LHM & partial fundoplication is insufficient in patient with terminal achalasia: 3 fields laparoscopic esophagectomy for final management


INTRODUCTION: Achalasia is an esophageal motor disorder characterized by progressive dysphagia. The laparoscopic Heller myotomy with partial fundoplication is the standard of management in these patients. In those with large esophageal dilatation it is insufficient, because although cure dysphagia, regurgitation secondary to ineffective motility and accumulation of food makes the patient’s quality of life deteriorates

AIM: Show the effectiveness and minimal morbidity of laparoscopic esophagectomy in patients on prior myotomy and partial fundoplication for achalasia

METHODS: Male patient, 26 y.o. One year ago consult for dysphagia, his exams: Endoscopy with food debris, esophageal dilation and suspected achalasia, Manometry confirmed diagnosis. For technical reasons it is not possible to esophagogram. It is scheduled to Laparoscopy Heller myotomy and Dor fundoplication. Nutritional profile normal levels. The patient had no postoperative dysphagia, tolerated good soft diet,  but at 3 months postoperative regurgitation complains. Esophagogram is performed showing great dilation of the esophagus with colonic appearance. I decided to symptom management with diet, prokinetics but 12 months post surgery , patient didn’t resist the symptoms and we were agree to schedule Minimally invasive esophagectomy

RESULTS:  three fields esophagectomy (prone thoracoscopy, laparoscopy and cervicotomy) procedure was done, operative time was 4 hours, dilation of the esophagus was observed during thoracic dissection. Abdominal time was easy,  clearing type Dor fundoplication was not difficult and we could sleeve great curvature. Cervicotomy and manual traction of esophagus with laparoscopy wiew the mobilization of the stomach to the chest to avoid twists. Laterolateral cervical anastomosis with staplers. Cervical drainage and rigth toracostomy. Enteral feeding begins at 6 hours postoperatively. Swallom barium third postoperative day to check anastomosis and we started oral intake with liquids, next day thoracostomy and cervical drainage.

CONCLUSION: Minimally invasive management of achalasia or conversion esophagectomy should be performed by trained surgeons in advanced techniques. It is clear that in patients with achalasia with huge esophageal dilation the best option is the esophagectomy but in cases that previously made a myotomy with fundoplication, the procedure can be performed safely with low morbidity and mortality if they are in expert hands.

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