Achalasia Treatment: Improved Outcome of Laparoscopic Myotomy with Operative Manometry

Hypothesis: Operative manometry detects residual esophagogastric junction (EGJ) high pressure, ensuring complete myotomy. Design: Consecutive patients undergoing laparoscopic myotomy. Setting: Tertiary care academic medical center. Patients: From 1997 to 2003, 139 patients with achalasia underwent laparoscopic myotomy. Interventions: We assessed myotomy completeness by operative endoscopy and performed operative manometry to measure pressure across the EGJ myotomy. Residual high pressure was isolated and intact muscle divided. Main Outcome Measures: Esophageal manometry, quality of life, and dysphagia severity score. Results: Median lower esophageal sphincter pressure was 27 mm Hg preoperatively; 10 patients had sigmoid esophagus and 57 had previous dilation and/or toxin injection. There were 136 laparoscopic myotomies and 3 conversions to open procedures (2%). Operative endoscopy was performed in all patients. Operative manometry, completed in 132 patients (95%), identified residual EGJ high pressure leading to myotomy revision in 45 patients (31 in the first 70 treated). Small perforations occurred in 19 patients, associated with previous dilation and/or toxin injection in 12 patients. One-month follow-up was available in 136 patients (98%); 126 patients had minimal symptoms (93%), whereas 1 had recurrent EGJ high pressure, 5 esophagitis, 3 sigmoid esophagus, and 1 paraesophageal hernia. In 60 patients with complete 1-year follow-up, quality of life and dysphagia improved (P<.05); mean lower esophageal sphincter pressure decreased to 7.6 mm Hg (P<.05). Conclusions: Operative manometry identifies residual EGJ high pressure and reduces the incidence of incomplete myotomy. Laparoscopic myotomy improves quality of life and dysphagia symptoms and may be the treatment of choice in most patients with achalasia.