Laparoscopic anterior cardiomyotomy plus anterior Dor fundoplication without division of lateral and posterior periesophageal anatomic structures for treatment of achalasia of the esophagus

Abstract

Laparoscopic cardiomyotomy is the treatment of choice for patients with achalasia of the esophagus. Several different techniques and modifications have been reported concerning the approach (thoracoscopic or laparoscopic), type and length of the myotomy, with or without fundoplication, type of fundoplication, etc. In this prospective study, we report our simplified technique for anterior cardiomyotomy with Dor fundoplication and the results obtained using this procedure. Only the anterior wall of the esophagus was exposed without dissection of the lateral or posterior periesophageal anatomic structures for the technique. Twenty-five patients were operated by a single surgeon. The diagnosis was based on the clinical, radiologic, endoscopic, and functional esophageal tests. Achalasia was classified into 3 types: achalasia type I was diagnosed in 5 patients, type II in 6 patients, and type III in 14 patients. Manometry demonstrated a mean resting pressure of 33.5 mm Hg (range, 18 to 55), associated with incomplete relaxation. The hospital stay was 3 days; the median operative time was 115 minutes (range, 90 to 150), 2 small mucosal perforations occurred which were immediately sutured during surgery without conversion into open technique and no postoperative complications occurred. After operation, lower esophageal sphincter pressure returned to normal values and complete relaxation in all patients. In type II and III achalasia, the esophageal body diameter decreased more than 50% (P=0.001) compared with the preoperative diameter, and the internal diameter of the esophagogastric junction increased significantly (P=0.001). Only 2 patients presented occasional heartburn and 2 patients received 1 session of hydrostatic dilatation due to mild residual dysphagia. No late recurrence of dysphagia has been observed to the present time (1 to 5 y of follow-up). In conclusion, the goals of the surgery for achalasia are obtained with this simplified technique.