Operation for esophageal achalasia. Results of esophagomyotomy without an antireflux operation

Between January, 1970, and January, 1984, 113 patients with esophageal achalasia underwent 115 esophagomyotomies at the Lahey Clinic. Twenty-nine patients had been treated on one or more occasions by forceful dilation, and 18 had been operated upon before. Results are based on follow-up studies of 103 patients operated on 1 to 13.5 years ago (average follow-up period, 6.75 years). Six patients were lost to follow-up study, and six were operated upon less than a year ago. The condition of 94 patients (91%) was improved by operation. The improvement rate was 94% for those who underwent a primary operation and 76% for those who underwent reoperation. Only four of the nine poor results were caused by reflux esophagitis, and these patients are satisfactorily managed medically. Multiple regression analysis of risk factors including age, sex, duration of symptoms, severity of disease, length of follow-up, previous operation, and forceful dilations revealed that only previous operation correlated significantly with poor results (p = 0.0004). Preoperative and postoperative manometric assessment of the lower esophageal sphincter was made on some of these patients. The amplitude of lower esophageal sphincter pressure dropped from 32.5 +/- 1.6 (SEM) to 14.5 +/- 1.4 mm Hg, and the length of the lower esophageal sphincter decreased from 3.7 +/- 0.1 to 2.2 +/- 0.1 cm. These differences were highly significant (p = 0.001). After myotomy a short subhiatal remnant of the lower esophageal sphincter remains with pressure within the normal range, which minimizes the risk of postoperative gastroesophageal reflux. Because of the high success rate of limited esophagomyotomy and the low incidence of significant reflux symptoms after its use, we recommend that it be performed without an associated antireflux procedure.