Prevalence of gastroesophageal reflux after laparoscopic Heller myotomy

Background: There is still some controversy over the need for antireflux pr ocedures with Heller myotomy in the treatment of achalasia. This study was undertaken in an effort to clarify this question. Methods: To determine whether Heller myotomy alone would cause significant gastroesophageal reflux (GER), we studied 16 patients who had undergone lap aroscopic Heller myotomy without: concomitant antireflux procedures, Patien ts were asked to return for esophageal manometry and 24-h pH studies after giving informed consent for the Institutional Review Board (IRB)-approved s tudy at a median follow-up time of 8.3 months (range, 3-51). Results are ex pressed as the mean +/- SEM. Results: Fourteen of the 16 patients reported good to excellent relief of d ysphagia after myotomy. They were subsequently studied with a 24-h pH probe and esophageal manometry. These 14 patients had a significant fall in lowe r esophageal sphincter (LES) pressure from 41.4 +/- 4.2 mmHg to 14.2 +/- 1. 3 mmHg, after the myotomy (p < 0.01, Student's t-test). The two patients wh o reported more dysphagia postoperatively had LES pressures of 20 and 25 mm Hg, respectively. Two of 14 patients had DeMeester scores of >22 (scores = 61.8, 29.4), while only one patient had a pathologic total time of reflux ( percent time of reflux, 8%). The mean percent time of reflux in the other 1 3 patients was 1.9 +/- 0.6% (range, 0.1-4%), and the mean DeMeester score w as 11.7 +/- 4.6 (range, 0.48-19.7). Conclusions: Laparoscopic Heller myotomy is effective for the relief of dys phagia in achalasia if the myotomy lowers the LES pressure to <17 mmHg. Tf performed without dissection of the entire esophagus, the laparoscopic Hell er myotomy does not create significant GER in the postoperative period. Cle arance of acid refluxate from the aperistaltic esophagus is an important co mponent of the pathologic gastroesophageal reflux disease (GERD) seen after Heller myotomy for achalasia. Furthermore, GERD symptoms do not correlate with objective measurement of GE reflux in patients with achalasia. Objecti ve measurement of GERD with 24 h pH probes may be indicated to identify tho se patients with pathologic acid reflux who need additional medical treatme nt.