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Ann Thorac Surg 1996;62:327-330
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Results of Myotomy and Partial Fundoplication After Pneumatic Dilation for Achalasia

Department of Surgery, The University of Chicago, Chicago, Illinois

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. We questioned whether results of myotomy for achalasia are influenced by previous pneumatic dilation and whether surgical outcome is influenced by a dilation-related perforation necessitating urgent operation.

Methods. We performed a retrospective analysis of 60 patients who underwent transthoracic myotomy and fundoplication from 1977 to 1995. Dysphagia, heartburn, pain, and regurgitation were scored on a scale of 0 to 3 and results were classified according to combined symptom score.

Results. Dilation was performed before myotomy once in 15 patients, twice in 25, 3 times or more in 9, and never in 11 patients. Operation was urgent due to perforation in 6 patients (10%). There was no postoperative leak or mortality. Overall symptom score at last follow-up (57 ± 8 months; 90% of patients) was improved compared with preoperative score (2.1 ± 0.3 months versus 5.1 ± 0.2 months; p < 0.0001). Outcome was unrelated to whether or not a perforation occurred (excellent/good outcomes in 100% and 88%, respectively) or to whether or not preoperative dilations had been performed (excellent/good outcomes in 90% and 89%, respectively).

Conclusions. Myotomy and partial fundoplication is an effective technique for management of achalasia. Results are unaffected by the need for urgent operation for perforation and are unrelated to whether pneumatic dilation is performed preoperatively.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
See also page 330.

The optimal initial therapy for achalasia remains controversial. In a recent review of therapeutic options for the management of achalasia, pneumatic dilation was described as being successful in excess of 70% of patients and the risk of perforation was less than 2% [1]. More recently published findings demonstrate that pneumatic dilation results in improvement in more than 85% of patients [2–4] and show that the relative cost of pneumatic dilation is substantially lower than that of surgical myotomy [5].

The favorable results and low cost associated with pneumatic dilation have fueled the controversy over whether myotomy or dilation is the best initial therapy for achalasia. Although a recently published algorithm suggests that a treatment regimen beginning with pneumatic dilation has lower overall costs than one starting with myotomy [5], many surgeons are reluctant to pursue this course of action because of concerns over whether a previous dilation, particularly one associated with a perforation, will adversely affect the results of a subsequent myotomy. We conducted a review of patients treated by myotomy for achalasia at our medical center to determine whether results are influenced by previous pneumatic dilation and to assess whether outcome is influenced by a dilation-related perforation necessitating urgent operation.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
We retrospectively reviewed hospital records of patients who received therapy for esophageal achalasia at The University of Chicago Medical Center from 1977 to 1995. Patients selected for inclusion in the data base had achalasia documented by barium swallow, endoscopy, and usually esophageal manometry, and had undergone no operation for achalasia before definitive surgical therapy. The choice of initial therapy was made by the patient upon the recommendation of the attending surgeon or gastroenterologist after a thorough discussion of the options available. Pneumatic dilation was performed in the earlier years with a silk-covered rubber balloon and in the later years with a polyurethane balloon. Patients were routinely observed in the hospital overnight for complications associated with pneumatic dilation. Contrast esophagrams were not performed routinely. Esophageal perforation was diagnosed on the basis of patient symptoms, physical examination, chest radiograph, and barium swallow. Urgent operation was performed for patients exhibiting clinical signs of an esophageal perforation, and included primary closure of the perforation followed by myotomy and fundoplication as performed in elective operations. Elective esophageal myotomy was performed using an open transthoracic approach, combining a myotomy onto the stomach with a modified Belsey Mark IV fundoplication (partial fundoplication). Follow-up was obtained from hospital and clinic records, from a mailed questionnaire, and from telephone interviews.

Information on the timing, technique, and outcome of treatments was recorded. Dysphagia, heartburn, pain, and regurgitation were each scored preoperatively and at intervals postoperatively on a scale of 0 (no symptoms) to 3 (severe symptoms). A combined symptom score was calculated by adding the total of the scores for the individual symptoms, with 12 being the worst possible score. Postoperative combined symptom scores were classified as excellent (0 to 2), good (3 to 4), fair (5 to 6), or poor (score more than 6 or failed myotomy requiring reoperation).

Data are expressed as mean ± one standard error of the mean. Categoric data were assessed using ² analysis. Nonparametric data were analyzed with the Mann-Whitney test. Continuous variables were assessed with the nonpaired Student's t-test and with one-way analysis of variance using the Bonferroni correction where appropriate. A p value less than 0.05 was accepted as being statistically significant.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
We evaluated 60 patients, of whom 30 were men and 30 were women whose mean age was 42.0 years (range, 15 to 81 years). Patients had a history of symptoms compatible with achalasia for 5.6 years (median, 3 years; range, 2 months to 30 years) before operation. Among 50 patients for whom information on preoperative weight was available, the average amount of weight loss from the onset of symptoms to operation was 7.9 ± 1.3 kg. The most prominent symptoms were dysphagia and regurgitation, followed by pain and heartburn (Table 1). The average combined symptom score was 5.1 ± 0.2. Information from contrast radiographs was available in 56 patients and included evidence for esophageal dilatation that was mild in 8 patients, moderate in 39, and severe in 7 patients. Results of esophageal motility studies were available in 34 patients. The mean resting lower esophageal sphincter pressure was 28.9 ± 2.9 mm Hg, and lower esophageal sphincter pressure was elevated more than 20 mm Hg in 24 patients (70%).

Follow-up was available in 54 patients (90%) for a mean duration of 57.3 ± 8.3 months (range, 2 months to 19 years). Weight increased by 4.4 ± 0.9 kg in 42 patients in whom preoperative and postoperative weights were available. Individual symptom scores at last follow-up improved significantly compared with preoperative scores in every category except heartburn, in which there was only a slight improvement (Table 1). Combined symptom scores also improved significantly (Table 2)tab 2. At last follow-up results were good or excellent in 48 of 54 patients (89%). There was a tendency for the combined symptom score to worsen as the duration of the post- operative interval increased (Fig 1). The combined symptom score during 0 to 5 years of follow-up was 1.2 ± 0.2, during 5 to 10 years of follow-up it was 2.2 ± 0.6, and for more than 10 years of follow-up it was 3.0 ± 0.5 (p = 0.001 by analysis of variance; p < 0.03 comparing the first and last intervals). Similarly, the percentage of patients experiencing good or excellent results decreased from 99% in the early follow-up interval to 82% and 77% in the middle and final intervals, respectively.

View larger version (20K): [in this window] [in a new window]   Fig 1. . Combined symptom scores for patients undergoing esophageal myotomy and partial fundoplication. Error bars indicate ± one standard error of the mean.

Results of myotomy and fundoplication were not affected by whether or not patients had a previous esophageal pneumatic dilation. Preoperative symptom scores were similar regardless of the number of dilations that were performed preoperatively and improved significantly at last follow-up in all categories. Similarly, the preoperative combined symptom scores were the same regardless of whether a dilation had been performed and improved significantly at last follow-up (Table 2). Good or excellent results at last follow-up were found in 9 of 10 patients without previous dilation (90%) compared with 39 of 44 patients who had previous dilation (89%).

The development of a dilation-related perforation did not adversely affect long-term outcome. Patients who suffered perforation were followed up for a mean interval of 49 ± 25 months, whereas those without perforation were followed up for 58 ± 9 months. The combined symptom score at last follow-up was 2.2 ± 0.3 for patients without perforation compared with 1.2 ± 0.4 for patients who suffered perforation (p = 0.06). Good or excellent results were found in 42 of 48 patients (88%) without perforation, whereas all 6 patients who suffered perforation had an excellent outcome.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The most appropriate initial therapy for achalasia has been a topic of discussion for many years. Despite the fact that a randomized, prospective study demonstrated superior long-term results of myotomy compared with pneumatic dilation [6], gastroenterologists continue to cite the low cost, short recovery time, efficacy, and safety of pneumatic dilation as reasons to consider it first-line therapy [7, 8]. The suggestion that patients have two successful treatment options, myotomy and pneumatic dilation, to choose between [9] is of concern to some surgeons. To be effective, forceful dilation must rupture the muscular layers of the esophagus. Obliteration of the submucosal plane by postdilation fibrosis makes the conduct of a subsequent myotomy technically more difficult, and theoretically puts patients at risk for suboptimal long-term results after myotomy. Similarly, the inflammation that accompanies esophageal perforation also makes the conduct of esophageal myotomy more difficult and might adversely affect long-term outcome. It was with these issues in mind that the present study was conducted.

Confirming a previous report from our institution [10], we found that the outcome of myotomy and partial fundoplication in our patients was very good and was comparable to results reported by other centers of myotomy alone or combined with fundoplication [11–14]. The results of esophageal myotomy deteriorated over time, such that good or excellent outcomes were present in only 77% of patients followed up for more than 10 years. These results are similar to those reported by other centers for long-term follow-up of patients after myotomy alone [13] or combined with fundoplication [15, 16].

There is very little information published on the effects of pneumatic dilation on the outcome after subsequent esophageal myotomy. We found that the performance of pneumatic dilation before operation had no effect on immediate or long-term results of myotomy and partial fundoplication. This finding was true regardless of the number of dilations performed before operation. There was no apparent increase in the technical difficulty of performing myotomy after previous pneumatic dilation, and no special techniques were necessary to accomplish a satisfactory myotomy in these patients. This suggests that the concern that fibrosis might develop in the submucosal plane after dilation is unfounded.

We assessed the outcome of myotomy and fundoplication in 6 patients who suffered perforation due to pneumatic dilation. All perforations were diagnosed in the early postoperative period and were operated on urgently, with uniformly good short-term and long-term results. These results are similar to those reported previously, in which the cumulative rate of excellent or good outcome was 94% in 19 patients [17–21], and are substantially better than those obtained in our institution for a large group of patients suffering from perforation in the absence of esophageal malignancy [22]. A recent report suggests that successful nonsurgical management of patients with dilation-related perforation is possible with good results present at long-term follow-up [23]. However, the hospital stay in the 3 patients in that report was prolonged, and the risk of sepsis associated with a continued and uncontrolled leak in such patients is very real. The excellent surgical results in patients operated for dilation-related perforation suggest that individuals who have an uncontained leak or who develop systemic symptoms should undergo urgent repair followed by definitive operation for their underlying motility disorder.

As newer therapies for achalasia are introduced, the debate over which treatment is optimal becomes more complicated. Minimally invasive approaches offer potential long-term benefit at a substantially lower cost than current surgical remedies. The injection of botulinum toxin provides short-term outcomes equivalent to those obtained with pneumatic dilation while reducing the risk of acute complications such as perforation. Our findings do not provide information that will assist in the choice among these options, but, along with results of other recent studies [11–14], serve as a current standard to which results of newer treatments may be compared.

We conclude that myotomy and partial fundoplication is an effective technique for management of achalasia. Results of this procedure are not affected by the need for urgent operation due to esophageal perforation and are unrelated to whether pneumatic dilation is performed preoperatively.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Presented at the Thirty-second Annual Meeting of The Society of Thoracic Surgeons, Orlands, FL, Jan 29-31, 1996.

Address reprint requests to Dr Ferguson, Department of Surgery, The University of Chicago Medical Center, 5841 S Maryland Ave, MC 5035, Chicago, IL 60637

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Ferguson MK. Achalasia: current evaluation and therapy. Ann Thorac Surg 1991;52:336–42.[Abstract]
2. Kadakia SC, Wong RKH. Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia. Am J Gastroenterol 1993;88:34–8.[Medline]
3. Abid S, Champion G, Richter JE, McElvein R, Slaughter RL, Koehler RE. Treatment of achalasia: the best of both worlds. Am J Gastroenterol 1994;89:979–85.[Medline]
4. Lambroza A, Schuman RW. Pneumatic dilation for achalasia without fluoroscopic guidance: safety and efficacy. Am J Gastroenterol 1995;90:1226–9.[Medline]
5. Parkman HP, Reynolds JC, Ouyang A, Rosato EF, Eisenberg JM, Cohen S. Pneumatic dilatation or esophagomyotomy treatment for idiopathic achalasia: clinical outcomes and cost analysis. Dig Dis Sci 1993;38:75–85.[Medline]
6. Csendes A, Braghetto I, Henriquez A, Cortes C. Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut 1989;30:299–304.[Abstract/Free Full Text]
7. Richter JE. Surgery or pneumatic dilatation for achalasia: a head-to-head comparison. Now are all the questions answered? Gastroenterology 1989;97:1340–6.[Medline]
8. Richter JE. Achalasia: Whether the knife or balloon? Not such a difficult question. Am J Gastroenterol 1991;86:810–1.[Medline]
9. Katz P. Achalasia: two effective treatment options-Let the patient decide. Am J Gastroenterol 1994;89:969–73.[Medline]
10. Little AG, Soriano A, Ferguson MK, Winans CS, Skinner DB. Surgical treatment of achalasia: results with esophagomyotomy and Belsey repair. Ann Thorac Surg 1988;45:489–94.[Abstract]
11. Paricio PP, Martinez de Haro LM, Ortiz A, Aguayo JL. Achalasia of the cardia: long-term results of oesophagomyotomy and posterior partial fundoplication. Br J Surg 1990;77:1371–4.[Medline]
12. Bonavina L, Nosadini A, Bardini R, Baessato M, Peracchia A. Primary treatment of esophageal achalasia. Arch Surg 1992;127:222–7.[Abstract/Free Full Text]
13. Ellis FH Jr. Oesophagomyotomy for achalasia: a 22-year experience. Br J Surg 1993;80:882–5.[Medline]
14. Donahue PE, Schlesinger PK, Sluss KF, et al. Esophagocardiomyotomy-Floppy Nissen fundoplication effectively treats achalasia without causing esophageal obstruction. Surgery 1994;116:719–25.[Medline]
15. Topart P, Deschamps C, Taillefer R, Duranceau A. Long-term effect of total fundoplication on the myotomized esophagus. Ann Thorac Surg 1992;54:1046–52.[Abstract]
16. Malthaner RA, Todd TR, Miller L, Pearson FG. Long-term results in surgically managed esophageal achalasia. Ann Thorac Surg 1994;58:1343–7.[Abstract]
17. Slater G, Sicular AA. Esophageal perforations after forceful dilatation in achalasia. Ann Surg 1982;195:186–8.[Medline]
18. Miller RE, Tiszenkel HI. Esophageal perforation due to pneumatic dilation for achalasia. Surg Gynecol Obstet 1988;166:458–60.[Medline]
19. Schwartz HM, Cahow CE, Traube M. Outcome after perforation sustained during pneumatic dilatation for achalasia. Dig Dis Sci 1993;38:1409–13.[Medline]
20. Nair LA, Reynolds JC, Parkman HP, et al. Complications during pneumatic dilation for achalasia or diffuse esophageal spasm. Dig Dis Sci 1993;38:1893–1904.[Medline]
21. Molina EG, Stollman N, Grauer L, Reiner DK, Barkin JS. Conservative management of esophageal nontransmural tears after pneumatic dilation for achalasia. Am J Gastroenterol 1996;91:15–8.[Medline]
22. Reeder LB, DeFilippi VJ, Ferguson MK. Current results of therapy for esophageal perforation. Am J Surg 1995;169:615–7.[Medline]
23. Swedlund A, Traube M, Siskind BN, McCallum RW. Nonsurgical manage ment of esophageal perforation from pneumatic dilatation in achalasia. Dig Dis Sci 1989;34:379–84.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mark K. Ferguson Laurie B. Reeder Jemi Olak Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ferguson, M. K. Articles by Olak, J. Search for Related Content PubMed PubMed Citation Articles by Ferguson, M. K. Articles by Olak, J. Related Collections Related Article