Two Decades of Experience with Modified Hellefs Myotomy for Achalasia Ganesh I?. Pai, M.D., R. G. Ellison, M.D., J. W. Rubin, M.D., C.M., and H. V. Moore, M.D. ABSTRACT We reviewed the hospital records of 36 patients who underwent modified Heller s myotomy for achalasia between January, 1961, and December, 1982. There were 18 male and 18 female patients ranging between 17 months and 75 years old. The most frequent symptom was dysphagia, followed by regurgitation of ingested food and weight loss. Modified Heller s myotomy was performed through a transthoracic incision in 35 patients and a transabdominal incision in l. An antireflux procedure in addition to esophagomyotomy was performed in 20 patients. There was 1 postoperative death. Thirty-three patients were followed up for periods ranging from 9 months to 21 years. The results were considered good in 27, fair in 2, and poor in 4. One of the 4 underwent repeat esophagomyotomy 7% years after the initial operation with a good result. The remaining 3 had an antireflux procedure at the time of esophagomyotomy. Because of recurrence of symptoms, esophagogastrostomy was performed in 1 and colon interposition in 2. These results suggest that an antireflux procedure should not be added to modified Heller s operation in the treatment of achalasia. Seventy years have passed since Heller [l] described the technique of esophagomyotomy in the treatment of esophageal achalasia. His technique included an anterior and a posterior lower esophageal myotomy extending onto the cardia. Modification of Heller s operation consisting of a single anterior esophagomyotomy was reported 9 years later by Zaaijer [2]. This technique is still widely used in the treatment of achalasia and provides good results. During the last two decades because of a high incidence of reflux esophagitis following esophagomyotomy [3-61, some surgeons routinely added an antireflux procedure at the time of esophagomyotomy [3, 7-91. Within that period, some of our patients who underwent the modified Heller s procedure had a concomitant antireflux procedure. This report examines our results of esophagomyotomy with and without an antireflux procedure. From the Section of Thoracic and Cardiac Surgery, Medical College of Georgia, Eugene Talmadge Memorial Hospital, Augusta, GA. Presented at the Thirtieth Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 3-5, 1983. Address reprint requests to Dr. Fai, Section of Thoracic and Cardiac Surgery, Medical College of Georgia, Augusta, GA 30912. Material and Methods Thirty-six patients with symptomatic achalasia underwent modified Heller s myotomy between January, 1961, and December, 1982, at the Medical College of Georgia in Augusta. The study group (Fig 1) was composed of 18 male and 18 female patients between 17 months and 75 years of age (mean, 43.2 years). Dysphagia was the presenting symptom in all patients. Regurgitation of previously ingested food occurred in 20 (56%) and weight loss in 18 (50%). Pain and hematemesis were infrequent complaints in this series. The duration of symptoms ranged from a few weeks to 25 years. The diagnosis in all patients was based on the results of barium esophagography. In the last 5 years of the study, esophageal manometry was utilized in 4 patients to substantiate the diagnosis. Preoperatively, hydrostatic dilation was performed in 7 patients; relief of symptoms ranged from a few days to 2 months. In 1 patient, hydrostatic dilation resulted in esophageal perforation. The esophagus was approached by a left thoracotomy in 35 patients and by a laparotomy in 1. During the transthoracic approach, the esophagus was mobilized with careful preservation of the vagus nerves. After exposure of the lower esophagus, the myotomy usually was performed over a large (50F) Hurst or Maloney dilator. Precautions were taken to minimize dissection at the esophagogastric junction. The length of the myotomy was recorded in 31 of the 36 patients and ranged from 5 to 12 cm, most commonly 8 to 10 cm. The myotomy was also extended onto the stomach for a distance of 0.5 to 2 cm. The esophageal mucosa was carefully dissected away from the muscle layer for about one-half of the circumference of the esophagus. In 10 patients operated on early in the series, the fundus of the stomach was opened transversely so that the myotomy could be carried out with an index finger in the cardia and lower esophagus. The gastrotomy was closed in two layers. An esophageal diverticulum was excised in 1 patient. During myotomy, the esophageal mucosa was inadvertently entered in 5 patients, none of whom had a complicated postoperative course. The mucosal perforations were repaired by interrupted nonabsorbable suture material. An antireflux procedure was performed in 20 patients. A Belsey Mark IV repair was done in 17, Allison s repair in 2, and Nissen s fundoplication in 1. The transabdominal approach was utilized in the patient in whom hydrostatic dilation resulted in disruption of the lower esophagus and cardia. Esophagomyotomy 201
202 The Annals of Thoracic Surgery Vol 38 No 3 September 1984 Table 1. Results of Esophagomyotomy Fig 1. Age distribution of patients undergoing esophagomyotomy. Ages are shown in years. was carried out after repair of the lacerated mucosa, and a Nissen fundoplication was performed to reinforce the esophageal repair. Results Of the 35 patients who were discharged from the hospital, 33 were followed up for periods ranging from 9 months to 21 years (mean, 65 months). A detailed history, physical examination, and barium esophagogram were routinely obtained at the time of follow-up. The criteria for evaluating the success of esophagomyotomy were based on the degree of relief of symptoms postoperatively. Results were considered to be good if the patient was totally relieved of dysphagia and gained weight. Results were considered fair if the patient had some improvement over the preoperative symptoms but experienced residual dysphagia. Results were considered poor if the patient showed no improvement in symptoms. Table 1 summarizes the results of operation. Based on these criteria, results were good in 27, fair in 2, and poor in 4. Of the 4 with poor results, 1 had esophagomyotomy alone and the other 3 had a concomitant antireflux procedure. The case histories of these patients follow. Case Reports PATIENT 1. A 17-month-old boy was seen with a 1-year history of dysphagia, weight loss, and recurrent bouts of upper respiratory infection. A barium esophagogram (Fig 2A) demonstrated findings consistent with achalasia. A 12-cm myotomy was performed through a left thoracotomy that extended 1 cm below the esophagogastric junction. The patient had excellent symptomatic relief for 7 years, after which dysphagia recurred. A barium esophagogram at that time revealed a lower esophageal obstruction and massive dilatation of the upper esophagus (Fig 2B). Esophagomyotomy combined with Nissen fundoplication was performed through a thoracoabdominal incision with excellent relief of symptoms (Fig 2C). At the time of reoperation, the cause of the recurrent obstruction was observed to be due to formation of dense scar tissue at the esophagomyotomy site. PATIENT 2. A 47-year-old man with a history of dysphagia, regurgitation, and weight loss of 22.68 kg underwent an 11-cm esophagomyotomy extending 1 cm onto the stomach. A 2-mm hole in the esophageal mucosa Variable No. of patients Sex distribution Mean age (yr) Mean duration of follow-up (mo) Postop deaths (early) Lost to follow-up Results of operation Good Fair Poor Esophago- Esophagomyotomy + myotomy Antireflux Alone Procedure 16 8M,8F 43 61 0 0 15 (94%) 0 1 (6%) 20 10 M, 10 F 43 69 1 L 12 (70%) 2 (12%) 3 (18%) was sutured with fine silk. A Belsey antireflux procedure was performed, and the patient was asymptomatic for a year. During the follow-up period, symptoms of reflux developed. A sliding hiatus hernia associated with severe reflux esophagitis, esophageal ulceration, and gastric hyperacidity was noted at this time. Vagotomy, pyloroplasty, and a Belsey antireflux procedure were carried out. Dysphagia persisted despite antegrade dilations. Colon interposition was performed with good symptomatic relief for 6 years. Because of progressive dysphagia, the patient was hospitalized at another institution and underwent esophagogastrostomy. PATIENT 3. A 22-year-old man with a 2-year history of dysphagia and weight loss underwent a modified Heller myotomy and an Allison repair of hiatus hernia (Fig 3A). He had no improvement of symptoms and continued to have dysphagia, which improved minimally after periodic dilations, and severe gastroesophageal reflux, which resulted in a lower esophageal stricture (Fig 3B). Colon interposition was performed with good results (Fig 3C). PATIENT 4. A 61-year-old man underwent esophagomyotomy and Belsey Mark IV repair for symptomatic achalasia (Fig 4A). He was symptom free for 6 years following operation; then progressive dysphagia and weight loss developed. A barium esophagogram showed a markedly dilated esophagus with a distal stricture (Fig 4B). Esophagogastrostomy was performed with the anastomosis to the cervical esophagus (Fig 4C). Excellent symptomatic relief was achieved. Eight weeks later, the diseased esophagus was excised through a right thoracotomy. The patient has been well since then. Deaths and Complications There was 1 postoperative death in this series. A 61- year-old woman underwent a technically uncomplicated operative procedure. Pneumonia, Gram-negative septicemia, septic shock, and renal failure developed, and she died fourteen days after operation.
203 Pai et al: Modified Heller's Myotomy for Achalasia A B Fig 2. (A) Preoperative barium esophagogram shows findings consistent with achalasia. ( B ) Barium esophagogram made 7 years after esophagomyotomy demonstrates markedly dilated thoracic esophagus and almost total obstruction at esophagogastric junction. (C) Barium esophagogram made a year after repeat esophagornyotomy and Nissen fundoplication shows good results. A B Fig 3. (A) Preoperative barium esophagogram reveals findings consistent with achalasia. ( B ) Barium esophagogram made 2% years after esophagornyotomy and Allison's repair shows distal esophageal stricture. (C) Barium esophagogram made 3 months after colon interposition shows good results. C C
204 The Annals of Thoracic Surgery Vol 38 No 3 September 1984 A B C Fig 4. (A) Preoperative barium esophagogram shows findings consistent with achalasia. (B) Barium esophagogram made 10 years after esophagomyotomy and Belsey repair demonstrates distal esophageal obstruction. (C) Barium esophagogram made 3 months after esophagogastrostomy (stomach brought up retrosternally and anastomosis in the neck) reveals good results. A subphrenic abscess developed postoperatively in the patient who sustained an esophageal perforation during hydrostatic dilation. Laparotomy and drainage of the abscess resolved the problem. Atelectasis of the left lower lobe developed in 1 patient and a pleural effusion in another; both conditions resolved without sequelae. Symptoms occurring after esophagomyotomy with and without an antireflux procedure are summarized in Table 2. Two patients died late of causes unrelated to the operative procedure. Primary adenocarcinoma of the right lung developed in a 61-year-old man 7 years after esophagomyotomy. He died of metastatic disease 3 years after a right lower lobectomy. A 16-year-old boy died of complications of juvenile diabetes, ketoacidosis, and bilateral bacterial pneumonia 3% years after esophagomyotomy. Comment Achalasia cardia, a functional disease of the esophagus, is characterized by a disturbance of esophageal motility with uncoordinated peristalsis in the lower two-thirds of the esophagus and the failure of the physiological sphincter at its lower end to open in coordination with swallowing. The etiology of this abnormality is unknown. Histological study of the involved esophagus demonstrates numerous changes in the ganglion cells of Auerbachs plexus. The ganglion cells are either absent or decreased in number and are sometimes accompanied by marked infiltration of round cells. It is not known whether these changes represent a primary or secondary manifestation of the disease. Pathological studies by Cassella and associates [lo] demonstrated that in addi- Table 2. Symptoms after Esophagomyotomy Operative No. of Patients No. of Patients Gastroesophageal Pulmonary Symptoms Procedure Involved Followed Up Dysphagia Regurgitation Reflux from Aspiration Esophagomyotomy 16 16 1 1 1 0 alone Esophagomyotomy 17 14 4 3 2 1 + Belsey repair Esophagomyotomy 2 2 1 0 0 0 + Allison repair Esophagomyotomy 1 1 0 0 0 0 + Nissen repair Total 36 33 6 4 3 1
205 Pai et al: Modified Heller s Myotomy for Achalasia tion to the changes in Auerbach s plexus, the vagus nerves also revealed wallerian degeneration and marked diminution in the cell counts of the central motor nuclei of the vagus nerves. Changes similar to those seen in achalasia were reproduced in an experimental model by Higgs and colleagues [ll] when they destroyed the central motor nuclei of the vagi in dogs and cats using stereotaxic techniques. The failure of coordinated relaxation of the lower end of the esophagus together with ineffective peristalsis of the body of the esophagus results in functional obstruction. This is followed by progressive dilatation of the proximal esophagus, dysphagia, regurgitation, weight loss, and often symptoms related to pulmonary aspiration. Since there are no known methods by which the normal motility pattern of the esophagus can be restored, surgical therapy is directed toward drainage of the esophagus by esophagocardiomyotomy [12, 131. During the last 20 years, a high incidence of gastroesophageal reflux [3-61 and esophagitis following esophagocardiomyotomy led to the addition of an antireflux procedure to complement the myotomy [3, 7-9, 14, 151. Barker and Franklin [16] reported a 37% incidence of postoperative reflux esophagitis. Barlow [17] noted the development of reflux esophagitis in 21 of his 59 patients who underwent Heller s operation; esophageal strictures developed in 6 of them. Several authors have studied this serious problem of reflux that develops after esophagomyotomy. Ellis and Cole [6] presented a series of 56 patients with achalasia, 16 of whom experienced reflux after operation; 7 were asymptomatic. The authors thought the factors contributing to the development of reflux included duodenal ulceration, previous esophageal operations, double and strip myotomies, and disruption of the hiatus. Utilizing esophageal ph measurements with the standard acid reflux test, Peyton and co-workers [7] observed a 50% incidence of gastroesophageal reflux in patients with achalasia compared with a 21% incidence by radiography in the same group of patients. Therefore, they stressed the necessity for the antireflux procedure as a routine addition at the time of esophagomyotomy. However, their findings refuted those of a prior study indicating the rarity of hiatus hernia and associated reflux with achalasia [MI. Numerous procedures have been advocated to complement esophagocardiomyotomy. Effler and coworkers [19] proposed reconstruction of the hiatus and phrenoesophageal ligament to anchor the cardia below the diaphragm. Rees and colleagues [20] suggested the addition of vagotomy and a drainage procedure or vagotomy with gastric resection to accompany esophagocardiomyotomy. Nelems and associates [21] advocated mobilization of the stomach to ensure adequate myotomy, and formal repair of the hiatal hernia so created by a partial fundoplication of the Belsey type. Black and co-authors [14] reported excellent results with the Collis plastic repair. Menguy [22] obtained good results with transabdominal cardiomyotomy and Nissen fundoplication. Gallone and colleagues [23] proposed proximal gastric vagotomy and anterior fundoplication as a complementary procedure to Heller s operation. Duranceau and co-workers [9] reported excellent results in 12 patients with achalasia who underwent esophageal myotomy plus short (2 cm) total fundoplication over a 56F mercury bougie. In an experimental evaluation, Ellis and associates [24] performed three types of myotomy on 20 dogs. Analysis of the results indicated that esophagocardiomyotomy of an adequate length with extension of only a few millimeters over the stomach provided excellent esophageal drainage without development of reflux. On the other hand, when the myotomy extended several centimeters below the gastroesophageal junction, 34% of patients had reflux. In two large series [25, 261, the problem of postmyotomy reflux after a simple esophagomyotomy was encountered in only 3% of patients. The authors of both series concluded that a concomitant antireflux procedure is unnecessary. In our series, only 1 of the 16 patients who underwent simple esophagomyotomy had dysphagia that necessitated a repeat myotomy. The other 15 had good results. There were mild symptoms of reflux in only 1. Of the 17 patients who had a concomitant antireflux procedure at the time of myotomy 12 had good results on long-term follow-up. Five had unsatisfactory results; 3 of them required operative procedures to bypass the lower esophageal obstruction. This experience suggests than an antireflux procedure in addition to myotomy is not needed and perhaps is contraindicated because of the high incidence of complications. References 1. Heller E: Extramukose Kardioplastic beim chronischen Cardiospasmus mit Dilatation der Oesophagus. Mitt Grenzeb Med Chir 27:141, 1913 2. Zaaijer JH: Cardiospasm in the aged. Ann Surg 77615,1923 3. Mansour KA, Symbas PN, Jones EL, Hatcher CR A combined surgical approach in the management of achalasia of the esophagus. Am Surg 42:192, 1976 4. Jara FM, Toledo-Pereyra LH, Lewis JW, Magilligan DJ: Long-term results of esophagomyotomy for achalasia of the esophagus. Arch Surg 114:935, 1979 5. Jekler J, Lhotka J, Borek J: Surgery for achalasia of the esophagus. Ann Surg 160793, 1964 6. Ellis F, Cole FL: Reflux after cardiomyotomy. Gut 6:80, 1965 7. Peyton MD, Greenfield LJ, Elkins RC: Combined myotomy and hiatal hemiorrhaphy: a new approach to achalasia. Am J Surg 128:786, 1974 8. Veiga-Fernandes F, Pinheiro MF, Didia-Guerreiro: Cardiomyotomy associated with anti-reflux surgery in treatment of achalasia. World J Surg 5697, 1981 9. Duranceau A, La Fontaine ER, Vallieres B: Effects of total fundoplication on function of the esophagus after myotomy for achalasia. Am J Surg 14322, 1982 10. Cassella RR, Brown AL, Sayre GP, Ellis FH Jr: Achalasia of the esophagus: pathologic and etiologic considerations. Ann Surg 160:474, 1964 11. Higgs B, Kerr FWL, Ellis FH Jr: The experimental produc-
206 The Annals of Thoracic Surgery Vol 38 No 3 September 1984 tion of esophageal achalasia by electrolytic lesions in the medulla. J Thorac Cardiovasc Surg 50:613, 1965 12. Le Roux BT, Wright JT: Cardiospasm. Br J Surg 48:619, 1961 13. Barrett NR: Achalasia of the cardia: reflection upon a clinical study of over 100 cases. Br Med J 13135, 1964 14. Black J, Vorback AN, Collis JL: Results of Heller s operation for achalasia of the oesophagus: the importance of hiatal repair. Br J Surg 63:949, 1976 15. Belsey R Functional disease of the esophagus. J Thorac Cardiovasc Surg 52:164, 1966 16. Barker JR, Franklin RH Heller s operation for achalasia of the cardia: a study of the early and late results. Br J Surg 58:466, 1971 17. Barlow D: Problems of achalasia. Br J Surg 48:642, 1961 18. Binder HJ, Clemett AR, Thayer WR, Spiro HM: Rarity of hiatus hernia in achalasia. N Engl J Med 272:680, 1965 19. Effler DB, Loop FD, Groves L, Favaloro RG: Primary surgical treatment for esophageal achalasia. Surg Gynecol Obstet 132:1057, 1971 20. Rees JR, Thorbjarnarson B, Barnes WH: Achalasia: results of operation in 84 patients. Ann Surg 171:195, 1970 21. Nelems JMB, Cooper JD, Pearson FG: Treatment of achalasia: esophagomyotomy with anti-reflux procedure. Can J Surg 23:588, 1980 22. Menguy R: Management of achalasia by transabdominal cardiomyotomy and fundoplication. Surg Gynecol Obstet 133:482, 1971 23. Gallone L, Peri G, Galliera M: Proximal gastric vagotomy and anterior fundoplication as complementary procedures to Heller s operation for achalasia. Surg Gynecol Obstet 155:337, 1982 24. Ellis FH Jr, Kiser JC, Schlegel JF, et al: Esophago-myotomy for esophageal achalasia: experimental, clinical and manometric aspects. Ann Surg 166:640, 1967 25. Okike N, Payne WS, Neufeld DM, et al: Esophagomyotomy versus forceful dilation for achalasia of the esophagus: results in 899 patients. Ann Thorac Surg 28:119, 1979 26. Ellis FH Jr, Gibb PS, Crozier RE: Esophagomyotomy for achalasia of the esophagus. Ann Surg 192:157, 1980