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Post-Operative Gastroesophageal Reflux After Laparoscopic Heller-Dor for Achalasia: True Incidence With an Objective Evaluation
Renato Salvador*, Mario Costantini, Elisa Pesenti, Laura Gobbi, Lorenzo Spadotto, Guerrino Voltarel, Francesco Cavallin, Loredana Nicoletti, Giovanni Capovilla, Stefano Merigliano
University of Padova, Padova, Italy
Introduction: Laparoscopic Heller-Dor (LHD) is the current treatment of choice for patients with esophageal achalasia with a reported good outcome between 85%-95%. The most frequent complication after LHD is Gastroesophageal Reflux Diseases (GERD) reported as high as 34%. Our aims were: a) to analyse the true incidence of post-operative reflux with objective evaluation (endoscopy, esophageal manometry and 24 hour pH-monitoring) in a large group of achalasia patients who underwent LHD, b) to verify if the presence of typical symptoms as heartburn or acid regurgitation correlate with the real incidence of post-operative GERD.
Methods: We evaluated the patients who underwent LHD from 1992 to January 2015. Patients who had already been treated with surgical or endoscopic myotomy were ruled out. Pre-operative symptoms were scored using a detailed symptom questionnaire. After LHD the patients were assessed with symptom score, endoscopy, esophageal manometry and 24-hour pH-monitoring. All test were performed off-antireflux therapy. Patients were classified in two groups: normal post-operative 24-hour pH-monitoring (group A) and pathological post-operative acid exposure of the esophagus (group B). Traces from patients with abnormal reflux on computer analysis were carefully reviewed to distinguish true gastroesophageal reflux episodes from false reflux due to stasis.
Results: Our study population consisted in 463 patients who accepted to perform the manometry and the 24-hour pH-monitoring out of 806 patients who underwent LHD in the study period. At a median follow-up of 49 months (IQR 16-97), a normal pH study (group A) was seen in 423 patients (91.4%) while 40 patients (8.6%) had a pathological acid exposure (group B). The median symptom scores was similar between the two groups: group A 1.0 (IQR 0-3) and group B 1.0 (IQR 0-3) (p=0.20). At manometry, only the median Lower Esophageal Sphincter basal pressure was different: group A 11 mmHg (IQR 8-15) vs group B 9 mmHg (IQR 6.5-12) (p<0.01). At endoscopy, the percent of esophagitis of any grade was not different (group A 11%, group B 19.1% p=0.28). Only one patient of group B had grade D esophagitis.
This study demonstrated that in a reference center, the true incidence of post-operative GERD after LHD is very low. The incidence of such a post-treatment complication should be assessed only by pH-monitoring, since the endoscopic findings and symptoms reported by the patients may be misleading.
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