Gastro-esophageal reflux (GER) is a common complication after Heller myotomy for achalasia. Preoperative risk factors for GER after Heller myotomy have not been identified as prior studies have focused only on postoperative GER prevalence.
Aim: To identify risk factors for development of GER after Heller myotomy.
Methods: Patients who underwent laparoscopic Heller myotomy without concomitant antireflux procedures were asked to return for esophageal manometry and 24-h pH study after giving an IRB approved informed consent. After undergoing 24-h pH study, the patients were diagnosed with GER if distal esophageal acid exposure time was >4.0%. Logistic regression was used in both univariate and multivariate modeling to identify independent preoperative variables associated with the presence of postoperative GER. Independent variables examined included 12 putative preoperative risk factors. Model parameters were estimated by the maximum-likelihood method. From these estimates, odds ratios (OR) with 95 % confidence intervals (CI) were computed.
Results: The study enrolled 48 patients, 46 reported good to excellent relief of dysphagia after myotomy. The prevalence of postoperative GER was 37.5% (18/48 patients). Postoperative lower esophageal sphincter pressure (LESP) was similar in the two groups (GER: 15.0 ± 8.2 vs. NO-GER: 13.8 ±4.2 mmHg, P=0.5). On univariate analysis, the only preoperative factor associated with GER was the preoperative LESP (NO-GER: 40.3 ± 12.3 vs. GER: 32.4 ± 13.0 mmHg, P=0.04). Preoperative LESP remained an independent risk factor for GER in the multivariate logistic regression model after adjusting for covariates. A pressure lower than 25 mmHg increased seven times the risk to develop GER postoperatively (OR 7.1; 95% CI, 1.1-48.4; P=0.04). Another significant risk factor was age at the time of surgery. Patients younger than 45 years were at more than nine times the risk to develop GER after myotomy compared to those older than 45 years (OR, 9.9; 95% CI, 1.7-57.8; P=0.01).
Conclusion: 1. Heller myotomy is associated with high prevalence of postoperative GER. 2. Age <45 years and preoperative LES pressure <25 mmHg are independent and significant risk factors to develop GER after Heller myotomy. ±