Preoperative lower esophageal sphincter pressure has little influence on the outcome of laparoscopic Heller myotomy for achalasia

Background: It is believed that in untreated patients with achalasia, the lower esophageal sphincter (LES) is almost always hypertensive and a Heller myotomy resolves symptoms by decreasing the LES pressure. The incidence of a normal or hypotensive LES in untreated achalasia patients is unknown. The goals of this study were to determine the incidence of a normal or hypotensive LES in untreated achalasia patients and the outcome of laparoscopic Heller myotomy in achalasia patients with either normal or low LES pressure. Methods: Between January 1990 and May 2002, a diagnosis of achalasia was made in 239 patients. Among 109 patients (46%) who had not previously received any form of treatment, 53 patients underwent laparoscopic Heller myotomy and Dor fundoplication. Based on the preoperative LES pressure (normal, 14-24 mmHg) they were divided into three groups: group A-four patients (7.5%), LES pressure <14 mmHg; group B-18 patients (34%), LES pressure 14-24 mmHg; and group C-31 patients (58.5%), LES pressure >24 mmHg. Results: Among the 109 untreated patients, the LES was hypertensive in 49 patients (45%), normal in 29 patients (27%), and hypotensive in 31 patients (28%). The clinical outcome was good among the three groups of patients who underwent laparoscopic Heller myotomy, with poor outcome in only approximately 10% in each group. Conclusions: These data show that in 55% of untreated, achalasia patients the LES pressure is either normal or low, and that laparoscopic Heller myotomy usually relieves symptoms regardless of preoperative LES pressure.