Peter G Devitt, Dr, Sarah K Thompson, Dr, Glyn G Jamieson, Dr. University of Adelaide
The standard of care for achalasia of the cardia is laparoscopic cardiomyotomy. This procedure achieves satisfactory and long-standing results in over 85% of patients. For those who have a less-than-satisfactory result from cardiomyotomy or who present with more advanced disease, there are several options to consider. First, redo laparoscopic cardiomyotomy. Provided the esophago-gastric junction is not unduly distorted and scarring is minimal, this may be a feasible approach. If the achalasia is advanced with gross esophageal dilatation and sump formation of the distal esophagus, then esophagectomy may be the only realistic achieving esophageal emptying.
An alternative approach might be the esophago-gastrostomy, originally described by Herovsky in 1913. The development of the angulated stapling devices now makes this operation feasible by a laparoscopic approach.
The patient is prepared as for laparoscopic cardiomyotomy. Two or three days of restricted oral intake is advisable in order to reduce the risk of aspiration on induction of anaesthesia and to facilitate an endoscopic view of the esophagus during surgery. The left lobe of the liver is retracted out of the field of view and the esophagus approached as for cardiomyotomy. The sump of the esophagus is exposed, but mobilisation is not necessary. The fundus of the stomach is mobilised sufficient to allow it to be swung anteriorly over the cardia to be stapled to the sump of esophagus. The angle of His is identified and four cm below this point and three cm in from the lesser curve of the stomach, an incision is made into the stomach of sufficient size to allow the stapler to be inserted. The stapler is inserted, the jaws opened, with one going into the fundus and the other through the cardia and into the esophagus. The stapler is then closed and fired, creating a three cm esophago-gastrostomy. The gastrostomy is sutured closed. After the stoma has been created there is not usually sufficient fundus to create any anti-reflux fundoplication.
A contrast study is performed the following day to assess esophageal emptying and to check for leaks. The esophago-gastrostomy has the potential to provide adequate symptomatic relief for those with end-stage achalasia without the hazards of esophagectomy.
This video shows the indications for laparoscopic esophago-gastrostomy and the technique of the procedure.
Program Number: V047