SUCCESSFUL TREATMENT OF ESOPHAGEAL ACHALASIA WITH LAPAROSCOPIC HELLERMYOTOMY AND TOUPET FUNDOPLICATION

BACKGROUND: Recently, investigators have reported the use of endoscopi c myotomy in the treatment of esophageal achalasia. As with the open o peration, considerable disagreement exists regarding the appropriate l ength of the myotomy and the need for a concomitant antireflux procedu re. METHODS: Patients presenting with symptomatic achalasia between 19 93 and 1997 were included in this prospective study. Preoperative stud ies included barium upper gastrointestinal study, endoscopy, and esoph ageal manometry. Laparoscopic myotomy was completed in all 20 patients ; 18 had concomitant Toupet fundoplication. RESULTS: Operative times r anged from 95 to 345 minutes (mean 216). Blood loss ranged from 50 to 300 cc (mean 100 cc). There were 7 minor complications (5 mucosal inju ries repaired laparoscopically, 1 bile leak and 1 splenic capsular tea r). Nine patients began a liquid diet on the first day postoperatively ; 19 were tolerating liquids by postoperative day 3. Hospital stay ran ged from 2 to 20 days (mean 5). Eighteen patients had complete relief of dysphagia, with less than one reflux episode per month. One individ ual continues to have mild persistent solid food dysphagia. Another pa tient initially did well but subsequently developed mild recurrent dys phagia and reflux. One patient required laparoscopic take-down of the wrap because of recurrent dysphagia and now has no problems swallowing , but does complain of mild reflux. Two other patients also have mild reflux, 1 of whom did not undergo fundoplication. CONCLUSIONS: Laparos copic Heller myotomy can be performed safely with excellent results in patients with achalasia. Adding a partial fundoplication appears to h elp control postoperative symptoms of reflux. This procedure should be considered the procedure of choice in patients with symptomatic esoph ageal achalasia, (C) 1997 by Excerpta Medica, Inc.