Laparo-endoscopic Single Site (less) Heller Myotomy and Anterior Fundoplication for Achalasia

Introduction: Laparo-Endoscopic Single Site (LESS) surgery is beginning to include advanced laparoscopic operations, such as Heller myotomy with anterior fundoplication. However, the feasibility and efficacy of LESS Heller myotomy and anterior fundoplication has not been established. This study was undertaken to evaluate our initial experience with LESS Heller myotomy and anterior fundoplication for achalasia.

Methods: Transumbilical LESS Heller myotomy with concomitant anterior fundoplication for achalasia was undertaken in 51 patients since October 2007. Outcomes, including operative time, complications, and length of stay were recorded and compared to an earlier consecutive contiguous group of 51 patients undergoing conventional multi-incision laparoscopic Heller myotomy with anterior fundoplication. Symptoms before and after myotomy were scored by patients using a Likert scale (0=never / not severe to 10=always / very severe). Data were analyzed using the Mann-Whitney test, Wilcoxon matched pairs test, and Fisher exact test, where appropriate. Data are presented as median (mean ± SD).

Results: Patients undergoing LESS Heller myotomy vs. conventional laparoscopic Heller myotomy were similar in gender, age, BMI, blood loss, and length of hospital stay (Table). However, patients undergoing LESS Heller myotomies had operations of significantly longer duration. With LESS myotomy, 10 patients (20%) required an additional port / incision. No patients were converted to “open” operations. No patients had procedure specific complications. Symptom reduction was dramatic, satisfying, and similar after both LESS and conventional laparoscopic myotomy and fundoplication (Table). Patients undergoing Heller myotomy and anterior fundoplication using LESS approach had no apparent scars.

Conventional lap Heller LESS Heller
Patients (N): 51 51
Gender: 25 m / 26 f 25 m / 26 f NS
Age: 50 years (52 years ± 19.1) 57 years (55 years ± 16.0) NS
BMI: 24 kg/m2 (24 kg/m2 ± 4.2) 25 kg/m2 (24 kg/m2± 3.8) NS
Length of Operation: 106 min (109 min± 32.4) 133 min (131 min± 41.5) 0.002
Blood Loss: 47 (<100ml), 4(100-250ml) 51 (<100ml) NS
Length of Stay: 1 day (1.9 days± 1.8) 1 day (1.6 days± 1.0) NS

Dysphagia Severity Before Myotomy

Dysphagia Severity After Myotomy

9 (8 ± 1.6)

2 (2 ±1.3)*

8 (8 ± 2.3)

1 (2± 2.1)*

NS

NS

Heartburn Severity Before Myotomy

Heartburn Severity After Myotomy

5 (5± 2.3)

2 (3± 1.9)*

5 (5 ± 2.0)

2 (3± 1.8)*

NS

NS

* p<0.01, less than before myotomy and anterior fundoplication, Wilcoxon matched pairs test

Conclusion: Heller myotomy with anterior fundoplication effectively treats achalasia. LESS Heller myotomy and anterior fundoplication is feasible, safe, and efficacious. While the LESS approach increases operative time, it does not increase procedure related morbidity or hospital length of stay and avoids apparent scarring. LESS surgery represents a paradigm shift to more minimally invasive surgery and is applicable to advanced laparoscopic operations such as Heller myotomy and anterior fundoplication.


Session: Podium Presentation

Program Number: S074

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