Manometric assessment of Heller-Dor operation for esophageal achalasia.

Background/aims: The aim of this study was to evaluate changes occurring in esophageal motility through a systematic manometric study performed before, during and after Heller-Dor operation (8) and to correlate the possible post-operative symptoms to the manometric and pH-recording patterns detected, in order to provide useful elements that may optimize surgical therapy for esophageal achalasia.

Materials And Methods: Between January 1981 and January 1991, 27 patients affected by esophageal achalasia underwent Heller's operation with Dor's anti-reflux procedure. Assessment involved clinical, radiological and manometric investigations.

Results: Intra-operative manometry was performed on 11 patients, in whom LES pressure reached values lower than 5 mmHg. Post-operative control, performed 2 years after operation on 25 patients, showed the complete absence of dysphagia in 22 (88%) and occasional dysphagia in 3 (12%). Post-operative manometry in all the patients showed a decreased LES resting pressure (from 32.6 to 7.2 mmHg, p < 0.001), LES residual pressure (from 16.4 to 5.0 mmHg, p < 0.001) and esophageal tone (from 4.8 to -3.5 mmHg, p < 0.001). Patients free of dysphagia presented LES basal and residual pressures lower than the other patients (6.2 and 4.6 vs 15.1 and 7.7 mmHg respectively, p < 0.01 and p < 0.05). 24-hour-esophageal pH-metry showed pathologic reflux in 3 patients with reflux symptoms and in 1 without symptoms. All had LES basal and residual pressures equivalent to non refluxing patients (5.7 and 5.0 vs 7.5 and respectively 4.9 mmHg, p = n.s. and p = n.s.). On the contrary, a difference was found in abdominal LES length between the two groups (0.5 vs 1.6 cm, p < 0.01). Patients with intra-operative manometry presented a lower incidence of residual dysphagia than patients without it (0% vs 21.5%), but a higher incidence of reflux (18.2% vs 7.3%).

Conclusion: Heller-Dor operation induces a definitive disappearance of dysphagia when it is complete in depth and length. Prevention of gastro-esophageal reflux requires the preservation of a sufficiently long portion of esophagus in the abdomen.