SURGERY FOR ESOPHAGEAL ACHALASIA - LONG-TERM RESULTS WITH 3 DIFFERENTTECHNIQUES

Background/Aims: In surgery for achalasia, the length of the myotomy a nd the opportunity of associating an antireflux procedure are still de bated. Prospective and comparative studies on different techniques are few. The aims of this work is to compare the long term results of thr ee different techniques successively adopted by the same surgical grou p. Materials and Methods: Between January 1955 and December 1991, 185 achalasic patients were submitted to myotomy by using in temporal sequ ence three different techniques. The first technique utilized (1955-19 72) was a long esophagogastric abdominal myotomy (83 patients), second ly (1973-1978) a limited transthoracic myotomy (30 patients) and at la st (1979-1991) a long esophagogastric abdominal myotomy associated to the Dor gastroplasty (72 patients). Since 1972, patients were prospect ively followed up according to a protocol which included a clinical in terview, x-rays, manometry and endoscopy at given dates. Post-operativ e esophagogastric transit and gastro-esophageal reflux were assessed t o verify the therapeutical outcome. Results obtained with the three di fferent techniques were analysed and compared by using the actuarial K aplan-Meier curves. Results: The mean follow up was 193.3 months for t he patient group that underwent abdominal myotomy (62/83 patients), 13 7.3 months for the thoracic myotomy group (30/30 patients) and 86.9 mo nths for the abdominal myotomy plus Dor gastroplasty group (69/72 pati ents). Long-term results in the abdominal myotomy and in the thoracic muyotomy groups were respectively poor in 51.6% and in 46.6% of patien ts. Major causes of failure were insufficient myotomy (6.5%), periesop hageal scarring (9.6%) and reflux esophagitis (22.6%) for the abdomina l myotomy group; insufficient myotomy (20%) and reflux esophagitis (23 %) for the thoracic myotomy group. In the abdominal myotomy plus Dor g astroplasty group lone-term results were excellent or good in 87% of p atients and poor in 13%. Reflux esophagitis (10% of cases) was the pri ncipal cause of failure. Conclusions: The comparison of the actuarial curves shows a significantly better long term outcome for the abdomina l myotomy plus Dor antireflux procedure than for the abdominal myotomy (p=0.01) and for the thoracic myotomy (p=0.002) techniques.