[Surgical treatment of esophageal achalasia. Personal trend].
OBJECTIVE
Achalasia of the esophagus involves the entire esophagus from the upper esophageal sphincter (UES) to the lower esophageal sphincter (LES) together with a wide spectrum of physiopathological and clinical variations. Therefore, the need to know exactly the different involvement either of the body of the esophagus or the LES for each case is underlined. In our experience, the cineradiology is the only technique that allows a complete morphologic and functional study of the disease. It is through cinesophagography that we can exactly establish the extension of myotomy according to the physiopathological aspects that will suggest the most accurate surgical treatment. It is our opinion to perform a short myotomy, to the gastroesophageal junction, through an abdominal approach in grade II and III achalasia, when the most important physiopathological aspects involve only the LES area (hypertonic LES or dischalasia). We extend the myotomy from the LES up to the aortic arch through a thoracic approach.


METHODS
From 1984 to 2002, we have treated 148 achalasic patients, 90 through an abdominal approach, 22 by VALS (Video Assisted Laparoscopic Surgery) and 36 through a thoracic approach. In the first 2 groups we performed a short myotomy with a Dor antireflux procedure, in the 3rd group we performed a long myotomy with a Belsey Mark IV antireflux procedure.


RESULTS
Our trend to calibrate the surgical treatment on the physiopathological and morphofunctional data, allowed to optimize the post-operative clinical results, particularly with a better control of dysphagia.


CONCLUSIONS
Surgical treatment of achalasia must be differentiated according to the pathophysiological basis in order to improve the surgical results.
Dipartimento di Chirurgia Generale, Urgenza e Trapianti d'Organo, Università degli Studi di Palermo, Palermo, Italy. alfonso.maiorana@libero.it
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Maiorana
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Damiani