Background: Heller myotomy is the preferred mode of treatment for achalasia. The prevailing literature suggests that postoperative results are better when performed laparoscopically at large volume centers. We have been treating achalasia laparoscopically at the Scripps Clinic since 2001. A lack of data from smaller centers motivated us to conduct a retrospective analysis on our patients to compare the findings with published results.
Methods: Between 2001- 2006, 14 subjects were operated for Heller myotomy at Scripps Clinic. Four of these were redo operation from previous surgeries done elsewhere. The operation comprised of an 8-cm myotomy, which extended 2 cm onto the gastric wall. All except one received a Dor fundoplication. One subject received Toupet fundoplication because of a hiatal hernia. Data was analyzed for operative time, hospital stay, follow up and post operative complications.
Results: 14 patients underwent surgery for achalasia, majority being male (57%) with an overall median age of 35 yrs (std. dev. 16.35). Dysphagia, loss of weight, chest pain and heartburn were the presenting symptoms present for a mean duration of 3 years. A complete work up including esophagogram, pH study, manometry and esophagogastroduodenoscopy was done to confirm the diagnosis of achalasia before surgery. All procedures were completed laparoscopically. Our median operative time was 127.5 min (std. dev 22.16) with a median length of stay was 2 days (std. dev. 1.22). Intra-operatively, one esophageal rupture and one gastric perforation occurred (and treated laparoscopically) and there were no deaths. Subjects who underwent redo surgery had similar operative time but stayed longer (4 days vs. 2 days) than those who received primary Heller myotomy. Follow up was achieved in 92.8% patients with a median of 7 months (range 1- 60 months). 71.4% patients reported complete symptom resolution post operatively, supported by weight gain. Late complications and disease progression were seen in four subjects, two with end stage achalasia (sigmoid esophagus) and two with esophageal stricture. Balloon dilation in one patient and botox injection for the other was performed to treat esophageal stricture.
Conclusions: Results from our retrospective analysis for Heller myotomy performed at Scripps Clinic are similar to most of the published studies. We suggest that Heller myotomy done laparoscopically, can be performed at smaller centers by well trained laparoscopic surgeons and that longer follow up is required to detect late complications.