Abstracts
1997 Digestive Disease Week

Comparison of thoracoscopic and laparoscopic Heller myotomy for achalasia.

MG Patti, M De Pinto, M Arcerito, J Tong, CV Feo, W Gantert, LW Way. Department of Surgery, University of California, San Francisco.

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the H1 operation have appeared in earlier publications, but it is used here as controls for comparison with the unpublished H2 data.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.