Laparoscopic Heller myotomy for achalasia

Abstract

Background: Laparoscopic Heller myotomy provides similar results to open Heller myotomy for the treatment of oesophageal achalasia with the advantage of quicker recovery. The present series examines the evolution of operative technique, postoperative outcome and the effect of the 'learning curve' in a group of 70 consecutive patients.

Methods: Between 1992 and 1999, details of all patients undergoing oesophagogastric myotomy for achalasia were prospectively entered on a database. Patients were followed with a biannual postal symptom questionnaire and scores were obtained for dysphagia, heartburn, regurgitation and chest pain. Comparison between preoperative and postoperative symptom scores, and case number and operative complications was made using Fisher's exact test or Mann-Whitney U-test where appropriate.

Results: The indication for surgery was as a primary procedure in 20 cases; after failed endoscopic treatment in 48 cases; and after a 'failed' fundoplication in two cases. Myotomy was combined with a 360 degrees fundoplication in 57 patients and with an anterior fundoplication in 13 patients. Mucosal perforation occurred intraoperatively in 11 cases. Conversion to an open procedure was required in seven patients. Seven patients required a second operation. At a mean follow up of 2.9 years, symptom scores were significantly improved from preoperative values for dysphagia, regurgitation and chest pain (P < 0.001). There was no increase in the postoperative score for heartburn. The 'learning curve' contributed significantly to the length of the procedure, and the need for reoperation.

Conclusions: Laparoscopic Heller myotomy is a technically challenging procedure that provides good early palliation of the symptoms associated with achalasia.