title: Minimally-invasive esophagomyotomy in 200 consecutive patients: factors influencing postoperative outcomes.
abstract: BACKGROUND
  The primary objective of this study was to review our experience with minimally-invasive esophagomyotomy as primary therapy for achalasia, and to identify those clinical variables most predictive of myotomy failure.
  
  
  METHODS
  We reviewed our experience with all patients who underwent minimally-invasive Heller myotomy from 1992 to 2005. Outcome variables analyzed included perioperative morbidity and mortality, symptomatic improvement, and requirement for postoperative interventions. Multivariate analysis was performed to identify clinical variables predictive of myotomy failure.
  
  
  RESULTS
  A total of 200 consecutive patients (104 men and 96 women) underwent minimally-invasive laparoscopic (n = 194) or thoracoscopic (n = 6) Heller myotomy with partial fundoplication. Mean follow-up was 31.6 months. Median hospital stay was 2 days, with no operative mortality. There were 119 patients (59.5%) who had undergone prior endoscopic treatment (endoscopic dilation or botulinum toxin injection). An increased failure rate was noted in patients with prior endoscopic therapies (16.8% versus 3.7% with no prior treatment, p = 0.003). Multivariate analysis also revealed that longer duration of symptoms, sigmoidal esophageal changes, and low preoperative lower esophageal sphincter pressures impact adversely on the success of myotomy.
  
  
  CONCLUSIONS
  There was an increase in treatment failures among patients undergoing preoperative endoscopic treatment. Other factors associated with failure during long-term follow-up include longer duration of symptoms, sigmoidal esophagus, and low baseline lower esophageal sphincter pressure. Although endoscopic modalities remain an important component of the armamentarium in the treatment of patients with achalasia, consideration should be given to minimally-invasive Heller myotomy as primary therapy for this condition.
authors.affiliation: Division of Thoracic Surgery, Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Schuchert
authors.forename: James D
authors.initials: JD
authors.lastname: Luketich
authors.forename: Rodney J
authors.initials: RJ
authors.lastname: Landreneau
authors.forename: Arman
authors.initials: A
authors.lastname: Kilic
authors.forename: William E
authors.initials: WE
authors.lastname: Gooding
authors.forename: Miguel
authors.initials: M
authors.lastname: Alvelo-Rivera
authors.forename: Neil A
authors.initials: NA
authors.lastname: Christie
authors.forename: Sebastien
authors.initials: S
authors.lastname: Gilbert
authors.forename: Arjun
authors.initials: A
authors.lastname: Pennathur
mesh_terms: D015331:Cohort Studies; D003131:Combined Modality Therapy; D004931:Esophageal Achalasia / Q000175:diagnosis / Q000601:surgery*; D004945:Esophagoscopy; D004947:Esophagus / Q000601:surgery; D005260:Female; D018662:Fundoplication; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008365:Manometry; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D009130:Muscle, Smooth / Q000601:surgery*; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology*; D019233:Retreatment; D012307:Risk Factors; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D017211:Treatment Failure