No abstract

Background In the last decade of the past century, primary Laparoscopic Heller-Dor (LHD) for Achalasia progressively became the procedure of choice in the new millennium. The aim of this study was to assess the long-term outcome of LHD to treat Achalasia at a single high-volume institution during the past 25 years. Methods 1000 patients underwent LHD from 1992-2017 by 6 staff surgeons alternatively. Patients who had already been treated with surgical or endoscopic myotomy were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium-swallow, endoscopy, manometry were performed, before and after surgery while, 24-hour pH monitoring were performed 6 months after surgery. Results LHD was the primary treatment for 1000 patients (M:F=536:464); the median age was 46 (IQR 36-54), 183 (18.3%) had a history of endoscopic treatments (pneumatic dilation or botox injections, or both). The surgical procedure was completed laparoscopically in all but 7 patients (0.7%) and there was one perioperative death for heart attack. There were 25 perforations (2.5%): 22 were recognized and repaired during the operation, 3 were detected by postoperative contrast swallow. The outcome was positive in 902 patients (90.2%). In patients who had a previous treatment the failures were 25/183 (13.7%) while in the primary treatment group the failures were 73/817 (8.9%) (p=0.055). All the 98 patients whose LHD failed subsequently underwent one or more endoscopic pneumatic dilations, which ameliorated their recurrent symptoms in all but 11 patients (10 of whom required reoperation). The overall success rate of the combination of LHD and endoscopic dilations (where necessary) was 98.4%. At univariate analysis, manometric pattern (p=0.001), sigmoid megaesophagus (p=0.003) and a chest pain score (p=0.002) were the only factors predictive of a positive final results. At multivariate analysis, these three factors were independently associated to good outcome. Postoperative 24-hour pH-monitoring was abnormal in 50/590 patients (8.5%) Two patients developed an esophageal cancer during the follow-up time. Conclusions In a university tertiary referral center LHD can durably relieve achalasia symptoms. Preoperative manometric pattern, a presence of a sigmoid esophagus and the chest pain score represent the strongest predictor of outcome.