Perioperative management - Myotomy and Dor fundoplication, robotically assisted

Primary Achalasia (Type I and Type II according to the Chicago classification)

• In patients with a clear diagnosis of achalasia, especially when there is a pronounced obstruction of the cardia.
• Type II (pan-esophageal pressure increase) often responds well to myotomy.

Failed conservative therapy

• Insufficient symptom control after medication therapy (e.g., calcium channel blockers, nitrates).
• Insufficient effect or rapid recurrence after pneumatic dilation.

Recurrent symptoms after botulinum toxin injections

• Botulinum toxin usually only acts short-term and is particularly less effective in younger patients.

Young patients (< 40–50 years)

• Since the success rate of pneumatic dilation increases with age, younger patients are often directly advised to undergo myotomy.

Type III Achalasia ("spastic achalasia")

• In combination with a distal myotomy, a laparoscopic myotomy can be effective, often supplemented by a POEM (Peroral Endoscopic Myotomy).

Secondary Achalasia (e.g., after esophageal surgeries)

• After failed prior treatments or after fundoplication, a myotomy may be necessary.

Additional Considerations

• Antireflux prophylaxis: A partial fundoplication (Dor or Toupet) is usually performed to prevent postoperative gastroesophageal reflux.
• POEM as an alternative: In certain patients (e.g., with spastic achalasia), peroral endoscopic myotomy can be a good alternative.

Laparoscopic myotomy is considered a very effective and long-term successful treatment option for achalasia, especially in patients with pronounced symptoms and insufficient conservative therapy.

The laparoscopic/robot-assisted myotomy (Heller myotomy or Gottstein-Heller myotomy) is a proven surgical treatment for achalasia. However, there are absolute and relative contraindications that exclude surgery or require special caution.

- Absolute Contraindications

Severe comorbidities

• Poor general condition (ASA classification IV or V)
• Decompensated cardiopulmonary diseases (e.g., heart failure NYHA IV, severe COPD with FEV1 < 30%)
• Increased surgical risk (e.g., advanced coagulation disorders, uncontrolled diabetes mellitus)

Malignant diseases of the esophagus or stomach

• Achalasia-like symptoms due to carcinoma (pseudoachalasia)
• Esophageal or gastric carcinoma with local infiltration

End-stage megaesophagus (irreversible esophageal dilation)

• >10 cm diameter, pronounced atony and sigmoid esophagus → in these cases, an esophagectomy is often the better option.

Severe gastroesophageal reflux disease (GERD) with Barrett's esophagus

• If advanced Barrett's esophagus or high-grade dysplasia is already present, a myotomy may be contraindicated.

- Relative Contraindications

Previous major thoracoabdominal surgeries

• Previous stomach or esophagus surgeries (e.g., fundoplication, gastrectomy)
• Adhesions after multiple procedures → increased risk of intraoperative complications

Severe spastic achalasia (Type III according to the Chicago classification)

• The standard myotomy is often insufficient; here, an extended myotomy or POEM (Peroral Endoscopic Myotomy) may be a better option.

Condition after repeated dilations or botulinum toxin injections

• Increased risk of scarring and complicated myotomy

Uncontrolled autoimmune or neurological diseases

• In systemic diseases with esophageal involvement (e.g., scleroderma), myotomy may be ineffective.

- Alternative Treatment Options for Contraindications

• Pneumatic dilation (in older patients or high surgical risk)
• Botulinum toxin injections (in multimorbid patients or as a temporary measure)
• Esophagectomy (last resort in terminal megaesophagus or repeated failure of other therapies)

Preoperative diagnostics in achalasia are essential to confirm the diagnosis, exclude differential diagnoses, and assess the condition of the esophagus. Comprehensive diagnostics enable the correct therapeutic decision and reduce the risk of postoperative complications.

- 1. High-Resolution Esophageal Manometry (HRM)

• Gold standard for confirming achalasia and classification according to the Chicago Classification (Type I–III)
• Shows:
  • Absent or uncoordinated peristalsis
  • Increased resting pressure of the lower esophageal sphincter (LES)
  • Pan-esophageal pressure increases
  • Absent LES relaxation during swallowing (>15 mmHg Integrated Relaxation Pressure, IRP)
• Chicago Classification of Achalasia:
  • Type I (classic achalasia): No peristalsis, no pressure build-up.
  • Type II (compressive type): Pan-esophageal pressure increases.
  • Type III (spastic achalasia): Premature contractions with high amplitude.

- Necessary for accurate diagnosis and therapy planning.

- 2. Esophago-Gastro-Duodenoscopy (EGD)

• Exclusion of secondary achalasia (pseudoachalasia), e.g., due to:
  • Malignancies (gastric or esophageal carcinoma, lymphomas)
  • Peptic strictures
• Assessment of the mucosa for:
  • Inflammations or ulcerations due to impaired food passage
  • Candida esophagitis (common in long-standing achalasia)
• Allows biopsies if malignancy is suspected

- Necessary for clarification of differential diagnoses!

- 3. Esophageal Barium Swallow (Barium Swallow Study)

• Assessment of esophageal motility and dilation
• Typical signs in achalasia:
  • “Bird-beak sign” (tapering distal esophagus)
  • Dilated, flaccid esophagus
  • Delayed emptying of contrast medium
  • Sigmoid deformity (in advanced achalasia → poorer prognosis for myotomy)
• Dynamic images help to recognize megaesophagus (advanced stage).

- Helpful for staging and surgical planning.

- 4. pH-Metry or Impedance-pH-Metry

• If gastroesophageal reflux (GERD) is suspected.
• Indication: Patients with atypical symptoms (heartburn, regurgitation).
• Evidence of pathological acid reflux → important for decision on additional fundoplication (Dor/Toupet).

- Not always required, but important if GERD is suspected.

- 5. Thoracic CT or Endosonography (EUS)

• Indication: Suspected tumor or extrinsic compression of the esophagus.
• Exclusion of mediastinal masses or malignancies (especially in older patients with rapid symptom development).
• Endosonography (EUS) helps to identify submucosal tumors or thickening of the cardia wall.

- Individualized for suspected malignancy or unclear findings.

- 6. General Preoperative Assessment

• Laboratory diagnostics:
  • Blood count, coagulation, liver & kidney values (standard preoperative preparation)
• ECG & echocardiography (in case of cardiac risk factors)
• Pulmonary function test (FEV1, spirometry) (in COPD or impaired lung function)

- Standard of preoperative diagnostics for general surgical capability.

- 7. Eckardt Score for Symptom Quantification in Achalasia

The Eckardt Score is the established gold standard for evaluating achalasia symptoms before and after therapy (e.g., myotomy, POEM). It quantifies dysphagia, regurgitation, retrosternal pain, and weight loss on a scale of 0–12 points (0 = no complaints, 3 = maximum severity).​

Evaluation and Clinical Relevance
Score 0–3: Remission/success (clinical improvement >90% after myotomy). Score ≥4: Therapy failure or recurrence; cut-off ≥9 predicts POEM failure. The score is simple, validated, but with fair reliability (Cronbach’s α 0.57–0.65)

- Conclusion:

The essential examinations before a laparoscopic myotomy are:

1. High-resolution manometry → Confirmation of achalasia and type classification
2. Esophagogastroduodenoscopy → Exclusion of pseudoachalasia/malignancies
3. Barium swallow → Assess esophageal dilation & emptying
4. pH-metry → If reflux symptoms are present
5. CT/EUS → In case of suspected malignancy

Preoperative Preparation on the Ward

• Body care: shower the evening before (antiseptics)
• Shaving: nipples to thighs
• Preoperative nutrition: full diet
• Pre-medication clinic
• PDK: not indicated
• Antibiotics: Cefuroxime 1.5g i.v. to be given in the operating room
• Thrombosis prophylaxis (usually "Clexane 40"), compression stockings
• Breathing exercises

Note: Preoperative checking and adjustment of anticoagulant therapy:

• Perioperative therapy with aspirin can be continued.
• Clopidogrel (ADP inhibitor) should be paused at least 5 days prior.
• Vitamin K antagonists should be paused 7-10 days under INR control and bridged with low molecular weight heparin s.c.
• NOAC (new oral anticoagulants) should be paused 2-3 days preoperatively
• Always consult with the treating cardiologist if necessary

Note on Bridging:

• For vitamin K antagonists, bridging with short-acting heparins if INR is outside the target range
• For NOACs, bridging can usually be omitted due to the short half-life. In cases of very high risk of occlusion/insult: bridging under inpatient conditions with UFH

Preoperative Preparation in the OR

• I.v. access or central venous catheter placement (if necessary): usually during induction of anesthesia.
• Possibly arterial line during induction

1. Diagnosis & Indication

• Achalasia: Disorder of the esophageal muscles with impaired emptying into the stomach
• Goal of the surgery: Cutting the cramped esophageal muscles (Myotomy)

2. Surgical Procedure

• Minimally invasive technique (Robotically assisted laparoscopy): Access through small abdominal incisions
• Heller Myotomy: Cutting the circular muscles of the lower esophagus
• Additional Fundoplication (Dor/Nissen-Toupet) to prevent reflux

3. Alternatives to Surgery

• Balloon dilation
• Botox injection
• Medication therapy (limited effectiveness)

4. Risks & Complications

• General surgical risks: 
  • Bleeding, rebleeding
  • Infections
  • Wound healing disorders
  • Drain placement, catheter placement
  • Possible need for surgical revision due to a complication
  • Intra-abdominal abscess formation requiring interventional or surgical measures
  • Incisional hernia/trocar hernia
• Specific risks:
  • Perforation of the esophagus or stomach
  • Pneumothorax
  • Gastroesophageal reflux disease (GERD) (possibly requiring lifelong acid blockers)
  • Swallowing difficulties despite surgery
  • Injury to adjacent structures (vagus nerve, liver, spleen, intestine)
  • Need for open surgery (conversion)

5. Anesthesia & Perioperative Care

• General anesthesia required
• Preoperative examinations (laboratory, ECG, imaging)
• Postoperative nutrition: Gradual progression from liquid diet to solid food

6. Aftercare & Postoperative Behavior

• Observe dietary progression (liquid → pureed → soft → normal)
• Monitor reflux symptoms
• Do not lift heavy objects for several weeks
• Regular follow-ups (endoscopy, manometry)