The present study compares short- and long-term surgical results of our initial experience with 16 patients who underwent thoracoscopic Heller myotomy and 20 patients who underwent laparoscopic Heller myotomy. Only a few other studies7–11
have compared the results of these 2 procedures in the treatment of achalasia. Although no randomized, controlled trials have compared surgical outcomes after thoracoscopic versus laparoscopic Heller myotomy, a review of the literature shows that the laparoscopic approach offers superior results in patients with achalasia.5,9–18
Patti et al9
successfully treated 35 patients by using the thoracoscopic approach until 1994, but subsequently they switched to the laparoscopic approach with Heller myotomy for the next 133 patients. This decision was supported by the higher incidence of recurrent dysphagia (27% compared with 11%) and by the observation of an increased incidence of abnormal esophageal acid exposure by 24-hour pH monitoring.
In a recent study, Stewart et al10
showed that laparoscopic myotomy is superior to thoracoscopic myotomy regarding postoperative functional results. In the THM group, the incidence of dysphagia and heartburn was 69% and 33%, respectively, significantly higher compared with the 10% and 11% rate observed after LHM.
In the present series, although good control of preoperative symptoms was obtained after the thoracoscopic approach, we believe that laparoscopic myotomy offers a series of advantages that allow obtaining decreased morbidity and superior operative and functional outcomes. First, working on the distal esophagus from the abdominal cavity, the direction of the instruments is maintained tangentially and parallel to the axis of the lower esophagus. This was essential in our experience for performing the myotomy with great simplicity and to prevent mucosal injury.
In our study, we directly compared the incidence of mucosal injury in both surgical approaches. Perforation of the esophageal mucosa occurred in 2 patients (12.5%) in the THM group, whereas it occurred only in 1 patient (5%) who underwent LHM (P=NS). In this patient, we repaired the perforation laparoscopically adding an anterior partial fundoplication to protect the mucosal suture. For this, during the laparoscopic approach, we recommend achieving the completeness of myotomy without extreme apprehension of injury to the mucosa in particular at levels of the gastroesophageal junction. In fact, even in this circumstance, the laparoscopic repair of a mucosal lesion is easy to perform, and the anterior partial fundoplication can be added with a maximal guarantee of good functional outcomes.
Regarding long-term results, several studies reported that the laparoscopic technique is associated with a lower rate of dysphagia, heartburn, and regurgitation compared with the thoracoscopic technique. In a retrospective study, Stewart et al10
reported relief of dysphagia in 90% of patients treated with LHM and in 31% of those treated with THM. In addition, the authors found a lower incidence of heartburn (11%) and regurgitation (6%) after LHM compared with that observed after THM (33% and 14%, respectively). Patti et al9
reported the occurrence of persistent dysphagia in 27% of patients who underwent THM and in 11% of patients who underwent LHM. Our study validates the hypothesis that the laparoscopic approach is superior to the thoracoscopic one in relieving dysphagia and preventing heartburn and regurgitation. Good to excellent results were observed in 95.2% of patients who underwent LHM, compared with 62.5% of patients treated with THM. The higher incidence of persistent or recurrent dysphagia observed in the THM group should be correlated to the inadequate extension of the myotomy distally onto the stomach. We agree with other authors 5,9,10,14,15,18
in recognizing that the crucial and decisive part of the procedure is to carry the myotomy 2 to 3 centimeters distally.
Furthermore, with the laparoscopic approach, an antireflux procedure can be added to decrease the incidence of gastroesophageal reflux. Pellegrini et al2
reported an incidence of abnormal esophageal acid exposure of 13% after THM without an antireflux procedure. Patti et al9
in an extensive study of 168 patients with achalasia reported postoperative gastroesophageal reflux in 6 of 10 patients tested (60%) after THM and in only 17% of those tested after LHM with Dor fundoplication.
The results of the present experience show that the occurrence of reflux symptoms is significantly higher in the group treated thoracoscopically. In these patients, we found an increase in esophageal acid exposure with a significantly higher rate of heartburn (12.5%) and regurgitation (18.7%), presumably because of an insufficient and slow clearance of acid during reflux episodes.
Although several recent studies have suggested that an associated fundoplication is necessary to prevent gastroesophageal reflux after the myotomy,5,10,13,15
the debate is still open. Yamamura et al18
recently reviewed 21 cases of laparoscopic Heller myotomy with anterior fundoplication and observed significant improvement in dysphagia, heartburn, supine and upright regurgitation, and chest pain in 95.2% of patients. Patti et al9
suggest that an anterior fundoplication does not increase the risk of postoperative dysphagia or prevent gastroesophageal reflux. However, similar results have been published by other authors17,19
in a series of patients treated with laparoscopic Heller myotomy without an antireflux procedure. Wang et al,17
in a series of 25 patients, obtained postoperatively a 14% incidence of regurgitation and 11% of heartburn. Richards et al19
reviewed the results of esophageal function tests in 14 of 16 patients treated with laparoscopic Heller myotomy without antireflux surgery and found a gastroesophageal reflux rate of 21%. The patient with the highest DeMeester score had a postoperative LES pressure higher than 20 mm Hg, indicating that the clearance of acid reflux was significantly impaired. This study demonstrated that the incidence of gastroesophageal reflux can be low even without a fundoplication in the presence of a postoperative LES pressure ≤10 mm Hg, with a poor correlation between LES pressure and the degree of acid reflux by 24-h pH monitoring. In some cases, anterior fundoplication may lead to rehealing and reapproximation of the myotomy with secondary development of stricture and recurrent achalasia, as argue the opponents of this procedure.16
In our study, 3 patients who underwent LHM with reconstruction of the angle of His had an abnormal esophageal acid exposure with symptoms of heartburn in only 1 patient. This patient was treated successfully with acid suppressant medications. It is important to emphasize that some patients are asymptomatic refluxers. In fact, the absence of reflux symptoms is not necessarily connected with objective abnormal acid reflux episodes encompassed at the pH monitoring as a decrease of esophageal pH below 4. The 2 subgroups of LHM patients treated, respectively, with or without fundoplication are too small to draw any conclusion to the real efficacy of the anterior fundoplication in the prevention of GER. In addition, the results of pH monitoring are still not complete and we are waiting to finalize our evaluation.
In spite of the fact that an anterior fundoplication can be followed by the potential problem of “rehealing” of the myotomy, the results obtained in our experience have led us to prefer this procedure to other fundoplications. The operation should be performed with limited dissection of the esophagus, as we believe that preserving the support of the posterior structures around the gastroesophageal junction is essential to maintain the mechanism of a competent cardia. In fact, the potential problem of rehealing of the myotomy has led us to treat 7 of our patients with long-standing achalasia who have developed an esophagus with a diameter >6 cm, with myotomy followed by reconstruction of the angle of His. We have not seen any difference in clinical outcomes between these patients and those who underwent Dor fundoplication.
In conclusion, we agree with those authors4,9
who support the laparoscopic Heller-Dor procedure. This procedure is highly effective in abolishing dysphagia and in preventing postoperative reflux and heartburn. We believe that the dispute between thoracoscopic and laparoscopic approaches for Heller myotomy should be definitively ended, despite the absence of prospective randomized studies.