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Long-Term Symptomatic Outcomes After Laparoscopic Heller Myotomy for Achalasia
Ezra N. Teitelbaum*, Ryan T. Sieberg, Raymond Zhang, Fahd O. Arafat, Chen-Yuan Lin, Eric S. Hungness, Nathaniel J. Soper
Northwestern University, Chicago, IL
INTRODUCTION: Despite the proven short-term effectiveness of laparoscopic Heller myotomy (LHM) for the treatment of achalasia, over time a significant portion of patients develop recurrent symptoms and/or iatrogenic gastroesophageal reflux (GER). In this study we examined symptomatic outcomes from a LHM series and sought to determine preoperative patient characteristics and perioperative events that were predictive of poor long-term results.
METHODS: Patients undergoing LHM for treatment of achalasia were enrolled in a prospective outcomes database beginning in 2004. Diagnosis was confirmed with high-resolution manometry (HRM). Preoperative patient characteristics and perioperative outcomes were recorded prospectively. To determine current symptoms, we attempted to contact all patients via telephone. The Eckardt symptom score and GerdQ surveys were then administered to assess for recurrent achalasia symptoms and iatrogenic GER respectively. Associations between pre and perioperative variables and current symptom scores were tested using a bivariate Pearson's correlation.
RESULTS: From April, 2004 to August, 2012, 117 patients underwent LHM and were enrolled in the database. Of these patients, 67 (57%) were successfully contacted to obtain current symptom scores and were included in the subsequent analysis. At the time of LHM, patients had a mean age of 55 ±16, symptom duration of 4 ±5 years, and 43% had prior endoscopic treatment for achalasia. Operative time was 123 ±21min and EBL was 90 ±55ml. Length of stay 1.1 ±0.4 days. No mortalities or major complications occurred and 10% of patients had a minor (Grade I) complication. The follow-up interval from LHM to current symptom surveys was 4.2 ±2.1 years. Current Eckardt scores were decreased from preoperatively (pre 7.6 ±2.6 vs. current 1.9 ±1.8, scale 0-12, p<.001) and 85% of patients had treatment successes (ie. Eckardt < 4). Currently, 27% of patients had symptoms of GER (ie. GerdQ score > 7) and 45% were taking daily anti-reflux medications. Patients with chest pain preoperatively had higher current Eckardt scores (ie. worse outcomes) (r=.41, p<.001). Operative EBL and periop complications were also positively associated with current Eckardt score (r=.29 and .27, both p<.05). Patients with higher current Eckardt scores were more likely to have symptomatic GER (r=.33, p=.01), an association that remained significant when the chest pain component of the Eckardt score was subtracted from the total.
CONCLUSIONS: In this series, LHM was performed safely with an average hospital stay of one day. At a mean of four years after surgery, 85% of patients had relief of achalasia symptoms, but 27% had symptoms of iatrogenic GER. Higher operative blood loss was associated with worse long-term outcomes. Interestingly, patients with more severe achalasia symptoms, were also more likely to have symptomatic GER.
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