Results of short- and long-segment cardioesophageal myotomy for achalasia

Abstract

Background/Aim:We report the results of a short- and long-segment cardiomyotomy for relief of the symptoms of achalasia.Patients and Methods:From 1997 to 2009, 41 patients (22 men, 19 women) with achalasia underwent cardiomyotomy. Patients were divided into 2 groups [short-segment group (SSG) and long-segment group (LSG)]. SSG include 22 patients with laparotomy and 8-cm short-segment myotomy and Dor fundoplication. LSG includes 19 patients with thoracotomy and 12-cm long-segment myotomy and Belsey partial fundoplication.Results:Median follow up was 48 months (range: 12–70 months). Postoperative dysphagia improved in 20 patients in SSG and in 17 patients in LSG (P < 0.001). Slow emptying sensation improved in 19 patients in SSG and in 16 patients in LSG postoperatively (P < 0.001). Heartburn was present in 2 patients in SSG and 3 patients in LSG postoperatively (P = 0.179). Radiologically, barium stasis decreased significantly from 88% to 25% in SSG and from 85% to 30% in LSG. The lower esophageal sphincter (LES) gradient decreased from 32 to 10 mmHg in SSG and from 34 to 14 mmHg in LSG (P < 0.001).Conclusions:Short-segment cardiomyotomy reduces the LES gradient and relieves obstructive symptoms.

Impact of the Myotomy Extent on Gastric Side on Surgical Outcome After Heller’s Cardiomotomy for Achalasia

“…16 The gastric myotomy is not an easy step of the operation as the muscle layers are ill defined and the submucosal plane is poorly cleared, submucosal gastric vessels are easily divided, bleed and masking the field by bleeding, and the mucosa is delicate and thin. [16][17][18][19][20] Incidence of perforation of the esophageal mucosa was higher in the group with myotomy <1.5 cm, whereas incidence of perforation of the gastric mucosa was higher in the group with myotomy 1.5 to 2.5 cm. However, this difference was statistically insignificant.…”

“…Some authors tried to minimize it in order to safeguard part of the lower esophageal sphincter expecting that protect against GERD. [17][18][19][20] Other authors adopted more extension of the myotomy ( > 2 to 3 cm) on the gastric side to achieve much better ablation to the LES and achieve better elimination of dysphagia. 4,21,22 Oelschlager et al 14 reported that extended myotomy on the gastric side of 3 cm more efficiently divides the LES than 1.5 cm myotomy, thus improving the surgical outcomes of LHM in terms of improvement of dysphagia without development of abnormal GERD provided that a Toupet fundoplication is performed.…”

“…The ideal length of myotomy on the gastric side below the GEJ continues to be a matter debate. [13][14][15][16][17][18][19] The aim of this retrospective study was to compare the impact of the extent of myotomy on the gastric side on the outcome of laparoscopic Heller cardiomyotomy for patients with achalasia.…”