After a long history, is it still appropriate to use a myotomy ?

C.T. Bombeck, L.M. Nyhus, Ph. E. Donahue (Chicago)

The answer to this question depends on the precise meaning of a «long history » is meant. After a long history of no treatment at all, except for medications, the treatment of first choice is still debatable; in many cases the patient will choose the approach which is presented in the most attractive fashion by the consultant. If the consultant has no knowledge or possibility of performing surgical myotomy,

the pneumatic dilation may be presented as the most attractive approach, when in reality there is an advantage for surgical myotomy in the long run.

On the other hand, if the patient has had multiple dilatations, then our treatment of choice would be myotomy, coupled with a loose or « floppy » Nissen fundoplication. As with any esophageal surgery, the surgeon should not begin the operation without several possible treatment options at his or her disposal; final decisions depend upon intraoperative findings. If, for some reasons, a controlled myotomy cannot be performed, then other procedures such as the Thal-Hatafuku operation, or esophageal resection, with gastric or jejunal interposition can be considered.

We would not recommend primary esophago-gastrectomy, reconstructed by means of an intrathoracic Nissen fundoplication, even though we described that procedure for otherwise undilatable stricture. The problem with intrathoracic fundoplications is not the control of reflux ; on the contrary, reflux control is good with this procedure. Unfortunately, and a finding which we did not anticipate in the mid 1970's, the intrathoracic fundoplication has the clinical sequellae of acquired paraesophageal hernia; problems such as incarceration of the stomach, chronic ulcer or bleeding, or perforation are best avoided.

A word of caution should be made about some older operative procedures, which were once performed for achalasia, but are now obsolete. Operations such as the Wendel cardioplasty or Heyrovsky operation, should not be performed because they guarantee vigorous reflux in the post operative period. Although it is now rare to encounter one of these procedures in a patient with long standing achalasia, serious consideration should be given to reoperating and converting such a patient to a jejunal interposition. We have lost one patient to an adenocarcinoma arising in a Barrett's esophagus which occurred after such an operation.

In summary, the length of the history that a patient has of achalasia is no contraindication to any form of therapy. Everything depends on what has been done to the lower end of the esophagus in the past. With respect to the risk of gastroesophageal reflux after pneumatic dilation compared to the risk of reflux after myotomy, there is no question that each approach has a risk of reflux subsequently ; it is incorrect to assume that dilation is free of this complication. Refinements in surgical technique have decreased the incidence of reflux after surgical myotomy, while more effective pneumatic dilation may even increase the chance for post dilation reflux disease. When pneumatic dilatation is considered the procedure of first choice in palliating otherwise uncomplicated achalasia it is the obligation of the pneumatic surgeon to fully inform the patient about the potential risks and complications. If a patient has proven reflux prior to dilation, of course, the pneumatic procedure is contraindicated. Other contraindications include epiphrenic diverticulum, and inability to traverse the narrowed lower esophageal sphincter segment with the dilator. The latter problem is rarely a problem with the newer balloons which can be ferried into position with the aid of a pediatric endoscope.

Perhaps the real question which needs to be addressed is when does one give up with balloon dilatation and proceed to direct myotomy with or without a complementary fundoplication. When and if dilation fails, of course, myotomy should be performed. If a dilation is complicated by an acute perforation of the esophagus, the surgeon who operates promptly has the opportunity to perform myotomy and a buttress fundoplication at the same time the perforation is repaired.

He wrote these pages in Paris, optimistic and confident as always, even though awaiting another

heart transplant.

His thoughts and spirit still remain with us.

Thank you, Tom, for all that you have contributed.