Long-term results of the Heller–Dor operation with intraoperative manometry for the treatment of esophageal achalasia

Abstract

Quality of outcome of the Heller-Dor operation is sometimes different between studies, likely because of technical reasons. We analyze the details of myotomy and fundoplication in relation to the results achieved over a 30-year single center's experience. From 1979-2008, a long esophagogastric myotomy and a partial anterior fundoplication to protect the surface of the myotomy was routinely performed with intraoperative manometry in 202 patients (97 men; median age, 55.5 years; interquartile range, 43.7-71 years) through a laparotomy and in 60 patients (24 men; median age, 46 years; interquartile range, 36.2-63 years) through a laparoscopy. The follow-up consisted of periodical interview, endoscopy, and barium swallow, and a semiquantitative scale was used to grade results. Mortality was 1 of 202 in the laparotomy group and 0 of 60 in the laparoscopy group. Median follow-up was 96 months (interquartile range, 48-190.5 months) in the laparotomy group and 48 months (interquartile range, 27-69.5 months) in the laparoscopy group. At intraoperative manometry, complete abolition of the high-pressure zone was obtained in 100%. The Dor-related high-pressure zone length and mean pressure were 4.5± 0.4 cm and 13.3± 2.2 mm Hg in the laparotomy group and 4.5± 0.5 cm and 13.2± 2.2 mm Hg in the laparoscopy group (P=.75). In the laparotomy group poor results (19/201 [9.5%]) were secondary to esophagitis in 15 (7.5%) of 201 patients (in 2 patients after 184 and 252 months, respectively) and to recurrent dysphagia in 4 (2%) of 201 patients, all with end-stage sigmoid achalasia. In the laparoscopy group 2 (3.3%) of 60 had esophagitis. A long esophagogastric myotomy protected by means of Dor fundoplication cures or substantially reduces dysphagia in the great majority of patients affected by esophageal achalasia and effectively controls postoperative esophagitis. Intraoperative manometry is likely the key factor for achieving the reported results.