LAUSR

Achalasia is at present classified in 3 manometric patterns. Pattern III is the most unfrequent pattern and is correlated with the worst outcome after all available treatments. We aimed to investigate the final outcome after classic laparoscopic myotomy (CLM) as compared with a longer laparoscopic myotomy both downwards and upwards with (LLM) in patients with pattern III achalasia. The study population consisted of 61 consecutive patients with pattern III achalasia who underwent laparoscopic myotomy between 1997-2017. Patients who had already been treated with surgical or endoscopic procedures were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium-swallow, endoscopy, manometry were performed, before and after surgical treatment. In CLM the total length of the myotomy was ≤ 9 cm, while myotomies extended both downwards and upwards to a length >9 cm were defined as LLM. Of the 61 patients representing the study population, 24 had CLM and 37 had LLM. In addition, all the patients add an anterior, partial fundoplication (Dor). The patients’ demographic and clinical parameters (sex, symptom-score, duration of symptoms, esophageal-diameter) were similar in both groups. One mucosal perforation was detected and repaired intraoperatively in the LLM group. The median length of the myotomy was 8 cm (IQR:8-9) in the CLM and 10 cm (IQR:10-12) in the LLM (p<0.001). The median of follow-up was 94 months (IQR:52-126) in the CLM and 24 months (IQR:16-40) in the LLM. As a whole, the two groups had a different drop in their symptom score: 22 (17-26) versus 4 (0-8), and 20 (18-27) versus 3 (0-6) for the CLM and LLM respectively (p<0.01). Moreover, failures were 8/24 (33.3%) in the CLM and 4/37 (10.8%) in the LLM (p<0.05). An abnormal acid exposure was detected after the treatment in 4 patients of CLM and in 3 of LLM (p=n.s.). The extension of the length of the myotomy both downwards and upwards improves the final outcome of the laparoscopic Heller-Dor procedure in patients with pattern III achalasia. On the other hand, a longer myotomy does not influence the development of postoperative gastroesophageal reflux.