Management of achalasia with transabdominal esophagocardiomyotomy and partial posterior fundoplication

Results after laparoscopic Heller-Dor operation for esophageal achalasia in 100 consecutive patients

The laparoscopic Heller-Dor operation has been the procedure of choice for the treatment of achalasia. However, because the incidence of achalasia is low, reports on the outcome of surgical treatment for achalasia are limited. In this study, the therapeutic results after laparoscopic Heller-Dor operation for achalasia at a single university hospital were evaluated. Between August 1994 and July 2006, 100 consecutive patients underwent laparoscopic Heller-Dor operation. The therapeutic results after laparoscopic Heller-Dor operation were assessed based on complications, operation time, blood loss, postoperative hospital stay, and the standardized questionnaire for satisfaction by telephone or outpatient clinic interview. With respect to perioperative complications, lower esophageal mucosal perforation occurred in 14 patients, but all of them could be suture-obliterated laparoscopically. One patient was converted to laparotomy because of uncontrolled bleeding from the short gastric artery. The mean operative time was 169 minutes, and the mean perioperative blood loss was 22 mL. The median postoperative hospital stay was 7 days. Reflux esophagitis, which was seen in five patients, was treated successfully with a proton pump inhibitor. According to the standardized questionnaire for satisfaction, 77 patients rated their recovery as 'excellent', 17 as 'good', 4 as 'fair', and 2 as 'poor'; thus, the overall success rate was 94%. There were no significant differences in surgical outcomes by morphologic type and severity of esophageal dilatation; however, the success rate deteriorated significantly with progression of the morphologic type. Laparoscopic Heller-Dor operation is a safe and effective surgical treatment for achalasia.

Long-term effects of achalasia on esophageal motility following temporary internal metal stent dilation

AIM: To explore the long term effects of achalasia on esophageal motility following temporary internal metal stent dilation.

METHODS: Nineteen patients with achalasia had temporary internal metal stents (20-25 mm diameter) placed under X-ray guidance. After stent dilation over 3-7 d, the stents were removed by endoscopy. We measured lower esophageal sphincter (LES) pressure, LES relaxation rate, and 24-hours pH in the 19 patients and 12 healthy control subjects (HS).

RESULTS: LES residual pressure before stent dilation was markedly higher than at 2 wk and 2 years after stent dilation (47.43 ± 9.84 mmHg vs 12.32 ± 5.87 mmHg, and 14.21 ± 7.34 mmHg; P < 0.05). LES relaxation rate was significantly different before stent dilation that at 2 wk and 2 years after (13.33% vs 76.66%, and 73.46%, P < 0.05). The frequency of gastroesophageal reflux (GER) at 2 years after stent dilation was markedly higher than before and two wk and before stent dilation (66.12% vs 27.72%, 2.95%, P < 0.01); residual pressure and relax rate showed no significant difference between HS and after stent dilation of 2 wk and 2 years.

CONCLUSION: Temporary internal metal stent dilation results in lower LES pressure and a higher rate of GER for patients with achalasia in the long term.