Manometric assessment of Heller-Dor operation for esophageal achalasia

The aim of this study was to evaluate changes occurring in esophageal motility through a systematic manometric study performed before, during and after Heller-Dor operation (8) and to correlate the possible post-operative symptoms to the manometric and pH-recording patterns detected, in order to provide useful elements that may optimize surgical therapy for esophageal achalasia.

Between January 1981 and January 1991, 27 patients affected by esophageal achalasia underwent Heller's operation with Dor's anti-reflux procedure. Assessment involved clinical, radiological and manometric investigations.

Intra-operative manometry was performed on 11 patients, in whom LES pressure reached values lower than 5 mmHg. Post-operative control, performed 2 years after operation on 25 patients, showed the complete absence of dysphagia in 22 (88%) and occasional dysphagia in 3 (12%). Post-operative manometry in all the patients showed a decreased LES resting pressure (from 32.6 to 7.2 mmHg, p < 0.001), LES residual pressure (from 16.4 to 5.0 mmHg, p < 0.001) and esophageal tone (from 4.8 to -3.5 mmHg, p < 0.001). Patients free of dysphagia presented LES basal and residual pressures lower than the other patients (6.2 and 4.6 vs 15.1 and 7.7 mmHg respectively, p < 0.01 and p < 0.05). 24-hour-esophageal pH-metry showed pathologic reflux in 3 patients with reflux symptoms and in 1 without symptoms. All had LES basal and residual pressures equivalent to non refluxing patients (5.7 and 5.0 vs 7.5 and respectively 4.9 mmHg, p = n.s. and p = n.s.). On the contrary, a difference was found in abdominal LES length between the two groups (0.5 vs 1.6 cm, p < 0.01). Patients with intra-operative manometry presented a lower incidence of residual dysphagia than patients without it (0% vs 21.5%), but a higher incidence of reflux (18.2% vs 7.3%).

Heller-Dor operation induces a definitive disappearance of dysphagia when it is complete in depth and length. Prevention of gastro-esophageal reflux requires the preservation of a sufficiently long portion of esophagus in the abdomen.