title: Difficult myotomy is not determined by preoperative therapy and does not impact outcome.
abstract: OBJECTIVE
  The impact of preoperative endoscopic therapy on the difficulty of laparoscopic Heller myotomy and the impact of the difficulty of the myotomy on long-term outcome has not been determined. This study was undertaken to determine whether preoperative therapy impacts the difficulty of laparoscopic Heller myotomy and whether preoperative therapy or difficulty of myotomy impacts long-term outcomes.
  
  
  METHODS
  Since 1992, 305 patients, 56% male, median age 49 years, underwent laparoscopic Heller myotomy and were prospectively followed. The difficulty of the laparoscopic Heller myotomy was scored by the operating surgeon for the most recent 170 consecutive patients on a scale of 1 (easiest) to 5 (most difficult). Patients scored their symptoms before and after myotomy using a Likert scale from 0 (never/not bothersome) to 10 (always/very bothersome).
  
  
  RESULTS
  Before myotomy, 66% of patients underwent endoscopic therapy: 33% dilation, 11% Botox, and 22% both. Preoperative endoscopic therapy did not correlate with the difficulty of the myotomy (P=NS). Median follow-up was 25 months. Regardless of the difficulty of the myotomy, dysphagia improved with myotomy (P<0.0001). By regression analysis, the frequency and severity of post-myotomy dysphagia correlated with neither preoperative endoscopic therapy nor the difficulty of the myotomy.
  
  
  CONCLUSIONS
  Laparoscopic Heller myotomy improves the frequency and severity of dysphagia. The difficulty of laparoscopic Heller myotomy is not impacted by preoperative therapy, and neither preoperative therapy nor difficulty of the myotomy impact long-term outcome.
authors.affiliation: Digestive Disorders Center, Department of Surgery, Tampa General Hospital, Tampa, FL 33601, USA. scowgill@health.usf.edu
authors.forename: Sarah M
authors.initials: SM
authors.lastname: Cowgill
authors.forename: Desiree V
authors.initials: DV
authors.lastname: Villadolid
authors.forename: Sam
authors.initials: S
authors.lastname: Al-Saadi
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Rosemurgy
mesh_terms: D000328:Adult; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use; D004106:Dilatation; D004931:Esophageal Achalasia / Q000601:surgery*; D018662:Fundoplication; D006801:Humans; D010535:Laparoscopy; D007902:Length of Stay; D016896:Treatment Outcome
chemical_list: D019274:Botulinum Toxins, Type A