ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2010;89:392-396. doi:10.1016/j.athoracsur.2009.10.046
© 2010 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Christian J. Finley
Joanne Clifton
John Yee
Richard Finley
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Finley, C. J.
Right arrow Articles by Finley, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Finley, C. J.
Right arrow Articles by Finley, R.
Related Collections
Right arrow Esophagus - other

Original Articles: General Thoracic

Factors Associated With Postoperative Symptoms After Laparoscopic Heller Myotomy

Christian J. Finley, MDa,*, Jennifer Kondra, MSb, Joanne Clifton, MSb, John Yee, MD, FRCSCb, Richard Finley, MD, FRCSCb

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).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
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.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Idiopathic esophageal achalasia is a primary motility disorder of the esophagus of unknown etiology. The underlying pathophysiology appears to be a loss of ganglion cells in the esophagus resulting in absence of peristalsis of the esophageal body, failure of the lower esophageal sphincter (LES) to relax with swallowing and normal or elevated resting LES pressures. A functional obstruction at the level of the lower esophageal sphincter results in progressive dysphagia for liquids and solids. Without adequate treatment, regurgitation, aspiration, and weight loss develop. Presently, all forms of treatment are directed at relieving the functional obstruction at the level of the lower esophageal sphincter by poisoning or disrupting the muscles contributing to the high pressure zone. These therapeutic interventions include botulinum toxin injection, pneumatic dilation, and Heller esophageal myotomy of the lower esophageal sphincter. The symptoms of dysphagia, heartburn, and regurgitation are commonly experienced by patients with achalasia. In this paper, heartburn is defined as a painful burning sensation in the chest. All these symptoms are frequently alleviated with a Heller myotomy, which is superior to pneumatic dilation [1]. Although botulinum toxin injection has shown some benefit, it frequently does not provide long-term symptomatic relief [2]. Both the open and laparoscopic techniques for Heller esophageal myotomy have been shown to have long-term benefit [3–5].

Because the lower esophageal sphincter is the primary barrier to gastroesophageal reflux, disruption places the patient at risk for pathological gastroesophageal reflux. Treatment of patients with achalasia must strike a balance between the relief of dysphagia and the potential creation of pathological gastroesophageal reflux. The efficacy of antireflux procedures in protecting against reflux after esophageal Heller myotomy is controversial. Opponents believe that fundoplication causes a functional obstruction to an already aperistaltic esophagus. Total Nissen fundoplication after myotomy resulted in a 30% reoperation rate for dysphagia [6]. The proponents of an antireflux fundoplication procedure cite a relatively high rate of subsequent gastroesophageal reflux after myotomy alone [7, 8], as well as the protective effect against esophageal leaks. In a randomized controlled trial, Richards and colleagues [7] showed that Heller myotomy plus Dor anterior fundoplication was superior to Heller myotomy alone in reducing postoperative esophageal acid exposure.

Most studies suggest that Heller myotomy can be performed safely and effectively after botulinum toxin injection and dilation [9–12]. However, there is some debate whether preoperative treatment with dilation and botulinum toxin injection makes a Heller myotomy technically more challenging with inferior results. Some believe that pneumatic dilation does not appreciably affect these results [9, 12]. In one small series, however, mucosal perforation rate for Heller myotomy after dilation was 30% [13]. In a larger series, Patti and associates [3] found anatomic planes were affected by dilation, and even more so in patients who responded to botulinum toxin injection. That resulted in perforation rates of 5% and 50%, respectively, and worse symptomatic results with effective botulinum injection [9]. In another paper, anatomic planes were affected in 53% of cases after effective botulinum toxin injection, resulting in a 13.3% perforation rate [11].

To date, little information exists on the effect of preoperative therapies and their influence on the outcomes of heartburn, regurgitation, and dysphagia in the long term. Hence, the primary objective of this study is to examine the preoperative and operative factors influencing early and late postoperative heartburn, regurgitation, and dysphagia.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
From 1994 to 2008, 261 patients at the Vancouver Hospital and Health Sciences Center undergoing laparoscopic esophageal myotomy for achalasia were enrolled prospectively. The diagnosis of classic achalasia was made on the basis of clinical history, barium swallow, upper gastrointestinal endoscopy, and manometry. All patients had aperistalsis of the body of the esophagus and failure of relaxation of the lower esophageal sphincter. Exclusion criteria included age less than 18 years, pregnancy, and previous surgical treatment of achalasia or a hiatus hernia. A questionnaire regarding symptom severity, duration, and history of therapy for achalasia was completed by the physician for each patient included in the study. This information was obtained both preoperatively and at each postoperative visit. Demographic information was obtained from the patient's clinical chart.

Patients' symptom severity was ranked and subdivided into four classes as proposed by Van Trappen and Helman [8]: class 1, no symptoms; class 2, symptom occurring less than once a week; class 3, symptom occurring more than once weekly; and class 4, persistent symptom. The symptoms analyzed include dysphagia, heartburn, and regurgitation. To analyze the proportion of patients who were symptomatic, a Van Trappen score of 2 or more was considered significant and considered to be positive in analysis. In this study, early follow-up was defined as occurring within 1 year (or the closest available follow-up) of the procedure and late follow-up, more than 1 year.

This study was approved by the Ethics Review Board of Vancouver Hospital and Health Sciences Center and the University of British Columbia.

The techniques of laparoscopic Heller myotomy with and without fundoplication were described in a previous paper [14] and were consistent throughout the study. The surgeon used a Dor anterior fundoplication in the first half of the study and no fundoplication in the second half of the study, as a change in practice pattern.

Statistical Analysis
Means and standard deviations were calculated for demographic data. A {chi}2 statistic was calculated for nonparametric data. Change in preoperative Van Trappen score to the early and late follow-up was performed using a paired Student t tests. Continuous variables were analyzed using a Student t test.

For exploratory purposes, univariate logistic regression was performed to evaluate the single variable effect of botulinum toxin injection, esophageal dilation, and anterior fundoplication on the primary outcomes of early and late dysphagia, heartburn, and regurgitation. These will be reported as odds ratios (OR). After univariate analysis, a backward multiple logistic regression was performed examining the effect of botulinum toxin injection, esophageal dilation, and anterior fundoplication on dysphagia, heartburn, and regurgitation in the early and later follow-up period, while controlling for age and sex. Statistical significance used, for all calculations, was p less than 0.05.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
There was no significant difference in preoperative demographics, symptom severity, duration and proportion of patients with symptoms in the early and late follow-up groups as shown in Table 1. Preoperatively, patients had mean Van Trappen scores for dysphagia, heartburn, and regurgitation of 3.9 ± 0.5, 2.1 ± 1.2, and 3.5 ± 1.0, respectively.


View this table:
[in this window]
[in a new window]

  		Table 1 Preoperative Demographic Data for the Early and Late Follow-Up Groups
 
All patients had successful laparoscopic Heller myotomy without open conversion and no perioperative deaths. One hundred and thirty-four patients (51.3%) received a Dor anterior fundoplication, and all other patients received no fundoplication. Major complications, intraoperatively, include 2 perforations (0.8%), which were closed at the time of the operation, 1 pneumothorax requiring a chest tube (0.4%), and 3 other minor complications (1.2%). Both perforations occurred in patients who received medication but no other form of therapy before their laparoscopic Heller myotomy. One patient with a perforation also received a Dor anterior fundoplication.

The mean length of stay was 2.4 ± 2.0 days. There were no major postoperative complications. Minor postoperative complications included wound infection 0.9%, pneumothorax 3.6%, pneumonia 0.9%, pleural effusion 0.9%, and atelectasis 3.2%.

Postoperatively, 261 patients were available for early follow-up (median months to follow-up, 1.4; range, 0 to 12.7). Of those, late follow-up was available on 165 patients (median months to follow-up, 36.4; range, 14.2 to 142.5). Eleven patients only had follow-up available for the early period as they had their procedure within 1 year of analysis. Table 2 displays the early and late symptom frequency and percentage of patients suffering from symptoms, by follow-up group.


View this table:
[in this window]
[in a new window]

  		Table 2 Symptom Frequency in Preoperative, Early, and Late Follow-Up Groups
 
Mean Van Trappen scores, as shown in Figure 1, in the early postoperative group were as follows: dysphagia 1.2 ± 0.6 (versus preoperative scores of 3.9 ± 0.5, t = 57.64, p < 0.001); heartburn 1.4 ± 0.7 (versus preoperative scores 2.1 ± 1.2, t = 8.69, p < 0.001); and regurgitation 1.1 ± 0.4 (versus preoperative scores 3.5 ± 1.0, t = 31.298, p < 0.001) . Mean Van Trappen scores in the late postoperative group were as follows: dysphagia 1.5 ± 0.8 (versus early scores 1.2 ± 0.6: t = –5.297, p < 0.001); heartburn 1.7 ± 0.9 (versus early scores 1.4 ± 0.7: t = –3.16, p = 0.002); and regurgitation 1.3 ± 0.6 (versus early scores 1.1 ± 0.4: t = –3.57, p < 0.001).


Figure 1
View larger version (26K):
[in this window]
[in a new window]

  		Fig 1. Mean Van Trappen scores for dysphagia (black bars), regurgitation (light gray bars), and heartburn (dark gray bars) in the preoperative, early postoperative, and late postoperative groups.

 
Univariate analysis (Table 3) showed a significant increase in early dysphagia rate between patients with a fundoplication and patients without (OR = 2.7, F = 9.654, p = 0.002), and a trend toward significance for patients with preoperative botulinum toxin (OR = 2.5, F = 3.838, p = 0.051). Univariate analysis also showed a significant increase of late dysphagia among patients who had preoperative botulinum toxin (OR = 5.1, F = 9.676, p = 0.002) and a trend toward less late regurgitation among patients who underwent preoperative dilations (OR = 0.9, F = 3.793, p = 0.053).


View this table:
[in this window]
[in a new window]

  		Table 3 Results of Univariate Regression on Outcomes of Early and Late Dysphagia, Regurgitation, and Heartburn
 
On multivariate regression controlling for age and sex, preoperative dilation (p = 0.031), injection of botulinum toxin (p = 0.044), and an anterior fundoplication (p = 0.005) were associated with significantly worse early postoperative dysphagia, with ORs of 2.119, 2.558, and 2.801, respectively.

On multivariate regression controlling for age and sex, previous botulinum toxin injection was associated with significantly worse late postoperative dysphagia (p = 0.001), regurgitation (p = 0.031), and heartburn (p = 0.049), with ORs of 5.236, 2.874, and 2.519, respectively. There was a trend for no fundoplication to be associated with late postoperative heartburn (p = 0.077) with an OR of 1.798.

In the postoperative period, 3 patients required reoperation and takedown of their fundoplication for relief of dysphagia, and 2 patients required balloon dilation of the esophagogastric junction for dysphagia relief.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
This study demonstrates that Heller myotomy is an effective treatment for classic achalasia, resulting in symptomatic improvement for the majority of patients with short length of stays and low morbidity rates. Furthermore, the operation can be performed after dilation and botulinum toxin injection without increased risk or perforation, which is different from previous reports [9, 11, 13]. Clinically, the average improvement in symptoms can be contextualized for the average patient's dysphagia as a change in symptom score from "persistent" to "less than once a week." This paper differs slightly from our previous analysis, since in this paper we defined any symptoms, even those occurring less than once a week as being significant.

In early follow-up, all three therapies of interest affected the early postoperative results. These findings are consistent with other papers that showed less symptomatic improvement in patients who received preoperative botulinum toxin injections or dilations [9, 11], in particular, that botulinum toxin has the most significant effect on early outcomes [3, 9]. Moreover, the early results are consistent with our own previous experience that anterior fundoplication does decrease esophageal clearance and increase dysphagia after Heller myotomy [14].

Most researchers have shown that botulinum toxin has a worse effect on the planes, resulting in fibrosis, which makes the operation technically more challenging [3, 9, 11, 13]. In our study, we have shown that it is the single most influential factor in long-term results, causing significantly worse dysphagia, heartburn, and regurgitation. The scope of this issue is emphasized by knowing that 50% of patients presented for surgery already have received some form of therapy affecting their long-term results. The low morbidity of the operation versus only temporary relief offered by botulinum toxin injection [2] and the increased risk of pneumatic dilation [1] suggests that the clinician should choose a laparoscopic Heller myotomy as the primary treatment for achalasia and that the other two modalities should only be used for patients who cannot tolerate an operation.

This study does have some limitations. Firstly, as only 165, or 59%, of patients were available in the late follow-up group, the results should be interpreted carefully. Were the patients missing to follow-up because of worse results? Or better? However, looking at Table 2, the results suggest that not only are the late follow-up patients proportionally representative in preoperative and intraoperative therapy, they are also similar in their preoperative and early postoperative symptoms. For this reason, we believe that the results are valid. Secondly, the questionnaires were given to the patients by the surgeon performing the operation. That could introduce some bias; however, it also ensures standardization of questions that are clinically relevant and contextualized. Overall, we are confident that this bias did not affect our results.

In conclusion, laparoscopic Heller myotomy remains a durable and well-tolerated operation for classic achalasia. Many patients presenting for Heller myotomy have previously undergone some other treatment. Early postoperative dysphagia was affected by dilation, botulinum toxin injection, and fundoplication. During the late period, botulinum toxin injection was associated with significantly more dysphagia, regurgitation, and heartburn.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Csendes A, Velasco N, Braghetto I, Henriquez A. A prospective randomized study comparing forceful dilatation and esophagomyotomy in patients with achalasia of the esophagus Gastroenterology 1981;80:789-795.[Medline]
  2. Pasricha P, Rai R, Ravich W, Hendrix T, Kalloo A. Botulism toxin for achalasia: long-term outcome and predictors of response Gastroenterology 1996;110:1410-1415.[Medline]
  3. Patti MG, Pellegrini CA, Horgan S, et al. Minimally invasive surgery for achalasia: an 8-year experience with 168 patients Ann Surg 1999;230:587-594.[Medline]
  4. Malthaner RA, Tood TR, Miller L, Pearson FG. Long-term results in surgically managed esophageal achalasia Ann Thorac Surg 1994;58:1343-1347.[Abstract/Free Full Text]
  5. Bonavina L, Nosadini A, Bardini R, Baessato M, Peracchia A. Primary treatment of esophageal achalasia. Long-term results of myotomy and Dor fundoplication. Arch Surg 1992;127:222-227.[Abstract/Free Full Text]
  6. Topart P, Deschamps C, Taillefer R, et al. Long-term effect of total fundoplication on the myotomized esophagus Ann Thorac Surg 1992;54:1046-1051.[Abstract/Free Full Text]
  7. Richards WO, Torquati A, Holzman, MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial Ann Surg 2004;240:405-415.[Medline]
  8. Van Trappen G, Hellemans J. Treatment of achalasia and related motor disorders Gastroenterology 1980;79:144-154.[Medline]
  9. Patti MG, Feo CV, Arcerito M, et al. Effects of previous treatment on results of laparoscopic Heller myotomy for achalasia Dig Dis Sci 1999;44:2270-2276.[Medline]
  10. Ponce J, Juan M, Garrigues V, Pascual S, Berenguer J. Efficacy and safety of cardiomyotomy in patients with achalasia after failure of pneumatic dilation Dig Dis Sci 1999;44:2277-2282.[Medline]
  11. Horgan S, Hudda K, Eubanks T, McAllister J, Pellegrini C. Does Botulinum toxin injection make esophagomyotomy a more difficult operation? Surg Endosc 1999;13:576-579.[Medline]
  12. Ferguson M, Reeder L, Olak J. Results of myotomy and partial fundoplication after pneumatic dilation for achalasia Ann Thorac Surg 1996;62:327-330.[Abstract/Free Full Text]
  13. Beckingham IJ, Callanan M, Louw JA, Bornman PC. Laparoscopic cardiomyotomy for achalasia after failed balloon dilatation Surg Endosc 1999;13:493-496.[Medline]
  14. Finley CJ, Clifton J, Yee J, Finley RJ. Anterior fundoplication decreases esophageal clearance in patients undergoing Heller myotomy for achalasia Surg Endosc 2007;21:2178-2182.[Medline]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
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]

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

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Christian J. Finley
Joanne Clifton
John Yee
Richard Finley
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Finley, C. J.
Right arrow Articles by Finley, R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Finley, C. J.
Right arrow Articles by Finley, R.
Related Collections
Right arrow Esophagus - other

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS