Thoracoscopic esophagomyotomy for achalasia: Maximum gain, minimal pain

Background. Achalasia can be effectively created by either hydrostatic balloon dilatation ol transthoracic modified Heller myotomy. The purpose of this study was to determine whether thoracoscopic methods could be used to achieve surgical results equal to the transthoracic approach with less pain. Methods. Twenty-one patients (10 men, 11 women; median age 42 years) had the diagnosis of achalasia confirmed by manometry, radiography, and endoscopy. All had dysphagia; five had weight loss. Median duration of symptoms was 12 months (range: 1 to 360 months). Eleven patients had under-gone previous unsuccessful hydrostatic dilatation. Mean esophageal diameter was 5.5 +/- 2.2 cm. Results. All patients underwent attempted modified Heller myotomy through a left thoracoscopic approach. Three patients required conversion to thoracotomy. The myotomy was extended < 1 cm past the squamocolumnar junction. There was one intraoperative perforation and no postoperative complications. All patients were begun on a regular diet on the first postoperative morning. Median length of stay was 2 days. Median follow-up was 22 months (range: 1 to 52 months). Sixteen patients (80%) had excellent relief of their dysphagia. Two patients (10%) had good relief and two patients had only a fair result, although even they claim to be much improved. Conclusions. Thoracoscopic Heller myotomy reproduces the superior results of open esophagomyotomy with a reduced hospitalization and reduced incisional pain and disability.