Abstracts
2000 Digestive Disease Week

# 2262 Thoracoscopic Esophagomyotomy (EM) for Achalasia. Preoperative Patterns of Acid Reflux and Long Term Followup.
James W. Maher, Jeffrey Conklin, Deb Heitshusen, Iowa City, IA

Controversies regarding use of EM in achalasia include: the best approach (thoracoscopic or laparoscopic) and the need for an antireflux procedure (ARP)). Postoperative pH studies have shown GER in many patients fueling the call for adding an ARP. Nevertheless, preop studies of acid reflux patterns have been scarce. Further, pH studies only recognize number and duration of pH <4 but do not differentiate gastroesophageal reflux (GER) from esophageal fermentation (EF). This study presents pH studies prior to EM as well as long term follow-up of patients undergoing thoracoscopic EM. Methods: Thirty-five patients have undergone thoracoscopic EM for achalasia. Nineteen also had 24 hr pH studies before treatment. All were interviewed regarding dysphagia, and reflux and were classified by a modified Visick score. Visick 1 and 2 patients (V1 and V2) were rated as excellent or good respectively. Visick 3 (V3) patients were satisfactory and Visick 4 (V4) patients were failures. Results: Pretreatment pH studies showed a pattern of GER (sharp drops in pH followed by gradual rise in pH) in 6 patients (31%). Eight patients (42%) showed a preop pH pattern characteristic of EF (slow drops in pH toward 4 during sleep with relative rapid increases with eating). One patient demonstrated both reflux and fermentation. There were no deaths. Follow-up was complete with a mean of 40 months; with eight followed for > 5 years. Eighty-three percent of patients have a good or excellent result while 11 percent have a fair result. Six percent are failures (both have dysphagia). Five (14%) have postop reflux symptoms; only three require medication (8%) and the symptoms are well-controlled in all. Three of these five patients with reflux had a preop pH study demonstrating GER. One with postop GER had an uninterpretable preop study and one did not have a preop study. Three patients with preoperative GER by pH study have a V1 result. No patient without preop GER complained of postoperative reflux. Two patients have required reoperation for dysphagia and are V1 results but are classified as failures because of the reoperation. Seven of eight patients greater than five years postop have V1 or V2 results. Conclusion: A high percentage of achalasia patients exhibit GER prior to EM and seem to be at higher risk for postoperative GER. Forty-two percent of patients exhibit a pattern of EF, which if unrecognized might be interpreted erroneously as GER. Postoperative results of thoracoscopic EM remain excellent even at five year follow-up.