Very Late Results of Esophagomyotomy for Patients With Achalasia

Department of Surgery, University Hospital, Santiago, Chile.
Annals of Surgery (Impact Factor: 8.33). 02/2006; 243(2):196-203. DOI: 10.1097/01.sla.0000197469.12632.e0
Source: PubMed

ABSTRACT Laparoscopic esophagomyotomy is the preferred approach to patients with achalasia of the esophagus, However, there are very few long-term follow-up studies (>10 years) in these patients.
To perform a very late subjective and objective follow-up in a group of 67 patients submitted to esophagomyotomy plus a partial antireflux surgery (Dor's technique).
In a prospective study that lasted 30 years, 67 patients submitted to surgery were divided into 3 groups: group I followed for 80 to 119 months (15 patients); group II, with follow-up of 120 to 239 months (35 patients); and group III, with follow-up more than 240 months (17 patients). They were submitted to clinical questionnaire, endoscopic evaluation, histologic analysis, radiologic studies, manometric determinations, and 24-hour pH studies late after surgery.
Three patients developed a squamous cell esophageal carcinoma 5, 7, and 15 years after surgery. At the late follow-up, Visick III and IV were seen in 7%, 23%, and 35%, according to the length of follow-up of each group. Endoscopic examination revealed a progressive nonsignificant deterioration of esophageal mucosa, histologic analysis distal to squamous-columnar junction showed a significant decrease of fundic mucosa in patients of group III, with increase of intestinal metaplasia, although not significant time. Lower esophageal sphincter showed a significant decrease of resting pressure 1 year after surgery, which remained similar at the late control. There was no return to peristaltic activity. Acid reflux measured by 24-hour pH studies revealed a progressive increase, and the follow-up was longer. Nine patients developed Barrett esophagus: 6 of them a short-segment and 3 a long-segment Barrett esophagus. Final clinical results in all 67 patients demonstrated excellent or good results in 73% of the cases, development of epidermoid carcinoma in 4.5%, and failures in 22.4% of the patients, mainly due to reflux esophagitis. Incomplete myotomy was seen in only 1 case.
In patients with achalasia submitted to esophagomyotomy and Dor's antireflux procedure, there is a progressive clinical deterioration of initially good results if a very long follow-up is performed (23 years after surgery), mainly due to an increase in pathologic acid reflux disease and the development of short- or long-segment Barrett esophagus.

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    • "Very long-term followup by Csendes et al. shows that failure rates after surgical treatment for achalasia are 7% after 10 years and 35% after 30 years of followup. The authors of this report conclude that this may be due to a progressive increase in esophageal exposure to abnormal gastric reflux, which they demonstrated using pH-metry [31]. "
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    ABSTRACT: Achalasia is an esophagealmotility disorder that leads to dysphagia, chest pain, and weight loss. Its diagnosis is clinically suspected and is confirmed with esophageal manometry. Although pneumatic dilation has a role in the treatment of patients with achalasia, laparoscopic Hellermyotomy is considered bymany experts as the best treatment modality formost patients with newly diagnosed achalasia. This review will focus on the surgical treatment of achalasia, with special emphasis on laparoscopic Heller myotomy.We will also present a brief discussion of the evaluation of patients with persistent or recurrent symptoms after surgical treatment for achalasia and emerging technologies such as LESS, robot-assisted myotomy, and POEM.
    Gastroenterology Research and Practice 10/2013; 2013(2). DOI:10.1155/2013/708327 · 1.75 Impact Factor
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    • "The addition of an incomplete fundoplication decreases, but does not eliminate, the complications of GERD.40 A recent study by Csendes et al,46 illustrates the potential for GERD complications, especially among patients followed for over 10 years. This study reported on 67 patients with Heller myotomy and Dor fundoplication after open laparotomy with a mean follow up of nearly 16 years (range 6.6%-30 years). "
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    ABSTRACT: Achalasia is an esophageal motility disorder of unknown cause, characterized by aperistalsis of the esophageal body and impaired lower esophageal sphincter relaxation. Patients present at all ages, primarily with dysphagia for solids/liquids and bland regurgitation. The diagnosis is suggested by barium esophagram and confirmed by esophageal manometry. Achalasia cannot be cured. Instead, our goal is to relieve symptoms, improve esophageal emptying and prevent the development of megaesophagus. The most successful therapies are pneumatic dilation and surgical myotomy. The overall success rate of graded pneumatic dilation is 78%, with women and older patients responding best. Laparoscopic myotomy, usually combined with a partial fundoplication, has an overall success rate of 87%. Young patients, especially men, are the best candidates for surgical myotomy. Botulinum toxin injection into the lower esophageal sphincter and smooth muscle relaxants are usually reserved for older patients or those with co-morbid illness. The prognosis for achalasia patients to return to near normal swallowing is good, but the disease is rarely "cured" with a single procedure and intermittent touch-up procedures may be required.
    Journal of neurogastroenterology and motility 07/2010; 16(3):232-42. DOI:10.5056/jnm.2010.16.3.232 · 2.30 Impact Factor
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    ABSTRACT: Achalasia is a motility disorder in which peristalsis is decreased in the body of the esophagus and the distal esophageal sphincter fails to relax properly during swallowing. The combination results in progressive inability to swallow. Early in the disease process, lower esophageal hypertrophy and failure to relax dominate the clinical picture, and hence the initial treatment is directed at this location. Various methods have been employed to disable or weaken the sphincter mechanism. Surgical therapy is employed when medical therapy or pneumatic dilatation are ineffective. This chapter explores alternatives in surgical therapy of uncomplicated achalasia. Chapter 15 discusses fundoplication as an adjunct to laparoscopic myotomy.
    Review of surgery 27(4):298-9. DOI:10.1007/978-0-387-76671-3_14
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