Predictors of Long-term Outcome After Laparoscopic Esophagomyotomy and Dor Fundoplication for Achalasia

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http://archsurg.ama-assn.org/cgi/content/abstract/146/9/1024?ct=ct

Predictors of Long-term Outcome After Laparoscopic Esophagomyotomy and Dor

Fundoplication for Achalasia

T. , MD;

Dennis Nguyen, MD;

Garrett R. Roll, MD;

Sandi W. Ma, MS;

Lawrence W. Way, MD

Arch Surg. 2011;146(9):1024-1028. doi:10.1001/archsurg.2011.214

Objective  To identify predictors of long-term outcome of laparoscopic Heller

myotomy for achalasia, including predictors of heartburn and recurrent

dysphagia, which occasionally develop postoperatively.

Design  Retrospective review using interviews of patients.

Setting  Academic university hospital.

Patients  One hundred sixty-five patients with achalasia who underwent a

laparoscopic esophagomyotomy and Dor fundoplication.

Main Outcome Measures  Dysphagia and heartburn before and after the operation

were assessed on a 4-point Likert scale, as were postoperative dilations,

reoperations, and antacid use. Potential predictors were age, race, sex, body

mass index, weight loss, duration of symptoms, manometry findings, esophageal

diameter, previous treatment, and operative technique.

Results  Follow-up averaged 62 (range, 1-174) months. Dysphagia frequency was

once a week or less in 128 patients (78%), several times per week in 25 (15%),

and daily in 12 (7%). Satisfaction scores averaged 3.7 on a 4-point scale.

Thirty patients (18%) required a postoperative dilation, and 6 (4%) underwent

another operation. The only predictor of postoperative dysphagia was duration of

symptoms longer than 10 years (odds ratio, 0.2; P = .03). Preoperative dilations

predicted the need for postoperative dilations (odds ratio, 2.4; P = .03). Only

20 patients (12%) reported heartburn more than once weekly, although 75 (45%)

reported taking antacids. No variable predicted postoperative heartburn or

antacid use.

Conclusions  Long-term outcomes after laparoscopic esophagomyotomy were

excellent across a wide spectrum of disease severity and presentations. Previous

treatments, such as balloon dilation or botulinum toxin (Botox) injection, did

not portend worse outcomes. When the myotomy was extended 2 cm onto the stomach

and a Dor fundoplication was performed, severe heartburn was rare.

Author Affiliations: Department of Surgery, University of California, San

Francisco.