Enhanced recovery protocols in laparoscopic treatment of achalasia

with Hellers cardiomyotomy and Dors fundoplication

Introduction
Esophageal achalasia is a primary esophageal motility disorder characterized by lack
of esophageal peristalsis and inability of the lower esophageal sphincter (LES) to
relax properly in response to swallowing. The etiology includes autoimmune, viral
immune, or neurodegenerative causes. Achalasia is a chronic condition without cure.
Current treatment options in achalasia are aimed at reducing the hypertonicity of the
LES by pharmacologic, endoscopic, or surgical means. As far as the surgical
treatment is concerned the procedure most commonly performed is cardiomyotomy
along with anterion fundoplication (Heller Dor procedure). The laparoscopic approach
has minimized the surgical trauma, the postoperative pain and enabled the integration
of

fast-track

protocols.

Fast-

track surgery is an interdisciplinary multimodal concept of minimally invasive surger

y or new incision lines and

cutting old plaits

(e.g.,

the use of drains or tubes). It uses modern intraoperative anesthesia (e.g., fluid restrict
ion)
and analgesia, including new drugs and novel ways of administration (e.g., thoracic ep
idural analgesia)

for postoperative pain relief,

in combination with the immediate mobilization of

the patient and early oral nutrition after the
operation. This approach requires a cooperating team of motivated nurses, physiothera
pists, anesthesiologists,

and surgeons,

in addition to continuous improvement of

the processes involved. The aim of this report was to present the outcome of the
application of ERAS protocols in surgical treatment of achalasia. This report was a

prospective evaluation of consecutive patients undergoing the application of ERAS

protocols in surgical treatment of achalasia.
Key words: achalasia, fast track, ERAS, cardiomyotomy, Heller
Materials and methods

Esophageal achalasia is a primary esophageal motility disorder characterized by lack

of esophageal peristalsis and inability of the lower esophageal sphincter (LES) to
relax properly in response to swallowing. Achalasia has an equal prevalence in both
men and women with incidence ranging 10 in 100,000 individuals annually. There is
no racial predilection. The peak incidence occurs between 30 and 60 years of age. The
clinical feature is dysphagia.

Between

2010 and 2015,

14 patients with esophageal motility disorders were

admitted to our clinic for further investigation and treatment. This was a prospective
study of 14 patients undergoing laparoscopic Hellers cardiomyotomy with Dors
fundoplication combined with an enhanced recovery protocol (early oral intake, no
drains or nasogastric tubes, no epidural analgesia, no use of urinary catheter and plan
discharge 12 to 24 hours after surgery). It included 8 women and 5 men ranging from
21 to 67 years of age (mean age 41). Standard preoperative evaluation included the
following ; a. Barium meal b. Manometry function tests c. Endoscopy d. Pneumatic
dilatations were performed in two patients previously. The operation performed was
laparoscopic Heller's cardiomyotomy with Dor's fundoplication. This involves a 5 cm
sero-muscular incision across the lower third of the esophagus and the first 2 cm of
the stomach . The first 1 or 2 short gastric vessels are ligated
in order for the gastric dome to be mobilized 180 degrees onto the

cardiomyotomy.
. All patients received antithrombotic intraoperative prophylaxis ( ). No abdominal drain was used. Liquid diet
initiated immediately after the operation. All patients mobilized as soon as the
recovered the anesthesia. No endoscopy was performed during surgery. No
gastrografin contrast was administered post operatively (unless it was considered
necessary). Postoperative pain control included paracetamol 1 g every 8 h and
tramadol 100 mg PRN.
Results
No conversions to open procedure were recorded. The duration of the operation
ranged between 70 and 120 minutes (mean duration 83 min). No drains were used
and no post operative complications were recorded. The patients were fed the same
afternoon and were discharged from our center the same day.

Discussion
Esophageal achalasia is a primary esophageal motility disorder characterized by lack
of esophageal peristalsis and inability of the lower esophageal sphincter (LES) to
relax properly in response to swallowing. The procedure of choice in the modern
surgical field is laparoscopic Heller's cardiomyotomy and Dor's fundoplication. In
1913, Ernest Heller reported the first successful cardiomyotomy for achalasia. He
used 8 cm parallel myotomies (anterior and posterior). These were considered
extensive, and, in 1918, De Brune Groenveidt and Zaaijer described the single
incision.

Laparoscopic Heller myotomy can safely and durably relieve symptoms of dysphagia while also

reducing symptoms of reflux. Length of stay is short and patient satisfaction is very high with extended follow-up.
Laparoscopic Heller myotomy is strongly encouraged for patients with symptomatic achalasia and is efficacious
even after failures of dilation and/or Botox therapy.

The first laparoscopic Heller myotomy took

place in 1992. As far as the operation is concerned, it enables us to implement fast-

track protocols. The integration of Fast-track protocols in laparoscopic Heller's

cardiomyotomy and Dor's fundoplication procedure is utilized to reduce healthcare
costs by reducing length of hospital stay, to reduce post operative pain and
complications.

Over the past decade, advances in healthcare with an evolution in peri- and postoperative care have led to a new surgical approach. Enhanced recovery after surgery
(ERAS) protocols, also known as fast-track surgery or multimodal optimisation,
are a combination of evidence based peri-operative strategies which work
synergistically to expedite recovery after surgery. These strategies include..
To the best of our knowledge, there is no previous report on the application of ERAS
protocols in the treatment of achalasia. Laparoscopic Heller myotomy gathers all the
conditions required for the application of fast-track surgery.
Conclusion
Laparoscopic Heller's cardiomyotomy and Dor's fundoplication is the procedure of choice in younger
patients with no co-morbidities. It offers a definitive advantage over pneumatic dilatations which only
give a short term solution the motility disorders of the esophagus.