Laparoscopic approach to esophageal perforation secondary to pneumatic dilation for achalasia

Perforation of the esophagus after pneumatic dilation for achalasia is a severe complication which should be treated accurately in order to obtain a successful immediate outcome and a satisfactory result for the underlying condition.

Five consecutive patients presenting with distal esophageal perforation after pneumatic dilation for achalasia were included in this study. All patients had gastrografin swallow performed to confirm the perforation, and one patient was also submitted to flexible esophagoscopy. Laparoscopic approach was performed in all patients with five portals. The phrenoesophageal membrane was opened on its anterior aspect. The distal esophagus was dissected free, and perforations were identified with the help of methylene blue or milk administration through the esophageal tube. All perforations were sutured with interrupted absorbable sutures. Contralateral myotomy and partial anterior Dor fundoplication completed the operation. Endoscopic control of length of myotomy and watertightness of mucosal closure was performed in all cases.

There were no intraoperative complications. After surgery all patients were maintained with nil per os until a barium swallow showed no leakage. One patient had a radiologic leakage sustained for 1 week. All patients were dismissed uneventfully. At 6 months after surgery, esophageal manometry was performed. Mean lower esophageal sphincter resting pressure had fallen from 30 to 8.7 mmHg.

Laparoscopy offers an excellent approach to treat distal esophageal instrumental perforations, perhaps even better than open surgery. Suture of the perforation, contralateral myotomy and partial anterior fundoplication is a good option in the treatment of perforated achalasia after pneumatic dilation.