Laparoscopic Heller myotomy for achalasia: analysis of successes and failures.

BACKGROUND/AIMS: The outcome of laparoscopic myotomy for achalasia is dictated by many factors. METHODOLOGY: A retrospective study was conducted between 1997-2007, 58 patients who fulfilled all criteria for the diagnosis of achalasia underwent laparoscopic Heller myotomy and 45 (77.6%) were included. Mean follow-up period was 36±15 months; 56 patients had Dor fundoplication; 17 patients had been previously treated by pneumatic dilatation. All steps of the procedure, esophageal manometric findings and radiological records were analyzed to determine factors contributing to the clinical success or failure of the operation. The main outcome measure was swallowing status. RESULTS: Median hospital stay was 3±1 days and mean operative time was 75±20min. There were 7 intra-operative mucosal injuries; all sutured laparoscopically (5 had previous pneumatic dilatation). Good or excellent relief of dysphagia was obtained in 41 patients and was persistent among 2 patients (both had pneumatic dilatation preoperatively). The remaining 2 patients developed gastroesophageal reflux symptoms. These 41 patients had a preoperative smaller diameter of the esophagus (stage I, II and III), while those with guarding results (4) had stages III and IV. There was a decrease in LES pressure from 45±7mmHg to 10±2mmHg without evidence of restoration of esophageal peristalsis in any patient. CONCLUSIONS: Laparoscopic Heller myotomy with Dor fundoplication significantly relieves the symptoms of achalasia without causing the symptoms of gastroesophageal reflux disease. A good postoperative result is expected when the length of myotomy is adequate, LES pressure declines substantially, preoperative esophageal dilation is not excessive and distortion of the distal esophagus is absent.

Nissen fundoplication in infants and children: a long-term clinical study.

BACKGROUND/AIMS: Infants and children who underwent open Nissen fundoplication for gastroesophageal reflux disease were retrospectively evaluated to assess the success and complications of this operation. METHODOLOGY: Twenty-six neurologically normal children (16 boys and 10 girls between 6 months and 11 years old) underwent Nissen fundoplication for intractable or complicated gastroesophageal reflux between October 1982 and February 2002. Before surgery and at follow-up visits, all children were subjected to thorough history, barium meal study and gastroscopy with multiple esophageal biopsies. The median follow-up period was 28 months (range: 11 months-19 years). RESULTS: Persistent vomiting or regurgitation since birth was the main symptom (24 patients, 92.3%), chest symptoms occurred in 5 patients (19.2%), malnutrition and retarded growth were found in 4 patients (15.4%), hematemesis and/or melena occurred in 2 patients (7.7%) and dysphagia due to esophageal stricture occurred in 4 patients (15.4%). There was no mortality. The mean hospital stay was 4.1 days. Twenty-two patients (84.6%) had no recurrent reflux. Reflux symptoms recurred in 4 cases (15.4%). One of these cases had no evidence of recurrent pathological reflux, 2 cases with preoperative stricture developed wrap disruption, recurrent reflux and re-stricture. Both refused a second operation. The fourth case developed melena and reflux esophagitis due to wrap herniation through the hiatus and was successfully managed by a second operation. CONCLUSIONS: Nissen fundoplication is an effective operation to correct gastroesophageal reflux in infants and children when the drug therapy fails. The operation should be done before occurrence of complications to decrease the recurrence of reflux.