11. Video-Assisted Thoracic Esophageal Myotomy with Intraoperative Manometry for Achalasia
Farid Gharagozloo, Mark Soberman*, Greg Trachiotis
Georgetown University Medical Center and The Veterans Affairs Medical Center
Washington, District of Columbia, USA
BACKGROUND
The treatment of esophageal achalasia remains controversial. The inconsistent surgical results are due in part to disagreement as to the thoracic versus abdominal approach, and the need for an added antireflux procedure.
MATERIAL AND METHODS
In a three-year period, 20 patients underwent video-assisted thoracic extramucosal esophageal myotomy with intraoperative manometry and esophagogastroscopy (EGD). There were 8 men and 12 women, with a mean age of 33.3
± 3.9 years. All patients had dysphagia. Median duration of symptoms was 2 years. Diagnosis of achalasia was confirmed by radiography, endoscopy, and measurement of the esophagogastric junction pressure (LES) by manometry. Of the 20 patients, 14 had undergone pneumatic or hydrostatic dilation, three of 20 patients had undergone botulinum toxin injection.All patients underwent intraoperative EGD with placement of the manometry catheter under direct vision. Esophageal manometry was performed while under anesthesia both in the supine and right lateral decubitus positions. Video-assisted myotomy was performed through four 2 cm incisions in the left chest. The mytomy was extended inferiorly until the esophagogastric junction pressure decreased to 8-10 mmHg. This pressure was selected as it represents the median esophagogastric pressure in a normal population. Manometry was repeated after the hiatal reapproximation to ensure that the esophagogastric junction pressure did not change. A gastrograffin swallow was obtained the day after surgery. No patients required a thoracotomy. There were no mucosal injuries. No leaks were detected on the gastrograffin study.
All patients were discharged from the hospital after 36 hours on a regular diet. In all patients, the esophagogastric pressure under anesthesia correlated with the preoperative study. The placement of the patients in the lateral decubitus position did not change the manometric readings.
Esophagogastric Junction Pressure (LES)(mmHg): Premyotomy Postmyotomy P value
26.8
± 3.3 9.1± 0.9 <0.05RESULTS
Mean follow-up was 18 months with a range of 1-35 months. At the time of the last follow-up, 19 patients (95%) had excellent swallowing and one patient (5%), with a severely dilated esophagus, had good swallowing. None of the patients experienced symptoms of gastroesophageal reflux.
CONCLUSION
These results suggest that video-assisted thoracic esophageal myotomy with intraoperative manometry results in immediate relief of dysphagia without causing gastroesophageal reflux.
