Does previous endoscopic treatment affect the outcome of laparoscopic Heller myotomy?

Study aim: Aim of this study was to assess symptomatic and objective outcom e in patients undergoing laparoscopic Heller myotomy after unsuccessful end oscopic treatment, compared to patients having primary surgery. Patients and method: Between November 1992 and December 1998, 92 patients w ith esophageal achalasia underwent laparoscopic Heller myotomy and Dor fund oplication. Intraoperative endoscopy was routinely performed. Sixty patient s had primary surgery (PS); 32 patients had surgery after unsuccessful pneu matic dilatation (PD) (n=22), or botulinum toxin (Botox) injection (n=10). Results: The mean operative time and the incidence of postoperative dysphag ia were similar in the two groups. The incidence of intraoperative mucosal tears was 5% in the PS group and 12.5% in the PD/Botox group (P=NS). Mucosa l tears occurred more frequently during the first 30 operations (17% vs 3.2 %, P < 0.05). Median follow-up was 28 months (range 4-76). An abnormal esop hageal acid exposure was documented in 2 patients in the PS group (7.7%), a nd in two patients in the PD/Botox group (13.3%) (P=NS). Lower esophageal s phincter pressure significantly decreased in both groups (P < 0.01). The me an percentage of radionuclide residual activity in the esophagus at 1 and 1 0 minutes significantly decreased in both groups (P < 0.01). Conclusion: There is only a trend, although not statistically significant, towards an increased risk of complications and adverse effects in patients previously treated by PD and/or Botox. The higher incidence of mucosal tear s during the first 30 operations suggests the effect of the learning curve. (C) 2000 Editions scientifiques et medicales Elsevier SAS.