Comparison of thoracoscopic and laproscopic esophagomyotomy with fundoplication for primary motility disorders

With the introduction of videoscopic techniques, controversy has arisen whether a thoracoscopic or laproscopic approach is indicated for the surgical management of symptomatic primary motility disorders. The aim of this study was to compare the outcomes of the two techniques performed by one group.

Between 1995 and 1997, 78 patients (42 female, 36 males: ages 21-86; mean 53 years) underwent a videoscopic esophagomyotomy with fundoplication via a thoracic (12) or abdominal (66) approach for dysphagia or chest pain. Pre-operative evaluation with esophagogastroscopy and manometry revealed a primary motility disorder in 64 and primary motility disorder with stricture in 14. Primary motility disorders exhibited were hypertensive LES (25), nutcracker (26), achalasia (14), and diffuse esophageal spasm (13). Associated fundoplications to prevent reflux included abdominal Toupet partial fundoplicatio (52), abdominal Nissen (14) and thoracic Belsey (12). Significance of variation in outcomes was determined by Mann-Whitney U-test.

There was no mortality. Follow-up ranged from 6-40 months (mean = 18). Early morbidity included dyshagia--chest pain greater than 6 weeks in 16 patients. (5 Belsey 41%, 10 Toupet 19%, 1 Nissen 7%) Late morbidity included three recurrent strictures requiring dilatation (Belsey 2/5, Toupet 1/7). Two patients (3.1%) experienced a recurrent motility disorder after abdominal short myotomy--Toupet. Five patients experienced postoperative gastroesophageal reflux after partial fundoplication (two Belsey = 16.6%, three Toupet = 5.7%). Overall 63 patients (81%) were completely relieved of dysphagia--chest pain.

Thoracoscopic esophagomyotomy with Belsey fundoplication was associated with a significantly higher incidence of post-operative dysphagia--chest pain (P = 0.05) and recurrent stricture (P = 0.01 ) than laproscopic esophagomyotomy with partial or total fundoplication, however, there was no significant difference in the incidence of recurrent motility disorders (P = 0.54) or gastroesophageal reflux disease (P = 0.12) between the techniques. Our results support utilization of a laproscopic approach for primary motility disorders.