Perioperative management - Myotomy and Fundoplication according to Dor, robotically assisted

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

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

Failed Conservative Therapy

• No adequate symptom control after medical therapy (e.g., calcium channel blockers, nitrates).
• Insufficient effect or rapid recurrences after pneumatic dilation.

Recurrent Symptoms after Botulinum Toxin Injections

• Botulinum toxin usually has only short-term effects 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 advised to undergo myotomy directly.

Type III Achalasia ("Spastic Achalasia")

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

Secondary Achalasia (e.g., after Esophageal Surgeries)

• After failed pretreatments or after fundoplication, myotomy may be necessary.

Supplementary Considerations

• Antireflux Prophylaxis: Usually, a partial fundoplication (Dor or Toupet) is performed to avoid 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 inadequate 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 a carcinoma (pseudoachalasia)
• Esophageal or gastric carcinoma with local infiltration

End-Stage Megaesophagus (irreversible esophageal dilatation)

• >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 gastric or esophageal surgeries (e.g., fundoplication, gastrectomy)
• Adhesions after multiple procedures → increased risk of intraoperative complications

Severe Spastic Achalasia (Type III according to 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 Dilatations 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), the myotomy may be ineffective.

- Alternative Treatment Options for Contraindications

• Pneumatic Dilatation (in older patients or high surgical risk)
• Botulinum Toxin Injections (in multimorbid patients or as a temporary measure)
• Esophagectomy (ultima ratio in terminal megaesophagus or repeated failure of other therapies)

Preoperative diagnostics for achalasia are essential to confirm the diagnosis, rule out differential diagnoses, and evaluate the condition of the esophagus. Comprehensive diagnostics enable the correct therapy 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
  • Elevated 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 buildup.
  • Type II (compressive type): Pan-esophageal pressure increases.
  • Type III (spastic achalasia): Premature contractions with high amplitude.

- Necessary for exact diagnosis and therapy planning.

- 2. Esophagogastroduodenoscopy (EGD)

• Exclusion of a 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 food passage disorder
  • Candida esophagitis (common in long-standing achalasia)
• Allows biopsies in case of suspicion of malignancy

- Necessary to clarify differential diagnoses!

- 3. Esophageal Barium Swallow (Barium Swallow Examination)

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

- Helpful for staging and surgical planning.

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

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

- Not always required, but important in case of GERD suspicion.

- 5. Thoracic CT or Endosonography (EUS)

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

- Individual in case of malignancy suspicion or unclear findings.

- 6. General Preoperative Evaluation

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

- Standard of preoperative diagnostics for basic surgical fitness.

- 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 dilatation & emptying
4. pH-metry → If reflux symptoms exist
5. CT/EUS → In case of malignancy suspicion

Preoperative Preparation on Ward

• Body care: shower the evening before (antiseptics)
• Shaving: nipples to thighs
• Preoperative nutrition: full diet
• Premedication clinic
• PDC: not indicated
• Antibiotics: Cefuroxime 1.5g i.v. administer in the operating room
• Thrombosis prophylaxis (usually “Clexane 40”), anti-thrombosis stockings
• Breathing training

Cave: Preoperative checking and adjustment of therapy with anticoagulants: 

• The perioperative therapy with Aspirin can be continued. 
• Clopidogrel (ADP inhibitor) should be paused at least 5 days beforehand. 
• Vitamin K antagonists should be paused 7-10 days under control of the INR and bridged with a low-molecular-weight heparin s.c.
• NOACs (new oral anticoagulants) should be paused 2-3 days preoperatively 
• Always, if necessary, after consultation with the treating cardiologist 

Note on Bridging: 

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

Preoperative Preparation in the OR

• I.v. access or CVC placement (if necessary): usually during anesthesia induction.
• If necessary, artery during induction

1. Diagnosis & Indication

• Achalasia: Disorder of the esophageal musculature with impaired emptying into the stomach
• Aim of the surgery: Severing of the cramped esophageal musculature (myotomy)

2. Surgical Procedure

• Minimally invasive technique (robotically assisted laparoscopy): Access via small abdominal incisions
• Heller myotomy: Severing of the circular musculature of the lower esophagus
• Additional fundoplication (Dor/Nissen-Toupet) to prevent reflux

3. Alternatives to Surgery

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

4. Risks & Complications

• General surgical risks: 
  • Bleeding, postoperative bleeding
  • Infections
  • Wound healing disorders
  • Drainage insertion, catheter insertion
  • 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
  • Reflux disease (GERD) (possibly lifelong acid blockers necessary)
  • 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 increase from liquid diet to solid food

6. Follow-up & Behavior after Surgery

• Observe dietary progression (liquid → pureed → soft → normal)
• Monitor reflux symptoms
• No lifting heavy loads for several weeks
• Regular follow-up checks (endoscopy, manometry)

• Intubation anesthesia in pneumoperitoneum
• If necessary, TAP Block (Transversus abdominis plane Block): Regional local anesthesia procedure of the anterolateral abdominal wall: the local anesthetic is injected between the internal oblique muscle and the transversus abdominis muscle.
• two peripheral accesses when forgoing a CVC (preferred)
• in case of cardiac risk factors: arterial access

Positioning is done in supine position on the large vacuum cushion. The left arm can be extended outwards. 

By using the cushion, all further supports are omitted. After inserting the trocars, the operating table is tilted to approx. 15°-anti-Trendelenburg and approx. 5°-right-side position (Tilt right).

Padding of the extremities and all pressure-sensitive areas is performed. A hoop for protecting the patient's face from the robot arms is recommended.

Caution: Vacuum cushions can have leaks. Check again before sterile draping

Note: The positioning is of particular importance due to the docking of the patient to the robot's manipulator. Risk of injury to the abdominal wall if the patient slips.

Note: With coupled tables available for the Xi System, intraoperative position changes are possible without undocking the robot. If the so-called “Table-Motion” technique is missing or with other systems, the OR robot must always be undocked and removed from the OR table before any position change.

• Surgeon at the console ideally also with the possibility to look at the patient and table assistant
• Table assistant to the right of the patient
• Anesthesia at the head of the patient
• Patient Cart is driven up to the patient from the left 
• Instrumenting OR nurse at the right hand of the table assistant 

Robotic Instrumentation:

• Cardiere or Tip-Up grasper, 
• bipolar Forceps, 
• Camera (30°), 
• monopolar scissors, 
• Vessel sealer extend
• If necessary, Suture cut needle holder

Trocars:

• Four 8 mm robotic trocars
• One or two 11 mm laparoscopic assistant trocars

Basic Instrumentation:

• No. 11 scalpel
• Dissecting scissors
• Langenbeck retractor
• Needle holder
• Suture scissors
• Forceps
• Compresses
• Swabs
• Suture material for the abdominal wall fascia in the area of trocars from 10 mm Vicryl 0 with UCLX needle, skin (3-0 monofil, absorbable)
• Veress needle
• If necessary, Backhaus clamps
• Adhesive tape

Additional Instrumentation 

• Gas system for pneumoperitoneum
• Laparoscopic atraumatic grasper
• If necessary, laparoscopic suction-irrigation system

Instrument setting for “two right hands“ 

Port 1 (8mm): bipolar forceps

Port 2 (8mm): Camera

Port 3 (8mm): monopolar scissors, Vessel sealer extend, needle holder

Port 4 (8mm): Cardiere or Tipup grasper

Postoperative Measures:

• Monitoring: post-op: recovery room
• Venous Accesses: CVC (if present) until 1st post-op day removal, leave one peripheral IV
• Nasogastric Tube removal at the end of the surgery
• Foley Catheter: removal on the day of surgery
• Mobilization: Early mobilization on the evening of the surgery. Prompt stepwise resumption of physical activity
• Physical Therapy: not required
• Breathing Exercises
• Diet Progression: stepwise diet progression starting with liquids, then pureed, and subsequently solid food
• Infusion: 500-1000 ml on the first post-op day, thereafter only if oral intake is insufficient
• Labs: 1stpost-op CBC, electrolytes, CRP, every 2 days
• Antibiotics: Single-shot 30 minutes before incision
• Thrombosis Prophylaxis: If no contraindications: for moderate thromboembolism risk (surgical procedure > 30 min duration): low-molecular-weight heparin in prophylactic dose (usually "Clexane 40"), possibly in weight- or risk-adapted dosing until full mobilization is achieved, physical measures, compression stockings 

Note: Follow the link here to the current guideline on Prophylaxis of Venous Thromboembolism (VTE) 

Caution: when administering heparin, note: renal function, HIT II (history, platelet monitoring), 

• Labs: on the 1st post-op day, and then every 2-3 days with normal course until discharge, in case of clinical deterioration immediately 
• Dressing every 2 days
• Staples/Sutures: if not absorbable, removal after 10 days
• Postoperative Analgesia: 
  • Non-steroidal anti-inflammatory drugs are usually sufficient
  • Base Medication: Oral analgesia: 4x1g Metamizole/3x1 g Acetaminophen, also combinable, e.g., fixed Metamizole and prn Acetaminophen prn up to 3x/day
  • Administration of Metamizole: 1g Metamizole in 100 ml saline solution over 10 minutes as short infusion iv, or 1 g as tablet oral or 30-40 drops Metamizole oral
  • Administration of Acetaminophen: 1g iv over 15 minutes every 8h, or 1g suppository every 8h rectal (Caution: note anastomosis height1), or 1g as tablets oral

Caution: The base medication should be tailored to the patient (age, allergies, renal function).

• PRN Medication: For VAS >= 4  prn Piritramide 7.5 mg as short infusion or sc, or 5 mg Oxycodone immediate-release
• if pain persistently post-op >= 4 administration of an extended-release opioid (e.g., Targin 10/5 2x/day)

Note: If pain occurs only during mobilization, PRN medication should be given 20 minutes before mobilization.

Note: Follow the link here to PROSPECT (Procedure Specific Postoperative Pain Management) as well as to the current guideline Treatment of acute perioperative and posttraumatic pain and observe the WHO pain ladder.

Note: Various scales are available for quantifying postoperative pain, with which the patient can determine their own pain level several times a day, such as the NRS (numerical rating scale 0–10), the VAS (visual analog scale) or the VRS (verbal rating scale). 

• Discharge: From the 3rd postoperative day
• Inability to Work: Sick leave usually until suture removal or 10-14 days