Previous endoscopic treatment does not affect complication rate and outcome of laparoscopic Heller myotomy and anterior fundoplication for oesophageal achalasia.

Abstract

Background: Anedoctal reports suggest a detrimental effect of pneumatic dilation and botulinum toxin injection in patients who are potential candidates for Heller myotomy.

Aims: To assess symptomatic and objective outcome in patients undergoing Heller myotomy as a primary procedure or after failed endoscopic treatment.

Patients: Between November 1992 and December 1998, 92 patients with oesophageal achalasia were treated. Sixty patients had primary surgery; 32 patients had surgery after unsuccessful pneumatic dilation (n = 22), or botulinum toxin injection (n = 10).

Methods: Laparoscopic Heller myotomy plus Dor fundoplication with routine intraoperative endoscopy. Operative records, symptoms, and results of radiological, manometric and scintigraphic assessment in the two groups of patients were compared.

Results: The mean operative time, the rate of intraoperative mucosal tears and the incidence of postoperative dysphagia were similar in the two groups. Mucosal tears occurred more frequently during the first 30 operations (p < 0.05). Median follow-up was 28 months (range 4-76). An abnormal oesophageal acid exposure was documented in 2 patients in the primary surgery group (7.7%), and in 2 patients in the pneumatic dilation/botulinum toxin group (13.3%) (p = ns). Lower oesophageal sphincter pressure significantly decreased in both groups (p < 0.01). The mean percentage of radionuclide residual activity in the oesophagus at 1 and 10 minutes significantly decreased in both groups (p < 0.01).

Conclusions: There was only a trend, although not statistically significant, towards an increased risk of complications and adverse effects in patients previously treated by pneumatic dilation or botulinum toxin. The higher incidence of mucosal tears during the first 30 operations suggests the effect of the learning curve.