Heller myotomy via minimal-access surgery. An evaluation of antireflux procedures.

BACKGROUND: Myotomy offers the best known cure for achalasia and can now be performed via minimal-access surgery.

OBJECTIVE: To examine the questions of surgical approach for Heller myotomy and choice of fundoplication in the setting of minimal-access surgery.

DESIGN: Thirty-nine patients with achalasia underwent Heller myotomy via either thoracoscopy or laparoscopy, with either a Dor or a Toupet fundoplication (Heller-Dor and Heller-Toupet procedures, respectively). Manometry, pH analysis, and clinical course were evaluated 3 to 9 months after surgery. Clinical course was reviewed at 11 to 46 months after surgery.

SETTING: University hospitals.

PATIENTS: Diagnosis of achalasia was based on history and physical examination, contrast radiography, stationary manometry, and 24-hour pH analysis. All patients participated in the clinical evaluations. Twenty-two patients consented to postoperative manometry and 18 to postoperative pH analysis.

INTERVENTIONS: Thoracoscopic Heller-Dor procedures (n = 4), laparoscopic Heller-Dor procedures (n = 6), and laparoscopic Heller-Toupet procedures (n = 29).

MAIN OUTCOME MEASURES: Hospital stay and recovery time were compared between thoracoscopic and laparoscopic groups. Decrease in the lower esophageal sphincter pressure, 24-hour esophageal pH, postoperative symptoms, and overall satisfaction were compared between the Dor and Toupet groups.

RESULTS: Only 1 patient was dissatisfied with the experience. Patients undergoing thoracoscopy had a longer convalescence. No postoperative reflux was identified, although some patients complained of heartburnlike symptoms. Dysphagia and heartburn were more prevalent among patients with Dor fundoplication than among patients with Toupet fundoplication.

CONCLUSIONS: Minimal-access myotomy is an excellent intervention for achalasia. The preferred approach is via laparoscopy. Our experience has led us to favor the Toupet over the Dor fundoplication after myotomy.