Laparoscopic myotomy for achalasia: predictors of successful outcome after 200 cases

Abstract

Objective: Laparoscopic myotomy is the preferred treatment of achalasia. Our objectives were to assess the long-term outcome of esophageal myotomy and to identify preoperative factors influencing the outcome.

Methods: Preoperative and long-term outcome data were collected from patients undergoing laparoscopic myotomy for achalasia at our institution. The primary endpoint of the study was the postoperative change (delta) in dysphagia score. This score was calculated by combining the frequency and the severity of dysphagia. Persistent postoperative dysphagia was defined as 1 standard deviation less than the mean delta score of all patients. Logistic regression was used to identify independent preoperative factors associated with successful myotomy.

Results: A total of 200 consecutive patients were included in the study. At a mean follow-up of 42.1 months, the mean delta dysphagia score was 7.1 +/- 2.6; therefore, the myotomy was considered successful when the delta score was >4.5. According to this definition, 170 (85%) patients achieved excellent dysphagia relief (responders). Responders had higher preoperative low esophageal sphincter (LES) pressure than nonresponders: 42.6 +/- 13.1 versus 23.8 +/- 7.0 mm Hg (P = 0.001). High preoperative LES pressure remained an independent predictor of excellent response in the multivariate logistic regression model. Patients with LES pressure >35 mm Hg had an odds ratio of 21.3, making more likely to achieve excellent dysphagia relief after myotomy compared with those with LES pressure < or =35 mm Hg (odds ratio, 21.3; 95% confidence interval, 6.1-73.5, P = 0.0001).

Conclusion: Laparoscopic myotomy can durably relieve symptoms of dysphagia. Elevated preoperative LES pressure represents the strongest positive outcome predictor.

FIGURE 1. Preoperative and postoperative dysphagia scores. Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line).

FIGURE 2. Distribution of responder and nonresponders according to the learning curve.

FIGURE 3. Preoperative LES pressure in the 2 groups. Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line).

FIGURE 4. Delta LES pressure correlate positively with delta dysphagia score after esophageal myotomy. The line represents the linear regression fitting.