Definition & Overview
Oesophagomyotomy is a surgical procedure used in the treatment of disorders of the oesophagus, such as achalasia, nutcracker oesophagus, and diffuse oesophagal spasm. The procedure involves creating an incision in the thick muscular layer of the lower oesophageal sphincter (LES). In the past, the procedure was performed through open surgery. However, laparoscopy, a minimally invasive surgical method, has made it possible to complete the process by creating only 5 or 6 small incisions. This significantly reduces trauma and recovery time.
One of the postoperative complications of oesophagomyotomy is the occurrence of gastroesophageal reflux in more than 60% of patients. To prevent such, another procedure called fundoplasty is subsequently performed.
Fundoplasty, also referred to as Dor fundoplication, involves tying up one end of the stomach and using it to cover a part of the oesophagus. According to one study, fundoplasty reduces the occurrence of postoperative reflux by around 9.1%. Patients who developed reflux even after fundoplasty was performed were simply treated with antacids.
Who Should Undergo & Expected Results
Laparoscopic oesophagomyotomy with fundoplasty is usually performed in patients with chronic or severe cases of diffuse oesophageal spasm, achalasia, or nutcracker oesophagus.
Diffuse oesophageal spasm is a condition that makes it difficult for the patient to swallow. In some cases, undigested food inside the oesophagus is expelled back into the mouth (regurgitation). Uncontrolled spasms of the oesophagus may cause severe pain similar to a heart attack.
On the other hand, achalasia occurs when food cannot pass through the oesophagus and then into the stomach due to the tightening of the oesophagus muscles. Nutcracker oesophagus, also called as jackhammer oesophagus, is another disorder of the oesophagus that produces symptoms similar to diffuse oesophagal spasm. Patients with this condition usually have difficulty swallowing and experience severe chest pains. However, there are cases wherein a patient may not display any symptoms.
If nonsurgical treatment methods fail to improve the conditions described above and if the patient's quality of life is severely affected, laparoscopic oesophagomyotomy with fundoplasty can be recommended.
Since the procedure is minimally invasive, patients can expect a shorter recovery period, minimal pain, and minimal scarring.
How is the Procedure Performed?
Patients who are scheduled to undergo laparoscopic surgery will need a few days to prepare for the procedure. Three days prior, they will be advised to switch to a diet of clear liquids. They will not be allowed to consume any type of solid food or alcohol during this period. They are also advised to refrain from smoking (if they are smokers) at least two weeks prior to the procedure.
If the patient is taking any medications for other medical conditions, the doctor may advise the patient to stop taking them or other medications that will not interfere with the surgery or recovery process may be prescribed.
Laparoscopic oesophagomyotomy with fundoplasty is performed while the patient is under general anaesthesia. The surgeon will create 5 or 6 small incisions in the upper stomach region. Miniature surgical instruments with a high definition video camera and light source are passed through the incisions and directed towards the LES. The surgeon will then create an incision in the LES to complete the myotomy procedure.
Using the same instruments, the surgeon will proceed to tie one end of the stomach and use it to cover the part where the myotomy was performed. The tied end will be kept in place using sutures. Once the procedure is complete, the surgeon will remove the instruments and close the small incisions in the upper stomach region.
In most cases, the patient will be advised to remain in the hospital for at least 24 hours. If complications do not develop during this period, the patient is discharged and allowed to continue recovery at home. While at home, patients are advised to follow a strict diet for about two weeks. After a follow-up consultation with the attending physician, patients may be allowed to change their diet.
Possible Risks and Complications
As with any type of surgical procedure, there are risks associated with laparoscopic oesophagomyotomy with fundoplasty. Laparoscopy may be minimally invasive but due to the limited view and space to perform the procedure, there is a risk of penetrating the oesophagus and creating a leak. If this happens, the leak will have to be closed using sutures.
As mentioned earlier, not all fundoplasty procedures prove to be successful. There is a small possibility that stomach acids may still reflux upwards. In the majority of cases, antacids are enough to treat the condition.
The procedure is considered to be a long-term cure for various problems of the oesophagus. However, it does not guarantee against recurrences. This is because the procedure does not address the underlying causes of the medical condition, only the symptoms.
Daniel T. Dempsey, MD, Matthew Delano, MD, Kevin Bradley, MD, Jeffrey Kolff, MD, Carol Fisher, BS, Dina Caroline, MD, John Gaughan, PhD, John E Meilahn, MD, John M. Daly, MD;”Laparoscopic Esophagomyotomy for Achalasia”; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356286/
David I Watson, Arul Immanuel;”Endoscopic and Laparoscopic Treatment of Gastroesophageal Reflux”; http://www.medscape.com/viewarticle/721059_5