Background: Laparoscopic esophagomyotomy is a safe and effective treatment for achalasia, but some patients have a poor outcome. We hypothesized that there are preoperative and intraoperative factors which might predict the outcome following this operation.
Methods: Thirty eight patients having minimally invasive esophagomyotomy by a single surgeon for achalasia over a 5 year period were interviewed at a mean of 23 months postoperatively. Patients who were satisfied with the operation and who would recommend the procedure to family or friend were graded as a good outcome; those who were dissatisfied or who would not recommend the operation were graded as a poor outcome. The following factors were recorded for each patient: age, sex, preoperative and postoperative symptoms (graded), duration of symptoms, previous endoscopic dilations and Botox treatments, length of myotomy, whether hemifundoplication was added to the myotomy, and whether intraoperative mucosal perforation occurred. All patients had barium esophagography within 48 hr of operation and esophageal diameter and tortuosity were graded by a single radiologist. Univariate logistic regression was applied to analyze the relationship between these clinical factors and patient outcome.
Results: All but one patient was done laparoscopically (one thoracoscopic), and four required conversion to an open procedure (two due to prior operation). There were no deaths. Good outcome was achieved in 31 of 38 patients (78%); poor outcome was achieved in 7 of 38 (22%). The following factors were significant predictors of good outcome: preoperative weight loss (odds ratio 13.3; 95%confidence interval 1.6 to 289) and hemifundoplication (odds ratio 6.9; 95% confidence interval 1.13 to 61.6). The following were predictors of poor outcome: long duration of symptoms (odds ratio 0.73; 95% CI 0.54 to 0.97); esophageal tortuosity (odds ratio 0.23; 95% CI 0.04 to 0.65); intraoperative perforation (odds ratio 0.06; 95% CI 0.01 to 0.77). The other aforementioned factors were not significant predictors of outcome.
Conclusions: Minimally invasive esophagomyotomy is effective in the majority of patients with achalasia. However, patients with advanced disease (long duration of symptoms and tortuous esophagus) are less likely to have a good outcome. Hemifundoplication should continue to be part of the operation and intraoperative perforation should be carefully avoided.