Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia: Analysis of Successes and Failures | Gastroenterology | JAMA Surgery | JAMA Network
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August 2001

Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia: Analysis of Successes and Failures

Author Affiliations

From the Department of Surgery, University of California, San Francisco.

Arch Surg. 2001;136(8):870-877. doi:10.1001/archsurg.136.8.870

Background  In the treatment of achalasia, surgery has been traditionally reserved for patients with residual dysphagia after pneumatic dilatation. The results of laparoscopic Heller myotomy have proven to be so good, however, that most experts now consider surgery the primary treatment.

Hypothesis  The outcome of laparoscopic myotomy and fundoplication for achalasia is dictated by technical factors.

Setting  University hospital tertiary care center.

Design  Retrospective study.

Patients and Methods  One hundred two patients with esophageal achalasia underwent laparoscopic Heller myotomy and Dor fundoplication. Fifty-seven patients had been previously treated by pneumatic dilatation or botulinum toxin. The design of the operation involved a 7-cm myotomy, which extended 1.5 cm onto the gastric wall, and a Dor fundoplication. Esophagrams, esophageal manometric findings, and video records of the procedure were analyzed to determine the technical factors that contributed to the clinical success or failure of the operation.

Main Outcome Measure  Swallowing status.

Results  In 91 (89%) of the 102 patients, good or excellent results were obtained after the first operation. A second operation was performed in 5 patients to either lengthen the myotomy (3 patients) or take down the fundoplication (2 patients). Dysphagia resolved in 4 of these patients. The remaining 6 patients were treated by pneumatic dilatation, but dysphagia improved in only 1. At the conclusion of treatment, excellent or good results had been obtained in 96 (94%) of the 102 patients.

Conclusions  These data show that a Heller myotomy was unsuccessful in patients with an esophageal stricture; a short myotomy and a constricting Dor fundoplication were the avoidable causes of residual dysphagia; a second operation, but not pneumatic dilatation, was able to correct most failures; and that the identified technical flaws were eliminated from the last half of the patients in the series.