Long-term outcome of Heller myotomy in achalasic sigmoid esophagus

We sought to assess the long-term outcome of Heller myotomy and anterior fundoplication in patients with achalasic sigmoid esophagus.

Fourteen patients with achalasia and sigmoid esophagus (median age, 42.5 years) operated on by the same surgeon through a laparotomy (n = 8) or laparoscopic approach (n = 6) between 1985 and 2000 were evaluated. According to a 4-grade classification (1, no symptoms; 4, persistent symptoms), both dysphagia and regurgitation had a median score of 4.0. Five patients complained of respiratory symptoms. Six patients had undergone previous pneumatic dilation. Preoperative and postoperative workup included an esophagogram, esophagoscopy, manometry, and health-related quality-of-life assessment with the Short-Form 36-item questionnaire.

Median follow-up was 85 months. At 24 months, esophageal width decreased by 10 mm (P =.003), and the change correlated inversely with the age of the patients (R = -0.61; P =.02). Lower esophageal sphincter pressure decreased by 17 mm Hg (P =.001), and both dysphagia and regurgitation scores decreased to 1.0 (P <.003). Comparison with the results of 37 patients with earlier-stage achalasia showed no difference in changes of esophageal width, lower esophageal sphincter pressure, dysphagia score, and regurgitation score. Quality-of-life Short-Form 36-item questionnaire domains, including general health, social functioning, and vitality, improved significantly. Overall results were classified as excellent or good in 10 patients and as satisfactory and unsatisfactory in 2 patients each. No patient required esophagectomy or had esophageal carcinoma.

In this study Heller myotomy proved effective in improving subjective, objective, and quality-of-life outcome measures in patients with achalasic sigmoid esophagus and should be considered as the first-choice treatment for this severe condition.