Preoperative lower esophageal sphincter pressure has little influence on the outcome of laparoscopic Heller myotomy for achalasia.

Abstract

It is believed that in untreated patients with achalasia, the lower esophageal sphincter (LES) is almost always hypertensive and a Heller myotomy resolves symptoms by decreasing the LES pressure. The incidence of a normal or hypotensive LES in untreated achalasia patients is unknown. The goals of this study were to determine the incidence of a normal or hypotensive LES in untreated achalasia patients and the outcome of laparoscopic Heller myotomy in achalasia patients with either normal or low LES pressure. Between January 1990 and May 2002, a diagnosis of achalasia was made in 239 patients. Among 109 patients (46%) who had not previously received any form of treatment, 53 patients underwent laparoscopic Heller myotomy and Dor fundoplication. Based on the preoperative LES pressure (normal, 14-24 mmHg) they were divided into three groups: group A--four patients (7.5%), LES pressure <14 mmHg; group B--18 patients (34%), LES pressure 14-24 mmHg; and group C-31 patients (58.5%), LES pressure >24 mmHg. Among the 109 untreated patients, the LES was hypertensive in 49 patients (45%), normal in 29 patients (27%), and hypotensive in 31 patients (28%). The clinical outcome was good among the three groups of patients who underwent laparoscopic Heller myotomy, with poor outcome in only approximately 10% in each group. These data show that in 55% of untreated. achalasia patients the LES pressure is either normal or low, and that laparoscopic Heller myotomy usually relieves symptoms regardless of preoperative LES pressure.