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      Laparoscopic Heller Myotomy With Epiphrenic Diverticulectomy

      case-report

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          Abstract

          Background and Objectives:

          To describe the technique and results of laparoscopic Heller myotomy and Toupet fundoplication combined with epiphrenic diverticulectomy.

          Case Report:

          A 75-year-old man presented to our institution complaining of dysphagia to solid foods and liquids. The preoperative preparation included a barium swallow, esophagoscopy, and esophageal manometry. Three months earlier, the patient had a botulinum toxin injection, which provided temporary relief. Ten months later, the patient underwent a laparoscopic Heller myotomy and Toupet fundoplication combined with an epiphrenic diverticulectomy.

          Results:

          No complications occurred. The patient tolerated clear liquids on postoperative day 1; on postoperative day 2, he was discharged tolerating full liquids. He returned to full activity in 1 week.

          Conclusions:

          Epiphrenic diverticulectomy combined with treatment for the underlying motor disorder and gastroesophageal reflux prevention is an accepted practice. We demonstrate that this rare problem can be approached with the laparoscopic technique. Given this favorable result, we plan to continue this technique and establish a longer follow-up and wider series.

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          Most cited references19

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          A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease.

          The authors examined indications, evaluations, and outcomes after laparoscopic fundoplication in patients with gastroesophageal reflux through this single-institution study. Laparoscopic fundoplication has been performed for less than 5 years, yet the early and intermediate results suggest that this operation is safe and equivalent in efficacy to open techniques of antireflux surgery. Over a 4-year period, 300 patients underwent laparoscopic Nissen fundoplication (252) or laparoscopic Toupet fundoplication (48) for gastroesophageal reflux refractory to medical therapy or requiring daily therapy with omeprazole or high-dose H2 antagonists. Preoperative evaluation included symptom assessment, esophagogastroduodenoscopy, 24-hour pH evaluation, and esophageal motility study. Physiologic follow-up included 24-hour pH study and esophageal motility study performed 6 weeks and 1 to 3 years after operation. The most frequent indication for surgery was the presence of residual typical and atypical gastroesophageal reflux symptoms (64%) despite standard doses of proton pump inhibitors. At preoperative evaluation, 51% of patients had erosive esophagitis, stricture, or Barrett's metaplasia. Ninety-eight percent of patients had an abnormal 24-hour pH study. Seventeen percent had impaired esophageal motility and 2% had aperistalsis. There were four conversions to open fundoplication (adhesions, three; large liver, one). Intraoperative technical difficulties occurred in 19(6%) patients and were dealt with intraoperatively in all but 1 patient (bleeding from enlarged left liver lobe). Minor complications occurred in 6% and major complications in 2%. There was no mortality. Median follow-up was 17 months. One year after operation, heartburn was absent in 93%. Four percent took occasional H2 antagonists, and 3% were back on daily therapy. Atypical reflux symptoms (e.g., asthma, hoarseness, chest pain, or cough) were eliminated or improved in 87% and no better in 13%. Overall patient satisfaction was 97%. Four patients have subsequently undergone laparotomy for repair of gastric perforation (1 year after operation), severe dumping, "slipped" Nissen, and repair of acute paraesophageal herniation. Two patients had laparoscopic revision of herniated fundoplications. Results of follow-up 24-hour pH studies were normal in 91% of patients more than 1 year after operation. In patients with poor esophageal motility, esophageal body pressure improved 1 year after operation in 75% and worsened in 10%. Although long-term efficacy data are lacking, intermediate follow-up shows laparoscopic fundoplication to be safe and effective. A physiologic approach to evaluation and follow-up of patients with gastroesophageal disease allows the surgeon to tailor antireflux surgery to esophageal body function and follow the function of the fundoplication and esophagus after operation.
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            Epiphrenic diverticulum: results of surgical treatment.

            From 1975 to 1991, 112 patients (64 men and 48 women) were found to have an epiphrenic diverticulum. Symptoms were absent or minimal in 71 patients and incapacitating in 41. All patients with minimal symptoms were managed conservatively; 35 were available for follow-up, which ranged from 1 to 25 years (median, 9 years). None of these 35 patients had clinically significant progression of symptoms. Surgical repair was done in 33 patients with incapacitating symptoms. Achalasia was present in 8 of the surgical patients (24.2%), diffuse esophageal spasm in 3 (9.1%), hypertensive lower esophageal sphincter alone in 1 (3.0%), and nonspecific motor abnormalities of the esophageal body in 7 (21.2%). Diverticulectomy and esophagomyotomy were performed in 22 patients, diverticulectomy alone in 7, esophageal resection in 3, and esophagomyotomy alone in 1. Concomitant hiatal hernia repair was done in 6 patients. Complications occurred in 11 patients; 6 had esophageal leaks. There were three operative deaths (9.1%), all occurring in patients with abnormal manometry. Follow-up was complete in 29 patients and ranged from 4 months to 15 years (median, 6.9 years). Long-term results were excellent in 14 patients (48.2%), good in 8 (27.6%), fair in 5 (17.2%), and poor in 2 (6.9%). We conclude that operation has significant risks and is not warranted in patients with minimal symptoms because progression is unlikely. Surgical treatment, however, is advisable in patients with incapacitating symptoms because most operative survivors will have long-term symptomatic palliation.
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              Laparoscopic Heller myotomy and fundoplication for achalasia.

              The goal of this study was to review the authors' results with laparoscopic cardiomyotomy and partial fundoplication for achalasia. Pneumatic dilatation and botulinum toxin (BOTOX) injection of the lower esophageal sphincter largely have replaced cardiomyotomy for treatment of achalasia. After a brief experience with a thoracoscopic approach, the authors elected to perform cardiomyotomy laparoscopically, in combination with a partial fundoplication (anterior or posterior). Forty patients were treated between July 1992 and November 1996. Thirty patients had previous therapy of achalasia, 21 with pneumatic dilation, 1 with BOTOX, 6 with balloon and BOTOX, and 2 with transthoracic cardiomyotomy. Three patients had previous laparoscopic fundoplication for gastroesophageal reflux. Symptom scores (0 = none to 4 = disabling) were obtained before surgery and after surgery. Barium swallows and esophagogastroduodenoscopy were performed in all patients. Esophageal motility study was performed in 36 patients. Laparoscopic Heller myotomy and fundoplication was performed through five upper abdominal trocars. A 7-cm myotomy extended 6 cm above the GE junction and 1 cm below the GE junction. A posterior fundoplication was performed in 32 patients, anterior fundoplication in 7 patients, and no fundoplication in 1 patient. Statistical inference was performed with a Wilcoxon signed rank test. Mean operative duration was 199 +/- 36.2 minutes. Mean hospital stay was 2.75 days (range, 1-13 days). Dysphagia was alleviated in all but four patients (90%), and regurgitation in all but two patients (95%) (p < 0.001). Chest pain and heartburn improved significantly (p < 0.01) as well. Intraoperative complications included mucosal laceration in six patients and hypercarbia in one. Postoperative pneumonia developed in two patients, and one patient had moderate hemorrhage from an esophageal ulcer 2 weeks after surgery. Laparoscopic cardiomyotomy and fundoplication appears to provide definitive treatment of achalasia with rapid rehabilitation and few complications.
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                Author and article information

                Journal
                JSLS
                JSLS
                jsls
                jsls
                JSLS
                JSLS : Journal of the Society of Laparoendoscopic Surgeons
                Society of Laparoendoscopic Surgeons (Miami, FL )
                1086-8089
                1938-3797
                Apr-Jun 2003
                : 7
                : 2
                : 165-169
                Affiliations
                Department of Surgery, Mount Carmel Health System, Columbus, Ohio, USA.
                Author notes
                Address reprint requests to: Timothy J. Pitchford, MD, Marshfield Clinic, 2116 Craig Rd, Eau Claire, WI 54701, USA. Telephone: 715 858 4747, Fax: 715 858 4505
                Article
                3015478
                12856850
                3496e602-1be3-4c2b-85fa-e950e30b437d
                © 2003 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License ( http://creativecommons.org/licenses/by-nc-nd/3.0/), which permits for noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited and is not altered in any way.

                History
                Categories
                Case Reports

                Surgery
                achalasia,esophageal diverticulum,laparoscopy
                Surgery
                achalasia, esophageal diverticulum, laparoscopy

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