Laparoscopic Heller myotomy relieves dysphagia in achalasia when the
esophagus is dilated
M. G. Patti, C. V. Feo, U. Diener, A. Tamburini, M. Arcerito, B. Safadi, L. W. Way
Department of Surgery, University of California, San Francisco, 533 Parnassus Avenue, Room U-122, San Francisco, CA 94143-0788, USA
Received: 1 March 1999/Accepted: 21 June 1999
Abstract
Background: It has been said that a Heller myotomy cannot
improve dysphagia in achalasia when the esophagus is
markedly dilated or sigmoid shaped. Those who hold this
belief recommend esophagectomy as the primary treatment
in such cases. This study aimed to compare the results of
laparoscopic Heller myotomy combined with Dor fundopli-
cation in 66 patients with and without esophageal dilatation,
all of whom had achalasia.
Methods: On the basis of the maximal diameter of the
esophageal lumen and the shape of the esophagus, the pa-
tients were placed into four groups: group A (esophageal
diameter <4.0 cm; 26 patients), group B (diameter 4.0–6.0
cm; 21 patients), group C1 (diameter >6.0 cm and straight
esophageal axis; 12 patients), and group C2 (diameter >6.0
cm and sigmoid-shaped esophagus; 7 patients). All patients
underwent a laparoscopic Heller myotomy and Dor fundo-
plication.
Results: The duration of the operation and the length of
hospital stay were similar among the four groups. Excellent
or good results were obtained in 88% of group A, 100% of
group B, 83% of group C1, and 100% of group C2. No
patient in this consecutive series ultimately required an
esophagectomy.
Conclusions: In patients with achalasia who have esopha-
geal dilation, a laparoscopic Heller myotomy and Dor fun-
doplication (a) took no longer and was no more difficult, (b)
was associated with no more postoperative complications,
and (c) gave just as good relief of dysphagia. We conclude
that esophageal dilation by itself should rarely serve as an
indication for esophagectomy rather than myotomy as the
initial surgical treatment.
Key words: Dilated esophagus — Dysphagia — Esopha-
geal achalasia — Esophagectomy — Heller myotomy—
Sigmoid esophagus
It has been claimed that a Heller myotomy is unable to
improve dysphagia in patients with achalasia who have
marked dilation or sigmoid changes of the esophagus.
Those who hold this view recommend esophagectomy as
the primary treatment in such cases [7, 12, 13]. This ques-
tion has not been systematically studied, however. It is es-
pecially germane today when the morbidity of a laparoscop-
ic Heller myotomy is so low [4, 5, 8, 14] compared with the
morbidity of esophagectomy (9).
The aim of this study was to determine how the results
of laparoscopic Heller myotomy combined Dor fundoplica-
tion were affected by the extent of esophageal dilation in
patients with esophageal achalasia.
Patients and methods
Between October 1993 and August 1998, 66 patients with esophageal
achalasia underwent laparoscopic Heller myotomy and Dor fundoplication.
There were 36 men and 30 women, whose mean age was 49 years (range,
15–96 years). The preoperative workup in every patient included an
esophagram, upper endoscopy, and esophageal manometry. On the basis of
the maximal diameter of the esophageal lumen and the shape of the esopha-
gus as seen on the esophagram, the patients were separated into four
groups: group A(esophageal diameter <4.0 cm; 26 patients), group B (di-
ameter 4.0–6.0 cm; 21 patients) group C1 (diameter >6.0 cm and straight
esophageal axis; 12 patients), and group C2 (diameter >6.0 cm and sig-
moid-shaped esophagus; 7 patients).
The esophagus of each patient in group C2 resembled the one shown in
Fig. 1, being truly sigmoid in shape. Table 1 shows the demographic data
and the treatment that antedated referral to our center. All patients com-
plained of dysphagia: 45 patients (68%) had regurgitation, and 40 patients
(61%) had chest pain (Table 2).
Esophageal manometry showed a mean lower esophageal sphincter
(LES) pressure of 21 ± 11 mmHg in group A, 21 ± 10 mmHg in group B,
16 ± 9 mmHg in group C1, and 16 ± 11 mmHg in group C2. All patients
Presented at the Annual Scientific Session of the Society of American
Gastrointestinal Endoscopic Surgeons (SAGES), San Antonio, Texas,
USA, 26 March 1999
Correspondence to: M. G. Patti
Surg Endosc (1999) 13: 843–847
© Springer-Verlag New York Inc. 1999