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Gharagozloo et al. Mini-invasive Surg 2020;4:22 I http://dx.doi.org/10.20517/2574-1225.2019.61 Page 5 of 9

Figure 4. Retroflexed endoscopic view of the intact gastroesophageal valve and trans-illuminated lateral esophageal myotomy

RESULTS
Forty-eight patients underwent RLHM. There were 25 men and 23 women with a mean age of 48 ± 21 years.
Median OR time was 85 min (range 60-132 min). There was no conversion to a laparotomy.

Median hospitalization was 2 days (range 2-3 days). There were no mucosal perforations, complications, or
deaths. Manometry data are shown in Table 1.

Following RLHM, the Lower esophageal (LES) Pressure decreased from 35 mmHg (range 18-120 mmHg)
to 13.2 mmHg (range 9.8-16.6 mmHg) (P < 0.0001). The length of the LES high-pressure zone decreased
from 5.5 cm (range 4-9 cm) to 2.2 cm (range 1.5-2.8 cm) (P < 0.0001) [Table 2].

Following RLHM, based on the DeMeester score, two patients (4.2%) had pathologic gastroesophageal
reflux. Median acid exposure in all patients was 0.4% (range 0%-17.8%), and the median Demeester score
was 7.5 (range 2-125).

Following RLHM, the dysphagia score decreased from 9 (range 8-10) to 1 (range 0-1) (P = 0.01) [Table 3].

Eckardt scores are shown in Table 4. Following RLHM, the Eckardt score decreased from 6.3 ± 1.8 to 0.8
± 1.8 (P < 0.0001) at 1 month and 0.8 ± 1.1 at 12 months (P < 0.0001). Postoperatively, all patients had an
Eckhardt score of less than 3.

DISCUSSION
The surgical therapy of achalasia has evolved with a better understanding of the disease process, the
anatomy of the GE junction, and the nature of the “antireflux barrier”, as well as advances in technology.

Over the years, surgical therapy for achalasia has been controversial. The controversy has centered on the
ideal operative approach, the extent of esophageal myotomy, and the need for the addition of an antireflux
procedure. With minor changes, presently, the same controversies continue.

A better understanding of the antireflux barrier has been crucial in understanding the reasons for
the controversies. The antireflux barrier, which corresponds to the high-pressure zone on esophageal
manometry, seems to be the result of the following: