Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated

Background: It has been said that a Heller myotomy cannot improve dysphagia in achalasia when the esophagus is markedly dilated or sigmoid shaped. Tho se who hold this belief recommend esophagectomy as the primary treatment in such cases. This study aimed to compare the results of laparoscopic Heller myotomy combined with Dor fundoplication in 66 patients with and without e sophageal dilatation, all of whom had achalasia. Methods: On the basis of the maximal diameter of the esophageal lumen and t he shape of the esophagus, the patients were placed into four groups: group A (esophageal diameter <4.0 cm; 26 patients), group B (diameter 4.0-6.0 cm ; 21 patients), group C1 (diameter >6.0 cm and straight esophageal axis; 12 patients), and group C2 (diameter >6.0 cm and sigmoid-shaped esophagus; 7 patients). All patients underwent a laparoscopic Heller myotomy and Dor fun doplication. Results: The duration of the operation and the length of hospital stay were similar among the four groups, Excellent or good results were obtained in 88% of group A, 100% of group B, 83% of group C1, and 100% of group C2. No patient in this consecutive series ultimately required an esophagectomy. Conclusions: In patients with achalasia who have esophageal dilation, a lap aroscopic Heller myotomy and Dor fundoplication (a) took no longer and was no more difficult, (b) was associated with no more postoperative complicati ons, and (c) gave just as good relief of dysphagia. We conclude that esopha geal dilation by itself should rarely serve as an indication for esophagect omy rather than myotomy as the initial surgical treatment.