Abstract
Background
In the past decades, Laparoscopic Heller-Dor (LHD) progressively became the treatment of choice for esophageal achalasia. Aim of this study was to assess our 25-year experience with LHD at a single high-volume institution.
Methods
1000 patients underwent LHD from 1992–2017 by 6 staff surgeons. Patients who had already been treated with surgical or endoscopic myotomy were ruled out. Symptoms were scored using a detailed questionnaire; barium swallow, endoscopy, manometry (conventional or High Resolution) were performed, before and after surgery, while 24-hour pH monitoring was performed 6 months after surgery. Treatment failure was defined as a postoperative symptom score >10th percentile of the preoperative score (i.e. >8).
Results
LHD was performed on 1000 patients (M: F = 536:464); the median age was 46 (IQR 36–54), 183 (18.3%) had a history of endoscopic treatments (pneumatic dilation or botox injections, or both). The surgical procedure was completed laparoscopically in all but 7 patients (0.7%) and there was one perioperative death for heart attack. There were 25 perforations (2.5%): 22 were recognized and repaired during the operation, 3 were detected by postoperative contrast swallow. In 674 patients the manometric pattern was classified as follows: 310 (46%) pattern I, 315 (46.7%) pattern II and 49 (7.3%) pattern III. The outcome was positive in 902 patients (90.2%). In patients who had a previous treatment the failures were 25/183 (13.7%) while in the primary treatment group the failures were 73/817 (8.9%) (P = 0.055). All the 98 patients whose LHD failed underwent one or more pneumatic dilations, which ameliorated their symptoms in all but 11 patients (10 required reoperation). The overall success rate of combined LHD and dilations was 98.4%. At univariate analysis, manometric pattern (P = 0.001), absent sigmoid megaesophagus (P = 0.003) and chest pain score (P = 0.002) were the only factors predictive of the result. At multivariate analysis, these three factors were independently associated with good outcome. Postoperative 24-hour pH was abnormal in 50/590 patients (8.5%). Two patients developed an esophageal cancer during follow-up.
Conclusion
In a university tertiary referral center, LHD relieves achalasia symptoms durably. The preoperative manometric pattern, the absence of a sigmoid esophagus and the chest pain score represent the strongest predictors of outcome.
Disclosure
All authors have declared no conflicts of interest.