Minimally invasive surgery for achalasia - An 8-year experience with 168 patients

Background Seven years ago, the authors reported on the feasibility and sho rt-term results of minimally invasive surgical methods to treat esophageal achalasia. In this report, they describe the evolution of the surgical tech nique and the clinical results in a large group of patients with long follo w-up. Patients and Methods Between January 1991 and October 1998, 168 patients (9 6 men, 72 women; mean age 45 years, median duration of symptoms 48 months), who fulfilled the clinical, radiographic, endoscopic, and manometric crite ria for a diagnosis of achalasia, underwent esophagomyotomy by minimally in vasive techniques. Forty-eight patients had marked esophageal dilatation (d iameter >6.0 cm). Thirty-five patients had a left thoracoscopic myotomy, an d 133 patients had a laparoscopic myotomy plus a partial fundoplication. Fo llow-up to October 1998 was complete in 145 patients (86%). Results Median hospital stay was 72 hours for the thoracoscopic group and 4 8 hours for the laparoscopic group. Eight patients required a second operat ion for recurrent or persistent dysphagia, and two patients required an eso phagectomy, There were no deaths, Good or excellent relief of dysphagia was obtained in 90% of patients (85% after thoracoscopic and 93% after laparos copic myotomy). Gastroesophageal reflux developed in 60% of tested patients after thoracoscopic myotomy and in 17% after laparoscopic myotomy plus fun doplication. Laparoscopic myotomy plus fundoplication corrected reflux pres ent before surgery in five of seven patients. Patients with a dilated esoph agus had excellent relief of dysphagia after laparoscopic myotomy; none req uired an esophagectomy. Conclusions Minimally invasive techniques provided effective and longlastin g relief of dysphagia in patients with achalasia. The authors prefer the la paroscopic approach for three reasons: it more effectively relieved dysphag ia, it was associated with a shorter hospital stay, and it was associated w ith less postoperative reflux, Laparoscopic Heller myotomy and partial fund oplication should be considered the primary treatment for esophageal achala sia.