Improved outcome after extended gastric myotomy for achalasia.
OBJECTIVE
There is general agreement that a Heller myotomy should extend 6 to 7 cm above the gastroesophageal junction. Results of most previous studies have recommended that the myotomy extend 1 to 1.5 cm below the gastroesophageal junction. We speculated that the effectiveness of the operation could be improved if a longer, 3-cm myotomy was carried out below the gastroesophageal junction, as it would more completely obliterate the lower esophageal sphincter. We, therefore, changed our technique in 1998. Concurrently, we converted from a Dor fundoplication to a Toupet fundoplication. This study analyzes the results of our new strategy.


METHODS
A case series using a prospectively maintained database.


METHODS
Tertiary referral center.


METHODS
One hundred ten consecutive patients with achalasia undergoing laparoscopic Heller myotomy.


METHODS
We analyzed the course of 52 patients treated with a standard laparoscopic esophagogastric myotomy (1.5 cm in the stomach) and a Dor fundoplication between September 1, 1994, and August 31, 1998, and 58 treated with an extended gastric myotomy (3 cm below the gastroesophageal junction) and a Toupet fundoplication between September 1, 1998, and August 31, 2001.


METHODS
Esophageal function testing (esophageal manometry and 24-hour pH monitoring), symptom questionnaire (frequency and severity), and postoperative interventions required.


RESULTS
Postoperatively the lower esophageal sphincter pressure was significantly lower after extended gastric myotomy and a Toupet fundoplication vs standard myotomy and a Dor fundoplication (9.5 vs 15.8 mm Hg). Dysphagia was both less frequent (1.2 vs 2.1) and less severe (visual analog scale, 3.2 vs 5.3) after extended gastric myotomy and Toupet fundoplication. In the standard laparoscopic esophagogastric myotomy and a Dor fundoplication group, 9 patients (17%) had recurrent, severe dysphagia, which was treated by dilation in 5 patients and by reoperation in 4 patients. In the extended gastric myotomy and Toupet fundoplication group, 2 patients (3%) developed recurrent dysphagia that resolved with dilatation. There were no reoperations in the extended gastric myotomy and Toupet fundoplication group. No difference was noted in the frequency of heartburn (1.3 vs 1.7), regurgitation (0.3 vs 0.8), and chest pain (0.3 vs 0.6), nor was there a difference between the 2 groups in proximal (1.7% vs 2.3%) and distal (6.0% vs 5.9%) esophageal acid exposure.


CONCLUSIONS
An extended gastric myotomy (3 cm) more effectively disrupts the lower esophageal sphincter, thus improving the results of surgical therapy for achalasia for dysphagia without increasing the rate of abnormal gastroesophageal reflux provided that a Toupet fundoplication is added.
Swallowing Center and Department of Surgery, University of Washington, Seattle 98195, USA. brant@u.washington.edu
Brant K
BK
Oelschlager
Lily
L
Chang
Carlos A
CA
Pellegrini
D003680:Deglutition Disorders / Q000601:surgery; D004106:Dilatation; D004931:Esophageal Achalasia / Q000601:surgery*; D018662:Fundoplication / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D008365:Manometry; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome