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A Thousand and One Laparoscopic Heller Myotomies for Esophageal Achalasia: a 25-Year Experience at a Single Tertiary Center

  • 2018 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

The aim of this study was to assess the long-term outcome of laparoscopic Heller-Dor (LHD) myotomy to treat achalasia at a single high-volume institution in the past 25 years.

Methods

Patients undergoing LHD from 1992 to 2017 were prospectively registered in a dedicated database. Those who had already undergone surgical or endoscopic myotomy were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium swallow, endoscopy, and manometry were performed before and after surgery; and 24-h pH monitoring was done 6 months after LHD.

Results

One thousand one patients underwent LHD (M:F = 536:465), performed by six staff surgeons. The surgical procedure was completed laparoscopically in all but 8 patients (0.8%). At a median of follow-up of 62 months, the outcome was positive in 896 patients (89.5%), and the probability of being cured from symptoms at 20 years exceeded 80%. Among the patients who had previously received other treatments, there were 25/182 failures (13.7%), while the failures in the primary treatment group were 80/819 (9.8%) (p = 0.19). All 105 patients whose LHD failed subsequently underwent endoscopic pneumatic dilations with an overall success rate of 98.4%. At univariate analysis, the manometric pattern (p < 0.001), the presence of a sigmoid megaesophagus (p = 0.03), and chest pain (p < 0.001) were the factors that predicted a poor outcome. At multivariate analysis, all three factors were independently associated with a poor outcome. Post-operative 24-h pH monitoring was abnormal in 55/615 patients (9.1%).

Conclusions

LHD can durably relieve achalasia symptoms in more than 80% of patients. The pre-operative manometric pattern, the presence of a sigmoid esophagus, and chest pain represent the strongest predictors of outcome.

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Acknowledgments

The authors acknowledge all the other surgeons who performed LHD at the Padova University Department of Surgery during the study period: Ermanno Ancona (1992–2012), Mauro Rossi (1992–2001), Giovanni Zaninotto (1995–2007), Christian Rizzetto (2009). Without their work and dedication, this study would not have been possible.

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Authors and Affiliations

  1. Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy

    Mario Costantini, Renato Salvador, Giovanni Capovilla, Lorenzo Vallese, Loredana Nicoletti, Dario Briscolini, Michele Valmasoni & Stefano Merigliano

  2. School of Medicine, Università Cattolica Sacro Cuore, Rome, Italy

    Andrea Costantini

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  1. Mario Costantini
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  2. Renato Salvador
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  3. Giovanni Capovilla
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  4. Lorenzo Vallese
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  5. Andrea Costantini
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  6. Loredana Nicoletti
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  9. Stefano Merigliano
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Contributions

Study design: Costantini M, Salvador, Briscolini, Merigliano

Data acquisition: Salvador, Vallese, Briscolini, Capovilla, Valmasoni, Nicoletti, Costantini A

Data interpretation: Costantini M, Salvador, Briscolini, Merigliano

Drafting of manuscript: Costantini M, Salvador, Costantini A, Vallese, Briscolini, Valmasoni, Capovilla, Nicoletti, Merigliano

Final approval: Costantini M, Salvador, Vallese, Briscolini, Capovilla, Valmasoni, Costantini A, Nicoletti, Merigliano

Agreement to be accountable for all aspects of the work: Costantini M, Salvador, Vallese, Briscolini, Capovilla, Valmasoni, Costantini A, Nicoletti, Merigliano

Corresponding author

Correspondence to Mario Costantini.

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Costantini, M., Salvador, R., Capovilla, G. et al. A Thousand and One Laparoscopic Heller Myotomies for Esophageal Achalasia: a 25-Year Experience at a Single Tertiary Center. J Gastrointest Surg 23, 23–35 (2019). https://doi.org/10.1007/s11605-018-3956-x

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  • DOI: https://doi.org/10.1007/s11605-018-3956-x

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