Very Late Results of Esophagomyotomy for Patients With Achalasia

ArticleinAnnals of Surgery 243(2):196-203 · February 2006with18 Reads
Impact Factor: 8.33 · 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.

Full-text

Available from: Italo Braghetto, Dec 06, 2015
Very Late Results of Esophagomyotomy for Patients
With Achalasia
Clinical, Endoscopic, Histologic, Manometric, and Acid Reflux Studies
in 67 Patients for a Mean Follow-up of 190 Months
Attila Csendes, MD, Italo Braghetto, MD, Patricio Burdiles, MD, Owen Korn, MD,
Paula Csendes, MD, and Ana Henrı´quez, MD
Introduction: Laparoscopic esophagomyotomy is the preferred ap-
proach to patients with achalasia of the esophagus, However, there
are very few long-term follow-up studies (10 years) in these
patients.
Objective: To perform a very late subjective and objective fol-
low-up in a group of 67 patients submitted to esophagomyotomy
plus a partial antireflux surgery (Dor’s technique).
Material and Methods: 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.
Results: 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.
Conclusion: In patients with achalasia submitted to esophagomyo-
tomy 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.
A
chalasia is a primary motor disorder characterized by a
hypertensive lower esophageal sphincter, which fails
to relax completely after swallowing and by aperistalsis
of the thoracic esophagus,
1– 4
due to a loss of Auerbach’s
plexuses.
3,4
As there is no medical or surgical cure for this
disease, all treatments are directed to obtain a good esopha-
geal emptying into the stomach by disrupting this hyperten-
sive lower esophageal sphincter. Surgical approach seems to
have much better long-term results than pneumatic dilata-
tion
5–9
and is the preferred treatment at this moment, due to
the fact that it can be performed by laparoscopic instead of
laparotomic approach.
10 –14
There are many reports concern-
ing results of open
15–20
or laparoscopic
10
esophagomyotomy
(up to 5 years), with near 90% of satisfactory results. How-
ever, only very few papers have evaluated by a long-term
follow-up (over 10 years) the final results, concerning to the
presence of gastroesophageal reflux and the appearance of
esophageal carcinoma.
The purpose of the present prospective study was to
perform a very late subjective and objective evaluation of a
group of 67 patients submitted to esophagomyotomy plus a
partial antireflux procedure.
MATERIALS AND METHODS
Patients Studied
The present prospective study started on March 1972,
when a prospective randomized study was designed to com-
pare surgery versus dilatation.
5,6
The end of the follow-up
From the Department of Surgery, University Hospital, Santiago, Chile.
Reprints: Attila Csendes, FACS, Department of Surgery, Clinical Hospital
University of Chile, Santos Dumont #999, Santiago, Chile. E-mail:
acsendes@machi.med.uchile.cl.
Page 1
was December 2002 and therefore is a 30-year prospective
study. A total of 106 patients were included during this period
of time and were operated on by 2 of the authors (A.C., I.B.).
During the follow-up, 25 (23.4%) patients died due to non-
related diseases with a mean age of 72 years at the moment of
their death (range, 30 –97 years). Fourteen patients (19.0%)
were lost from the late control, which means that a total of 67
patients were included in this follow-up (81% of follow-up).
They were divided into 3 groups, according to the length of
follow-up: group I, with 80 to 119 months of follow-up after
surgery (15 patients); group II, with 120 to 239 months
follow-up (35 patients); and group III, with more than 240
months follow-up (17 patients).
In the same period of time, 5 patients were submitted to
esophagectomy due to sigmoid-like achalasia but were not
included in the present investigation.
Clinical Questionnaire
A careful clinical assessment was performed by ques-
tionnaire in each patient before and late after surgery, asking
about the presence of:
1. Heartburn, graded as absent, occasional (less a week), and
frequent (more than once a week).
2. Dysphagia, graded as absent, occasional (once a week or
less), and frequent (more than once a week).
3. Gain or loss of weight, in kilograms, after surgery.
4. They were graded on a scale of 1 to 3 according to the
criteria described by DeMeester’s group.
21
For the late
clinical evaluation, a modified Visick gradation was used
with the following criteria:
1. Visick I asymptomatic.
2. Visick II presence of mild or episodic symptoms;
easily controlled by medical treatment or diet adjust-
ment with no need of permanent medication.
3. Visick III presence of frequent, daily symptoms;
easily controlled by medical treatment or diet adjust-
ment with no need of permanent medication.
4. Visick IV failure of the operation with severe
symptoms, which requires reoperation or produces a
serious metabolic disturbance.
Endoscopic Evaluation
All endoscopic procedures were performed by 2 of us
(A.C. and I.B.) using an Olympus GIF XQ-20 endoscope.
Special care was taken to measure the exact location of the
squamocolumnar junction at the beginning and at the end of
the procedure, avoiding the “push” and “pull” effects of the
endoscope. It was done in all patients before and late after
surgery, at the time of the last control. In the final procedure,
2 biopsy samples were taken from the antrum; and, in all
patients as well as in patients with suspected short-segment
Barrett esophagus (length 29 mm), 4-quadrant biopsy spec-
imens were taken 5 mm distal to the squamocolumnar junc-
tion (juxtacardial biopsies). In patients with suspected long-
segment Barrett esophagus (length 30 mm), 4-quadrant
biopsy specimens were taken every 2 cm from the squamo-
columnar junction until the lower esophageal sphincter. The
presence of a peptic ulcer was carefully determined, as well
as the presence of proximal erosions.
Radiologic Evaluation
A complete upper radiologic study of the GI tract was
performed in all patients before and 1 month after surgery.
No long-term radiographic evaluation was routinely per-
formed. This examination was performed after an overnight
fast, using a low-density barium sulfate suspension (45%
weight in volume). Patients were instructed to drink the
amount of barium that they could tolerate without regurgita-
tion or aspiration (usually between 150 and 200 mL). With
the patient in upright position, 4 radiographs (35 35 cm)
were taken between 1 and 4 minutes after the last swallow of
barium. Then the patient was placed in a supine position and
the other 4 films were taken. Two parameters were evaluated
and measured by an independent radiologist who did not
know the precedence and the name of the patient: 1) internal
diameter of the esophagogastric junction (identified by the
bird’s break appearance of the esophagogastric junction)
measured in millimeters; and 2) internal diameter of the
middle third of the esophagus, approximately at the level of
the bifurcation of the trachea in millimeters.
Histologic Evaluation
All biopsy samples were immediately submerged in a
10% formalin solution and sent for histologic examination.
They were stained with hematoxylin and eosin and Alcian
blue stain at pH 2.5. The type of epithelium lining the distal
esophagus was carefully determined, including the presence
of intestinal metaplasia. Fundic mucosa was identified by the
presence of parietal and chief cells at the deep glandular layer.
Cardiac mucosa was identified by the presence of mucus-
secreting columnar cells. Specialized intestinal metaplasia was
defined by the presence of well-defined goblet cells, confirmed
by positive staining with Alcian blue at pH 2.5.
The presence of Helicobacter pylori was investigated at
the juxtacardial biopsies and at the antrum.
Manometric Studies
Manometric testing was carried out after a 12-hour fast
with the patient in the supine position. The complete details
of this procedure have been fully explained in previous
reports.
22–24
The resting pressure of the lower esophageal
sphincter was measured. The location of the distal and prox-
imal ends of the lower esophageal sphincter was also mea-
sured in centimeters from the incisors to measure the total
length of the sphincter. The percentage of relaxation after
swallowing was also carefully evaluated. The amplitude of
the distal esophageal contractile waves was also determined
in mm Hg. This test was performed in all patients 3 times:
before surgery, 1 year after surgery, and at the late control,
when the last evaluation was performed.
24-Hour Intraesophageal pH Studies
This test was performed after a 12-hour fast,
25,26
intro
-
ducing the catheter through the nose until the stomach was
reached (Digitrapper; Synectics, Sweden). The catheter was
then placed 5 cm above the manometric upper border of the
lower esophageal sphincter (manometry is always done be-
Page 2
fore this procedure). Among the 6 different parameters that
can be evaluated, the most useful and practical is the total
percentage of time during which the intraesophageal pH
remains below 4, being our normal value less than 4% of the
time during a 24-hour period (55 minutes). This test was
carried out in all patients included in the present investigation
at the late control, when the last evaluation was performed.
Statistical Evaluation
For the calculation of statistical significances, the
2
test, the Fisher exact test, and the Mann-Whitney U test were
used, taking a P 0.05 as significant. All statistical calcu-
lations refer to comparison between the groups or within the
groups, according to the specific data.
Surgical Procedure
All operations were performed by the authors at the
Department of Surgery, University Hospital. After laparot-
omy and careful abdominal exploration, the abdominal
esophagus and esophagogastric junction was mobilized.
5– 8
The myotomy was 5 to 6 cm long at the esophagus and was
extended 1 cm onto the gastric wall. Short gastric vessels
were divided to avoid tension on the anterior fundoplication.
An anterior 180° Dor fundoplication was used in all pa-
tients.
5– 8,15
None of these patients was operated on by the
laparoscopic approach.
Follow-up
All patients were carefully followed by the main au-
thors 1 month, 6 months, 1 year, and then each 5 years after
surgery by clinical questionnaire. Manometric studies were
performed in each patient 3 times after surgery, while endos-
copy was done in all at the end of the study and occasionally
before; 24-hour pH studies were done only at the end of the
study.
RESULTS
Clinical Outcome
There was no operative mortality. Two patients (1.9%)
had postoperative fistula, one in June 1973 and other case
operated on October 1983. Both were reoperated and had an
uneventful recovery. There were no other postoperative com-
plications or splenectomy in any of the patients. The usual
hospital stay for 105 uncomplicated patients was 5.4 days
(range, 4 –7 days). Three patients (4.5%) developed an esoph-
ageal carcinoma 5, 7, and 15 years after surgery, which gives
a rate of 1 case per 120 patient/year. These patients were
excluded from the following tables, leaving only 64 patients
for the long-term follow-up. The main clinical features are
shown in Table 1. The gender distribution was similar in all
groups, as well as the presence of heartburn. Dysphagia
increased late after surgery, but without statistical signifi-
cance between the groups. More than 94% of all patients
gained weight after surgery.
Anatomic Studies
Table 2 demonstrates radiologic and endoscopic results
in these patients. Radiologic examinations showed a signifi-
cant increase of the internal diameter of the GE junction and
a significant decrease of the internal diameter of the thoracic
esophagus 1 month after surgery (P 0.001). Endoscopic
examination before surgery showed normal distal esophagus
in all. Late after operation, there was a progressive deterio-
ration of esophageal mucosa with time but without statistical
significance between the groups.
The main histologic findings at the GE junction and the
antrum are shown in Table 3. There was a significant de-
crease in the presence of fundic mucosa in patients of group
III compared with group I. Although an increase was dem-
onstrated in the presence of intestinal metaplasia at the GE
junction and distal esophagus in patients group III compared
with group I, this value did not reach statistical significance.
The presence of Helicobacter pylori was similar in all 3
groups of patients, as well as its presence in the antrum.
Among the 13 patients who had H. pylori at the GE junction,
9 (69.2%) was located in fundic mucosa and 4 (30.8%) in
cardial mucosa. No H. pylori was present in the presence of
intestinal metaplasia.
TABLE 1. Clinical Features of Patients With Achalasia Submitted to
Esophagomyotomy (n 64)
Group I
(n 13)
Group II
(n 34)
Group III
(n 17) P
Sex NS
Male 7 17 7
Female 6 17 10
Follow-up (mo) mean (range) 88 (80–110) 173 (125–216) 281 (241–360)
Heartburn NS
Occasional 3 (23%) 11 (32.3%) 3 (17.6%)
Frequent 1 (7.7%) 2 (5.9%) 5 (29.4%)
Dysphagia NS
Occasional 1 (7.7%) 9 (26.5%) 2 (11.8%)
Frequent 1 (7.7%) 2 (5.9%) 3 (17.6%)
Gain of weight (5 kg) 13 (100%) 33 (97%) 15 (94.1%) NS
Loss of weight (5 kg) 0 1 (3%) 1 (5.9%)
NS indicates not significant between groups.
Csendes et al
Page 3
Physiologic Studies
The manometric features of the lower esophageal
sphincter and of the distal esophageal waves are shown in
Table 4. Before surgery, the resting lower esophageal sphinc-
ter pressure was hypertensive in all groups. One year after
surgery, there was a significant decrease in resting pressure
(P 0.0001). At the late follow-up, sphincter pressure
remained in similar low values, as is seen in Figure 1. The
percentage of relaxation before surgery ranged between 20%
to 70%, with a mean of 40%. Late after surgery, sphincter
relaxation varied between 90% and 100% after swallowing.
The amplitude of the distal esophageal waves increased
significantly late after surgery in all patients, but aperistalsis
remained almost similar. The results of 24-hour pH monitor-
ing at the distal esophagus are shown in Table 5. There was
an increase in the prevalence of acid reflux as the follow-up
of patients increases, which was significant (P 0.05)
comparing patients of group I with group III. A normal acid
reflux test was observed in 69% of all patients. However, this
test was normal in 85% of patients in group I and only in 47%
of patients in group III, as can be seen in Figure 2 (P 0.05).
This table also shows the correlation between normal or
abnormal acid reflux values and the type of mucosa lining the
GE junction and distal esophagus. Among patients with
normal acid reflux, there was a significant decrease of fundic
mucosa and a significant increase in cardiac mucosa as the
follow-up is longer. Three patients of group II values showed
the presence of intestinal metaplasia at the GE junction.
Among patients with abnormal acid reflux values, only car-
diac mucosa or intestinal metaplasia were present at the GE
junction, with only 1 case with fundic mucosa. Fundic mu-
cosa was significantly lower in patients with abnormal reflux
(n 1) compared with those with normal acid reflux (n
20). Intestinal metaplasia was present significantly higher
(4.5%) in patients with abnormal reflux (n 9) compared
with patients with normal reflux (6.8%) (n 3). The corre-
lation with the presence of heartburn and a normal or abnor-
mal acid reflux test was also evaluated. There were 9 patients
who developed a short-segment Barrett esophagus, having
only 6 of them a pathologic acid reflux with a mean value of
17.3%. The 3 patients who developed a long-segment Barrett
esophagus, all had pathologic reflux with a mean value of
24.7%.
Final Results
The final clinical results in all 67 patients submitted to
esophagomyotomy are shown in Table 6. Excellent or good
results were observed in 73% of all patients at a mean
follow-up of 190 months (15.8 years). However, Visick
gradation was lower as the follow-up was longer, but without
statistical significance. Esophageal carcinoma appeared in 3
patients: 2 of them located at the proximal portion of the
esophagus and 1 at the distal portion. All 3 patients had
squamous cell carcinoma. This means a rate of 1 patient per
120 patient/year. All of them were operated, but died 12 to 24
TABLE 3. Histologic Findings Distal to Squamocolumnar
Junction in Patients With Achalasia Submitted to
Esophagomyotomy (Late After Surgery) (n 64)
Group I
(7–10 yr)
(n 13)
Group II
(10–20 yr)
(n 34)
Group III
(>20 yr)
(n 17) P
Type of mucosa
Fundic 8 (61.5%) 11 (32.3%) 2 (11.8%) 0.006
Cardiac 4 (30.8%) 17 (50%) 10 (58.8%) NS
Intestinal metaplasia 1 (7.7%) 6 (17.6%) 5 (29.4%) NS
H. pylori
Juxtacardial 3 (23%) 7 (20.6%) 3 (17.6%) NS
Antrum 6 (46.1%) 12 (35.3%) 6 (35.3%) NS
NS indicates not significant.
TABLE 2. Radiologic and Endoscopic Results in Patients With Achalasia Submitted to Esophagomyotomy (n 64)
Group I (7–10 yr)
(n 13)
Group II (10–20 yr)
(n 34)
Group III (>20 yr)
(n 17) P
Radiology
Mean internal diameter GE junction (mm)
Before operation 2.07 0.5 2.52 0.6 2.3 0.5 0.0001 (before and after
operation in each group)
1 mo after operation 9.35 1.1 10.6 1.8 10.7 1.7
P 0.001 0.001 0.001
Mean internal diameter of middle third
thoracic esophagus (mm)
Before operation 55 10.5 51.9 12 56 11.6 0.0001 (before and after
operation in each group)
1 mo after operation 25.3 5.5 26.8 5 26.7 6.2
P 0.0001 0.0001
Endoscopy
Time after surgery 88 mo 173 mo 281 mo
Normal 11 (84.6%) 26 (76.5%) 9 (52.9%)
Esophagitis 1 (7.7%) 2 (5.9%) 5 (29.4%) NS
Peptic ulcer
Esophagitis 1 (7.7%) 6 (17.6%) 3 (17.6%)
GE indicates gastroesophageal; NS, not significant.
Page 4
months after surgery. Poor or failure results were seen in
22.4% of the patients. It is important to stress that from the 15
patients with poor results, only 1(6.7%) corresponded to a
recurrence due to incomplete myotomy, who was reoperated.
The other 14 patients (92.3%) had some complications re-
lated to severe reflux disease, but only 2 of them were
reoperated performing a total duodenal diversion. The rest of
them (12 patients) are managed with proton pump inhibitors.
DISCUSSION
The results of the present investigation have some
unique features. They represent the longest follow-up ever
reported with the largest number of patients evaluated; endo-
scopic examination was performed in all cases, taking several
biopsies at the GE junction; manometric evaluation of the
lower esophageal sphincter and thoracic esophagus was per-
formed before operation and early and very late after surgery
in the same patient, and 24-hour pH studies were also per-
formed in all patients to objectively measure abnormal acid
reflux into the esophagus.
The results of our study suggest the following: 1) there
is a clinical deterioration of initially good clinical results if a
very long-term follow-up is performed; 2) late failures are
mainly due to an increase in severe pathologic acid reflux; 3)
endoscopic esophagitis increases as well as the presence of
short- or long-segment Barrett esophagus; 4) several impor-
tant histologic changes occur at the mucosa just distal to
squamous columnar epithelium, with decrease of the pres-
ence of fundic mucosa, increase of cardiac mucosa, and
progressive appearance of intestinal metaplasia as the fol-
low-up is longer; 5) there is no change of lower esophageal
sphincter pressure after surgery, remaining in low value
independent of the length of follow-up; and 6) acid reflux
measured by 24-hour pH studies shows a parallel increase of
abnormal reflux as follow-up is longer.
Our surgical technique has not changed over the last 3
decades, and the only difference is that we are performing
this operation by laparoscopic approach since the last 6 years.
However, none of the patients included in the investigation
has a laparoscopic approach. The main surgical principles
are:
1. To perform an anterior esophagomyotomy 5 to 6 cm long,
which should be called properly as Zaaijer’s technique
27
and not a Heller’s procedure,
28
which truly is an anterior
and posterior esophagomyotomy.
2. This myotomy should be prolonged at least 10 mm onto
the stomach, but not more than 20 mm, because severe
reflux may appear in almost all patients.
29
3. To perform an anterior hemifundoplication or Dor’s tech-
nique.
30
The present study suggests that there is a progressive
deterioration of initially 95% good results (at 5 years),
7,15
due
to late development (over 10 years) of disabling reflux dis-
ease. The review of the literature of the last over 20 years has
shown us that there are only 6 studies
31–36
who have reported
clinical results over 10 years of follow-up. Chen et al,
31
from
the group of Dr. Duranceau, reported 32 patients submitted to
anterior esophagomyotomy plus a partial Belsey fundoplica-
tion, followed for 7.2 years, but 16 of them were followed for
7 to 16 years. In this group, heartburn was present in 13% of
FIGURE 1. Lower esophageal sphincter pressure before oper-
ation and 1 year and at late control after surgery.
TABLE 4. Manometric Features of Patients With Achalasia Submitted to Esophagomyotomy (n 64)
Group I (7–10 yr)
(n 13)
Group II (10–20 yr)
(n 34)
Group III (>20 yr)
(n 17) P
Lower esophageal sphincter
pressure (mm Hg)
Before operation 41.8 14 39.7 9.2 45.6 14.8 0.001
1 yr after surgery 9.0 3.8 9.3 4.9 9.3 3.6
Late follow-up 7.1 2.5 8.4 3.2 8.7 2.9 NS
7 yr 16.5 yr 23 yr
Amplitude distal
Esophageal waves (mm Hg)
Before operation 18.6 8 15.2 10.4 20.3 10 0.01
Late follow-up 37.6 20.7 24.5 13.3 34.7 15
Peristaltic waves (%)
Before operation 0 0 2 (11.7%) NS
Late follow-up 2 (15.4%) 0 3 (17.6%)
NS indicates not significant at a late control.
Csendes et al
Page 5
patients at the 3-year follow-up and 19% at 7 to 16 years of
follow-up. Malthauer et al,
32
from the group of Dr. Pearson,
reported a very careful clinical and endoscopic follow-up in
22 patients operated by them with a mean of 10 years of
follow-up. Visick I and II (excellent and good results) were
present in 95% of the patients at 1 year, 77% at 5 years, 68%
at 10 years, and 67% at 20 years or more, which is very close
to our 65% of results at 23 years. They performed mainly
clinical evaluation, while endoscopy was performed in 13
patients. They concluded that there is a deterioration of the
good results due to development of severe reflux disease, but
only if patients are controlled 15 or 20 years after surgery.
Mattioli et al
33
compared 3 groups of patients: a) 83 were
submitted to long abdominal myotomy alone, with a mean
follow-up of 193 months; b) 30 patients were submitted to
thoracic myotomy and followed 137 months; and c) 72
patients had a long abdominal myotomy plus a Dor fundo-
plication, and were followed by for 87 months. Final excel-
lent and good results were seen in only 36% of group a and
44% of group b, while group c had 87% of good results.
Probably these results mainly reflect the differences in the
long-term follow-up (193 versus 87 months) more than the
surgical technique itself. Liu et al
34
reported on 145 patients
submitted to anterior Heller (Zaaijer) myotomy plus a Belsey
antireflux technique compared with myotomy alone. They
concluded that early improvement is seen in 98.4%, while at
the late control clinical improvement is only present in
55.6%, showing a progressive deterioration of the operated
patients with time, due to incomplete myotomy, fused or
healed myotomy, and gastroesophageal reflux. Ellis et al,
from England,
35,36
reported in 2 papers almost the same
patients and results. They followed 57 patients with a long-
term follow-up, including 67% of them for a mean follow-up
of 13.6 years. Excellent and good results were reported on
68% of the patients, a value almost identical to that reported
by Malthauer et al
32
and by us in the present study. The
incidence of clinical reflux reported by them was low (5%),
but no endoscopic evaluation was performed. Finally, Ellis,
36
from the United States, reported 67 patients followed for 10
years. Excellent and good results were seen in 63% while fair
and poor results were present in 37%, similar to our values.
As a conclusion of these publications, we can presume that 20
years after esophagomyotomy plus some partial antireflux
surgery, two thirds to three fourths of patients may have
excellent or good responses, while one third to one fourth
present poor results or failure due mainly to severe reflux
disease. In our study, only 1(1.5%) presented an incomplete
myotomy, while the rest of patients with failure had severe
reflux disease.
Endoscopic studies have been very scarcely reported by
the authors who mention a late follow-up. Chen et al
31
reported that erosive esophagitis was present in no patient at
1 year, while it was seen in 14% 7 to 16 years after surgery.
Barrett esophagus appeared in 1 case. Malthauer et al
32
performed endoscopy in 13 patients from the 22 followed at
late control. In 10 symptomatic patients, 7 had ulcerative
esophagitis and 3 a Barrett esophagus, while among 3 asymp-
tomatic patients, all 3 had erosive esophagitis. Mattioli et al
33
reported erosive esophagitis in 22% of patients followed 193
months and in 10% among patients followed 87 months. No
mention to Barrett esophagus is done. The other authors do
TABLE 5. Acid Exposure to the Distal Esophagus During 24-Hour Intraesophageal pH Monitoring and Type of Mucosa Lining
the Esophagogastric Junction in Patients With Achalasia Submitted to Esophagomyotomy at Late Control (n 64)
Group I (7–10 yr)
(n 13)
Group II (10–20 yr)
(n 34)
Group III (>20 yr)
(n 17) Total P
% of time with pH
4 in 24 hr (mean SD) 3.7 5.7 5.3 8.6 8.2 8.5 I vs. III: 0.05
Median 2.3 2.2 6.5
Normal reflux (n 44) (69%) 11 (85%) 25 (72%) 8 (47%) I vs. III: 0.05
Fundic mucosa 8 (73%) 10 (40%) 2 (25%) 20 (45.4%) I vs. III: 0.05
Cardiac mucosa 3 (27%) 12 (48%) 6 (75%) 21 (47.7%) I vs. III: 0.05
Intestinal metaplasia 0 3 (12%) 0 3 (6.8%) NS
Abnormal reflux (n 20) (31%) 2 (15%) 9 (28%) 9 (53%) I vs. III: 0.05
Fundic mucosa* 0 1 (11%) 0 1 (5%)
Cardiac mucosa 1 (50%) 5 (55%) 4 (44.4%) 10 (50%) NS
Intestinal metaplasia
1 (50%) 3 (33%) 5 (55.6%) 9 (45%) NS
*Fundic mucosa in normal (n 20) or abnormal reflux (n 1): P 0.001.
Intestinal metaplasia in normal (n 3) or abnormal reflux (n 9): P 0.007.
FIGURE 2. Percent of patients with normal or abnormal acid
reflux late after esophagomyotomy for achalasia.
Page 6
not mention endoscopic results. In our present investigation,
we have observed that a normal upper endoscopy was present
in 85% of patients followed for 10 years, a value that
decreased to 76% when the follow-up was 20 years and to
53% when the follow-up was more than 20 years, with
progressive appearance of erosive esophagitis and peptic
ulcer of the esophagus in short or long columnar lined
mucosa of the distal esophagus and Barrett esophagus. In
none of the cited reports is histologic analysis of the mucosa
at the GE junction and presence of Helicobacter pylori
mentioned. Therefore, this is the unique report concerning
this topic.
The present study could be considered as a “clinical
experiment” concerning the development of histologic
changes at the mucosa just distal to squamous-columnar
junction due to the presence of increasing acid reflux, very
similar to what the group of Dr. DeMeester has shown in
patients with GERD.
37
We obviously do not have any biopsy
sample before operation, but it is improbable that severe
histologic abnormalities could be present at that time. The
beginning of progressive histologic changes can be clearly
seen among patients with a short follow-up (10 years after
surgery) in whom fundic mucosa is mainly present, with less
proportion of cardiac mucosa and intestinal metaplasia in
only 7%. As the follow-up is longer, and parallel to the
increase of reflux disease, fundic mucosa is replaced by
cardial mucosa and intestinal metaplasia increases, always in
cardiac mucosa. These histologic findings suggest a progres-
sive metaplastic change from fundic mucosa to cardial mu-
cosa and then to intestinal metaplasia and seem to confirm the
hypothesis of Dr. DeMeester. The reports concerning mea-
surements of lower esophageal sphincter pressure have
shown that, at 5 to 7 years after surgery, a decreased sphincter
pressure is maintained
5,15,16,18
and usually is reduced to an
average of 10 mm Hg.
7,15
None of the authors reporting very
late results after surgery has mentioned measurements of
LES, except the group of Dr. Duranceau
31
who performed
systematic determinations of lower esophageal sphincter
pressure. The mean resting lower esophageal sphincter pres-
sure decreased from 36 mm Hg to 22 and 23 mm Hg at 7 and
16 years of follow-up, which is higher than the value that we
have found in all our patients. However, measuring LES
gradient pressure, they observed a decrease from 29 to 9 to 10
mm Hg. Also, they demonstrated an improvement in sphinc-
ter relaxation, exactly as our results. In our patients (Fig. 1),
resting lower esophageal sphincter pressure decreases signif-
icantly 1 year after surgery, and this pressure (mean, 9 mm
Hg) is maintained stable up to 23 years after surgery, sug-
gesting at least a constant partial barrier against reflux.
Gastroesophageal reflux in the most common and im-
portant complication in patients with achalasia submitted to
esophagomyotomy. Only a few papers have evaluated the
presence of reflux 5 to 7 years after surgery
15,16,18,38
noting
10% to 20% of acid reflux present, measured by objective
evaluation. A classic review
20
of the literature revealed that
postoperative reflux was present in 7.4% of patients who also
had an antireflux procedure compared with 13% of reflux in
patients with esophagomyotomy alone. However, the meth-
ods were different, and few random patients were evaluated
and in different periods of time after surgery (usually in early
periods). From the authors who reported results after 10 years
of follow-up,
31–36
only the group of Dr. Duranceau
31
has
performed systematic pH evaluation. Other authors
32,33
mea
-
sured reflux only by symptoms or endoscopic findings, re-
porting “massive postoperative reflux” or “severe reflux.” On
the contrary, Ellis et al
35,36
reported only 5% of “reflux”
based on clinical grounds. The findings reported by Chen et
al
31
are disturbing; they found 0% of reflux before and in
several controls late after surgery, which suggests complete
absence of reflux despite the decrease of sphincter pressure,
appearance of erosive esophagitis in 14%, and Barrett esoph-
agus in 1 case.
The return or not of peristaltic activity in the thoracic
esophagus has been a matter of debate. Chen et al
31
reported
return of peristalsis in some patients in the proximal esoph-
agus, while the distal esophagus remained aperistaltic. Al-
though some authors have reported return of esophageal
peristalsis after surgery,
39–41
especially among patients with
short clinical evolution and mild esophageal dilatation, in our
very late follow-up, return to partial peristaltic activity was
seen in only 15% of the patients, while the great majority
remained with a complete aperistalsis of the distal esophagus.
CONCLUSION
The present study is the longest follow-up ever reported
in patients with achalasia of the esophagus submitted to
esophagomyotomy and Dor’s anterior fundoplication. Late
evaluation (up to 30 years after surgery) by several objective
parameters (endoscopy, histologic analysis, computerized
TABLE 6. Final Clinical Results in Patients With Achalasia Submitted to Esophagomyotomy (n 67)
Group I (7–10 yr)
(n 15)
Group II (10–20 yr)
(n 35)
Group III (>20 yr)
(n 17) Total
Visick I–II (excellent–good) 12 (80%) 26 (74%) 11 (65%) 49 (73.1%)
Visick III–IV 1 8 6 15 (22.4%)
Esophageal cancer 2 1 0 3 (4.5%)
Causes of failure
BE esophagitis 1 4 4 (1 reop) 9 (13.4%)
Peptic ulcer carditis 3 (1 reop) 2 5 (7.5%)
Recurrence due to incomplete myotomy 1 0 1 (1.5%)
BE indicates Barrett esophagus; reop, reoperation.
Csendes et al
Page 7
manometry, and 24-hour pH study) has shown that 73% of
the patients have excellent or good results, while 4.5%
developed a squamous cell esophageal carcinoma and 21.4%
had poor results or failure, mainly due to the presence of
severe reflux disease, with progressive appearance of erosive
esophagitis and Barrett esophagus with intestinal metaplasia.
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