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Ann Thorac Surg 2008;85:1729-1734. doi:10.1016/j.athoracsur.2007.11.017
© 2008 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Minimally-Invasive Esophagomyotomy in 200 Consecutive Patients: Factors Influencing Postoperative Outcomes
Matthew J. Schuchert, MDa,
James D. Luketich, MDa,*,
Rodney J. Landreneau, MDa,
Arman Kilic, BSa,
William E. Gooding, MSb,
Miguel Alvelo-Rivera, MDa,
Neil A. Christie, MDa,
Sebastien Gilbert, MDa,
Arjun Pennathur, MDa
a Division of Thoracic Surgery, Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
b University of Pittsburgh Cancer Institute, Biostatistics Facility, Pittsburgh, Pennsylvania
Accepted for publication November 6, 2007.
* Address correspondence to Dr Luketich, Sampson Family Endowed Professor and Chief, Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, 200 Lothrop St, Suite C-800, Pittsburgh, PA 15213 (Email: luketichjd{at}upmc.edu).
Presented at the Poster Session of the Fifty-third Annual Meeting of the Southern Thoracic Surgical Association, Tucson, AZ, Nov 8–11, 2006.
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Abstract
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Background: The primary objective of this study was to review our experience with minimally-invasive esophagomyotomy as primary therapy for achalasia, and to identify those clinical variables most predictive of myotomy failure.
Methods: We reviewed our experience with all patients who underwent minimally-invasive Heller myotomy from 1992 to 2005. Outcome variables analyzed included perioperative morbidity and mortality, symptomatic improvement, and requirement for postoperative interventions. Multivariate analysis was performed to identify clinical variables predictive of myotomy failure.
Results: A total of 200 consecutive patients (104 men and 96 women) underwent minimally-invasive laparoscopic (n = 194) or thoracoscopic (n = 6) Heller myotomy with partial fundoplication. Mean follow-up was 31.6 months. Median hospital stay was 2 days, with no operative mortality. There were 119 patients (59.5%) who had undergone prior endoscopic treatment (endoscopic dilation or botulinum toxin injection). An increased failure rate was noted in patients with prior endoscopic therapies (16.8% versus 3.7% with no prior treatment, p = 0.003). Multivariate analysis also revealed that longer duration of symptoms, sigmoidal esophageal changes, and low preoperative lower esophageal sphincter pressures impact adversely on the success of myotomy.
Conclusions: There was an increase in treatment failures among patients undergoing preoperative endoscopic treatment. Other factors associated with failure during long-term follow-up include longer duration of symptoms, sigmoidal esophagus, and low baseline lower esophageal sphincter pressure. Although endoscopic modalities remain an important component of the armamentarium in the treatment of patients with achalasia, consideration should be given to minimally-invasive Heller myotomy as primary therapy for this condition.
Achalasia is a rare acquired motor disorder of the esophagus characterized by the manometric findings of an aperistaltic esophageal body associated with incomplete relaxation of the lower esophageal sphincter (LES) in response to swallowing. The etiology of primary achalasia remains unknown, and no therapy (medical or surgical) has achieved success in reversing or curing the underlying pathology. As such, both endoscopic and surgical interventions for achalasia are palliative in nature, and are directed at reducing or disrupting the muscular tone of the LES to facilitate esophageal emptying. The hallmark of surgical therapy for achalasia is cardiomyotomy, described originally by Heller in 1913 [1], and modified to include a single anterior myotomy, as popularized by Zaaijer in 1923 [2].
For more than 60 years, cardiomyotomy was performed through either an open thoracic or abdominal approach, fostering the development and widespread use of less-invasive endoscopic treatments including forceful pneumatic balloon dilatation and botulinum toxin injection. The introduction of minimally-invasive surgical approaches [3, 4] has resulted in shorter patient hospital stay, reduced morbidity, and a quicker return to daily activities [5], making the procedure an attractive primary therapeutic option for low-risk patients with achalasia. Since these initial reports, minimally-invasive approaches to Heller myotomy have become the standard operative approach for the treatment of achalasia in most centers. Despite published results documenting superior long-term outcomes with Heller myotomy compared with endoscopic therapy for achalasia [6–8], endoscopic treatments continue to be performed on the majority of patients before referral to surgery [9].
In the current study, we review our experience with minimally-invasive Heller myotomy for the treatment of achalasia and the factors affecting outcome.
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Patients and Methods
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Patients
Approval for this study was provided by the Institutional Review Board of the University of Pittsburgh. As this was a retrospective study, individual consent was waived.
We performed a retrospective review of 200 consecutive patients undergoing minimally-invasive Heller myotomy for achalasia at the University of Pittsburgh from 1992 to 2005. There were 106 male and 94 female patients with a mean age of 54.1 years (range, 14 to 96; Table 1). Seven patients (3.5%) underwent simultaneous repair of epiphrenic diverticuli.
Preoperative Evaluation and Therapy
The diagnosis of achalasia was confirmed by barium esophagram demonstrating the classic appearance of achalasia (proximal esophageal dilation with a distal "bird's beak") and esophageal manometry (aperistalsis; LES with incomplete relaxation). Manometry was attempted, but unsuccessful, in 7 patients owing to difficulty positioning the probe or to patient intolerance. All patients had a preoperative esophagogastroduodenoscopy to confirm the absence of other esophageal pathology before surgery. The most common presenting symptom was persistent or progressive dysphagia (98%). Dysphagia scores were assessed preoperatively and postoperatively utilizing the following scale: 1 = no dysphagia; 2 = difficulty with hard solids; 3 = difficulty with soft solids; 4 = difficulty with liquids; 5 = cannot swallow saliva. Mean preoperative dysphagia score was 3.3. Other modes of presentation included aspiration pneumonia in 2 patients and upper gastrointestinal bleeding from an esophageal diverticulum in 1 patient. Mean duration of symptoms for the entire patient cohort was 7.5 years. Endoscopic therapy (balloon dilation, botulinum toxin injection, or both) was performed in 119 patients (59.5%) before Heller myotomy (Table 2). Prior myotomy had been performed in 10 patients (5%).
Operative Technique
A laparoscopic approach was used in 194 (97%) of the patients. Six patients underwent a left video-assisted thoracoscopic surgical approach in conjunction with a Belsey (n = 3), Toupet (n = 1) or myotomy alone (n = 2). Minimally-invasive esophagomyotomy (± partial fundoplication) was performed as described previously [10, 11]. A partial fundoplication was performed in 194 patients (97%), with only 6 patients undergoing myotomy alone. In 173 patients (86.5%), a posterior (Toupet) fundoplication was performed. An anterior (Dor) wrap was performed in 18 patients (9%), and a Belsey fundoplication in 3 (1.5%) utilizing a video-assisted thoracoscopic surgical approach (Table 3).
Postoperative Course
Patients were typically extubated in the operating room at the conclusion of the case. A barium swallow was performed on the first postoperative day, and if satisfactory, a clear liquid diet was initiated. Patients were typically discharged on the second postoperative day. Our current protocol is to evaluate the patients at 2 weeks for the first postoperative visit. Follow-up at 6 months, 1 year, and yearly thereafter is performed with repeat barium swallows. Manometry and esophageal transit studies are optional, based on surgeon and patient preference.
Follow-Up
Follow-up data were gathered from the electronic medical record, direct patient contact, as well as hospital and office charts. Myotomy failure was defined as patients with no improvement in dysphagia score or those requiring reoperation (redo myotomy or esophagectomy). Postoperative dysphagia scores were assessed at each clinic or hospital visit, and compared with preoperative values.
Statistical Analysis
Statistical analysis included paired and one-sample t tests, 
2 tests, Fisher's exact test, and the Wilcoxon test depending upon the level of measurement of data and the shape of the distribution. Multivariable models combining individual covariates were constructed using recursive partitioning and logistic regression. The probability of failure-free survival was estimated with the Kaplan-Meier method, and group difference in time to failure was tested with the log-rank test.
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Results
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Perioperative Outcomes
A total of 200 consecutive patients underwent minimally-invasive esophagomyotomy. The operative mortality was 0%. Median hospital stay was 2 days (range, 1 to 56). Complications occurred in 32 patients (16%), and are outlined in Table 3. The most common complication was intraoperative esophageal or gastric mucosal perforation, which occurred in 8 patients (4%). Interestingly, 6 of these perforations occurred in the first 62 patients, with only 2 perforations among the last 138 patients, suggesting a technical learning curve with this procedure. In each instance, the perforation was recognized and repaired with interrupted sutures. When available, omentum was used to provide additional coverage with vascularized tissue. In 2 patients, successful repair required conversion to an open procedure to repair the perforation. In the remaining 6 patients, the perforation was repaired laparoscopically without further sequelae. There was a significantly increased incidence of overall intraoperative perforation and perioperative leak rate among patients undergoing prior endoscopic therapy (9 versus 1, p = 0.04). The occurrence of intraoperative perforations did not correlate with myotomy failure during the follow-up period.
Analysis of Failures
Dysphagia scores improved in 185 (92.5%) of patients at a mean follow-up of 31.6 months (mean improvement in dysphagia score: 3.30 to 1.36, p < 0.001). The overall failure rate was 11.5% (23 patients; 95% confidence interval: 7.4% to 16.8%), and the mean time to failure was 12 months (range, 0.5 to 83). Of the 23 patients who have failed, 18 patients failed within the first 18 months of follow-up.
Eight patients did not demonstrate improvement in dysphagia after myotomy (8 of 200; 4%), and were considered failures (Table 4). Five of these patients underwent subsequent esophagectomy. Two were palliated with dilations, and 1 refused additional therapy. Redo myotomy was performed in 11 patients (5.5%) secondary to refractory or recurrent dysphagia after primary myotomy. Seven of these patients were palliated successfully, with 4 patients requiring subsequent esophagectomy.
The overall esophagectomy rate was 6.5% (13 patients) in this series. Five patients underwent esophagectomy secondary to no improvement in symptoms after primary myotomy. Four additional patients ultimately required esophagectomy after a failed attempt at redo myotomy. The remaining 4 patients had recurrent dysphagia subsequent to myotomy and progressed to esophagectomy during the period of follow-up.
Impact of Endoscopic Therapy
Endoscopic therapy was performed on 119 patients (119 of 200; 59.5%) before minimally-invasive esophagomyotomy. There was no significant difference in sex distribution, age or dysphagia score compared with patients not receiving prior endoscopic therapy. Significant differences were noted in median duration of symptoms (5 versus 2 years, p < 0.001), preoperative lower esophageal sphincter pressure (LESP) (28.5 versus 32.1, p = 0.049), and the presence of a sigmoidal esophagus on preoperative barium swallows (18 [15.1%] versus 4 [4.9%], p = 0.042) in patients with preoperative endoscopic interventions compared with those without prior therapy (Table 1). Prior endoscopic therapy was associated with a higher rate of myotomy failure compared with patients undergoing primary myotomy. Of the 119 patients with prior endoscopic therapy, there were 20 failures (7.2%), compared with only 3 failures in the primary myotomy group (3.6%, p = 0.003). All 8 patients reporting no improvement in dysphagia had prior endoscopic therapy. Specifically, there was also increase in the rate of reoperation (p = 0.01) among patients with preoperative endoscopic intervention (Table 4). A history of preoperative interventions did not impact on hospital stay, improvement in mean dysphagia score, or overall complication rate (although overall perioperative perforation and leak rate was increased, as discussed above).
Predictors of Failure After Minimally-Invasive Heller Myotomy
Univariate analysis of individual covariates revealed that duration of symptoms (p = 0.006), prior myotomy (p = 0.002), prior endoscopic therapy (p = 0.012), LESP (p = 0.001), and sigmoid esophagus (p = 0.001) were significant predictors of myotomy failure. Logistic models combining individual covariates found that duration of symptoms, sigmoid esophagus, and low preoperative LESP were independent predictors of poor outcome (Table 5). In addition, recursive partitioning modeling selected duration of symptoms (>15 years), prior endoscopic therapy, and LESP (<38 mm Hg) as being important in discriminating those patients more likely to fail myotomy. Kaplan-Meier estimates of freedom from failure after myotomy similarly demonstrate superior outcomes among patients undergoing minimally-invasive myotomy as primary therapy (p = 0.008). The probability of 5-year freedom from failure was 92% (confidence interval: 83% to 100%) in the primary myotomy group versus 77% (confidence interval: 68% to 88%) in patients who had prior endoscopic intervention (log rank p = 0.008; Fig 1).
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Fig 1. Kaplan-Meier estimates of probability of freedom from myotomy failure. Patients without prior endoscopic therapy (solid line) have significantly improved outcomes at 5 years (p = 0.008). (Dotted line = prior therapy.)
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Comment
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Several preoperative factors have been postulated to affect outcomes after esophagomyotomy for achalasia. They include age, sex, dilated or sigmoidal esophagus, baseline LES resting pressures, and prior nonsurgical treatments such as botulinum toxin injection and esophageal dilation [12]. In our series, the main covariates predictive of myotomy failure were duration of symptoms, sigmoidal esophagus, and a decreased preoperative LESP by logistic regression analysis. Recursive partitioning modeling identified duration of symptoms (>15 years), prior endoscopic therapy, and decreased LESP (<38 mm Hg) as key variables in predicting myotomy failure. Among the 22 patients with longer than 15 years of symptoms, prior endoscopic therapy, and a low preoperative LESP (<38 mm Hg), more than 50% failed myotomy. Patients with these clinical features might represent a subgroup who would benefit from esophagectomy among patients with acceptable risk.
There has been much speculation regarding the impact of prior endoscopic therapy in achieving a successful myotomy for patients with achalasia. Several recent large series report no discernible difference in intraoperative mucosal perforations, complication rates or failure rates in patients undergoing prior endoscopic therapy (dilation or botulinum toxin, or both) [13, 14]. Although experienced surgeons can safely perform a myotomy after prior endoscopic therapy with a low complication rate, the impact of such treatments on the long-term outcome of the myotomy is only now becoming evident as large series with long-term follow-up are published. In a large series of 209 patients undergoing myotomy, by Smith and coworkers [9], 154 patients received endoscopic therapy before myotomy. A higher rate of intraoperative complications (9.7% versus 3.6%, p < 0.05), postoperative complications (10.4% versus 5.4%, p < 0.05), and myotomy failures (19.5% versus 10.1%) was observed among patients who had prior endoscopic therapy [9]. In another large series of 248 patients undergoing laparoscopic Heller myotomy with Dor fundoplication, logistic regression analysis identified the use of two botulinum toxin injections or combined botulinum toxin and dilations as independent risk factors for poor outcome after surgery at a median follow-up of 41 months [15]. Raftopoulos and associates [16] similarly identified a trend toward a higher incidence of intraoperative esophageal perforation and recurrent dysphagia, as well as impaired improvement in quality of life, among patients with prior endoscopic therapy.
In our series, prior endoscopic therapy was associated with a significantly higher risk of failure after myotomy, as well as reoperation rate, including esophagectomy. There was no apparent difference between prior dilation and botulinum toxin therapies and outcome after subsequent myotomy. It should be noted that multivariate analysis also identified duration of symptoms and presence of sigmoid esophagus as independent predictors of myotomy failure. Although it is possible that such negative predictors as sigmoidal esophageal changes and longer duration of symptoms might adversely influence the results of the prior endotherapy group (Table 1), it is also conceivable that multiple episodes of suboptimal palliation might contribute to repeated trauma at the gastroesophageal junction and promote proximal esophageal dilation and the development of sigmoidal changes, especially in patients with longer duration of symptoms. An earlier myotomy in these circumstances might avoid these potentially adverse events.
The management of the patient with end-stage achalasia and a sigmoid esophagus remains controversial. Patti and colleagues [17] reported good to excellent results in 7 patients with megaesophagus undergoing myotomy in the setting of a dilated esophagus. In another series of 14 patients with a dilated, sigmoidal esophagus by Mineo and coworkers [18], 10 of 14 patients achieved good to excellent results, with similar morbidities and hospital stays after the operation compared with those patients without a dilated esophagus. Longer-term success rates, however, do appear to diminish as the degree of esophageal dilation and tortuosity increase [19]. Several authors, therefore, are proponents of esophagectomy as primary therapy for the dilated, sigmoidal "end-stage" esophagus, contending that the megaesophagus becomes a functionless organ that is a potential source of retention esophagitis, regurgitation, tracheobronchial soilage, and a potential risk of cancer [20].
In our series, the presence of a sigmoidal esophagus was strongly associated with risk of myotomy failure compared with patients without sigmoidal changes. In the case of end-stage achalasia, surgical judgment and patient selection become very important in optimizing outcomes. Our preferred approach is to perform a laparoscopic myotomy in the setting of mild to moderate sigmoidal changes, with particular attention to mobilizing and straightening of the distal esophagus as part of the repair. For young patients with a significantly tortuous and dilated esophagus, we give strong consideration to performing a minimally-invasive esophagectomy, recognizing that a lesser procedure may fail over the decades, requiring a reoperation in a potentially higher risk setting [21].
Preoperative LESP measurements have been suggested to be predictive of myotomy success or failure. Specifically, low preoperative LESP measurements have been shown to be independent predictors of adverse outcomes after myotomy, including the need for reoperation [22, 23]. In the current series, LESP did appear to be a significant risk factor for myotomy failure in multivariate analysis and recursive partitioning (Table 5). Among those patients who failed myotomy, the mean preoperative LESP was 16.7 compared with a mean LESP of 31.8 among patients with good results (p < 0.05).
Whether to perform a partial fundoplication at the time of myotomy has been debated, with several large series reporting excellent results employing myotomy alone without fundoplication [13, 24]. Recently, however, Richards and associates [25] have demonstrated in a randomized trial that the addition of an anterior partial fundoplication significantly decreases the incidence of postoperative gastroesophageal reflux (from 47.6% with Heller alone to 9.1% with Heller/Dor) with no significant change in dysphagia. The preferred approach in this series was to perform a posterior Toupet fundoplication. There were no apparent differences between Toupet and Dor with regard to outcomes. Interestingly, over the last 2 to 3 years, there has been a resurgence of interest in the Dor fundoplication at our institution principally because it is simpler, quicker, and easier to teach. Thus, until randomized trials are published, the choice of Dor or Toupet fundoplication after laparoscopic myotomy in patients with achalasia should be based on the surgeon's preference and experience.
Laparoscopic Heller myotomy can be performed safely with excellent perioperative outcomes, and significant reduction of dysphagia. The incidence of technical perioperative complications decreases as experience is gained (learning curve). Duration of symptoms, preoperative endoscopic treatment, sigmoidal esophagus, and low baseline LESP all impact adversely on patient outcomes. Larger prospective studies with long-term follow-up are needed to validate these findings. Laparoscopic Heller myotomy is increasingly being considered as a first-line therapy for patients with achalasia, and as a definitive salvage option in patients who have failed prior endoscopic therapy. Thoracic surgeons can perform these operations effectively, and thoracic residency training programs should strive to optimize laparoscopic esophageal surgery experience.
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References
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Abstract
Introduction
