Laparoscopic myotomy for oesophageal achalasia--adding an antireflux procedure is not always necessary

Laparoscopy is the access of choice for functional surgery of the gastroesophageal junction, and oesophagocardiomyotomy, as the conventional surgical treatment of achalasia, is one of the favourable indications for laparoscopic surgery. Laparoscopic anterior myotomy technique is highly effective and secure for relieving dysphagia with minimal risk of gastroesophageal reflux. Fifteen patients with the diagnosis of achalasia were treated with laparoscopic anterior face oesophagocardiomyotomy without a concomitant antireflux procedure. There was not any perioperative complication and no procedure was converted to open operation. Oesophageal cineradiography, manometry and 24-h pH monitoring were repeated postoperatively. Manometry showed a significant reduction of the resting tone (48-34.4 to 18-3.2 mmHg), and patients were free of symptoms for reflux and dysphagia at the follow-up between 8 and 96 (median 42) months. Only one patient needed pneumatic dilation, 1 year after the operation for mild dysphagia, and one patient had moderate reflux, which was managed by medication. Thanks to minimal invasive technique of laparoscopic surgery and intraoperative endoscopy, oesophagocardiomyotomy can safely be performed in a length needed without dividing lateral and posterior phrenoesophageal ligamentous attachments. Consequently, adding an antireflux procedure routinely is not necessary. We advocate laparoscopic anterior oesophagocardiomyotomy alone as the first-line treatment for achalasia.