Long-term clinical results of thoracoscopic Heller''s myotomy in the treatment of achalasia

OBJECTIVE: The aim of this study is to review the immediate and long-term results of video-imaged thoracoscopic Heller's myotomy (THM). METHODS: All patients undergoing THM by a single surgeon at one institution were analysed. Follow-up was conducted using a structured questionnaire and oesophageal manometry and/or 24h pH monitoring were undertaken when clinically indicated. RESULTS: Fifty-six consecutive patients (32 males, 24 females, mean age 45+/-18.7 years) suffering from grade 4 dysphagia underwent THM between January 1992 and March 2006. Preoperative mean lower oesophageal sphincter (LOS) pressure was 38.4+/-10.6 mmHg. Eighteen patients (32.1%) had undergone previous pneumatic dilatations. There were no hospital deaths. Oesophageal perforation occurred in two patients; one repaired thoracoscopically and one at thoracotomy. Mean hospital stay was 4+/-1.37 days. At mean follow-up of 5.9+/-4.66 years, freedom from any reintervention was 87% (49/56). Twenty-nine patients (52%) were asymptomatic. In patients with residual or recurrent symptoms (n=27), their severity was significantly reduced from the preoperative period (dysphagia score 1.37+/-0.77 vs 4.00+/-0; p<0.001). Seven patients (12.5%) with troublesome residual or recurrent grade 3-4 dysphagia underwent repeat oesophageal manometric study, showing a mean reduction in LOS pressure from their baseline values of 46.8+/-6.1-30.0+/-5.4 mmHg (p<0.001). Of these patients, three patients with grade 4 dysphagia were reoperated: one open Heller's myotomy and two by cardia resection. Eleven patients complained of troublesome postoperative heartburn; distal oesophageal acid exposure was shown to be abnormal in nine patients (16.9%) and all were successfully managed with medical therapy. CONCLUSION: The results of thoracoscopic treatment for achalasia are at least equivalent to historical outcomes obtained with open surgery but the patient is spared major thoracotomy or the acid reflux associated with a laparoscopic approach.