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Endoskopie heute 2012; 25(3): 180-183
DOI: 10.1055/s-0032-1325364
Originalarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Chirurgische Therapie der Achalasie

Surgical Treatment for Achalasia
S. B. Reiser
,
D. Wilhelm
,
M. Kranzfelder
,
S. Gillen
,
H. Friess
,
H. Feußner
Further Information

Publication History

Publication Date:
12 October 2012 (online)

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Zusammenfassung

Die laparoskopische Myotomie gilt heute als Verfahren der Wahl für die Therapie der Stadien I und II der Achalasie, sofern es sich bei den Betroffenen um junge Patienten unter 40 Jahren handelt, während bei älteren Patienten primär ein konservativer Behandlungsversuch (ein- bis zweimalige pneumatische Dilatation) infrage kommt. Im eigenen Krankengut wird etwa die Hälfte der Patienten interventionell-endoskopisch und die andere Hälfte chirurgisch behandelt. Der operative Eingriff der laparoskopischen Myotomie sollte mit einer Antirefluxmaßnahme in Form einer Fundoplastik (nach Thal/Dor oder nach Toupet) kombiniert werden, um postoperativem Reflux vorzubeugen. Zudem soll sie narbenbedingte Rezidive verhindern. In der Literatur wird über eine deutliche Verbesserung der klinischen Symptomatik nach diesem Eingriff in 74 – 95 % der nachuntersuchten Fälle berichtet. Unter den Folgewirkungen sind Refluxbeschwerden relevant, die aber mit Protonenpumpenblockern gut behandelbar sind. Beim Stadium III der Achalasie („End-Stage-Achalasie“), das nach langjährigem Verlauf der Krankheit etwa 5 % der Achalasie-Patienten betrifft, stellt eine Indikation für ein radikaleres operatives Vorgehen im Sinne einer Ösophagektomie dar. Gründe hierfür sind ein ausgedehnter und irreversibler Funktionsverlust der Speiseröhre mit Syphonbildung, der durch eine Myotomie nicht mehr beeinflusst werden kann, sowie das deutlich erhöhte Risiko, bei langjährigem Verlauf der Achalasie ein Plattenepithelkarzinom zu entwickeln.

Abstract

Laparoscopic myotomy is currently the treatment of choice for achalasia of stages I and II in patients younger than 40 years of age. In patients of older age, pneumatic dilatation may be priorily attempted. However, it should not be performed more than twice. In our own group of patients, half of the patients are treated by pneumatic dilatation and the other half by cardiomyotomy. Laparoscopic cardiomyotomy should always be combined with a so called fundoplasty according to Dor/Thal in order to prevent postoperative reflux or scar-induced dysphagia. In final stages of achalasia with massive dilatation of the esophagus with bulging of its distal part, esophagectomy is indicated. Beyond of massive problems of stasis related dysphagia, the high risk of squamous cell carcinoma warrant this more invasive approach.

Schlüsselwörter

Achalasie - End-Stage - chirurgische Therapie - laparoskopische Myotomie - Fundoplastik - Ösophagektomie

Key words

achalasia - end stage - surgical treatment - laparoscopic myotomy - fundoplasty - esophagectomy
 

  • Literatur

  • 1 Khajanchee YS, Kanneganti S, Leatherwood AEB et al. Laparoscopic Heller myotomy with Toupet fundoplication. Arch Surg 2005; 140 (09) 827-834
    CrossrefPubMedGoogle Scholar
  • 2 Csendes A, Braghetto I, Henríquez A et al. Late results of a prospective randomized study comparing forceful dilatation and esophagomyotomy in patients with achalasia. Gut 1989; 30 (03) 299-304
    CrossrefPubMedGoogle Scholar
  • 3 Kostic S, Kjellin A, Ruth M et al. Pneumatic dilatation or laparoscopic cardiomyotomy in the management of newly diagnosed idiopathic achalasia. Results of a randomized controlled trial. World J Surg 2007; 31 (03) 470-478
    CrossrefPubMedGoogle Scholar
  • 4 Lapushinsky SR, Urbach DR. Pneumatic dilatation and surgical myotomy for achalasia. JAMA 2006; 296 (18) 2227-2233
    CrossrefPubMedGoogle Scholar
  • 5 Boeckxstaens GE, Annese V, des Varannes SB et al. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med 2011; 364 (19) 1807-1816
    Google Scholar
  • 6 Alderliesten J, Conchillo JM, Leeuwenburgh I et al. Predictors for outcome offailure of balloon dilatation in patients with achalasia. Gut 2011; 60 (01) 10-16
    CrossrefPubMedGoogle Scholar
  • 7 Eckardt VF, Gockel I, Bernhard G. Pneumatic dilation for achalasia: late results of a prospective follow up investigation. Gut 2004; 53 (05) 629-633
    CrossrefPubMedGoogle Scholar
  • 8 Stefanidis D, Richardson W, Farrell TM et al. SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 2011; 26: 296-311
    PubMedGoogle Scholar
  • 9 Burpee SE, Mamazza J, Schlachta CM et al. Objective analysis of gastroesophageal reflux after laparoscopic heller myotomy: An anti-reflux procedure is required. Surg Endosc 2004; 19: 9-14
    PubMedGoogle Scholar
  • 10 Rossetti G, Brusciano L, Amato G et al. A total fundoplication is not an obstacle to esophageal emptying after Heller myotomy for achalasia: results of a long term follow up. Ann Surg 2005; 241: 614-621
    CrossrefPubMedGoogle Scholar
  • 11 Campos GM, Vittinghoff E, Rabl C et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 2009; 249 (01) 45-57
    CrossrefPubMedGoogle Scholar
  • 12 Richards WO, Torquari A, Holzman MA et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004; 240 (03) 405-412
    CrossrefPubMedGoogle Scholar
  • 13 Rawlings A, Soper NJ, Oelschlager B et al. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomiced-controlled trial. Surg Endosc 2011; 26 (01) 18-26
    PubMedGoogle Scholar
  • 14 Yamamura MS, Gilster JC, Myers BS et al. Laparoscopic Heller myotomy and anterior fundoplication for achalasia results in a high degree of patient satisfaction. Ann Surg 2000; 135 (08) 902-906
    PubMedGoogle Scholar
  • 15 Tsuboi K, Omura N, Yano F et al. Results after laparoscopic Heller-Dor operation for esophageal achalasia in 100 consecutive patients. Dis. Esophagus 2009; 22 (2) 169-176
    CrossrefPubMedGoogle Scholar
  • 16 Bonatti H, Hinder RA, Klocker J et al. Long-term results of laparoscopic Heller myotomy with partial fundoplication for the Tratment of achalasia. Am J Surg 2009; 190 (06) 874-878
    PubMedGoogle Scholar
  • 17 Kilic A, Schuchert MJ, Pennathur A et al. Long-term outcomes of laparoscopic Heller myotomy for achalasia. Surgery 2009; 146 (04) 826-831
    CrossrefPubMedGoogle Scholar
  • 18 Jeansonne LO, Brent CW, Kelly EP et al. Ten-year follow-up of laparoscopic Heller myotomy for achalasia shows durability. Surg Endosc 2007; 21: 1498-1502
    CrossrefPubMedGoogle Scholar
  • 19 Tsiaoussis J, Athanasakis E, Pechlivanides G et al. Long-term functional results after laparoscopic surgery for esophageal achalasia. Am J Surg 2007; 193 (01) 26-31
    CrossrefPubMedGoogle Scholar
  • 20 Csendes A, Braghetto I, Burdiles P et al. Very late results of esophagomyotomy for patients with achalasia. Ann Surg 2006; 243 (02) 196-203
    CrossrefPubMedGoogle Scholar
  • 21 Mayo D, Griffiths EA, Khan OA et al. Does the addition of a fundoplication improve outcomes for patients undergoing laparoscopic Heller’s cardiomyotomy?. Int J Surg 2012; Apr. 14 Epub
    PubMedGoogle Scholar
  • 22 Schulz HG, Loick J, Hessling M et al. Laparoscopic Heller cardiomyotomy either combined with a Dor or Toupet procedure in the treatment of achalasia. Zentralbl Chir 2004; 129 (05) 381-386
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Molena D, Yang SC. Surgical management of end-stage achalasia. Semin Thoracic Surg 2012; 24: 19-26
    PubMedGoogle Scholar
  • 24 Duranceau A, Liberman M, Martin J et al. End-stage achalasia. Dis Esophagus 2010; 25 (04) 319-330
    PubMedGoogle Scholar
  • 25 Leeuwenburgh I, Haringsma J, Van Dekken H et al. Long-term risk of oesophagitis, Barrett’s oesophagus and oesophageal cancer in achalasia patients. Scand J Gastroenterol Suppl 2006; 243: 7-10
    PubMedGoogle Scholar
  • 26 Meijssen MAC, Tilanus HW, van Blankenstein M et al. Achalasia complicated by oesophageal squamous cell carcinoma: a prospective study in 195 patients. Gut 1992; 33: 155-158
    CrossrefPubMedGoogle Scholar
  • 27 Brücher BL, Stein HJ, Bartels H et al. Achalasia and oesophageal cancer: incidence, prevalence, and prognosis. World J Surg 2001; 25 (06) 745-749
    CrossrefPubMedGoogle Scholar