title: Video-assisted surgical management of achalasia of the esophagus.
abstract: OBJECTIVE
  Video-assisted surgical approaches to esophageal achalasia continue to be explored by many surgeons involved in the management of this motor disorder. We report our experience with thoracoscopic and laparoscopic esophagomyotomy to more clearly define the efficacy and safety of these approaches.
  
  
  METHODS
  Over 73 months, 58 patients with achalasia underwent thoracoscopic myotomy (n = 19) alone or laparoscopic myotomy (n = 39) with partial fundoplication (anterior = 15; posterior = 24). Mean age was 47.2 years and average length of symptoms was 60 months. Primary symptoms were as follows: dysphagia, 100%; pulmonary abnormalities, 22%; weight loss; 47%, and pain, 45%. Mean esophageal diameter was 6 cm and tortuosity was present in 16% (9/58) of patients. Prior management consisted of dilation (n = 47), botulinum toxin injection (n = 8), and prior myotomy (n = 1).
  
  
  METHODS
  In the operating room all patients underwent endoscopic examination and evacuation of retained esophageal contents. The esophagomyotomy was extended 4 cm superiorly and inferiorly to 1 cm beyond the lower esophageal sphincter. Thoracoscopic and laparoscopic procedures were completed in all patients without conversion to an open operation. Mean operative time was 183 minutes (+/-58.1) and hospital stay averaged 2.3 days (+/-0.8). There was no operative mortality. The 1 operative complication was a perforation that was identified during the operation and repaired thoracoscopically.
  
  
  RESULTS
  Symptoms improved in 97% of patients. Mean dysphagia scores (range 0-10) decreased from 9.8 +/- 1.6 before the operation to 2.0 +/- 1.5 after the operation (P <.001) at a mean follow-up of 6 months. Postoperative reflux symptoms developed in 5% (1/19) of the thoracoscopy group and 8% (4/39) of the laparoscopy group. Nine patients have persistent or recurrent dysphagia (16%). Seven patients have successfully undergone Savary dilation, and 2 required esophagectomy to manage recalcitrant dysphagia.
  
  
  CONCLUSIONS
  At this intermediate term analysis, video-assisted approaches for management of achalasia are a reasonable alternative to extended medical therapy or open operations.
authors.affiliation: Allegheny University Hospitals, Allegheny General, Pittsburgh, PA 15212-4772, USA.
authors.forename: R J
authors.initials: RJ
authors.lastname: Wiechmann
authors.forename: M K
authors.initials: MK
authors.lastname: Ferguson
authors.forename: K S
authors.initials: KS
authors.lastname: Naunheim
authors.forename: S R
authors.initials: SR
authors.lastname: Hazelrigg
authors.forename: M J
authors.initials: MJ
authors.lastname: Mack
authors.forename: R J
authors.initials: RJ
authors.lastname: Aronoff
authors.forename: R J
authors.initials: RJ
authors.lastname: Weyant
authors.forename: T
authors.initials: T
authors.lastname: Santucci
authors.forename: R
authors.initials: R
authors.lastname: Macherey
authors.forename: R J
authors.initials: RJ
authors.lastname: Landreneau
mesh_terms: D003680:Deglutition Disorders / Q000517:prevention & control; D004931:Esophageal Achalasia / Q000601:surgery*; D004947:Esophagus / Q000601:surgery; D005260:Female; D018662:Fundoplication / Q000379:methods; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D020775:Thoracic Surgery, Video-Assisted