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.

Abstract

INTRODUCTION:

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.

OBJECTIVE:

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).

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 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.

• Authors: Attila Csendes, Italo Braghetto, Patricio Burdiles, Owen Korn, Paula Csendes, Ana Henríquez
• Journal: Annals of surgery (Ann Surg) Vol. 243 Issue 2 Pg. 196-203 (Feb 2006) ISSN: 0003-4932 [Print] United States
• PMID: 16432352 (Publication Type: Journal Article)

Topics

• Adult
• Aged
• Aged, 80 and over
• Barrett Esophagus (epidemiology)
• Chi-Square Distribution
• Esophageal Achalasia (diagnosis, physiopathology, surgery)
• Esophageal Neoplasms (epidemiology)
• Esophagoscopy
• Female
• Follow-Up Studies
• Gastric Acidity Determination
• Humans
• Male
• Manometry
• Middle Aged
• Postoperative Complications (epidemiology)
• Prospective Studies
• Statistics, Nonparametric
• Surveys and Questionnaires
• Treatment Outcome