Laparoscopic Heller cardiomyotomy and dor fundoplication for esophageal achalasia - Possible factors predicting outcome

Hypothesis: Laparoscopic Heller myotomy with anterior hemifundoplication is the surgical procedure of choice for the treatment of esophageal achalasia . Specific factors, eg, severity of esophageal body deformity, might affect postoperative outcome. Design: Prospective case-control study Setting: Academic referral center for gastrointestinal tract motility disor ders. Patients: Twenty-nine patients with esophageal achalasia who underwent 1 to 3 sessions of failed pneumatic dilation each. Intervention: Laparoscopic Heller myotomy with anterior (Dor) hemifundoplic ation. Main Outcome Measures: Preoperative and postoperative symptomatic evaluatio n, esophagoscopy, esophagography, stationary and ambulatory esophageal mano metry, and pH monitoring. Results: Three patients has a stage I disease, 10 had stage II, 12 had stag e III, and 4 had stage IV at preoperative radiologic examination. At surger y, there were no conversions to open procedures, and 2 mucosal perforations were immediately identified and sutured. Good or excellent results ware se en in 26 patients. All patients with stage I or II disease had excellent fu nctional results. Of patients with stage III disease, results were excellen t in 7, good in 4, and bad in 1. Of patients with stage IV disease, 2 had g ood results and 2 had bad results. After surgery, lower esophageal sphincte r pressure was reduced significantly (from 46.1 +/- 12.1 to 5.4 +/- 1.8 mm Hg: P < .001), as was esophageal diameter (from 61 +/- 17 to 35 +/- 19 mm; P < .001) (data are given as mean +/- SD). However, an excellent result occ urred only in patients with a postoperative esophageal diameter less than 4 0 mm. Conclusion: Functional outcome of laparoscopic Heller-Dor procedure for ach alasia is related to the preoperative stage of the disease on the esophagog ram and to the extent of reduction in esophageal width after surgery.