title: Four hundred laparoscopic myotomies for esophageal achalasia: a single centre experience.
abstract: OBJECTIVE
  Laparoscopic myotomy is the currently preferred treatment for achalasia. Our objectives were to assess the long-term outcome of this operation and preoperative factors influencing said outcome.
  
  
  METHODS
  Demographic and clinical characteristics and data on long-term outcome were prospectively collected on patients undergoing laparoscopic myotomy for achalasia at our institution from 1992 to 2007. Treatment failure was defined as a postoperative symptom score higher than the 10th percentile of the preoperative score (>9). Logistic regression analysis was used to identify independent preoperative factors associated with successful myotomy.
  
  
  RESULTS
  Four hundred seven consecutive patients (220 men, 187 women) underwent the laparoscopic Heller-Dor procedure during the study period; 89 (22%) of them had previously had endoscopic treatment(s). The mortality rate was 0; the conversion and morbidity rates were 1.5% and 1.9%, respectively. The operation failed in 10% of patients (39/407) and the 5-year actuarial probability of being asymptomatic was 87%. Most failures (25/39, 64%) occurred within 12 months of the operation and can be considered as technical failures (incomplete myotomy). Pneumatic dilation overcome the dysphagia in 75% of patients whose surgery was unsuccessful. Considering both the primary surgery and this ancillary treatment, the operation was effective in 97% of achalasia patients. The frequency of sigmoid esophagus, lower esophageal sphincter (LES) resting pressures, and chest pain scores differed statistically between patients with and without recurrences. At multivariate analysis, high preoperative LES pressures (>30 mm Hg) was an independent predictor of a good response. The presence of chest pain and of sigmoid esophagus independently predicted the failure of the procedure.
  
  
  CONCLUSIONS
  Laparoscopic myotomy can durably relieve dysphagia symptoms. High preoperative LES pressures represent the strongest predictor of a positive outcome, probably reflecting a less severely damaged esophageal muscle.
authors.affiliation: Department of General Surgery, S Giovanni e Paolo Hospital, Venice, Italy. giovanni.zaninotto@unipd.it
authors.forename: Giovanni
authors.initials: G
authors.lastname: Zaninotto
authors.forename: Mario
authors.initials: M
authors.lastname: Costantini
authors.forename: Christian
authors.initials: C
authors.lastname: Rizzetto
authors.forename: Lisa
authors.initials: L
authors.lastname: Zanatta
authors.forename: Emanuela
authors.initials: E
authors.lastname: Guirroli
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Portale
authors.forename: Loredana
authors.initials: L
authors.lastname: Nicoletti
authors.forename: Francesco
authors.initials: F
authors.lastname: Cavallin
authors.forename: Giorgio
authors.initials: G
authors.lastname: Battaglia
authors.forename: Alberto
authors.initials: A
authors.lastname: Ruol
authors.forename: Ermanno
authors.initials: E
authors.lastname: Ancona
mesh_terms: D000328:Adult; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage; D003131:Combined Modality Therapy; D004106:Dilatation; D004931:Esophageal Achalasia / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D018662:Fundoplication; D006801:Humans; D010535:Laparoscopy; D016015:Logistic Models; D008297:Male; D008365:Manometry; D008875:Middle Aged; D015999:Multivariate Analysis; D009465:Neuromuscular Agents / Q000008:administration & dosage; D011183:Postoperative Complications / Q000453:epidemiology; D016896:Treatment Outcome
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A