Clincal Study On Laparoscopy Combined With Esophagogastroscopy In The Minimally Invasive Treatment Of Achalasia

Objective:Internationally, the laparoscopic gastric cardia sphincterotomy is the preferred surgical treatment of achalasia. In China, the most severe patients still choose to medical treatment. This operation can only be carried out in a very small number of hospitals.The aim of this study was to investigate the clinical outcome and advantage of laparoscopy combined with esophagogastroscopy in the treatment of achalasia.Methods:Between February 2005 and January 2011, a total of 33 patients with achalasia underwent a combined laparoscopic and esophagogastroscopic surgery which comprised of laparoscopic Heller myotomy and Dor fundoplication at the center of Tianjin minimally invasive surgery. Among them,18 were male and 15 were female with an average age of 43 years (24-70). Patients were symptomatic for a mean of 42 months (range,18 to 105 months) before operation. The average preoperative weight loss was 5-25kg (mean 10kg). Preoperatively,2 patients accepted endoscopic injection of botulinum toxin and 2 underwent endoscopic dilation. All patients had dysphagia and received upper gastrointestinal series (barium swallow), esophagogastroscopy, esophageal manometry to confirm the diagnosis and to exclude esophageal carcinoma, and 33 patients also had 24-hour ambulatory pH studies. All patients were operated by laparoscopic modified Heller myotomy with Dor 180°fundoplication. In addition, intraoperative esophagogastroscopy was applied to guide the scope and depth of myotomy and to confirm the esophageal mucosa exposed completely. At the same time, intraoperative endoscopy was used to detect mucosal perforation, and could help repair the mucosa directly. Follow-up was carried out by telephone or correspondence.The patients were asked about postoperative dysphagia, heartburn, chest pain. We assess the clinical value and advantage of laparoscopy combined with esophagogastroscopy in the treatment of achalasia through analyzing the preoperative data and the postoperative data.Results:All laparoscopic surgeries were accomplished successfully. There were no patients required conversion from laparoscopic to open operation and no operative deaths. The average operating time was 90.26 minutes (range,60-145), operative blood loss averaged 45 ml (50-150), and the median hospital stay was 5.2 day (4-9). Intraoperative mucosal perforation was encountered in one patients who undergone endoscopic injection of botulinum toxin and lead to fibrosis of the mucosa and muscular layers of the esophagus. This was noted intraoperatively by esophagogastroscopy and repaired by laparoscopic suture. After suture, esophagogastroscopy was used again to confirm. No significant morbidities and no esophageal leaks were noted in this study. With postoperative follow-up of months, all patients had dysphagia relieved. As a result, postoperative assessment consisted of endoscopic, radiologic, manometric and pH metric studies showed a satisfactory result.Conclusions1.The laparoscopic Heller-Dor operation is the preferred surgical treatment of achalasia.Laparoscopic cardiomyotomy is a safe, highly effective and minimally invasive treatment for achalasia. Combined with intraoperative gastroscopic guidance and examination, we can improve the security and decrease the complication during laparoscopy operation.2. The myotomy should be carried cephalad for at about 4-6cm and through the longitudinal and circular muscle fibers down to the esophageal submucosa and extended about 1.5 cm in the caudal direction from the GEJ on the anterior stomach to ensure complete division of the sling fibers.3. Longer duration of symptoms, sigmoidal esophageal changes impact adversely on the success of myotomy.4. Endoscopic dilation or endoscopic injection leads to fibrosis of the mucosa and muscular layers of the esophagus. Laparoscopic myotomy is great difficult in these patients who have been previously treated with endoscopic.