Laparoscopic Heller myotomy relieves dysphagia in patients with achalasia and low LES pressure following pneumatic dilatation.

BACKGROUND: Although pneumatic dilatation is said to relieve dysphagia in achalasia if it decreases lower esophageal sphincter (LES) pressure to 10 mmHg (n = 23); group C, no previous balloon dilatation and LES pressure >10 mmHg (n = 25). All patients underwent a laparoscopic Heller myotomy and Dor fundoplication. The severity of dysphagia was gauged on a scale of 0-4.

RESULTS: In group A, LES pressure was 7 +/- 2 mmHg preoperatively and 8 +/- 3 mmHg postoperatively; the dysphagia score was 3.3 +/- 0.7 preoperatively and 0.9 +/- 1.1 postoperatively. Eighty-nine percent of patients had excellent or good results. In group B, LES pressure was 23 +/- 8 mmHg preoperatively and 10 +/- 1 mmHg postoperatively; the dysphagia score was 3.3 +/- 0.7 preoperatively and 0.3 +/- 0.5 postoperatively. All patients had excellent or good results. In group C, LES pressure was 23 +/- 11 mmHg preoperatively and 14 +/- 12 mmHg postoperatively; the dysphagia score was 3.6 +/- 0.6 preoperatively and 0.2 +/- 0.5 postoperatively. All patients had excellent or good results.

CONCLUSIONS: These results show that (a) a LES pressure of <10 mmHg after pneumatic dilatation does not guarantee relief of dysphagia, and (b) laparoscopic Heller myotomy relieves dysphagia in most patients with a postdilatation LES pressure <10 mmHg. Thus, a laparoscopic Heller myotomy is indicated if dilatation does not relieve dysphagia, even if LES pressure has been decreased to <10 mmHg. Esophagectomy should be reserved for the occasional failure of this simpler operation.