Objectives: In some centers, esophagectomy is performed in patients with achalasia who have a dilated esophagus, on the assumption that a myotomy cannot resolve dysphagia. This study aimed to compare the results of laparoscopic Heller myotomy and Dor fundoplication in 139 patients with and without esophageal dilatation.
Methods: On the basis of the maximal diameter of the esophageal lumen and the shape of the esophagus, the patients were placed into four groups: group A (esophageal diameter <4.0 cm; 54 patients), group B (diameter 4.0-6.0 cm; 42 patients), group C1 (diameter >6.0 cm and straight esophageal axis; 30 patients), and group C2 (diameter >6.0 cm and sigmoid-shaped esophagus; 13 patients). All patients underwent a laparoscopic Heller myotomy and Dor fundoplication. The median length of follow-up was 15 months (range 1 month to 10 years).
Results: The postoperative morbidity and length of hospital stay was similar among the four groups. Fifteen patients (11%) underwent an average of 2.4 dilatations postoperatively. Eleven patients (8%) required more than one myotomy. Excellent or good results were obtained in 96% of group A, 95% of group B, 93% of group C1, and 92% of group C2. No patient in this consecutive series ultimately required an esophagectomy.
Conclusions: In patients with achalasia who have esophageal dilation, a laparoscopic Heller myotomy and Dor fundoplication (a) was not more difficult, (b) was associated with no more postoperative complications, and (c) gave just as good relief of dysphagia. Based on this data, we feel that the majority of patients with achalasia can be successfully treated without esophagectomy.