Can Findings On Esophagography Predict Palliation of Achalasia After Laparoscopic Heller Myotomy and Anterior Fundoplication?

Alexander S Rosemurgy, MD, Krishen Patel, Kenneth Luberice, BS, Harold Paul, BS, Abigail Espeut, BS, David S Estores, MD, H. Worth Boyce, MD, Sharona Ross, MD. University of South Florida, Department of Surgery, Tampa Florida Tampa General Medical Group, Tampa General Hospital, Tampa Florida

Introduction: Laparoscopic Heller myotomy with anterior fundoplication (LHMAF) is the “gold standard” for palliation of achalasia. This study was undertaken to determine if postoperative outcomes after LHMAF could be predicted by preoperative findings on esophagography.

Methods: Preoperative barium esophagrams of 122 patients undergoing LHMAF were reviewed through protocol and the number of esophageal curves, esophageal width, and angulation of the gastroesophageal (GE) junction were determined. These findings were correlated with symptoms of achalasia, which were scored by the patients preoperatively and at last follow-up utilizing a Likert scale (1=least bothersome/never to 10=most bothersome/always). Median data are presented.

Results: Before LHMAF, symptoms of achalasia were frequent and severe (e.g., dysphagia =8,9 and regurgitation =7,9, respectively). LHMAF greatly reduced the frequency and severity of symptoms (e.g.,dysphagia=2,1 and regurgitation =0,0, respectively, p<0.05 for each). There were no significant relationships among the number of esophageal curves, esophageal width, and angulation of the GE junction. Postoperatively, only the number of esophageal curves correlated with only one symptom frequency. (Table)

Postoperative Symptom Frequency Postoperative Symptom Severity
Factors
Regurgitation Dysphagia Vomiting Regurgitation Dysphagia Vomiting
Angle NS NS NS NS NS NS
Curve NS P = 0.05* NS NS NS NS
Width NS NS NS NS NS NS
Table. This displays the correlations (represented by p-values) between factors and postoperative symptoms (frequency and severity). * = p-value<0.05 NS = not significant

84% of patients rated their overall experience as very satisfied or satisfied. The number of preoperative esophageal curves, esophageal width, or angulation of the GE junction did not predict postoperative satisfaction.

Conclusions: LHMAF provides dramatic palliation for achalasia; salutary benefits are profound and broad. Findings on preoperative esophagography generally do not predict symptoms after LHMAF; the only significant relationship is “flat” and patients can expect remarkable relief. Surgeons should not be deterred in applying LHMAF for achalasia even when the preoperative esophagram denotes “end-stage” achalasia because significant and dramatic palliation should be expected.