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


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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Available from: Italo Braghetto, Dec 06, 2015
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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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    • "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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