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

Mattioli, Sandro; Ruffato, Alberto; Lugaresi, Marialuisa; Pilotti, Vladimiro; Aramini, Beatrice; D'Ovidio, Frank

doi:10.1016/j.jtcvs.2010.07.053

« Previous Next »The Journal of Thoracic and Cardiovascular Surgery
Volume 140, Issue 5 , Pages 962-969, November 2010

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

Read at the 90th Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, May 1–5, 2010.

Sandro Mattioli, MD
- Division of Thoracic Surgery, Center for the Study and Therapy of Diseases of the Esophagus, Alma Mater Studiorum–University of Bologna and GVM Care and Research, Cotignola, Italy
- Address for reprints: Sandro Mattioli, MD, Department of Surgery and Organs Transplantation, Faculty of Medicine, Alma Mater Studiorum–University of Bologna, Via G. Massarenti 9, 40138 Bologna, Italy.
Alberto Ruffato, MD, PhD
- Division of Thoracic Surgery, Center for the Study and Therapy of Diseases of the Esophagus, Alma Mater Studiorum–University of Bologna and GVM Care and Research, Cotignola, Italy
Marialuisa Lugaresi, MD, PhD
- Division of Thoracic Surgery, Center for the Study and Therapy of Diseases of the Esophagus, Alma Mater Studiorum–University of Bologna and GVM Care and Research, Cotignola, Italy
Vladimiro Pilotti, MD
- Division of Thoracic Surgery, Center for the Study and Therapy of Diseases of the Esophagus, Alma Mater Studiorum–University of Bologna and GVM Care and Research, Cotignola, Italy
Beatrice Aramini, MD
- PhD Course in Pneumo-Cardio-Thoracic Sciences, Alma Mater Studiorum–University of Bologna; and the Division of Cardiothoracic Surgery, Columbia University, New York, NY
Frank D'Ovidio, MD, PhD
- PhD Course in Pneumo-Cardio-Thoracic Sciences, Alma Mater Studiorum–University of Bologna; and the Division of Cardiothoracic Surgery, Columbia University, New York, NY

Received 30 April 2010; received in revised form 11 July 2010; accepted 19 July 2010. published online 09 September 2010.

Objective

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.

Methods

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.

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.

Conclusions

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.

CTSNet classification: 8, 8.6, 8.7, 28

Abbreviations and Acronyms: HPZ, high-pressure zone, IQR, interquartile range, LES, lower esophageal sphincter, RE, reflux esophagitis