Transthoracic Heller Myotomy for Esophageal Achalasia: Analysis of Long-Term Results

DOI: 10.1016/j.athoracsur.2006.01.039 2006;81:2044-2049 Ann Thorac Surg

and Douglas J. Mathisen Henning A. Gaissert, Ning Lin, John C. Wain, Grant Fankhauser, Cameron D. Wright

ResultsTransthoracic Heller Myotomy for Esophageal Achalasia: Analysis of Long-Term

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ransthoracic Heller Myotomy for Esophagealchalasia: Analysis of Long-Term Results

enning A. Gaissert, MD, Ning Lin, BS, John C. Wain, MD, Grant Fankhauser, BS,ameron D. Wright, MD, and Douglas J. Mathisen, MD

ivision of Thoracic Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

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Background. Swallowing deteriorates over time inome patients after transthoracic esophagomyotomy forchalasia. The causes of decline are poorly understood.Methods. We report a retrospective analysis of trans-

horacic esophagomyotomy for achalasia. Symptom re-ief, patient satisfaction, and late intervention were de-ermined during short- and long-term follow-up.redictors of long-term outcome were identified by lo-istic regression.Results. From 1962 to 1999, 64 patients underwent

ransthoracic esophagomyotomy. Five patients had re-eat myotomy. Sigmoid esophagus was present in 12

18%). Fundoplication was absent in 50 patients (myot-my only) and added in 15 (myotomy plus fundoplica-ion). Follow-up was complete in 86% (56 of 65); meanollow-up was 154 months. Thirty-one patients (48%)ere followed for more than 10 years. Short-term resultsere good to excellent in 91% (51 of 56) and long-term in

3% (33 of 52; p < 0.0005). Late peptic stricture occurred in

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ddress correspondence to Dr Gaissert, Massachusetts General Hospital,lake 1570, Fruit St, Boston, MA 02114; e-mail: [email protected].

2006 by The Society of Thoracic Surgeonsublished by Elsevier Inc

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undoplication, 2 of 14 [14%]). Fewer patients had refluxymptoms after fundoplication (myotomy only, 16 of 3842%]; myotomy plus fundoplication, 4 of 14 [29%]),hereas late dysphagia was not reduced (myotomy only,

3 of 38 [34%]; myotomy plus fundoplication, 5 of 1436%]). Two patients after myotomy plus fundoplicationnd 1 after myotomy only had esophagectomy. Earlyecurrence of symptoms predicted late poor outcome (p <.001), whereas sigmoid esophagus, fundoplication, orarly postoperative reflux did not.Conclusions. Early good results after esophagomyo-

omy for achalasia deteriorate over time. Recurring dys-hagia early after operation predicts late failure, whileigmoid esophagus does not. Fundoplication reduceseflux symptoms, but not late poor results. These datahould be considered in the evaluation of newer, mini-ally invasive procedures.

(Ann Thorac Surg 2006;81:2044–9)

sophageal myotomy is the primary mode of palliationin achalasia. Myotomy carries a lower risk of perfo-

ation than forceful disruption by balloon [1], with betteresults 5 years after intervention [2]. Long-term outcomes important, as swallowing after operations on thesophagogastric junction may deteriorate over time, andecause achalasia often arises in younger patients. Trans-

horacic myotomy was first described over 40 years ago,et reports of long-term results are small in number andheir conclusions disagree regarding extent of myotomy,ddition of fundoplication, and cause of late failure [3, 4].hese reports originated in high-volume centers anday not reflect the results of centers where lower num-

ers of myotomy are performed. There are also feweports on the long-term outcome of sigmoid esophagus,nd as a result, disagreement on the indications foryotomy. Esophagectomy is selected at some centers as

he initial surgical therapy [5], in contrast to our prefer-nce for myotomy. Comparative long-term observationor laparoscopic myotomy and its modifications are notet available.Transthoracic myotomy has been applied at Massa-

ccepted for publication Jan 4, 2006.

husetts General Hospital (MGH) for 43 years. Weought to study the results of this experience.

atients and Methods

e retrospectively reviewed all patients who were diag-osed with achalasia and underwent a transthoraciceller myotomy in the MGH Division of Thoracic Sur-

ery between 1962 and 1999. The MGH Institutionaleview Board approved this study first on August 5, 2002.onsent was received from patients before obtaining

ollow-up information.Early in the series, preoperative evaluation of patients

onsisted of radiographic contrast studies and upperndoscopy in all, and esophageal manometry in someatients; all three are part of the current standard eval-ation, and 64% (41 of 64) underwent manometry. Myot-my was considered in patients with a dilated (width � 6m) sigmoid esophagus. Fundoplication was performedccording to surgeon preference. Redo myotomy waserformed when symptoms persisted after previous my-tomy in the absence of stricture. Long-term follow-upfter myotomy was established by telephone interview.atients who improved after operation had no standard

0003-4975/06/$32.00doi:10.1016/j.athoracsur.2006.01.039

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2045Ann Thorac Surg GAISSERT ET AL2006;81:2044–9 TRANSTHORACIC MYOTOMY FOR ESOPHAGEAL ACHALASIA

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Preoperative symptoms, perioperative complications,nd postoperative outcomes were recorded. Radiographsere not reviewed. Short-term results were assessed at 2

o 6 months from office notes and hospital records, andong-term results were obtained 1 to 31 years afterperation from patient contact. A questionnaire regard-

ng preoperative symptoms, postoperative relief, andostoperative quality of life was administered. Dyspha-ia to liquids and solids, regurgitation, a history ofspiration, nocturnal cough, or pneumonia, and need forostoperative nonoperative intervention or reoperationas recorded. Postoperative outcomes were graded by

ndependent interviewers. Patients with excellent resultad total symptomatic relief, no additional surgical oronsurgical intervention, and were highly satisfied. Aood result indicated major relief with less than onceeekly mild symptoms, no or infrequent (less than twice

nnual) dilatations, no additional operation, and a satis-ed patient. Some relief, but frequently recurrent symp-

oms, frequent dilatations, no additional operation, andoderate satisfaction were described as a fair result. A

oor outcome meant no relief, frequent dilatations, and aatient who was the same or worse off compared with thereoperative state. Patient satisfaction was a classifier toistinguish fair from poor results. Excellent, good, or fairesults were considered improved from preoperativeymptoms.

urgical Techniquerocedures were performed by 10 thoracic surgeons. Thesophagus was approached by a left thoracotomyhrough the seventh or eighth interspace. The standard

odification of the Heller myotomy divided esophagealuscle from the first submucosal gastric vein to the level

f the inferior pulmonary vein. For myotomy alone, theistal esophagus was encircled preserving the vaguserves. When a fundoplication was added, the cardia wasircumferentially dissected and the myotomy was ex-ended to expose gastric submucosal veins over severalentimeters. A standard (270 degrees in two layers) orodified (180 or 270 degrees in one layer) Belsey fundo-

lication was usually constructed. Esophageal mucosand muscle were dissected over more than half of theircumference, placing sutures to fold back the muscledge sometimes to prevent reapproximation. In 3 pa-ients who underwent myotomy without fundoplicationnd had no leak, an intercostal muscle flap was suturednto the esophageal mucosa to separate the gapinguscle. Mucosal leaks discovered during operation were

losed with a primary reinforced repair using intercostaluscle or pericardial fat.

tatistical Analysisategorical data were expressed as percentage and ana-

yzed with the Wilcoxon test. For outcome analysis,atients were divided into those with or without anntireflux procedure. A multivariable Cox regressionodel was constructed to extract predictors of functional

utcome. Differences were considered significant at p less

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ower, the model was constructed of no more than sevennputs formed through various combinations of variablesncluding age at operation, sex, symptom duration, pre-ious esophageal trauma (myotomy or pneumatic dilata-ion), sigmoid esophagus, addition of fundoplication,ntraoperative perforation, postoperative complication,arly recurrence of dysphagia, and early occurrence ofeflux. To compare a sufficient number of events, theinary output was set to favorable for good or excellentesults and to unfavorable for fair or poor results. Allnalyses were performed with Statistica (StatSoft, Tulsa,klahoma).

esults

etween 1962 and 1999, 64 patients underwent transtho-acic esophagomyotomy for achalasia. Patient character-stics are summarized in Table 1. Five patients presented

ith persistent dysphagia after esophagomyotomy else-here. One patient underwent both initial and redoyotomy at MGH. Dysphagia was present in all patients,

nd regurgitation and weight loss were both commonymptoms. Twenty-two of 64 patients (34%) complainedf symptoms suggestive of aspiration such as nocturnalough and sputum production, 4 had been diagnosedith aspiration pneumonia, and 1 underwent myotomy

fter esophageal perforation due to pneumatic dilation.welve patients were found to have a sigmoid esophagusn barium swallow studies and 3 of these had a previousyotomy.Fifty patients underwent myotomy alone, and 15 hadyotomy with fundoplication. Thirteen had standard orodified Belsey fundoplication, 1 underwent a Hill pro-

edure, and 1 patient had an unnamed fundoplication.wo patients had resection of an esophageal diverticu-

um. Four of 6 patients undergoing redo myotomy had aundoplication. Intraoperative mucosal perforation in 4ases was repaired without complication. One otheratient was found to have an esophageal leak 7 days afterperation and underwent operative repair. Seven pa-ients were treated for postoperative pneumonia. Thereas no hospital mortality. One patient had an adenocar-

inoma of the esophagus 8 years after myotomy and diedmonths after the diagnosis.

ollow-Upt least 6 months of follow-up (“short term”) was ob-

ained in 56 of 64 patients (87%). Follow-up in 52 patients81%) was available for more than 1 year (“long term”).hirty-one patients were followed for more than 10 yearsfter operation. Mean follow-up was 12.5 (� 8.4) years.unctional results and patient satisfaction deterioratedver time (Table 2, Fig 1). Ninety-three percent of pa-ients (51 of 56) had good or excellent results less than 6

onths after the operation, but only 63% (33 of 52) in theong term (p � 0.001). Recurrent dysphagia was the mostommon complaint: more than half of patients (29 of 52)eported at least mild dysphagia during long-term fol-

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2046 GAISSERT ET AL Ann Thorac SurgTRANSTHORACIC MYOTOMY FOR ESOPHAGEAL ACHALASIA 2006;81:2044–9

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ysphagia (19 of 52). Heartburn (38%) and at least occa-ional regurgitation (25%) were also frequently reported.

Among 52 patients with long-term follow-up, 14 had anntireflux procedure. Length of mean follow-up wasomparable: myotomy only 11.5 (1 to 27) years, myotomylus fundoplication 11.0 (1.5 to 32) years. The long-term

unctional results were similar with and without fundo-lication (Fig 2, p � 0.05). Fewer patients with fundopli-ation complained of reflux symptoms (4 of 14, 28%)ompared with myotomy alone (16 of 38, 42%), whereashe proportion of patients with late dysphagia was the

able 1. Patient Characteristics and Preoperative Data

VariablesMyotomy Alone

(n � 50)

ge (years)Median 45.5Range 16–79

ex, n (%)Male 30Female 20

ymptom duration (years) 7.62 � 9.41ymptoms, n (%)Dysphagia to solids 50Dysphagia to liquids 18Weight loss 31Regurgitation 37Nocturnal or postprandial cough 17Aspiration pneumonia 3

reoperative perforation n (%) 1igmoid esophagus, n (%) 9revious intervention, n (%)Botox injection 3Pneumatic dilatation 16Heller myotomy 2

able 2. Comparison of Short- and Long-Term Functionalesults and Symptoms

Excellent Good Fair Poor All n (%)

ll patients� 6 months 36 15 3 2 56Long term 13 20 12 7 52ysphagia� 6 months 0 8 3 2 13 (23)Long term 0 10 12 7 29 (56)eartburn� 6 months 0 3 0 2 5 (9)Long term 0 10 7 3 20 (38)

egurgitation� 6 months 0 2 2 1 5 (9)Long term 0 3 5 4 12 (23)one� 6 months 36 0 0 0 36 (64)

i

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ame (myotomy alone 37%, myotomy plus fundoplication6%; Table 3). Of 8 patients with standard Belsey, theong-term result was excellent in 3, good in 1, fair in 2,nd poor in 2, with 1 reoperation. Of 5 patients withodified Belsey, the result was good in 3 and poor in 1,ith 1 reoperation. A Hill procedure in 1 had an excellentutcome, and an unnamed fundoplication a good long-erm result.

Patients with early or late poor functional resultsnderwent further evaluation. After myotomy alone, 4atients had poor results: 1 underwent reoperation at 6onths for dysphagia due to incomplete myotomy, and 1

nderwent colon interposition at 3 months for poor

Myotomy Plus Fundoplication(n � 15) All (n � 65)

50 4712–71 12–79

6 36 (55)9 29 (45)

4.48 � 6.78 6.9 � 8.8

15 65 (100)4 22 (34)9 40 (62)9 46 (71)5 22 (34)1 4 (6)0 1 (2)3 12 (18)

1 4 (6)1 17 (26)4 6 (9)

ig 1. The deterioration of functional results over time. Numbers

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2047Ann Thorac Surg GAISSERT ET AL2006;81:2044–9 TRANSTHORACIC MYOTOMY FOR ESOPHAGEAL ACHALASIA

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sophageal emptying and dysphagia; the other 2 werereated with dilatation. After myotomy and fundoplica-ion, 3 patients had poor results: 1 required esophagec-omy at 5 months; the other 2 had esophageal stricturefter redo myotomy (14%), 1 requiring esophagectomy 22ears after second myotomy. Strictures were confirmedy endoscopy.

igmoid Esophaguswelve of 64 patients (19%) were found to have a sigmoidsophagus (Table 4). Nine underwent myotomy alone,nd 3 had fundoplication. An esophageal diverticulumas resected in 1 patient. Compared with patients with-ut sigmoid esophagus, this group had a longer durationf symptoms (mean 11.6 � 9.1 versus 5.9 � 8.6 years).ong-term functional results were similar to those with-ut sigmoid esophagus (Fig 3). Four patients requiredilatation after operation. Poor results in 2 patients weressociated with a stricture in 1.

ultivariable Analysisecurrence of dysphagia within 6 months of the opera-

ion was the only predictor reaching statistical signifi-

ig 2. Comparison of long-term functional results in patients withnd without antireflux procedure. (Shaded bars � myotomy alone;pen bars � myotomy plus fundoplication.)

able 3. Long-Term Results and Symptoms After Myotomy O

Symptoms Excellent No. G

ysphagiaMyotomy only 0Myotomy and fundoplication 0eartburnMyotomy only 0Myotomy and fundoplication 0

egurgitationMyotomy only 0Myotomy and fundoplication 0oneMyotomy only 9Myotomy and fundoplication 4

otalMyotomy only 9

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ance, whereas sigmoid esophagus, fundoplication, andarly occurrence of reflux symptoms after operation wereot significant.

omment

e report one of the largest cohorts of patients whonderwent surgical therapy for achalasia with a fol-

ow-up of more than 10 years. Overall, 93% of patientsad good or excellent swallowing early after operation,imilar to the satisfaction achieved in reported series ofoth transthoracic [6, 7] and laparoscopic Heller myot-my [8–10]. Late after myotomy, swallowing deterioratedwing to obstruction, although most patients (87%), clas-ified as either excellent, good, or fair, remained im-roved at last follow-up. This outcome is also comparableith that of series reporting more than 10 years of

or Myotomy Plus Fundoplication (Excluding Redo Myotomy)

No. Fair No. Poor No. Total No. (%)

10 4 14 (37)2 3 5 (36)

5 1 16 (42)1 2 4 (28)

4 1 7 (18)1 3 5 (36)

0 0 9 (24)0 0 4 (28)

10 4 38

able 4. Data of 12 Patients With Sigmoid Esophagusa

Value

ge (years)Median 52.5Range 12–78

ex (n)Male 6Female 6

ymptom duration (years) 11.6 � 9.1revious intervention (n)Botox injection 0Pneumatic dilatation 1Myotomy 3

ong-term functional result, n (%)Excellent 4 (36)Good 2 (18)Fair 3 (27)Poor 2 (18)

Long-term data for 11 patients.

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ollow-up [3, 4]. The limitation of our study consists ofroviding single-point, rather than longitudinal, fol-

ow-up in most patients and observing loss to follow-upf 19%. While a systematic functional evaluation latefter myotomy is desirable, we believe that the goal of theperation, palliation of swallowing, may be adequately

udged by a dispassionate interview.This series, to which 10 different surgeons contributed,

s also an evaluation of a low-volume procedure. Onverage, two myotomies were performed each year.here were few reoperations: 3 patients required even-

ual esophagectomy after failed myotomy and 1 needededo myotomy. Such results do not favor esophagectomys the initial surgical therapy for achalasia, even if therue rate was underestimated owing to loss of follow-up.

e also found no reason to resect sigmoid esophagus onrinciple. In labeling this condition as “end-stage,” somedvocate to replace the esophagus with either colon ortomach as primary treatment, believing that Helleryotomy alone would not improve dysphagia [5, 11]. Yet

ll three conduits lack propulsive peristalsis. Success inny of these options depends on swallowing propelled byravity alone— not enough, we believe, to accept areater operative risk and give up on an acceptableonduit. Rather than a terminal stage, sigmoid esophaguss shown in our and at least one other study [12] reflects

longer duration of symptoms. We and others havehown that more than 90% of patients rate swallowing asatisfactory in the short term. And no definitive evidenceupports esophagectomy as superior to myotomy inong-term result of sigmoid esophagus. Of our patients,4% had good to excellent results and 82% noted overallmprovement—a functional result similar to those with-ut sigmoid esophagus. Esophagomyotomy is an effec-ive first-line treatment for sigmoid esophagus.

The addition of an antireflux procedure formed a majorontroversy in the two long-term studies by Ellis andssociates [3] and Malthaner and colleagues [4]. Al-hough a 360-degree fundoplication is avoided by most13], several authors reported that a partial fundoplica-

ig 3. Long-term functional results of patients with and without sig-oid esophagus. (Shaded bars � nonsignoid esophagus; open barssigmoid esophagus.)

ion reduces heartburn [14, 15] and asymptomatic acid

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eflux [16] without increasing early dysphagia. Malthanernd associates [4] postulated that reflux disease resultedn late recurrence of dysphagia and eventual failure of

yotomy. Heartburn was a common late symptom in ourtudy. Malthaner and associates [4] noted a rise in refluxymptoms from 37% at 5 years to 78% at 20 years,uggesting that these symptoms spell a time-dependenteterioration of reflux protection.Although fundoplication seemed to reduce the inci-

ence of late reflux symptoms (28% versus 42%) in oureries, late recurrence of moderate to severe dysphagiaas not decreased (36% versus 37%; Table 4). Similarroportions of patients with and without fundoplicationeported good to excellent results in long-term follow-upFig 2). In our multivariable analysis, fundoplication wasot a significant predictor of outcome. Moreover, fundo-lication did not seem to prevent the late disabling effectf reflux disease, as severe esophagitis and strictureeveloped in 2 patients in each group.The accumulated rate of esophagectomy after primary

sophagomyotomy and fundoplication in Malthaner’seport, 29%, raises the question whether the extendedyotomy typically employed before fundoplication cre-

tes a defect that later favors reflux. Therefore, theddition of fundoplication may carry some risk andhould be considered in the presence of a hiatal hernia orhen circumferential dissection of the hiatus is obliga-

ory as for a redo myotomy.Larger prospective studies are needed to further eval-

ate the role of fundoplication in treating achalasia andhe etiology of late recurrence of dysphagia. The deteri-ration of long-term results creates a group of patients ineed of medical management and endoscopic interven-

ion to extend palliation achieved by myotomy.

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2. Csendes A, Braghetto I, Henriquez A, Cortes C. Late resultsof a prospective randomised study comparing forceful dila-tation and oesophagomyotomy in patients with achala-sia.Gut 1989;30:299–304.

3. Ellis FH Jr, Watkins E Jr, Gibb SP, Heatley GJ. Ten to 20-yearclinical results after short esophagomyotomy without anantireflux procedure (modified Heller operation) for esoph-ageal achalasia. Eur J Cardiothorac Surg 1992;6:86–9.

4. Malthaner RA, Tood TR, Miller L, Pearson FG. Long-termresults in surgically managed esophageal achalasia. AnnThorac Surg 1994;58:1343–6.

5. Orringer MB, Stirling MC. Esophageal resection for achala-sia: indications and results. Ann Thorac Surg 1989;47:340–5.

6. Ferguson MK. Achalasia: current evaluation and therapy.Ann Thorac Surg 1991;52:336–42.

7. Ellis FH Jr, Gibb SP, Crozier RE. Esophagomyotomy forachalasia of the esophagus. Ann Surg 1980;192:157–61.

8. Patti MG, Molena D, Fisichella PM, et al. LaparoscopicHeller myotomy and Dor fundoplication for achalasia: anal-ysis of successes and failures. Arch Surg 2001;136:870–7.

9. Finley RJ, Clifton JC, Stewart KC, Graham AJ, Worsley DF.

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ing and the symptoms of achalasia. Arch Surg 2001;136:892–6.

0. Decker G, Borie F, Bouamrirene D, et al. Gastrointestinalquality of life before and after laparoscopic Heller myotomywith partial posterior fundoplication. Ann Surg 2002;236:750–8.

1. Peters JH, Kauer WK, Crookes PF, Ireland AP, Bremner CG,DeMeester TR. Esophageal resection with colon interposi-tion for end-stage achalasia. Arch Surg 1995;130:632–6.

2. Mineo TC, Pompeo E. Long-term outcome of Heller myot-omy in achalasic sigmoid esophagus. J Thorac Cardiovasc

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3. Topart P, Deschamps C, Taillefer R, Duranceau A. Long-term effect of total fundoplication on the myotomized esoph-agus. Ann Thorac Surg 1992;54:1046–51.

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NVITED COMMENTARY

he article by Gaissert and colleagues [1] represents aarge series of patients treated by a very experiencedroup during 4 decades. The authors show that post-sophagomyotomy results are excellent in 91% of pa-ients early after surgery, and that this outcome deterio-ates to 61% of patients with long-term follow-up. Earlyostoperative dysphagia predicts late failure. The addi-

ion of fundoplication is not a significant predictor ofutcome in their analysis. Finally, sigmoid esophagus isot an independent predictor of failure after esophago-yotomy. Therefore, esophagomyotomy, not esophagec-

omy with reconstruction, should be the first-line therapyor achalasia patients with sigmoid esophagus.

It is essential to maintain a lifelong perspective inreating achalasia, as patients present at a young age, andreatment is considered palliative. An ideal treatmentption is safe, durable, and does not preclude furtherreatment options. Clearly the excellent results presentedy Gaissert and colleagues [1] will serve as a benchmark

o compare with other treatments, including minimally-nvasive esophagomyotomy methods.

Optimal management of the subset of achalasia pa-ients with sigmoid esophagus remains an unresolvedssue. Gaissert and colleagues [1] argue that esophago-

yotomy, not esophagectomy, should be the first line ofurgical treatment, because transthoracic myotomy isafe and results are comparable with its use in patientsithout esophageal enlargement. The authors argue that

eplacing one aperistaltic conduit (i.e., the native esoph-gus) with another one (i.e., the stomach, colon, orejunum) does not make sense and does not justify theisks involved. However, the authors’ conclusions areased on results with 12 patients over 40(�) years, inhich long-term data was available for only 11 years. In

he basis of size (i.e., diameter � 6 cm). In fact, in mostchalasia patients, as the esophagus dilates (� 6 cm), itlso lengthens and begins to twist and fold. It is thiscquired luminal tortuosity, not luminal diameter, thatenders an esophagus as “end-stage.” A dilated, tortuoussophagus will not empty well even with esophagomy-tomy, because of its shape. Esophageal replacement fornd-stage achalasia can be performed safely and withood results. The report by Banbury and colleagues [2] isn example of this. There were no deaths in their series of2 patients, and 83% were able to swallow with no or mildysphagia. Eighty-seven percent felt better after esoph-gectomy. Median follow-up time was only 43 months;owever, as shown in the current study, early failuresredict long-term outcome. Furthermore, there is noeason to expect deterioration in the long-term swallow-ng result after esophagectomy.

ichard F. Heitmiller, MD

epartment of Surgerynion Memorial Hospitaluite 610PB 3333 N Calvert Staltimore, MD 21218-2895-mail: [email protected]

eferences

. Gaissert HA, Lin N, Wain JC, Fankhauser G, Wright CD,Mathisen DJ. Transthoracic Heller myotomy for esophagealachalasia: analysis of long-term results. Ann Thorac Surg2006;81:2044–9.

. Banbury MK, Rice TW, Goldblum JR, et al. Esophagectomywith gastric reconstruction for achalasia. J Thorac Cardiovasc

0003-4975/06/$32.00doi:10.1016/j.athoracsur.2006.01.095

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DOI: 10.1016/j.athoracsur.2006.01.039 2006;81:2044-2049 Ann Thorac Surg

and Douglas J. Mathisen Henning A. Gaissert, Ning Lin, John C. Wain, Grant Fankhauser, Cameron D. Wright

ResultsTransthoracic Heller Myotomy for Esophageal Achalasia: Analysis of Long-Term

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