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Eur J Cardiothorac Surg 2003;24:620-624
© 2003 Elsevier Science NL

Clinical results of thoracoscopic Heller's myotomy in the treatment of achalasia

Department of Thoracic Surgery, Royal Infirmary, Little France, Edinburgh EH16 4SA, UK

Received 10 November 2002; received in revised form 24 April 2003; accepted 23 June 2003.

^* Corresponding author. Tel.: +44-131-242-3907; fax: +44-131-242-3930
e-mail: wsw{at}holyrood.ed.ac.uk

Objectives: Ideal treatment for achalasia permanently eliminates the dysfunctional lower oesophageal sphincter, relieving dysphagia and regurgitation. The aim of this study was to review the results in a series of patients undergoing video-imaged thoracoscopic Heller's myotomy (THM). Methods: Records of all patients undergoing THM by a single surgeon at one institution were analysed. Follow-up was conducted using a structured questionnaire together with oesophageal manometry and/or 24 h pH monitoring when clinically indicated. Results: Twenty-five consecutive patients (13 males, 12 females, mean age 40.3±19.9 years) suffering from grade 4 dysphagia underwent THM between 1993 and 2001. Preoperative mean lower oesophageal sphincter (LOS) pressure was 42.6±6.3 mmHg. Seven patients (28%) had undergone previous pneumatic dilatations. There were no hospital deaths and no oesophageal perforations. Length of hospital stay was 4.3±1.8 days. One patient died 3 years after surgery from unrelated causes. At follow-up of 5.4±2.1 years, freedom from any reintervention was 95.8% (23/24). Eleven patients (45.8%) were asymptomatic. In patients with residual or recurrent symptoms (n=13), their severity was significantly reduced from the preoperative period (dysphagia score 1.7±0.8 versus 4±0; P0.05). Four patients (16%) with troublesome residual or recurrent grade 3–4 dysphagia underwent repeat oesophageal manometric study, showing a mean reduction in LOS pressure from their baseline values of 46.8±6.1 to 30±5.4 mmHg (P0.01). One of these patients (4.2%) required repeat Heller's myotomy 1.5 years after THM. Six patients complained of troublesome postoperative heartburn; distal oesophageal acid exposure was shown to be abnormal in 3 (12.5%) of these patients and all enjoyed symptomatic relief with medical therapy. Conclusions: THM is a safe and effective procedure in the treatment of achalasia. Some patients do experience recurrence of symptoms; however, these are significantly less severe. The incidence of postoperative heartburn is acceptably low and can be controlled with oral medications, making the addition of an anti-reflux procedure not necessary. Longer-term follow up and randomised studies comparing THM to other therapeutic modalities are needed to ascertain respectively the durability of this approach and its relative advantages.

Key Words: Achalasia • Video-assisted • Minimally invasive • Thoracoscopic • Heller's myotomy