Minimally Invasive Surgery as First-Line Therapy for Achalasia

Abstract

To the Editor, The optimal choice of treatment in patients with achalasia has been the subject of an ongoing discussion. Wang et al. [1] have provided an important meta-analysis of randomized and controlled treatment trials for achalasia. Laparoscopic myotomy proved to be the preferred method for patients with achalasia. The advantage of myotomy over other techniques had not been clearly demonstrated before. We would like to point out in the context of this recent analysis that minimally invasive myotomy should be regarded as the first-line therapy for achalasia. Surgical myotomy has been used to successfully treat achalasia since the early 1900s [2]. Relief of dysphagia is achieved in 90–95% of patients, and symptoms are alleviated in the long term. Young age was—among other baseline factors investigated by our group—associated with increased need for surgery in patients with achalasia [3]. Minimally invasive surgery has influenced the management of achalasia more than any other gastrointestinal disorder. Laparoscopic Heller myotomy has become the most frequently performed procedure for this disorder. Also, in another recently published meta-analysis, laparoscopic myotomy with partial fundoplication was the most effective surgical technique compared with all endoscopic and other surgical approaches, with a low complication rate and minimal development of gastroesophageal reflux [4]. Thus, the application of minimally invasive surgery to the therapy of esophageal achalasia has determined an unexpected change in the treatment algorithm of the disease. The minimally invasive approach offers several more inherent advantages, such as superior visualization of the gastroesophageal junction and a magnified view of both layers of the esophageal muscularis propria as well as of the oblique gastric fibres. Furthermore, the technical innovation introduced in the laparoscopic era is the use of intraoperative endoscopy to identify precisely the gastroesophageal junction and to examine the completeness of the myotomy, as well as to discover occult perforations by transillumination and air insufflation. An extended myotomy of 3 cm below the gastroesophageal junction more effectively disrupts the lower esophageal sphincter, thus improving the results of surgical therapy for dysphagia without an increased rate of abnormal gastroesophageal reflux [5]. A matter of debate has been the direction of the myotomy over the stomach, which may be closer to the lesser or to the greater curvature, and can divide the semicircular (clasp) fibres and the oblique (sling) fibres in distinct proportions [6]. The muscle edges are to be separated to expose the mucosa for about 30–40% of the circumferential diameter. The major cause of failures after Heller myotomy is incomplete distal myotomy on account of the danger of mucosal perforation. However, recurrent or persistent achalasia in most cases derives from undissected distal muscle layers and will require revisional surgery. Also, in patients previously treated with injection of botulinum toxin developing fibrosis and inflammation at the level of the gastroesophageal junction with loss of the anatomic planes, the dissection may be difficult and risky due to occult mucosal leakages. These margins, the most distal dissection of the myotomy, and patients with previous Botox therapy render the most dangerous and challenging components of the surgical myotomy. I. Gockel (&) H. Lang Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany e-mail: gockel@ach.klinik.uni-mainz.de