100 consecutive minimally invasive Heller myotomies: lessons learned

Area of Science:

• Gastroenterology
• Minimally Invasive Surgery
• Esophageal Motility Disorders

Background:

• Achalasia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter.
• Traditional treatment often involved open surgical myotomy, which can be associated with significant morbidity.
• Minimally invasive approaches, such as laparoscopic Heller myotomy, have emerged as alternatives.

Purpose of the Study:

• To evaluate the outcomes of the first 100 patients treated for achalasia using a minimally invasive approach.
• To assess the efficacy and safety of laparoscopic and thoracoscopic Heller myotomies.
• To correlate patient outcomes with objective measurements like lower esophageal sphincter pressure.

Main Methods:

• A retrospective review of 100 patients (95 laparoscopic, 5 thoracoscopic Heller myotomies) with manometrically confirmed achalasia.
• Patients underwent myotomy with or without an antireflux procedure.
• Outcomes were assessed via patient questionnaires and esophageal manometry, including 24-hour pH monitoring in a subset of patients.

Main Results:

• 93% of patients reported satisfactory relief of dysphagia.
• Eight intraoperative perforations and four conversions to open surgery occurred.
• Postoperative lower esophageal sphincter pressure (LESP) decreased significantly (37 to 14 mm Hg), with lower LESP (<18 mm Hg) correlating with better symptom relief.
• Heartburn was reported as moderate to severe in 14% of patients.

Conclusions:

• Minimally invasive Heller myotomy for achalasia yields results comparable to historical open surgical outcomes.
• A postoperative LESP of 18 mm Hg or less is associated with the best patient outcomes.
• Antireflux procedures are generally not required after Heller myotomy, as abnormal esophageal acid exposure is uncommon.