[Long-term results for Heller-myotomy with anterior semifundoplication in achalasia].
BACKGROUND
The positive success rate of cardiomyotomy in the treatment of achalasia has recently - especially in young patients - resulted in a primary operative treatment concept. Few studies of long-term effects of myotomy concerning the removal of dysphagia and the development of gastroesophageal reflux have been submitted.


METHODS
In the period between September 1985 and March 2003, an open, transabdominal Heller-myotomy combined with a Dor-semifundoplication was carried out in 93 patients with achalasia. 77 patients were followed for more than 6 months postoperatively (median follow-up: 70 months). The procedure was prospectively observed, and patients were questioned concerning their clinical symptoms by means of structured interviews. X-ray examinations of the esophagus were pre- and postoperatively available of 47 patients, manometrical findings before and after myotomy of 26 patients.


RESULTS
The pre-operatively existing symptoms dysphagia, regurgitation, retrosternal pain and weight-loss could be improved by myotomy in 97 % of the patients with good to excellent long-term results. Post-operatively, a significant reduction of the median maximum diameter of the esophagus of 50 mm to 30 mm was evident (p < 0.001), whereas the diameter of the cardia increased from 3 mm to 10 mm (p < 0.001). The pre-operative resting pressure of the lower esophageal sphincter (LES) of 29.3 mmHg was reduced to 7.9 mmHg (p < 0.001). Patients suffering from reflux esophagitis showed a significant lower resting pressure of the LES (4 mmHg) in comparison with patients without reflux esophagitis (8.5 mmHg) after myotomy (p=0.045). The clinical long-term results of patients with preceding pneumatic dilation did not differ significantly from those with primary myotomy.


CONCLUSIONS
Conventional Heller-myotomy with anterior semifundoplication can in the long run remove the symptoms existent in achalasia with high efficiency. If the decrease of the post-operative resting pressure of the LES is too intense (< 5 mmHg), a possible gastroesophageal reflux has to be taken into account. The results of open cardiomyotomy have to be regarded as standard for assessing the minimal-invasive procedure.
Klinik für Allgemein- und Abdominalchirurgie, Johannes Gutenberg-Universität Mainz. gockel@ach.klinik.uni-mainz.de
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Gockel
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Kneist
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Eckardt
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T
Junginger
D000293:Adolescent; D000328:Adult; D000368:Aged; D002299:Cardia / Q000601:surgery*; D003627:Data Interpretation, Statistical; D004931:Esophageal Achalasia / Q000601:surgery*; D004942:Esophagitis, Peptic / Q000175:diagnosis; D004947:Esophagus / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000379:methods*; D006801:Humans; D008297:Male; D008365:Manometry; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D011183:Postoperative Complications; D011446:Prospective Studies; D011795:Surveys and Questionnaires; D013997:Time Factors