Surgery for esophageal achalasia. long-term results with three different techniques

In surgery for achalasia, the length of the myotomy and the opportunity of associating an antireflux procedure are still debated. Prospective and comparative studies on different techniques are few. The aims of this work is to compare the long term results of three different techniques successively adopted by the same surgical group.

Between January 1955 and December 1991, 185 achalasic patients were submitted to myotomy by using in temporal sequence three different techniques. The first technique utilized (1955-1972) was a long esophagogastric abdominal myotomy (83 patients), secondly (1973-1978) a limited transthoracic myotomy (30 patients) and at last (1979-1991) a long esophagogastric abdominal myotomy associated to the Dor gastroplasty (72 patients). Since 1972, patients were prospectively followed up according to a protocol which included a clinical interview, x-rays, manometry and endoscopy at given dates. Post-operative esophagogastric transit and gastro-esophageal reflux were assessed to verify the therapeutical outcome. Results obtained with the three different techniques were analyzed and compared by using the actuarial Kaplan-Meier curves.

The mean follow up was 193.3 months for the patient group that underwent abdominal myotomy (62/83 patients), 137.3 months for the thoracic myotomy group (30/30 patients) and 86.9 months for the abdominal myotomy plus Dor gastroplasty group (69/72 patients). Long-term results in the abdominal myotomy and in the thoracic myotomy groups were respectively poor in 51.6% and in 46.6% of patients. Major causes of failure were insufficient myotomy (6.5%), periesophageal scarring (9.6%) and reflux esophagitis (22.6%) for the abdominal myotomy group; insufficient myotomy (20%) and reflux esophagitis (23%) for the thoracic myotomy group. In the abdominal myotomy plus Dor gastroplasty group long-term results were excellent or good in 87% of patients and poor in 13%. Reflux esophagitis (10% of cases) was the principal cause of failure.

The comparison of the actuarial curves shows a significantly better long term outcome for the abdominal myotomy plus Dor antireflux procedure than for the abdominal myotomy (p = 0.01) and for the thoracic myotomy (p = 0.002) techniques.