Laparoscopic limited Heller myotomy without anti-reflux procedure does not induce significant long-term gastroesophageal reflux
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Laparoscopic Heller myotomy with partial fundoplication is the gold standard treatment for achalasia. Laparoscopic limited Heller myotomy (LLHM) with no anti-reflux procedure is another possible option.
A review of prospectively collected data was performed on patients who underwent LLHM from January 1998 to December 2012. Evaluation included gastroscopy, esophageal manometry, 24-h pH-metry, and the Short Form(36) Health Survey(SF-36) questionnaire at baseline and 6 months, as well as the global symptom score at baseline, 6 months, and 5 years post-surgery. Comparison between outcomes was performed with a paired t student’s test.
126 patients underwent LLHM. Of these, 60 patients had complete pre and post-operative motility studies. 57 % were female, patient mean age was 45.7 years, with a mean follow-up of 10.53 months. Mean operative time was 56.1 min, and the average length of stay was 1.7 days. At 6 months, a significant decrease in the lower esophageal sphincter resting pressure (29.1 vs. 7.1 mmHg; p < 0.001) and nadir (16.4 vs. 4.3 mmHg; p < 0.001) was observed. Normal esophageal acid exposure (total pH <4 %) was observed in 68.3 % patients. Nevertheless, of the remaining 31.7 % with abnormal pH-metry, only 21.6 % were clinically symptomatic and all were properly controlled with medical treatment without requiring anti-reflux surgery. Significant improvement in all pre-operative symptoms was observed at 6 months and maintained over 5 years. Dysphagia score was reduced from 9.8 pre-operatively to 2.6 at 5 years (p < 0.001), heartburn score from 3.82 to 2 (p < 0.01), and regurgitation score from 7.5 to 0.8 (p < 0.001). Only one patient (0.8 %) presented with recurrent dysphagia requiring reoperation.
LLHM without anti-reflux procedure is an effective long-term treatment for achalasia and does not cause symptomatic GERD in three quarters of patients. The remaining patients are well controlled on anti-reflux medications. It is believed that similar clinical results would be obtained during a clinical investigation of the POEM procedure.
KeywordsAchalasia Limited Heller myotomy Fundoplication Gastroesophageal reflux Peroral endoscopic myotomy
Zurita Macías Valadez, Pescarus, Hsieh, Wasserman, Apriasz, Hong, Gmora, Cadeddu, Anvari have no conflict of interest or any financial ties to disclose with relevance to this study.
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