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Videoscopic Heller myotomy for achalasia--results beyond short-term follow-up.

BACKGROUND: Heller myotomy has long been utilized for patients failing nonoperative management of achalasia. Videoscopy has been advocated to decrease the morbidity of Heller myotomy; however, few reports document outcome beyond 1 year after videoscopic Heller myotomy.

PURPOSE: To determine perioperative morbidity, relief of dysphagia, and the incidence of postoperative reflux symptoms following videoscopic Heller myotomy with follow-up to over 4 years.

METHODS: Patients with achalasia documented by barium esophogram and esophageal manometry underwent videoscopic Heller myotomy beginning in 1992. Intraoperative peroral endoscopy was utilized to guide the cephalad and caudad extent of myotomy. A barium esophogram was undertaken in the immediate postoperative period to evaluate for subclinical leak and assess esophageal emptying.

RESULTS: Seventy-eight patients underwent videoscopic Heller myotomy. The mean age was 51 years +/- 19 (range 14 to 91). Most (62%) patients had undergone pneumatic dilation prior to surgical consultation and 54% had previous botox injections. All patients complained of dysphagia and 40% had symptoms of heartburn prior to myotomy. After myotomy, 91% of patients stated that their swallowing was improved with myotomy. Thirteen patients (18%) experience heartburn more than once per week after myotomy. The average length of stay was 2 +/- 2 days, with 72% of patients spending 2 days or fewer in the hospital. Six (7.7%) major complications occurred: five esophageal perforations and one enterotomy without long-term sequellae. Three procedures (3.8%) were converted to "open" procedures. No deaths occurred. We conclude that videoscopic Heller myotomy is safe and efficacious, with low morbidity and mortality. Videoscopic myotomy provides relief beyond the short term for dysphagia due to achalasia with minimal reflux symptoms. We advocate videoscopic Heller myotomy in the treatment of severe dysphagia due to achalasia not adequately palliated by or amenable to nonoperative management.

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