Laparoscopic Heller myotomy with Toupet fundoplication: outcomes predictors in 121 consecutive patients.
OBJECTIVE
This study was performed to assess the intermediate-term outcomes after laparoscopic Heller myotomy and posterior Toupet fundoplication in a single-surgeon series with the expectation of identifying patient and disease factors associated with poor outcomes.


METHODS
Retrospective analysis of prospectively collected data.


METHODS
Tertiary care teaching hospital with a comprehensive esophageal physiology laboratory.


METHODS
A total of 121 patients undergoing laparoscopic Heller myotomy with Toupet fundoplication (between December 1, 1996, and December 31, 2004) for achalasia were included.


METHODS
All patients had preoperative objective documentation of achalasia. A 5- to 6-cm-long myotomy was performed on the distal esophagus. The myotomy incision was extended 2 cm onto the stomach. A partial (270 degrees ) posterior Toupet fundoplication was performed as an antireflux mechanism in all patients.


METHODS
Data on preoperative and postoperative symptoms, manometry, and 24-hour ambulatory pH were prospectively collected. Symptoms were recorded with a standardized assessment tool. Patients with postoperative dysphagia scores of 2 or greater were considered treatment failure. Logistic regression modeling was performed to identify variables significant for poor outcomes.


RESULTS
Preoperatively, 89 patients (73.6%) had severe dysphagia (dysphagia score, 3 or 4) and 32 patients (26.4%) had mild or moderate dysphagia (dysphagia score, 1 or 2). After a median follow-up period of 9 months, 102 patients (84.3%) (P<.001) had excellent relief of dysphagia (dysphagia score, 0 or 1). Eight additional patients (6.6%) demonstrated a significant (25%-75% [P=.01]) improvement in dysphagia scores. Only 11 patients (9.0%) had either no change or worse dysphagia. Postoperatively, all patients with manometry had a normal lower esophageal sphincter pressure (mean +/- SD, 14.7 +/- 6.6 mm Hg; P<.001) and good lower esophageal sphincter relaxation. Odds of failure were greatest for patients with severe preoperative dysphagia, male patients, and patients with classic amotile achalasia. Of the 60 patients having heartburnlike symptoms preoperatively (mean +/- SD score, 2.52 +/- 1.00), 19 (31.7%) continued to have similar symptoms after surgery. Sixteen (33.3%) of the 48 patients having postoperative pH studies demonstrated objective reflux (DeMeester score, >14.7). Five (31.2%) of these patients had symptoms of their reflux.


CONCLUSIONS
Dysphagia improves in most patients after laparoscopic Heller myotomy with partial fundoplication. Patients with severe preoperative dysphagia, esophageal dilation, or amotile achalasia may have greater chances of a poor outcome.
Khajanchee
Yashodhan S
YS
Minimally Invasive Surgery Department, Legacy Health System, Portland, Ore., USA.
Kanneganti
Shalini
S
Leatherwood
Amy E B
AE
Hansen
Paul D
PD
Swanström
Lee L
LL
D000328:Adult; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D004931:Esophageal Achalasia / Q000601:surgery*; D005260:Female; D018662:Fundoplication; D005764:Gastroesophageal Reflux / Q000517:prevention & control; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome