title: Minimally invasive surgery for achalasia: an 8-year experience with 168 patients.
abstract: BACKGROUND
  Seven years ago, the authors reported on the feasibility and short-term results of minimally invasive surgical methods to treat esophageal achalasia. In this report, they describe the evolution of the surgical technique and the clinical results in a large group of patients with long follow-up.
  
  
  METHODS
  Between January 1991 and October 1998, 168 patients (96 men, 72 women; mean age 45 years, median duration of symptoms 48 months), who fulfilled the clinical, radiographic, endoscopic, and manometric criteria for a diagnosis of achalasia, underwent esophagomyotomy by minimally invasive techniques. Forty-eight patients had marked esophageal dilatation (diameter >6.0 cm). Thirty-five patients had a left thoracoscopic myotomy, and 133 patients had a laparoscopic myotomy plus a partial fundoplication. Follow-up to October 1998 was complete in 145 patients (86%).
  
  
  RESULTS
  Median hospital stay was 72 hours for the thoracoscopic group and 48 hours for the laparoscopic group. Eight patients required a second operation for recurrent or persistent dysphagia, and two patients required an esophagectomy. There were no deaths. Good or excellent relief of dysphagia was obtained in 90% of patients (85% after thoracoscopic and 93% after laparoscopic myotomy). Gastroesophageal reflux developed in 60% of tested patients after thoracoscopic myotomy and in 17% after laparoscopic myotomy plus fundoplication. Laparoscopic myotomy plus fundoplication corrected reflux present before surgery in five of seven patients. Patients with a dilated esophagus had excellent relief of dysphagia after laparoscopic myotomy; none required an esophagectomy.
  
  
  CONCLUSIONS
  Minimally invasive techniques provided effective and long-lasting relief of dysphagia in patients with achalasia. The authors prefer the laparoscopic approach for three reasons: it more effectively relieved dysphagia, it was associated with a shorter hospital stay, and it was associated with less postoperative reflux. Laparoscopic Heller myotomy and partial fundoplication should be considered the primary treatment for esophageal achalasia.
authors.affiliation: Department of Surgery at the University of California, San Francisco 94143-0788, USA.
authors.forename: M G
authors.initials: MG
authors.lastname: Patti
authors.forename: C A
authors.initials: CA
authors.lastname: Pellegrini
authors.forename: S
authors.initials: S
authors.lastname: Horgan
authors.forename: M
authors.initials: M
authors.lastname: Arcerito
authors.forename: P
authors.initials: P
authors.lastname: Omelanczuk
authors.forename: A
authors.initials: A
authors.lastname: Tamburini
authors.forename: U
authors.initials: U
authors.lastname: Diener
authors.forename: T R
authors.initials: TR
authors.lastname: Eubanks
authors.forename: L W
authors.initials: LW
authors.lastname: Way
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D004931:Esophageal Achalasia / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D013997:Time Factors; D017211:Treatment Failure; D016896:Treatment Outcome