Video-assisted surgical management of achalasia of the esophagus

Purpose: Video-assisted surgical approaches to esophageal achalasia continu e to be explored by many surgeons involved in the management of this motor disorder, We report our experience with thoracoscopic and laparoscopic esop hagomyotomy to more clearly define the efficacy and safety of these approac hes, Patients: Over 73 months, 58 patients with achalasia underwent thoraco scopic myotomy (n = 19) alone or laparoscopic myotomy (n = 39) with partial fundoplication (anterior = 15; posterior = 24). Mean age was 47.2 gears an d average length of symptoms was 60 months. Primary symptoms were as follow s: dysphagia, 100%; pulmonary abnormalities, 22%; weight loss; 47%, and pai n, 45%. Mean esophageal diameter was 6 cm and tortuosity was present in 16% (9/58) of patients. Prior management consisted of dilation (n = 47), botul inum toxin injection (n = 8), and prior myotomy (n = 1), Methods: In the op erating room all patients underwent endoscopic examination and evacuation o f retained esophageal contents. The esophagomyotomy was extended 4 cm super iorly and inferiorly to 1 cm beyond the lower esophageal sphincter, Thoraco scopic and laparoscopic procedures were completed in all patients without c onversion to an open operation, Mean operative time was 183 minutes (+/-58. 1) and hospital stay averaged 2.3 days (+/-0.8). There was no operative mor tality. The 1 operative complication was a perforation that was identified during the operation and repaired thoracoscopically, Results: Symptoms impr oved in 97% of patients, Mean dysphagia scores (range 0-10) decreased from 9.8 +/- 1.6 before the operation to 2.0 +/- 1.5 after the operation (P < .0 01) at a mean follow-up of 6 months, Postoperative reflux symptoms develope d in 5% (1/19) of the thoracoscopy group and 8% (4/39) of the laparoscopy g roup, Nine patients have persistent or recurrent dysphagia (16%). Seven pat ients have successfully undergone Savary dilation, and 2 required esophagec tomy to manage recalcitrant dysphagia, Conclusion: At this intermediate ter m analysis, video-assisted approaches for management of achalasia are a rea sonable alternative to extended medical therapy or open operations.