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Mucosal Perforation During Laparoscopic Heller Myotomy Doesn't Influence the Final Outcome of the Treatment
Renato Salvador*1, Mario Costantini1, Cristina Longo1, Francesco Cavallin2, Lisa Zanatta1, Loredana Nicoletti1, Giovanni Capovilla1, Edoardo Savarino1, Francesca Galeazzi1, Giovanni Zaninotto1
1Department of Surgical and Gastroenterological Sciences, University of Padua, Padua, Italy; 2Surgical Oncology, Istituto Oncologico Veneto, IOV-IRCCS, Padua, Italy
BACKGROUND: Laparoscopic Heller-Dor (LHD) is the currently accepted treatment for esophageal achalasia. The most common intraoperative complication (2-33%) is inadvertent mucosal perforation. There are no studies to determine whether the mucosal perforation affects the final outcome of LHD. The aim was to evaluate the final outcome in patients with accidental perforation detected during the operation or by the routine post-operative contrast swallow.
MATERIALS AND METHODS: 713 patients underwent LHD from 1992 to 2012 by 6 staff surgeons alternatively. Mucosal perforation was detected in 22 patients (Group A). The patients who underwent the operation uneventfully were defined Group NP. Furthermore, two different patient groups were considered: Group B patients operated by the same surgeon immediately before and Group C immediately after a perforation occurred. Patients were evaluated preoperatively by a detailed symptom questionnaire, manometry, endoscopy and barium swallow. Treatment failure was defined as a postoperative symptom score >10th percentile of the preoperative score (i.e. > 8). Patients with a previous myotomy were excluded.
RESULTS: LHD was the primary treatment for 567 patients; 146 (20.5%) had a previous endoscopic treatment. There were 22 perforations (3.1%): 19 (86.5%) were recognized and repaired during the operation, 2 (9%) were detected by contrast swallow in the 1st POD and 1 (4.5%) was recognized in 3rd POD. The median follow-up was 35 months (IQR:15-79).
Perforation was not related to the symptoms score or duration, age, radiological-grade, manometric pattern or surgeon's experience. The LES residual pressure was the only variable associated to perforation risk (Group NP: 10mmHg vs Group A: 18 mmHg, p=0.03). A previous endoscopic treatment did not increase the perforation rate (3/146 vs 19/567, 2% vs 3.3%, p=0.59). The post-operative findings are shown in the table.
Symptoms recurred in 4 patients of group A (18,2%), 2 patients of group B (10%) and 3 patients of group C (15%) (p=0.99). The post-operative median symptom score was similar in all the 3 groups. The was no difference in the median procedure time between group B (148 min) and group C (138 min, p=0.38).
CONCLUSIONS: accidental perforation during LHD is infrequent and cannot be predicted by preoperative therapy or by the surgeon's personal experience. The only predictive factor of perforation risk is a high LES resting pressure. In spite of longer operation and hospital stay, the outcome of surgical treatment is similar to those undergoing uneventful myotomy. A recent mucosal lesion does not influence the surgeon's subsequent performance. Table: the post-operative findings | NP 691 pts | Group A 22 pts | p-value | | Hospital stay (days) | 5 (4-6) | 10 (10-15) | < 0.01 | | Symptoms score | 0 (0-3) | 3 (0-3) | 0.33 | | LES resting pressure | 11 (8-15) | 14.5 (8-20) | 0.15 | | LES residual pressure | 3 (1.5-6) | 4.3 (1-11.1) | 0.24 | | Failures | 12.2% | 18.2% | 0.34 | | Time of failures (months) | 12 (6-28) | 11.5 (11-12) | 0.79 |
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