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ANGLE OF HIS ACCENTUATION IS A VIABLE ALTERNATIVE TO DOR FUNDOPLICATION AS AN ADJUNCT TO LAPAROSCOPIC HELLER'S CARDIOMYOTOMY: RESULTS OF A RANDOMIZED CLINICAL TRIAL
Rajinder Parshad*1, Prince K. Gupta1, Pavithra Balakrishna1, Anoop Saraya2, Govind K. Makharia2, Sanjeev sachdeva3, Raju Sharma4
1DEPARTMENT OF SURGICAL DISCIPLINES, ALL INDIA INSTITUTE OF MEDICAL SCIENCES, DELHI, DELHI, India; 2DEPARTMENT OF GASTROENTEROLOGY, ALL INDIA INSTITUTE OF MEDICAL SCIENCES, DELHI, India; 3DEPARTMENT OF GASTROENTEROLOGY, G B PANT HOSPITAL, DELHI, India; 4DEPARTMENT OF RADIODIAGNOSIS, ALL INDIA INSTITUTE OF MEDICAL SCIENCES, DELHI, India
Background: Laparoscopic Heller’s cardiomyotomy (LHCM) with the antireflux procedure is the surgical procedure of choice for achalasia cardia. However, there is no clear consensus regarding the type of antireflux procedure. The aim of this study was to compare Angle of His accentuation (AOH) with Dor Fundoplication (Dor) as the adjunct to LHCM.
Methods: Patients with primary Achalasia cardia presenting for LHCM from March 2010 to July 2015 were recruited and randomized into Dor and AOH with 55 patients in each group. Patients not fit for surgery and not opting for the study were excluded. Symptom severity, Achalasia specific Quality of life (QoL) and patient satisfaction were assessed using predetermined standardized scores preoperatively and at 3 months, 6 months and then at yearly follow-up. The primary outcome was relief of oesophageal symptoms while secondary outcomes were new onset heartburn and postoperative QoL.
Results: Both groups were comparable with respect to the baseline demographic characteristics. Preoperatively dysphagia was present in all patients, regurgitation and heartburn were present in 96.4% and 69% patients respectively. Weight loss >10 kg was present in 23% of patients. Preoperative mean QoL score was 58.4 ± 8. Both groups had the similar preoperative score with no statistical difference. There was no conversion to open and no mortality. All cases were done by the single surgeon and myotomy length was 5 - 6 cm over esophagus and 2 - 3 cm over stomach in all cases. Operative complications were seen in 2.7% with 2 perforations (detected and repaired intraoperatively and reinforced with Dor fundoplication) and one minor splenic injury. Postoperative morbidity was seen in 9% (Clavien-Dindo Grade 1 and 2). Mean operative time was 128 min in AOH and 160 min in Dor group (p< 0.01). Median hospital stay was 3 days in both groups. Mean follow duration was 36 months with no difference between two groups. Follow-up was available in 98.2% (108/110) patients. Compared to preoperative score there was significant improvement in dysphagia (p= 0.006), regurgitation (p= 0.02) and heartburn scores (p= 0.03) in both groups. However, there was no statistically significant difference between 2 groups (p>0.05). New onset heartburn was seen in 10.9% in AOH and 9% in Dor group. Mean QoL score improved from 58.2±7.3 to 14.1±14.5 in AOH (p<0.05) and 58.6±8.7 to 13.3±16.4 (p<0.05) in Dor group. However, there was no difference between the two groups (p-0.83). Excellent or good satisfaction was reported in 100% in AOH and in 96.4% in Dor (p-0.59).
Conclusion: LHCM with the antireflux procedure is a safe and effective procedure for achalasia cardia with excellent short and long term outcome. Both AOH and Dor show similar efficacy and safety with significantly less operative time in AOH.
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