Chapter 40: Esophageal Myotomy, Laparoscopic

INDICATIONS

The manifestations of achalasia include chest pain, dysphagia, and in late situations malnutrition. Most patients have been treated for some length of time for the presumptive diagnosis of gastroesophageal reflux disease, but on objective evaluation the classic findings of aperistalsis of the esophagus and nonrelaxation of the lower esophageal sphincter are realized. Radiographic evidence may demonstrate long-standing disease and, in some situations, a dilated and distended esophagus.

The treatment of achalasia can be multidisciplinary. Endoscopic surveillance and exclusion of malignancy or mechanical obstruction are important. Injection of botulin toxin into the lower esophageal sphincter has been shown to provide relief, although this relief is temporary, and repeated injections may further complicate later definitive therapy. Botox injection for the treatment of achalasia should only be considered as a temporizing measure or as palliative therapy in selected patients. Pneumatic dilatation of the lower esophageal sphincter with a 3- or 4-cm balloon can be considered. This should be done under fluoroscopic guidance, and reports have demonstrated reasonable success rates, especially when combined with salvage therapy or recurrent dilatation. Despite these successes, surgical intervention remains the first-line therapy for most patients and is associated with good outcomes. Peroral endoscopic myotomy is an emerging therapy that allows for division of the circular muscle fibers alone via a transoral–transmucosal route and is under evaluation.

PREOPERATIVE PREPARATION

Patients should be screened for other medical conditions. In addition, careful attention should be paid to the risk of pulmonary disease because chronic aspiration maybe a significant factor. Malnutrition likewise should be addressed. When a dilated esophagus is seen or a chronic disease is suspected, careful preparation of the esophagus should be undertaken. Many patients require a liquid-only diet for several days prior to surgery to allow most of the solid contents of the esophagus to be gone at the time of induction of anesthesia and operative intervention. In planning the operative approach, the two standard approaches have been the left chest or through the abdomen. After extensive experience with laparoscopic exposure and laparoscopic manipulation of the gastroesophageal junction, the preferred method is now a transabdominal laparoscopic Heller myotomy.

ANESTHESIA

Patients are given a general anesthetic with careful attention to prevent aspiration on induction.

POSITION

Patients are placed in a supine position and can be in a leg split position with the arms extended or tucked at the sides. The operating surgeon can then stand between the patient's leg with an assistant on each side.

OPERATIVE PREPARATION

The patient is kept at noting by mouth after midnight. Standard prophylactic antibiotics are administered within 1 hour of the incision. Prophylaxis for thromboembolism is administered. Then a time-out is performed.

DETAILS OF THE PROCEDURE

Variable trocar positioning can be used, ...