SECTION II: ESOPHAGUS

Laparoscopic Heller Myotomy for Achalasia:

A Review of the Controversies
Virginia R. Litle, MD
Division of Thoracic Surgery, Department of Cardiothoracic Surgery, The Mount Sinai Medical Center, New York, New York

Achalasia is a rare primary motility disorder of the of combining a fundoplication with a laparoscopic my-
esophagus with a United States prevalence of less than otomy. The optimal length of myotomy as suggested in
0.001%. Laparoscopic modified Heller myotomy has be- the literature is also summarized. To complete the goal,
come the standard of care for palliation of this incurable peer-reviewed publications were identified in PubMed
but benign disease. The role of a fundoplication with the by search terms achalasia, myotomy, fundoplication, Nis-
myotomy continues to be controversial. This report sum- sen, Dor, and Toupet.
marizes the current laparoscopic management of achala- (Ann Thorac Surg 2008;85:S743– 6)
sia with a review of the medical literature on the outcome © 2008 by The Society of Thoracic Surgeons

A chalasia is an uncommon primary motility disorder

of the esophagus, with a prevalence or less than
0.001% in the United States [1]. Progressive dysphagia to
Minimally Invasive Approach
Within the past 15 years, the increased competence of
surgeons to perform minimally invasive surgery has
solids and liquids and chest pain are the predominant resulted in the laparoscopic, modified Heller myotomy
symptoms in more than 80% of patients, and regurgita- becoming in the gold standard treatment for achalasia. A
tion occurs in two-thirds [2, 3]. Aperistalsis and incom- left video-assisted thoracoscopic surgery (VATS) ap-
plete relaxation of the lower esophageal sphincter (LES) proach may still be performed at some centers or when a
by esophageal manometry are the sine qua non findings concurrent intrathoracic esophageal diverticulum is ex-
for diagnosing the disease. In addition, approximately cised. The original Heller myotomy described in 1913
60% of the patients have elevated resting LES pressure involved creating an anterior and posterior cardiomyo-
[4]. Not infrequently the diagnosis is initially suggested tomy, but the current technique was modified in 1923 to
by an upper endoscopy performed for dysphagia. This simply an anterior myotomy [5, 6]. The operative contro-
essentially rules out a diagnosis of pseudoachalasia from versies have most recently included the length of myot-
malignancy but does not eliminate the need for manom- omy and the addition of a concurrent antireflux
etry. A barium swallow is helpful for identifying a procedure.
megaesophagus or sigmoid esophagus from end-stage When a modified Heller myotomy is performed with a
achalasia because these patients may be offered imme- left VATS and the phrenoesophageal ligament remains
diate surgical resection vs dilation or myotomy. intact, an antireflux procedure should not be necessary.
Until the past 10 years, pneumatic esophageal dilation With a transabdominal Heller myotomy, however, a
was most commonly used to treat achalasia because it hiatal hernia is essentially created and reflux can occur. A
was the least invasive therapy and provided long-term routine antireflux procedure is controversial because of
relief for a subset of patients. Treatment with injection of the concomitant aperistaltic esophagus and because the
botulinum toxin A (Botox; Allergan Inc, Irvine, CA) in the long-term outcomes may not be better with a fundopli-
LES has not been associated with perforation similar to cation. A review of the role of fundoplication and other SUPPLEMENT
dilation but has a shorter and temporary therapeutic controversies in achalasia will be addressed separately
efficacy. The effect averages from 3 to 6 months, and below as ascertained from peer-reviewed publications in
duration is not clearly operator- or patient-dependent. PubMed.
Injection of botulinum toxin probably should be reserved
Laparoscopic Heller and Nissen Fundoplication
for poor operative candidates who classically are elderly
patients with recurrent aspiration pneumonia. In several early series in the minimally invasive era and
against conventional wisdom in an aperistaltic esopha-
gus, a complete 360° (Nissen) fundoplication was per-
formed with a laparoscopic Heller myotomy. In one
Presented at the Minimally Invasive Thoracic Surgery Summit, New review of 42 patients treated with various approaches, 9
York, NY, June 8 –9, 2007. patients underwent a Heller and a “floppy” Nissen over
Address correspondence to Dr Litle, Division of Thoracic Surgery, The
a 40F bougie. At a mean follow-up of 8.5 years in this
Mount Sinai Medical Center, 1190 Fifth Ave, Box 1028, New York, small group of patients, 22% (2 of 9) of patients com-
NY 10029-6574; e-mail: virginia.litle@mountsinai.org. plained of dysphagia to meat or bread and 30% com-

© 2008 by The Society of Thoracic Surgeons 0003-4975/08/$34.00

Published by Elsevier Inc doi:10.1016/j.athoracsur.2007.12.004
 S744 MINIMALLY INVASIVE THORACIC SURGERY SUMMIT LITLE Ann Thorac Surg
FUNDOPLICATION REVIEW IN ACHALASIA 2008;85:S743– 6

Table 1. Frequency of Dysphagia After Modified Heller Myotomy and Partial (Dor, Toupet) or Complete (Nissen)
Fundoplication
First Author, Year Patients, No. Type of wrap (No. of patients) Dysphagia, %

Wright [9], 2007 52 Dor 2

63 Toupet 2
Frantzides [5], 2004 53 Floppy Nissen (48) 4
Lyass [10], 2003 532 (15 studies) Dor (429), Toupet (103) 3.2
Luketich [11], 2001 62 Toupet (45), Dor (8), Belsey (3) 38
Patti [12], 2001 102 Dor 11

plained of reflux, although there was no objective evi- similar, as the 100 total respondents who underwent a
dence of this with 24-hour pH monitoring [7]. Heller or a Heller and Dor had an equal satisfaction rate
Another study in Australia included 49 patients who of 92%. Although the authors did not report rates of
underwent a laparoscopic myotomy and Nissen fundo- gastroesophageal reflux disease (GERD) in their cohort,
plication and 13 who had a myotomy and partial anterior we can at least conclude from this large series of patients
fundoplication [8]. The dysphagia score at 3 years and that dysphagia may not be a long-term complication after
then at 5 years for these two groups of patients trended the addition of a partial anterior fundoplication.
toward statistically significantly less dysphagia in the Intraoperative esophageal perforation has been re-
partial fundoplication group at 5 years (dysphagia score ported to occur in at least 10% to 14% of laparoscopic
difference at 5 years, p ⫽ 0.08). The authors concluded myotomy cases [13, 14], but is likely underreported and
that although partial fundoplication results in less dys- may not even be considered a complication by some.
phagia and chest pain than a complete wrap, there is no Again, the surgeon should be proficient at or have
evidence to suggest a total fundoplication resulted in a immediate access to a gastroenterologist to perform in-
worse outcome overall. The authors recommended a traoperative endoscopy so the perforation can be identi-
controlled randomized trial to answer the controversy [8]. fied and repaired immediately. Several sutures usually
The third report of a “floppy” Nissen combined with can be placed laparoscopically, but conversion to a lap-
myotomy was a review by Frantzides and colleagues [5] arotomy may be necessary. Only the minimal number of
of their 10-year experience that began in 1992. In this sutures (1 to 2) needed to reapproximate the mucosa
retrospective study of 53 patients, 48 (90%) had a con- should be placed, because the injury can be easily ex-
comitant Nissen fundoplication with the laparoscopic tended during suturing. If intraoperative perforation
myotomy. After completing a long myotomy with up to 7 does occur by the myotomy, the endoscope or a bougie,
cm on the cardia, a 50F bougie was placed and the 360° then an anterior (Dor) would provide both an antireflux
wrap completed. The laxity of the wrap was assessed by component and additional security that the perforation
placing a 1-cm instrument next to the esophagus. At a and postoperative leak risk has been minimized.
median 3-year follow-up, 2 of the 48 Nissen patients (4%) Because of the controversy of performing an antireflux
had dysphagia as determined by a modified Visick scor- procedure with the myotomy, a prospective randomized
ing system. The dysphagia was attributed to an incom- clinical trial of myotomy with and without Dor was
plete myotomy in one case and an excessively tight wrap completed at Vanderbilt University and reported in 2004
in the other. The authors attribute their success with a [15]. This study randomized 43 patients undergoing lapa-
low postoperative dysphagia rate after a Nissen fundo- roscopic myotomy for achalasia to Dor vs no Dor. Pa-
plication to the use of a lighted bougie that allows tients underwent manometry and 24-hour pH monitor-
performance of a complete myotomy with improved ing at 3 to 5 months postoperatively. Pathologic reflux
visualization and hence division of intact muscle fibers. was significantly less in the Dor group (9% vs 48% in
SUPPLEMENT

patients without the Dor); in addition, distal esophageal

Laparoscopic Heller and Dor Fundoplication acid exposure was significantly higher in the Heller-only
Several series have evaluated Heller myotomy with and group. Again, dysphagia was not a long-term complica-
without partial fundoplication, and most of the reports tion as judged by similar dysphagia scores between the
involve an anterior or Dor fundoplication (Table 1) [5, two groups.
9 –12]. One study that looked at quality of life (QOL) and The other studies looking at Dor fundoplication and
dysphagia after myotomy used a Medical Outcomes rates of postoperative dysphagia did not separate Dor
Study Short-Form 36 (SF-36) Health Survey QOL and a from Toupet, Nissen, or even Belsey patients, so we may
dysphagia scoring system [13]. These authors did not only conclude that rates of dysphagia after partial fun-
report the incidence of postoperative dysphagia with and doplication are 2% to 38% (Table 1). In the University of
without a Dor, but they found that at an average follow-up of Pittsburgh cohort, any patient who complained of some
3.3 years, the mean dysphagia score was not statistically dysphagia at a mean follow-up of 19 months contributed
worse when a Dor was performed. They also found that to the 38% rate of dysphagia. More important though, the
the mean SF-36 scores in the two groups at 3 years were dysphagia severity score was significantly improved in
Ann Thorac Surg MINIMALLY INVASIVE THORACIC SURGERY SUMMIT LITLE S745
2008;85:S743– 6 FUNDOPLICATION REVIEW IN ACHALASIA

Table 2. Incidence of Heartburn or Symptomatic Gastroesophageal Reflux after Heller Myotomy With and Without a
Fundoplication (Wrap)
First Author, Year No. of Patients Wrap Type (n) Heartburn, %

Wright [13], 2007 52 Yes Dor 1.6

63 Toupet 1.2
Richards [15], 2004 21 No ... 48
22 Yes Dor 9
Burpee [16], 2004 50 No ... 30
Frantzides [5], 2004 53 Yes Floppy Nissen (48) 8
Lyass [10], 2003 532 (15 studies) No ... 13
Yes Dor, Toupet 6
Donahue [14], 2002 81 Yes Toupet, Dor 26
Luketich [11], 2001 62 Yes Toupet, Dor, Belsey 9

more than 95% of patients, and similarly, more than 92% across the gastroesophageal junction after the myotomy.
of patients were satisfied with the operation [11]. Of course this assessment must be done carefully, be-
Although the goal of an antireflux procedure with the cause this may provide the greatest risk of perforation
myotomy is to prevent postoperative symptomatic and during the entire operation.
objective reflux and associated complications of esoph- Extent of myotomy on the gastric cardia (2 to 3 cm)
agitis, the randomized study by Richards and colleagues appears to reduce postoperative dysphagia and minimize
[15] provides the best evidence that the heartburn rates “recurrent” achalasia. Patti and colleagues [12] concluded
improved with a Dor fundoplication. The rates of heart- that an inadequate cardiomyotomy accounted for at least
burn with fundoplication were 8% to 26% in all series two failed Heller myotomies, with intraoperative video
(Table 2) [5, 10, 11, 13–16], and at least one patient (2%) in demonstrating impaired visualization of the gastroesopha-
a moderate-sized series had Barrett’s esophagus [14]. geal junction [12]. The extended myotomy recently en-
dorsed by Dr Pellegrini’s group involves more than 3 cm of
Laparoscopic Heller and Toupet Fundoplication cardiomyotomy [9]. The important technical message is
There are fewer total patients in the reports of the use of elevation of the anterior esophageal fat pad to provide
a partial posterior, or Toupet, fundoplication as an anti- accurate identification of the gastroesophageal junction and
reflux procedure after the myotomy. The only published completion of at least 2 cm of cardiomyotomy.
report directly comparing Dor and Toupet was from
Wright and colleagues [9] at the University of Washing- Secondary Achalasia After Complete Fundoplication
ton. These authors compared two groups of achalasia for Gastroesophageal Reflux Disease
patients treated with two different procedures: from 1994 Two reports of achalasia developing after antireflux sur-
to 1998, a standard myotomy (1 to 2 cm on the cardia) and gery have recently been published. One report from
a Dor fundoplication was done; whereas from 1998 to Toronto involved two such cases, one of which occurred
2003, an extended myotomy (more than 3 cm on the 12 years after the initial fundoplication. Both patients in
cardia) and a Toupet fundoplication was done. Using this report were then treated successfully with myot-
telephone surveys, they determined that dysphagia se- omies [18]. The message in this article was an endorse-
verity was lower in the extended myotomy and Toupet ment of preoperative manometry before antireflux sur-
group, although frequency of dysphagia was similar. In gery. Esophageal motility studies can be beneficial before
this study, postoperative heartburn and regurgitation routine fundoplication to reduce the risk of postoperative
frequencies were the similar after the two different dysphagia, but because the study cannot always be SUPPLEMENT
approaches. completed, an accurate history and a barium swallow
should prevent— or at least minimize—a misdiagnosis of
The Myotomy GERD in a patient with achalasia.
A method for assessing completeness of myotomy is to The other recent article on secondary achalasia after
perform intraoperative manometry to measure any resid- fundoplication supports the routine use of manometry
ual high pressure across the gastroesophageal junction before antireflux surgery [19]. In this review of 250
[17]. In this series of 132 patients, 34% had persistently patients who underwent laparoscopic Nissen fundoplica-
elevated pressures allowing immediate revision of their tion by one surgeon, late-onset postoperative dysphagia
myotomy, with a short postoperative success rate of 93% and manometric aperistalsis developed in 7 patients.
at 1 month. This technique of intraoperative manometry Only 2 patients had failure of LES relaxation, but all 7
is a good educational tool but is not typically available to were given a diagnosis of secondary achalasia. All the
surgeons. Probably a more common way of assessing the patients were treated with dilation, but 3 also responded
completeness of myotomy is with intraoperative endos- to botulinum toxin injection, and 1 patient underwent a
copy and the ease with which the operator passes it Heller myotomy. The incidence of achalasia after fundo-
 S746 MINIMALLY INVASIVE THORACIC SURGERY SUMMIT LITLE Ann Thorac Surg
FUNDOPLICATION REVIEW IN ACHALASIA 2008;85:S743– 6

plication in the series is less than 1%, with 2 patients 6. Payne WS. Heller’s contribution to the surgical treatment of
having standard manometry consistent with achalasia. achalasia of the esophagus. 1914. Ann Thorac Surg 1989;48:
Although fewer than 20 patients with post-Nissen acha- 876 – 81.
7. Jordan PH. Longterm results of esophageal myotomy for
lasia have been reported in the literature, this may achalasia. J Am Coll Surg 2001;193:137– 45.
provide evidence against choosing a Nissen as an anti- 8. Wills VL, Hunt DR. Functional outcome after Heller myot-
reflux procedure with a myotomy for achalasia. omy and fundoplication for achalasia. J Gastrointest Surg
2001;5:408 –13.
9. Wright AS, Williams CW, Pellegrini CA, Oelschlager BK.
Summary Long-term outcomes confirm the superior efficacy of ex-
tended Heller myotomy with Toupet fundoplication for
Laparoscopic-modified Heller esophagocardiomyotomy achalasia. Surg Endosc 2007;21:713– 8.
is the standard treatment for patients with achalasia but 10. Lyass S, Thoman D, Steiner JP, et al. Current status of an
without prohibitive comorbidities. Perioperative mortal- antireflux procedure in laparoscopic Heller myotomy. Surg
ity should approach 0%, and long-term patient satisfac- Endosc 2003;17:554 – 8.
11. Luketich JD, Fernando HC, Christie NA, et al. Outcomes
tion exceeds 90%. An antireflux procedure can reduce
after minimally invasive esophagomyotomy. Ann Thor Surg
postoperative heartburn rates by 80% and reduce risk of 2001;72:1909 –13.
esophagitis and peptic stricture. A Dor or Toupet fundo- 12. Patti MG, Molena D, Fisichella PM, et al. Laparoscopic
plication reduces reflux as well as a Nissen, but the Heller myotomy and Dor fundoplication for achalasia. Arch
partial wraps trend toward less dysphagia. The dyspha- Surg 2001;136:870 –7.
13. Youssef Y, Richards WO, Sharp, et al. Relief of dysphagia
gia rates attributed to fundoplication range from 0% to
after laparoscopic Heller myotomy improves long-term
8%. Failure of improvement with dilation suggests in- quality of life. J Gastrointest Surg 2007;11:309 –13.
complete myotomy and requires repeat manometry. Op- 14. Donahue PE, Horgan S, Liu KJ-M, et al. Floppy Dor fundo-
timal length of the cardiomyotomy is at least 2 cm. plication after esophagocardiomyotomy for achalasia. Sur-
Although a Dor fundoplication is more commonly re- gery 2002;132:716 –23.
ported, the choice of Toupet vs Dor depends on surgeon 15. Richards WO, Torquati A, Holzman MD, et al. Heller myot-
omy versus Heller myotomy with Dor fundoplication for
preference. achalasia: A prospective randomized double-blind clinical
trial. Ann Surg 2004;240:405–15.
16. Burpee SE, Mamazza J, Schlachta CM, et al. Objective
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SUPPLEMENT