The “Learning Curve” in Videoscopic Heller Myotomy

OBJECTIVES: In the early 1990s, minimally invasive videoscopy was applied to numerous operations. After undertaking more than 50 “open” Heller myotomies, our experience with videoscopic Heller myotomy began in 1992. We sought to determine whether the outcome following videoscopic Heller myotomy is influenced by surgeon experience. METHODS: Seventy-eight patients with severe dysphagia secondary to achalasia underwent videoscopic Heller myotomy between 1992 and 1998. Intraoperative endoscopy was utilized to ensure adequate myotomy in all patients. Patients were stratified into 3 groups: the first 25 patients (group I), the second 25 patients (group II), and the last 28 patients (group III). Clinical outcome was based on length of stay, incidence of intraoperative complications, conversion to an ‘open’ procedure, and postoperative symptoms. RESULTS: Perioperative complications occurred in 20% of patients in group I compared with 8% and 12% in groups II and III, respectively (P = NS). Only 3 patients required conversion to an ‘open’ procedure, all in group I (P < 0.05). Symptomatic improvement was achieved in 80% of patients in group I, 100% in group II, and 96% in group III (P < 0.05). Significant reductions in conversions to ‘open,’ length of stay, and postoperative symptoms were seen after 20 myotomies were undertaken. CONCLUSION: Outcome following videoscopic Heller myotomy, like other videoscopic operations, improves as surgeons progress along the videoscopic “learning curve.” After approximately 20 videoscopic Heller myotomies, surgeons can expect fewer conversions to open procedures, shorter hospital stays, and better symptomatic relief.