Surgical Therapy For Esophageal Achalasia: A Report Of 52 Cases

Background: Achalasia is a rare esophageal motor disorder with an estimated annual incidence of 1/100,000. Characterized by aperistalsis or uncoordinated contractions of the esophageal body and impaired relaxation of a frequently hypertensive lower esophageal sphincter (LES), achalasia is secondary to irreversible degeneration of esophageal myenteric plexus neurons, and the cause of which remains unknown. The symptoms of achalasia include dysphagia, regurgitation, heartburn, postprandial chest pain, and weight loss. Its diagnosis is mainly based on the clinical manifestation, contrast barium compound examination, esophagoscopy and esophageal pressure measurement. As no currently available treatments can restore esophageal motility, all known therapeutic methods merely aim at lowering the resting pressure of the lower esophageal sphincter and palliation of dysphagia and other symptoms essentially related to esophageal stasis. The main treatments include drug, botulismotoxin injection, Mechanical Dilation, operation and so on. Use of calcium channel blockers or long acting nitrates is only suit for dysphagia remission temporarily or preoperative preparation, because of its minimal effect; botulismotoxin injection and Mechanical Dilation can show effect merely in a short period. The operation, however, have acceptable short-term and long-term results. On the other hand, there are still many altercations, including the option of the operative approach, whether the anti-relfux procedure is essential and which kind of procedure is better.Objective: To objectively assess various operative procedures for achalasia, and to provide basis for selecting operations.aterials and Methods: Between January 1998 and September 2007, 52 patients with achalasia underwent Heller's myotomy in the First Hospital of Jilin Medical University.There were 24 male and 28 females, with a mean age of 38.8 years (rage 2 to 72). All patients had dysphagia, and mean duration of symptoms was 3.2 years (range 1 month to 30 years). All patients had a dilated esophagus with bird beak appearance on Upper gastrointestinal barium meal examination. Heller's myotomy was performed in 39 patients. Heller's myotomy with anti-reflux procedure in 13 patients. Myotomy was performed through thoracic approach in23 patients, and abdominal approach in 29 patients. Follow-up was carried out by telephone or correspondence, and the patients were asked about postoperative dysphagia, heartburn, chest pain. The curative effect of operation were evaluated as excellent (symptom disappears completely) and good (light symptom does not need to deal with) and fair (light symptom need to deal with occasionally) and poor (symptom is obvious, need frequently deal with). According to the surgical methods, the patients were divided into group of patients undergoing Heller's myotomy without anti-reflux procedure (group 1) and group of patients with anti-reflux procedure (group 2). According to the surgery approach, the patients were divided into group through thoracic approach (group T) and group through abdominal approach (group A). The curative effect of different operation patterns and approaches was evaluated according to the post operative symptom scores and the outcomes of the follow-up.Results: 1. Outcomes assessed by patient questionnaires revealed excellent relief of dysphagia in 19 patients (36.5%), good relief in 28 patients (53.8%), fair relief in 5(9.6%), and a poor result in (0%). The overall excellent or good results were 92.3%, this percentage is 92.3% in group 1 and 84.6% in group 2 (P=0.415). This percentage is 91.3% in group T and 89.7% in group A (P=0.841). 2. The reflux rate of pure modified Heller operation through thoracic approach is not higher than through abdominal approach (P=0.54). The reflux rate of pure modified Heller operation through thoracic approach is higher than Heller operation added anti-reflux procedure (P=0.037). The reflux rate of the total length≥8cm incision group is higher than<8 cm group (P=0.003). 3. The average hospitalization cost of group A is more than group T. 4. The fasting time and Postoperative Hospitalization of group A is shorter than group T.Conclusions:1. The therapeutic efficacy and postoperative reflux rate of modified Heller through abdominal approach and through thoracic approach had no Statistical difference, but Heller through abdominal approach had less hospitalization costs, shorter recovery time, and with the merits of surgery convenient, mini trauma, less patient mental pressure, so it is more worthy to be extended in clinical practice.2. The therapeutic efficacy of additional anti-reflux procedure and simply modified Heller had no Statistical difference, and additional anti-reflux procedure markedly decreased the incidence of postoperative reflux, so it is worthy to be extended in clinical practice. Especially, those of the total incision length≥8cm should adopt additional anti-reflux surgery.