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Del Grande et al. Myotomy in end stage achalasia

LAPAROSCOPIC HELLER’S MYOTOMY
ROLE IN END-STAGE ACHALASIA

Esophageal dilatation is more frequent in Chagas’
disease esophagopathy compared to idiopathic
achalasia with esophageal diameter over 10 cm found
from 10% to 37% of the cases . This observation
[4]
may explain the lack of international literature on the
treatment for massive dilated esophagi. Moreover,
end-stage achalasia is defined by esophageal
dilatation superior to 10 cm in Brazil, thus esophagi
between 6-10 cm will not be defined as advanced in
the Brazilian series and will probably undergo a LHM.

Esophageal resection is the procedure historically
established for end-stage achalasia in Latin
America as well as globally [11,23-27] . The number of
esophagectomies for the treatment of achalasia has
been decreasing after the 1990s [28] in favor of less
invasive methods since esophagectomy is associated
with significant complications and mortality [29] .
Moreover, surgical risk is directly linked to the degree of
esophageal dilatation [30] . Minimally invasive techniques
decreased morbidity although they are still especially
considering achalasia is a benign disease [31] . Other
Figure 1: Massive dilated megaesophagus in a patient with conservative surgical techniques were tried to minimize
Chagas’s disease esophagopathy
complications, such as cardioplasty + gastrectomy
(Holt and Large procedure, known in Brazil as Serra-
with marked esophageal dilatation or sigmoid-shaped Dória operation [32-34] ), esophageal mucosectomy and
esophagus the ideal surgical procedure is debatable . endomuscular gastric tube reconstruction [35] and
[9]
Esophagectomy is believed by several authors to be laparoscopic cardioplasty [36,37] . Long term results for
the operation of choice in these cases [11] . However, these procedures in a significant number of patients
others advocate for less invasive alternatives . are lacking.
[6]
This review discusses the role of LHM as the preferred Few series evaluated the results of LHM for the
treatment for achalasia irrespective of the degree of treatment of end-stage achalasia [Table 1]. Some
esophageal dilatation. advocate LHM as the primary option for advanced
diseases based on the idea that an esophagectomy
LAPAROSCOPIC HELLER’S MYOTOMY could be avoided. Others believe that a massive
ROLE IN NON-ADVANCED ACHALASIA and tortuous esophagus does not empty well if only
the obstacle at the esophagogastric junction is
LHM was described in the early 1990s [12,13] and alleviated [45-47] and found worse results for LHM when
since became a wildly accepted procedure for non- the esophagus is dilated [48,49] .
advanced achalasia [14] . Forceful pneumatic dilatation
of the cardia is also a widespread primary therapy [15] There are no prospective comparative studies
but recent meta-analyses showed inferior results to comparing LHM with other techniques for end-
dilatation as compared to LHM [10,16] . Indeed, a shift to stage achalasia. Some authors show similar
LHM to endoscopic dilatation has occurred [17] . LHM is outcomes (complications and dysphagia control)
associated to low rates of complications, null mortality, for LHM irrespective of the degree of esophageal
and excellent and long-lasting outcomes superior to dilatation [9,38,42,45] . In general, excellent results may be
90% of dysphagia relief in most series [18-20] . LHM is obtained from 54-100% of the cases, with an average
still the gold-standard treatment for non-advanced of almost 80% [Table 1].
achalasia that must be used to compare the outcomes
of other treatments such as the newly developed LHM is not more demanding in patients with massive
peroral endoscopic myotomy (POEM) [21,22] . dilated esophagus [38] . A careful dissection of the
122 Mini-invasive Surgery ¦ Volume 1 ¦ September 30