Comparison Of Thoracoscopic And Thoracotomy Heller Myotomy For Achalasia

Objective:The purpose of this study is to compare the clinical features and efficacy of thoracoscopic and thoracotomy Heller myotomy for achalasia.Materials and methods : Twenty-one patients for achalasia were diagnosed in Xi'an railway central of hospital from June 2006 to June 2010, the clinical data contains name, sex, age, medical history, surgical procedure, preoperative and postoperative barium swallow. Undergoing barium esophagogram examination, all patients had been showed the typical performance of achalasia preoperative, expansion of the proximal esophagus, esophageal cardia showed a bird-beak deformity, endoscopy ruled out organic stenosis and esophageal malignant disease. Using a visual analogue scores to evaluate the severity of symptoms, including dysphagia, esophageal reflux, chest pain, (0 indicates asymptomatic, 10 indicates very severe symptoms. )Barium swallow examination suggest the severity for achalasia of the maximum diameter with esophageal body expansion, esophageal body diameter <4.0cm indicates mild expansion, esophageal body diameter of 4～6cm indicates moderate expansion, esophageal body diameter >6.0cm indicates severe expansion. All patients were divided thoracoscopic Heller group (thoracoscopic group) in 9 cases and thoracotomy Heller group (thoracotomy group) in 12 cases. According to the criteria described below to determine the efficacy of surgery, VAS scores 1 to 4 points and esophageal body diameter <4.0cm standards for good, VAS scores 4～7 points and esophageal body diameter 4～6.0cm standards for fair, VAS 7～10 points and esophageal body diameter > 6.0cm standard for poor, efficacy:(cases of cured+cases of improved)/total cases×100%. All patients had to be closed that thoracic drainage was less than 100ml/d, removed the gastri-tube and began to have liquid diet after 3～5 days, it was allowed apply for discharged barium swallow examination of normal features, and nursing the transition to a balance diet grandually. All patients were followed up after discharge 1 months, including the difficulty of swallowing, esophageal reflux, chest pain, using VAS scores for the assessment of symptom, comparing the change of esophageal body diameter by barium esophagogram.Results : Esophageal mucosal perforation occurred in 1 patient in thoracoscopic group, repairing transthoracoscopic successfully, esophageal reflux occurred in 2 patients, in thoracotomy group esophageal mucosal perforation and esophageal reflux occurred in 2 patients, repairing transthoracic successfully, givening the proton pump inhibitors and gastric motility oral treatment, chest pain and heartburn had improved. Operation time for the thoracoscopic group was 1.3～2.5h, an average of 1.9±0.4h, blood loss was 50～120ml, an average of 76.7±18.9ml, hospital stay was 4～9d, an average of 5.4±1.5d, operation time for the thoracotomy group was 1.5～3.5h, an average of 2.3±0.6h, blood loss was 80～250ml, an average of 142.5±54.0ml, hospital stay 5～12d, an average of 8.2±2.1d. Followed up after 1 month, all patients of symptoms were improved, thoracoscopic group of 9 cases with VAS scores from 6.3±0.8 down to 4.7±0.9, esophageal body diameter from 4.4±1.6cm down to 4.1±1.4cm, efficiency 88.9%, thoracotomy group of 12 cases with VAS scores from7.1±1.3 down to 4.8±1.2, esophageal body diameter from 5.0±1.6cm down to 4.5±1.2cm, efficiency 83.3%, the difference was not statistically significant.Conclusions:Heller myotomy is widely used surgical treatment for achalasia, as compared with traditional transthoracic surgery, Heller transthoracoscopic has a advantage of less trauma, less bleeding, shorter hospital stay, rapid recovery, and is worthy of clinical promotion.