THE NATURAL HISTORY OF OPERATED ACHALASIA: THE LONG-TERM RESULTS OF LAPAROSCOPIC HELLER–DOR OPERATION.
Andrea Costantini*, Renato Salvador, Giovanni Capovilla, Luca Provenzano, Loredana Nicoletti, Michele Valmasoni, Lucia Moletta, Elisa Sefora Pierobon, Stefano Merigliano, Mario Costantini
University of Padua, Padova, Italy
BACKGROUND Since its introduction in 1993, Laparoscopic Heller-Dor (LHD) operation has been the gold standard treatment for esophageal achalasia. Little is known, however, of the natural history of the operated patients in the long run. Thus, the aim of this study was to assess the long-term outcome of patients who had undergone LHD more than 20 years before, in order to ascertain if early and mid-term results are confirmed over time.
METHODS All patients who underwent LHD from 1992 to 1999 at our institution were evaluated. Patients with previous traditional endoscopic treatment were included, whereas patients with previous myotomy were ruled out. Symptoms were prospectively collected and scored using a detailed questionnaire. Barium swallow, endoscopy and manometry were performed before and 6-12 months after the operation, together with 24-h pH-study. Endoscopy was then suggested every 2 years. Treatment failure was defined as a postoperative symptom score >10th percentile of the preoperative score (i.e. > 8) or the need for further treatment.
RESULTS Out of the 112 patients who underwent LHD during the study period, only the 87 who had completed a minimum 10-year follow-up were evaluated (M:F=52:35, median age 40, IQR 34-51). Twelve (13.8%) had had undergone endoscopic treatments (pneumatic dilation - PD - or Botox) before LHD. The surgical procedure was completed laparoscopically in all but 4 (4.6%). There were 4 mucosal lesions (4.6%) that were recognized and repaired during the operation. All recovered uneventfully. The median follow-up was 20 years, IQR 13-24. One patient died for esophageal squamous cancer 11.5 years after the operation: for recurrence of symptoms he had undergone 2 PD, 1 and 2 years after LHD. Eight additional patients died from 11 to 24 years after LHD for causes unrelated to the disease. One needed one complementary PD 10 years after LHD for recurrent dysphagia, whereas all the others said that they were highly satisfied with the results of the operation when last seen. In overall, symptoms recurred in 23 patients (26.4%) from 1 month to 13.5 years after: all of them received 1 to 6 PD that were effective in 16: 3 patients required revisional myotomy and 3 still need periodic PD to control their symptoms. As said, 1 patient underwent esophagectomy for cancer. Good long-term outcome of LHD was therefore recorded in 73.6% of patients, whereas the overall final satisfaction of combined treatment (LHD + complementary PD) was 92% (Fig. 1). Post-operative reflux (pH and/or endoscopy-proven) developed in 10 patients only (11.5%).
CONCLUSION LHD durably relieves symptoms in the majority of patients, though some of them may require complementary PD to maintain effective symptom control. LHD confirms to be an excellent long-term treatment for achalasia and these results represent the reference point to match for all other treatments.
Long-term symptom control after LHD alone and after complementary PD
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