For 3 decades experts have argued the relative merits of two methods of
performing Heller myotomy for achalasia: 1) a myotomy (H1) that extends only a
few mm onto the stomach, done without an antireflux procedure; and 2) one (H2)
that extends farther (1.5 cm) onto the stomach, done with an antireflux
procedure. We compared the results of these two operations in 60 patients (H1,
30 pts; H2, 30 pts) treated between 1991 and 1996. The H1 operations were
performed thoracoscopically and the H2 operations laparoscopically. The
antireflux procedure was a Dor anterior fundoplication. Some of the data
regarding the H1 operation have appeared in earlier publications, but it is used
here as controls for comparison with the unpublished H2 data. The H1 and H2
groups were similar with respect to demographic characteristics, clinical
findings, and extent of manometric abnormalities.
Routine preoperative pH monitoring revealed five H2 patients whose reflux
score exceeded 30 (normal < 15), all of whom had been treated by balloon
dilatation; reflux was suspected by the clinical findings in only two of these
patients.
Thoracoscopic Laparoscopic
Results Heller (H1) Heller and Dor (H2)
(30 pts) (30 pts)
Excellent (no dysphagia) 70% 77%
Good (dysphagia < once/week) 17% 13%
Duration of operation (minutes) 150±16 166±10
Hospital stay (hours) 84 42
Abnormal GER (% pts) 20 3
Six of the seven patients in whom abnormal GER was identified
postoperatively were asymptomatic.
These data lead us to conclude that the H2 operation was superior to the H1
operation. Both relieve dysphagia. But even though the extent of the myotomy was
strictly limited in the H1 operation (using esophagoscopic control), only the H2
operation reliably avoided postoperative reflux. Furthermore, the H2 operation
even corrected pre-existing reflux that had resulted from balloon dilatation.
Finally, the patients were more comfortable and left the hospital earlier after
the H2 compared with the H1 myotomy.
