Long-term outcome of Heller myotomy in achalasic sigmoid esophagus

OBJECTIVE: We sought to assess the long-term outcome of Heller myotomy and anterior fundoplication in patients with achalasic sigmoid esophagus. METHODS: Fourteen patients with achalasia and sigmoid esophagus (median age, 42.5 years) operated on by the same surgeon through a laparotomy (n = 8) or laparoscopic approach (n = 6) between 1985 and 2000 were evaluated. According to a 4-grade classification (1, no symptoms; 4, persistent symptoms), both dysphagia and regurgitation had a median score of 4.0. Five patients complained of respiratory symptoms. Six patients had undergone previous pneumatic dilation. Preoperative and postoperative workup included an esophagogram, esophagoscopy, manometry, and health-related quality-of-life assessment with the Short-Form 36-item questionnaire. RESULTS: Median follow-up was 85 months. At 24 months, esophageal width decreased by 10 mm (P =.003), and the change correlated inversely with the age of the patients (R = -0.61; P =.02). Lower esophageal sphincter pressure decreased by 17 mm Hg (P =.001), and both dysphagia and regurgitation scores decreased to 1.0 (P <.003). Comparison with the results of 37 patients with earlier-stage achalasia showed no difference in changes of esophageal width, lower esophageal sphincter pressure, dysphagia score, and regurgitation score. Quality-of-life Short-Form 36-item questionnaire domains, including general health, social functioning, and vitality, improved significantly. Overall results were classified as excellent or good in 10 patients and as satisfactory and unsatisfactory in 2 patients each. No patient required esophagectomy or had esophageal carcinoma. CONCLUSIONS: In this study Heller myotomy proved effective in improving subjective, objective, and quality-of-life outcome measures in patients with achalasic sigmoid esophagus and should be considered as the first-choice treatment for this severe condition.