DEPARTMENT OF SURGERY UNIVERSITY HOSPITAL csendes 1.15 wed.pdf · department of surgery. university...

LATE RESULTS OF ESOHAGOMYOTOMY IN

PATIENTS WITH ACHALASIA

PROFESSOR AND CHAIRMAN,DEPARTMENT OF SURGERY,

UNIVERSITY OF CHILE

DEPARTMENT OF SURGERYUNIVERSITY HOSPITAL

Which are the late results of oesophagomyotomy in patients with achalasia, usually young adults (40 to 50 years age) with a life expectancy of more than 30 years?


There are many articles dealing with surgical treatment of patients with achalasia.

• The majority with follow up less than 5 years• Very few with follow up longer than 10 years• None with follow up longer than 20 years.


LATE RESULTS IN ACHALASIA SUBMITTED TO OESOPHAGOMYOTOMY

Started 1972 n = 81Closed 1998Follow up ended in 2004 (32 years)Lost from follow up 14 (19%)Included in follow up 67 (81%)- Group I follow up 119 months (15)- Group II follow up 120-239 months (35)- Group III follow up longer to 240 months (17)

Csendes A, Ann. Surg. 2006;243:196.


ESOPHAGOMYOTOMY IN ACHALASIA

Surgical details.- Good exposure GE junction- Section proximal short vessels- 6 to 7 cms length myotomy in esophagus- 10 to 15 mm on stomach-Dor, partial fundoplication

Csendes A, 2010


DETAILS OF ESOPHAGOMYOTOMY

- To assure completeness of myotomy.-To prevent later healing or approximation of muscular bordes of the myotomy.- To avoid too radical myotomy that might result in development of G-E reflux.

Csendes A, 2010



Where should the esophagomyotomyperformed?

Korn O., Csendes A. Dis. Esophag. 2000;13:104

Korn O, Csendes A, Dis. Esoph. 2000;13:104


HOW LONG IS THE MYOTOMY AT GASTRIC SIDE?

121 followed 85 months after surgery.- 24% reflux 1 year after surgery.- 48% reflux 10 years after surgery.

Extension of the incision at the stomach more than 2 cms = 100% incidence of reflux.

Jara F., M. Arch. Surg. 1979;114:935-936.


Dor´s anterior hemifundoplication


ESOPHAGOMYOTOMY ALONE AND MYOTOMY PLUS PARTIAL DOR FUNDOPLICATION

Prospective ramdomized study:Myotomy alone Myotomy plus Dor

LESP(mmHg) 13.7 13.9 n.s.

24-hrs pH 47.6% 9.1% <0.001

Richards W. O. Ann. Surg. 2004;240:405-415.



Richards W.O., Ann. Surg.2004;240:405-415.

COMPLICATIONS OF ESOPHAGOMYOTOMY

1.- Mucosal tear, usually at the distal portion.

2.- Not recognized burning of the mucosa.


LATE RESULTSN = 67

- 3 patients (45%) developed epidermoid carcinoma 8, 9 and 15 years after surgery.

- 64 patients were alive and followed by subjective and objective evaluations.


CLINICAL AND LABORATORY EVALUATIONS IN ALL PATIENTS N = 64

- Clinical questionnaire 100%- Endoscopic evaluation 100%- Radiological studies 100%- Histological analysis 100%- Manometric evaluation 192 times

(3 times each)- 24 h pH studies 100%



CLINICAL FEATURES OF PATIENTS WITH ACHALASIA SUBMITTED TO OESOPHAGOMYOTOMY

Group I Group II Group III

Follow up (mo) 88 173 281Heartburn 30% 38% 37% n.s.Dysphagia 15% 32% 30% n.s.Gain of weight 100% 97% 94% n.s.




PREOP 1 MONTHS AFTER SURGERY

RADIOLOGICAL EVALUATIONS BEFORE AND 1 MONTH AFTER SURGERY

Internal diameterGO junction

Internaldiametermiddlethirdoesophagus (mm)

0

2

4

6

8

10

12

BeforeOperation

1 monthsafter surgery

P <0.001

P <0.001

05

101520253035404550

BeforeOperation

1 monthsafter surgery



ENDOSCOPIC EVALUATION LATE AFTER OESOPHAGOMYOTOMY

Group I Group II Group IIIn = 13 n = 34 n = 17

Oesophagitis 7.7%(1) 5.9%(2) 29.4%(5) n.s.

Barrett´s Oesophagus 7.7%(1) 17.6%(6) 29.4%(5) n.s.

Carcinoma 15.4%(2) 2.9%(1)



FIG. 1. LOWER ESOPHAGEAL SPHINCTER PRESSURE BEFORE OPERATION AND 1 YEAR AND AT LATE

CONTROL AFTER SURGERY


AFTER OPERATIONS

n.s.

P < 0.001 9

05

10152025303540

Preop Lateafter

surgery

mm

Total length L.O.S. Abdominal length L.O.S.

0

5

10

15

Preop Lateafter

surgery

mmn.s.

n.s.


Csendes A. Ann. Surg. 2006;243:196.

MANOMETRIC FEATURES OF OESOPHAGEAL BODY LATE AFTER OESOPHAGOMYOTOMY


Amplitude (mmHg)Preop 19 15 20Postop 38 25 35

% peristalsisPreop 0 0 12%Postop 15 0 17%



% PATIENTS WITH ABNORMAL 24-H pH STUDIES

05

101520253035404550

Group I n =13

Group II n= 34

Group III n= 17


n.s n.s

P < 0.05%ofpatients


HISTOLOGICAL FINDINGS DISTAL TO SQUAMO-COLUMNAR JUNCTION

%patients

H. Pylori 23% 20.6% 17.6%


010203040506070

Group Iup to119

months

Group II120-239months

GroupIII > 240months

Fundic mucosaCardiac mucosaIntestinal metaplasia

24 H pH STUDIES ACCORDING TO THE LENGTH OF BARRETT OESOPHAGUS

N = 12

A.- Short-segment BO: n = 9 (75%)15-25 mm = 17.2%

B.- Long-segment BO: n = 3 (25%)35-40 mm = 24.3%



Visick I-II 12(92.3%) 26(76.9%) 11(64.7%) p<0.05Visick III-IV 1(7.7%) 7(20.5%) 6(35.3%) p<0.05

- GOR 1 7 6-Incomplete myotomy 0 1 0

Development ofBO 1(7.7%) 6(17.6%) 5(29.4%)

Csendes A, Ann. Surg. 2006;243:196


FINAL CLINICAL RESULTS (EXCLUDING CARCINOMA)N = 64

LATE RESULTS IN SURGICALLY MANAGED OESOPHAGEAL ACHALASIA

Pearson G., Ann. Thorac. Surg. 1994;58:1343.

Visick I-II 95% 1 year68% 10 year67% > 20 year

Deterioration of initially good results due to late development of disabling reflux disease.


LATE RESULTS OF ESOPHAGOMYOTOMY FOR ACHALASIA (FOLLOW UP > 100 MONTHS)

Author n Follow up Improvement GER(months)

Jaakola (1991) 26 104 46% 39%Picciocchi (1993) 101 114 89% 11%Malthaner (1994) 22 120 67% 35%Mineo (2004) 39 107 90% 8%Mathioli (2006) 123 105 88% 8%Csendes (2006) 67 190 73% 25%


RESULTS AFTER LAPAROSCOPIC ESOPHAGOMYOTOMY IN ACHALASIA

39 authors3086 patientsFollow up 35 monthsImprovement 89%GE reflux a.- With antireflux surgery 8.8%

b.- Without antireflux surgery 31.5%

Campos G., Ann. Surg. 2009;249:45-57.


CONCLUSIONS I

1.- Lower oesophageal sphincter pressure remains in a similar low value (near 10 mmHg) along the follow up.

2.- There is no recovery of peristalsis at the late follow up.

3.- Pathologic acid reflux increases significantly as follow up is longer (more than 20 years).


CONCLUSIONS II

4.- Intestinal metaplasia at the distal oesophagus appears almost exclusively in patients with abnormal acid reflux.

5.- The prevalence of intestinal metaplasia (Barrett´s oesophagus) increases parallel to the length of follow up.

6.- There is a progressive deterioration of good results if the follow up is very long.

<10 years 92% of Visick I-II> 20 years 65% of Visick I-II


“DIFFICULT” ACHALASIAS

N° patients

- With epiphrenic diverticula 4

- “Sigmoid shape” esophagus 6

- Peptic strictures with Barrett´s esophagus 12

- Failed esophagomyotomy 5


EPIPHRENIC DIVERTICULA

- Laparoscopic approach

- Pinotti´s maneuver

- Extensive dissection of GE junction and distal esophagus

- Resection of diverticula with EndoGIA and placing a bougie 36 inside the lumen.

- Esophagomyotomy plus Dor fundoplication







POSTOPERATIVE APPEARANCE

“SIGMOID SHAPE” ESOPHAGUS

- Classic esophagomyotomy = only partial results in 50%.

- Laparoscopic esophaguectomy and gastric ascensus by posterior mediatinum.a.- Complex operationb.- Hemotorax in 2 patients



SIGMOID SHAPE ESOPHAGUS

ACHALASIA OF THE ESOPHAGUS: CLASSIFICATION

Type IV Severe:Dilatation > 10 cm(mega-esophagus, sigmoïd)


PEPTIC STRICTURES OF THE ESOPHAGUS WITH BARRETT´S ESOPHAGUS

- Laparotomic or laparoscopic approach.

- Inverted cardioplasty+ antrectomy and Roux-en-Y anastomosis.


Braghetto I, Csendes A., Dis. Esoph. 1998;11:58-61.

ESOPHAGEAL ACHALASIA:CURRENT TREATMENT

Alternative in selected cases: Esophagus - cardioplastyinverted Y + VT + antrectomy+ Roux en Y gastrojejunalanastomosis.

Braghetto I., Diseases of the Esophagus1998;11:58-61



POSTOPERATIVE GASTROESOPHAGEAL REFLUX


POSTOPERATIVE BARRETT´S ESOPHAGUS


POSTOPERATIVE BARRETT´S ESOPHAGUS

CAUSES FOR FAILED ESOPHAGOMYOTOMY

- Short and insufficient esophagomyotomy

- Incomplete myotomy (intact circular fibers)

- Fibrous healing of myotomy.

- Very tight fundoplication.


FAILED ESOPHAGOMYOTOMY

- Laparotomic reoperation.

- Stricture at the distal end of GE junction.

- Re-myotomy until 15 mm to the stomach and Dor fundoplication.





WHY A PREVIOUS ENDOSCOPIC THERAPY INCREASES COMPLICATIONS DURING ESOPHAGOMYOTOMY.

1.- With Botox: severe fibrotic reaccion at the GE junction, making difficult to separate muscular layer from mucosa.

Patti M., Dig. Dis. Sci. 1999;44:2270-2276.Horgan S., Surg. Endosc. 1999;13:576-579.

2.- With pneumatic dilatation: It produces hematoma and fibrosis at the GE junction.

Morino M., Surg. Endosc. 1997;11:359-361.Vantrappen G., Gut 1971;12:268-277.West RL., Dig. Dis. Sci. 1998;43:1973-1974.


LESSONS LEARNED AFTER 40 YEARS TREATING PATIENTS WITH ACHALASIA.

154 patients laparotomic172 patients laparoscopica.- Abdominal approach is better than thoracic approach.b.- Laparoscopic approach is ideal.c.- Esophagomyotomy at least 6 cms and 10 to 15 mm at the stomach. d.- Partial fundoplication decreases postop. reflux.

Csendes A., 2010


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