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A short 4-cm oesophageal myotomy relieves the obstructive symptoms of achalasia

Department of Surgery, Division of Thoracic Surgery, Université de Montréal, Centre Hospitalier de l’Université de Montréal, Pavillon Lachapelle, Suite D-8051, 1580 rue Sherbrooke Est, Montréal, QC, CH2L 4M1, Canada

Received 7 October 2008; received in revised form 15 April 2009; accepted 20 April 2009.

^_* Corresponding author. Address: Department of Surgery, Université de Montréal, Division of Thoracic surgery, Centre Hospitalier de l’Université de Montréal, QC, Canada. Tel.: +1 514 890 8000x26253; fax: +1 514 412 7855. (Email: andre.duranceau{at}umontreal.ca).

Objective: Controversy still persists regarding the ideal length of myotomy to treat oesophageal achalasia. This investigation reports the effects of a short myotomy with an added partial fundoplication for reflux prevention. Methods: From 1997 to 2007, 22 patients (13 men, 9 women, median age: 41 years) with achalasia underwent a 6-cm short myotomy (four oesophagus and two stomach) with a Belsey partial fundoplication by left thoracotomy. Assessments include clinical and radiological evaluation, radionuclide transit studies, manometry, 24-h pH and endoscopy. Results: No morbidity and no mortality occurred. Median follow-up is 54 months (range: 4–139 months). Dysphagia present in all 22 patients left an episodic slow emptying sensation in three patients after operation (p < 0.001). Fresh food regurgitation decreased significantly after the myotomy (17 pre-, four post-regurgitation, p < 0.001). Heartburn present in four patients before the operation was recorded in nine patients postoperatively (p = 0.179). Radiologically, barium stasis decreased significantly from 85% to 30% (p = 0.007). No diverticular formation was seen in the myotomy zone. On the oesophageal scintigram, stasis at 2 min decreased from a median of 60% before the operation to 16% (p < 0.001). The lower oesophageal sphincter (LOS) gradient decreased from 30 to 9.7 mmHg (p < 0.001). LOS relaxation improved from 40% pre- to 93% postoperatively (p = 0.003). Endoscopies and biopsies documented increased mucosal damage after the operation (one preoperative, 13 postoperative; p < 0.001). Conclusions: When treating achalasia, the myotomy, despite being shortened in length, reduces the LOS gradient, relieves obstructive symptoms and improves oesophageal emptying. The LOS relaxation is improved. Complete coverage of the myotomysed zone by the fundus prevents diverticular formation. Oesophageal mucosal damage from reflux is significant despite the partial fundoplication.

Key Words: Oesophagus • Achalasia • Myotomy • Fundoplication • Anti-reflux procedure • Gastro-oesophageal reflux