Our experience with Laparoscopic Modified Heller myotomy and Dor fundoplication in Esophageal Achalasia

INTRODUCTION: In this study we have retrospectively evaluated the patients which underwent laparoscopic modified Heller myotomy for achalasia.
METHODS: Between January 2006 and January 2011, 20 patients underwent laproscopic Heller myotomy and Dor fundoplication in Istanbul Faculty of Medicine Department of General Surgery. The files of the patients were evaluated retrospectively.
RESULTS: The mean age of the patients were 45.3± 10.9 years and female /male ratio was 1.86/1 (13/7). The mean symptom period was 17±4.9 months. In the preoperative period, 14(%70) patients underwent one, 6 (%30) patients underwent two times of pneumatic esophageal dilatation. Botox treatment was performed in 4 (%20) of the patients before the pneumatic dilatation. The mean lower esopghageal sphincter (LES) pressure of the patients was 24,2±11,6 mmHg. All of the patients were underwent laproscopic Heller myotomy and Dor fundoplication. The mean operation time was 62 ±17.6 minutes. The esophageal mucosal rupture occured in 1 (%5) patient during the operation and repaired laparoscopically. The mean hospitalization time was 2.3±0.6 days. The mean follow-up time was 26,2±20,2 months. No recurrence was occured during the follow-up period. Gastro-esophageal reflux (GER) was occurred in 2 (%10) patients with mild symptoms and treated medically. Port site hernia was occured in 1 (%5) patient.
DISCUSSION AND CONCLUSION: Laproscopic Heller myotomy is the most effective treatment for esophageal achalasia. Because of the higher GER rates in patients without antireflux procedure, we recommend that Dor fundoplication should be added to the Heller myotomy.

Akalazyalý Hastalarda Laparoskopik Modifiye Heller Myotomi ve Dor Fundoplikasyon Deneyimimiz

GÝRÝÞ ve AMAÇ: Bu çalýþmada akalazya tanýsýyla laparoskopik modifiye Heller myotomi ve Dor fundoplikasyon uyguladýðýmýz hastalarý deðerlendirmeyi ve bu konudaki deneyimizi aktarmayý amaçladýk.
YÖNTEM ve GEREÇLER: Çaluþmaya Ocak 2006 –Ocak 2008 yýllarý arasýnda Akalazya tanýsý ile Ýstanbul Týp Fakültesi Genel Cerrahi Anabilim Dalý’nda laparoskopik modifiye Heller myotomi ve Dor fundoplikasyonu uygulanan 20 hasta alýnmýþ ve dosya bilgileri retrospektif olarak incelenmiþtir.
BULGULAR: Ortalama yaþ 45.3± 10.9 yýl, K/E oran› 1.86/1 (13/7) olarak saptandý. Hastalarýn ortalama þikayet süresi 17±4.9 ay olarak bulundu. Ameliyat öncesi dönemde hastalarýn 14 (%70)’ine 1 kez, 6 (%30)’sýna 2 kez balon dilatasyon, 4 (%20) hastaya ise ameliyat öncesi dönemde botulinum toksini ile tedavi denenmiþti. Ameliyat öncesi manometrik incelemede ortalalama AÖS basýncý 24,2±11,6 mmHg saptandý. Hastalarýn tümüne myotomi ve 180° Dor fundoplikasyon uygulandý. Ortalama ameliyat süresi 62 ±17.6 dk olarak saptandý. Ameliyat sýrasýnda 1(%5) hastada mukozal açýlma oldu ve laparoskopik olarak tamir edildi. Hastalar›n ortalama hastanede kalýþ süresi 2.3±0.6 gün olarak bulundu. Ameliyat sonrasý dönemde 1(%5) hastada port yerinden geliþen kesi fýtýð dýþýnda herhangi bir komplikasyon saptanmadý. Hastalar ortalama 26,2±20,2 ay takip edildi. Takip süresi içinde hastalarýn hiçbirinde nüks saptanmadý. Ýki (%10) hastada takip süresi içinde hafif gastroözofageal reflü semptomlarý geliþti. Bu hastalarda uygulanan medikal tedavi ile semptomlar geriledi ve ek giriþim gerekmedi.
TARTIÞMA ve SONUÇ: Akalazyalý hastalarda günümüzde en etkin tedavi yöntemi laparoskopik modifiye Heller myotomidir. Myotomiye antireflü bir prosedür eklenmeyen hastalarda ameliyat sonrasý patolojik reflü saptanma riskinin daha yüksek olmasý nedeni ile Heller myotomiye anti reflü giriflim olarak Dor fundoplikasyonunun da eklenmesi gerektiðini düþünmekteyiz.