Heller’s Myotomy with Reconstruction of the Angle of His in Achalasia. Impact on Postoperative Gastroesophageal Reflux and Les Pressure

Introduction: Although Heller´s myotomy has proven to be the best treatment for patients with Achalasia, the addition of an antireflux procedure is still debatable. The aim of the study is to analyze the impact of the Heller myotomy without an antireflux procedure on postoperative gastroesophageal reflux and LES pressure in patients with Achalasia.
Methods: From a total of 28 patients with Classic Achalasia who underwent Heller´s myotomy between 2007 and 2008 and were invited to participate in the study, 16 patients with a minimum follow-up of 6 months agreed to undergo esophageal testing. The surgical technique included: 1) opening of the anterior aspect of the esophagus preserving the posterior attachments, 2) a 5 to 6 cm myotomy with 1cm on the gastric side and 3) Fixation of the gastric fundus to the left lip of the myotomy with 3 interrupted stitches of non absorbable suture in order to reinforce the angle of His. Evaluation of gastroesophageal symptoms, manometry and 24h esophageal pH monitoring were performed ≥6 months after surgery. Clinical symptoms were assessed using a score scale from 0 to 4. (0 = never, 1 = rarely, 2 = sometimes, 3 = frequently, 4 = always).
Results: There were 2 males and 14 females with a mean age of 35.4±11.3 years. Median operative time was 130 mins (85-187), Postoperative evaluation was performed 16±6 months after surgery. Postoperatively dysphagia score was 3 in 2 patients (12.5%), 2 in 5 (31.3%) and 0 or 1 in 9 (56.3%). Regurgitation scores were 4 in 1 patient (6.3%), 3 in 1 (6.3%), 2 in 3 (18.8%), and 0 or 1 in 11 (68.8%). Heartburn score was 3 in 4 (25%), 2 in 4 (25%) and 0 or 1 in 8 patients (50%). LES pressure was 28.5?18.3 before surgery and 14.6?7.9 mmHg after surgery (p<0.005). By pHmetry 7/16 patients (44%) presented pathological reflux. Median De-Meester score in patients with pathologic reflux was 88 (26.9-166.6) and it was 6.7 (0.3-40.5) in patients without reflux.
Conclusion: Heller´s myotomy without an antireflux procedure is a very effective procedure to treat Achalasia. The frequency of gastroesophageal reflux detected by pHmetry in this series was high but it had low clinical impact.

Session: Poster

Program Number: P352

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