Objective: Achalasia is an uncommon motility disorder of the esophagus affecting one in 100,000 people per year. Laparoscopic Heller Myotomy (LHM) has supplanted other forms of therapy due to its long-term effectiveness and minimal morbidity. However, these patients are at high risk for respiratory complications which can cause serious morbidity and increase health care cost. Few studies have reported on the significance of aspiration pneumonia/pneumonitis after laparoscopic Heller myotomy. We evaluated the incidence of pulmonary complications in a large series of patients undergoing LHM.
Methods: All patients undergoing LHM with Dor fundoplication (LHMDF) for achalasia by a single surgeon (AP) from 2003 through 2006 were retrospectively reviewed at a multi-center academic institution. Demographic, peri-operative and follow-up data were collected.
Results: A total of 54 patients underwent LHMDF for the treatment of achalasia. All patients underwent esophagogastroduedonoscopy, barium esophagogram and esophageal manometry to confirm the diagnosis of achalasia. The average age was 50 years (+/- 17.8) and the average BMI was 26.7 (+/- 6.3). 52% were female and 48% were male. Average operative times, EBL, and length of stay were 113 minutes (+/- 32), 54ml (+/- 23), and 35 hours (+/- 36) respectively. Botox injection therapy, dilatation, and both modalities were used preoperatively in 24%, 43%, and 13% of patients, respectively. Early complications occurred in 9 patients (16.7%): 3 wound infections (5.6%), one urinary retention (1.9%), bleeding requiring transfusion (1.9%), and 4 (7.4%) respiratory complications. Each respiratory complication was attributed to aspiration confirmed on chest radiograph or CT in all patients with in 24 hours of the operation. 2 patients (50%) required intubation for 24 hours and 3 (75%) were treated with antibiotics. Three patients (75%) required ICU admission for at least 24hours. The average hospital LOS for the patients with respiratory complications was 134hours (+/- 87) versus 27 hours (+/- 11.9) (p = 0.045). Only one of these patients had preoperative dilatation therapy.
Conclusion: LHMDF for the treatment of achalasia is safe, effective and associated with minimal morbidity. However, these patients are at significant risk for aspiration and maximal preoperative anesthetic precautions should be instituted. The development of aspiration pneumonia/pneumonitis is associated with a significantly increased length of hospitalization, utilization of resources, and cost.