title: Laparoscopic limited Heller myotomy without anti-reflux procedure does not induce significant long-term gastroesophageal reflux.
abstract: BACKGROUND
  Laparoscopic Heller myotomy with partial fundoplication is the gold standard treatment for achalasia. Laparoscopic limited Heller myotomy (LLHM) with no anti-reflux procedure is another possible option.
  
  
  METHODS
  A review of prospectively collected data was performed on patients who underwent LLHM from January 1998 to December 2012. Evaluation included gastroscopy, esophageal manometry, 24-h pH-metry, and the Short Form(36) Health Survey(SF-36) questionnaire at baseline and 6 months, as well as the global symptom score at baseline, 6 months, and 5 years post-surgery. Comparison between outcomes was performed with a paired t student's test.
  
  
  RESULTS
  126 patients underwent LLHM. Of these, 60 patients had complete pre and post-operative motility studies. 57 % were female, patient mean age was 45.7 years, with a mean follow-up of 10.53 months. Mean operative time was 56.1 min, and the average length of stay was 1.7 days. At 6 months, a significant decrease in the lower esophageal sphincter resting pressure (29.1 vs. 7.1 mmHg; p < 0.001) and nadir (16.4 vs. 4.3 mmHg; p < 0.001) was observed. Normal esophageal acid exposure (total pH < 4 %) was observed in 68.3 % patients. Nevertheless, of the remaining 31.7 % with abnormal pH-metry, only 21.6 % were clinically symptomatic and all were properly controlled with medical treatment without requiring anti-reflux surgery. Significant improvement in all pre-operative symptoms was observed at 6 months and maintained over 5 years. Dysphagia score was reduced from 9.8 pre-operatively to 2.6 at 5 years (p < 0.001), heartburn score from 3.82 to 2 (p < 0.01), and regurgitation score from 7.5 to 0.8 (p < 0.001). Only one patient (0.8 %) presented with recurrent dysphagia requiring reoperation.
  
  
  CONCLUSIONS
  LLHM without anti-reflux procedure is an effective long-term treatment for achalasia and does not cause symptomatic GERD in three quarters of patients. The remaining patients are well controlled on anti-reflux medications. It is believed that similar clinical results would be obtained during a clinical investigation of the POEM procedure.
authors.affiliation: Centre for Minimal Access Surgery (CMAS), St. Joseph's Hospital, McMaster University, Hamilton, ON, Canada, drluiszurita@gmedico.com.
authors.forename: L C
authors.initials: LC
authors.lastname: Zurita Macías Valadez
authors.forename: R
authors.initials: R
authors.lastname: Pescarus
authors.forename: T
authors.initials: T
authors.lastname: Hsieh
authors.forename: L
authors.initials: L
authors.lastname: Wasserman
authors.forename: I
authors.initials: I
authors.lastname: Apriasz
authors.forename: D
authors.initials: D
authors.lastname: Hong
authors.forename: S
authors.initials: S
authors.lastname: Gmora
authors.forename: M
authors.initials: M
authors.lastname: Cadeddu
authors.forename: M
authors.initials: M
authors.lastname: Anvari
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D004931:Esophageal Achalasia / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000379:methods; D005764:Gastroesophageal Reflux / Q000209:etiology* / Q000517:prevention & control; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications / Q000517:prevention & control; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult