Laparoscopic anterior esophageal myotomy and Toupet fundoplication for achalasia

Achalasia is an esophageal motility disorder characterized by the failure o f lower esophageal sphincter relaxation and the absence of esophageal peris talsis. The purpose of this study was to evaluate the clinical outcomes of patients undergoing laparoscopic esophageal myotomy and Toupet fundoplicati on for achalasia. A 9-cm. myotomy was performed in most cases extending 7 c m above and 2 cm below the gastroesophageal junction. Severity of dysphagia , heartburn, chest pain, and regurgitation was graded preoperatively and po stoperatively using a five-point symptomatic scale (0-4). Patients also gra ded their outcomes as excellent, good, fair, or poor. Between December 1995 and November 2000 a total of 49 patients (23 male, 26 female) with a mean age of 44.3 years (range 23-71 years) were diagnosed with achalasia. Mean d uration of symptoms was 40.2 months (range 4-240 months). Thirty-seven pati ents (76%) had had a previous nonsurgical intervention or combinations of n onsurgical interventions [pneumatic dilation (23), bougie dilation (five), and botulinum toxin (19)], and two patients had failed esophageal myotomies . Forty-five patients underwent laparoscopic esophageal myotomy and Toupet fundoplication. Two patients received laparoscopic esophageal myotomies wit hout an antireflux procedure, and two were converted to open surgery. One p atient presented 10 hours after a pneumatically induced perforation and und erwent a successful laparoscopic esophageal myotomy and partial fundoplicat ion. Mean operative time was 180.5 minutes (range 145-264 minutes). Mean le ngth of stay was 1.98 days (range 1-18 days). There were five (10%) periope rative complications but no esophageal leaks. There was a significant diffe rence (P < 0.05) between the preoperative and postoperative dysphagia, ches t pain, and regurgitation symptom scores. All patients stated that they wer e improved postoperatively. Eighty-six per cent rated their outcome as exce llent, 10 per cent as good, and 4 per cent as fair. Laparoscopic anterior e sophageal myotomy and Toupet fundoplication effectively alleviates dysphagi a, regurgitation, and chest pain accompanying achalasia and is associated w ith high patient satisfaction, a rapid hospital discharge, and few complica tions.