Surg Today Jpn J Surg (1996) 26:541-545 @ SURGERvToDAv

© Springer-Verlag 1996

Management of Failed Heller's Operations JXNos Kiss, 1 ATTILA VOROS, 1 ENDRE NZIR~NYI, 1 •RON ALTORJAY, 1 and A~N~S BOH~K 2

Departments of ~ Surgery and 2 Radiology, Imre Haynal University of Health Sciences, Postgraduate Medical School, Szabolcs u. 33, P.O.B. 112, Budapest 1389, Hungary

Abstract: An analysis of 29 patients who collectively required 33 reoperations for failed Heller's esophagocardiomyotomy performed during the period between 1972 and 1992 was con- ducted. In the majority of patients, the reoperation was neces- sitated because the original myotomy was not long or deep enough, or because of iatrogenic gastroesophageal reflux and its sequelae such as strictures. Identification of the exact cause of failure requires careful analysis of the patient's symptoms and of the findings of various diagnostic examinations. The treatment for inadequate myotomy generally involves per- forming a second myotomy, which is completed by adding a nonobstructive antireflux repair. It appears that abolition of the "sigmoid sac" is essential even when the esophagogastric junction has a sufficiently large diameter. A so-called esophagoplication was performed in 3 patients, and an interposition at the site of esophageal resection, using an isoperistaltic esophagojejunogastric loop of appropriate length, was performed in 14 patients. There were no deaths following reoperation. In fact, the results were excellent or good in 23 cases and fair in 3.

Key Words: esophagus, achalasia, surgery, reoperation

Introduction

Extramucosal cardiomyotomy was initially described by Heller in 1914, since when the modified Heller esophagomyotomy with or without associated antireflux repair has become the standard surgical treatment for achalasia of the cardia. However, failure of this proce- dure with persistent or recurrent symptoms occurs in approximately 10% of patients, half of whom will re- quire second or even more reoperations.

Identification of the exact cause of failure requires careful analysis of the patient's symptoms, and of the

Reprint requests to: J. Kiss (Received for publication on July 3, 1995; accepted on Jan. 5, 1996)

findings of various diagnostic examinations including barium studies, esophagoscopy, 24-h pH monitoring, manometry, and histological examination. The follow- up of patients who have undergone Heller's operation, analyses of the nature of the condition, and evaluations of the results of surgical treatment have revealed that the major causes of recurrence are:

1. Failure or inappropriate healing of the myotomy. 2. Stricture of the esophagus due to postoperative gas-

troesophageal reflux. 3. An enormously dilated and sigma-shaped, nonfunc-

tioning esophagus or megaesophagus. 4. Even after the operation, the long-lasting achalasic

condition is believed to be a precancerous state.

Materials and Methods

During the period between October 31, 1972, and De- cember 31, 1992, a total of 172 operations were per- formed for achalasia cardia at the Department of Surgery of Imre Haynal University of Health Sciences. There were 139 patients who underwent a first opera- tion and 29 patients who collectively underwent 33 reoperations, 4 of whom had undergone previous op- erations in our department. Of those reoperated on, the youngest was 3 years old and the oldest, 73 years old, the mean age being 46 years. Patients operated on for cancer were excluded from this evaluation.

Results

Table 1 shows the pathological conditions requiring reoperation and the types of corrective surgery per- formed. The most frequent cause for reoperation was that the myotomy incision was not long and deep enough, or that the incision had "healed" in time, while aboral failure necessitated a reoperation in two pa-

Table 1. Pathological conditions justifying reopera t ion and the type of corrective surgery per formed

First reoperation Second reoperation Third reoperation

Failure of myotomy 4----~ Failure of myotomy in 2,- --~

the aboral direction

Failure of myotomy + megaesoph.

/ 6--~

Barrett's dysplasia 1 ~ Esophageal stricture 5---~ Esophageal stricutre + 6, ---~

megaesoph,

Heller's op. + antireflux proc. 6

Heller's operation 3 ---~ Distal gastric resection with 2 Roux-en-Y jejunal loop (for duod.-gastr.-esoph. reflux)

Heller's operation + 2 esophagoplication

Distal resection of esophagus, esophagojejunogastrostomy

Distal resection of esophagus, esophagojejunogastrostomy

12

Planocellular 2---~ Subtotal res. of esophagus, 2 esophago-gastrostomy

Esophageal cancer

Adenocarcinoma 1--, . Distal res. of esophagus and

total gastrect, and Roux-en- Y esophagojejunostomy

2 - -~ Abolition of Belsey's plasty Megaesophagus - - condition following Heller-Belsey's op.

2 - -~ Distal res. of esophagus and esophagojejunogastrostomy

1 ~ Esophagoplication 1

megaesoph., megaesophagus; op., operation; proc., procedure; res., resection; gastrect., gastrectomy; duod.-gastr.-esoph., duodenal-gastric-esophageal

Fig. 1. Hel ler ' s myotomy, per formed insufficiently in the downward direction

Fig. 2. Insufficient myotomy and sigmoid sac

542

J. Kiss et al.: Management of Failed Heller's Operations 543

~ ~~

Y

,¢ 9' ~

/ /

'%

Fig. 3. Diagrammatic representation of esophagoplication

Fig. 4. Postoperative appearance of myotomy and esophagoplication

tients. Surgical failure of this type is usually followed by a deterioration in the patient's condition within a short time after surgery. The radiographic appearance of the barium meal examination is characteristic, as it shows the mucosa bulging in the myotomized area, or diverticularization of the mucosa above the nontran- sected fibers at the esophagocardiac junction (Fig. 1). When an inadequate myotomy has been performed, a second myotomy is generally required. The second myotomy is performed away from the previous myotomy to decrease the risk of mucosal perforation. The procedure is completed by adding a nonobstructive antireflux repair, to prevent gastroesophageal reflux following dissection of the cardia.

In two of our patients, a reoperation was necessitated in the early postoperative period when the antire- fluxplasty was abolished following the Heller-Belsey operation. In one of these patients, the first reoperation was successful; however, the other patient required two reoperations, in the form of distal resection of the esophagus with esophagojejunogastrostomy the first time, followed by abolition of the sigma-shaped dilatation of the esophagus by esophagoplication. The dysphagic complaints ceased only after a third reoperation.

It appears that abolition of the sigmoid sac is required even when the esophagogastric junction has a suffi- ciently large diameter. A so-called esophagoplication was performed in three patients. In contrast to what was suggested by Meyer in 1911, we did not strive to narrow the lumen of the dilated esophagus. Instead, we placed an oblique suture to eliminate the sigmoid sac (Figs. 2- 4). Iatrogenic gastroesophageal reflux and its associated sequelae, such as stricture, is the second most common cause of Heller's procedure failing. The aperistaltic esophagus in achalasia is particularly prone to the rav- ages of gastroesophageal reflux due to the loss of esoph- ageal acid clearance. Esophagoscopy is essential for establishing the diagnosis since it demonstrates a true cicatricial narrowing, rather than the spastic cardia characteristic of a residual muscle band. In 11 of our patients it was the development of gastroesophageal reflux after the first operation and its sequelae, respec- tively, that made reoperation necessary. At the distal esophageal resection we performed interposition with an isoperistaltic jejunal loop 1 of appropriate length (Figs. 5-8).

In one patient pyloroplasty was performed in addi- tion to the remyotomy, because of a lesion along the vagal nerve. However, severe alkaline reflux developed, requiring a second reoperation, involving a distal gastric resection with a Roux-en-Y jejunal loop. 2 There were no deaths in the course of reoperation in the present series. In fact, the results were excellent or good in 23 cases and fair in 3.

Fig. S. Stricture of the esophagogastric junction and Fig. 7. Postoperative appearance ofesophagojejunostomy megaesophagus

Fig. 6. Diagram showing jejunal interposition

Fig. 8. Postoperative appearance of a jejunogastrostomy per- formed with sufficient length of jejunal interposition

544

J. Kiss et al.: Management of Failed Heller's Operations 545

Discussion

About 10% of patients who undergo Heller's operation have an unsatisfactory postoperative outcome. To im- prove the results the operation must be performed early and using a careful surgical technique. Nevertheless, complications such as gastroesophageal reflux causing esophageal stricture may develop even after an effec- tive myotomy has been performed. Therefore, most sur- geons now combine esophagocardiomyotomy with an effective antireflux operation, although even the antirefluxplasty may present an obstacle to food passing through an enormously dilated amotile esophagus. In such patients, either the consequences of eventual gas- troesophageal reflux or the hazards of a major opera- tion such as resection with interposition must be accepted. The Heller operation may produce good re- sults even in patients with a megaesophagus, but it ap- pears that abolition of the sigmoid sac is an important feature of the correction. Even after operative treat-

ment, the long-lasting achalasic condition is believed to be a precancerous state. Thus, continuous control examinations seem to be justified in this group of patients. 3

In conclusion, selecting the most appropriate correc- tive method is of the utmost importance. While surgery may range from reperformance of Heller's myotomy to resection, it stands to reason that good surgical tactics and techniques will produce satisfactory functional results.

References

1. Allison PR, Wooler GH, Gunning AJ (1957) Esophago- iejunogastrostomy. J Thorac Surg 33:738-741

2. Gayet G, F6kdt6 F (1991) Surgical management of failed esophagomyotomy. (Heller's operation). Hepatogastroenterology 38:488-492

3. Horv~ith ~)P, L/tzfir G (1991) Failed operations for achalasia. Dis Esoph 3:149-153