Laparoscopic Heller Myotomy Improves Esophageal Emptying and the Symptoms of Achalasia

Abstract

Hypothesis: Laparoscopic Heller esophageal myotomy improves esophageal clearance and symptoms of achalasia in the early and late postoperative periods. Design: We followed up 98 consecutive patients attending a referral center between February 1, 1994, and July 1, 2000, who underwent laparoscopic myotomy. Operative time, complications, and length of stay were recorded. Postoperative outcomes were assessed using Van Trappen symptom scores (1 indicates no symptoms; 2, symptoms occurring less than once a week; 3, symptoms occurring more than once weekly; and 4, persistent symptoms) and scintigraphic esophageal transit studies. Results: Of 98 patients, 91 underwent anterior fundoplication. There were no open conversions and 1 mucosal perforation, which was closed laparoscopically without complications. Mean operative times and postoperative days were 3.2 hours and 4.3 days, respectively, in the first 32 patients and 1.7 hours and 2.3 days, respectively, in the last 32 patients (PϽ.001). Postoperative complications included pneumothorax (4% of patients), atelectasis (5%), and delayed gastric emptying (1%). Seventy-five percent of patients gained weight after surgery. At longest followup, 91% of patients were satisfied with the outcome of the procedure. Mean Van Trappen scores for dysphagia improved from 4.0 in the preoperative period to 1.2 at early and late follow-up (PϽ.001). Fluid retention at 10 minutes in the upright position was 47% in the preoperative period and improved at early and late follow-up to 21% and 20%, respectively (PϽ.001). Conclusions: Laparoscopic Heller myotomy can safely reverse the symptoms of achalasia and improve esophageal transit. These benefits, realized during the early postoperative period, were maintained at longest follow-up.

Laparoscopic management of achalasia cardia

“…Oesophageal perforation was the most common complication of this procedure which was encountered in most of the other studies like Yamamura MS et al, Peclivanides G et al, Finely RJ et al, Decker G et al and Chuah S et al 9,11,14,14,18 In all the above studies including present study oesophageal perforation was sutured intraoperatively without any major complication.…”

“…Finley RJ et al, showed only 2 patients (3.50%) developed new heart burn and reflux oesophagitis postsurgery on regular follow up 14 Sharp KW et al, showed that only mild degree of relax oesophagitis developed in 14 patients out of 100 patients who underwent laparoscopic Heller's myotomy. 12 Zaninotto G et al, showed recurrence of dysphasia in 10% of patients with mean follow up of 8 months.…”

Review article: the management of achalasia – a comparison of different treatment modalities1

“…63 This technique is associated with greater decreases in dysphagia, shorter hospital stays, lower risks of post-operative GER, improved oesophageal emptying and low complications. 38,[64][65][66] Large series and reviews have demonstrated 90% overall symptomatic improvement following the surgery 18,38 with >80% remaining dysphagia free at 5 years.…”

Minimally invasive surgery for esophageal achalasia

“…Studies including large number of patients have shown that an extramucosal myotomy of the esophagus and cardia combined with an anterior fundoplication can be performed safely and effectively through laparoscopy, with clinical and functional results similar to that obtained with the open transabdominal approach and relief of dysphagia in more than 90% of patients [17][18][19][20][21][22] . Although previous endoscopic treatments, such as balloon dilatation or intrasphincteric botulinum toxin injection, may cause submucosal scarring at the esophagogastric junction resulting in a more difficult surgical procedure and an increased operative morbility, no statistically significant differences as far as concern the clinical outcome have been reported [15] .…”