Limited Heller Myotomy Without Anti Reflux Procedure Is Similar to Poem and Does Not Induce Significant Gerd.

Luis C Zurita MV, MD, Radu Pescarus, MD, Lukas Wasserman, MD, Izabela Apriasz, MD, Dennis Hong, MD, MSc, FRCSC, FACS, Scott Gmora, MD, FRCSC, Margherita Cadeddu, MD, FRCSC, Mehran Anvari, MB, BS, PhD, FRCSC, FACS

Department of Surgery, Centre of Minimal Access Surgery, St. Joseph’s Healthcare, Hamilton, ON, Canada.

Introduction. Laparoscopic Heller myotomy with partial fundoplication is the gold standard treatment for achalasia, although around 30% of patients complain of gastroesophageal reflux disease (GERD) after surgery. Laparoscopic limited Heller myotomy without dissection of the angle of His and with no anti-reflux procedure is another possible option. This surgery is the premise for the peroral endoscopic myotomy (POEM).

Methods and procedures. A review of prospectively collected data was performed on patients who underwent laparoscopic limited Heller myotomy (myotomy of 8cm distal esophagus and LES) without dissection of the angle of His and with no anti-reflux procedure from January 1998 to December 2012. Patients underwent extensive pre and 6 months postoperative clinical evaluation including: gastroscopy, esophageal manometry, 24 hours pH-metry and the achalasia severity symptom score (ASSS) and SF-36 questionnaires were answered. Comparison between outcomes was performed with paired t student test.

Results. One hundred twenty six patients underwent laparoscopic limited Heller myotomy. Of these, 60 patients had complete motility studies performed pre and postoperatively, while 53 patients were just followed up clinically and endoscopically, and 13 patients did not reach the 6 months follow up threshold.

From the 60 patients with complete motility studies, 34 patients were female and 26 male. Patient mean age was 45.7±15.2 years and mean follow up was 10.53 ±11.1 months. Mean operative time was 56.1±16.2 minutes and mean length of stay was 1.7±0.6 days. After surgery, patients gained a mean of 12 ±15.5 lbs. (162.35 vs. 174.52; p<0.001).

A significant decrease in the lower esophageal sphincter (LES) resting pressure (29.1±18 vs. 7.1±6; p<0.001) and in the LES nadir (16.4±11.9 vs. 4.3±4.6; p<0.001) was observed when the preoperative and postoperative data was compared.

After surgery, normal total pH<4% (mean 0.67%±0.89%) and DeMeester score (mean 3.66 ±4.12) were observed in 68.3% patients. Never the less, from the 31.6% with GERD by ph-metry, only 24.1% patients were clinically symptomatic, requiring daily proton pump inhibitors. All patients with GERD were properly controlled with medical treatment and no patient required further anti-reflux surgery.
There was a significant improvement on dysphagia (9.82±3.4 vs 2.05±3.1; p<0.001), heartburn (3.82±3.9 vs 1.72±2.8; p<0.01) and regurgitation (7.55±4.4 vs. 0.65±1.9; p<0.001) scores after surgery. Patients reported a significant quality of life improvement after surgery according to the SF-36 questionnaire (physical (p<0.001) and mental component summary (p<0.01)).

One patient (0.8%) presented significant dysphagia after surgery and transthoracic Heller myotomy with an anti-reflux procedure was performed.

Conclusion. Limited Heller myotomy without dissection of the angle of His and with no anti-reflux procedure is an effective treatment for achalasia. Postoperatively, a significant manometric, symptomatic and quality of life improvement is obtained while conserving a similar GERD rate as the traditional Heller myotomy with an anti-reflux procedure. We should expect similar clinical results from POEM.

Session: Podium Presentation

Program Number: S115

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