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Year : 2019  |  Volume : 11  |  Issue : 2  |  Page : 67-71

The outcome of modified Heller's myotomy for achalasia: A 3-center study in Nigeria

1 Department of Surgery, Federal Medical Centre, Lokoja, Kogi, Nigeria
2 Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria
3 Department of Surgery, Federal Teaching Hospital, Abakaliki, Ebonyi, Nigeria

Date of Submission19-May-2018
Date of Decision02-Jul-2018
Date of Acceptance09-Jul-2018
Date of Web Publication22-May-2020

Correspondence Address:
Dr. Ndubuisi Anumenechi
Department of Surgery, Federal Medical Centre, Lokoja, Kogi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/NJGH.NJGH_6_20

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Background: Achalasia is a rare disease. The present standard treatment is laparoscopic Heller's myotomy. Some centers still use thoracoscopy, thoracotomy, or laparotomy. Newer approaches such as the per-oral endoscopic esophagomyotomy are being evaluated.
Objectives: The objective of the study was to review the diagnostic procedures for achalasia cardia and the therapeutic approaches being used in the study centers and to evaluate the dysphagia and reflux esophagitis outcomes and the occurrence of operative complications.
Methods: This is a retrospective study over 10 years (2008–2017) from three centers in Nigeria. The clinical and operative records were reviewed. The route and outcome of modified Heller's myotomy for achalasia cardia were reviewed.
Results: The total number of cases was 16. The male-to-female ratio was 1:1, and age ranged from 3 to 55 years. Diagnosis was done by clinical features and barium swallow test. Two of the 16 cases were done via the laparotomy approach, while the remaining 14 were achieved via a left thoracotomy. Only in one case was fundoplication done. Perioperative mortality was zero. Overall long-term dysphagia and reflux outcomes were satisfactory.
Conclusion: Clinical and radiological features are predominantly used to diagnose achalasia; esophageal manometry was not available. Surgery was predominantly done by the thoracotomy approach, with occasional fundoplication.

Keywords: Achalasia, Heller's myotomy, laparotomy, outcome, thoracotomy

How to cite this article:
Anumenechi N, Edaigbini SA, Ezeanwu A, Delia IZ, Aminu MB, Alioke II. The outcome of modified Heller's myotomy for achalasia: A 3-center study in Nigeria. Niger J Gastroenterol Hepatol 2019;11:67-71

How to cite this URL:
Anumenechi N, Edaigbini SA, Ezeanwu A, Delia IZ, Aminu MB, Alioke II. The outcome of modified Heller's myotomy for achalasia: A 3-center study in Nigeria. Niger J Gastroenterol Hepatol [serial online] 2019 [cited 2021 Dec 3];11:67-71. Available from: https://www.njghonweb.org/text.asp?2019/11/2/67/284718

  Introduction Top

Achalasia is a primary motility disorder of the esophagus, characterized by absent antegrade peristalsis in the body of the esophagus and failure of reflex relaxation of the lower esophageal sphincter (LES).[1] It is a rare disease with a worldwide incidence of 0.03–1.6 per 100,000 persons per year.[2],[3] The predominant symptoms are dysphagia and regurgitation. Weight loss, cough, and features of reflex esophagitis can also manifest. In some patients, parotid swelling may also be found.[4],[5]

Diagnosis is based on clinical, radiological, esophagoscopic, and manometric features. Contrast esophagogram findings in established disease are classically described as a bird's beak appearance of the distal esophagus with a dilated esophageal body.[3] An esophagoscopy is important in the evaluation for achalasia. Esophagoscopy serves to rule out pseudoachalasia. Pseudoachalasia can cause abnormal esophageal body function and impaired esophagogastric junction (EGJ) relaxation, just like achalasia. Esophagoscopic findings in achalasia may be normal or it may reveal a roomy esophageal body, with advancement of the scope through the EGJ being associated with only mild resistance. EGJ resistance greater than mild resistance or inability to advance the scope into the stomach should raise the suspicion of pseudoachalasia.[6],[7] Pseudoachalasia can be due to malignant or benign stricture.

The oesophageal manometric study is the gold standard of diagnosis.[3] This serves to confirm the diagnosis, especially in early cases, and to rule out other esophageal motility disorders. The usual manometric findings in achalasia are aperistalsis in the esophageal body and failure of reflex relaxation of the LES to swallowing.[3] Contrast esophagogram and esophagoscopy may not be sensitive enough to diagnose all cases of achalasia. In these cases, esophageal manometric studies will help to make the diagnosis. Manometry is complementary in cases where contrast esophagogram and esophagoscopy show classic features of achalasia but also helps to classify the types of achalasia. High-resolution manometry (HRM) has a higher sensitivity than conventional manometry and more easily classifies the types of achalasia.[8] HRM also reduces interobserver variability, compensates for movement artifacts, and is more comfortable for the patient.[9] Based on the HRM findings in the Chicago classification version 3.0, achalasia is defined by aperistalsis and abnormal LES relaxation (integrated relation pressure >15 mmHg) and has been classified into Types I, II, and III. Type I has incomplete LES relaxation, aperistalsis, and the absence of esophageal pressurization; Type II has incomplete LES relaxation, aperistalsis, and panesophageal pressurization in at least 20% of swallows, while Type III is spastic achalasia, characterized by incomplete LES relaxation and premature contractions (distal latency <4.5 s) in at least 20% of swallows.[9] The response to treatment is best for Type II, followed in response rate by Type I, whereas Type III is the least responsive to treatment.[10],[11]

Patients with achalasia may also complain of heartburn and regurgitation. Some of them are therefore initially managed as gastroesophageal reflux, with delay in diagnosis, especially in the early stages of achalasia.[12] These peptic symptoms may also be due to retention esophagitis or true gastroesophageal reflux and may also arise as complications of treatment for achalasia.[13] A 24-h pH study helps to evaluate reflux symptoms in patients with achalasia, with a diagnosis of gastroesophageal reflux made when the DeMeester score is above 14.72.[14]

The extent of investigations depends on the available modalities and local practice guidelines. Achalasia cardia is incurable; the aim of the treatment is to reduce the tone of the LES.[1] The standard of care is esophageal myotomy; the approach and extent to this myotomy are widely debated.[15] The original Heller's myotomy was a combined anterior and posterior myotomy via a left thoracoabdominal approach performed in 1913 by German surgeon Ernest Heller; it was associated with severe reflux esophagitis.[16],[17] The Dutch surgeon Zaaijer modified this in 1918 to only an anterior myotomy.[18] Further modifications included just a thoracotomy approach, then a laparotomy approach; afterward, fundoplications were added to reduce reflux complications.[15] However, laparoscopic esophageal myotomy and fundoplication is currently regarded as the standard surgical approach.[19] Nevertheless, laparotomy, thoracotomy, and thoracoscopic approaches are still been practiced, depending on the availability of skill and equipment. For megaesophagus or repeated failed myotomy, esophagectomy and conduit replacement can also be done;[20] another option is cardioplasty involving resection of the EGJ and esophagogastrostomy.[21],[22]

Nonsurgical management includes balloon myoplasty, botulinum toxin injection, and medical management using calcium channel blockers and long-acting nitrates.[19]

The peroral endoscopic myotomy is a newer approach with acceptable outcomes.[23]

Surgeries can be complicated by perforation, reflux esophagitis, and residual dysphagia among other problems.[24] Achalasia increases the risk to esophageal carcinoma, with absolute risk increase for squamous cell carcinoma of 308.1 cases per 100,000 patients per year and an increase for adenocarcinoma of 18.03 cases per 100,000 patients per year.[25],[26] The objectives of this study were to review the diagnostic and therapeutic approaches in the management of achalasia cardia and to evaluate the outcome of its surgical treatment.

  Methods Top

This study is a retrospective review of the cases of achalasia operated over 10 years (2008–2017) from three centers in Nigeria – Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria; Federal Medical Centre, Lokoja, Kogi, Nigeria; and Federal Teaching Hospital, Abakaliki, Ebonyi, Nigeria.

Ethical approval for the study was obtained from the ethical review committee.

All the patients were referred from the gastrointestinal units of these hospitals. The clinical and operative records of the patients were reviewed for data on clinical features, diagnostic and therapeutic approaches, and outcomes.

Patients were evaluated clinically and using available investigational facilities. They were resuscitated and prepared for surgery. Operative access was obtained via a standard left posterolateral thoracotomy or upper midline laparotomy incision. The esophagus was mobilized at the esophageal hiatus. An 8 cm myotomy was made on the distal esophagus, extending 0.5–1 cm across the EGJ to the stomach. The longitudinal and circular muscles were widely dissected to allow the glistening mucosa to pop out.

In cases where mucosal perforations complicated the procedure, such perforations were closed with polyglactin 2/0, without a second myotomy done and a nasogastric tube was left in situ. Routine chest or abdominal closures were done. Cases with mucosal perforation were placed on nil per oral for 5–7 days.

Patients were placed on proton-pump inhibitors for 4–6 weeks. They were followed up in clinics looking out for the occurrence of dysphagia and/or reflux symptoms.

  Results Top

The total number of cases done was 16, with a male to female ratio of 1:1. The age of the patients ranged from 3 to 55 years, with a mean of 30.4 (12.8) years. Symptoms consisted mainly of dysphagia, regurgitation, and weight loss. The diagnosis was based on clinical features, barium swallow test, and esophagoscopy. None of the centers had esophageal manometry.

The operative approach was via laparotomy in 2 cases (12.5%) and left posterolateral thoracotomy in 14 cases (87.5%). A Belsey Mark IV fundoplication was done in one case (6.25%). The mean operative time was 2.5 (0.8) h, with a range of 2–4 h. Oral feeding was commenced on the 1st postoperative day. There were three complications of mucosal perforations (18.75%). In those with mucosal perforation, oral feeding was delayed till at least the 5th postoperative day.

There were no wound infections. Patients reported varying degrees of dyspepsia, which lasted between 2 and 8 weeks. There was one case of postoperative residual dysphagia, which was due to sigmoid megaesophagus; this case required an esophagectomy with colon interposition. Dysphagia resolution was 94%. Intensive care unit admission lasted between 24 and 48 h, with no perioperative mortality. The mean hospital stay was between was 7 (2) days, range: 5 and 14 days; and the follow up period was between 3 and 24 months, mean 12 (3.3) months.

  Discussion Top

Achalasia is not a common disease. The incidence, age, and sex distribution found in this study reflect results from other centers.[2],[27] Achalasia has been reported in children as young as 1 year.[28] Esophageal manometry was not available in any of the centers; therefore, the diagnosis was based on the clinical presentation and radiological and esophagoscopic findings. This scenario can be found in another study where manometry was not available, but the approach was predominantly by the laparotomy approach.[29] The hospital stay was expectedly higher than in studies with procedures done laparoscopically.[30] In the absence of skill for laparoscopic modified Heller's myotomy in these institutions, a posterolateral thoracotomy was preferred. In the two cases where laparotomy was used, one was based on the patient's preference; the second was because the patient already had a laparotomy for a missed diagnosis of gastric outlet obstruction. Earlier studies from one of the centers favored the laparotomy approach.[31],[32] A thoracotomy has the advantage of patients being able to commence oral feeding on the 1st postoperative day but with greater postoperative pain. In laparotomy approach, feeding commences when bowel sounds return. However, in this study, the cases of perforation occurred with the laparotomy approach. Therefore, the 5 days taken to commence oral feeding in the patients who had laparotomy was due to the wait for mucosal healing and cannot be attributed to just the approach.

Popular teaching about repair of mucosal perforations is to repair both the mucosa and myotomy, then creating a fresh myotomy 180° opposite the initial myotomy. This method increases operation time, is technically more demanding, and with the possibility of greater morbidity. Ensuring just an airtight mucosal repair may suffice. The authors have achieved good results with such repair of mucosal perforations, as there was no persistent mucosal leak. In cases of mucosal perforation, the patients were placed on nil per oral for 5 to 7 days to allow for mucosal healing. However, the patients without mucosal perforations started oral feeding on the 1st postoperative day.

Fundoplication of some sort is recommended during esophageal myotomy to reduce the incidence of reflux esophagitis;[15] however, some authors consider fundoplication unnecessary if the myotomy is less than 5mm on the gastric cardia.[28],[33] The authors routinely limited the distal extent of the myotomy to 0.5–1 cm on the gastric cardia. With this approach, the rate and severity of reflux are generally acceptable.[34] In one case in this study, the gastric component of the myotomy was deemed excessive, and a fundoplication was done. To further prevent reflux symptoms, patients were placed on proton-pump inhibitors for 4–6 weeks postsurgery. In this series, there were no medium-term reflux symptoms. However, follow-up was up to a maximum of 24 months. Dysphagia can complicate fundoplication in 0%–8% of cases post myotomy;[35],[36] however, comparable dysphagia outcomes have been achieved with or without fundoplication.[32],[37] The outcome on dysphagia in this study was good and may be attributed to adequacy of the myotomy aided by the omission of fundoplication. The rate and duration of reflux symptoms are not different from what has been reported in other studies.[15],[29],[28] The singular case that had residual dysphagia was a case of megaesophagus. This case of megaesophagus eventually had an esophagectomy and colon replacement. The wound outcomes were acceptable and no septic incidents followed the cases that had mucosal perforation.[38]

Follow-up was for a few months to 2 years. The recommended follow-up is for life so as to be able to detect the development of esophageal cancer, which these patients are at risk of having.[25],[39] The patients in this study stopped coming for follow-up after a few months, probably because of their sense of wellness.

  Conclusion Top

The three centers arrived at the diagnosis predominantly by clinical, radiological, and esophagoscopic features. Manometry was not available.

Thoracotomy was preferred over laparotomy for surgical approach to modified Heller's myotomy, and laparoscopic surgery was not available. Fundoplication was not done routinely. The outcome was satisfactory. Efforts should be made to get manometric studies before surgery, and a longer follow-up is recommended.

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Conflicts of interest

There are no conflicts of interest.

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