[Heller's intervention for esophageal achalasia]

From 1962 to 1992 sixtythree patients with esophageal achalasia underwent primary surgical treatment. The intervention performed was a cardiomiotomy according to Heller in 20 patients (Group A), a cardiomiotomy according to Heller with anti-reflux procedure according to Lortat-Jacob in 12 patients (Group B), a cardiomiotomy according to Heller with fundoplicatio according to Dor in 31 patients (Group C). Preoperative study was performed by radiological evaluation in patients of Group A, while patients of Group B and Group C were submitted also to endoscopy and esophageal manometry. Postoperative evaluation in Group A was performed by clinical and endoscopical controls, while in Groups B and C by clinical and radiological studies 6 months after the intervention and by clinical and endoscopical studies every two years. During the early two years after operation a functional study (esophageal manometry and esophagogastric pH-monitoring) was performed. The follow-up was complete for 13 patients of Group A, 10 patients of Group B and 28 patients of Group C. Good results (complete absence or slight dysphagia) have been obtained in 70% of Group A, in 90% of Group B and 90% of Group C. Esophageal manometry found a decrease of both resting pressure and length in every patient in Groups B and C. Gastro-esophageal reflux symptoms were found in 15% of Group A, 20% of Group B and 11% of Group C. A various degree of esophagitis was found by endoscopy in 40% of Group A, 50% of Group B and 18% of Group C. Esophago-gastric pH-monitoring, performed in Group C patients, showed pathologic refluxes in 22% of the subjects. The clinical and functional study demonstrates that Heller's cardiomiotomy, in the way it is performed nowadays (complete miotomy over 7 cm of the esophagus and 3-4 cm of the stomach), allows the complete disappearance of dysphagia. On the other side the anti-reflux procedures till now performed (including the 180 degrees fundoplicatio according to Dor) are not effective enough to avoid post-operative gastro-esophageal reflux.