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Racial Disparities in the Characteristics of Surgically Treated Achalasia Patients
Carla N. Holcomb*, Laura a. Graham, Robert Rhyne, Mary T. Hawn
Surgery, University of Alabama at Birmingham, Birmingham, AL
I. Introduction
Achalasia is one the most common esophageal motility disorders and Heller myotomy is the gold standard of surgical treatment. To date, there has been no description of racial disparities in the presentation, treatment, and outcomes of patients with achalasia undergoing surgical treatment.
II.Methods
Patients undergoing a laparoscopic Heller myotomy with or without Dor fundoplication at a single center between the years of 2002-2013 were identified using CPT codes. All surgeries were performed by the same surgeon. A retrospective chart review to abstract data from the electronic medical record was performed. Achalasia classification was based on barium swallow radiographic findings. The independent variable of interest was race categorized as African American versus Caucasian/Others. Univarate and bivariate frequencies were used to examine differences by race along with Chi-square tests for categorical variables and Wilcoxon rank sums for continuous variables. All analyses were performed using SAS version 9.4.
III. Results
The patient population consisted of 287 patients undergoing laparoscopic Heller myotomy for achalasia with African-Americans composing 28% (n=82) of the population. Race was classified as "other" in the medical record of 7.6% (n=22) of the patients and these were included with the Caucasian population in the analysis phase. The African-American patients were more likely to be female (63.4% vs 44.9% P=0.01), younger (median age 41 vs 50 years, P=<0.001) and report regurgitation as a preoperative symptom (80.5% vs 60.3% P=<0.001) when compared to Caucasian/Others. African Americans were more likely to be classified as having Type 1 achalasia (81.4% versus 65.5% P=0.03) and to have undergone a previous Heller myotomy (15.9% vs 7.8% P=0.04) at the time of presentation. No significant difference was observed when comparing a history of previous esophageal dilatations, overall achalasia recurrence rates, or median time to recurrence between races (see Table).
IV. Conclusions
In this single center study, racial disparities exist among achalasia patients with African Americans being predominantly classified as having Type 1 disease and more likely to present with failure after Heller myotomy despite presenting at a younger age. However, rates of achalasia recurrence were not significantly different between the two races. Long-term follow-up is needed to assess if racial differences in treatment outcomes are present and independent of other known predictors of failure. | Overall | African-American | Caucasian/Others | P-Value | | N | % | N | % | N | % | | | 287 | 100% | 82 | 28.6% | 205 | 71.4% | | | Gender | | | Male | 143 | 49.8% | 30 | 36.6% | 113 | 55.1% | 0.01 | | Female | 144 | 50.2 % | 52 | 63.4% | 92 | 44.9% | | Median Age (years) | 48 | IQR (37-65) | 41 | IQR (34-53) | 50 | IQR (38-66) | 0.001 | | Preoperative Characteristics | | | Dysphagia | 246 | 86% | 59 | 72% | 187 | 91.7% | <0.001 | | Regurgitation | 189 | 66.1% | 66 | 80.5% | 123 | 60.3% | 0.001 | | Weight Loss | 158 | 55.2% | 47 | 57.3% | 111 | 54.4% | 0.66 | | Achalasia Classification | | | Type 1 | 173 | 70% | 57 | 81.4% | 116 | 65.5% | 0.03 | | Type 2 | 60 | 24.3 % | 12 | 17.1% | 48 | 27.1% | | Type 3 | 14 | 5.7% | 1 | 1.4% | 13 | 7.3% | | Previous Heller Myotomy | 29 | 10.1% | 13 | 15.9% | 16 | 7.8% | 0.04 | | Previous Esophageal Dilatation | 97 | 33.9% | 26 | 31.7% | 71 | 34.8% | 0.62 | | Postoperative Outcomes | | | Achalasia Recurrence | 37 | 13.9% | 13 | 16.9% | 24 | 12.7% | 0.37 | | Median Time to Recurrence (Months) | 6 | IQR (2.5-11.0) | 6 | IQR (2.3-6.8) | 7.4 | IQR (3.3-28.0) | 0.22 |
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