Heller Myotomy with Esophageal Diverticulectomy: An Operation in Need of Improvement

Sharona B Ross, MD, Prashant Sukharamwala, MD, Andrew Boland, MD, Carrie E Ryan, MS, Frank De Stefano, Alexander S Rosemurgy, MD. Florida Hospital Tampa

Introduction: Achalasia can be complicated by a distal esophageal pulsion diverticulum. This study was undertaken to determine outcomes after Heller myotomy, anterior fundoplication, and diverticulectomy.

Methods: 617 patients undergoing laparoscopic Heller myotomy and anterior fundoplication 1992-2014 are prospectively followed; patients were sorted for those undergoing concomitant diverticulectomy. Patients graded symptom frequency/severity before/after myotomy using a Likert scale (0= never/not bothersome to 10= always/very bothersome). Data are presented as median (mean ± SD).

Results: 35 patients, age 71years (68±12.3), underwent Heller myotomy, anterior fundoplication, and diverticulectomy. Operative time was 176 minutes (184±55). 62% of patients had comorbidities (primarily cardiorespiratory). 38% of patients had postoperative complications: most notable were leaks at the diverticulectomy site (n=5) and pulmonary (n=6; 4 pneumonia, 1 effusion, 1 empyema). Length of stay (LOS) was 2 days (5±8.9). 4 of 5 leaks occurred after discharge and resolved with drainage and TPN without sequela. Median follow-up is 44 months. Symptoms significantly improved postoperatively, including severity of dysphagia [6 (6±3.7) to 1(3±3.5)] (Figure). 80% of patients rated their symptoms at last follow-up as satisfying/very satisfying. 77% of patients had symptoms once per week. 83% would have the operation again knowing what they know now. Recurrence of the diverticulum occurred in 1 (3%) patient.

Conclusions: Heller myotomy, anterior fundoplication, and diverticulectomy well palliate symptoms of achalasia with accompanying diverticulum. However, the patients are generally older and deconditioned and the operations are generally longer and are accompanied by a relatively longer LOS. Complications are relatively frequent and severe (e.g., leaks and pneumonia). Leaks at the diverticulectomy site are unpredictable, occur after discharge, and remain vexing. For this advanced form of achalasia, long-term symptom relief and patient satisfaction is to be expected after Heller myotomy with anterior fundoplication and concomitant diverticulectomy. Effort must be expended to decrease the frequency of leaks at the diverticulectomy site.