423. DYSPHAGIA AND RE-INTERVENTION AFTER MYOTOMY FOR ACHALASIA: A MATTER OF TECHNIQUE, OR A MATTER OF TIME?

Abstract

Abstract Background Achalasia is an incurable neurodegenerative disease of the esophagus. Palliative treatment includes disruption of the lower esophageal sphincter via multiple techniques, including open Heller myotomy (OHM), laparoscopic Heller myotomy (LHM), and per-oral esophageal myotomy (POEM). There is a paucity of data comparing long-term outcomes between OHM, LHM, and POEM. We sought to evaluate the relationship of these methods with clinical outcome parameters using our institution’s experience. Methods Patients greater than 3 years removed from myotomy for achalasia were studied. Post-operative Eckardt Symptom (ES) score and daily proton pump inhibitor (PPI) usage was recorded. Patients underwent timed barium esophagram (TBE) as clinically indicated. Retention was defined as a persistent column >5 cm at 5 minutes. Post-operative interventions included Savary dilation, Botox injection, pneumatic dilation, surgical myotomy, and esophagectomy. Groups were stratified by surgery type (OHM, LHM, POEM) and by time since surgery (3–6 years, 6–10 years, >10 years). A logistic regression analysis was performed examining the relationship of surgery type, time, symptomatic/objective outcomes, and post-operative interventions. Results 172 patients had long-term data available. Mean follow up was 7.8 years (3.1–19.5 years). Nearly one-third of patients had a post-operative intervention (31%, 53/172). On regression analysis, OHM was associated with a higher risk of intervention (OR 9.4, p < 0.05). Barium retention was significantly associated with LHM (OR 15.9, p < 0.05) and the 3–6 year post-operative period (OR 11.1, p < 0.05). PPI usage was not associated with surgery type, but was associated with the 3–6 year post-operative period (OR 3.2, p < 0.05). There was no significant association of dysphagia with surgery type or time. Conclusion Post-operative barium retention and interventions are associated with specific myotomy techniques, but not time. PPI usage is associated with the early post-operative period, but not technique. Neither myotomy technique nor time alone are sufficient to predict risk of abnormal ES or dysphagia.