Laparoscopic Heller myotomy and Dor fundoplication for achalasia - Analysis of successes and failures

Background: In the treatment of achalasia, surgery has been traditionally r eserved for patients with residual dysphagia after pneumatic dilatation. Th e results of laparoscopic Heller myotomy have proven to be so good, however , that most experts now consider surgery the primary treatment. Hypothesis: The outcome of laparoscopic myotomy and fundoplication for acha lasia is dictated by technical factors. Setting: University hospital tertiary care center. Design: Retrospective study. Patients and Methods: One hundred two patients with esophageal achalasia un derwent laparoscopic Heller myotomy and Dor fundoplication. Fifty-seven pat ients had been previously treated by pneumatic dilatation or botulinum toxi n. The design of the operation involved a 7-cm myotomy, which extended 1.5 cm onto the gastric wall, and a Dor fundoplication. Esophagrams, esophageal manometric findings, and video records of the procedure were analyzed to d etermine the technical factors that contributed to the clinical success or failure of the operation. Main Outcome Measure: Swallowing status. Results: In 91 (89%) of the 102 patients, good or excellent results were ob tained after the first operation. A second operation was performed in 5 pat ients to either lengthen the myotomy ( 3 patients) or talc down the fundopl ication (2 patients). Dysphagia resolved in 4 of these patients. The remain ing 6 patients were treated lay pneumatic dilatation, but dysphagia improve d in only 1. At the conclusion of treatment, excellent or good results had been obtained in 96 (94%) of the 102 patients. Conclusions: These data chow that a Heller myotomy was unsuccessful inpatie nts with an esophageal stricture; a short myotomy and a constricting Dor fu ndoplication were the avoidable causes of residual dysphagia; a second oper ation, but not pneumatic dilatation, was able to correct most failures; and that the identified technical flaws were eliminated from the last half of the patients in the series.