Thoracoscopic esophagomyotomy for achalasia: Preoperative patterns of acid reflux and long-term follow-up

Abstract

Background. The best technique for surgical esophagomyotomy to treat achalasia remains contentious. The controversies include the best approach (thoracoscopic or laparoscopic) and the need for an antireflux procedure. Postoperative pH studies have suggested pathologic gastroesophageal reflux (GER) in many cases; however, control studies of reflux patterns are scarce. This study presents pH studies before esophagomyotomy as well as long-term follow-up of patients undergoing esophagomyotomy. Methods. Forty-nine patients underwent esophagomyotomy (45 thoracoscopically, 4 laparoscopically) for achalasia. Before treatment, 24-hour pH studies were conducted for 38 patients with achalasia. The patients were evaluated postoperatively for dysphagia and reflux. Results were classified as excellent, good, fair, or poor. Results. The findings of the pretreatment pH studies were abnormal in 15 patients (39%). Twelve patients (32%) had GER either with esophageal fermentation (6 patients [16%]) or without fermentation (6 patients [16%]). Eight percent had esophageal fermentation alone. There was no correlation between GER and previous pneumatic dilatation. Twenty-three patients (60%) had normal pH scores; of these, 24% had esophageal fermentation, whereas 29% had neither reflux nor fermentation. Operative results were excellent in 70% of patients, good in 10%, and fair in 20%. All patients considered their conditions improved. Four patients required a subsequent operation because of dysphagia (n = 3) or reflux (n = 1), and their original procedures were classified as failures. Their current status is fair (n = 2), good (n = 1), and excellent (n = 1). GER was documented before the original operation in 3 of the 4 patients in whom the procedure failed. Fifteen patients were eligible for 5-year follow-up. Their results are excellent or good (n = 11) (73%) and fair (n = 4) (27%). Conclusions. A high percentage of patients with achalasia exhibit pathologic GER before surgical therapy and seem to be at higher risk for failed surgical treatment. Thoracoscopic esophagomyotomy resulted in improvement in 92% of patients, and long-term follow-up indicates that these results are durable. (Surgery 2001;130:570-7.)