Intraoperative mucosal perforation during laparoscopic achalasia surgery: impact of preoperative pneumatic balloon dilation

Yoshihito Souma, MD¹, Kiyokazu Nakajima, MD, FACS², Eiji Taniguchi Eiji Taniguchi, MD³, Tsuyoshi Takahashi, MD², Yukinori Kurokawa, MD, FACS², Makoto Yamasaki, MD², Yasuhiro Miyazaki, MD², Tomoki Makino, MD², Takeyoshi Yumiba, MD¹, Shuichi Ohashi, MD¹, Shuji Takiguchi, MD², Masaki Mori, MD, FACS², Yuichiro Doki, MD². ¹1. Department of Surgery, Osaka Central Hospital, Osaka, Japan, ²2. Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan, ³3. Department of surgery, Otemae hospital, Osaka, Japan

INTRODUCTION: Pneumatic balloon dilation (PBD) has been preferred as the primary treatment for esophageal achalasia since it is relatively easy to perform, generally requires no hospital stay, and is cost-efficient in short-term. However, laparoscopic cardiomyotomy is eventually required in refractory cases as a definitive treatment after failed PBD. The forceful tear of lower esophageal sphincter (LES) during PBD potentially causes post-procedural reactive fibrosis around LES, and controversy has still remained regarding whether preoperative PBD can be a potential hazard of perioperative complication, such as intraoperative mucosal perforation, and adverse effect on postoperative esophageal function. The aim of this study was to evaluate whether preoperative PBD represents a risk factor of surgical complications and affects the symptomatic and/or functional outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD).

Methods: A retrospective chart review was conducted on the prospectively complied surgical database including 103 consecutive patients with esophageal achalasia who underwent LHD from November 1994 to September 2014. The following data were compared between the patients with preoperative PBD (PBD group; n=26) and without PBD (non-PBD group; n=77): 1) patient’s demographics; age, gender, body mass index, duration of symptoms and severity of disease. 2) operative findings; operating time, blood loss, intraoperative complications. 3) postoperative outcome; complications, symptom relief, and necessity of postoperative treatments. 4) pre- and post-operative manometric data and profile of 24-hour esophageal pH monitoring.

Results: 1) No significant differences were observed between PBD and non-PBD groups in the patients’ demographics. 2) Operative findings were similar between the two groups, but the incidence of intraoperative mucosal perforation was significantly higher in PBD group (n=8; 30.7%) compared to non-PBD group (n=6; 7.9%) (p=0.005). 3) Postoperative complication was not encountered in both groups. The differences were not significant in postoperative clinical symptoms and necessity of postoperative treatments. Endoscopically proven gastro-esophageal reflux disease were developed in 3 patients in PBD group, and in 5 patients in non-PBD group (p=0.40). 4) LES pressure was effectively reduced in both groups, and no differences were observed in manometric data and profile of 24-hour pH monitoring between the two groups. Multivariate logistic regression analysis showed that the history of preoperative PBD was significantly associated with intraoperative mucosal perforation (odds ratio: 4.96 [95% CI: 1.39 to 17.61, p=0.013]).

Conclusions: Although postoperative outcomes are not affected, a special caution should be required in patients with preoperative PBD when performing LHD.