Results of laparoscopic treatment of achalasia

• Galliamov E.A.
• Shestakov A.L.
• Dmitriy A. Erin
• Gololobov G.Yu.
• Chicherina M.A.
• Alexandr I. Burmistrov
• Yurkuliev N.A.

Abstract

Despite the variety of accumulated data on the methods of treatment of achalasia and its effectiveness, many issues of therapy of this pathology remain controversial.

Aim - to retrospectively analyze the intraoperative, early and late postoperative results of laparoscopic Heller esophagocardiomyotomy with anterior fundoplication as modified by Dor and posterior partial fundoplication with posterior cruroraphy in order to optimize the tactics of treatment of patients with achalasia.

Material and methods. The study group included 48 patients (21 men and 27 women) with a diagnosis of achalasia. The mean age of patients at the time of admission was 44.8±11.93 years, the mean BMI was 22.03+2.85 kg/m². According to the degree of anesthetic risk, 11 (22.9%) patients were assigned to the I class of physiological status according to the ASA, 37 (77.1%) - to the II class. In the study group, 1 (2.1%) patient was with stage I achalasia according to B.V. Petrovsky, 23 (47.9%) with stage II, 22 (45.8%) with stage III, with stage IV - 2 (4.2%) patients. At the time of examination of patients at admission to the hospital, the average score according to the Eckardt questionnaire was 9.1±2.43. All patients were examined according to a unified record, which included contrast-enhanced radiography of the esophagus, esophagogastroduodenoscopy, and electrocardiography as well as a complex of laboratory tests (clinical and biochemical blood tests, coagulogram). The sample consisted of patients who underwent laparoscopic Heller esophagocardiomyotomy with anterior fundoplication as modified by Dor and posterior partial fundoplication with posterior cruroraphy. Recurrent forms were not included in the sample. Long-term results were studied in 31 patients. 

Results. According to the data obtained as a result of the study, the average operation time was 100.8±23 min, blood loss was 16.5 ml (5-30 ml), and the postoperative bed-day was 4.8±1.0. Intraoperative complications were detected in 5 (10.4%) patients. Perforation of the esophageal mucosa was diagnosed in 4 (8.3%) of them. The defect was sutured with interrupted sutures. 1 (2.1%) patient developed carboxytorax. On the third day, one patient was found to have free fluid in the abdominal cavity. During an emergency operation, an acute perforated ulcer was revealed. The ulcer was sutured, which corresponds to grade IIIb complications according to Clavien-Dindo classification. In the postoperative period, dysphagia is absent in all patients. The average Eckardt score before surgery was 9.1±2.43, after 3 months or more - 1.5±1.2. The recurrence of symptoms of the disease in the long term is absent in all patients (the median of follow-up was 15 months). The mean GERD-HRQL score in the postoperative period was 1.9±1.4, which indicates the formation of a functioning antireflux mechanism.

Conclusion. Laparoscopic Heller cardiomyotomy with Dor fundoplication with the formation of a posterior partial cuff should be considered the operation of choice for the treatment of achalasia. The advantage of this method is the effectiveness of treatment at all stages of the disease, a low risk of postoperative complications, including GERD.

Keywords:achalasia; laparoscopic Heller cardiomyotomy with Dor fundoplication; methods of achalasia treatment

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