Introduction. Surgical treatment of Achalasia is currently the best option to alleviate this disease. Laparoscopic Heller myotomy has been extensively used worldwide combined with different types of antirreflux procedures or alone. However, advanced stages of Achalasia with extensive dilation of the esophagus require a more aggressive therapy. In this study we review our surgical experience with emphasis on the indication based on the radiological findings.
Methods: 134 patients were operated between 1994 and 2006. All patients were categorized between Grade I and IV, following the Ressano-Malenchini-Lemberg radiological classification. 112 patients (4 Grade I, 81 Grade II, 27 Grade III) underwent laparoscopic Heller myotomy with 180ο (n=78) or 270ο (n=34) funduplication. 14 patients (1 Grade II, 6 Grade III, 7 Grade IV) underwent a mid laparotomic cardioplasty (n=3), an extensive dissection of the esophagus (n=5) or a total esophagectomy (n=6). 8 patients had a recurrent Achalasia and a laparotomic re-Heller was performed. Median follow-up was 32 months and complications as well as therapeutic success (absence of dysphagia) were assessed during that period.
Results: Out of the 112 laparoscopic procedures, 6 required conversion to laparotomic approach (5.3%). Intraoperative mucosal lesion was detected in 9 patients (8%). 5 of them were sutured laparoscopically and 4 required conversion. There was a 90.6% of therapeutic success with only 8.5% of the patients (n=9) manifesting a relapse of symptoms (dysphagia). 8 out of 9 of those patients underwent pneumatic dilation with a 30mmHg balloon catheter and 1 required re-operation. Overall mortality was 0.9% due to acute myocardial infarction. All patients with advanced disease had a favorable outcome with major procedures.
Discussion: Surgical treatment of Achalasia is a suitable option for a definitive treatment of a complex pathology. Preoperative classification and understanding of the anatomical findings is essential to decide the best surgical approach. Laparoscopic Heller myotomy is a safe procedure with low morbidity and excellent outcome in majority of patients. Advanced cases, requiring a more aggressive treatment, can be safely treated obtaining satisfactory results.