Surgery for achalasia: 1998

Technical controversies abound regarding the surgical treatment of achalasi a. To determine the value of a concomitant antireflux procedure, the best a ntireflux; procedure, the correct length for gastric myotomy the optimal su rgical approach (thoracic or abdominal), and the equivalency of minimally i nvasive surgery, a literature review uas carried out. The review is based o n 23 articles on open transabdominal or transthoracic myotomy, 14 articles on laparoscopic myotomy: and four articles on thoracoscopic myotomy. Postop erative results of traditional open thoracic or transabdominal myotomy as d etermined by symptomatology were better with fundoplication than without fu ndoplication. The incidence of postoperative reflux as proved by pH monitor ing was high in patients who had an open transabdominal myotomy without fun doplication. The type of antireflux procedure used and the length of gastri c myotomy had little effect on results. The results of transthoracic Heller myotomy do not require a concomitant fundoplication. Laparoscopic and thor acoscopic myotomy had excellent results at short-term follow-up. A fundopli cation must be added if the myotomy is performed transabdominally. a random ized prospective study is required to determine the best fundoplication and the extent of gastric myotomy. Although minimally invasive surgery for ach alasia has excellent initial results, longer follow-up in a larger populati on of patients is needed.