Improving the surgery for sigmoid achalasia: long-term results of a technical detail

• Published in: European journal of cardio-thoracic surgery Vol. 32; no. 6; pp. 827 - 833
• Main Authors: Faccani, Enrico, Mattioli, Sandro, Lugaresi, Maria Luisa, Di Simone, Massimo Pierluigi, Bartalena, Tommaso, Pilotti, Vladimiro
• Format: Journal Article Conference Proceeding
• Language: English
• Published: Amsterdam Elsevier Science B.V 01.12.2007; Elsevier Science
• Subjects: Achalasia; Adult; Aged; Aged, 80 and over; Biological and medical sciences; Deglutition Disorders - etiology; Esophageal Achalasia - complications; Esophageal Achalasia - pathology; Esophageal Achalasia - physiopathology; Esophageal Achalasia - surgery; Esophagitis, Peptic - etiology; Female; Follow-Up Studies; Gastrointestinal Motility; Humans; Male; Medical sciences; Middle Aged; Oesophageal benign diseases; Oesophageal motility; Oesophageal surgery; Oesophagus; Retrospective Studies; Severity of Illness Index; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Treatment Outcome; Oesophageal surgery; Achalasia; Oesophagus; Oesophageal benign diseases; Oesophageal motility; Motility; Prognosis; Disease; Cardiovascular disease; Long term; Esophagus; Improvement; Treatment; Heart disease; Surgery; Technique
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/j.ejcts.2007.09.009

Objective: Heller myotomy results for the treatment of sigmoid achalasia are worse than those achieved for fusiform achalasia. We retrospectively examined two groups of sigmoid achalasia patients, in which we performed (1) the standard Heller–Dor procedure (no pull-down) and (2) the Heller–Dor plus a technique apt to obtain the verticality of the oesophageal axis (pull-down). We verified whether the latter technique improved long-term results. Materials and methods: We considered 33 patients affected by primitive oesophageal sigmoid achalasia operated upon consecutively (1979–2005). Diagnosis was based on symptoms, manometry, radiology and endoscopy. After 1987, we routinely isolated 360° of the gastro-oesophageal junction and the lower oesophagus and applied U stitches at the right side of the lower oesophagus to pull down and rotate the gastro-oesophageal junction toward the right. Fifteen patients underwent the no pull-down and 18 patients underwent the pull-down technique. Postoperative follow-up included objective clinical and instrumental evaluation (questionnaire filled by a surgeon including the assessment of symptoms and endoscopic reflux oesophagitis according to a semi-quantitative scale) and subjective evaluation (self-evaluation SF-36 questionnaire). Results: The mean follow-up period was 89 months (range 12–261 months). The postoperative dysphagia score was significantly improved in the entire group. Excellent results were present in 12 patients (36.4%), good in 11 (33.3%), fair in 3 (9.1%) and insufficient in 7 patients (21.2%). No statistically significant differences were observed between the two groups with regard to the postoperative symptoms and oesophagitis. Postoperative radiological measurements of oesophageal diameter and residual barium column were significantly improved in the whole group and within each group with respect to the radiological variables measured preoperatively (p = 0.000). In the comparison of the two groups, statistically significant differences were observed with regard to mean oesophageal diameter (p = 0.030) (pull-down, 4 ± 0.9 cm; no pull-down, 4.7 ± 0.6 cm) and residual barium column (p = 0.048) (pull-down, 6.2 ± 3.4 cm; no pull-down, 9.6 ± 5.8 cm). Conclusions: The Heller–Dor operation is effective in the presence of sigmoid achalasia. The clinical objective and subjective evaluations show a trend toward the improvement of results with the pull-down technique. Stronger statistical significance would probably be obtained from a larger case series.