Stapler esophagofundoanastomosis «side to side» in the treatment of achalasia of the cardia

Achalasia of the cardia is a neuromuscular disease of the esophagus. There are various surgical approaches for the treatment of achalasia of the cardia, which indicates the complexity and insufficient knowledge of this pathology. Currently, the «gold standard» of surgical treatment of achalasia of the cardia is Heller’s laparoscopic operation with incomplete Dor esophagofundoplication. However, this operation is not ideal for the treatment of achalasia of the cardia, due to the high level of postoperative complications and relapses of the disease. Our clinic has developed an original side-to-side stapler esophagofundostomy method for the treatment of achalasia of the cardia. This article provides a comparative analysis of Heller’s surgery and stapler esophagofundostomy. The proposed method successfully eliminates the symptoms of dysphagia in patients with achalasia cardia, and it also has an advantage over the Heller operation in reducing the incidence of intraoperative complications, in restoring the passage of food through the esophagus more effectively, and in improving the motility of the esophagus and eliminating the spasm of the lower esophageal sphincter. In the postoperative period after stapler esophagofundostomy, the likelihood of developing gastroesophageal reflux is higher, therefore, in our opinion, it should be combined with a more reliable anti-reflux barrier, for example, Nissen fundoplication. The indication for performing a side-to-side stapler esophagofundostomy, in our opinion, is achalasia of the cardia of stage III–IV according to Petrovsky’s classification, with the development of fibrous scarring of the cardia and esophagus, since during Heller’s operation, in this case, there is a certain risk of intraoperative perforation of the cardia and esophageal mucosa, with possible subsequent the development of serious complications.

1. Oude Nijhuis, R. A. B. European Guideline on Achalasia – UEG and ESNM recommendations / R. A. B. Oude Nijhuis [et al.] // United European Gastroenterol. J. – 2020. – Vol. 8, № 1. – Р. 13–34. – doi: 10.1177/2050640620903213.

2. Vasilenko, V. H. Ahalaziya kardii [Achalasia of the cardia] / V. H. Vasilenko, T. A. Suvorova, A. L. Grebenev // Medicina. – 1976. – С. 280 [In Russian]

3. Bogopolskii, P. M. K istorii hirurgicheskogo lecheniya kardiospazma v Rossii v XX veke [On the history of surgical treatment of cardiospasm in Russia in the 20th century] / P. M. Bogopolskii, D. A. Balalikin, M. M. Abakumov // Vestnik hirurgicheskoi gastroenterologii. – 2012. – № 3. – S. 88–94 [in Russian]

4. Boeckxstaens, G. E. Achalasia / G. E. Boeckxstaens, G. Zaninotto, J. E. Richter // The Lancet. – 2014. – Vol. 383, № 9911. – Р. 83–93. – doi: 10.1016/S0140-6736(13)60651-0.

5. Enestvedt, B. K. Epidemiology and Practice Patterns of Achalasia in a Large MultiCenter Database / B. K. Enestvedt, J. L. Williams, A. Sonnenberg // Aliment Pharmacol. Ther. – 2011. – Vol. 33, № 11. – P. 1209–1214. – doi: 10.1111/j.1365-2036.2011.04655.x.

6. Gallyamov, E. A. Rezultati laparoskopicheskogo lecheniya ahalazii kardii [Results of laparoscopic treatment of achalasia cardia] / E. A. Gallyamov, A. L. Shestakov, A. S. Erin [et al.] // Klinicheskaya i eksperimentalnaya hirurgiya. – 2022. – Vyp. 10.1, № 35. – S. 26–33 [in Russian].

7. Gottstein, G. Technik und Klinik der Oesophagoskopie / G. Gottstein // Mitt. grenzgeb. med. chir. – 1901. – Jg. 8. – S. 157–152.

8. Heller, E. Extramuköse cardiaplastik beim chronischen Cardiospasmus mit Dilatation des Oesophagus / E. Heller // Mitt Grenzgeb Med Chir. – 1914. – № 27. – Р. 141–155.

9. Karpuschenko, E. G. Prodolnaya ezofagokardiomiotomiya – 100 let v klinicheskoi praktike [Longitudinal esophagocardiomyotomy – 100 years in clinical practice] / E. G. Karpuschenko, D. V. Ovchinnikov // Vestnik Rossiiskoi voenno-medicinskoi akademii im. S. M. Kirova. – 2014. – Vyp. 2, № 46. – S. 237–241 [in Russian].

10. Allahverdyan, A. S. Nepolnaya kosaya zadnebokovaya fundoplikaciya pri ezofagokardiomiotomii po povodu ahalazii kardii [Incomplete oblique posterolateral fundoplication in esophagocardiomyotomy for achalasia of the cardia] / A. S. Allahverdyan, V. S. Mazurin // Grudnaya i serdechno-sosudistaya hirurgiya. – 2007. – № 6. – S. 32–36 [in Russian].

11. Shalimov, A. A. Nervno-myshechnye zabolevaniya pishchevoda [Neuromuscular diseases of the esophagus] / A. A. Shalimov, V. F. Saenko, S. A. Shalimov // Hirurgiya pishchevoda. – 1975. – S. 67–97 [in Russian].

12. Campos, G. M. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis / G. M. Campos, E. Vittinghoff, C. Rabl [et al.] // Ann Surg. – 2009. – № 249. – Р. 45–57. – doi: 10.1097/SLA.0b013e31818e43ab.

13. Snyder, C. W. Multiple preoperative endoscopic interventions are associated with worse outcomes after laparoscopic Heller myotomy for achalasia / C. W. Snyder, R. C. Burton, L. E. Brown [et al.] // J Gastrointest Surg. – 2009. – № 13. – Р. 103. – doi: 10.1007/s00464-023-10314-4.

14. Costantini, M. The laparoscopic Heller Dor operation remains an eff ective treatment for esophageal achalasia at a minimum 6-year follow-up / M. Costantini, G. Zaninotto, E. Guirroli [et al.] // Surg Endosc. – 2005. – № 19. – Р. 51. – doi: 10.1007/s00464-004-8941-7.

15. Chen, Z. Laparoscopic cardiomyotomy for achalasia: clinical outcomes beyond 5 years / Z. Chen, J. R. Bessell, A. Chew [et al.] // J Gastrointest Surg. – 2010. – № 14. – Р. 594–600. – doi: 10.1007/s11605-010-1158-2.

16. Ross, S. W. National outcomes of laparoscopic Heller myotomy: operative complications and risk factors for adverse events / S. W. Ross, B. Oommen, B. A. Wormer, A. L. [et al.] // Surg Endosc Other Interv Tech. – 2015. – Vol. 29, № 11. – Р. 105. – doi: 10.1007/s00464-014-4054-0.

17. Wang, W. P. Is the endoscopic Dor fundoplication definitely effective? / W. P. Wang, H. L. Zhang, L. Q. Chen // Endoscopy. – 2019. – Vol. 51, № 7. – Р. 697.

18. Richards, W. O. Heller myotomy versus heller myotomy with dor fundoplication for achalasia: A prospective randomized double-blind clinical trial / W. O. Richards, A. Torquati, M. D. Holzman [et al.] // Annals of Surgery. Lippincott, Williams, and Wilkins. – 2004. – Vol. 240, № 3 – Р. 405–415. – doi: 10.1097/01.sla.0000136940.32255.51.

19. Eckardt, V. F. Predictors of outcome in patients with achalasia treated by pneumatic dilatation / V. F. Eckardt, C. Aignherr, G. Bernhard // Gastroenterology. – 1992. – Vol. 103. – P. 1732–1 738. – doi: 10.1016/0016-5085(92)91428-7.

20. Jones, R. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesoph. reflux disease in primary care / R. Jones, O. Junghard, J. Dent, N. Vakil, К. Halling, В. Wernersson, Т. Lind // Alimentary Pharmacology & Therapeutics. – 2009. – Vol. 30, № 10. – P. 1030–1038. – doi: 10.1111/j.1365-2036.2009.04142.x.

21. Velanovich, V. The development of the GERD-HRQL symptom severity instrument / V. Velanovich // Dis Esophagus. – 2007. – Vol. 20, № 2. – P. 130–134. – doi: 10.1111/j.1442-2050.2007.00658.x.

22. Ware J r, J . E . T he M OS 3 6-item s hort-form h ealth survey (SF-36). I. Conceptual framework and item selection / J. E. Ware Jr, C. D. Sherbourne // Medical Care. – 1992. – Vol. 30, № 6. – P. 473–483.

23. Grishin, I. N. Kardiospazm, ahalaziya kardii i perforacii pishchevoda [Cardiospasm, achalasia of the cardia and esophageal perforation] / I. N. Grishin, Ya. L. Perelygin. – Minsk: Vyshejsh. shk., 2013. – S. 41–45 [in Russian].