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)