title: The laparoscopic approach with antireflux surgery is superior to the thoracoscopic approach for the treatment of esophageal achalasia. Experience of a single surgical unit.
abstract: BACKGROUND
  Since its first description in the early 1990s, minimally invasive Heller myotomy has become the treatment of choice for esophageal achalasia. We report the experience of a single unit with thoracoscopic Heller myotomy (THM) and laparoscopic Heller myotomy (LHM) and we analyze the short- and long-term surgical outcomes in patients treated by each of the two approaches.
  
  
  METHODS
  We evaluated retrospectively 33 patients who underwent surgical treatment for achalasia. Sixteen patients underwent THM without an antireflux procedure, and 17 patients underwent LHM and partial anterior fundoplication (n = 10) or closure of the angle of His (n = 7).
  
  
  RESULTS
  Mean operative time was significantly shorter for LHM than for THM (150 vs 222 min, respectively) (p = 0.0001). Mean hospital stay was significantly shorter after LHM than after THM (2.0 +/- 1.0 vs 5.1 +/- 2.2 days, respectively) (p = 0.0001). Six of 16 patients (37.5%) in the THM group experienced persistent or recurrent dysphagia compared to one of 17 patients (5.8%) in the LHM group (p = 0.04). Heartburn developed in five patients (31.2%) after THM and in one patient (5.8%) after LHM (p = 0.07). Regurgitation developed in four patients (25%) after THM and in one patient (5.8%) after LHM (p = 0.149). Lower esophageal sphincter (LES) basal pressure decreased significantly from 30.1 +/- 5.07 to 15.3 +/- 2.1 after THM and from 32.1 +/- 5.9 to 10.5 +/- 1.7 after LHM (p = 0.0001). Mean esophageal diameter was significantly reduced after LHM compared to THM (from 54.5 +/- 5.7 mm to 27.1 +/- 3.3 mm vs 50.8 +/- 7.6 mm to 37.2 +/- 6.9 mm, respectively) (p = 0.0001).
  
  
  CONCLUSIONS
  In our experience, LHM is associated with a shorter operative time and a shorter hospital stay, and it is superior to THM in relieving dysphagia. LHM with partial anterior fundoplication should be considered the treatment of choice for achalasia.
authors.affiliation: Department of Surgery Pietro Valdoni, University La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy. giovanni.ramacciato@uniromal.it
authors.forename: G
authors.initials: G
authors.lastname: Ramacciato
authors.forename: P
authors.initials: P
authors.lastname: Mercantini
authors.forename: P M
authors.initials: PM
authors.lastname: Amodio
authors.forename: N
authors.initials: N
authors.lastname: Corigliano
authors.forename: M
authors.initials: M
authors.lastname: Barreca
authors.forename: F
authors.initials: F
authors.lastname: Stipa
authors.forename: V
authors.initials: V
authors.lastname: Ziparo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D004931:Esophageal Achalasia / Q000601:surgery*; D005260:Female; D018662:Fundoplication / Q000379:methods; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006356:Heartburn / Q000209:etiology; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000209:etiology; D012008:Recurrence; D012189:Retrospective Studies; D013906:Thoracoscopy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome