Surgical Treatment of Achalasia: Results with Esophagomyotomy and Belsey Repair

To address the controversy regarding the choice of operation for achalasia, the cases of 57 patients having operation, 38 for the first time (Group 1) and 19 with a previous procedure (Group 2), were reviewed. Surgical emphasis was on hiatal dissection to maximize exposure and use of the Belsey fundoplication to achieve cardiac competence without obstruction. Operative mortality was 1 (1.8%) of 57 patients. In group 1, 21 of the 38 had prior pneumatic dilations. All were treated with esophagomyotomy and a Belsey fundoplication. Clinical results are excellent or good in 30 (88%) of the 34 patients for whom follow-up is available, and are similar in patients with and without prior dilation. Lower esophageal sphincter (LES) pressure decreased from 22.3 to 7.7 mm Hg ( p < 0.001), and pH testing shows no reflux in any of 13 patients. In Group 2, previous operations were esophagomyotomy in 13, esophagomyotomy plus a Nissen fundoplication in 3, and a Nissen fundoplication only in 3. The initial operation failed because of inadequate myotomy in 6 patients, an obstructive Nissen fundoplication in 6, and reflux esophagitis in 7. In these 7 patients, acid reflux testing documented reflux due to cardiac incompetence and delayed clearance. Reoperations included takedown of a Nissen fundoplication in 6, esophagomyotomy and Belsey procedure in 15, Belsey procedure in 1, and resection plus colon interposition in 2. Clinical results are excellent or good in 12 (75%) of the patients with follow-up. These conclusions can be drawn. (1) Esophagomyotomy and Belsey fundoplication lowers LES pressure and provides good results with low risk, even after pneumatic dilation. (2) Failure of myotomy alone is due to either reflux or an inadequate myotomy, both of which are uncommon when exposure for the myotomy is maximal and cardiac competence is reestablished with a Belsey procedure. (3) This approach is also satisfactory for reoperations, although results are poorer.