84: DOES CHEST PAIN INFLUENCE NEGATIVELY LONG TERM CLINICALRESULTS OF THE SURGICAL TREATMENT FOR ESOPHAGEAL ACHALASIA?

Abstract

Abstract Background and aim Recently it has been recommended not to perform the Heller myotomy in Achalasia type III (Chicago classification) because of the persistence of chest pain after surgery; alternatively, POEM was proposed. This position is based on short term follow up studies. In the last 40 years our group performed the Heller-Dor operation (HD) in achalasia diagnosed according to Vantrappen and Castell PMDE classification also in the presence of chest pain (vigorous achalasia included, diffuse spasm and nutcracker esophagus excluded). In cases operated upon of HD, we investigated in the long term chest pain, inside the global surgery evaluation. Methods Between 1978 and 2020, 390 achalasia patients underwent the Heller-Dor operation. Among them, 79 preoperatively complained of chest pain (group A), 311 did not (group B). Patients were preoperatively classified and postoperatively followed up according to a timed protocol based on clinical assessment of intensity and frequency of dysphagia (D0 absent—D3 daily), GERD symptoms (RS0 absent-RS3 daily); chest pain was quantified according to the Eckardt’s scale (0 none—3 each meal). Barium swallow and endoscopy (E0: normal, E1: mild esophagitis, E2–3: erosive/ulcerative esophagitis) were performed at each planned control. A and B groups were compared. Results Groups were homogeneous according to sex (P = 0.42) and age (P = 0.51). After HD median follow-up was 10 years (IQR 4.7–12.6 years) for A, 14 years (IQR 5.6–20 years) for B (P = 0.166); at barium swallow the percentage of decrease in esophageal diameter and barium column was similar (P = 0.59 and P = 0.85, respectively) as well as the frequency of GERD symptoms and esophagitis (P = 0.27). Chest pain progressively attenuated; median Eckard score preoperatively was 3, at follow-up it was 1 (P < 0.001). The clinical evaluation at the last control was significantly more favorable for A (satisfactory D0–2, RS0–2, and E1 in 95%) versus B (satisfactory in 89%) (P = 0.02). Conclusion In the long term HD achieves very satisfactory results with the decrease/disappearance of chest pain possibly present in regular achalasia. The clinical-radiological-manometric patterns of type 3 achalasia should be revised, to eliminate eventual misunderstandings.