title: Improving the surgery for sigmoid achalasia: long-term results of a technical detail.
abstract: OBJECTIVE
  Heller myotomy results for the treatment of sigmoid achalasia are worse than those achieved for fusiform achalasia. We retrospectively examined two groups of sigmoid achalasia patients, in which we performed (1) the standard Heller-Dor procedure (no pull-down) and (2) the Heller-Dor plus a technique apt to obtain the verticality of the oesophageal axis (pull-down). We verified whether the latter technique improved long-term results.
  
  
  METHODS
  We considered 33 patients affected by primitive oesophageal sigmoid achalasia operated upon consecutively (1979-2005). Diagnosis was based on symptoms, manometry, radiology and endoscopy. After 1987, we routinely isolated 360 degrees of the gastro-oesophageal junction and the lower oesophagus and applied U stitches at the right side of the lower oesophagus to pull down and rotate the gastro-oesophageal junction toward the right. Fifteen patients underwent the no pull-down and 18 patients underwent the pull-down technique. Postoperative follow-up included objective clinical and instrumental evaluation (questionnaire filled by a surgeon including the assessment of symptoms and endoscopic reflux oesophagitis according to a semi-quantitative scale) and subjective evaluation (self-evaluation SF-36 questionnaire).
  
  
  RESULTS
  The mean follow-up period was 89 months (range 12-261 months). The postoperative dysphagia score was significantly improved in the entire group. Excellent results were present in 12 patients (36.4%), good in 11 (33.3%), fair in 3 (9.1%) and insufficient in 7 patients (21.2%). No statistically significant differences were observed between the two groups with regard to the postoperative symptoms and oesophagitis. Postoperative radiological measurements of oesophageal diameter and residual barium column were significantly improved in the whole group and within each group with respect to the radiological variables measured preoperatively (p=0.000). In the comparison of the two groups, statistically significant differences were observed with regard to mean oesophageal diameter (p=0.030) (pull-down, 4+/-0.9 cm; no pull-down, 4.7+/-0.6 cm) and residual barium column (p=0.048) (pull-down, 6.2+/-3.4 cm; no pull-down, 9.6+/-5.8 cm).
  
  
  CONCLUSIONS
  The Heller-Dor operation is effective in the presence of sigmoid achalasia. The clinical objective and subjective evaluations show a trend toward the improvement of results with the pull-down technique. Stronger statistical significance would probably be obtained from a larger case series.
authors.affiliation: Department of Surgery, Intensive Care, and Organ Transplantation, Division of Esophageal and Pulmonary Surgery Villa Maria Cecilia e San Pier Damiano Hospitals, Cotignola and Faenza (Ravenna), University of Bologna, Bologna, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Faccani
authors.forename: Sandro
authors.initials: S
authors.lastname: Mattioli
authors.forename: Maria Luisa
authors.initials: ML
authors.lastname: Lugaresi
authors.forename: Massimo Pierluigi
authors.initials: MP
authors.lastname: Di Simone
authors.forename: Tommaso
authors.initials: T
authors.lastname: Bartalena
authors.forename: Vladimiro
authors.initials: V
authors.lastname: Pilotti
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003680:Deglutition Disorders / Q000209:etiology; D004931:Esophageal Achalasia / Q000150:complications / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D004942:Esophagitis, Peptic / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D005769:Gastrointestinal Motility; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome