Minimally invasive surgical treatment of esophageal achalasia

A minimally invasive approach is considered the treatment of choice for esophageal achalasia. We report the evolution of our experience from thoracoscopic Heller myotomy (THM) to laparoscopic Heller myotomy (LHM). Our objective is to define the efficacy and safety of these 2 approaches.

Between March 1993 and December 2001, 36 patients underwent minimally invasive surgery for achalasia. Sixteen patients underwent THM without an antireflux procedure, and 20 patients underwent LHM with partial anterior fundoplication (n = 13) or closure of the angle of His (n = 7).

Mean operative time and mean hospital stay were significantly shorter for LHM compared with that of THM (148.3 +/- 38.7 vs 222 +/- 46.1 min, respectively; P = 0.0001) and (2.06 +/- 0.65 days vs 5.06 +/- 0.85 days, respectively; P = 0.0001). Six of 16 patients (37.5%) in the THM group experienced persistent or recurrent dysphagia compared with 1 of 20 patients (5%) in the LHM group (P = 0.01). Heartburn developed in 5 patients (31.2%) after THM and in 1 patient (5%) after LHM (P = 0.06). Regurgitation developed in 4 patients (25%) after THM and in 2 patients (10%) after LHM (P = 0.2). Lower esophageal sphincter (LES) basal pressure decreased significantly from 30.1 +/- 5.07 to 15.3 +/- 2.1 after THM and from 31.8 +/- 6.2 to 10.4 +/- 1.7 after LHM (P = 0.0001). Mean esophageal diameter was significantly reduced after LHM compared with that after THM (from 53.9 +/- 5.9 mm to 27.2 +/- 3.3 mm vs 50.8 +/- 7.6 mm to 37.2 +/- 6.9 mm respectively: P = 0.0001).

In our experience, LHM is associated with better short-term results and is superior to THM in relieving dysphagia. LHM with partial anterior fundoplication should be considered the treatment of choice for achalasia.