monthly focus

surgical intervention video

Cardiomyotomie de Heller assistée par robot avec fundoplicature antérieure selon Dor pour achalasie de type II

This video aims to describe the surgical steps for a robot-assisted Heller’s cardiomyotomy with Dor fundoplication (HCM+DF) in a patient with type II achalasia. The procedural steps shown in the video are intended to serve as an aid to surgeons considering such a surgical approach, which initial studies have suggested may reduce the risk of iatrogenic oesophageal perforation, compared to a laparoscopic approach (1).



This is a case of a 24-year-old lady who presented with intermittent chest pain since the age of 13, with a negative series of cardiology examinations when she was 18, and a 12 to 18-month period of ‘bulimia’ when aged 19-20. When she was 22, her symptoms progressed, and she began to experience dysphagia and would regurgitate food with every meal. Her weight fell from 58 to 49kg. She travelled everywhere with a receptacle for the regurgitant. She had no other past medical history. She had been investigated prior to referral and found to have a 1cm sliding hiatal hernia. There was no evidence of eosinophilic oesophagitis on oesophageal biopsies.

The patient underwent further work-up: 

i) A repeat upper gastrointestinal endoscopy demonstrated a mildly dilated oesophagus full of saliva, tapering at the gastro-oesophageal junction (GOJ). No hiatus hernia was identified. 

ii) Bread-barium examination: the liquid study demonstrated hold-up at the GOJ and reduced/disordered peristaltic contraction in the distal oesophagus. With bread, there was significant dysmotility and failure of relaxation of the lower oesophageal sphincter (LOS). 

iii) High-resolution manometry (HRM) initially demonstrated absent contractility within the oesophageal body and normal LOS relaxation on liquid swallows. However, LOS relaxation became more impaired with both rapid liquid and solid swallows. There was also pan-oesophageal pressurisation after solid swallows. 

The clinical picture and the manometric findings favoured a diagnosis of type II achalasia.

The patient was counselled for endoscopic and surgical management of achalasia and opted for a surgical HCM+DF using a robot-assisted approach.

The procedure was performed without incident using the da Vinci Xi™ surgical robotic platform. There were no intraoperative or postoperative complications. She went home the day after surgery on a pureed diet, and soon progressed without regurgitation. By 2.5 weeks, she had gained 4.5kg and by five months postoperatively, she had gained 15kg. Her symptoms of dysphagia and regurgitation resolved. She did still experience episodes of chest pain. These were frequent at the first follow-up, but were less frequent/intrusive at 5 months postoperatively. 

Disclosures: The surgery was performed by a specialist oesophagogastric surgeon. At the time of submission, the video was not presented at any meeting and was not recorded during a live broadcast. Informed consent has been granted by the patient to use the recorded surgery to produce an educational video. The authors do not have any conflict of interest to report. 



Bibliography:

(1). Fiume I, Molena D. Robotic esophagomyotomy for achalasia: technical note and review of the literature. Minerva Surg. 2022 Apr;77(2):157-170. doi: 10.23736/S2724-5691.21.08979-6. PMID: 34693674.



Take-home messages:

During robotic assisted Heller’s cardiomyotomy, the magnified 3D view, motion scaling, and enhanced stability of the platform allows for precise tissue dissection of oesophago-gastric muscle fibres, hence potentially reducing the risk of iatrogenic perforation or incomplete cardiomyotomy, compared to a laparoscopic approach (1).

Robotic assisted Heller’s cardiomyotomy with Dor fundoplication for type II achalasia

video lecture

In this key lecture, Dr. Bernard Dallemagne outlines the surgical and endoscopic management of Zenker's diverticulum.

Zenker's diverticulum: surgical and endoscopic treatment

Diverticule de Zenker : traitement chirurgical et endoscopique

Esophageal cancer is the 8th most common malignancy in the world. It is usually diagnosed in advanced stages, with an unfavorable prognosis. 

The incidence of adenocarcinoma is rising, mainly in Western countries, and the minimally invasive approach combined with a stepwise lymphadenectomy might provide an enhanced recovery for the patient.



Bibliography:

1. Fang-Liang Huang, Sheng-Jie Yu,Esophageal cancer: Risk factors, genetic association, and treatment, Asian Journal of Surgery, Volume 41, Issue 3, 2018, Pages 210-215 https://pubmed.ncbi.nlm.nih.gov/27986415/.

2. Uhlenhopp, DJ, Then, EO, Sunkara, T. et al. Epidemiología del cáncer de esófago: actualización de tendencias globales, etiología y factores de riesgo. Clin J Gastroenterol 13 , 1010–1021 (2020). https://pubmed.ncbi.nlm.nih.gov/32965635/.



Laparoscopic Ivor-Lewis esophagectomy with standard laparoscopic lymphadenectomy for adenocarcinoma of the esophagogastric junction 

Introduction: Achalasia is a rare and incurable esophageal motility disorder (EMD) characterized by aberrant peristalsis and insufficient lower esophageal sphincter (LES) relaxation. It is predominantly an idiopathic disease resulting from a selective loss of inhibitory neurons in the myenteric plexus of the distal esophagus and LES, most likely due to an autoimmune response to unknown antigens. Secondary achalasia occurs due to pathologies that cause esophageal motor abnormalities similarly to primary achalasia. Conditions such as Chagas disease, amyloidosis, sarcoidosis, neurofibromatosis, eosinophilic esophagitis, multiple endocrine neoplasia type 2B, juvenile Sjögren’s syndrome, chronic idiopathic intestinal pseudo-obstruction, and Fabry disease have been associated with achalasia-like motor abnormalities. 

The reported global incidence ranges from 0.03 to 1.63 per 100,000 persons per year, and global prevalence from 1.8 to 12.6 per 100,000 persons per year respectively. It affects both genders and all races equally, with incidence increasing with age. Achalasia has an insidious onset, and the disease progresses gradually. Patients commonly present with progressive dysphagia to solids and liquids (70-97%), regurgitation (75%), occasional chest pain (40-60%), and varying degrees of weight loss or nutritional deficiencies. Patients are often initially treated for gastroesophageal reflux disease (GERD) before being diagnosed with achalasia. Objective: This video aims to demonstrate a laparoscopic Heller’s cardiomyotomy and Dor fundoplication, as performed at the authors’ institution. 

Methodology: The authors present the clinical case of a 38-year-old female patient with a 5-year history of dysphagia for liquids and solids. She reported a weight loss of 15kg over this period. A guided study was performed, including upper digestive endoscopy and manometry, leading to the diagnosis of type I achalasia. The authors present a video of laparoscopic Heller’s cardiomyotomy and Dor fundoplication performed in this patient. The patient was discharged on postoperative day 4. 

Conclusion: The diagnosis of achalasia is suggested by clinical features and confirmed through diagnostic tests such as upper endoscopy, barium swallow, and manometry. Although endoscopy has a low accuracy in diagnosing achalasia, it should be performed in all patients with dysphagia and suspected achalasia to rule out esophageal cancer or the development of premalignant or malignant lesions. A barium swallow is essential to define esophageal morphology and associated conditions, and the classical finding is the "bird’s beak" configuration. However, the barium test is not sensitive for achalasia, as it may appear normal in one third of patients. Esophageal manometry is necessary to establish the diagnosis of achalasia, revealing the absence of peristalsis in the distal two thirds of the esophagus and incomplete LES relaxation. Esophageal manometry provides a high level of certainty in diagnosing achalasia, even in the early stages. The Chicago classification, based on manometry results, significantly contributes to establish the prognosis and determine the most appropriate initial approach for achalasia. While more conservative treatments such as pneumatic dilatation or surgical myotomy appear to be good options for types I and II, type III achalasia seems to be better managed with peroral endoscopic myotomy (POEM) than surgical myotomy. 

Since the first report of laparoscopic Heller myotomy in 1991, minimally invasive techniques have been increasingly used to treat achalasia. Through surgical advances, it has been demonstrated that the addition of an antireflux procedure (Dor or Toupet) reduces the risk of pathological gastroesophageal reflux following the Heller myotomy up to 9-fold. The Eckardt symptom score (ESS) is the grading system most frequently used to evaluate symptoms, stages, and efficacy of achalasia treatment. However, the efficacy of all achalasia treatments decreases over time, and many patients will require repeat treatment within ten years. 



Bibliography: 

1. Richards, W. O., Torquati, A., Holzman, M. D., Khaitan, L., Byrne, D., Lutfi, R., & Sharp, K. W. (2004). Heller myotomy versus heller myotomy with dor fundoplication for achalasia : A prospective randomized double-blind clinical trial. Annals of Surgery, 240(3), 405. https://doi.org/10.1097/01.sla.0000136940.32255.51.

2. Schlottmann, F., Neto, R. M. L., Herbella, F. A. M., & Patti, M. G. (2018). Esophageal achalasia : Pathophysiology, clinical presentation, and diagnostic evaluation. The American Surgeon, 84(4), 467‑472.

3. Vaezi, M. F., Pandolfino, J. E., Yadlapati, R. H., Greer, K. B., & Kavitt, R. T. (2020). Acg clinical guidelines : Diagnosis and management of achalasia. Official Journal of the American College of Gastroenterology | ACG, 115(9), 1393. https://doi.org/10.14309/ajg.0000000000000731.



Laparoscopic Heller's cardiomyotomy and Dor fundoplication, a stepwise approach to achalasia

Cardiomyotomie de Heller par laparoscopie et fundoplicature antérieure selon Dor : prise en charge par étapes de l'achalasie

In this key lecture, Dr. van Hillegersberg, MD, PhD, outlines the intrathoracic anastomosis in robot-assisted minimally invasive esophagectomy (RAMIE).

Focus on upper GI surgery

Zenker's diverticulum: surgical and endoscopic treatment

Robotic assisted Heller’s cardiomyotomy with Dor fundoplication for type II achalasia

Laparoscopic Heller's cardiomyotomy and Dor fundoplication, a stepwise approach to achalasia

Laparoscopic Ivor-Lewis esophagectomy with standard laparoscopic lymphadenectomy for adenocarcinoma of the esophagogastric junction

Intrathoracic anastomosis in robot-assisted minimally invasive esophagectomy (RAMIE)