Current Treatment Options in Gastroenterology (2015) 13:1–15 DOI 10.1007/s11938-014-0035-6
Esophagus (E Dellon, Section Editor)
Optimizing Patient Selection and Outcomes for Surgical Treatment of GERD and Achalasia Steven R. DeMeester, MD Address The University of Southern California, Los Angeles, CA, USA Email: [email protected]
Published online: 18 January 2015 * Springer Science+Business Media, LLC 2015
This article is part of the Topical Collection on Esophagus Keywords Gastroesophageal reflux disease I Antireflux surgery I Nissen fundoplication I Achalasia I Per-oral endoscopic myotomy I Laparoscopic Heller myotomy
Opinion statement Gastroesophageal reflux disease is a common disorder in the United States and other western countries. In addition to troublesome symptoms, this condition is associated with impaired quality of life and the potential for disease progression to esophageal adenocarcinoma. Acid suppression medications are extremely effective for the relief of heartburn symptoms, but don’t address the physiologic derangements that cause reflux. The goal of an antireflux procedure is to correct these defects and abolish the dietary and lifestyle compromises that accompany medical therapy for gastroesophageal reflux. The Nissen fundoplication has a long and well-established track record and new options such as the LINX magnetic sphincter augmentation device allow correction of reflux with fewer sideeffects than a fundoplication in appropriate patients. These options should be considered in patients incompletely satisfied on medical therapy and in those with risk factors for disease progression. The role of these therapies in patients with gastroesophageal reflux disease will be reviewed in this chapter. Achalasia is an uncommon motility disorder of the esophagus that leads to profound dysphagia symptoms and greatly impaired alimentary satisfaction. Pneumatic dilation offers an endoscopic approach to the management of these patients, but often requires repeated dilatations due to the inconsistent disruption of the lower esophageal sphincter with this technique. An alternative is a laparoscopic Heller myotomy, which offers precise division of the muscle of the lower esophageal sphincter, but requires incisions and lifestyle restrictions while healing. A new therapy, per-oral endoscopic myotomy, allows the precise division of the lower esophageal sphincter muscle as in a laparoscopic myotomy, but is done endoscopically with no external incisions. The role of these therapies in patients will be reviewed in this chapter.
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Esophagus (E Dellon, Section Editor)
Introduction Gastroesophageal reflux disease is one of the most common ailments in western society, and affects millions of Americans. Most commonly, symptoms are managed with acid-suppressing medications, of which the most potent are the proton pump inhibitors. However, medications don’t prevent gastroesophageal reflux, they only alter the pH of the refluxed material, and symptoms and disease progression can occur despite the use of these medications on a regular basis. Antireflux surgery is an option that allows a return to normal lifestyle and diet without the need for medications, and can prevent the development of some of the complications of gastroesophageal reflux disease. The traditional surgical therapy for gastroesophageal reflux is a fundoplication, but there are now new options for correction of the physiologic defects that cause reflux in a way that leads to fewer side-effects than with a Nissen fundoplication. The outcome of surgical intervention is directly related to the ability of the procedure to impact the pathophysiology of the disease process. Therefore, a precise diagnosis is mandatory for a good outcome with
surgical intervention for functional disorders such as gastroesophageal reflux disease (GERD) and achalasia. While a Nissen fundoplication is very effective in patients with GERD, it will worsen symptoms in those with achalasia or other non-GERD etiologies for their symptoms. Symptoms are a useful guide but can’t be relied upon alone for a diagnosis prior to surgical intervention. Even classic GERD symptoms of heartburn and regurgitation are at best 80 % reliable, and there is frequently symptom overlap with motility abnormalities and non-GERD etiologies. For example, it is common for patients with achalasia to have been given a trial of proton pump inhibitor (PPI) medication for symptoms presumed to be secondary to GERD. Although unfortunate, at least medications can be discontinued. Surgical intervention is much more difficult to undo, and therefore, the level of diagnostic accuracy must be much more stringent. An accurate diagnosis based on physiologic testing will ensure the best surgical outcomes in patients with foregut disorders.
Esophageal and foregut functional testing The essential tests to evaluate patients with foregut symptoms are similar, but should be modified based on the suspected diagnosis. A standard videoesophagram is extremely useful for patients without achalasia since video sequences are obtained in both a prone and upright position to allow evaluation of esophageal bolus transport with and without the aid of gravity. In patients with achalasia there is no bolus movement independent of gravity, and therefore, a timed barium swallow provides much more useful information regarding the severity of LES outflow obstruction and esophageal retention. Upper endoscopy including a retroflexed view of the hiatus with a careful evaluation of the esophageal and gastric mucosa is essential in any patient with foregut symptoms. Biopsies should be taken of any abnormal lesions, of a columnar-lined lower esophagus, of the antrum and body of the stomach to evaluate for H. pylori infection, and, in my opinion, even at a normal-appearing gastroesophageal junction (GEJ) to evaluate for the presence of intestinal metaplasia of the cardia. Intestinal metaplasia anywhere in the esophagus or stomach is abnormal and pre-malignant. Esophageal manometry, now typically done using solid-state high resolution systems (HRM: high-resolution esophageal manometry), is another critical test for the evaluation of patients with foregut symptoms. There are two reasons for the use of manometry. The first is to evaluate the LES and esophageal body function, and the second is to locate precisely the LES to facilitate accurate placement of a pH monitoring probe in patients suspected of having GERD. Esophageal pH testing allows confirmation of a diagnosis of GERD, and is recommended in all patients
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except those with unequivocal erosive esophagitis (using the LA grading system) or those with biopsy-proven Barrett’s esophagus. Most commonly, pH monitoring is done using the Bravo system which allows for 48 h or longer of esophageal pH data, but a standard or dual-probe pH catheter is useful in some patients. Placement of the Bravo probe is best done trans-nasally using the LES location based on manometry rather than endoscopically based on the visualized GEJ. In patients with extra-esophageal symptoms, or in those with laryngopharyngeal reflux (LPR) symptoms, use of the Resteck pharyngeal pH monitoring system can identify patients that might be missed with standard pH testing alone [1]. Additional tests to consider are a 4-h nuclear medicine gastric emptying study in patients suspected of having altered gastric emptying and impedance-pH monitoring in those with symptoms perhaps related to weak or non-acid reflux events.
Who are surgical candidates, and who are the best candidates? GERD Therapy for GERD consists of dietary and lifestyle modifications along with acid-suppressing medications. While anyone with proven GERD is a candidate for an antireflux procedure, in most circumstances surgery is reserved for incomplete response to medical therapy, inability or a desire not to take lifelong GERD medications, or disease progression on medical therapy. Since the outcome of antireflux surgery will depend on the relationship between a patient’s symptoms and the presence of GERD, the better the correlation, the greater the patient will be satisfied with a fundoplication or an alternative antireflux procedure. Thus, the first key concept is that prior to an antireflux procedure the presence of abnormal reflux of gastric contents into the esophagus must be documented. This documentation can be in the form of an abnormal pH test, endoscopic erosive esophagitis, or pathologically confirmed Barrett’s esophagus. The second key concept is that just because someone has proven GERD does not mean that they should be offered antireflux surgery. A fundoplication very effectively stops reflux, but it comes with side effects. The type of fundoplication, partial versus complete, likely influences the frequency and severity of complications, but to some degree all fundoplications should be considered capable of inducing changes which can be permanent. If the severity of reflux is not enough to offset the potential side-effects, then these patients may be best served with continued medical therapy or an alternative antireflux procedure with fewer side-effects such as the LINX device. Further, there are occasionally patients with such advanced reflux disease, including those with scleroderma, where a fundoplication is unlikely to lead to a successful outcome and alternative options should be considered. Prior to an antireflux operation it is important to set the expectations so that patients are not surprised or alarmed by the functional changes which accompany a fundoplication. I tell patients to expect to be unable to belch and vomit, have increased flatulence, and experience dysphagia which is generally limited to the first 4-8 weeks but can be protracted beyond that occasionally. Further, even in the absence of dysphagia, patients are able to out-eat their esophagus after a fundoplication, and meals need to become more social or “European” in style. I also warn patients that bloating can occur and be troublesome, particularly if there are concerns about abnormal gastric emptying. However, the benefits of a fundoplication are that the dietary and lifestyle modifications that accompany reflux disease such as eating early before bedtime, sleeping with the head of the bed elevated, and avoiding reflux-inducing types of foods all go
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Esophagus (E Dellon, Section Editor) away. Patients can eat what they want when they want without the fear of experiencing symptoms of GERD. In my experience, patients with significant GERD symptoms despite good medical management will almost always find the trade-off favorable, and in fact a common comment in the post-op clinic from these patients is “why did I wait so long to have this done? This has given me my life back.” The best candidates for an antireflux operation are those with classic reflux symptoms responsive or partially responsive to proton pump inhibitors (PPIs). In a multivariable analysis of 233 patients who had an antireflux procedure, we found that the three predictors of a good response to a fundoplication in rank order of significance were an abnormal score on esophageal pH monitoring, a typical primary symptom of reflux (heartburn or regurgitation), and complete or partial response to acid suppression therapy [2••]. When all three of these conditions were met, 97 % of patients had an excellent or good outcome after a fundoplication. Satisfaction after a fundoplication decreased steadily with an increasing number of unmet conditions, and when none of the three were present, nearly half of the patients did not have an excellent or good outcome. Thus, in the absence of typical symptoms it is very important that the patient have a positive pH test confirming reflux, an excellent response of their symptoms to PPI medications, or both. Likewise, rather than “failure of medical [PPI] therapy” being an indication for surgery, it is actually a large red flag indicating that the patient may not be satisfied with the outcome of an antireflux operation unless they have typical symptoms and a positive pH test. Surgeons should use these three established predicators to discuss with patients the likelihood of an excellent or good outcome after a fundoplication. It is critical for surgeons to recognize that a referral for antireflux surgery from a gastroenterologist should not mean that the patient needs an operation. Instead, the referral provides the opportunity for a surgeon to advise the patient on the pros and cons of an antireflux procedure, outline to the patient the likelihood they would be satisfied with a fundoplication, and recommend against an antireflux procedure in patients at increased risk of being dissatisfied. Another important issue is that of a hiatal hernia. A sliding or type I hernia is characterized by having the GEJ herniated into the chest but it remains above the fundus of the stomach. It may reduce in the upright position, and if it does there should be no concern about a foreshortened esophagus. Type I hernias are the most common type of hiatal hernia. Importantly, the presence of a sliding hiatal hernia is not an indication for surgery, and symptoms attributed solely to a sliding hiatal hernia seldom warrant surgical intervention. Instead, the indication for surgery in a patient with a sliding hiatal hernia is the presence of documented GERD. With that said, patients with a large sliding hiatal hernia are often those with significant GERD symptoms, particularly regurgitation, that are difficult to control with PPI therapy. These patients are also those at risk for complications of their reflux disease including strictures, Barrett’s esophagus, and pulmonary problems such as aspiration pneumonia and fibrosis. Commonly, these patients are referred for consideration of surgery. A careful evaluation of esophageal motility in these patients is warranted since with severe longstanding GERD there may be impaired motility that might increase the risk of prolonged dysphagia if a Nissen or 360 degree fundoplication is performed. Further, these hernias often do not spontaneously reduce in the upright position and repair may require a Collis gastroplasty to lengthen the esophagus if excess tension is encountered intra-operatively.
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The other type of hernia is the paraesophageal hernia (PEH) in which the fundus of the stomach is above the GEJ, and often most or all of the stomach has herniated into the chest. These are subdivided based on the amount of stomach in the chest (Types II and III) and the presence of organs in addition to the stomach in the chest (Type IV). In contrast to a sliding hiatal hernia, a symptomatic PEH is an indication for repair even in the absence of GERD. This is an important distinction, and all too often patients with a symptomatic PEH are not appropriately referred for surgical correction related to a misunderstanding of the differences in these hernias. Further, it is often underappreciated in the gastroenterology community that a large PEH is associated with anemia and that correction of the PEH will resolve the anemia in most patients [3]. Consequently, an extensive evaluation for the source of anemia in a patient with an unrepaired PEH is unwarranted. Antireflux surgery is markedly different from procedures that remove an organ such as an appendectomy or cholecystectomy since antireflux surgery aims to re-establish function of the organ. In these types of procedures, technique correlates significantly with outcome. The fundamentals of antireflux surgery include repair of a co-existent hiatal hernia and augmentation of the LES with a partial or complete fundoplication. Simple in concept, there are a myriad of details that go into a long-term, successful antireflux procedure. One important concept for improving success is to understand the causes of failure. The leading form of anatomic failure after a laparoscopic fundoplication is a recurrent hiatal hernia (Fig. 1). Many recurrent hernias are small and asymptomatic, but if the hernia enlarges or the fundoplication disrupts, patients may develop recurrent symptoms that require PPI medication or a reoperation. Therefore, analyzing factors that lead to a recurrent hiatal hernia and keeping them in mind at the time of the initial operation should lead to improved outcomes. Here it is valuable to review the experience with PEH repairs, where hernia recurrence is an even more frequent problem [4]. One issue that surgeons must address during crural closure is the fact that the crura, like filet mignon, have no fascia and as such hold sutures poorly. Any tension on the crural repair will encourage breakdown and hernia recurrence. Pedgets and horizontal mattress sutures are classically used in surgery when suturing tissues with poor integrity such as the heart or blood vessels. The use of pledgets for crural repair may be beneficial particularly in the setting of thin or widely separated crural pillars. I prefer absorbable pledgets since permanent materials can erode into the esophagus. I make pledgets from the absorbable mesh that I will use to reinforce the crural repair. The use of mesh at the hiatus is controversial, and has not been proven to reduce hiatal hernia recurrence. However, mesh use at hernia sites elsewhere in the body has been proven beneficial, and I believe that prior studies on mesh at the hiatus have used the wrong mesh, wrong technique, or both. Mesh, if used, should never bridge the crura since with permanent mesh this is associated with the highest risk for mesh erosion into the stomach or esophagus, and an absorbable mesh bridge will lead to a recurrent hernia. Instead, if mesh is used, my preference is an absorbable mesh onlay over the primary crural closure. There are several types of absorbable mesh that have shown excellent early results [5–7].
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Esophagus (E Dellon, Section Editor) The second issue surgeons should recognize is that tension at the hiatus can come from two directions. The first is axial tension related to a short esophagus. Risk factors for esophageal shortening include a 5 cm or larger sliding or paraesophageal hernia, a recurrent hiatal hernia after prior repair, and an esophageal stricture [8]. Mediastinal esophageal mobilization can provide adequate esophageal length in most patients, but in some, a Collis gastroplasty is necessary. A general guide during a laparoscopic fundoplication is that in the relaxed state, i.e. no downward tension on a penrose around the esophagus, there should be 23 cm of intra-abdominal esophagus. During laparoscopic surgery the diaphragms are artificially elevated by the pneumoperitonuem, and release of the carbon dioxide at the end of the procedure will reduce the intra-abdominal length of esophagus and put tension on a repair done with less than 3 cm of intra-abdominal esophagus. A Collis gastroplasty can be done laparoscopically using the wedge fundectomy technique and is associated with few complications [9]. The second form of tension at the hiatus is lateral tension related to very widely splayed crura, typically seen in patients with a very large sliding or more commonly a paraesophageal hernia. In these patients, a crural-relaxing incision, typically on the right, allows for crural re-approximation with acceptable tension. The defect created by the relaxing incision is then repaired with a small patch of permanent mesh (Fig. 2) [10]. Incorporation of these techniques including the use of absorbable mesh reinforcement of the primary crural closure and adjunct procedures for esophageal tension when present has in our experience improved outcomes with antireflux surgery and PEH repair [11]. The use of a fundoplication to augment the LES is inherent in an antireflux procedure. It is also a critical component of PEH repair. Historically, the Allison repair was a simple correction of the hiatal hernia without the addition of a fundoplication and it was associated with a high frequency of reflux post-operatively [12]. A randomized study has confirmed the lifetime observations by Dr. Allison that, indeed, an antireflux procedure should be added to hiatal hernia repair for the best outcome with PEH repair [13]. The decision in most patients is between a Toupet 270 degree partial fundoplication or a complete 360 degree Nissen fundoplication. The Dor 180 degree partial fundoplication is typically reserved for patients with achalasia, since long-term followup from centers in Australia that used it in GERD patients have shown higher rates of recurrent reflux compared to a more complete fundoplication [14]. Centers in Europe have contended that the Toupet fundoplication allows similar control of reflux with less side-effects than the Nissen, but studies from the US raise concern about the durability of a partial fundoplication in patients with advanced reflux disease [15]. This issue remains controversial and may in part relate to different patients and meal sizes in Europe and the United States. The higher tendency toward obesity and the consumption of large quantities of food at one setting in US patients may contribute to a higher failure rate of partial fundoplications. My preference is to do a Nissen fundoplication unless poor esophageal motility would indicate an increased risk for protracted dysphagia.
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Fig. 1. Retroflex view on upper endoscopy of an intact fundoplication herniated partially into the chest. This is the most common form of anatomic failure of a laparoscopic fundoplication.
The degree of esophageal motility abnormalities that should preclude a Nissen fundoplication are clear only at the extreme where there is absent peristalsis, as in a patient with achalasia or scleroderma. In all other patients judgment is necessary. The classic suggestion that esophageal body contraction amplitudes of 30 mmHg or more are necessary for a Nissen are probably too stringent, but an amplitude of 20 mmHg is likely the lower limit of what should be acceptable since the outflow resistance of a Nissen fundoplication is approximately 20 mmHg. However, even with amplitudes of contraction above 20 mmHg patients with dysphagia symptoms or evidence of impaired bolus transport on videoesophagram may have troublesome dysphagia after a Nissen
Fig. 2. A right crural relaxing incision has been performed which allowed the primary crural closure to be accomplished with minimal tension. A 1-mm Gortex patch will be sewn in place to close the defect in the diaphragm and then an absorbable mesh will be used to buttress the primary crural closure.
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Esophagus (E Dellon, Section Editor) fundoplication. Ultimately, surgeons and patients must weigh the potentially higher risk of protracted dysphagia with a Nissen fundoplication against the potentially higher long-term failure rate of a partial fundoplication when there is concern about esophageal body function. In these situations a careful and detailed discussion with the patient about the issues and options can minimize frustration and dissatisfaction post-operatively. An important issue in some patients with GERD is co-existent delayed gastric emptying. When evaluating a patient for possible antireflux surgery, it is important to get a history about frequent nausea or bloating symptoms as well as difficulty with early or prolonged satiety. When present, these symptoms as well as a history of diabetes or prior antireflux surgery where vagal nerve injury may have occurred are, in my opinion, an indication for evaluation of gastric function pre-operatively. A fundoplication has been shown to improve gastric emptying since a portion of the fundus, which is involved in receptive relaxation, is used to augment the LES. A critical issue though is whether the improvement in gastric emptying will offset the loss of the ability of the stomach to vent. If so, patients usually do very well without significant boating symptoms. If not, these patients can be miserable with bloating and distension. There are no hard and fast rules to guide how patients with symptoms and evidence of delayed gastric emptying will do with a fundoplication, but in my experience, the presence of a bezoar on pre-operative endoscopy after an overnight fast is an ominous finding. In the presence of delayed gastric empting, I prefer a Nissen fundoplication since a partial fundoplication may not adequately control reflux in these patients. When significant bloating occurs unexpectedly after a fundoplication I have found a temporary percutaneous gastrostomy tube can allow venting of the stomach until gastric function returns. However, in patients with permanent gastric dysfunction measures such as pyloroplasty or partial gastrectomy with roux-en-y gastrojejunostomy, may be necessary to improve symptoms. A trial of prokinetic medications, and perhaps pyloric injection of Botox, may be useful prior to surgical intervention in these patients. Here again, careful pre-operative counseling of patients with the potential for problems related to delayed gastric emptying can minimize post-operative frustration and dissatisfaction. The role of a fundoplication in patients with Barrett’s esophagus (BE) has long been controversial. First, since BE occurs as a consequence of GERD, any patient with BE is a candidate for an antireflux procedure for control of symptoms and complications related to their reflux disease. However, patients with BE often have advanced reflux disease with impaired esophageal body function and a large hiatal hernia. In these patients the longevity of a fundoplication is not as good as in patients with less severe disease, and careful consideration should be given to the downsides of a failed fundoplication. In addition to recurrent symptoms, a failed fundoplication is a risk factor for progression of BE to adenocarcinoma [16]. The impact of a functioning fundoplication on BE progression is controversial. A careful analysis of published studies suggests that an antireflux procedure can alter the natural history of the disease and reduce the risk of progression [17, 18]. However, it certainly won’t prevent all adenocarcinomas in these patients, and to recommend a fundoplication solely on the basis of trying to prevent cancer in a patient with BE is, in my opinion, ill-
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advised. Instead, patients with BE should have a fundoplication to improve their overall quality of life, and if it reduces the risk of BE progression that is a bonus, but it should not be the sole indication for an operation. Instead, the best cancer prevention strategy with or without a fundoplication is careful annual surveillance of the Barrett’s with ablation for progression to dysplasia. Another issue is how to manage reflux in patients that have had endoscopic resection or ablation for high-grade dysplasia or intra-mucosal adenocarcinoma. These patients need to be on high-dose acid suppression medications or alternatively have an antireflux procedure. Data on which approach will lead to the best long-term results are currently not available, but I favor a fundoplication in suitable operative candidates in this situation. Lastly, an important issue to consider is the use of an antireflux procedure early in the course of patients at risk for progressive disease. In the ProGERD study from Europe, 2,721 patients with reflux were followed for 5 years, and multivariate analysis of baseline factors identified a family history of GERD and unhealed esophagitis after initial treatment as risk factors for progressive disease [19••]. Further, in a follow-up study of this cohort almost 10 % of patients had progressed to BE by 5 years. Risk factors by multivariate analysis for progression to BE were baseline esophagitis and regular intake of alcohol or PPI medications. In patients with intestinal metaplasia of the cardia upon entry into the study more than 20 % developed endoscopic BE within 5 years [20]. Most was short segment, but some patients developed long-segment BE during follow-up. On multivariate analysis the factors associated with progression were smoking, a long history of GERD, and severe esophagitis. It is worth considering the option of an antireflux procedure in these patients in an effort to modify this natural history. For those with early disease, an excellent option is the LINX device. The LINX is a bracelet of magnets that is laparoscopically fitted around the LES and provides effective relief of reflux symptoms and in most cases normalization of esophageal acid exposure with fewer of the side-effects that accompany a standard fundoplication [21]. It is interesting to speculate whether early intervention with either the LINX device or a fundoplication might prevent disease progression in appropriate patients. There is some evidence in support of this concept. A study with careful long-term follow-up from Sweden compared the likelihood of intestinal metaplasia developing in patients on medical therapy versus after antireflux surgery [22]. This studied showed that the likelihood of developing BE was significantly reduced in patients that had a fundoplication. These findings taken together suggest a potential role for early intervention with an antireflux procedure in patients at risk for progressive disease.
Achalasia Esophageal distension from impaired lower esophageal sphincter (LES) relaxation can produce “heartburn” type symptoms in patients with achalasia, and the bland regurgitation of esophageal contents in a patient with achalasia can be mistaken for the more common regurgitation of gastric juice in a patient with poor LES function and GERD. However, achalasia and GERD are opposite ends of the LES spectrum. In patients with GERD, the LES is generally hypotensive and incompetent, allowing gastric juice to go up into the esophagus. In contrast, the LES in a patient with achalasia is normotensive or hypertensive and fails to
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Esophagus (E Dellon, Section Editor) relax appropriately, leading to an inability of the esophagus to empty appropriately. The diagnosis is most conclusively made with esophageal manometry where the characteristic findings are an incompletely relaxing lower esophageal sphincter (LES) and absent peristalsis in the esophageal body. Esophageal pressurization and a hypertensive LES may also be present. The introduction of high resolution esophageal manometry (HRM) into clinical practice has provided more detail about esophageal function, and HRM studies in patients with achalasia have identified three subtypes of this disease. Characteristic of all three types is an elevated integration relaxation pressure (IRP) above 15 mmHg. The subtypes are Type I or “classic” achalasia with incomplete LES opening and an aperistaltic esophageal body, Type II with panesophageal pressurization, and Type III with no normal peristalsis, but evidence of distal esophageal spasm [23]. The integrated relaxation pressure (IRP) is elevated above 15 in all three types. The two main long-term treatment options for patients with achalasia have been pneumatic dilatation and Heller myotomy. Injection of botulium toxin is typically reserved for patients who are poor candidates for a more definitive therapy since it is temporary and can complicate the performance of other therapies. Pneumatic dilatation is done with an achalasia balloon that is at least 150 % the normal size of the esophagus (30 mm) in an effort to disrupt the dysfunctional LES musculature without leading to a perforation of the mucosa. A single dilatation is unlikely to provide permanent relief of symptoms, but repeated dilatations and use of larger balloons for recurrent symptoms leads to improved results. In a randomized trial from Europe, an aggressive pneumatic dilatation protocol led to success rates similar to that observed with a laparoscopic Heller myotomy, but with a 4 % risk of esophageal perforation [24]. Importantly, in a subsequent analysis of the outcome of pneumatic dilatation by HRM subtype, successful relief of symptoms was best in patients with Type II achalasia, but poor in patients with Type III achalasia [25••]. These same poor results were not seen after laparoscopic Heller myotomy and Dor in patients with Type III achalasia. Thus, the HRM type is important for selecting therapy, and in patients with Type III achalasia pneumatic dilatation should be avoided. The Heller myotomy was described over 100 years ago by the German surgeon Ernest Heller. This procedure, with three important modifications, has become the gold standard therapy in the US and most centers worldwide for the treatment of achalasia. The first important modification is to perform the myotomy in a minimally invasive laparoscopic fashion. Pelegrini and colleagues introduced the minimally invasive surgical treatment for achalasia in 1992 with the description of a thoracocsopic Heller myotomy [26]. However, with the introduction of laparoscopy it became clear that a laparoscopic approach led to superior outcomes. There are a number of reasons why a laparoscopic approach is the standard of care including the ease of extending the myotomy distally on the stomach with the laparoscopic approach, the ability to add a partial fundoplication and cover the full extent of the myotomy, the recognition of the importance of keeping the myotomy below the hiatus in the abdomen to avoid development of a diverticulum in the chest, no need for single lung ventilation during the surgery, no need for a chest drain postoperatively, and the fact that conversion if necessary is a laparotomy not a thoracotomy. Current indications for a thoracoscopic approach are limited to patients with a hostile abdomen, the presence of an epiphrenic diverticulum
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that can’t be addressed laparoscopically, or for patients where a long esophageal myotomy is planned. The second important modification is to extend the myotomy 3 cm down onto the stomach below the GEJ. Previously, a Heller myotomy stopped 1 cm below the GEJ. This was adequate in some patients, but was associated with recurrent or persistent dysphagia in others. An analysis of failed myotomies found that failure was related to an inadequate distal myotomy, and showed that extension of the myotomy further onto the stomach reduced the failure rate [27]. A corollary modification is that since failure is not related to an inadequate proximal myotomy, the myotomy should not extend above the hiatus. Over time, an intra-thoracic myotomy has been associated with the development of a diverticulum in the chest. Management of these patients is difficult and often requires esophagectomy. The third important modification is to add a partial fundoplication, either a Dor or a Toupet, to reduce reflux after the myotomy. In a randomized trial comparing outcome after laparoscopic myotomy alone versus with a partial fundoplication Richards et al showed that the addition of a Dor fundoplication led to significantly less reflux by pH monitoring with no difference in the successful relief of dysphagia [28]. No significant outcome differences have been found between a Dor partial anterior and the Toupet partial posterior fundoplication, but the faster and easier Dor is preferred in most centers. Further, the Dor fundoplication covers the myotomy site and reduces the risk of a post-operative leak from an unrecognized mucosal injury or after repair of a mucosal perforation intra-operatively. In patients with achalasia and a hiatal hernia the Toupet is often preferred since the hiatus is mobilized to repair the hiatal hernia. If the myotomy is kept well on the left side of the esophagus the mucosa can be covered by the Toupet by sewing the anterior fundus to the upper edge of the myotomized esophagus. A laparoscopic Heller myotomy with these modifications has become the gold standard therapy for achalasia. It has shown durable, excellent results and these results have been reproduced at centers around the world. Several metaanalyses have shown that compared to other therapies, the laparoscopic Heller myotomy and Dor has a lower rate of re-intervention. Further, it is applicable to all HRM subtypes of achalasia. Recently, a new procedure for achalasia has been introduced, the per-oral endoscopic myotomy, or POEM. The POEM procedure represents a paradigm shift since previously efficacy was related to invasiveness in patients with achalasia. On the low efficacy and low invasiveness side are Botox injection and a single pneumatic dilatation, and moving toward more invasive and better efficacy are multiple pneumatic dilatations and laparoscopic Heller myotomy and Dor. The POEM procedure provides the efficacy of the laparoscopic Heller with the invasiveness of a single pneumatic dilatation. It may be the best of both worlds, allowing a precise myotomy with the recovery benefits of no external incisions and no physical restrictions. The POEM procedure was first used to treat achalasia in a human by Inoue in 2008, and his initial experience was reported in 2010 [29]. An advantage of the POEM procedure is that the myotomy can be started high in the esophagus for patients with spastic disorders or Type III achalasia, and extended down several centimeters onto the stomach to minimize the risk of an inadequate myotomy. Since Inoue’s first procedure there have now been several thousand POEM procedures performed worldwide.
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Esophagus (E Dellon, Section Editor) While most are done for achalasia, the indications have expanded to diffuse esophageal spasm, hypertensive LES and as a technique to remove smooth muscle tumors in the muscularis propria of the esophagus and gastroesophageal junction [30]. The concepts have also been applied to performing an endoscopic myotomy of the pylorus for delayed gastric emptying and of the cricopharyngeous for Zenker’s diverticulum or cricopharyngeal dysfunction. The basic concept of these procedures is that an incision is created in the mucosa followed by creation of a submucosal tunnel. The tunnel is then used to perform the myotomy of the circular fibers of the upper esophageal sphincter, lower esophageal sphincter, or the pylorus. The procedure is completed by closing the mucosal defect either with clips or sutures. There have now been a number of publications on the early results of POEM for achalasia, both from single centers and from an international prospective trail [31, 32]. From these, a number of conclusions can be drawn regarding POEM. First, POEM is very safe, even during the learning curve [33, 34]. There have been no reports of mortality with the procedure. A number of complications including subcutaneous emphysema, pneumothorax, and pnuemoperitoneum were reported with the use of air rather than carbon dioxide for insufflation. When using carbon dioxide, the frequency of these complications is much lower [32]. Capnoperitoneum occurs commonly, but only in 5-10 % of patients is it necessary to decompress the abdomen with an angiocath or Veress needle. Bleeding from large submucosal vessels can be problematic but typically is readily controlled with the use of coagulating forceps, and with experience is much easier avoided than treated during creation of the submucosal tunnel [35]. Delayed bleeding occurs rarely, although in some cases has required reexploration of the tunnel. Another occasional source of morbidity is the mucosal closure. Typically a barium swallow is done later that day or the day after the procedure to verify the integrity of the closure. A leak into the submucosal tunnel should prompt re-exploration. The most serious reported complication has been a contained esophageal perforation at the level of the gastroesophageal junction [36]. Treatment in this patient consisted of endoscopic and laparoscopic evaluation of the area with placement of drains. Overall, for a novel procedure there has been remarkably little morbidity, although most reports are from centers with significant experience in the management of patients with esophageal disorders. Second, POEM results in significant improvement in dysphagia and regurgitation symptoms. In a series by Swanstom et al., the median Eckardt score of 20 patients at 1 month after POEM was 1, down from 6 pre-POEM, and over half of the patients had complete resolution of dysphagia [31]. These results persisted with longer follow-up. At 18 months after the procedure, the median Eckardt score was 0; most patients had no dysphagia symptoms, and all were satisfied with the results of the procedure. On objective evaluation, the median emptying at 5 min by timed barium swallow had improved from 48 % to 100 % at 6 months post-POEM [36]. Similarly, in an international, multiinstitution series of 70 patients, the median Eckardt score had dropped from 7 to 1 at 3 months after POEM, and treatment success was achieved in 97 % of patients. The mean LES pressure decreased from 28 to 9 mmHg. At 12 months after POEM, sustained treatment success was present in 82 % of patients, and
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the mean Eckardt score was 1.7 in the 51 patients available for follow-up [32]. Importantly, POEM can be used to relieve symptoms in all Chicago highresolution subclasses of achalasia, even for patients with Type III that respond poorly to endoscopic balloon dilatation [37]. Third, POEM can lead to gastroesophageal reflux. Any procedure to open up the LES in patients with achalasia and improve esophageal emptying can lead to gastroesophageal reflux. The POEM, by virtue of its excellent myotomy without a partial fundoplication, is perhaps more likely to lead to reflux than other procedures. In the series by Swanstom et al., 44 % of patients reported heartburn after POEM, and all of these patients were taking acid suppression medications [31]. On upper endoscopy, erosive esophagitis was seen in 28 %, and on 24-h pH testing, 46 % of patients had increased esophageal acid exposure. In the international series 37 % of patients had reflux symptoms and erosive esophagitis was present in 42 % of patients at 12 months post-POEM [32]. Fourth, compared to a laparoscopic Heller myotomy with partial fundoplication, POEM has been shown to lead to a similar good outcome in two series comparing these procedures. The first, by Hungness et al, showed that operative times were shorter with POEM but complications and the median length of hospital stay were similar for the two procedures [36]. The second, by Bhayani et al, showed that post-operative Eckhardt scores were lower after POEM and 100 % of patients had relief of dysphagia after POEM compared to 97 % after laparoscopic Heller myotomy and partial fundoplication [38]. Symptoms of heartburn, reflux, and chest pain were similar for the two procedures. On objective testing the absolute and relative decreases in LES resting pressures were similar, but the resting pressure was higher after POEM. On 24-h pH monitoring, the frequency of increased esophageal acid exposure was similar at about 35 % after each procedure.
Conclusions The outcome of surgical intervention for benign esophageal disorders is directly related to the accuracy of the diagnosis and the technique of the procedure. Errors in either will diminish the efficacy of the procedure and the satisfaction of the patient. New technologies for antireflux procedures may draw interest from the sizeable segment of patients incompletely satisfied with acid suppression therapy, and early intervention in patients at risk for progression may alter the natural history of reflux disease. In patients with achalasia, the laparoscopic Heller myotomy that is extended 3 cm down onto the stomach and combined with a Dor partial fundoplication has become the gold standard therapy with excellent results reported from centers around the globe. Further, outcomes are excellent in all HRM types of achalasia. Aggressive pneumatic dilatation may achieve similar results, but should not be used in patients with Type III achalasia where outcomes are worse. A new paradigm in achalasia treatment is the POEM procedure which may offer the benefits of the precise myotomy achieved with a laparoscopic approach combined with the recovery benefits of an endoscopic approach. Early results are excellent and POEM has proven safe and reproducible at centers with experience treating patients with esophageal disorders. Long-term results and wider application of the
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Esophagus (E Dellon, Section Editor) procedure are necessary before firm conclusions can be made about its place in the management of patients with achalasia.
Compliance with Ethics Guidelines Conflict of Interest Steven R. DeMeester has received consultancy fees, paid travel accommodations, and payment for development of educational presentations from Bard and Novadaq. Dr. DeMeester also has received honoraria from Bard and consultancy fees from C2 Therapeutics.
Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: •• Of major importance 1.
Worrell SG, DeMeester SR, Greene CL, et al. Pharyngeal pH monitoring better predicts a successful outcome for extraesophageal reflux symptoms after antireflux surgery. Surg Endosc. 2013;27:4113–8. 2.•• Campos GM, Peters JH, DeMeester TR, et al. Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg. 1999;3:292–300. This article defines the key factors that predict successful outcome with a fundoplication. 3. Collis JL. An operation for haitus hernia with short esophagus. J Thorac Surg. 1957;34:768–78. 4. Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: longterm follow-up from a multicenter, prospective, randomized trial.[Erratum appears in J Am Coll Surg. 2011 Dec;213(6):815]. J Am Coll Surg. 2011;213:461–8. 5. Alicuben ET, Worrell SG, DeMeester SR. Resorbable biosynthetic mesh for crural reinforcement during hiatal hernia repair. Am Surg. 2014;80:1030–3. 6. Zehetner J, Lipham JC, Ayazi S, et al. A simplified technique for intrathoracic stomach repair: laparoscopic fundoplication with Vicryl mesh and BioGlue crural reinforcement. Surg Endosc. 2010;24:675–9. 7. Alicuben ET, Worrell SG, DeMeester SR. Impact of crural relaxing incisions, collis gastroplasty, and noncross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates. J Am Coll Surg. 2014;219:988–92.
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Ritter MP, Peters JH, DeMeester TR, et al. Treatment of advanced gastroesophageal reflux disease with Collis gastroplasty and Belsey partial fundoplication. Arch Surg. 1998;133:523–8. discussion 528–529. Zehetner J, DeMeester SR, Ayazi S, et al. Laparoscopic wedge fundectomy for collis gastroplasty creation in patients with a foreshortened esophagus. Ann Surg. 2014;260:1030–3. Greene CL, DeMeester SR, Zehetner J, et al. Diaphragmatic relaxing incisions during laparoscopic paraesophageal hernia repair. Surg Endosc. 2013;27:4532–8. Zehetner J, Demeester SR, Ayazi S, et al. Laparoscopic versus open repair of paraesophageal hernia: the second decade. J Am Coll Surg. 2011;212:813–20. Allison PR. Hiatus hernia: (a 20-year retrospective survey). Ann Surg. 1973;178:273–6. Furnee EJ, Draaisma WA, Gooszen HG, et al. Tailored or routine addition of an antireflux fundoplication in laparoscopic large hiatal hernia repair: a comparative cohort study. World J Surg. 2011;35:78–84. Broeders JA, Broeders EA, Watson DI, et al. Objective outcomes 14 years after laparoscopic anterior 180degree partial versus nissen fundoplication: results from a randomized trial. Ann Surg. 2013;258:233–9. Horvath KD, Jobe BA, Herron DM, Swanstrom LL. Laparoscopic Toupet fundoplication is an inadequate procedure for patients with severe reflux disease. J Gastrointest Surg. 1999;3:583–91.
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Lagergren J, Ye W, Lagergren P, Lu Y. The risk of esophageal adenocarcinoma after antireflux surgery. Gastroenterology. 2010;138:1297–301. 17. DeMeester SR, DeMeester TR. Columnar mucosa and intestinal metaplasia of the esophagus: fifty years of controversy. Ann Surg. 2000;231:303–21. 18. DeMeester SR. Reflux, Barrett’s, and adenocarcinoma of the esophagus: can we disrupt the pathway? J Gastrointest Surg. 2010;14:941–5. 19.•• Malfertheiner P, Nocon M, Vieth M, et al. Evolution of gastro-oesophageal reflux disease over 5 years under routine medical care–the ProGERD study. Aliment Pharmacol Ther. 2012;35:154–64. This article shows the natural history of medical therapy in a cohort of patients followed with endoscopy over 5 years, and details the progression to Barrett’s esophagus in some patients. Risk factors for progressive disease are identified. 20. Leodolter A, Nocon M, Vieth M, et al. Progression of specialized intestinal metaplasia at the cardia to macroscopically evident Barrett’s esophagus: an entity of concern in the ProGERD study. Scand J Gastroenterol. 2012;47:1429–35. 21. Ganz RA, Peters JH, Horgan S, et al. Esophageal sphincter device for gastroesophageal reflux disease. N Engl J Med. 2013;368:719–27. 22. Oberg S, Johansson J, Wenner J, et al. Endoscopic surveillance of columnar-lined esophagus: frequency of intestinal metaplasia detection and impact of antireflux surgery. Ann Surg. 2001;234:619–26. 23. Pandolfino JE, Kahrilas PJ. Presentation, diagnosis, and management of achalasia. Clin Gastroenterol Hepatol. 2013;11:887–97. 24. Boeckxstaens GE, Annese V, des Varannes SB, et al. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med. 2011;364:1807–16. 25.•• Rohof WO, Salvador R, Annese V, et al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology. 2013;144:718–25. This article shows that manometric subtypes of achalsia influence outcome with pneumatic dilatation, and the poor outcome with Type III patients suggests that alternative treatments should be used for patients with this subtype of achalasia. 26. Pellegrini C, Wetter LA, Patti M, et al. Thoracoscopic esophagomyotomy. Initial experience with a new approach for the treatment of achalasia. Ann Surg. 1992;216:291–6. discussion 296-299.
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Oelschlager BK, Chang L, Pellegrini CA. Improved outcome after extended gastric myotomy for achalasia. Arch Surg. 2003;138:490–5. discussion 495-497. Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg. 2004;240:405– 12. discussion 412-405. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42:265–71. Inoue H, Ikeda H, Hosoya T, et al. Submucosal endoscopic tumor resection for subepithelial tumors in the esophagus and cardia. Endoscopy. 2012;44:225–30. Swanstrom LL, Kurian A, Dunst CM, et al. Longterm outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg. 2012;256:659–67. Von Renteln D, Fuchs KH, Fockens P, et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology. 2013;145:309–311.e301–303. Teitelbaum EN, Soper NJ, Arafat FO, et al. Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM). J Gastrointest Surg. 2014;18:92–8. discussion 98-99. Kurian AA, Dunst CM, Sharata A, et al. Peroral endoscopic esophageal myotomy: defining the learning curve. Gastrointest Endosc. 2013;77:719–25. Li QL, Zhou PH, Yao LQ, et al. Early diagnosis and management of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy for achalasia (with video). Gastrointest Endosc. 2013;78:370–4. Hungness ES, Teitelbaum EN, Santos BF, et al. Comparison of perioperative outcomes between peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy. J Gastrointest Surg. 2013;17:228–35. Greene CL, Chang EJ, Oh DS et al. High resolution manometry sub-classification of Achalasia: does it really matter? : does Achalasia sub-classification matter? Surg Endosc 2014. Bhayani N, Kurian A, Dunst CM, et al. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg. 2014;259:1098–103.
Esophagus (E Dellon, Section Editor)
Optimizing Patient Selection and Outcomes for Surgical Treatment of GERD and Achalasia Steven R. DeMeester, MD Address The University of Southern California, Los Angeles, CA, USA Email: [email protected]
Published online: 18 January 2015 * Springer Science+Business Media, LLC 2015
This article is part of the Topical Collection on Esophagus Keywords Gastroesophageal reflux disease I Antireflux surgery I Nissen fundoplication I Achalasia I Per-oral endoscopic myotomy I Laparoscopic Heller myotomy
Opinion statement Gastroesophageal reflux disease is a common disorder in the United States and other western countries. In addition to troublesome symptoms, this condition is associated with impaired quality of life and the potential for disease progression to esophageal adenocarcinoma. Acid suppression medications are extremely effective for the relief of heartburn symptoms, but don’t address the physiologic derangements that cause reflux. The goal of an antireflux procedure is to correct these defects and abolish the dietary and lifestyle compromises that accompany medical therapy for gastroesophageal reflux. The Nissen fundoplication has a long and well-established track record and new options such as the LINX magnetic sphincter augmentation device allow correction of reflux with fewer sideeffects than a fundoplication in appropriate patients. These options should be considered in patients incompletely satisfied on medical therapy and in those with risk factors for disease progression. The role of these therapies in patients with gastroesophageal reflux disease will be reviewed in this chapter. Achalasia is an uncommon motility disorder of the esophagus that leads to profound dysphagia symptoms and greatly impaired alimentary satisfaction. Pneumatic dilation offers an endoscopic approach to the management of these patients, but often requires repeated dilatations due to the inconsistent disruption of the lower esophageal sphincter with this technique. An alternative is a laparoscopic Heller myotomy, which offers precise division of the muscle of the lower esophageal sphincter, but requires incisions and lifestyle restrictions while healing. A new therapy, per-oral endoscopic myotomy, allows the precise division of the lower esophageal sphincter muscle as in a laparoscopic myotomy, but is done endoscopically with no external incisions. The role of these therapies in patients will be reviewed in this chapter.
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Introduction Gastroesophageal reflux disease is one of the most common ailments in western society, and affects millions of Americans. Most commonly, symptoms are managed with acid-suppressing medications, of which the most potent are the proton pump inhibitors. However, medications don’t prevent gastroesophageal reflux, they only alter the pH of the refluxed material, and symptoms and disease progression can occur despite the use of these medications on a regular basis. Antireflux surgery is an option that allows a return to normal lifestyle and diet without the need for medications, and can prevent the development of some of the complications of gastroesophageal reflux disease. The traditional surgical therapy for gastroesophageal reflux is a fundoplication, but there are now new options for correction of the physiologic defects that cause reflux in a way that leads to fewer side-effects than with a Nissen fundoplication. The outcome of surgical intervention is directly related to the ability of the procedure to impact the pathophysiology of the disease process. Therefore, a precise diagnosis is mandatory for a good outcome with
surgical intervention for functional disorders such as gastroesophageal reflux disease (GERD) and achalasia. While a Nissen fundoplication is very effective in patients with GERD, it will worsen symptoms in those with achalasia or other non-GERD etiologies for their symptoms. Symptoms are a useful guide but can’t be relied upon alone for a diagnosis prior to surgical intervention. Even classic GERD symptoms of heartburn and regurgitation are at best 80 % reliable, and there is frequently symptom overlap with motility abnormalities and non-GERD etiologies. For example, it is common for patients with achalasia to have been given a trial of proton pump inhibitor (PPI) medication for symptoms presumed to be secondary to GERD. Although unfortunate, at least medications can be discontinued. Surgical intervention is much more difficult to undo, and therefore, the level of diagnostic accuracy must be much more stringent. An accurate diagnosis based on physiologic testing will ensure the best surgical outcomes in patients with foregut disorders.
Esophageal and foregut functional testing The essential tests to evaluate patients with foregut symptoms are similar, but should be modified based on the suspected diagnosis. A standard videoesophagram is extremely useful for patients without achalasia since video sequences are obtained in both a prone and upright position to allow evaluation of esophageal bolus transport with and without the aid of gravity. In patients with achalasia there is no bolus movement independent of gravity, and therefore, a timed barium swallow provides much more useful information regarding the severity of LES outflow obstruction and esophageal retention. Upper endoscopy including a retroflexed view of the hiatus with a careful evaluation of the esophageal and gastric mucosa is essential in any patient with foregut symptoms. Biopsies should be taken of any abnormal lesions, of a columnar-lined lower esophagus, of the antrum and body of the stomach to evaluate for H. pylori infection, and, in my opinion, even at a normal-appearing gastroesophageal junction (GEJ) to evaluate for the presence of intestinal metaplasia of the cardia. Intestinal metaplasia anywhere in the esophagus or stomach is abnormal and pre-malignant. Esophageal manometry, now typically done using solid-state high resolution systems (HRM: high-resolution esophageal manometry), is another critical test for the evaluation of patients with foregut symptoms. There are two reasons for the use of manometry. The first is to evaluate the LES and esophageal body function, and the second is to locate precisely the LES to facilitate accurate placement of a pH monitoring probe in patients suspected of having GERD. Esophageal pH testing allows confirmation of a diagnosis of GERD, and is recommended in all patients
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except those with unequivocal erosive esophagitis (using the LA grading system) or those with biopsy-proven Barrett’s esophagus. Most commonly, pH monitoring is done using the Bravo system which allows for 48 h or longer of esophageal pH data, but a standard or dual-probe pH catheter is useful in some patients. Placement of the Bravo probe is best done trans-nasally using the LES location based on manometry rather than endoscopically based on the visualized GEJ. In patients with extra-esophageal symptoms, or in those with laryngopharyngeal reflux (LPR) symptoms, use of the Resteck pharyngeal pH monitoring system can identify patients that might be missed with standard pH testing alone [1]. Additional tests to consider are a 4-h nuclear medicine gastric emptying study in patients suspected of having altered gastric emptying and impedance-pH monitoring in those with symptoms perhaps related to weak or non-acid reflux events.
Who are surgical candidates, and who are the best candidates? GERD Therapy for GERD consists of dietary and lifestyle modifications along with acid-suppressing medications. While anyone with proven GERD is a candidate for an antireflux procedure, in most circumstances surgery is reserved for incomplete response to medical therapy, inability or a desire not to take lifelong GERD medications, or disease progression on medical therapy. Since the outcome of antireflux surgery will depend on the relationship between a patient’s symptoms and the presence of GERD, the better the correlation, the greater the patient will be satisfied with a fundoplication or an alternative antireflux procedure. Thus, the first key concept is that prior to an antireflux procedure the presence of abnormal reflux of gastric contents into the esophagus must be documented. This documentation can be in the form of an abnormal pH test, endoscopic erosive esophagitis, or pathologically confirmed Barrett’s esophagus. The second key concept is that just because someone has proven GERD does not mean that they should be offered antireflux surgery. A fundoplication very effectively stops reflux, but it comes with side effects. The type of fundoplication, partial versus complete, likely influences the frequency and severity of complications, but to some degree all fundoplications should be considered capable of inducing changes which can be permanent. If the severity of reflux is not enough to offset the potential side-effects, then these patients may be best served with continued medical therapy or an alternative antireflux procedure with fewer side-effects such as the LINX device. Further, there are occasionally patients with such advanced reflux disease, including those with scleroderma, where a fundoplication is unlikely to lead to a successful outcome and alternative options should be considered. Prior to an antireflux operation it is important to set the expectations so that patients are not surprised or alarmed by the functional changes which accompany a fundoplication. I tell patients to expect to be unable to belch and vomit, have increased flatulence, and experience dysphagia which is generally limited to the first 4-8 weeks but can be protracted beyond that occasionally. Further, even in the absence of dysphagia, patients are able to out-eat their esophagus after a fundoplication, and meals need to become more social or “European” in style. I also warn patients that bloating can occur and be troublesome, particularly if there are concerns about abnormal gastric emptying. However, the benefits of a fundoplication are that the dietary and lifestyle modifications that accompany reflux disease such as eating early before bedtime, sleeping with the head of the bed elevated, and avoiding reflux-inducing types of foods all go
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Esophagus (E Dellon, Section Editor) away. Patients can eat what they want when they want without the fear of experiencing symptoms of GERD. In my experience, patients with significant GERD symptoms despite good medical management will almost always find the trade-off favorable, and in fact a common comment in the post-op clinic from these patients is “why did I wait so long to have this done? This has given me my life back.” The best candidates for an antireflux operation are those with classic reflux symptoms responsive or partially responsive to proton pump inhibitors (PPIs). In a multivariable analysis of 233 patients who had an antireflux procedure, we found that the three predictors of a good response to a fundoplication in rank order of significance were an abnormal score on esophageal pH monitoring, a typical primary symptom of reflux (heartburn or regurgitation), and complete or partial response to acid suppression therapy [2••]. When all three of these conditions were met, 97 % of patients had an excellent or good outcome after a fundoplication. Satisfaction after a fundoplication decreased steadily with an increasing number of unmet conditions, and when none of the three were present, nearly half of the patients did not have an excellent or good outcome. Thus, in the absence of typical symptoms it is very important that the patient have a positive pH test confirming reflux, an excellent response of their symptoms to PPI medications, or both. Likewise, rather than “failure of medical [PPI] therapy” being an indication for surgery, it is actually a large red flag indicating that the patient may not be satisfied with the outcome of an antireflux operation unless they have typical symptoms and a positive pH test. Surgeons should use these three established predicators to discuss with patients the likelihood of an excellent or good outcome after a fundoplication. It is critical for surgeons to recognize that a referral for antireflux surgery from a gastroenterologist should not mean that the patient needs an operation. Instead, the referral provides the opportunity for a surgeon to advise the patient on the pros and cons of an antireflux procedure, outline to the patient the likelihood they would be satisfied with a fundoplication, and recommend against an antireflux procedure in patients at increased risk of being dissatisfied. Another important issue is that of a hiatal hernia. A sliding or type I hernia is characterized by having the GEJ herniated into the chest but it remains above the fundus of the stomach. It may reduce in the upright position, and if it does there should be no concern about a foreshortened esophagus. Type I hernias are the most common type of hiatal hernia. Importantly, the presence of a sliding hiatal hernia is not an indication for surgery, and symptoms attributed solely to a sliding hiatal hernia seldom warrant surgical intervention. Instead, the indication for surgery in a patient with a sliding hiatal hernia is the presence of documented GERD. With that said, patients with a large sliding hiatal hernia are often those with significant GERD symptoms, particularly regurgitation, that are difficult to control with PPI therapy. These patients are also those at risk for complications of their reflux disease including strictures, Barrett’s esophagus, and pulmonary problems such as aspiration pneumonia and fibrosis. Commonly, these patients are referred for consideration of surgery. A careful evaluation of esophageal motility in these patients is warranted since with severe longstanding GERD there may be impaired motility that might increase the risk of prolonged dysphagia if a Nissen or 360 degree fundoplication is performed. Further, these hernias often do not spontaneously reduce in the upright position and repair may require a Collis gastroplasty to lengthen the esophagus if excess tension is encountered intra-operatively.
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The other type of hernia is the paraesophageal hernia (PEH) in which the fundus of the stomach is above the GEJ, and often most or all of the stomach has herniated into the chest. These are subdivided based on the amount of stomach in the chest (Types II and III) and the presence of organs in addition to the stomach in the chest (Type IV). In contrast to a sliding hiatal hernia, a symptomatic PEH is an indication for repair even in the absence of GERD. This is an important distinction, and all too often patients with a symptomatic PEH are not appropriately referred for surgical correction related to a misunderstanding of the differences in these hernias. Further, it is often underappreciated in the gastroenterology community that a large PEH is associated with anemia and that correction of the PEH will resolve the anemia in most patients [3]. Consequently, an extensive evaluation for the source of anemia in a patient with an unrepaired PEH is unwarranted. Antireflux surgery is markedly different from procedures that remove an organ such as an appendectomy or cholecystectomy since antireflux surgery aims to re-establish function of the organ. In these types of procedures, technique correlates significantly with outcome. The fundamentals of antireflux surgery include repair of a co-existent hiatal hernia and augmentation of the LES with a partial or complete fundoplication. Simple in concept, there are a myriad of details that go into a long-term, successful antireflux procedure. One important concept for improving success is to understand the causes of failure. The leading form of anatomic failure after a laparoscopic fundoplication is a recurrent hiatal hernia (Fig. 1). Many recurrent hernias are small and asymptomatic, but if the hernia enlarges or the fundoplication disrupts, patients may develop recurrent symptoms that require PPI medication or a reoperation. Therefore, analyzing factors that lead to a recurrent hiatal hernia and keeping them in mind at the time of the initial operation should lead to improved outcomes. Here it is valuable to review the experience with PEH repairs, where hernia recurrence is an even more frequent problem [4]. One issue that surgeons must address during crural closure is the fact that the crura, like filet mignon, have no fascia and as such hold sutures poorly. Any tension on the crural repair will encourage breakdown and hernia recurrence. Pedgets and horizontal mattress sutures are classically used in surgery when suturing tissues with poor integrity such as the heart or blood vessels. The use of pledgets for crural repair may be beneficial particularly in the setting of thin or widely separated crural pillars. I prefer absorbable pledgets since permanent materials can erode into the esophagus. I make pledgets from the absorbable mesh that I will use to reinforce the crural repair. The use of mesh at the hiatus is controversial, and has not been proven to reduce hiatal hernia recurrence. However, mesh use at hernia sites elsewhere in the body has been proven beneficial, and I believe that prior studies on mesh at the hiatus have used the wrong mesh, wrong technique, or both. Mesh, if used, should never bridge the crura since with permanent mesh this is associated with the highest risk for mesh erosion into the stomach or esophagus, and an absorbable mesh bridge will lead to a recurrent hernia. Instead, if mesh is used, my preference is an absorbable mesh onlay over the primary crural closure. There are several types of absorbable mesh that have shown excellent early results [5–7].
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Esophagus (E Dellon, Section Editor) The second issue surgeons should recognize is that tension at the hiatus can come from two directions. The first is axial tension related to a short esophagus. Risk factors for esophageal shortening include a 5 cm or larger sliding or paraesophageal hernia, a recurrent hiatal hernia after prior repair, and an esophageal stricture [8]. Mediastinal esophageal mobilization can provide adequate esophageal length in most patients, but in some, a Collis gastroplasty is necessary. A general guide during a laparoscopic fundoplication is that in the relaxed state, i.e. no downward tension on a penrose around the esophagus, there should be 23 cm of intra-abdominal esophagus. During laparoscopic surgery the diaphragms are artificially elevated by the pneumoperitonuem, and release of the carbon dioxide at the end of the procedure will reduce the intra-abdominal length of esophagus and put tension on a repair done with less than 3 cm of intra-abdominal esophagus. A Collis gastroplasty can be done laparoscopically using the wedge fundectomy technique and is associated with few complications [9]. The second form of tension at the hiatus is lateral tension related to very widely splayed crura, typically seen in patients with a very large sliding or more commonly a paraesophageal hernia. In these patients, a crural-relaxing incision, typically on the right, allows for crural re-approximation with acceptable tension. The defect created by the relaxing incision is then repaired with a small patch of permanent mesh (Fig. 2) [10]. Incorporation of these techniques including the use of absorbable mesh reinforcement of the primary crural closure and adjunct procedures for esophageal tension when present has in our experience improved outcomes with antireflux surgery and PEH repair [11]. The use of a fundoplication to augment the LES is inherent in an antireflux procedure. It is also a critical component of PEH repair. Historically, the Allison repair was a simple correction of the hiatal hernia without the addition of a fundoplication and it was associated with a high frequency of reflux post-operatively [12]. A randomized study has confirmed the lifetime observations by Dr. Allison that, indeed, an antireflux procedure should be added to hiatal hernia repair for the best outcome with PEH repair [13]. The decision in most patients is between a Toupet 270 degree partial fundoplication or a complete 360 degree Nissen fundoplication. The Dor 180 degree partial fundoplication is typically reserved for patients with achalasia, since long-term followup from centers in Australia that used it in GERD patients have shown higher rates of recurrent reflux compared to a more complete fundoplication [14]. Centers in Europe have contended that the Toupet fundoplication allows similar control of reflux with less side-effects than the Nissen, but studies from the US raise concern about the durability of a partial fundoplication in patients with advanced reflux disease [15]. This issue remains controversial and may in part relate to different patients and meal sizes in Europe and the United States. The higher tendency toward obesity and the consumption of large quantities of food at one setting in US patients may contribute to a higher failure rate of partial fundoplications. My preference is to do a Nissen fundoplication unless poor esophageal motility would indicate an increased risk for protracted dysphagia.
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Fig. 1. Retroflex view on upper endoscopy of an intact fundoplication herniated partially into the chest. This is the most common form of anatomic failure of a laparoscopic fundoplication.
The degree of esophageal motility abnormalities that should preclude a Nissen fundoplication are clear only at the extreme where there is absent peristalsis, as in a patient with achalasia or scleroderma. In all other patients judgment is necessary. The classic suggestion that esophageal body contraction amplitudes of 30 mmHg or more are necessary for a Nissen are probably too stringent, but an amplitude of 20 mmHg is likely the lower limit of what should be acceptable since the outflow resistance of a Nissen fundoplication is approximately 20 mmHg. However, even with amplitudes of contraction above 20 mmHg patients with dysphagia symptoms or evidence of impaired bolus transport on videoesophagram may have troublesome dysphagia after a Nissen
Fig. 2. A right crural relaxing incision has been performed which allowed the primary crural closure to be accomplished with minimal tension. A 1-mm Gortex patch will be sewn in place to close the defect in the diaphragm and then an absorbable mesh will be used to buttress the primary crural closure.
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Esophagus (E Dellon, Section Editor) fundoplication. Ultimately, surgeons and patients must weigh the potentially higher risk of protracted dysphagia with a Nissen fundoplication against the potentially higher long-term failure rate of a partial fundoplication when there is concern about esophageal body function. In these situations a careful and detailed discussion with the patient about the issues and options can minimize frustration and dissatisfaction post-operatively. An important issue in some patients with GERD is co-existent delayed gastric emptying. When evaluating a patient for possible antireflux surgery, it is important to get a history about frequent nausea or bloating symptoms as well as difficulty with early or prolonged satiety. When present, these symptoms as well as a history of diabetes or prior antireflux surgery where vagal nerve injury may have occurred are, in my opinion, an indication for evaluation of gastric function pre-operatively. A fundoplication has been shown to improve gastric emptying since a portion of the fundus, which is involved in receptive relaxation, is used to augment the LES. A critical issue though is whether the improvement in gastric emptying will offset the loss of the ability of the stomach to vent. If so, patients usually do very well without significant boating symptoms. If not, these patients can be miserable with bloating and distension. There are no hard and fast rules to guide how patients with symptoms and evidence of delayed gastric emptying will do with a fundoplication, but in my experience, the presence of a bezoar on pre-operative endoscopy after an overnight fast is an ominous finding. In the presence of delayed gastric empting, I prefer a Nissen fundoplication since a partial fundoplication may not adequately control reflux in these patients. When significant bloating occurs unexpectedly after a fundoplication I have found a temporary percutaneous gastrostomy tube can allow venting of the stomach until gastric function returns. However, in patients with permanent gastric dysfunction measures such as pyloroplasty or partial gastrectomy with roux-en-y gastrojejunostomy, may be necessary to improve symptoms. A trial of prokinetic medications, and perhaps pyloric injection of Botox, may be useful prior to surgical intervention in these patients. Here again, careful pre-operative counseling of patients with the potential for problems related to delayed gastric emptying can minimize post-operative frustration and dissatisfaction. The role of a fundoplication in patients with Barrett’s esophagus (BE) has long been controversial. First, since BE occurs as a consequence of GERD, any patient with BE is a candidate for an antireflux procedure for control of symptoms and complications related to their reflux disease. However, patients with BE often have advanced reflux disease with impaired esophageal body function and a large hiatal hernia. In these patients the longevity of a fundoplication is not as good as in patients with less severe disease, and careful consideration should be given to the downsides of a failed fundoplication. In addition to recurrent symptoms, a failed fundoplication is a risk factor for progression of BE to adenocarcinoma [16]. The impact of a functioning fundoplication on BE progression is controversial. A careful analysis of published studies suggests that an antireflux procedure can alter the natural history of the disease and reduce the risk of progression [17, 18]. However, it certainly won’t prevent all adenocarcinomas in these patients, and to recommend a fundoplication solely on the basis of trying to prevent cancer in a patient with BE is, in my opinion, ill-
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advised. Instead, patients with BE should have a fundoplication to improve their overall quality of life, and if it reduces the risk of BE progression that is a bonus, but it should not be the sole indication for an operation. Instead, the best cancer prevention strategy with or without a fundoplication is careful annual surveillance of the Barrett’s with ablation for progression to dysplasia. Another issue is how to manage reflux in patients that have had endoscopic resection or ablation for high-grade dysplasia or intra-mucosal adenocarcinoma. These patients need to be on high-dose acid suppression medications or alternatively have an antireflux procedure. Data on which approach will lead to the best long-term results are currently not available, but I favor a fundoplication in suitable operative candidates in this situation. Lastly, an important issue to consider is the use of an antireflux procedure early in the course of patients at risk for progressive disease. In the ProGERD study from Europe, 2,721 patients with reflux were followed for 5 years, and multivariate analysis of baseline factors identified a family history of GERD and unhealed esophagitis after initial treatment as risk factors for progressive disease [19••]. Further, in a follow-up study of this cohort almost 10 % of patients had progressed to BE by 5 years. Risk factors by multivariate analysis for progression to BE were baseline esophagitis and regular intake of alcohol or PPI medications. In patients with intestinal metaplasia of the cardia upon entry into the study more than 20 % developed endoscopic BE within 5 years [20]. Most was short segment, but some patients developed long-segment BE during follow-up. On multivariate analysis the factors associated with progression were smoking, a long history of GERD, and severe esophagitis. It is worth considering the option of an antireflux procedure in these patients in an effort to modify this natural history. For those with early disease, an excellent option is the LINX device. The LINX is a bracelet of magnets that is laparoscopically fitted around the LES and provides effective relief of reflux symptoms and in most cases normalization of esophageal acid exposure with fewer of the side-effects that accompany a standard fundoplication [21]. It is interesting to speculate whether early intervention with either the LINX device or a fundoplication might prevent disease progression in appropriate patients. There is some evidence in support of this concept. A study with careful long-term follow-up from Sweden compared the likelihood of intestinal metaplasia developing in patients on medical therapy versus after antireflux surgery [22]. This studied showed that the likelihood of developing BE was significantly reduced in patients that had a fundoplication. These findings taken together suggest a potential role for early intervention with an antireflux procedure in patients at risk for progressive disease.
Achalasia Esophageal distension from impaired lower esophageal sphincter (LES) relaxation can produce “heartburn” type symptoms in patients with achalasia, and the bland regurgitation of esophageal contents in a patient with achalasia can be mistaken for the more common regurgitation of gastric juice in a patient with poor LES function and GERD. However, achalasia and GERD are opposite ends of the LES spectrum. In patients with GERD, the LES is generally hypotensive and incompetent, allowing gastric juice to go up into the esophagus. In contrast, the LES in a patient with achalasia is normotensive or hypertensive and fails to
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Esophagus (E Dellon, Section Editor) relax appropriately, leading to an inability of the esophagus to empty appropriately. The diagnosis is most conclusively made with esophageal manometry where the characteristic findings are an incompletely relaxing lower esophageal sphincter (LES) and absent peristalsis in the esophageal body. Esophageal pressurization and a hypertensive LES may also be present. The introduction of high resolution esophageal manometry (HRM) into clinical practice has provided more detail about esophageal function, and HRM studies in patients with achalasia have identified three subtypes of this disease. Characteristic of all three types is an elevated integration relaxation pressure (IRP) above 15 mmHg. The subtypes are Type I or “classic” achalasia with incomplete LES opening and an aperistaltic esophageal body, Type II with panesophageal pressurization, and Type III with no normal peristalsis, but evidence of distal esophageal spasm [23]. The integrated relaxation pressure (IRP) is elevated above 15 in all three types. The two main long-term treatment options for patients with achalasia have been pneumatic dilatation and Heller myotomy. Injection of botulium toxin is typically reserved for patients who are poor candidates for a more definitive therapy since it is temporary and can complicate the performance of other therapies. Pneumatic dilatation is done with an achalasia balloon that is at least 150 % the normal size of the esophagus (30 mm) in an effort to disrupt the dysfunctional LES musculature without leading to a perforation of the mucosa. A single dilatation is unlikely to provide permanent relief of symptoms, but repeated dilatations and use of larger balloons for recurrent symptoms leads to improved results. In a randomized trial from Europe, an aggressive pneumatic dilatation protocol led to success rates similar to that observed with a laparoscopic Heller myotomy, but with a 4 % risk of esophageal perforation [24]. Importantly, in a subsequent analysis of the outcome of pneumatic dilatation by HRM subtype, successful relief of symptoms was best in patients with Type II achalasia, but poor in patients with Type III achalasia [25••]. These same poor results were not seen after laparoscopic Heller myotomy and Dor in patients with Type III achalasia. Thus, the HRM type is important for selecting therapy, and in patients with Type III achalasia pneumatic dilatation should be avoided. The Heller myotomy was described over 100 years ago by the German surgeon Ernest Heller. This procedure, with three important modifications, has become the gold standard therapy in the US and most centers worldwide for the treatment of achalasia. The first important modification is to perform the myotomy in a minimally invasive laparoscopic fashion. Pelegrini and colleagues introduced the minimally invasive surgical treatment for achalasia in 1992 with the description of a thoracocsopic Heller myotomy [26]. However, with the introduction of laparoscopy it became clear that a laparoscopic approach led to superior outcomes. There are a number of reasons why a laparoscopic approach is the standard of care including the ease of extending the myotomy distally on the stomach with the laparoscopic approach, the ability to add a partial fundoplication and cover the full extent of the myotomy, the recognition of the importance of keeping the myotomy below the hiatus in the abdomen to avoid development of a diverticulum in the chest, no need for single lung ventilation during the surgery, no need for a chest drain postoperatively, and the fact that conversion if necessary is a laparotomy not a thoracotomy. Current indications for a thoracoscopic approach are limited to patients with a hostile abdomen, the presence of an epiphrenic diverticulum
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that can’t be addressed laparoscopically, or for patients where a long esophageal myotomy is planned. The second important modification is to extend the myotomy 3 cm down onto the stomach below the GEJ. Previously, a Heller myotomy stopped 1 cm below the GEJ. This was adequate in some patients, but was associated with recurrent or persistent dysphagia in others. An analysis of failed myotomies found that failure was related to an inadequate distal myotomy, and showed that extension of the myotomy further onto the stomach reduced the failure rate [27]. A corollary modification is that since failure is not related to an inadequate proximal myotomy, the myotomy should not extend above the hiatus. Over time, an intra-thoracic myotomy has been associated with the development of a diverticulum in the chest. Management of these patients is difficult and often requires esophagectomy. The third important modification is to add a partial fundoplication, either a Dor or a Toupet, to reduce reflux after the myotomy. In a randomized trial comparing outcome after laparoscopic myotomy alone versus with a partial fundoplication Richards et al showed that the addition of a Dor fundoplication led to significantly less reflux by pH monitoring with no difference in the successful relief of dysphagia [28]. No significant outcome differences have been found between a Dor partial anterior and the Toupet partial posterior fundoplication, but the faster and easier Dor is preferred in most centers. Further, the Dor fundoplication covers the myotomy site and reduces the risk of a post-operative leak from an unrecognized mucosal injury or after repair of a mucosal perforation intra-operatively. In patients with achalasia and a hiatal hernia the Toupet is often preferred since the hiatus is mobilized to repair the hiatal hernia. If the myotomy is kept well on the left side of the esophagus the mucosa can be covered by the Toupet by sewing the anterior fundus to the upper edge of the myotomized esophagus. A laparoscopic Heller myotomy with these modifications has become the gold standard therapy for achalasia. It has shown durable, excellent results and these results have been reproduced at centers around the world. Several metaanalyses have shown that compared to other therapies, the laparoscopic Heller myotomy and Dor has a lower rate of re-intervention. Further, it is applicable to all HRM subtypes of achalasia. Recently, a new procedure for achalasia has been introduced, the per-oral endoscopic myotomy, or POEM. The POEM procedure represents a paradigm shift since previously efficacy was related to invasiveness in patients with achalasia. On the low efficacy and low invasiveness side are Botox injection and a single pneumatic dilatation, and moving toward more invasive and better efficacy are multiple pneumatic dilatations and laparoscopic Heller myotomy and Dor. The POEM procedure provides the efficacy of the laparoscopic Heller with the invasiveness of a single pneumatic dilatation. It may be the best of both worlds, allowing a precise myotomy with the recovery benefits of no external incisions and no physical restrictions. The POEM procedure was first used to treat achalasia in a human by Inoue in 2008, and his initial experience was reported in 2010 [29]. An advantage of the POEM procedure is that the myotomy can be started high in the esophagus for patients with spastic disorders or Type III achalasia, and extended down several centimeters onto the stomach to minimize the risk of an inadequate myotomy. Since Inoue’s first procedure there have now been several thousand POEM procedures performed worldwide.
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Esophagus (E Dellon, Section Editor) While most are done for achalasia, the indications have expanded to diffuse esophageal spasm, hypertensive LES and as a technique to remove smooth muscle tumors in the muscularis propria of the esophagus and gastroesophageal junction [30]. The concepts have also been applied to performing an endoscopic myotomy of the pylorus for delayed gastric emptying and of the cricopharyngeous for Zenker’s diverticulum or cricopharyngeal dysfunction. The basic concept of these procedures is that an incision is created in the mucosa followed by creation of a submucosal tunnel. The tunnel is then used to perform the myotomy of the circular fibers of the upper esophageal sphincter, lower esophageal sphincter, or the pylorus. The procedure is completed by closing the mucosal defect either with clips or sutures. There have now been a number of publications on the early results of POEM for achalasia, both from single centers and from an international prospective trail [31, 32]. From these, a number of conclusions can be drawn regarding POEM. First, POEM is very safe, even during the learning curve [33, 34]. There have been no reports of mortality with the procedure. A number of complications including subcutaneous emphysema, pneumothorax, and pnuemoperitoneum were reported with the use of air rather than carbon dioxide for insufflation. When using carbon dioxide, the frequency of these complications is much lower [32]. Capnoperitoneum occurs commonly, but only in 5-10 % of patients is it necessary to decompress the abdomen with an angiocath or Veress needle. Bleeding from large submucosal vessels can be problematic but typically is readily controlled with the use of coagulating forceps, and with experience is much easier avoided than treated during creation of the submucosal tunnel [35]. Delayed bleeding occurs rarely, although in some cases has required reexploration of the tunnel. Another occasional source of morbidity is the mucosal closure. Typically a barium swallow is done later that day or the day after the procedure to verify the integrity of the closure. A leak into the submucosal tunnel should prompt re-exploration. The most serious reported complication has been a contained esophageal perforation at the level of the gastroesophageal junction [36]. Treatment in this patient consisted of endoscopic and laparoscopic evaluation of the area with placement of drains. Overall, for a novel procedure there has been remarkably little morbidity, although most reports are from centers with significant experience in the management of patients with esophageal disorders. Second, POEM results in significant improvement in dysphagia and regurgitation symptoms. In a series by Swanstom et al., the median Eckardt score of 20 patients at 1 month after POEM was 1, down from 6 pre-POEM, and over half of the patients had complete resolution of dysphagia [31]. These results persisted with longer follow-up. At 18 months after the procedure, the median Eckardt score was 0; most patients had no dysphagia symptoms, and all were satisfied with the results of the procedure. On objective evaluation, the median emptying at 5 min by timed barium swallow had improved from 48 % to 100 % at 6 months post-POEM [36]. Similarly, in an international, multiinstitution series of 70 patients, the median Eckardt score had dropped from 7 to 1 at 3 months after POEM, and treatment success was achieved in 97 % of patients. The mean LES pressure decreased from 28 to 9 mmHg. At 12 months after POEM, sustained treatment success was present in 82 % of patients, and
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the mean Eckardt score was 1.7 in the 51 patients available for follow-up [32]. Importantly, POEM can be used to relieve symptoms in all Chicago highresolution subclasses of achalasia, even for patients with Type III that respond poorly to endoscopic balloon dilatation [37]. Third, POEM can lead to gastroesophageal reflux. Any procedure to open up the LES in patients with achalasia and improve esophageal emptying can lead to gastroesophageal reflux. The POEM, by virtue of its excellent myotomy without a partial fundoplication, is perhaps more likely to lead to reflux than other procedures. In the series by Swanstom et al., 44 % of patients reported heartburn after POEM, and all of these patients were taking acid suppression medications [31]. On upper endoscopy, erosive esophagitis was seen in 28 %, and on 24-h pH testing, 46 % of patients had increased esophageal acid exposure. In the international series 37 % of patients had reflux symptoms and erosive esophagitis was present in 42 % of patients at 12 months post-POEM [32]. Fourth, compared to a laparoscopic Heller myotomy with partial fundoplication, POEM has been shown to lead to a similar good outcome in two series comparing these procedures. The first, by Hungness et al, showed that operative times were shorter with POEM but complications and the median length of hospital stay were similar for the two procedures [36]. The second, by Bhayani et al, showed that post-operative Eckhardt scores were lower after POEM and 100 % of patients had relief of dysphagia after POEM compared to 97 % after laparoscopic Heller myotomy and partial fundoplication [38]. Symptoms of heartburn, reflux, and chest pain were similar for the two procedures. On objective testing the absolute and relative decreases in LES resting pressures were similar, but the resting pressure was higher after POEM. On 24-h pH monitoring, the frequency of increased esophageal acid exposure was similar at about 35 % after each procedure.
Conclusions The outcome of surgical intervention for benign esophageal disorders is directly related to the accuracy of the diagnosis and the technique of the procedure. Errors in either will diminish the efficacy of the procedure and the satisfaction of the patient. New technologies for antireflux procedures may draw interest from the sizeable segment of patients incompletely satisfied with acid suppression therapy, and early intervention in patients at risk for progression may alter the natural history of reflux disease. In patients with achalasia, the laparoscopic Heller myotomy that is extended 3 cm down onto the stomach and combined with a Dor partial fundoplication has become the gold standard therapy with excellent results reported from centers around the globe. Further, outcomes are excellent in all HRM types of achalasia. Aggressive pneumatic dilatation may achieve similar results, but should not be used in patients with Type III achalasia where outcomes are worse. A new paradigm in achalasia treatment is the POEM procedure which may offer the benefits of the precise myotomy achieved with a laparoscopic approach combined with the recovery benefits of an endoscopic approach. Early results are excellent and POEM has proven safe and reproducible at centers with experience treating patients with esophageal disorders. Long-term results and wider application of the
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Esophagus (E Dellon, Section Editor) procedure are necessary before firm conclusions can be made about its place in the management of patients with achalasia.
Compliance with Ethics Guidelines Conflict of Interest Steven R. DeMeester has received consultancy fees, paid travel accommodations, and payment for development of educational presentations from Bard and Novadaq. Dr. DeMeester also has received honoraria from Bard and consultancy fees from C2 Therapeutics.
Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: •• Of major importance 1.
Worrell SG, DeMeester SR, Greene CL, et al. Pharyngeal pH monitoring better predicts a successful outcome for extraesophageal reflux symptoms after antireflux surgery. Surg Endosc. 2013;27:4113–8. 2.•• Campos GM, Peters JH, DeMeester TR, et al. Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg. 1999;3:292–300. This article defines the key factors that predict successful outcome with a fundoplication. 3. Collis JL. An operation for haitus hernia with short esophagus. J Thorac Surg. 1957;34:768–78. 4. Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: longterm follow-up from a multicenter, prospective, randomized trial.[Erratum appears in J Am Coll Surg. 2011 Dec;213(6):815]. J Am Coll Surg. 2011;213:461–8. 5. Alicuben ET, Worrell SG, DeMeester SR. Resorbable biosynthetic mesh for crural reinforcement during hiatal hernia repair. Am Surg. 2014;80:1030–3. 6. Zehetner J, Lipham JC, Ayazi S, et al. A simplified technique for intrathoracic stomach repair: laparoscopic fundoplication with Vicryl mesh and BioGlue crural reinforcement. Surg Endosc. 2010;24:675–9. 7. Alicuben ET, Worrell SG, DeMeester SR. Impact of crural relaxing incisions, collis gastroplasty, and noncross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates. J Am Coll Surg. 2014;219:988–92.
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