Abstract
Background
The standard Heller myotomy (SM) for achalasia extends 1 to 2 cm on to the stomach. The authors perform an extended myotomy (EM) (>3 cm) with the goal of reducing postoperative dysphagia. This study examines the long-term efficacy and durability of EM compared with SM.
Methods
Patients with achalasia who underwent a laparoscopic Heller myotomy were identified from a prospective database that includes symptom evaluation and results of esophageal functional studies. From September 1994 to August 1998, the authors performed SM with Dor fundoplication, and from September 1998 through 2003, they performed EM with Toupet fundoplication. In 2001, they performed a telephone survey of all available patients. This was repeated in 2005 for the EM group. The survey included scales of symptom frequency (0 [never], 1 [once per month], 2 [once per week], 3 [once per day], 4 [more than once per day]) and severity (0 [no symptoms] to 10 [symptoms equal to preoperative state]) as well as the need to undergo postoperative intervention for dysphagia.
Results
For this study, 52 patients underwent SM with Dor fundoplication (median follow-up period, 46 ± 24 months), and 63 patients underwent EM with Toupet fundoplication (median follow-up period, 45 ± 17 months. Postoperative dysphagia severity was significantly better in the EM group (4.8 ± 2.3 vs 3.1 ± 2.6; p < 0.005). There was no significant difference in postoperative heartburn frequency, esophageal acid exposure, or lower esophageal sphincter pressure. In the SM group, 9 patients (17%) required reintervention for dysphagia: 14 endoscopic interventions for 5 patients (10%) and reoperation for 4 patients. Three patients (5%) in the EM group required reintervention for dysphagia: one endoscopic intervention each and no reoperations (p < 0.05). A total of 30 patients in the EM group were contacted in both 2001 (median follow-up period, 19 ± 11 months) and 2005 (median follow-up period, 63 ± 10 months). There was no significant change over time in dysphagia severity (2.6 ± 1.9 vs 3.7 ± 2.0; p = 0.19).
Conclusions
For the treatment of achalasia, EM with Toupet fundoplication provides excellent durable dysphagia relief that is superior to SM with Dor fundoplication.
Similar content being viewed by others
References
Bortolotti M (1999) Medical therapy of achalasia: a benefit reserved for few. Digestion 60(1):11–16
Gelfond M, Rozen P, Gilat T (1982) Isosorbide dinitrate and nifedipine treatment of achalasia: a clinical, manometric, and radionuclide evaluation. Gastroenterology 83(5):963–969
Kadakia SC, Wong RK (1993) Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia. Am J Gastroenterol 88(1):34–38
West RL, Hirsch DP, Bartelsman JF, de Borst J, Ferwerda G, Tytgat GN, Boeckxstaens GE (2002) Long-term results of pneumatic dilation in achalasia followed for more than 5 years. Am J Gastroenterol 97(6):1346–1351
Csendes A, Braghetto I, Henriquez A, Cortes C (1989) Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut 30(3):299–304
Zaninotto G, Annese V, Costantini M, Del Genio A, Costantino M, Epifani M, Gatto G, D'Onofrio V, Benini L, Contini S, Molena D, Battaglia G, Tardio B, Andriulli A, Ancona E (2004) Randomized controlled trial of botulinum toxin versus laparoscopic Heller myotomy for esophageal achalasia. Ann Surg 239(3):364–370
Heller E (1913) Extramuköse Kardiaplastik beim chronischen Kardiospasmus mit dilatation des oesophagus. Mit Grenzab Med Chir 27:141–149
Costantini M, Zaninotto G, Guirroli E, Rizzetto C, Portale G, Ruol A, Nicoletti L, Ancona E (2005) The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up. Surg Endosc 19(3):345–351
Douard R, Gaudric M, Chaussade S, Couturier D, Houssin D, Dousset B (2004) Functional results after laparoscopic Heller myotomy for achalasia: a comparative study to open surgery. Surgery 136(1):16–24
Khajanchee YS, Kanneganti S, Leatherwood AE, Hansen PD, Swanstrom LL (2005) Laparoscopic Heller myotomy with Toupet fundoplication: outcomes predictors in 121 consecutive patients. Arch Surg 140(9):827–833, discussion 833–824
Ellis FH Jr, Gibb SP, Crozier RE (1980) Esophagomyotomy for achalasia of the esophagus. Ann Surg 192(2):157–161
Pellegrini C, Wetter LA, Patti M, Leichter R, Mussan G, Mori T, Bernstein G, Way L (1992) Thoracoscopic esophagomyotomy: initial experience with a new approach for the treatment of achalasia. Ann Surg 216(3):291–296, discussion 296–299
Oelschlager BK, Chang L, Pellegrini CA (2003) Improved outcome after extended gastric myotomy for achalasia. Arch Surg 138(5):490–495, discussion 495–497
Ali A, Pellegrini CA (2001) Laparoscopic myotomy: technique and efficacy in treating achalasia. Gastrointest Endosc Clin North Am 11(2):347–358, vii
Horgan S, Pellegrini CA (1997) Surgical treatment of gastroesophageal reflux disease. Surg Clin North Am 77(5):1063–1082
Di Martino N, Monaco L, Izzo G, Cosenza A, Torelli F, Basciotti A, Brillantino A (2005) The effect of esophageal myotomy and myectomy on the lower esophageal sphincter pressure profile: intraoperative computerized manometry study. Dis Esophagus 18(3):160–165
Bonatti H, Hinder RA, Klocker J, Neuhauser B, Klaus A, Achem SR, de Vault K (2005) Long-term results of laparoscopic Heller myotomy with partial fundoplication for the treatment of achalasia. Am J Surg 190(6):874–878
Patti MG, Pellegrini CA, Horgan S, Arcerito M, Omelanczuk P, Tamburini A, Diener U, Eubanks TR, Way LW (1999) Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg 230(4):587–593, discussion 593–584
Dempsey DT, Delano M, Bradley K, Kolff J, Fisher C, Caroline D, Gaughan J, Meilahn JE, Daly JM (2004) Laparoscopic esophagomyotomy for achalasia: does anterior hemifundoplication affect clinical outcome? Ann Surg 239(6):779–785, discussion 785–777
Richards WO, Sharp KW, Holzman MD (2001) An antireflux procedure should not routinely be added to a Heller myotomy. J Gastrointest Surg 5(1):13–16
Richards WO, Torquati A, Holzman MD, Khaitan L, Byrne D, Lutfi R, Sharp KW (2004) Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 240(3):405–412, discussion 412–405
Falkenback D, Johansson J, Oberg S, Kjellin A, Wenner J, Zilling T, Johnsson F, Von Holstein CS, Walther B (2003) Heller’s esophagomyotomy with or without a 360 degrees floppy Nissen fundoplication for achalasia: long-term results from a prospective randomized study. Dis Esophagus 16(4):284–290
Wills VL, Hunt DR (2001) Functional outcome after Heller myotomy and fundoplication for achalasia. J Gastrointest Surg 5(4):408–413
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Wright, A.S., Williams, C.W., Pellegrini, C.A. et al. Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia. Surg Endosc 21, 713–718 (2007). https://doi.org/10.1007/s00464-006-9165-9
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-006-9165-9