Thoracic Surgery Interesting Case Hadley Wesson February 21, 2013 49 yo female with history of achalasia Left thoracotomy with Heller myotomy in 1979 Symptoms resolved until late 1980s Underwent multiple dilations without improvement Manometry 3 years ago Aperistalsis Incomplete relaxation of the LES Taken to OR for redo laparoscopic Heller myotomy and Dor fundoplication Intra-operatively 5 cm 3 cm Heller myotomy 3 cm Dor fundoplication Surgical Approaches to Achalasia Advances in the field since 1979 Achalasia Motility disorder of the esophagus Diagnosed by manometry Incomplete relaxation of the LES Aperistalsis of the esophageal body Surgical Treatment Directed at obliterating the dysfunctional LES Myotomy of the lower esophagus and GEJ Surgical Treatment Directed at obliterating the dysfunctional LES Myotomy of the lower esophagus and GEJ 2 incision approach described by Heller in 1913 Modified in 1923 into a single incision Surgical Treatment In 1962, Dor described a partial fundoplication Fundus is anchored to the right myotomized esophagus and right crus Operative Controversies Role of minimally invasive surgery Addition of a concurrent antireflux procedure The length of the myotomy Role of Minimally Invasive Surgery Reported Swallowing Results in Long Run Role of Minimally Invasive Surgery Reported Swallowing Results in Long Run Role of Minimally Invasive Surgery Effect of Laparoscopic Heller Myotomy Mean esophageal diameterLES pressure Operative Controversies Role of minimally invasive surgery Addition of a concurrent antireflux procedure The length of the myotomy Operative Controversies Role of minimally invasive surgery Addition of a concurrent antireflux procedure The length of the myotomy Concurrent antireflux procedure Does Dor fundoplication affect incidence of pathologic GER? N=43 patients 21 Heller 22 Heller plus Dor Follow up 3-5 months with pH study and questionnaire Concurrent antireflux procedure Pathologic GER Heller: 48% Heller + Dor: 9% RR 0.11 (95% CI ; P=0.01) Concurrent antireflux procedure Distal esophageal acid exposure was lower Myotomy Length Traditionally, the recommendation was to end the myotomy as it crossed the GEJ (0.5 cm) Preserved an effective anti-reflex barrier Myotomy Length Traditionally, the recommendation was to end the myotomy as it crossed the GEJ (0.5 cm) Preserved an effective anti-reflex barrier In the 1990s, recommended length was 1.5 cm Myotomy Length Traditionally, the recommendation was to end the myotomy as it crossed the GEJ (0.5 cm) Preserved an effective anti-reflex barrier In the 1990s, recommended length was 1.5 cm In 1998, University of Washington extended the myotomy 3 cm to further decrease reoccurrence Myotomy Length N=110 patients Standard laparoscopic myotomy (1.5 cm in the stomach) plus Dor = 52pts ( ) Extended laparoscopic myotomy (3 cm) plus Toupet = 58 pts ( ) Myotomy Length Pre-operative characteristics Myotomy Length Pre-operative characteristics Myotomy Length Limitations Study design Different time intervals Different follow up periods Standard myotomy: 46 months Extended myotomy: 16 months Different fundoplications Extended myotomy group had worse pre-operative dysphasia Operative Controversies Role of minimally invasive surgery Addition of a concurrent antireflux procedure The length of the myotomy Operative Controversies Role of minimally invasive surgery Addition of a concurrent antireflux procedure The length of the myotomy Remain