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Original Articles: General Thoracic

Factors Associated With Postoperative Symptoms After Laparoscopic Heller Myotomy

^a Division of Thoracic Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Canada
^b Division of Thoracic Surgery, Department of Surgery, Faculty of Medicine, University of British Columbia and the Vancouver Hospital, Vancouver, British Columbia, Canada

Accepted for publication October 16, 2009.

^_* Address correspondence to Dr Christian Finley, Division of Thoracic Surgery, Department of Surgery, 200 Elizabeth St, EN9-946, Toronto, Ontario, M5G 2C4, Canada (Email: christianfinley{at}shaw.ca).

Background: Our objective is to ascertain if preoperative and perioperative treatments affect the short- and long-term symptom frequency or symptom scores for dysphagia, regurgitation, and heartburn in patients with laparoscopic Heller myotomy for achalasia.

Methods: From 1994 to 2008, 261 patients undergoing laparoscopic esophageal myotomy were enrolled prospectively. The diagnosis of classic achalasia was made on clinical history, barium swallow, endoscopy, and manometry. A validated symptom questionnaire and history was taken for each patient at the preoperative visit and at each postoperative visit.

Results: In all, 261 patients had laparoscopic Heller myotomy during the study period. Preoperatively, 137 patients (62.3%) tried medications, 101 (38.7%) were treated with pneumatic dilation, and 29 (11.1%) were treated initially with at least one injection of botulinum toxin into the lower esophageal sphincter. In all, 134 patients (51.3%) received a Dor anterior fundoplication. On multivariate regression controlling for age and sex, preoperative dilation (p = 0.031), injection of botulinum toxin (p = 0.044), and a fundoplication (p = 0.005) were associated with significantly worse early postoperative dysphagia, with odds ratios of 2.11, 2.56, and 2.80, respectively; previous botulinum toxin injection was associated with worse late postoperative dysphagia (p = 0.001), regurgitation (p = 0.031), and heartburn (p = 0.049), with odds ratios of 5.24, 2.87, and 2.52, respectively. There was a trend for no fundoplication to be associated with late postoperative heartburn (p = 0.077) with an odds ratio of 1.80.

Conclusions: Many patients presenting for Heller myotomy have previously undergone a different form of treatment. Early postoperative dysphagia was affected by dilation, botulinum toxin injection, and fundoplication. Only botulinum toxin injection was associated with late symptoms.

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Invited Commentary

Raja M. Flores
Ann. Thorac. Surg. 2010 89: 396. [Extract] [Full Text] [PDF]

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				S. Mattioli, A. Ruffato, M. Lugaresi, V. Pilotti, B. Aramini, and F. D'Ovidio Long-term results of the Heller-Dor operation with intraoperative manometry for the treatment of esophageal achalasia J. Thorac. Cardiovasc. Surg., November 1, 2010; 140(5): 962 - 969. [Abstract] [Full Text] [PDF]

				R. M. Flores Invited Commentary Ann. Thorac. Surg., February 1, 2010; 89(2): 396 - 396. [Full Text] [PDF]