disorders.Surg Endosc 14:746, 2000
25. Oleynikov D, Eubanks TR, Oelschlager BK, et al:Total fundoplication is the operation of choice forpatients with gastroesophageal reflux and defectiveperistalsis. Surg Endosc 16:909, 2002
26. Patti MG, Pellegrini CA, Arcerito M, et al:Comparison of medical and minimally invasivesurgical therapy for primary esophageal motilitydisorders. Arch Surg 130:609, 1995
27. Richards WO, Torquati A, Holzman MD, et al:Heller myotomy versus Heller myotomy and Dorfundoplication for achalasia: a prospective ran-domized, double-blind clinical trial. Ann Surg240:405, 2004
28. Patti MG, Diener U, Molena D: Esophageal acha-lasia: preoperative assessment and postoperativefollow-up. J Gastrointest Surg 5:11, 2001
29. Moonka R, Patti MG, Feo CV, et al: Clinical pre-sentation and evaluation of malignant pseudo-achalasia. J Gastrointest Surg 3:456, 1999
30. Watson DI, Liu JF, Devitt PG, et al: Outcome oflaparoscopic anterior 180-degree partial fundopli-cation for gastroesophageal reflux disease. JGastrointest Surg 4:486, 2000
31. Patti MG, Molena D, Fisichella PM, et al:Laparoscopic Heller myotomy and Dor fundopli-cation for achalasia: analysis of successes and fail-
ures. Arch Surg 136:870, 2001
32. Patti MG, Fisichella PM, Perretta S, et al: Impactof minimally invasive surgery on the treatment ofesophageal achalasia: a decade of change. J AmColl Surg 196:698, 2003
33. Patti MG, Gorodner MV, Galvani C, et al: Thespectrum of esophageal motility disorders: impli-cations for diagnosis and treatment. Arch Surg (inpress)
34. Lord RVN, Kaminski A, Oberg S, et al:Absence ofgastroesophageal reflux disease in a majority ofpatients taking acid suppression medications afterNissen fundoplication. J Gastrointest Surg 6:3,2002
35. Horgan S, Pohl D, Bogetti D, et al: Failed antire-flux surgery: what have we learned from reopera-tions? Arch Surg 134:809, 1999
36. Zaninotto G, Costantini M, Portale G, et al:Etiology, diagnosis and treatment of failures afterlaparoscopic Heller myotomy for achalasia. AnnSurg 235:186, 2002
