Preoperative Endoscopic Treatment for Achalasia Does Not Affect Perioperative Outcomes in Patients Undergoing Laparoscopic Heller Myotomy

Michael J Pucci, Richard A Burkhart, Wei Phin Tan, Alexandra Columbus, Ernest L Rosato, Karen A Chojnacki, Francesco Palazzo

Thomas Jefferson University

Laparoscopic Heller myotomy (LHM) has been proven to provide a safe, effective, and durable treatment for patients with achalasia. Despite good surgical outcomes, many patients continue to be referred for surgical evaluation only after multiple endoscopic interventions have failed. It remains unclear whether prior endoscopic treatments render the surgical myotomy more complex and increase procedure-related risks. Herein, we review our experience with LHM, focusing on prior endoscopic interventions and their effect on perioperative outcomes.

We performed a retrospective review of patients who underwent LHM for achalasia from August 2002 – August 2012 at a single high-volume center. Patients were stratified into groups based on preoperative endoscopic management (pneumatic dilation, botulinum toxin injection, both, or none). Operative notes and perioperative outcomes were analyzed. Categorical variables were compared using Fischer exact testing. Continuous variables were evaluated using Wilcoxon rank-sum testing.

A total of 160 patients underwent LHM during the study period. While the vast majority of patients underwent preoperative endoscopic therapy (125 patients, 78%), the groups were well matched. There was no difference in recognized intraoperative mucosal injury, postoperative complications, or subjective perioperative outcomes. There was a trend towards shorter operative times in patient who underwent both endoscopic interventions preoperatively. There were no differences in return to the operating room, hospital length of stay, or readmission rates between the groups (See Table 1).

In our experience, preoperative endoscopic interventions do not affect intraoperative esophageal mucosal injury or perioperative complication rates. LHM remains a safe procedure in the face of prior endoscopic therapies of the lower esophageal sphincter.

Table 1.

No intervention
(n=35, 22%)
Pneumatic dilations only
(n = 17, 11%)
Botox only
(n = 70, 43%)
Both interventions
(n = 38, 24%)
Age (years), median (range)51 (21-83)53 (30-80)52 (10-85)56 (24-90) NS
Female gender, number (%)16 (46%)3 (18%)37 (53%)21 (55%)<0.01
Pre-operative characteristics
LES pressure, median (range)50 (11-94)36 (7-61)45 (6-91)36 (10-65)NS
Impaired sphincter relaxation, n (%)6 (17%)3 (18%)10 (14%)3 (8%)NS
Aperistalsis, n (%)27 (77%)12 (71%)58 (83%)27 (71%)NS
Intraoperative characteristics
Operative time (min), median (range)120 (73-238)125 (71-224)127.5 (73-248)103 (67-277)0.024
Intraoperative endoscopy performed, n (%)7 (20%)5 (29%)14 (20%)6 (16%)NS
Methylene blue leak check, n (%)2 (6%)4 (24%)12 (17%)2 (5%)NS
Recognized mucosal perforation, n (%)3 (9%)2 (12%)7 (10%)3 (8%)NS
Post-operative characteristics
Subjective swallowing improvement, n (%)28 (80%)13 (76%)59 (84%)33 (87%)NS
Perioperative Complications, n (%)2 (6%)1 (6%)6 (9%)5 (13%)NS
Re-exploration, n (%)0 (0%)0 (0%)0 (0%)1(3%)NS
30 day readmission, n (%)0 (0%)0 (0%)2 (3%)0 (0%)NS
Length of stay, median (range)2 (1-10)2 (1-7)2 (1-12)2 (1-19)NS

NS non-significant; LES lower esophageal sphincter.

Session: Poster Presentation

Program Number: P258

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