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

Objective: In the last 10 years, the Heller-Dor operation has by far been the most reported technique in the English literature for treating esophageal achalasia. Quality of outcome is sometimes different between studies, which is likely due to technical reasons. The aim of this study was to analyze the details of myotomy and fundoplication in relation to curing dysphagia and the occurrence of post-operative reflux esophagitis (RE) achieved over 30 years of a single center’s experience. Methods: This study examined the period between January 1979 and December 2008 in which the same technique was performed by five staff surgeons and several residents. Intraoperative manometry was used in 100% of the 262 patients to abolish the high pressure zone (HPZ) with a long esophagogastric myotomy and to protect the surface of the myotomy with a long but soft anterior fundoplication (six to eight sutures on each side of the myotomy, trimmed to avoid RE without impairing esophageal emptying). A total of 202 patients [97 men, median age 55.5 years; interquartile range (IQR) = 43.7-71] underwent laparotomy, and another 60 patients (24 men, median age 46 years; IQR = 36.2-63) underwent laparoscopy. The follow up consisted of a clinical interview, an endoscopy, barium swallow at given intervals and manometry when needed. We then used a semiquantitative scale to grade the results. Results: Death occurred in 1/202 patients in the laparotomy group (severe portal hypertension in congenital cardiopathy) and 0/60 in the laparoscopy group, with three conversions. All patients received follow-up care. The median follow ups in the laparotomy and laparoscopy groups were 96 months (IQR = 48-190.5) and 48 months (IQR = 27-69.5), respectively. At intraoperative manometry, myotomy resulted in a complete abolition of the HPZ in 100% of the patients. The Dor-related HPZ length and mean pressure were 4.5 (± 0.4) cm and 13.3 (± 2.2) mmHg in the laparotomy group and 4.5 (± 0.5) cm and 13.2 (± 2.2) mmHg in the laparoscopy group (p = 0.75;). In the laparotomy group, poor results [19/201 (9.5%)] were secondary to RE in 15/201 (7.5%) of the patients. In two patients, RE was diagnosed after 184 and 252 months, and recurrent dysphagia was diagnosed in 4/201 patients (2%), all resulting in end-stage sigmoid achalasia. In the laparoscopy group, 2/60 patients (3.3%) had RE and none had recurrent dysphagia. 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.