title: Laparoscopic cardiomyotomy for achalasia after failed balloon dilatation.
abstract: BACKGROUND
  This study was designed to determine the feasibility and outcome of laparoscopic cardiomyotomy in patients with achalasia who have persistent or recurrent dysphagia following balloon dilatation.
  
  
  METHODS
  Ten patients who had undergone a minimum of two (range, two to seven) previous balloon dilatations underwent a single anterior cardiomyotomy extending from the gastroesophageal junction onto the esophagus proximally for 6 cm. Four patients had a Toupet fundoplication. Patients were analyzed using pre- and postoperative DeMeester symptom scores for dysphagia, regurgitation, and heartburn (0 = none-3 = maximal) and esophageal manometry.
  
  
  RESULTS
  Mean operating time was 90 min. Periesophagitis was noted in some patients but was rarely troublesome. Submucosal fibrosis was present in all patients and made dissection more difficult particularly around the cardioesophageal junction. As a result, three patients had mucosal perforations that required repair by laparoscopic suturing. There were no subsequent postoperative complications. Median (IQR) postoperative stay was 3 (2-4) days. At 3-month reassessment, there was a reduction in the median dysphagia score from 3 to 0, and also in the regurgitation score from 3 to 0. At last follow-up (median, 22 months), one patient had developed recurrent dysphagia (grade 2), which improved with dilatation. Overall success of the laparoscopic procedure was therefore 90%. Only one patient developed new symptoms of reflux (mild, grade 1) after surgery.
  
  
  CONCLUSIONS
  Laparoscopic cardiomyotomy provides good control of the symptoms of dysphagia and regurgitation without the morbidity of a laparotomy or thoracotomy incision. Although technically more difficult, the technique can be extended to those who have had previous balloon dilatation with complication and success rates similar to published results in patients who have not undergone previous dilatation.
authors.affiliation: Surgical Gastroenterology, Gastrointestinal Clinic, E23, Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa.
authors.forename: I J
authors.initials: IJ
authors.lastname: Beckingham
authors.forename: M
authors.initials: M
authors.lastname: Callanan
authors.forename: J A
authors.initials: JA
authors.lastname: Louw
authors.forename: P C
authors.initials: PC
authors.lastname: Bornman
mesh_terms: D000328:Adult; D002404:Catheterization / Q000009:adverse effects*; D003680:Deglutition Disorders / Q000209:etiology / Q000601:surgery; D004931:Esophageal Achalasia / Q000150:complications / Q000601:surgery*; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D012720:Severity of Illness Index; D016896:Treatment Outcome