Simon C Chow, MD, Carlos H Chan, MD PhD, Mathieu Rousseau, MD, Stephen Gowing, MD, Serge Mayrand, MD, Melina C Vassiliou, MD MEd, Gerald M Fried, MD, Lorenzo E Ferri, MD PhD. McGill University
INTRODUCTION: Laparoscopic Heller myotomy with partial fundoplication is a highly effective treatment for achalasia, however it carries a risk of mucosal injury. The natural tendency is to either stop or proceed tentatively with the myotomy if a mucosal perforation occurs, potentially resulting in less effective surgical palliation of dysphagia. The objective of our study is to compare the short and long-term outcomes in patients with intraoperative esophageal perforation to those patients without this complication.
METHODS AND PROCEDURES: A retrospective review was performed on a prospectively entered database for all patients who underwent primary Heller myotomy and anterior fundoplication for achalasia between 1999 and 2010 at a single institution. Demographic, pre-surgical treatment, peri-operative outcomes (operative time, complications, length of stay), and post-operative symptom scores (dysphagia – 0 best: 5 worse) were compared between patients with (Perf) and without (NoPerf) mucosal perforation. For Perf patients, we employed a strategy of completing the myotomy even if extension of the mucosal injury was required to do so. Wilcoxon Signed Rank and Mann-Whitney U tests determined significance (*p<0.05). Data is presented as median with range.
RESULTS: 121 patients underwent Heller myotomy and Dor fundoplication for achalasia. The median age was 47 (20-84) and symptom duration was 3 years (0.5-20). Intra-operative mucosal perforation was identified in 7 (5.8%) and was repaired primarily by laparoscopy (6/7) or laparotomy (1/7). No patient had delayed perforation, developed intra-abdominal abscess, or required reoperation. Twelve patients (9.9%) had prior endoscopic interventions (botulinum toxin = 5, pneumatic dilatation = 9). Two of 12 (16.7%) with prior intervention had perforation, while 5 of 109 (4.6%) without prior intervention had perforation; this was not statistically different. Preoperatively, the dysphagia score was Perf=3 (2-5):NoPerf=4 (1-5)NS. The length of the myotomy was Perf=7cm (6-8):NoPerf=7cm (4.5-11)NS, and patients stayed in the hospital for Perf=3 days (1-13):NoPerf=1 day (1-5)NS. The operative time was longer in the Perf group (140 vs. 120 minutes*). For all patients, the preoperative dysphagia score decreased dramatically as early as 6 weeks postoperatively [1 (0-3)*] and remained at that level at 12 months [0 (0-5)*]. Between the Perf and NoPerf groups, the dysphagia scores at 6 weeks [0 (0-3) vs. 0 (0-3)], 3 months [0 (0-1) vs. 0 (0-4)], 6 months [1 (0-2) vs. 0 (0-4)], and 1 year [1 (0-4) vs. 0 (0-5)] postoperatively were not significantly different.
CONCLUSION: Esophageal perforations may occur at the time of Heller myotomy, but do not seem to impact surgical outcomes. By ensuring an adequate myotomy distal to the injury, accompanied with primary suture repair of the perforation and Dor fundoplication, we have avoided complications and provided our patients with excellent control of their dysphagia.
Program Number: S018