Postmyotomy recollection of premyotomy symptoms of achalasia is very accurate,supporting longitudinal studies of symptom improvement

Background Recollection of preoperative symptom frequency and severity may change postoperatively, thus invalidating longitudinal studies. This study was undertaken to compare symptoms of achalasia before myotomy to patients’ postoperative recollection of premyotomy symptoms. Methods A total of 173 patients, 54% male, of median age 48 years, have undergone laparoscopic Heller myotomy and have been followed through a prospectively maintained registry. Preoperatively, patients scored the frequency and severity of their symptoms on a Likert scale: 0 (never/very bothersome) to 10 (always/very bothersome). Similarly, after laparoscopic Heller myotomy, patients scored the frequency and severity of their symptoms, and re-scored their preoperative symptoms. Data are presented as median, mean ± SD. Results Before myotomy, dysphagia, regurgitation, choking, chest pain, vomiting, and heartburn were particularly notable; symptom scores nearly globally improved after myotomy (p < 0.05 for all, Wilcoxon matched pairs test), especially obstructive symptoms. Postmyotomy recollection of premyotomy symptom frequency and severity was neither substantively nor consistently different from premyotomy scoring. Conclusions Before myotomy, patient symptom scores reflected the deleterious impact of achalasia. After myotomy, patient symptom scores dramatically improved, reflecting the favorable impact of laparoscopic Heller myotomy. Even years after myotomy, patient recollection of premyotomy symptom severity and frequency is very accurate and supports longitudinal studies of symptom improvement after myotomy. Presented at the 25th Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, Texas, 26–29 May 2006     

Preoperative intervention does not affect esophageal muscle histology or patient outcomes in patients undergoing laparoscopic Heller myotomy

Botox injection and pneumatic dilation are common therapies for achalasia. We sought to determine the impact of these preoperative therapies on esophageal muscle histology and outcomes after laparoscopic Heller myotomy. A total of 73 consecutive patients had esophageal muscle biopsies taken from the gastroesophageal junction at the time of myotomy between November 1998 and November 2001. Muscle fibrosis was graded by a senior pathologist who was blinded to preoperative treatments and postoperative outcomes. Patients graded their dysphagia and heartburn symptoms before and after myotomy and graded their outcomes at follow-up. Patients were grouped according to the preoperative endoscopic treatment (dilation, Botox, both, or neither) and the groups were compared. Preoperative therapy did not correlate with esophageal fibrosis or postoperative outcomes, and the degree of esophageal muscle fibrosis was not predictive of outcome. Symptom scores improved significantly for dysphagia (4.5 ± 0.9 vs. 1.6 ± 1.6) and heartburn (2.3 ± 1.8 vs. 1.5 ± 1.4) irrespective of preoperative therapy or fibrosis. Overall, excellent or good outcomes were obtained in 92% of patients at follow-up of 15.7 months ± 14.4. Successful outcomes are highly probable after laparoscopic Heller myotomy regardless of preoperative interventions. The amount of fibrosis in the esophageal muscle is not related to preoperative intervention and is not predictive of outcomes. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

Does concomitant anterior fundoplication promote dysphagia after laparoscopic Heller myotomy?

Concerns for gastroesophageal reflux after laparoscopic Heller myotomy for achalasia justify considerations of concomitant anterior fundoplication. This study was undertaken to determine if concomitant anterior fundoplication reduces symptoms of reflux after myotomy without promoting dysphagia. From 1992 to 2004, 182 patients underwent laparoscopic Heller myotomy without fundoplication. After a prospective randomized trial justified its concomitant application, anterior fundoplication was undertaken with laparoscopic Heller myotomy in 171 patients from 2004 to 2007. All patients have been prospectively followed. Pre and postoperatively, patients scored the frequency and severity of symptoms of achalasia (including dysphagia, choking, vomiting, regurgitation, chest pain, and heartburn) using a Likert Scale (0 = never/not bothersome to 10 = always/very bothersome). Before myotomy, symptoms of achalasia were frequent and severe for all patients. After myotomy, the frequency and severity of all symptoms of achalasia significantly decreased for all patients (P < 0.001, Wilcoxon matched pairs test). Notably, relative to patients undergoing laparoscopic Heller myotomy alone, concomitant anterior fundoplication led to significantly less frequent and severe heartburn after myotomy (P < 0.05, Mann-Whitney Test) and to less frequent and severe dysphagia and choking (P < 0.05, Mann-Whitney Test). Laparoscopic Heller myotomy reduces the frequency and severity of symptoms of achalasia. Concomitant anterior fundoplication decreases the frequency and severity of heartburn and dysphagia after laparoscopic Heller myotomy. Concomitant anterior fundoplication promotes salutary relief in the frequency and severity of symptoms after myotomy and is warranted.     

Esophagotomy during laparoscopic Heller myotomy cannot be predicted by preoperative therapies and does not influence long-term outcome

The conventional wisdom is that inadvertent esophagotomy complicates laparoscopic Heller myotomy. This study was undertaken to determine if esophagotomy at myotomy can be predicted by preoperative therapy, and if esophagotomy and/or its repair jeopardizes outcomes. Of 222 laparoscopic Heller myotomies undertaken since 1992, inadvertent esophagotomy occurred in 16 patients (7%); 60 patients who underwent myotomy without esophagotomy were utilized for comparison. Dysphagia and reflux before/ after myotomy were scored by patients on a Likert scale (0-5). The median (mean _ SD) follow-up after myotomy with esophagotomy was 38.8 months (31.6 ± 21.9 months) versus 46.3 months (51.0 ± 21.2 months) after myotomy alone. All esophagotomies were immediately recognized and repaired. Patients who experienced esophagotomy were similar to those who did not in application of Botox (56% vs. 77%) or dilation (44% vs. 65%), years of dysphagia (7.3 ± 5.4 vs. 7.4 ± 6.0), and mean preoperative dysphagia score (4.9 ± 0.4 vs. 4.8 ± 0.4). Esophagotomy led to longer hospitalizations (5.2 days ± 2.5 days vs. 1.5 days ± 0.7 days, P < 0.05) but not different postoperative dysphagia scores (1.5 ± 1.7 vs. 2.1 ± 1.4), reflux scores (1.4 ± 1.7 vs. 2.3 ± 1.3), or good or excellent outcomes (86% vs 84%). Esophagotomy during laparoscopic Heller myotomy is infrequent and cannot be predicted by preoperative therapy or duration or severity of dysphagia. Furthermore, complications after esophagotomy are infrequent and outcomes are indistinguishable from those of patients undergoing uneventful myotomy. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (poster presentation).     

Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than heller myotomy alone

OBJECTIVE: Heller myotomy has been shown to be an effective primary treatment of achalasia. However, many physicians treating patients with achalasia continue to offer endoscopic therapies before recommending operative myotomy. Herein we report outcomes in 209 patients undergoing Heller myotomy with the majority (74%) undergoing myotomy as secondary treatment of achalasia. METHODS: Data on all patients undergoing operative management of achalasia are collected prospectively. Over a 9-year period (1994-2003), 209 patients underwent Heller myotomy for achalasia. Of these, 154 had undergone either Botox injection and/or pneumatic dilation preoperatively. Preoperative, operative, and long-term outcome data were analyzed. Statistical analysis was performed with multiple chi and Mann-Whitney U analyses, as well as ANOVA. RESULTS: Among the 209 patients undergoing Heller myotomy for achalasia, 154 received endoscopic therapy before being referred for surgery (100 dilation only, 33 Botox only, 21 both). The groups were matched for preoperative demographics and symptom scores for dysphagia, regurgitation, and chest pain. Intraoperative complications were more common in the endoscopically treated group with GI perforations being the most common complication (9.7% versus 3.6%). Postoperative complications, primarily severe dysphagia, and pulmonary complications were more common after endoscopic treatment (10.4% versus 5.4%). Failure of myotomy as defined by persistent or recurrent severe symptoms, or need for additionally therapy including redo myotomy or esophagectomy was higher in the endoscopically treated group (19.5% versus 10.1%). CONCLUSION: Use of preoperative endoscopic therapy remains common and has resulted in more intraoperative complications, primarily perforation, more postoperative complications, and a higher rate of failure than when no preoperative therapy was used. Endoscopic therapy for achalasia should not be used unless patients are not candidates for surgery.     

Achalasia: the case for primary laparoscopic treatment

Laparoscopic Heller myotomy offers the best-known surgical therapy for esophageal achalasia. Nevertheless, this procedure continues to compete with alternative endoscopic treatment and is often considered only as a secondary resort. In this study, the authors performed a review of the results of laparoscopic Heller myotomy and an evaluation of the impact of previous endoscopic treatment regarding perioperative complications and late results. Twenty-seven patients with achalasia confirmed by a manometry examination underwent a primary laparoscopic Heller myotomy (group 1, n = 14) or experienced endoscopic treatment failure (group 2, n = 13). A dysphagia score (0-4) was obtained before and after surgery. Clinical course was reviewed at 2 months and then every 6 months after surgery. In December 1999, patients answered a questionnaire regarding surgery satisfaction, postoperative reflux, and dysphagia for statistical analysis. There were no deaths. Mean hospital stay was 5.6 days. Three perforations occurred in group 2 (25%) versus one in group 1 (6%) (not statistically significant). At a mean 27-month follow-up, the dysphagia score was significantly (P < 0.001) improved in both groups but more significantly in group 1 versus group 2 (not statistically significant). Only one patient in group 2 reported heartburn. All patients in group 1 (100%) were satisfied with surgery as opposed to 10 of 13 patients (75%) in group 2 (P < 0.10). Primary laparoscopic Heller myotomy appears to be the treatment of choice for achalasia. Previous endoscopic treatment increases intraoperative complications and may affect long-term results.     

Laparoscopic Heller myotomy provides durable relief from achalasia and salvages failures after botox or dilation

OBJECTIVE: To report outcome after laparoscopic Heller myotomy in a large number of patients. SUMMARY BACKGROUND DATA: Laparoscopic Heller myotomy has been undertaken for over a decade, but most studies involve small numbers of patients with limited follow-up. METHODS: Since 1992, 262 patients have undergone laparoscopic Heller myotomy and been prospectively followed. Concomitant fundoplication was undertaken for a patulous hiatus or large hiatal hernia or to buttress the repair of an esophagotomy until recently when it became routinely applied. With mean follow-up at 32 months, symptoms were scored by patients on a Likert scale (frequency: 0 = Never to 10 = Every time I eat/always; severity: 0 = Not bothersome to 10 = Very bothersome). RESULTS: Before myotomy, 79% received Botox or bag dilation: 52% had Botox, 59% underwent dilation, and 36% had both. Inadvertent esophagotomy occurred in 5%. Concomitant diverticulectomy was undertaken in 4%, and fundoplication was undertaken in 30%. Complications were infrequent. Median length of stay was 1 day. After myotomy, the frequency and severity of symptoms of achalasia and reflux significantly decreased. Eighty-eight percent of patients felt their symptoms were greatly improved or resolved, and 90% felt their outcome was satisfying or better. Ninety-three percent felt they would undergo myotomy again, if necessary. CONCLUSIONS: 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.     

Age affects presenting symptoms of achalasia and outcomes after myotomy

Older patients with achalasia presumably have had a longer, more indolent course than younger patients. This study was undertaken to determine the impact of patient age and duration of symptoms on symptom severity and outcome after Heller myotomy. Two hundred sixty-two patients (142 men and 120 women), of average age 49 years +/- 17.7 (SD), have undergone laparoscopic Heller myotomy. Patients scored their symptoms using a Likert scale and subjectively rated their overall outcome. Data are presented as median, mean +/- SD, when appropriate. Follow-up is 25 months, 32 months +/- 28.7. Symptom severity scores improved after myotomy (P < 0.001 for all, paired Student's t test). Before myotomy, older patients had less dysphagia, regurgitation, choking, and chest pain (P < 0.05). Duration of preoperative symptoms did not correlate with frequency of symptoms. After myotomy, older patients had lower scores for dysphagia, chest pain, choking, and heartburn (P < 0.01); patients with prolonged durations of symptoms had lower dysphagia and choking scores. Neither age nor duration of symptoms had a significant effect on overall subjective outcomes. All patients should expect significant reductions in symptoms of achalasia following myotomy. Age and duration of symptoms impact symptoms before and after myotomy, but neither seem to impact subjective measure of outcome.     

Videoscopic heller myotomy as first-line therapy for severe achalasia.

To many nonsurgeons myotomy is considered an excessively invasive treatment for achalasia and has become a salvage procedure when esophageal dilation and botulinum toxin (botox) injections fail. We sought to examine our experience with videoscopic Heller myotomy to determine whether preoperative therapy predicts perioperative complications and long-term outcome. Videoscopic Heller myotomy was undertaken in 111 patients with achalasia between June 1992 and May 2000. Intraoperative endoscopy was used in all patients. Fundoplication was used selectively for patients with large hiatal hernias or as part of repair of esophageal perforation. Patients were asked to grade their dysphagia and reflux symptoms before and after myotomy on a scale of 0 (no symptoms) to 5 (severe symptoms). Patients were also asked to rate their outcome as excellent (no symptoms), good (greatly improved), fair (slightly improved), or poor (not improved) compared with their preoperative status. Patients were stratified on the basis of preoperative intervention (botox, pneumatic dilation, botox and pneumatic dilation, or no botox or dilation) and compared. Previous pneumatic dilation and/or botox injection had been undertaken before operation in 88 (79%) patients whereas 23 (21%) patients had no invasive preoperative therapy. The overall mean preoperative dysphagia score was 4.8+/-0.8 and mean preoperative reflux score was 3.3+/-2.1. Groups of patients undergoing preoperative interventions were similar to those patients not undergoing preoperative interventions in terms of preoperative symptoms, dysphagia scores, and reflux scores. Postoperative complications (13%) and perforations (8%) were slightly more common in patients who had undergone preoperative botox or dilation (P = not significant). Subjectively, operative myotomy was more difficult in patients who had preoperative botox or dilation. Patients had significant improvement in dysphagia, dysphagia score, reflux score, emesis/ regurgitation, and chest pain (P < 0.05) regardless of preoperative intervention. After myotomy patients who had never undergone botox or pneumatic dilation were less likely to have mild dysphagia compared with those with previous botox injections (30% vs 53%; P = 0.09), previous dilations (30% vs 54%; P = 0.09), or both (30% vs 59%; P = 0.04). As well, dysphagia scores were better if no preoperative therapy had been undertaken: botox 0.8+/-1.3, dilation 1.0+/-1.4, botox and dilation 1.0+/-1.3, and no therapy 0.3+/-0.7 (P < 0.05). Overall 97 per cent of patients stated that their symptoms were improved although more patients tended to have excellent or good outcomes if no preoperative intervention was undertaken (91%) compared with patients undergoing preoperative botox (86%), dilation (83%), or both (82%) (P = not significant). We conclude that videoscopic Heller myotomy is safe and efficacious particularly in patients who have not undergone previous endoscopic interventions. The difference in patients' outcomes based on preoperative therapy may be related to a less difficult operation in patients who forgo endoscopic therapy and elect to undergo early myotomy. Although videoscopic Heller myotomy provides good outcomes as a salvage procedure after failed dilations and/or botox injections for achalasia we advocate it as first-line therapy in reasonable operative candidates.     

Outcomes promote reoperative Heller myotomy for symptoms of achalasia

Background Heller myotomy is accepted as first-line therapy for achalasia, yet for a small number of patients, symptoms persist or recur after myotomy. This study was undertaken to report our results with reoperative laparoscopic Heller myotomy for recurrent symptoms of achalasia. Methods We have undertaken laparoscopic Heller myotomy in 275 patients and reoperative myotomy in 12 patients for recurrent dysphagia, of which three had their initial myotomy undertaken by us. For each, studies prior to reoperative Heller myotomy documented a nonrelaxing lower esophageal sphincter without stricture. Patients scored symptoms before and after reoperative myotomy. Results Before reoperative myotomy, 75% underwent dilation and 42% underwent Botox injection. Ten of twelve reoperative myotomies were undertaken and completed laparoscopically. Median follow-up is 24.1 months (29.0 months + 25.89). Symptom frequency and severity scores improved significantly after reoperative myotomy. Frequency of vomiting and frequency and severity of heartburn were improved after reoperative myotomy, but not to a significant extent. However, they were not particularly notable prior to surgery, compared to obstructive symptoms, such as dysphagia. Excellent or good outcomes were reported in 73%, and notably, 91% stated that they would have the operation again after having been through the process firsthand and knowing their outcomes. Conclusion Patient outcomes promote the application of reoperative Heller myotomy for recurrent or persistent symptoms of achalasia following Heller myotomy.     

Laparoscopic Heller myotomy with anterior fundoplication ameliorates symptoms of achalasia in pediatric patients

BACKGROUND: This study was undertaken to define outcomes after laparoscopic Heller myotomy with anterior fundoplication in pediatric patients and compare their outcomes with those in adults. STUDY DESIGN: A total of 337 patients have undergone laparoscopic Heller myotomy with anterior fundoplication since 1992, and were prospectively followed; 14 were pediatric patients of median age 17 years (range 11 to 19 years). Symptoms noted by pediatric patients before and after myotomy were compared with symptoms of 56 concurrently treated adults (4 treated adults for each pediatric patient) of median age 48 years. Among many symptoms, patients scored the severity and frequency of dysphagia, chest pain, regurgitation, choking, vomiting, and heartburn before and after myotomy using a Likert scale, ranging from 0 (never/not bothersome) to 10 (always/very bothersome). Followups were 38 months, 42 months+/-33.1. Data are reported as median, mean +/- SD. RESULTS: For pediatric patients, length of stay after myotomy was 2 days, 3 days+/-2.9 versus 2 days, 2+/-2.1 for adults. Before myotomy, symptom frequency and severity were similar between groups. After myotomy, symptom frequency and severity were similar between pediatric and adult patients, except for the frequency of chest pain. CONCLUSIONS: Achalasia can produce disabling symptoms, which were similar between pediatric and adult patients before myotomy. Laparoscopic Heller myotomy with anterior fundoplication ameliorated symptoms of achalasia in all patients, with postmyotomy symptoms similar between pediatric and adult patients. Laparoscopic Heller myotomy dramatically improved symptoms of achalasia in pediatric patients and its use is encouraged.     

Early results of laparoscopic Heller myotomy do not necessarily predict long-term outcome

BACKGROUND: We sought to evaluate how patients' symptoms evolve after laparoscopic Heller myotomy. METHODS: Before and after laparoscopic Heller myotomy, 88 patients graded dysphagia and heartburn on a Likert scale (0 = none; 5 = severe). Patients graded outcomes as excellent, good, fair, or poor. Outcomes were compared in the same patients at 1 and 3 years of follow-up. RESULTS: At early follow-up (10.6 +/- 7.8 months) significant reductions were noted in dysphagia (11% versus 100%), dysphagia scores (0.6 +/- 1.1 versus 4.7 +/- 0.7), heartburn (31% versus 72%), and heartburn scores (1.2 +/- 1.6 versus 2.7 +/- 1.9). By late follow-up (37.6 months +/- 18.0) these values increased (47%, 1.9 +/- 1.7, 48%, 1.8 +/- 1.5, respectively) but remained significantly reduced compared with before operation. Excellent/good outcomes at early and late follow-up were 89% and 85%, respectively (P = not significant). CONCLUSIONS: Laparoscopic Heller myotomy is highly effective at palliating the symptoms of achalasia. With time, symptoms may recur owing to esophageal dysmotility, mandating continued surveillance.     

Laparoscopic cardioplasty to avoid esophageal resection in patient not responsive to Heller myotomy

Some achalasia patients do not ameliorate dysphagia after Heller myotomy. If stenosis does not respond to endoscopic dilatations and persists after a second extended myotomy, an esophageal resection is considered unavoidable. This article describes an original technique of treating this type of persistent stenosis with an esophageal stricturoplasty. The procedure was completed under laparoscopy. The postoperative course was uneventful. Resolution of all preoperative symptoms was achieved at the first year follow-up. Control of gastroesophageal reflux was documented by 24-hour pH-impedance. If confirmed by further cases, laparoscopic esophageal stricturoplasty could become a valid option for a conservative treatment of these patients.     

After Laparoscopic Heller Myotomy,Do Emergency Department Visits or Readmissions Predict Poor Long-Term Outcomes?

Introduction  Laparoscopic Heller myotomy is a first-line treatment for achalasia. To improve outcomes after myotomy and to determine if poor early results predict later outcomes, emergency department (ED) visits and readmissions within 60 days following laparoscopic Heller myotomy were studied. Materials and Methods  Since 1992, 352 patients have undergone laparoscopic Heller myotomy and are followed through a prospectively maintained registry. Causes of ED visits and readmissions within 60 days after myotomy were determined. Patients scored their symptoms of achalasia before myotomy and at last follow-up; scores were compared to determine if the reasons leading to ED visits and/or readmissions impacted long-term outcome after myotomy. Results  Fourteen (4%) patients had ED visits, and 18 (5%) patients had readmissions within 60 days following myotomy. Sixty-four percent of ED visits were for dysphagia/vomiting and 36% were for abdominal/chest pain, while 37% of readmissions were for dysphagia/vomiting. Pneumonia was complicated by empyema in four patients, all without leaks; two patients expired. Despite ED visits/readmissions, achalasia symptom (e.g., dysphagia, regurgitation, choking, heartburn, and chest pain) frequency and severity scores improved after myotomy (p < 0.05 for all). Conclusions  ED visits and readmissions are infrequent following laparoscopic Heller myotomy. ED visits were generally due to complaints related to achalasia or edema after myotomy, while readmissions were generally related to complications of operative intervention or chronic ill health. Despite ED visits or readmissions early after myotomy, symptoms of achalasia are well palliated by myotomy long-term. Presented at the Society for Surgery of the Alimentary Tract 48th Annual Meeting, Washington, DC, May 19–24, 2007.     

Current status of an antireflux procedure in laparoscopic Heller myotomy

BACKGROUND: Persistent dysphagia and postoperative gastroesophageal reflux (GER) are the most cited reasons for surgical failure of laparoscopic Heller myotomy. Adding an antireflux procedure to Heller myotomy has been proposed to prevent reflux. We hypothesized that an antireflux procedure added to laparoscopic Heller myotomy has little effect on preventing the symptoms or long-term sequelae of GER in achalasia patients. METHODS: We performed a meta-analysis of studies on human subjects reported in the English language literature from 1991 to 2001 years. RESULTS: An antireflux procedure accompanied laparoscopic myotomy in 15 studies with 532 patients. In 6 studies of 69 patients, no antireflux procedure was added to laparoscopic myotomy. Follow-up was available on 489 patients (92%) with partial fundoplication. The rate of GER diagnosed in pH studies was 7.9% (18 of 228 patients studied), whereas only 5.9% of patients experienced symptoms of GER (29 of 489 patients followed). Of the 69 patients without fundoplication, 47 (68%) were available for follow-up. Forty patients (85%) were studied with pH monitoring postoperatively, with 4 (10%) demonstrating reflux. Six (13%) of 47 patients had symptoms of GER. The difference in the rate of GER diagnosed in postmyotomy pH studies in wrapped and nonwrapped patients was not significant (7.9 vs 10%, respectively; p = 0.75). There was also no significant difference in the incidence of postmyotomy GER symptoms in wrapped and nonwrapped patients (5.9 vs 13% respectively; p = 0.12). CONCLUSIONS: Reflux is not necessarily eliminated with the addition of a partial fundoplication. Based on the published data, recommendations cannot be made regarding the efficacy of adding an antireflux procedure to laparoscopic Heller myotomy. Prospective randomized study is needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.     

Minimally invasive surgery for achalasia: A 10-year experience

Minimally invasive esophagomyotomy for achalasia has become the preferred surgical treatment; the employment of a concomitant fundoplication with the myotomy is controversial. Here we report a retrospective analysis of 53 patients with achalasia treated with laparoscopic Heller myotomy; fundoplication was used in all patients except one, and 48 of the fundoplications were complete (floppy Nissen). There were no deaths or reoperations, and minor complications occurred in three patients. Good-to-excellent long-term results were obtained in 92% of the subjects (median follow-up 3 years). Two cases (4%) of persistent postoperative dysphagia were documented, one of which was treated with dilatation. Postoperative reflux occurred in five patients, four of whom did not receive a complete fundoplication; these patients were well controlled with medical therapy. We suggest that esophageal achalasia may be successfully treated with laparoscopic Heller myotomy and floppy Nissen fundoplication with an acceptable rate of postoperative dysphagia. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21, 2003 (poster presentation).     

Laparoscopic Heller myotomy with Toupet fundoplication: outcomes predictors in 121 consecutive patients

HYPOTHESIS: This study was performed to assess the intermediate-term outcomes after laparoscopic Heller myotomy and posterior Toupet fundoplication in a single-surgeon series with the expectation of identifying patient and disease factors associated with poor outcomes. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Tertiary care teaching hospital with a comprehensive esophageal physiology laboratory. PATIENTS: A total of 121 patients undergoing laparoscopic Heller myotomy with Toupet fundoplication (between December 1, 1996, and December 31, 2004) for achalasia were included. INTERVENTIONS: All patients had preoperative objective documentation of achalasia. A 5- to 6-cm-long myotomy was performed on the distal esophagus. The myotomy incision was extended 2 cm onto the stomach. A partial (270 degrees ) posterior Toupet fundoplication was performed as an antireflux mechanism in all patients. MAIN OUTCOME MEASURES: Data on preoperative and postoperative symptoms, manometry, and 24-hour ambulatory pH were prospectively collected. Symptoms were recorded with a standardized assessment tool. Patients with postoperative dysphagia scores of 2 or greater were considered treatment failure. Logistic regression modeling was performed to identify variables significant for poor outcomes. RESULTS: Preoperatively, 89 patients (73.6%) had severe dysphagia (dysphagia score, 3 or 4) and 32 patients (26.4%) had mild or moderate dysphagia (dysphagia score, 1 or 2). After a median follow-up period of 9 months, 102 patients (84.3%) (P<.001) had excellent relief of dysphagia (dysphagia score, 0 or 1). Eight additional patients (6.6%) demonstrated a significant (25%-75% [P=.01]) improvement in dysphagia scores. Only 11 patients (9.0%) had either no change or worse dysphagia. Postoperatively, all patients with manometry had a normal lower esophageal sphincter pressure (mean +/- SD, 14.7 +/- 6.6 mm Hg; P<.001) and good lower esophageal sphincter relaxation. Odds of failure were greatest for patients with severe preoperative dysphagia, male patients, and patients with classic amotile achalasia. Of the 60 patients having heartburnlike symptoms preoperatively (mean +/- SD score, 2.52 +/- 1.00), 19 (31.7%) continued to have similar symptoms after surgery. Sixteen (33.3%) of the 48 patients having postoperative pH studies demonstrated objective reflux (DeMeester score, >14.7). Five (31.2%) of these patients had symptoms of their reflux. CONCLUSIONS: Dysphagia improves in most patients after laparoscopic Heller myotomy with partial fundoplication. Patients with severe preoperative dysphagia, esophageal dilation, or amotile achalasia may have greater chances of a poor outcome.     

Comparison of thoracoscopic and laparoscopic heller myotomy for achalasia

For more than three decades experts have debated the relative merits of thoracoscopic Heller myotomy (no antireflux procedure) vs. laparoscopic Heller myotomy plus Dor fundoplication for treatment of achalasia. The aim of this study was to compare the results of these two methods with respect to (1) relief of dysphagia, (2) incidence of postoperative gastroesophageal reflux, and (3) hospital course. Sixty patients with esophageal achalasia were operated on between 1991 and 1996. Thirty underwent a thoracoscopic Heller myotomy and 30 had a laparoscopic Heller myotomy with a Dor fundoplication. The two groups were similar with respect to demographic characteristics, clinical findings, and extent of manometric abnormalities. Preoperative pH monitoring showed abnormal reflux in two patients in the laparoscopic group. Average hospital stay was 84 hours for the thoracoscopic group and 42 hours for the laparoscopic group. Excellent (no dysphagia) or good (dysphagia less than once a week) results were obtained in 87% of patients in the thoracoscopic group and in 90% of patients in the laparoscopic group. Postoperative pH monitoring showed abnormal reflux in 6 (60%) of 10 patients in the thoracoscopic group and in 1 (10%) of 10 patients in the laparoscopic group. The two patients in the laparoscopic group who had reflux preoperatively had normal reflux scores postoperatively. Laparoscopic Heller myotomy with Dor fundoplication was found to be superior to thoracoscopic Heller myotomy. Both operations relieved dysphagia, but the laparoscopic approach avoided postoperative reflux and even corrected reflux present preoperatively. In addition, the patients were more comfortable and left the hospital earlier following a laparoscopic myotomy. Whether it is truly possible to perform a Heller myotomy without an antireflux procedure in a way that relieves dysphagia and regularly avoids reflux remains questionable. Presented at the Thirty-Eighth Annual Meeting ofThe Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997 (poster presentation).     

Laparoscopic treatment of recurrent dysphagia following transthoracic myotomy for achalasia

BACKGROUND: The choice of treatment of recurrent dysphagia following transthoracic myotomy is unclear. Often pneumatic dilatation is tried first, followed by esophagectomy in case of failure. We propose laparoscopic Heller myotomy as an alternative treatment for this group of patients. METHODS: Three patients underwent laparoscopic Heller myotomy for the treatment of recurrent dysphagia following transthoracic myotomy. The patients had undergone an average of 7 pneumatic dilatations (range, 2 to 10) prior to referral for surgery, without resolution of their dysphagia. RESULTS: All patients successfully underwent a laparoscopic myotomy on the right side of the esophagus with a Dor fundoplication. Good or excellent results were achieved in all patients. Average followup was 18 months. CONCLUSIONS: Laparoscopic Heller myotomy is a very effective treatment for patients who experience recurrent dysphagia following a transthoracic myotomy.     

Surgical treatment of achalasia: current status and controversies

OBJECTIVE: To review the current management of achalasia, and the controversies regarding the different treatment options. METHODS: A review of the literature was performed. The key words used were esophageal achalasia, Heller myotomy, endoscopic balloon dilatation, laparoscopic Heller myotomy, and fundoplication. RESULTS: Patients who fail medical therapy (e.g. pharmacologic therapy, botulinum toxin, balloon dilatation) should be considered for surgical therapy for the management of achalasia. Currently, numerous surgical procedures exist for the treatment of achalasia (transabdominal cardiomyotomy, thoracoscopic or open transthoracic cardiomyotomy, and laparoscopic Heller myotomy with an antireflux procedure). CONCLUSIONS: Laparoscopic Heller myotomy is generally accepted as the operative procedure of choice for achalasia. However, controversy exists as to whether a concomitant antireflux procedure is necessary, and if so, what type should be performed. Given the deleterious effects of postoperative reflux, and the facility of including an antireflux procedure at the time of the myotomy, there is merit in undertaking an antireflux procedure at the time of the laparoscopic Heller myotomy.