Laparoscopic Heller myotomy relieves dysphagia in patients with achalasia and low LES pressure following pneumatic dilatation

Background: Although pneumatic dilatation is said to relieve dysphagia in a chalasia if it decreases lower esophageal sphincter (LES) pressure to < 10 mmHg, dysphagia persists in some cases. Performing a Heller myotomy in this setting has been challenged on the assumption that everything possible has already been done to eliminate the barrier posed by the malfunctioning sph incter. Therefore, we set out to assess the results of laparoscopic Heller myotomy and Dor fundoplication in achalasia in relation to LES pressure. Methods: Fifty-seven patients with achalasia were divided into the followin g three groups, based on the LES pressure and previous treatment: group A, previous balloon dilatation and LES pressure less than or equal to 10 mmHg (n = 9); group B, previous balloon dilatation and LES pressure > 10 mmHg (n = 23); group C, no previous balloon dilatation and LES pressure > 10 mmHg (n = 25). All patients underwent a laparoscopic Heller myotomy and Dor fund oplication, The severity of dysphagia was gauged on a scale of 0-4. Results: In group A, LES pressure was 7 +/- 2 mmHg preoperatively and 8 +/- 3 mmHg postoperatively; the dysphagia score was 3.3 +/- 0.7 preoperatively and 0.9 +/- 1.1 postoperatively, Eighty-nine percent of patients had excel lent or good results. In group B, LES pressure was 23 +/- 8 mmHg preoperati vely and 10 +/- 1 mmHg postoperatively; the dysphagia score was 3.3 +/- 0.7 preoperatively and 0.3 +/- 0.5 post operatively. All patients had excellen t or good results. In group C, LES pressure was 23 +/- 11 mmHg preoperative ly and 14 +/- 12 mmHg postoperatively; the dysphagia score was 3.6 +/- 0.6 preoperatively and 0.2 +/- 0.5 postoperatively. All patients had excellent or good results. Conclusions: These results show that (a) a LES pressure of < 10 mmHg after pneumatic dilatation does not guarantee relief of dysphagia, and (b) laparo scopic Heller myotomy reliev es dysphagia in most patients with a postdilat ation LES pressure < 10 mmHg. Thus, a laparoscopic Heller myotomy is indica ted if dilatation does not relieve dysphagia, even if LES pressure has been decreased to < 10 mmHg. Esophagectomy should be reserved for the occasiona l failure of this simpler operation.