Previous endoscopic treatment does not affect complication rate and outcome of laparoscopic Heller myotomy and anterior fundoplication for oesophageal achalasia

Background, Anedoctal reports suggest a detrimental effect of pneumatic dil ation and botulinum toxin injection in patients who are potential candidate s for Heller myotomy. Aims. To assess symptomatic and objective outcome in patients undergoing He ller myotomy as a primary procedure or after failed endoscopic treatment Patients, Between November 1992 and December 1998, 92 patients with oesopha geal achalasia were treated. Sixty patients had primary surgery; 32 patient s had surgery after unsuccessful pneumatic dilation (n=22) or botulinum tox in injection (n=10). Methods, Laparoscopic Heller myotomy plus Dor fundoplication with routine i ntraoperative endoscopy. Operative records, symptoms, and results of radiol ogical, manometric and scintigraphic assessment in the two groups of patien ts were compared. Results, The mean operative time, the rate of intraoperative mucosal rears and the incidence of postoperative dysphagia were similar in the two groups . Mucosal rears occurred more frequently during the first 30 operations (p< 0.05). Median follow-up was 28 months (range 4-76). An abnormal oesophageal acid exposure was documented in 2 patients in the primary surgery group (7 .7%), and in 2 patients in the pneumatic dilation/botulinum toxin group (13 .3%) (p=ns). Lower oesophageal sphincter pressure significantly decreased i n both groups (p<0.01). The mean percentage of radionuclide residual activi ty in the oesophagus at 1 and 10 minutes significantly decreased in both gr oups (p<0.01). Conclusions, There was only a trend, although nor statistically significant , towards an increased risk of complications and adverse effects in patient s previously treated by pneumatic dilation or botulinum toxin. The higher i ncidence of mucosal tears during the first 30 operations suggests the effec t of the learning curve.