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SURGICAL OUTCOMES IN PATIENTS WITH PRE-OPERATIVE OPIOID USE AND TYPE III ACHALASIA
Archana Jeeji
*, Peter T. White, Adam J. Bograd, Alexander S. Farivar, Emily M. Mackay, Brian E. Louie
Thoracic Surgery, Swedish Medical Center, Seattle, WA
BACKGROUND
Opioid use is highly prevalent in the United States and has effects on esophageal function which present as disorders of esophageal spasticity and outflow obstruction. Recommendations are to repeat studies with patients off opioids but this is not always possible. Previous studies have shown high prevalence of opioid use in those with achalasia Type III. However, studies on treatment outcomes in this cohort is limited and data is contradictory. We aim to investigate the treatment response to surgical myotomy in patients with and without chronic pre-operative opioid use treated as achalasia Type III.
METHODS
We conducted a retrospective review of all consecutive patients undergoing primary myotomy for achalasia classified as Type III or achalasia variants with Type III features. Chronic use of opioids was determined by presence of an opioid on medication list at time of surgery not related to a recent procedure or acute event. The primary outcome was symptomatic response assessed using the Eckardt score (ES) with a score of ? 3 classified as success. The secondary outcome was need for re-intervention at 3 years.
RESULTS
There were 48 patients including Type III (38) and achalasia variants (9). Twelve of 48 had chronic pre-operative opioid use (OU) vs 36 with no opioid use (NU). The groups were different in sex (10/12 female OU vs 18/36 female NU; p=0.04) and average BMI (33.3 OU vs 27.3 NU, p<0.01) but similar in age (61.9 OU vs 57.9 NU; p=0.20).
Opioid users and non-opioid users had similar pre-operative Eckardt scores (6 (4.75-6.25)OU vs 6(4.75-8.25) NU, p=0.26). Opioid users underwent per-oral endoscopic myotomy (POEM) at higher rates. There was no difference in myotomy lengths between the groups (table 1).
After myotomy, both groups had similar rates of success defined as ES ? 3 (9/11 OU vs 27/32 NU, p=0.84). However, non-opioid users had milder symptoms with higher rates of ES 0 or 1 compared to opioid users (5/11 OU vs 26/32 NU, p=0.02) (table 2).
Re-interventions occurred in 5/12 (41.7%) of opioid users compared to 4/36 (11.1) non-opioid users, p=0.01 (table 2).
CONCLUSION
Patients with preoperative opioid use had less optimal response to myotomy at 3 years compared to those without opioid use. They had higher need to re-intervention including multiple re-interventions compared to non-opioid users. Patients with type III achalasia using opioids should be counselled about these outcomes.
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