Abdominal versus thoracic approach for myotomy in esophageal achalasia

Abstract

Miotomy is the most common operation for the treatment of achalasia of the esophagus. The most important complication of this operation is gastro-esophageal reflux, and controversy exists in the choice of a thoracic or abdominal approach to this operation. From 1974 until 1988, our group performed 45 miotomies for achalasia of the esophagus. Follow-up was obtained in 82% of the patients. The thoracic approach was used in 21 cases (tor), and 24 patients were operated through an abdominal approach (abd). All the miotomies had an anti-reflux procedure associated. Post-operative evaluation consisted of: clinical score determination; endoscopy with biopsy; manometry; 24 Phmetry. The clinical score revealed that 47% of the patients in the group tor were asymptomatic, and in the group abd this rate was 53%. Absence of macroscopic esophagitis was registered in 75% of the patients in the group tor, and in 91% in the group abd. Microscopic esophagitis was observed in 42% of the cases in the group tor, and in 45% of the group abd. Manometry revealed a low pressure in the inferior esophageal sphincter in 90% of the cases of the group tor, and in 80% of the group abd. Pathological gastro-esophageal reflux, detected by 24 h Phmetry, was present in 29% of the group tor, and in 36% of the group abd. The results in these two groups were very similar, uniformly favourable, and without evidence of superiority of either operation. The choice of a thoracic, or abdominal approach should depend on associated factors such as patient age, respiratory disease, etc.