Thoracoscopic versus laparoscopic modified Heller myotomy for achalasia: Efficacy and safety in 87 patients

Background: The ideal treatment for achalasia permanently eliminates the dy sfunctional lower esophageal sphincter, relieving dysphagia and regurgitati on; prevents gastroesophageal reflux; and has an acceptable morbidity rate. Controversy exists concerning whether the thoracoscopic Heller Myotomy (TH M) or laparoscopic Heller myotomy (LHM) technique is the best approach to a modified Heller myotomy for achalasia. Study Design: We performed a retrospective comparison of the patient charac teristics, operative results, postoperative symptoms, and the learning curv es for the procedures of 24 patients undergoing THM and 63 patients undergo ing LHM between 1991 and 1998. Results: Preoperative patient variables in each group revealed similar dist ributions for age, gender, and prevalence of previous pneumatic dilation. M ean operating room (OR) times were 4.3 hours (range 2.9 to 5.6 hours) for T HM and 3.0 hours (range 1.5 to 6.5 hours) for LHM (p = 0.01). Three esophag eal perforations occurred in the THM group and two in the LHM group. Conver sion to an open procedure took place in five THM operations (21%) and one L HM operation (2%) (p = 0.005). There were no postoperative esophageal leaks . Mean postoperative length of stay (LOS) for THM was 6.1 days (range 1 to 17 days) and for LHM was 4.0 days (range 1 to 12 days) (p = 0.03). Learning -curve analysis of the first 24 LHM patients compared with the most recent 24 revealed greater OR time in the first 24 mean 3.6 hours, (range 2.0 to 6 .5 hours) versus mean 2.3 hours, (range 1.5 to 3.7 hours; p 0.01), and grea ter LOS mean 5.5 days, (range 3 to 12 days) versus mean 3.1 days, (range 1 to 8 days; p < 0.01). One esophageal perforation occurred in each subgroup. A similar analysis in the first 12 THM patients compared with the most rec ent 12 revealed no significant improvement in OR times or LOS. Three esopha geal perforations occurred in the latter subgroup only. All patients had pr eoperative daily dysphagia to solids. Followup data for LHM (n = 49) (media n 17 months, range 1 to 39 months) and THM (n = 15) (median 42 months, rang e 1 to 69 months) revealed no or minimal dysphagia in 90% (44 of 49) after LHM and 31% (4 of 13) after THM (p < 0.01). No or minimal heartburn was pre sent in 89% (41 of 46) after LHM and 67% (8 of 12) after THM (p < 0.05). Re gurgitation was absent or minimal in 94% (46 of 49) after LHM and 86% (12 o f 14) after THM (p = 0.3). Conclusions: LHM was associated with decreased OR time, decreased rate of c onversion to an open procedure, and shorter LOS compared with THM. LHM was superior to THM in relieving dysphagia and preventing heartburn. LHM may be the preferred surgical treatment of achalasia in some patients. (J Am Coll Surg 1999;189:164-170. (C) 1999 by the American College of Surgeons).