Ann Thorac Surg 2006;81:2044-2049
© 2006 The Society of Thoracic Surgeons
Original article: General thoracic
Transthoracic Heller Myotomy for Esophageal Achalasia: Analysis of Long-Term Results
Henning A. Gaissert, MD
*
,
Ning Lin, BS,
John C. Wain, MD,
Grant Fankhauser, BS,
Cameron D. Wright, MD,
Douglas J. Mathisen, MD
Division of Thoracic Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Accepted for publication January 4, 2006.
* Address correspondence to Dr Gaissert, Massachusetts General Hospital, Blake 1570, Fruit St, Boston, MA 02114 (Email: hgaissert{at}partners.org).
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Abstract
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BACKGROUND: Swallowing deteriorates over time in some patients after transthoracic esophagomyotomy for achalasia. The causes of decline are poorly understood.
METHODS: We report a retrospective analysis of transthoracic esophagomyotomy for achalasia. Symptom relief, patient satisfaction, and late intervention were determined during short- and long-term follow-up. Predictors of long-term outcome were identified by logistic regression.
RESULTS: From 1962 to 1999, 64 patients underwent transthoracic esophagomyotomy. Five patients had repeat myotomy. Sigmoid esophagus was present in 12 (18%). Fundoplication was absent in 50 patients (myotomy only) and added in 15 (myotomy plus fundoplication). Follow-up was complete in 86% (56 of 65); mean follow-up was 154 months. Thirty-one patients (48%) were followed for more than 10 years. Short-term results were good to excellent in 91% (51 of 56) and long-term in 63% (33 of 52; p < 0.0005). Late peptic stricture occurred in 4 patients (myotomy only, 2 of 38 [5%]; myotomy plus fundoplication, 2 of 14 [14%]). Fewer patients had reflux symptoms after fundoplication (myotomy only, 16 of 38 [42%]; myotomy plus fundoplication, 4 of 14 [29%]), whereas late dysphagia was not reduced (myotomy only, 13 of 38 [34%]; myotomy plus fundoplication, 5 of 14 [36%]). Two patients after myotomy plus fundoplication and 1 after myotomy only had esophagectomy. Early recurrence of symptoms predicted late poor outcome (p < 0.001), whereas sigmoid esophagus, fundoplication, or early postoperative reflux did not.
CONCLUSIONS: Early good results after esophagomyotomy for achalasia deteriorate over time. Recurring dysphagia early after operation predicts late failure, while sigmoid esophagus does not. Fundoplication reduces reflux symptoms, but not late poor results. These data should be considered in the evaluation of newer, minimally invasive procedures.
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Introduction
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Esophageal myotomy is the primary mode of palliation in achalasia. Myotomy carries a lower risk of perforation than forceful disruption by balloon [1], with better results 5 years after intervention [2]. Long-term outcome is important, as swallowing after operations on the esophagogastric junction may deteriorate over time, and because achalasia often arises in younger patients. Transthoracic myotomy was first described over 40 years ago, yet reports of long-term results are small in number and their conclusions disagree regarding extent of myotomy, addition of fundoplication, and cause of late failure [3, 4]. These reports originated in high-volume centers and may not reflect the results of centers where lower numbers of myotomy are performed. There are also few reports on the long-term outcome of sigmoid esophagus, and as a result, disagreement on the indications for myotomy. Esophagectomy is selected at some centers as the initial surgical therapy [5], in contrast to our preference for myotomy. Comparative long-term observation for laparoscopic myotomy and its modifications are not yet available.
Transthoracic myotomy has been applied at Massachusetts General Hospital (MGH) for 43 years. We sought to study the results of this experience.
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Patients and Methods
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We retrospectively reviewed all patients who were diagnosed with achalasia and underwent a transthoracic Heller myotomy in the MGH Division of Thoracic Surgery between 1962 and 1999. The MGH Institutional Review Board approved this study first on August 5, 2002. Consent was received from patients before obtaining follow-up information.
Early in the series, preoperative evaluation of patients consisted of radiographic contrast studies and upper endoscopy in all, and esophageal manometry in some patients; all three are part of the current standard evaluation, and 64% (41 of 64) underwent manometry. Myotomy was considered in patients with a dilated (width > 6 cm) sigmoid esophagus. Fundoplication was performed according to surgeon preference. Redo myotomy was performed when symptoms persisted after previous myotomy in the absence of stricture. Long-term follow-up after myotomy was established by telephone interview. Patients who improved after operation had no standard office follow-up.
Preoperative symptoms, perioperative complications, and postoperative outcomes were recorded. Radiographs were not reviewed. Short-term results were assessed at 2 to 6 months from office notes and hospital records, and long-term results were obtained 1 to 31 years after operation from patient contact. A questionnaire regarding preoperative symptoms, postoperative relief, and postoperative quality of life was administered. Dysphagia to liquids and solids, regurgitation, a history of aspiration, nocturnal cough, or pneumonia, and need for postoperative nonoperative intervention or reoperation was recorded. Postoperative outcomes were graded by independent interviewers. Patients with excellent result had total symptomatic relief, no additional surgical or nonsurgical intervention, and were highly satisfied. A good result indicated major relief with less than once weekly mild symptoms, no or infrequent (less than twice annual) dilatations, no additional operation, and a satisfied patient. Some relief, but frequently recurrent symptoms, frequent dilatations, no additional operation, and moderate satisfaction were described as a fair result. A poor outcome meant no relief, frequent dilatations, and a patient who was the same or worse off compared with the preoperative state. Patient satisfaction was a classifier to distinguish fair from poor results. Excellent, good, or fair results were considered improved from preoperative symptoms.
Surgical Technique
Procedures were performed by 10 thoracic surgeons. The esophagus was approached by a left thoracotomy through the seventh or eighth interspace. The standard modification of the Heller myotomy divided esophageal muscle from the first submucosal gastric vein to the level of the inferior pulmonary vein. For myotomy alone, the distal esophagus was encircled preserving the vagus nerves. When a fundoplication was added, the cardia was circumferentially dissected and the myotomy was extended to expose gastric submucosal veins over several centimeters. A standard (270 degrees in two layers) or modified (180 or 270 degrees in one layer) Belsey fundoplication was usually constructed. Esophageal mucosa and muscle were dissected over more than half of the circumference, placing sutures to fold back the muscle edge sometimes to prevent reapproximation. In 3 patients who underwent myotomy without fundoplication and had no leak, an intercostal muscle flap was sutured onto the esophageal mucosa to separate the gaping muscle. Mucosal leaks discovered during operation were closed with a primary reinforced repair using intercostal muscle or pericardial fat.
Statistical Analysis
Categorical data were expressed as percentage and analyzed with the Wilcoxon test. For outcome analysis, patients were divided into those with or without an antireflux procedure. A multivariable Cox regression model was constructed to extract predictors of functional outcome. Differences were considered significant at p less than 0.05. In order to achieve statistically acceptable power, the model was constructed of no more than seven inputs formed through various combinations of variables including age at operation, sex, symptom duration, previous esophageal trauma (myotomy or pneumatic dilatation), sigmoid esophagus, addition of fundoplication, intraoperative perforation, postoperative complication, early recurrence of dysphagia, and early occurrence of reflux. To compare a sufficient number of events, the binary output was set to favorable for good or excellent results and to unfavorable for fair or poor results. All analyses were performed with Statistica (StatSoft, Tulsa, Oklahoma).
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Results
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Between 1962 and 1999, 64 patients underwent transthoracic esophagomyotomy for achalasia. Patient characteristics are summarized in Table 1. Five patients presented with persistent dysphagia after esophagomyotomy elsewhere. One patient underwent both initial and redo myotomy at MGH. Dysphagia was present in all patients, and regurgitation and weight loss were both common symptoms. Twenty-two of 64 patients (34%) complained of symptoms suggestive of aspiration such as nocturnal cough and sputum production, 4 had been diagnosed with aspiration pneumonia, and 1 underwent myotomy after esophageal perforation due to pneumatic dilation. Twelve patients were found to have a sigmoid esophagus on barium swallow studies and 3 of these had a previous myotomy.
Fifty patients underwent myotomy alone, and 15 had myotomy with fundoplication. Thirteen had standard or modified Belsey fundoplication, 1 underwent a Hill procedure, and 1 patient had an unnamed fundoplication. Two patients had resection of an esophageal diverticulum. Four of 6 patients undergoing redo myotomy had a fundoplication. Intraoperative mucosal perforation in 4 cases was repaired without complication. One other patient was found to have an esophageal leak 7 days after operation and underwent operative repair. Seven patients were treated for postoperative pneumonia. There was no hospital mortality. One patient had an adenocarcinoma of the esophagus 8 years after myotomy and died 7 months after the diagnosis.
Follow-Up
At least 6 months of follow-up ("short term") was obtained in 56 of 64 patients (87%). Follow-up in 52 patients (81%) was available for more than 1 year ("long term"). Thirty-one patients were followed for more than 10 years after operation. Mean follow-up was 12.5 (± 8.4) years. Functional results and patient satisfaction deteriorated over time (Table 2, Fig 1). Ninety-three percent of patients (51 of 56) had good or excellent results less than 6 months after the operation, but only 63% (33 of 52) in the long term (p < 0.001). Recurrent dysphagia was the most common complaint: more than half of patients (29 of 52) reported at least mild dysphagia during long-term follow-up, and more than a third had moderate or severe dysphagia (19 of 52). Heartburn (38%) and at least occasional regurgitation (25%) were also frequently reported.
Among 52 patients with long-term follow-up, 14 had an antireflux procedure. Length of mean follow-up was comparable: myotomy only 11.5 (1 to 27) years, myotomy plus fundoplication 11.0 (1.5 to 32) years. The long-term functional results were similar with and without fundoplication (Fig 2, p > 0.05). Fewer patients with fundoplication complained of reflux symptoms (4 of 14, 28%) compared with myotomy alone (16 of 38, 42%), whereas the proportion of patients with late dysphagia was the same (myotomy alone 37%, myotomy plus fundoplication 36%; Table 3). Of 8 patients with standard Belsey, the long-term result was excellent in 3, good in 1, fair in 2, and poor in 2, with 1 reoperation. Of 5 patients with modified Belsey, the result was good in 3 and poor in 1, with 1 reoperation. A Hill procedure in 1 had an excellent outcome, and an unnamed fundoplication a good long-term result.
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Fig 2. Comparison of long-term functional results in patients with and without antireflux procedure. (Shaded bars = myotomy alone; open bars = myotomy plus fundoplication.)
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Table 3. Long-Term Results and Symptoms After Myotomy Only or Myotomy Plus Fundoplication (Excluding Redo Myotomy)
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Patients with early or late poor functional results underwent further evaluation. After myotomy alone, 4 patients had poor results: 1 underwent reoperation at 6 months for dysphagia due to incomplete myotomy, and 1 underwent colon interposition at 3 months for poor esophageal emptying and dysphagia; the other 2 were treated with dilatation. After myotomy and fundoplication, 3 patients had poor results: 1 required esophagectomy at 5 months; the other 2 had esophageal stricture after redo myotomy (14%), 1 requiring esophagectomy 22 years after second myotomy. Strictures were confirmed by endoscopy.
Sigmoid Esophagus
Twelve of 64 patients (19%) were found to have a sigmoid esophagus (Table 4). Nine underwent myotomy alone, and 3 had fundoplication. An esophageal diverticulum was resected in 1 patient. Compared with patients without sigmoid esophagus, this group had a longer duration of symptoms (mean 11.6 ± 9.1 versus 5.9 ± 8.6 years). Long-term functional results were similar to those without sigmoid esophagus (Fig 3). Four patients required dilatation after operation. Poor results in 2 patients were associated with a stricture in 1.
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Fig 3. Long-term functional results of patients with and without sigmoid esophagus. (Shaded bars = nonsignoid esophagus; open bars = sigmoid esophagus.)
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Multivariable Analysis
Recurrence of dysphagia within 6 months of the operation was the only predictor reaching statistical significance, whereas sigmoid esophagus, fundoplication, and early occurrence of reflux symptoms after operation were not significant.
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Comment
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We report one of the largest cohorts of patients who underwent surgical therapy for achalasia with a follow-up of more than 10 years. Overall, 93% of patients had good or excellent swallowing early after operation, similar to the satisfaction achieved in reported series of both transthoracic [6, 7] and laparoscopic Heller myotomy [8–10]. Late after myotomy, swallowing deteriorated owing to obstruction, although most patients (87%), classified as either excellent, good, or fair, remained improved at last follow-up. This outcome is also comparable with that of series reporting more than 10 years of follow-up [3, 4]. The limitation of our study consists of providing single-point, rather than longitudinal, follow-up in most patients and observing loss to follow-up of 19%. While a systematic functional evaluation late after myotomy is desirable, we believe that the goal of the operation, palliation of swallowing, may be adequately judged by a dispassionate interview.
This series, to which 10 different surgeons contributed, is also an evaluation of a low-volume procedure. On average, two myotomies were performed each year. There were few reoperations: 3 patients required eventual esophagectomy after failed myotomy and 1 needed redo myotomy. Such results do not favor esophagectomy as the initial surgical therapy for achalasia, even if the true rate was underestimated owing to loss of follow-up. We also found no reason to resect sigmoid esophagus on principle. In labeling this condition as "end-stage," some advocate to replace the esophagus with either colon or stomach as primary treatment, believing that Heller myotomy alone would not improve dysphagia [5, 11]. Yet all three conduits lack propulsive peristalsis. Success in any of these options depends on swallowing propelled by gravity alone— not enough, we believe, to accept a greater operative risk and give up on an acceptable conduit. Rather than a terminal stage, sigmoid esophagus as shown in our and at least one other study [12] reflects a longer duration of symptoms. We and others have shown that more than 90% of patients rate swallowing as satisfactory in the short term. And no definitive evidence supports esophagectomy as superior to myotomy in long-term result of sigmoid esophagus. Of our patients, 54% had good to excellent results and 82% noted overall improvement—a functional result similar to those without sigmoid esophagus. Esophagomyotomy is an effective first-line treatment for sigmoid esophagus.
The addition of an antireflux procedure formed a major controversy in the two long-term studies by Ellis and associates [3] and Malthaner and colleagues [4]. Although a 360-degree fundoplication is avoided by most [13], several authors reported that a partial fundoplication reduces heartburn [14, 15] and asymptomatic acid reflux [16] without increasing early dysphagia. Malthaner and associates [4] postulated that reflux disease resulted in late recurrence of dysphagia and eventual failure of myotomy. Heartburn was a common late symptom in our study. Malthaner and associates [4] noted a rise in reflux symptoms from 37% at 5 years to 78% at 20 years, suggesting that these symptoms spell a time-dependent deterioration of reflux protection.
Although fundoplication seemed to reduce the incidence of late reflux symptoms (28% versus 42%) in our series, late recurrence of moderate to severe dysphagia was not decreased (36% versus 37%; Table 4). Similar proportions of patients with and without fundoplication reported good to excellent results in long-term follow-up (Fig 2). In our multivariable analysis, fundoplication was not a significant predictor of outcome. Moreover, fundoplication did not seem to prevent the late disabling effect of reflux disease, as severe esophagitis and stricture developed in 2 patients in each group.
The accumulated rate of esophagectomy after primary esophagomyotomy and fundoplication in Malthaner's report, 29%, raises the question whether the extended myotomy typically employed before fundoplication creates a defect that later favors reflux. Therefore, the addition of fundoplication may carry some risk and should be considered in the presence of a hiatal hernia or when circumferential dissection of the hiatus is obligatory as for a redo myotomy.
Larger prospective studies are needed to further evaluate the role of fundoplication in treating achalasia and the etiology of late recurrence of dysphagia. The deterioration of long-term results creates a group of patients in need of medical management and endoscopic intervention to extend palliation achieved by myotomy.
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References
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Abstract
Introduction
