Esophagomyotomy for Achalasia of the Esophagus

Abstract

Currently conflicting opinions regarding the efficacy of esophagomyotomy alone as the preferred treatment for esophageal achalasia prompted this review of the results in 69 patients treated at the Lahey Clinic between January 1970 and January 1980. Preoperative symptoms were alleviated completely or partially in 92% of the 60 patients operated on more than 12 months ago and who were available for follow-up study (average: 42 months). Excellent or good results were achieved in 84% of patients. Only one of the poor results was due to reflux esophagitis. It is concluded that an antireflux procedure is not routinely necessary to prevent postoperative reflux esophagitis if the technique of esophagomyotomy follows certain specific guidelines.

Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia

“…When myotomy is performed via thoracotomy, most surgeons extend it just across the GEJ, with the hope of leaving a sufficient inherent antireflux barrier to avoid postoperative reflux [11]. In fact, when we started applying minimally invasive approaches to the treatment of achalasia in 1991 via the thoracoscopic approach, we used a limited gastric myotomy (0.5 cm) [12].…”

Pneumatic Balloon Dilation Therapy Is as Effective as Esophagomyotomy for Achalasia

“…Our excellent outcome in the PBD group may be the result of using newer Rigiflex balloons and a better technique of ballooning (7-10 psi and at least a 5 min dilation are more forceful and longer than many other centers). The good results from PBD were criticized by several studies, which cited a suboptimal dilation technique and a greater baseline of disease severity among patients in the dilation group [13,30]. We emphasize that duration of dilation (at least 5 min), strength of dilation (7-10 psi), and careful patient selection are important factors in achieving excellent results.…”

“…The standard ''open'' myotomy can be performed using either an abdominal or, more commonly, a thoracic approach [13,14]. Pneumatic dilation is often the first line of nonsurgical treatment offered to patients with achalasia, with a success rate ranging from 70% to 90% with 0-7% risk of perforation [15][16][17][18][19].…”

Evidence for Reflux in Patients with Achalasia

“…The incidence of gastroesophageal reflux following dilatation is low, but does exist, and is the major long-term complication following myotomy which includes stricture [16]. It has been shown in one series to increase with time [10], and debate currently exists as to whether an antireflux procedure should be performed in addition to the myotomy [3,8], A variety of antireflux procedures have been used to diminish the likelihood of reflux after myotomy [3,7,9], but little has been documented preoperatively as to the propensity of patients to reflux postoperatively [2,13]. It is uncertain to what degree gastroesophageal reflux occurs in achala sia, because physiologic assessment of esophageal pH exposure has not been done.…”