Laparoscopic Heller-Dor Surgery for Esophageal Achalasia: Impact of Intraoperative Real-Time Manometric Feedback on Postoperative Outcomes

Abstract

Background: Laparoscopic Heller myotomy with Dor fundoplication (LHD) is one of the most established surgical procedures for esophageal achalasia. Preoperative esophageal manometry has been reported as useful to evaluate lower esophageal sphincter (LES) pressure. However, the feasibility, safety, and impact of its intraoperative use have not been fully evaluated, especially when enhanced with real-time 3-D pressure imaging. Methods: LHD was attempted on 24 consecutive patients with esophageal achalasia. Manometry was performed at 3 time points during LHD: before myotomy, after myotomy, and after fundoplication. Investigations included esophagography, manometry, and 24-hour esophageal pH monitoring in the preoperative, short-term (0–5 months) and long-term (1–3 years) follow-up periods. Results: The 3-D intraoperative manometric images were presented to the surgical crew on a monitor screen immediately after each measurement in all attempted cases (n = 13). Any residual high pressure zone of the LES was easily recognized and resolved with additional myotomy. Postoperative esophagographies showed resolution of esophageal dilatation. Manometric examination revealed significant reduction of LES pressure in the short-/long-term follow-up periods. PH monitoring showed no increase in acid reflux. Overall outcomes were satisfactory (symptom relief = 95%). Conclusion: Intraoperative manometry with real-time pressure feedback is a feasible, safe, and useful adjunct in LHD.

SAGES guidelines for the surgical treatment of esophageal achalasia

“…Any residual fibers can be divided as needed. Some authors have suggested the use of intraoperative manometry to assess the myotomy for completeness [43], but comparative data are lacking. The myotomy also can be assessed for perforation by placing it under a column of saline and inflating gently through the endoscope.…”

Intraoperative Assessment of Esophagogastric Junction Distensibility During Laparoscopic Heller Myotomy

“…13 Current practice is to perform a myotomy that adheres to whatever length the surgeon believes is appropriate based on the above, and to determine the adequacy of the myotomy based on the appearance of the EGJ endoscopically following myotomy. 3 Some investigators advocate for the use of intraoperative manometry, 14,15 but this is cumbersome and not a common practice. An intraoperative, objective assessment that could guide the surgeon and provide real-time feedback that the extent of the myotomy is adequate would be invaluable.…”

Treatment and surveillance strategies in achalasia: an update

“…Although advanced age is frequently viewed as an obstacle to surgery, mostly because of the increased frequency of clinically significant comorbidi ties, a 2010 study suggests that laparoscopic myotomy can achieve excellent outcomes in patients >60 years of age. 62 The introduction of realtime, intra operative mano metry 63,64 and robotic-assisted myotomy 65,66 may further improve postoperative outcomes, but these methods are not widely established.…”

“…At our center, to avoid misinterpretation of success by immediate treatment effects, such as intramural hematoma, we preferentially perform these studies 4 weeks after therapy. However, some centers assess treatment success by esophageal manometry intraoperatively 63,64 or immediately after pneumatic dilation. 12 In a very ambitious approach, Hulselmans et al 12 even performed serial pneumatic dilations with daily esophageal manometry over 1-3 days to achieve and assess their manometric treatment goal.…”