LAPAROSCOPIC HELLER MYOTOMY AND FUNDOPLICATION FOR ACHALASIA

Objective The goal of this study was to review the authors' results wi th laparoscopic cardiomyotomy and partial fundoplication for achalasia . Summary Background Data Pneumatic dilatation and botulinum toxin (BO TOX) injection of the lower esophageal sphincter largely have replaced cardiomyotomy for treatment of achalasia. After a brief experience wi th a thoracoscopic approach, the authors elected to perform cardiomyot omy laparoscopically, in combination with a partial fundoplication (an terior or posterior). Patients and Methods Forty patients were treated between July 1992 and November 1996. Thirty patients had previous the rapy of achalasia, 21 with pneumatic dilation, 1 with BOTOX, 6 with ba lloon and BOTOX, and 2 with transthoracic cardiomyotomy. Three patient s had previous laparoscopic fundoplication for gastroesophageal reflux . Symptom scores (0 = none to 4 = disabling) were obtained before surg ery and after surgery. Barium swallows and esophagogastroduodenoscopy were performed in all patients. Esophageal motility study was performe d in 36 patients. Laparoscopic Heller myotomy and fundoplication was p erformed through five upper abdominal trocars. A 7-cm myotomy extended 6 cm above the GE-junction and 1 cm below the GE junction. A posterio r fundoplication was performed in 32 patients, anterior fundoplication in 7 patients, and no fundoplication in I patient. Statistical infere nce was performed with a Wilcoxon signed rank test. Results Mean opera tive duration was 199 +/- 36.2 minutes. Mean hospital stay was 2.75 da ys (range, 1-13 days). Dysphagia was alleviated in all but four patien ts (90%), and regurgitation in all but two patients (95%) (p < 0.001). Chest pain and heartburn improved significantly (p < 0.01) as well. I ntraoperative complications included mucosal laceration in six patient s and hypercarbia in one. Postoperative pneumonia developed in two pat ients, and one patient had moderate hemorrhage from an esophageal ulce r 2 weeks after surgery; Conclusions Laparoscopic cardiomyotomy and fu ndoplication appears to provide definitive treatment of achalasia with rapid rehabilitation and few complications.