Improving the surgery for Sigmoid Achalasia: long-term results of a technical detail.

Objective: Results of Heller myotomy for the treatment of sigmoid achalasia are worst than those achieved for fusiform achalasia. We retrospectively examined two groups of sigmoid achalasias in which we performed (1) the standard Heller-Dor procedure, (2) the Heller-Dor plus a technique apt to obtain the verticality of the esophageal axis. We verified if the latter technique had improved long-term results. Methods: Among a total of 188 laparotomic and laparoscopic case series (1979–2005) we considered 33 patients affected by primitive esophageal sigmoid achalasia consecutively operated upon. Diagnosis was based on symptoms, manometry, radiology and endoscopy. Since 1987 before performing the Heller-Dor procedure we routinely isolated 360° the ge-junction and the lower esophagus and we applied U stitches at the right side of the lower esophagus in order to pull down and to rotate toward the right side the ge-junction. Fifteen patients had the No Pull-down and 18 patients had the Pull-down technique. Postoperative follow-up included barium swallow, endoscopy, objective clinical evaluation (questionnaire filled by a surgeon SR reflux symptoms, D dysphagia, E, endoscopic reflux esophagitis), subjective evaluation (self evaluation SF-36 questionnaire). Results: No postoperative complications were secondary to the pull down technique. Conclusions: The clinical objective and subjective evaluations show a trend toward the results improvement with the pull-down technique. Stronger statistical significance would probably be obtained inside a larger case series. A multicentric study could help to know more on this interesting topic.