Abstracts
1999 Digestive Disease Week

# 4677 ONE-HUNDRED LAPAROSCOPIC HELLER-DOR OPERATIONS: OUR EXPERIENCE IN TREATING PRIMARY ESOPHAGEAL ACHALASIA
Mario Costantini, G Zaninotto, D Molena, F Buin, L Nicoletti, E Ancona, Univ of Padua Italy

From 1992 to November 1998, 100 patients with primary esophageal achalasia underwent laparoscopic Heller myotomy plus Dor fundoplication. They were 56 males and 44 females, with a median age of 39 years (range: 14-73) and a median duration of symptomes of 24 months (r.: 6-240). Only 10 of them had had a previous unsuccessful endoscopic treatment (dilations and/or BotoxÒ injections). Ninety-four patients had the operation completed through the laparoscopic approach, whereas in 6 cases the operation was completed through a laparotomy. The median operative time was 150 min. (r.: 100-260). We recorded 5 intraoperative complications (4 mucosal tears, 1 spleen, damage). Overall morbidity accounted for 5.2%. No mortality was recorded. The median hospital stay was 4 days (r.: 3-16), and the patients returned to work within two weeks after the operation. No patients were lost to follow up. Overall median follow-up was 20.5 months, and 60 patients had a follow-up greater than 12 months. Long-term satisfactory results were achieved in 93 patients: 72 were free of dysphagia whereas 21 had minimal, occasional dysphagia. The median weight increase was 5 Kg, with a maximum of 30 Kg. A significant reduction in the esophageal radiological diameter, in the LES resting tone and LES residual pressure at swallowing was observed after the operation (p<0.01). Post-operative pH-monitoring showed abnormal acid reflux in 4 of the 63 tested patients (6.3%). Failure of the surgical treatment was observed in 7 patients: in all but one the recurrence of symptoms occurred early after surgery, and was related to an incomplete myotomy, being in the last patients due to fibrosis at the GE junction. Recurrence of symptoms was successfully addressed with pneumatic dilations (median 3 per patient, r.: 2-6) with Rigiflex 3.5 and 4.0 cm balloon dilators. Pre-operative clinical, morphological and functional parameters did not differ between patients with satisfactory results and patients with failure of surgical treatment. A similar decrease in the LES pressure was observed in both group of patients. The only functional difference was the appearance of partial peristaltic activity at 24-hour motility testing in patients with good results. Further, patients with good results had a greater reduction in the radiological caliber of the gullet than patients with recurrence of symptoms. In conclusion, laparoscopic Heller-Dor operation allows primary control of dysphagia in 93% of the treated patients, with a low morbidity. The complementary pneumatic dilation of surgical failures increases the success rate to 99%. Post-operative reflux represents a complication in 6.3% of patients. These figures are similar to the results of the well established ''open'' procedure, and superior to those achievable with the sole endoscopic treatment. Thus, laparoscopic myotomy and fundoplication represents the treatment of choice for esophageal achalasia.

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