Kristy Kummerow Broman, MD, MPH1, Sharon E Phillips, MSPH1, Adil Faqih, BE1, Joan Kaiser, RN1, Richard A Pierce, MD, PhD1, Benjamin K Poulose, MD, MPH1, William O Richards, MD2, Kenneth W Sharp, MD1, Michael D Holzman, MD, MPH1. 1Vanderbilt University Medical Center, 2University of South Alabama
Background: Our prior randomized controlled trial of Heller myotomy alone (HA) versus Heller myotomy with Dor fundoplication (HD) for achalasia from 2000-2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after HD. Patient-reported outcomes are needed to determine whether the findings are sustained long-term, particularly given introduction of Per Oral Endoscopic Myotomy (POEM) which does not include fundoplication.
Methods: We actively engaged participants from the prior randomized cohort, making up to six contact attempts per person using telephone, mail, and electronic messaging from 2014-2016. We collected patient-reported measures of dysphagia and gastroesophageal reflux using the Dysphagia Score and the Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) instrument, which were compared using Wilcoxon rank sum tests. Patient-reported re-interventions for dysphagia were verified by obtaining longitudinal medical records.
Results: Among living participants, 27/41 (66%) were contacted and all completed the follow-up study at a mean of 11.8 years postoperatively. Median Dysphagia Scores were overall worse (4, Interquartile Range 2-7) than the immediate postoperative baseline of 0 in both groups. Dysphagia Scores and GERD-HRQL scores were slightly worse for HA than HD but were not statistically different (Table). Five patients in HA and 6 in HD underwent re-intervention for dysphagia with most occurring more than five years postoperatively. One patient in each group underwent redo Heller myotomy and subsequent esophagectomy. Nearly all patients (96%) would undergo the operation again.
Conclusions: Long-term patient-reported outcomes after HA and HD for achalasia are comparable. The equivalent long-term results and high patient satisfaction support the performance of Heller myotomy with and without fundoplication.
Heller Alone (HA)
Heller + Dor (HD)
|Dysphagia Scorea, median (IQR)||6 (4-8)||3 (0-5)||0.08|
|GERD Scoreb, median (IQR)||15 (11-19)||12.5 (5-15)||0.25|
|Intervention for Recurrent Dysphagia, N (%)||5 (38)||6 (43)||0.82|
|Redo Heller & Esophagectomy||1 (8)||1 (7)||0.96|
|EGD||5 (38)||6 (42)||0.82|
a Range 0-10; higher=more symptomatic
b Range from 0-48; h&igher=more symptomatic
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 78687
Program Number: S096
Presentation Session: Foregut 2
Presentation Type: Podium