Oesophagomyotomy for achalasia: A 22-year experience

Abstract

To determine the clinical results in achalasia, particularly as regards postoperative gastro-oesophageal reflux, a 22-year personal experience with transthoracic short oesophagomyotomy without an antireflux procedure was analysed. A total of 185 such procedures were performed, of which 179 (97 per cent) were available for analysis. There was an overall improvement rate of 89 per cent over a mean postoperative interval of 9 years. Primary procedures were followed by a 93 per cent rate of improvement. Twenty patients, nine of whom had previously undergone one or more oesophageal operations, were considered as having a poor result. Marked gastro-oesophageal reflux accounted for a poor outcome in nine patients. Although the overall rate of postoperative improvement did not deteriorate significantly with time, the level of improvement did, the proportion of excellent results declining from 54 to 32 per cent (P = 0.02) at 10-20 years after operation. These findings substantiate the view that a short transthoracic oesophagomyotomy without an antireflux procedure provides excellent long-term relief of dysphagia for the patient with oesophageal achalasia and is accompanied by an extremely low risk of serious postoperative gastro-oesophageal reflux.

Resultados tardios da operação de Heller associada à fundoplicatura no tratamento do megaesôfago: análise de 83 casos

“…Tal fato fica mais evidente com a constatação que dois (2,4%) dos nossos doentes assintomáticos apresentavam esôfago de Barrett. Alguns autores 8,19 preconizam a miotomia curta, sem atingir o estômago, o que garantiria a integridade parcial do esfíncter e eliminaria a necessidade de realização de válvula anti-refluxo, mesmo correndo o risco de persistência da disfagia 19 . O mesmo ocorre com as fundoplicaturas totais, que exibem menores índices de refluxo, porém piores resultados frente à disfagia 17 .…”

“…No paciente submetido a fundoplicatura e miotomia também esse seguimento deve ser regra, pois a ocorrência de câncer também está descrita nesses doentes 3,7,11,16,19 , como pudemos observar em nossa casuística, já que dois (2,4%) doentes desenvolveram câncer do esôfago na evolução pós-operatória, dois e quatro anos após a cirurgia. O uso do lugol é descrito como forma de detecção precoce da neoplasia, porém, não foi empregado em nenhum de nossos casos.…”

Minimally invasive surgery for esophageal achalasia

“…Ellis, the pioneer of the transthoracic approach, advocated a limited (< 1 cm) gastric myotomy without an antireflux procedure. However, at a very late follow-up the level of symptomatic improvement markedly deteriorated over time with this approach, and the rate of excellent results (i.e., asymptomatic patients) progressively decreased from 54% at 10 years to 32% at 20 years [8] . The majority of European surgeons have instead favored the transabdominal approach which includes a longer gastric myotomy (1 to 2 cm) and a fundoplication to protect the esophagus from iatrogenic gastroesophageal reflux.…”

Revisional Surgery after Heller Myotomy for Treatment of Achalasia: A Comparative Analysis Focusing on Operative Approach

“…Interestingly, this study showed that surgeons performing Heller myotomy as a primary procedure have also performed an additional procedure at the same time, the most likely reason being to prevent postoperative reflux. Procedures such as truncal vagotomy [10,11], pyloroplasty [10,11,16], cardioplasty [10], antrectomy [11,12,21,27], Belsey repair [14,26,27,32], and roux-en-Y gastrojejunostomy [12,21,23,27,30] have been documented.…”