Long-term outcome after laparoscopic myotomy for achalasia

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.