Laparoscopic hand-sewn cardioplasty: an alternative procedure for end-stage achalasia

Abstract

Background: Primary achalasia is a rare oesophageal motor disorder characterized by the absence of swallow-induced relaxation of the lower oesophageal sphincter and diminished or absent oesophageal body peristalsis. Around 5% of these patients will develop end-stage achalasia, where oesophagectomy may be advocated. We present the laparoscopic hand-sewn cardioplasty as an alternative 'oesophagus-preserving' procedure in patients with end-stage achalasia.

Methods: We present a retrospective review of four patients who underwent laparoscopic hand-sewn cardioplasty. Data collected included pre-operative demographic information and investigations; and post-operative outcomes. Patients were scored pre- and post-operatively using Reflux Symptom Index, Eating Assessment Tool-10 and Voice Handicap Index-10 questionnaires.

Results: Four patients underwent laparoscopic hand-sewn cardioplasty during the study period. In one patient, it was performed as a rescue procedure during attempted myotomy following multiple perforations of friable mucosa. In the other three patients, laparoscopic hand-sewn cardioplasty was performed for end-stage achalasia. None of the patients had post-operative complications and all patients were discharged on the second post-operative day. All patients experienced improvement in swallowing symptoms (EAT-10; p = 0.03) but developed post-operative gastroesophageal reflux.

Conclusion: To our knowledge, this is the first published case series of laparoscopic hand-sewn cardioplasty for end-stage achalasia. It appears to be a safe and effective procedure for the treatment of end-stage achalasia, offering an alternative minimally invasive procedure to oesophagectomy. Laparoscopic hand-sewn cardioplasty can also be used as a 'rescue' procedure during myotomy in patients who have poor-quality mucosa which perforates intra-operatively or is at high risk of perforation/leaking post-operatively.

Keywords: Achalasia; Cardioplasty; Intraoperative endoscopy; Laparoscopy; Lower oesophageal sphincter.

Fig. 1

Dissection of the hiatus and tie surrounding oesophagus

Fig. 2

Preparation of anastomosis site: suture of the gastric fundus to the left side of the oesophagus

Fig. 3

Oesophagotomy with endoscope inside

Fig. 4

Gastrotomy and exposure of the angle of His. Suture of the posterior wall of the gastroesophageal anastomosis

Fig. 5

Suture of the anterior wall of the gastroesophageal anastomosis