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Ann Thorac Surg 1996;61:1106-1110
© 1996 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Onset Timing of Delayed Complications and Criteria of Follow-up After Operation for Esophageal Achalasia

Department of Surgery, Intensive Care, and Organ Transplantation and Clinical Department of Radiology and Pathology, University of Bologna, Bologna, Italy

Accepted for publication December 21, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The purpose of this study was to define the length of follow-up necessary to obtain definitive results of the Heller myotomy for the therapy of esophageal achalasia and the modalities of long-term follow-up. Insufficient myotomy, periesophageal scarring, and gastroesophageal reflux esophagitis are the most common late complications of operation for achalasia. Columnar-lined esophagus with or without dysplasia and cancer can further complicate postoperative reflux esophagitis. Because progressive worsening of results with time has been reported, we assessed the timing of appearance of these complications.

Methods. Since 1973, 129 patients submitted to Heller myotomy were clinically and objectively followed up. Mean follow-up was 97.4 months (range, 12 to 268 months). Of 129 patients, 42 were followed up for less than 5 years (17 voluntary drop outs, 10 reoperations, 3 deaths, 12 in follow-up), 47 more than 5 years, 26 more than 10 years, 12 more than 15 years, and 2 more than 20 years. The timing of onset of symptoms and complications related to the myotomy were evaluated as was the development of dysplasia and cancer.

Results. In 11 patients, severe dysphagia due to insufficient myotomy reappeared a mean of 12.4 months after the operation (range, 3 to 30 months). In 7 patients with periesophageal scarring, dyshagia recurred a mean of 18.8 months (range, 6 to 28 months) after the operation. Postoperative reflux esophagitis appeared in 22 patients a mean of 76.5 months (range, 21 to 168 months) after the operation. Columnar-lined esophagus was detected in 8 patients a mean of 143.1 months (range, 85 to 230 months) after the operation. Mild to moderate dysplasia was found in 5 of 8 patients with columnar-lined esophagus a mean of 191.6 months after the operation (range, 152 to 287 months), and intramucosal adenocarcinoma was found in 1 patient with columnar-lined esophagus after 8 years.

Conclusions. Dysphagia secondary to insufficient myotomy and periesophageal scarring recurs early, not later than 3 years. Conversely, abnormal gastroesophageal reflux with related complications can appear more than 10 years postoperatively. Five years after the operation the follow-up should be primarily endoscopic and histologic. Results should withstand a follow-up of at least 10 years.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 1110.

Results of myotomy for esophageal achalasia tend to worsen with time [1–6]. Thus, an objective evaluation and the comparison with other reported series that have different follow-up criteria is difficult. In fact, a minimum follow-up period after which results must be considered to be definitive has not been established [3, 7].

The most common causes of failure of the Heller operation are the relapse of dysphagia due to insufficient myotomy or periesophageal scarring, and gastroesophageal reflux and esophagitis secondary to the iatrogenic cardial incompetence [8–11]. Another cause of poor long-term outcome in achalasic patients who have undergone myotomy is cancer, although there is no general agreement on the real risk [12, 13]. The development of cancer can be related to myotomy or not. Epidermoid carcinoma, which is the most common cancer to occur in achalasic patients, is unrelated to mytomy [10, 14]. In contrast, adenocarcinoma in columnar-lined esophagus (CLE) is a rare complication that develops after long-standing postoperative gastroesophageal reflux disease [15, 16].

Since 1973 we have been following up all achalasic patients operated on in our department according to a prospective study protocol [17, 18]. After 20 years the collected data were reviewed to assess the timing of appearance and the clinical patterns of complications related to the Heller myotomy. The purpose of this study was to define the length of follow-up necessary to obtain a definitive evaluation of results of Heller myotomy and the modalities of follow-up to avoid not only unnecessary tests but also inaccurate evaluations and delayed diagnoses.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The study protocol involved 129 patients affected by esophageal achalasia who initially underwent Heller myotomy between January 1970 and December 1991; 115 patients were operated on in our department. Fourteen patients were referred to us because of failure of the Heller operation early postoperatively. In all patients the diagnosis of achalasia was established on the basis of esophageal manometry [19], upper gastrointestinal tract roentgenography, and endoscopy.

The follow-up protocol of patients operated on for esophageal achalasia started in January 1973. Fourteen patients submitted to myotomy before this date were included in the study because they had yearly follow-up after the operation; data were drawn from the outpatient clinic records.

The follow-up was performed as follows: Clinical interview was done at 3 and 6 months for the first year after the operation and subsequently every 12 months. Barium swallow and esophageal manometry were performed at years 1, 3, 5, and 10. Endoscopy and multiple biopsies were done at years 1, 3, and 5 and subsequently every 3 years. In patients with reflux esophagitis and Barrett's esophagus, endoscopy was performed yearly. Instrumental investigations were performed other than according to the fixed schedule when suggested by the clinical picture. Since 1973, the clinical and instrumental examinations were performed or supervised by two of us (S.M. and F.B.).

Symptoms related to esophageal obstruction and gastroesophageal reflux were evaluated according to semiquantitative scales. Dysphagia symptoms (DS) were graded as follows: DS0 = symptom free, DS1 = occasional dysphagia or pain less than once a week, DS2 = dysphagia once or more a week without regurgitation, DS3 = daily dysphagia with regurgitation and weight loss. Gastroesophageal reflux symptoms (RS) were graded as follows: RS0 = symptom free, RS1 = heartburn after postural change once a day and occasional acid regurgitation, RS2 = postural and spontaneous heartburn up to a maximum of four times a day with occasional acid regurgitation, RS3 = spontaneous or postural heartburn more than four times a day with acid regurgitation.

The differential diagnosis between insufficient myotomy and periesophageal scarring was made on the basis of the radiologic, endoscopic, and manometric patterns and on the basis of the operative findings when patients underwent reoperation [8, 9]. The diagnosis of insufficient myotomy was based on barium swallow that revealed persistence of a ``bird beak'' image of the cardia, endoscopy that revealed a soft cardia, and manometric assessment of a residual high pressure zone in the lower esophageal sphincter. The diagnosis of scar stenosis was based on barium swallow that showed stenosis of the cardia having irregular margin and endoscopy that revealed rigidity of the cardia without signs of reflux esophagitis.

The status of the esophageal mucosa was studied with endoscopy and histology. The Z-line distance from the dental arcade was measured at endoscopy. Biopsies were performed on all macroscopically suspicious lesions and randomly on the four quadrants every 3 cm starting upward from the Z-line. A topographic localization of each biopsy was made by defining the quadrant and distance from the Z-line to precisely identify the lesion on the successive follow-ups. In patients with sigmoid achalasia, endoscopy was performed after 3 to 5 days of liquid diet and lavage of the visceral lumen to eliminate food residual. Differentiation between reflux esophagitis and nonspecific chronic esophagitis secondary to stasis was based on Morson and associates' histologic criteria [20].

Reflux esophagitis (E) was graded according to the following semiquantitative scale: E0 = absence of macroscopic and microscopic patterns of reflux esophagitis, E1 = microscopic esophagitis with or without hyperemia and edema, E2 = nonconfluent erosions; E3 = confluent (360-degree) erosions, ulcer, stenosis, or a combination of these.

Barrett's esophagus was diagnosed by the histologic identification of CLE above the Z-line. Columnar-lined esophagus was endoscopically classified following Bremner's criteria: stage 1 = creeping substitution, stage 2 = developing Barrett's with columnar spread less than 3 cm, stage 3 = established Barrett's circumferentially more than 3 cm [21]. Dysplasia was defined as mild, moderate, and severe [22].

We considered only the patients who had at least a 1-year follow-up and a complete clinical and instrumental control. The follow-up was measured from the time of operation until the time of last clinical and instrumental control. For patients who underwent reoperation or dilation therapy the follow-up was terminated at the time of appearance of the complication that led to the second treatment. The timing of onset of symptoms and complications related to the myotomy as well as dysplasia and cancer was looked for and reported.

Data on the appearance of dysphagia and reflux symptoms were analyzed similarly to the survival curves applying the Kaplan-Meier actuarial method. For each symptom patients with grade 0 and 1 were grouped as alive and patients with grade 2 and 3 as dead.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The mean follow-up of the 129 patients was 97.4 months (range, 12 to 268 months). Table 1 shows the distribution of the follow-up and the causes of dropout.

View larger version (22K): [in this window] [in a new window]   Fig 1. . Distribution of the time of appearance of complications.

The curve representing the rate of patients free from dysphagia after the operation (Fig 2) drops to 77.3% at the third year postoperatively and remains stable until the 10th year after the operation; it further decreases to 71.9% at the 11th year and then remains stable until the 20th postoperative year.

View larger version (20K): [in this window] [in a new window]   Fig 2. . Actuarial analysis of the onset of gastroesophageal reflux symptoms (RS) and dysphagia (DS) in 129 achalasic patients submitted to myotomy.

Reflux esophagitis, absent in all patients preoperatively, appeared in 22 patients (E2 = 9; E3 = 13) a mean of 76.5 months after the operation (range, 21 to 168 months) (see Fig 1). Of the 18 patients with severe reflux symptoms, 16 had severe esophagitis (E2 = 4; E3 = 12) and 2 had mild esophagitis (E1). Conversely, of the 22 patients with erosive (E2) or ulcerative (E3) esophagitis, 16 patients had severe reflux symptoms (RS2 or RS3), whereas 6 had occasional symptoms.

Columnar-lined esophagus, absent in all patients preoperatively, was detected in 8 of 22 patients affected by reflux esophagitis (36.4%) a mean of 143.1 months postoperatively (range, 85 to 230 months). Two patients had Bremner's stage 1 and 6 a stage 2. Four mild and 1 moderate dysplasia were found in 5 of 8 patients after a mean of 191.6 months postoperatively (range, 152 to 287 months). An intramucosal adenocarcinoma developed in CLE in 1 patient 8 years after the operation. Table 2 shows the onset time and evolution of CLE, dysplasia, and cancer in 8 patients with postoperative reflux esophagitis.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Dysphagia and gastroesophageal reflux symptoms are the clinical parameters most commonly used to evaluate the results of the surgical therapy for achalasia. After extramucosal myotomy, the immediate disappearance of symptoms is obtained in more than 90% of patients [3, 11]. Persistence or relapse of dysphagia is due to an incomplete myotomy with a residual high-pressure zone, to the early scarring of the myotomy area, or to the inefficiency of myotomy in decompensated sigmoid esophagus [3, 5].

In our patients dysphagia secondary to insufficient myotomy or to scar stenosis always occurred within the first 3 years after the operation. Dysphagia for ineffective myotomy was also responsible for the initial percentage drop. After 10 years cancer in sigmoid esophagus was the late cause of relapse of dysphagia.

Development of gastroesophageal reflux is the major sequel after Heller myotomy [1, 2, 6, 11, 23]. In the literature, the frequency of reflux symptoms is subject to a great variability (from 0% to 50%) related not only to the technique and to the surgeon, but also to the duration of the follow-up [3].

The onset timing curve of reflux symptoms has a more regular shape, with a progressive percentage drop reaching that of the dysphagia curve at 20 years after the operation. Correspondence between symptoms and reflux esophagitis is not always present. In fact, esophagitis has been documented in the presence of mild reflux symptoms.

The most severe consequences of postoperative gastroesophageal reflux, CLE and dysplasia, occurred at least 10 years after the operation. Barrett's esophagus and adenocarcinoma in Barrett's esophagus after cardiomyotomy for achalasia are rare. To date, only 14 cases of CLE and 2 cases of adenocarcinoma in CLE after myotomy have been reported [15, 16, 24]. The high percentage of CLE in our patients with iatrogenic reflux esophagitis (36%) is probably the result of an accurate and prolonged follow-up. The development of dysplasia in 5 of 8 patients with CLE studied and of adenocarcinoma in another 1 suggests that in achalasic patients, postoperative gastroesophageal reflux can be a potentially severe complication. Patients in whom Barrett's esophagus develops after Heller myotomy should be considered at risk for cancer, and therefore included in a specific follow-up protocol.

The presence of sigmoid esophagus with food stasis and chronic irritation and a long-standing disease are risk factors for the development of epidermoid cancer; the outcome of the operation seems not to be influential as previously suggested [12, 25].

In conclusion, the results of myotomy for esophageal achalasia tend to worsen with time. A follow-up period of at least 10 years is necessary before results may be considered definitive. Insufficient myotomy and scar stenosis are evident within the first 3 postoperative years. Therefore, examinations such as manometry and radiology performed more than 5 years after the operation are no longer justified. Gastroesophageal reflux symptoms and esophagitis occur late. Cancer in CLE should be considered another long-term complication of myotomy. After 5 years the follow-up protocol should be primarily endoscopic and histologic for early identification of reflux esophagitis and its complications and cancer. Patients with CLE and patients with sigmoid esophagus should be submitted to endoscopy on a yearly basis. In patients with sigmoid esophagus, endoscopy should be performed after 3 to 5 days of a liquid diet and after lavage of the esophagus.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Mattioli, Dipartimento di Discipline Chirurgiche, Rianimatorie e dei Trapianti, Sezione Chirurgia Generale, Universita di Bologna, Via Massarenti, 9, 40138 Bologna, Italy.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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