149. LAPAROSCOPIC HELLER CARDIO-MYOTOMY IS NOT ALWAYS A SAFE OPERATION

Background

Laparoscopic Heller cardio-myotomy is the standard surgical treatment of achalasia. Although POEM (Per-oral endoscopic myotomy) has gained wide acceptance among gastroenterologists, yet many surgeons are still loyal to this operation. One of the complications of the operation which could happen is esophageal or gastric perforation during the myotomy. Intra-operative detection of the perforation and meticulous repair is very important to prevent serious sequelae.

Methods

Between may 2021 and Jan 2023, 46 cases of achalasia (Type I and II) were treated by laparoscopic Heller cardio-myotomy and anti-reflux procedure (Dor or Toupet). Myotomy was performed using muscles splitting combined with either harmonic or hook diathermy. Intra-operative perforations were reported and were repaired in all cases and tested for absence of leakage. Post-operative follow up of cases having intraoperative perforations and its management were documented. For those having perforations postoperative gastrographin swallow and meal was done and oral fluids intake started second postoperative day.

Results

Perforations occurred in 11 cases (24%) and were repaired using 3 l0 suture: monofilament non-absorbable suture: prolene (polypropyelene, J&J MedTech) in 4 cases, monofilament absorbable suture monocryl (poliglecaprone 25, J&J MedTech) in 3 cases and vicryl (polyglactin 910, J&J MedTech) in 4 cases.

Smooth post-operative recovery was noted in 7 cases having perforations (64%). Four patients (36%) developed Leakage second postoperative day confirmed by investigations. All these cases were repaired with Vicryl. Endoscopic stent was inserted with improvement of the condition in 3 cases (75%). One patient required reoperations twice and expired in the 29th day postoperative from ARDS.

Conclusion

Although perforations could happen during laparoscopic Heller cardio-myotomy, it has a benign postoperative course in most cases. This doesn’t mean that it is a simple operation. Laparoscopic Heller cardio-myotomy should be done in highly specialized esophageal center because its complications could lead to death if badly managed.