Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Surgical Endoscopy
Published in: Surgical Endoscopy 4/2008

01-04-2008

Results of laparoscopic Heller myotomy without anti-reflux procedure in achalasia. Monocentric prospective study of 106 cases

Authors: M. Robert, G. Poncet, F. Mion, J. Boulez

Published in: Surgical Endoscopy | Issue 4/2008

Login to get access

Abstract

Background

Heller myotomy (HM) combined with an anti-reflux procedure has been shown to be effective for the treatment of achalasia, as postoperative gastro-esophageal reflux (GER) is observed in about 10% of the cases. Laparoscopy has brought an undeniable benefit in providing excellent visualisation of the gastro-esophageal junction (GEJ) without lateral and posterior dissection. Respecting the anatomical fixation of the GEJ seems to permit the performing of HM without an anti-reflux procedure, the need for which is therefore debatable. The purpose of this study was to analyse the results of this controversial procedure.

Methods

A monocentric prospective study was carried out on 106 patients who underwent HM without an anti-reflux procedure. The postoperative assessment consisted of a manometry and a 24-hour pH study two months after surgery, and a yearly clinical examination for a minimum of five years. The data capture was done using a statistical analysis.

Results

There was no mortality, one conversion to an open procedure, and four mucosal perforations. Postoperative morbidity was 2%. The average follow-up period was 55 months (range, 2 to 166), with 10 patients lost to follow-up. Good functional results were observed in 91.4% of patients at one year, and 78.6% at five years. Two months after surgery, a 9.4% prevalence of GER was detected in the pH study, and the lower esophageal sphincter pressure had significantly decreased. After a long term follow-up we observed an 11.3% global rate of GER. No repeat surgery was necessary to control postoperative GER.

Conclusions

Laparoscopic HM without anti-reflux procedure gives good functional results provided the anatomical fixation of the GOJ is respected.
Literature
1.
Gholoum S, Feldman LS, Andrew CG, Bergman S, Demyttenaere S, Mayrand S, Stanbridge DD, Fried GM (2006) Relationship between subjective and objective outcome measures after Heller myotomy and Dor fundoplication for achalasia. Surg Endosc 20:214–219PubMedCrossRef
2.
Mattioli G, Esposito C, Pini Prato A, Doldo P, Castagnetti M, Barabino A, Gandullia P, Staiano AM, Settimi A, Cucchiara S, Montobbio G, Jasonni V (2003) Results of the laparoscopic Heller-Dor procedure for pediatric esophageal achalasia. Surg Endosc 17:1650–1652PubMedCrossRef
3.
Frantzides CT, Moore RE, Carlson MA, Madan AK, Zografakis JG, Keshavarzhian A, Smith C (2004) Minimally invasive surgery for achalasia: a 10-year experience. J Gastrointest Surg 8:18–23PubMedCrossRef
4.
Ho KY, Tay HH, Kang JY (1999) A prospective study of the clinical features, manometric findings, incidence and prevalence of achalasia in Singapore. J Gastroenterol Hepatol 14:791–795PubMedCrossRef
5.
Moreno Gonzalez E, Garcia Alvarez A, Landa Garcia I, Gomez Gutierrez M, Rico Selas P, Garcia Garcia I, Jover Navalon JM, Arias Diaz J (1988) Results of surgical treatment of esophageal achalasia. Multicenter retrospective study of 1,856 cases. GEEMO (Groupe Europeen Etude Maladies Oesophageennes) Multicentric Retrospective Study. Int Surg 73:69–77PubMed
6.
Bonavina L, Nosadini A, Bardini R, Baessato M, Peracchia A (1992) Primary treatment of esophageal achalasia. Long-term results of myotomy and Dor fundoplication. Arch Surg 127:222–226PubMed
7.
Rosemurgy A, Villadolid D, Thometz D, Kalipersad C, Rakita S, Albrink M, Johnson M, Boyce W (2005) Laparoscopic Heller myotomy provides durable relief from achalasia and salvages failures after botox or dilation. Ann Surg 241:725–733PubMedCrossRef
8.
Patti MG, Pellegrini CA, Horgan S, Arcerito M, OMelanczuk P, Tamburini A, Diener U, Eubanks TR, Way LW (1999) Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg 230:587–593PubMedCrossRef
9.
Douard R, Gaudric M, Chaussade S, Couturier D, Houssin D, Dousset B (2004) Functional results after laparoscopic Heller myotomy for achalasia: A comparative study to open surgery. Surgery 136:16–24PubMedCrossRef
10.
Patti MG, Fisichella PM, Peretta S, Galvani C, Gorodner MV, Robinson T, Way LW (2003) Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change. J Am Coll Surg 196:698–703PubMedCrossRef
11.
Zaninotto G, Costantini M, Molena D, Buin F, Carta A, Nicoletti L, Ancona E (2000) Treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor partial anterior fundoplication: prospective evaluation of 100 consecutive patients. J Gastrointest Surg 4:282–289PubMedCrossRef
12.
Costantini M, Zaninotto G, Guirroli E, Rizzetto C, Portale G, Ruol A, Nicoletti L, Ancona E (2005) The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up. Surg Endosc 19:345–351PubMedCrossRef
13.
Lyass S, Thoman D, Steiner JP, Phillips E (2003) Current status of an antireflux procedure in laparoscopic Heller myotomy. Surg Endosc 17:554–558PubMedCrossRef
14.
Richards WO, Sharp KW, Holzman MD (2001) An antireflux procedure should not routinely be added to a Heller myotomy. J Gastrointest Surg 5:13–16PubMedCrossRef
15.
Cortesini C, Cianchi F, Pucciani F (2002) Long-term results of Heller myotomy without an antireflux procedure in achalasic patients. Chir Ital 54:581–586PubMed
16.
Vela MF, Richter JE, Wachsberger D, Connor J, Rice TW (2004) Complexities of managing achalasia at a tertiary referral center: use of pneumatic dilatation, Heller myotomy, and botulinum toxin injection. Am J Gastroenterol 99:1029–1036PubMedCrossRef
17.
West RL, Hirsch DP, Bartelsman JF, De Borst J, Ferwerda G, Tytgat GN, Boeckxstaens GE (2002) Long term results of pneumatic dilation in achalasia followed for more than 5 years. Am J Gastroenterol 97:1346–1351PubMedCrossRef
18.
Gockel I, Junginger T, Bernhard G, Eckardt VF (2004) Heller myotomy for failed pneumatic dilation in achalasia: how effective is it? Ann Surg 239:371–377PubMedCrossRef
19.
Bloomston M, Fraiji E, Boyce HW Jr, Gonzalvo A, Johnson M, Rosemurgy AS (2003) Preoperative intervention does not affect esophageal muscle histology or patient outcomes in patients undergoing laparoscopic Heller myotomy. J Gastrointest Surg 7:181–188PubMedCrossRef
20.
Zaninotto G, Annese V, Costantini M, Del Genio A, Costantino M, Epifani M, Gatto G, D’Onofrio V, Benini L, Contini S, Molena D, Battaglia G, Tardio B, Andriulli A, Ancona E (2004) Randomized controlled trial of botulinum toxin versus laparoscopic Heller myotomy for esophageal achalasia. Ann Surg 239:364–370PubMedCrossRef
21.
Horgan S, Hudda K, Eubanks T, McAllister J, Pellegrini CA (1999) Does botulinum toxin injection make esophagomyotomy a more difficult operation? Surg Endosc 13:576–579PubMedCrossRef
22.
Patti MG, Albanese CT, Holcomb GW, Molena D, Fisichella PM, Peretta S, Way LW (2001) Laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children. J Pediatr Surg 36:1248–1251PubMedCrossRef
23.
Patti MG, Arcerito M, Tong J, De Pinto M, De Bellis M, Wang A, Feo CV, Mulvihill SJ, Way LW (1997) Importance of preoperative and postoperative pH monitoring in patients with esophageal achalasia. J Gastrointest Surg 1:505–510PubMedCrossRef
24.
Maher JW, Conklin J, Heitshusen DS (2001) Thoracoscopic esophagomyotomy for achalasia: preoperative patterns of acid reflux and long-term follow-up. Surgery 130:570–576PubMedCrossRef
25.
Patti MG, Diener U, Molena D (2001) Esophageal achalasia: preoperative assessment and postoperative follow-up. J Gastrointest Surg 5:11–12PubMedCrossRef
26.
Benini L, Sembenini C, Castellani G, Bardelli E, Brentegani MT, Giorgetti P, Vantini I (1996) Pathological esophageal acidification and pneumatic dilitation in achalasic patients. Too much or not enough? Dig Dis Sci 41:365–371PubMedCrossRef
27.
Ramacciato G, Mercantini P, Amodio PM, Stipa F, Corigliano N, Ziparo V (2003) Minimally invasive surgical treatment of esophageal achalasia. JSLS 7:219–225PubMed
28.
Ramacciato G, Mercantini P, Amodio PM, Corigliano N, Barreca M, Stipa F, Ziparo V (2002) The laparoscopic approach with antireflux surgery is superior to the thoracoscopic approach for the treatment of esophageal achalasia. Experience of a single surgical unit. Surg Endosc 16:1431–1437PubMedCrossRef
29.
Boulez J, Meeus P, Espalieu P (1997) Heller’s esocardiomyotomy without anti-reflux procedure by the laparoscopic approach. Analysis of a series of 27 cases. Ann Chir 51:232–236PubMed
30.
Oelschlager BK, Chang L, Pellegrini CA (2003) Improved outcome after extended gastric myotomy for achalasia. Arch Surg 138:490–495PubMedCrossRef
31.
Falkenback D, Johansson J, Oberg S, Kjellin A, Wenner J, Zilling T, Johnsson F, Von Holstein CS, Walther B (2003) Heller’s esophagomyotomy with or without a 360 degrees floppy Nissen fundoplication for achalasia. Long-term results from a prospective randomized study. Dis Esophagus 16:284–290PubMedCrossRef
32.
Chapman JR, Joehl RJ, Murayama KM, Tatum RP, Shi G, Hirano I, Jones MP, Pandolfino JE, Kahrilas PJ (2004) Achalasia treatment: improved outcome of laparoscopic myotomy with operative manometry. Arch Surg 139:508–513PubMedCrossRef
33.
Zaninotto G, Costantini M, Portale G, Battaglia G, Molena D, Carta A, Costantino M, Nicoletti L, Ancona E (2002) Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg 235:186–192PubMedCrossRef
34.
Bloomston M, Durkin A, Boyce HW, Johnson M, Rosemurgy AS (2004) Early results of laparoscopic Heller myotomy do not necessarily predict long-term outcome. Am J Surg 187:403–407PubMedCrossRef
35.
36.
Peters JH (2001) An antireflux procedure is critical to the long-term outcome of esophageal myotomy for achalasia. J Gastrointest Surg 5:17–20PubMedCrossRef
37.
Gallez JF, Berger F, Moulinier B, Partensky C (1987) Esophageal adenocarcinoma following Heller myotomy for achalasia. Endoscopy 19:76–78PubMedCrossRef
38.
Galvani C, Gorodner MV, Moser F, Baptista M, Donahue P, Horgan S (2006) Laparoscopic Heller myotomy for achalasia facilitated by robotic assistance. Surg Endosc 20(7):1105–12PubMedCrossRef
39.
Richards WO, Clements RH, Wang PC, Lind CD, Mertz H, Ladipo JK, Holzman MD, Sharp KW (1999) Prevalence of gastroesophageal reflux after laparoscopic Heller myotomy. Surg Endosc 13:1010–1014PubMedCrossRef
40.
Donahue PE, Horgan S, Liu KJ, Madura JA (2002) Floppy Dor fundoplication after esophagocardiomyotomy for achalasia. Surgery 132:716–722PubMedCrossRef
41.
Robertson GS, Lloyd DM, Wicks AC, De Caestecker J, Veitch PS (1995) Laparoscopic Heller’s cardiomyotomy without an antireflux procedure. Br J Surg 82:957–959PubMedCrossRef
42.
Dempsey DT, Delano M, Bradley K, Kolff J, Fisher C (2004) Laparoscopic esophagomyotomy for achalasia: does anterior hemifundoplication affect clinical outcome? Ann Surg 239:779–785PubMedCrossRef
43.
Baigrie RJ, Cullis SN, Ndhluni AJ, Cariem A (2005) Randomized double-blind trial of laparoscopic Nissen fundoplication versus anterior partial fundoplication. Br J Surg 92:819–823PubMedCrossRef
44.
Limpert PA, Naunheim KS (2005) Partial versus complete fundoplication: is there a correct answer? Surg Clin North Am 85:399–410PubMedCrossRef
45.
Topart P, Deschamps C, Taillefer R, Duranceau A (1992) Long-term effect of total fundoplication on the myotomized esophagus. Ann Thorac Surg 54:1046–1051PubMedCrossRef
46.
Ponce M, Ortiz V, Juan M, Garrigues V, Castellanos C, Ponce J (2003) Gastroesophageal reflux, quality of life, and satisfaction in patients with achalasia treated with open cardiomyotomy and partial fundoplication. Am J Surg 185:560–564PubMedCrossRef
47.
Richards WO, Torquati A, Holzman MD, Khaitan L, Byrne D, Lutfi R, Sharp KW (2004) Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 240:405–412PubMedCrossRef
48.
Boulez J, Baulieux J, Mayer B, Peix JL, Donne R, Maillet P (1981) Résultats éloignés de la myotomie de Heller dans le traitement de l’achalasie oesophagienne. A propos de 103 cas. Ann Gastroenterol Hepatol 17:321–328
Metadata
Title
Results of laparoscopic Heller myotomy without anti-reflux procedure in achalasia. Monocentric prospective study of 106 cases
Authors
M. Robert
G. Poncet
F. Mion
J. Boulez
Publication date
01-04-2008
Publisher
Springer-Verlag
Published in
Surgical Endoscopy / Issue 4/2008
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI
https://doi.org/10.1007/s00464-007-9600-6

Other articles of this Issue 4/2008

Surgical Endoscopy 4/2008 Go to the issue

OriginalPaper

Laparoscopic training on Thiel human cadavers: A model to teach advanced laparoscopic procedures

OriginalPaper

Laparoscopic sleeve gastrectomy with ileal transposition (SGIT): A new surgical procedure as effective as gastric bypass for weight control in a porcine model

OriginalPaper

Ideal manipulation angle and instrument length in hand-assisted laparoscopic surgery

OriginalPaper

Minimally invasive myotomy for achalasia in the elderly

OriginalPaper

Videothoracoscopic thymectomy for nonthymomatous myasthenia gravis: Results of 90 patients

Reply to Letter

Inclusion of the transcervical approach in video-assisted thoracoscopic extended thymectomy (VATET) for myasthenia gravis: a prospective trial