A Review of 74 Patients With Oesophageal Achalasia: The Results of Hellers Cardiomyotomy, With and Without Nissen Fundoplication

Abstract

A survey is presented of 74 patients with achalasia of the oesophagus treated surgically at the Royal Prince Alfred Hospital, Sydney, Australia. This survey spans a 27‐year period. Thirty‐nine patients underwent Heller's operation, 23 (58.9%) had excellent results six months after operation, and 17 (43.5%) still had excellent results more than two years after operation. This group had a high recurrence of symptoms due to oesophageal reflux (30.8%) and the development of strictures (20.5%) at the lower end of the oesophagus. Thirty‐five patients underwent Heller's operation together with Nissen fundoplication. Thirty‐two patients (91.4%) in this group had excellent results six months after operation, and 30 of these patients (85.7%) still had excellent results more than two years after operation. These results suggest that symptoms of oesophageal reflux and subsequent oesophageal stricture following Heller's operation for achalasia can be considerably reduced, if not prevented, by Nissen fundoplication – a relux‐preventing procedure.

A Controversy That Has Been Tough to Swallow: Is the Treatment of Achalasia Now Digested?

“…In 1918, the Dutch surgeon Zaaijer85 described a modification of Heller's original technique to a single, anterior cardiomyotomy that has remained the myotomy of choice until now. Based on Heller’s original idea, many surgeons performed the distal esophageal and LES myotomy through a left thoracotomy86 as a way to perform an appropriate myotomy while attempting to preserve the natural anatomical antireflux components of the gastroesophageal junction, such as the His angle and the phrenoesophageal membrane, thereby possibly preventing postoperative GER. Both the transabdominal and transthoracic techniques have been used since.…”

“…A 360° Nissen fundoplication has been used in selected series;98,102,103 however, a Nissen fundoplication may hinder esophageal clearance, resulting in progressive postoperative dilatation of the aperistaltic esophagus and recurrent dysphagia. Although a few centers with significant experience in esophageal surgery still advocate a Nissen fundoplication after myotomy,103 most do not recommend it due to reported reoperation rates as high as 29% 10,32,86,104–108…”

Assessment of Gastroesophageal Reflux following Heller’s Myotomy Associated with a 270° Posterior Partial Fundoplication

“…In con trast, other authors [2-4, 6, 9-12] report higher reflux percentages, which on occasion affect 50% of the cases [23]. In some series [9] there is a high rate of reflux stric ture.…”

“…In order to avoid this burdensome complication, a second group of authors [2,3,9,[11][12][13][14][15][16][17][18][19][20] prefer to com plete Heller's myotomy with an antireflux mechanism. In this respect, the 360° fundoplication has proved to be the most efficient treatment [24], For this reason some surgeons [9,[14][15][16] associate it systematically with myo tomy, reporting in their series a minimum percentage of postoperative reflux, which was evaluated using clinical, radiological and isotopic studies.…”

“…In this respect, the 360° fundoplication has proved to be the most efficient treatment [24], For this reason some surgeons [9,[14][15][16] associate it systematically with myo tomy, reporting in their series a minimum percentage of postoperative reflux, which was evaluated using clinical, radiological and isotopic studies. However, as certain authors point out [25][26][27], this neovalve may cause esophageal obstruction when performed on an aperistaltic esophagus.…”