Long-term outcome after laparoscopic myotomy for achalasia

Pradheep Krishnamohan, Mark S. Allen, K. Robert Shen, Dennis A Wigle, Francis C. Nichols, Stephen D. Cassivi, William S. Harmsen, Claude Deschamps

Research output: Contribution to journalArticle

8 Citations (Scopus)

Abstract

Objectives Achalasia has a variety of therapeutic options. We sought to determine the long-term outcome of laparoscopic myotomy in a large group of patients. Methods We conducted a retrospective record review of 500 patients who underwent laparoscopic myotomy and follow-up with a standardized dysphagia questionnaire. Results Between April 1998 and June 2011, 276 men and 224 women underwent a laparoscopic myotomy. Their median age was 51 years (range, 8-89 years). Preoperative symptoms included dysphagia in 472 patients (94.4%), regurgitation in 382 patients (76.4%), heartburn in 203 patients (40.6%), chest pain in 168 (33.6%) patients, and weight loss (median, 10 kg) in 264 patients (52.8%). Prior therapy (dilation in 239, botulinum toxin type A in 135, or myotomy in 30) had been performed in 303 patients (60.6%). Preoperative manometry was available in 413 patients (82.6%) and revealed a median lower esophageal sphincter pressure of 31 mm Hg (range, 0-50 mm Hg), absent peristalsis in 97.6%, and no lower esophageal sphincter relaxation in 75.1%. A laparoscopic myotomy with partial fundoplication (Toupet n = 268, Dor n = 209) was done in 477 patients (95.4%) and myotomy only in 23 patients (4.6%). Conversion to open was necessary in 16 patients (3.2%). There were 52 (10.4%) esophageal perforations - all repaired during the myotomy - and 26 (5.2%) other complications, including bleeding, atrial fibrillation, and pneumonia. There was no operative mortality. Median length of stay was 2 days (range, 1-20 days). Dysphagia questionnaires were returned by 48.2% of patients (241 out of 500) a median of 77.5 months after myotomy (range, 15-176 months). Eighty patients (32.2%) reported no problems with swallowing at the time of the survey. Of 160 patients who had swallowing problems, 40 patients (22.2%) classified the problem as mild or less, 98 patients classified the problem as moderate (70.0%), and 22 patients classified the problem as severe (15.7%). The question concerning frequency of swallowing problems was answered by 160 patients and occurred once a week or less in 70 patients (43.8%), several times a week in 41 patients (25.6%), and at least daily in 49 patients (30.6%). Analysis of all 241 patients who returned questionnaires revealed that 170 out of 241 (70.5%) reported heartburn, 89 out of 241 (36.9%) reported regurgitation, and 159 out of 241 (66.0%) had taken antacids or histamine 2 blockers or proton pump inhibitors within the past 30 days of the survey. The only factor affecting outcome was age; patients older than age 65 years had a better chance of having no difficulty swallowing at follow-up (P =.0174). Sex, prior therapy, Toupet versus Dor, conversion to open, or esophageal mucosal perforation did not affect long-term swallowing outcome. Conclusions Laparoscopic myotomy with partial fundoplication is a safe operation. The long-term outcome is extremely effective and approximately one-third of patients have no evidence of persistent symptoms at follow-up. Furthermore, those who have persistent symptoms rarely have severe or very frequent complaints. Patients older than age 65 years tend to have a better outcome.

Original languageEnglish (US)
Pages (from-to)730-737
Number of pages8
JournalJournal of Thoracic and Cardiovascular Surgery
Volume147
Issue number2
DOIs
StatePublished - Feb 2014

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Esophageal Achalasia
Deglutition
Deglutition Disorders
Esophageal Perforation
Heartburn
Fundoplication
Lower Esophageal Sphincter

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery
  • Pulmonary and Respiratory Medicine

Cite this

Krishnamohan, P., Allen, M. S., Shen, K. R., Wigle, D. A., Nichols, F. C., Cassivi, S. D., ... Deschamps, C. (2014). Long-term outcome after laparoscopic myotomy for achalasia. Journal of Thoracic and Cardiovascular Surgery, 147(2), 730-737. https://doi.org/10.1016/j.jtcvs.2013.09.063

Long-term outcome after laparoscopic myotomy for achalasia. / Krishnamohan, Pradheep; Allen, Mark S.; Shen, K. Robert; Wigle, Dennis A; Nichols, Francis C.; Cassivi, Stephen D.; Harmsen, William S.; Deschamps, Claude.

In: Journal of Thoracic and Cardiovascular Surgery, Vol. 147, No. 2, 02.2014, p. 730-737.

Research output: Contribution to journalArticle

Krishnamohan, P, Allen, MS, Shen, KR, Wigle, DA, Nichols, FC, Cassivi, SD, Harmsen, WS & Deschamps, C 2014, 'Long-term outcome after laparoscopic myotomy for achalasia', Journal of Thoracic and Cardiovascular Surgery, vol. 147, no. 2, pp. 730-737. https://doi.org/10.1016/j.jtcvs.2013.09.063
Krishnamohan, Pradheep ; Allen, Mark S. ; Shen, K. Robert ; Wigle, Dennis A ; Nichols, Francis C. ; Cassivi, Stephen D. ; Harmsen, William S. ; Deschamps, Claude. / Long-term outcome after laparoscopic myotomy for achalasia. In: Journal of Thoracic and Cardiovascular Surgery. 2014 ; Vol. 147, No. 2. pp. 730-737.
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abstract = "Objectives Achalasia has a variety of therapeutic options. We sought to determine the long-term outcome of laparoscopic myotomy in a large group of patients. Methods We conducted a retrospective record review of 500 patients who underwent laparoscopic myotomy and follow-up with a standardized dysphagia questionnaire. Results Between April 1998 and June 2011, 276 men and 224 women underwent a laparoscopic myotomy. Their median age was 51 years (range, 8-89 years). Preoperative symptoms included dysphagia in 472 patients (94.4{\%}), regurgitation in 382 patients (76.4{\%}), heartburn in 203 patients (40.6{\%}), chest pain in 168 (33.6{\%}) patients, and weight loss (median, 10 kg) in 264 patients (52.8{\%}). Prior therapy (dilation in 239, botulinum toxin type A in 135, or myotomy in 30) had been performed in 303 patients (60.6{\%}). Preoperative manometry was available in 413 patients (82.6{\%}) and revealed a median lower esophageal sphincter pressure of 31 mm Hg (range, 0-50 mm Hg), absent peristalsis in 97.6{\%}, and no lower esophageal sphincter relaxation in 75.1{\%}. A laparoscopic myotomy with partial fundoplication (Toupet n = 268, Dor n = 209) was done in 477 patients (95.4{\%}) and myotomy only in 23 patients (4.6{\%}). Conversion to open was necessary in 16 patients (3.2{\%}). There were 52 (10.4{\%}) esophageal perforations - all repaired during the myotomy - and 26 (5.2{\%}) other complications, including bleeding, atrial fibrillation, and pneumonia. There was no operative mortality. Median length of stay was 2 days (range, 1-20 days). Dysphagia questionnaires were returned by 48.2{\%} of patients (241 out of 500) a median of 77.5 months after myotomy (range, 15-176 months). Eighty patients (32.2{\%}) reported no problems with swallowing at the time of the survey. Of 160 patients who had swallowing problems, 40 patients (22.2{\%}) classified the problem as mild or less, 98 patients classified the problem as moderate (70.0{\%}), and 22 patients classified the problem as severe (15.7{\%}). The question concerning frequency of swallowing problems was answered by 160 patients and occurred once a week or less in 70 patients (43.8{\%}), several times a week in 41 patients (25.6{\%}), and at least daily in 49 patients (30.6{\%}). Analysis of all 241 patients who returned questionnaires revealed that 170 out of 241 (70.5{\%}) reported heartburn, 89 out of 241 (36.9{\%}) reported regurgitation, and 159 out of 241 (66.0{\%}) had taken antacids or histamine 2 blockers or proton pump inhibitors within the past 30 days of the survey. The only factor affecting outcome was age; patients older than age 65 years had a better chance of having no difficulty swallowing at follow-up (P =.0174). Sex, prior therapy, Toupet versus Dor, conversion to open, or esophageal mucosal perforation did not affect long-term swallowing outcome. Conclusions Laparoscopic myotomy with partial fundoplication is a safe operation. The long-term outcome is extremely effective and approximately one-third of patients have no evidence of persistent symptoms at follow-up. Furthermore, those who have persistent symptoms rarely have severe or very frequent complaints. Patients older than age 65 years tend to have a better outcome.",
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T1 - Long-term outcome after laparoscopic myotomy for achalasia

AU - Krishnamohan, Pradheep

AU - Allen, Mark S.

AU - Shen, K. Robert

AU - Wigle, Dennis A

AU - Nichols, Francis C.

AU - Cassivi, Stephen D.

AU - Harmsen, William S.

AU - Deschamps, Claude

PY - 2014/2

Y1 - 2014/2

N2 - Objectives Achalasia has a variety of therapeutic options. We sought to determine the long-term outcome of laparoscopic myotomy in a large group of patients. Methods We conducted a retrospective record review of 500 patients who underwent laparoscopic myotomy and follow-up with a standardized dysphagia questionnaire. Results Between April 1998 and June 2011, 276 men and 224 women underwent a laparoscopic myotomy. Their median age was 51 years (range, 8-89 years). Preoperative symptoms included dysphagia in 472 patients (94.4%), regurgitation in 382 patients (76.4%), heartburn in 203 patients (40.6%), chest pain in 168 (33.6%) patients, and weight loss (median, 10 kg) in 264 patients (52.8%). Prior therapy (dilation in 239, botulinum toxin type A in 135, or myotomy in 30) had been performed in 303 patients (60.6%). Preoperative manometry was available in 413 patients (82.6%) and revealed a median lower esophageal sphincter pressure of 31 mm Hg (range, 0-50 mm Hg), absent peristalsis in 97.6%, and no lower esophageal sphincter relaxation in 75.1%. A laparoscopic myotomy with partial fundoplication (Toupet n = 268, Dor n = 209) was done in 477 patients (95.4%) and myotomy only in 23 patients (4.6%). Conversion to open was necessary in 16 patients (3.2%). There were 52 (10.4%) esophageal perforations - all repaired during the myotomy - and 26 (5.2%) other complications, including bleeding, atrial fibrillation, and pneumonia. There was no operative mortality. Median length of stay was 2 days (range, 1-20 days). Dysphagia questionnaires were returned by 48.2% of patients (241 out of 500) a median of 77.5 months after myotomy (range, 15-176 months). Eighty patients (32.2%) reported no problems with swallowing at the time of the survey. Of 160 patients who had swallowing problems, 40 patients (22.2%) classified the problem as mild or less, 98 patients classified the problem as moderate (70.0%), and 22 patients classified the problem as severe (15.7%). The question concerning frequency of swallowing problems was answered by 160 patients and occurred once a week or less in 70 patients (43.8%), several times a week in 41 patients (25.6%), and at least daily in 49 patients (30.6%). Analysis of all 241 patients who returned questionnaires revealed that 170 out of 241 (70.5%) reported heartburn, 89 out of 241 (36.9%) reported regurgitation, and 159 out of 241 (66.0%) had taken antacids or histamine 2 blockers or proton pump inhibitors within the past 30 days of the survey. The only factor affecting outcome was age; patients older than age 65 years had a better chance of having no difficulty swallowing at follow-up (P =.0174). Sex, prior therapy, Toupet versus Dor, conversion to open, or esophageal mucosal perforation did not affect long-term swallowing outcome. Conclusions Laparoscopic myotomy with partial fundoplication is a safe operation. The long-term outcome is extremely effective and approximately one-third of patients have no evidence of persistent symptoms at follow-up. Furthermore, those who have persistent symptoms rarely have severe or very frequent complaints. Patients older than age 65 years tend to have a better outcome.

AB - Objectives Achalasia has a variety of therapeutic options. We sought to determine the long-term outcome of laparoscopic myotomy in a large group of patients. Methods We conducted a retrospective record review of 500 patients who underwent laparoscopic myotomy and follow-up with a standardized dysphagia questionnaire. Results Between April 1998 and June 2011, 276 men and 224 women underwent a laparoscopic myotomy. Their median age was 51 years (range, 8-89 years). Preoperative symptoms included dysphagia in 472 patients (94.4%), regurgitation in 382 patients (76.4%), heartburn in 203 patients (40.6%), chest pain in 168 (33.6%) patients, and weight loss (median, 10 kg) in 264 patients (52.8%). Prior therapy (dilation in 239, botulinum toxin type A in 135, or myotomy in 30) had been performed in 303 patients (60.6%). Preoperative manometry was available in 413 patients (82.6%) and revealed a median lower esophageal sphincter pressure of 31 mm Hg (range, 0-50 mm Hg), absent peristalsis in 97.6%, and no lower esophageal sphincter relaxation in 75.1%. A laparoscopic myotomy with partial fundoplication (Toupet n = 268, Dor n = 209) was done in 477 patients (95.4%) and myotomy only in 23 patients (4.6%). Conversion to open was necessary in 16 patients (3.2%). There were 52 (10.4%) esophageal perforations - all repaired during the myotomy - and 26 (5.2%) other complications, including bleeding, atrial fibrillation, and pneumonia. There was no operative mortality. Median length of stay was 2 days (range, 1-20 days). Dysphagia questionnaires were returned by 48.2% of patients (241 out of 500) a median of 77.5 months after myotomy (range, 15-176 months). Eighty patients (32.2%) reported no problems with swallowing at the time of the survey. Of 160 patients who had swallowing problems, 40 patients (22.2%) classified the problem as mild or less, 98 patients classified the problem as moderate (70.0%), and 22 patients classified the problem as severe (15.7%). The question concerning frequency of swallowing problems was answered by 160 patients and occurred once a week or less in 70 patients (43.8%), several times a week in 41 patients (25.6%), and at least daily in 49 patients (30.6%). Analysis of all 241 patients who returned questionnaires revealed that 170 out of 241 (70.5%) reported heartburn, 89 out of 241 (36.9%) reported regurgitation, and 159 out of 241 (66.0%) had taken antacids or histamine 2 blockers or proton pump inhibitors within the past 30 days of the survey. The only factor affecting outcome was age; patients older than age 65 years had a better chance of having no difficulty swallowing at follow-up (P =.0174). Sex, prior therapy, Toupet versus Dor, conversion to open, or esophageal mucosal perforation did not affect long-term swallowing outcome. Conclusions Laparoscopic myotomy with partial fundoplication is a safe operation. The long-term outcome is extremely effective and approximately one-third of patients have no evidence of persistent symptoms at follow-up. Furthermore, those who have persistent symptoms rarely have severe or very frequent complaints. Patients older than age 65 years tend to have a better outcome.

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