Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures.
BACKGROUND
In the treatment of achalasia, surgery has been traditionally reserved for patients with residual dysphagia after pneumatic dilatation. The results of laparoscopic Heller myotomy have proven to be so good, however, that most experts now consider surgery the primary treatment.


OBJECTIVE
The outcome of laparoscopic myotomy and fundoplication for achalasia is dictated by technical factors.


METHODS
University hospital tertiary care center.


METHODS
Retrospective study.


METHODS
One hundred two patients with esophageal achalasia underwent laparoscopic Heller myotomy and Dor fundoplication. Fifty-seven patients had been previously treated by pneumatic dilatation or botulinum toxin. The design of the operation involved a 7-cm myotomy, which extended 1.5 cm onto the gastric wall, and a Dor fundoplication. Esophagrams, esophageal manometric findings, and video records of the procedure were analyzed to determine the technical factors that contributed to the clinical success or failure of the operation.


METHODS
Swallowing status.


RESULTS
In 91 (89%) of the 102 patients, good or excellent results were obtained after the first operation. A second operation was performed in 5 patients to either lengthen the myotomy (3 patients) or take down the fundoplication (2 patients). Dysphagia resolved in 4 of these patients. The remaining 6 patients were treated by pneumatic dilatation, but dysphagia improved in only 1. At the conclusion of treatment, excellent or good results had been obtained in 96 (94%) of the 102 patients.


CONCLUSIONS
These data show that a Heller myotomy was unsuccessful in patients with an esophageal stricture; a short myotomy and a constricting Dor fundoplication were the avoidable causes of residual dysphagia; a second operation, but not pneumatic dilatation, was able to correct most failures; and that the identified technical flaws were eliminated from the last half of the patients in the series.
Patti
M G
MG
Department of Surgery, University of California, 533 Parnassus Ave, Room U-122, San Francisco, CA 94143-0788, USA. pattim@surgery.ucsf.edu
Molena
D
D
Fisichella
P M
PM
Whang
K
K
Yamada
H
H
Perretta
S
S
Way
L W
LW
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D003679:Deglutition; D013505:Digestive System Surgical Procedures / Q000379:methods; D004931:Esophageal Achalasia / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D018662:Fundoplication / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011859:Radiography; D012189:Retrospective Studies; D016896:Treatment Outcome