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 Scopus citations

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 1 2014

ASJC Scopus subject areas

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

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  • Cite this

    Krishnamohan, P., Allen, M. S., Shen, K. R., Wigle, D. A., Nichols, F. C., Cassivi, S. D., Harmsen, W. S., & 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