Laparoscopic Heller cardiomyotomy and Dor fundoplication for esophageal achalasia: possible factors predicting outcome.

HYPOTHESIS Laparoscopic Heller myotomy with anterior hemifundoplication is the surgical procedure of choice for the treatment of esophageal achalasia. Specific factors, eg, severity of esophageal body deformity, might affect postoperative outcome. DESIGN Prospective case-control study. SETTING Academic referral center for gastrointestinal tract motility disorders. PATIENTS Twenty-nine patients with esophageal achalasia who underwent 1 to 3 sessions of failed pneumatic dilation each. INTERVENTION Laparoscopic Heller myotomy with anterior (Dor) hemifundoplication. MAIN OUTCOME MEASURES Preoperative and postoperative symptomatic evaluation, esophagoscopy, esophagography, stationary and ambulatory esophageal manometry, and pH monitoring. RESULTS Three patients had stage I disease, 10 had stage II, 12 had stage III, and 4 had stage IV at preoperative radiologic examination. At surgery, there were no conversions to open procedures, and 2 mucosal perforations were immediately identified and sutured. Good or excellent results were seen in 26 patients. All patients with stage I or II disease had excellent functional results. Of patients with stage III disease, results were excellent in 7, good in 4, and bad in 1. Of patients with stage IV disease, 2 had good results and 2 had bad results. After surgery, lower esophageal sphincter pressure was reduced significantly (from 46.1 +/- 12.1 to 5.4 +/- 1.8 mm Hg; P<.001), as was esophageal diameter (from 61 +/- 17 to 35 +/- 19 mm; P<.001) (data are given as mean +/- SD). However, an excellent result occurred only in patients with a postoperative esophageal diameter less than 40 mm. CONCLUSION Functional outcome of laparoscopic Heller-Dor procedure for achalasia is related to the preoperative stage of the disease on the esophagogram and to the extent of reduction in esophageal width after surgery.