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Laparoscopic Heller Myotomy Can Be Used As Primary Therapy for Esophageal Achalasia Regardless of Age

  • 2013 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

Laparoscopic Heller-Dor surgery is the current treatment of choice for patients with esophageal achalasia, but elderly patients are generally referred for less invasive treatments (pneumatic dilations or botulinum toxin injections).

Aim

To assess the effect of age on the surgical outcome of patients receiving laparoscopic Heller-Dor as primary treatment.

Methods

Demographic and clinical findings were prospectively collected on patients undergoing laparoscopic Heller-Dor from 1992 to 2012. Patients were classified in three age brackets: group A (≤45 years), group B (45–70), and group C (≥70). Treatment was defined as a failure if the postoperative symptom score was >10th percentile of the preoperative score (i.e., >8). We consecutively performed the Heller-Dor in 571 achalasia patients, 305 (53.4 %) in group A, 226 (39.6 %) in group B, and 40 (7 %) in group C.

Results

The mortality was nil; the conversion and morbidity rates were both 1.1 %. Group C patients had higher preoperative symptom scores (p = 0.02), while the symptom duration was similar in all three groups. Mucosal tears occurred in 17 patients (3 %): 6 (2 %) in group A, 8 (3.5 %) in group B, and 3 (7.5 %) in group C (p = 0.09). The postoperative hospital stay was slightly longer for group C (p = 0.06).

Discussion

The treatment failure rate was quite similar: 31 failures in group A (10.1 %), 19 in group B (8.4 %), and 3 in group C (7.5 %; p = 0.80). These failures were seen more in manometric pattern III (22.2 %, p = 0.002). Laparoscopic Heller-Dor can be used as the first therapeutic approach to achalasia even in elderly patients with an acceptable surgical risk.

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Authors and Affiliations

  1. Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy

    Renato Salvador, Mario Costantini, Lisa Zanatta, Elena Finotti, Cristina Longo, Loredana Nicoletti, Giovanni Capovilla & Romeo Bardini

  2. Department of General Surgery, SS Giovanni e Paolo Hospital, ULSS 12, Venice, Italy

    Giovanni Zaninotto

  3. Surgical Oncology, Istituto Oncologico Veneto, IOV-IRCCS, Padua, Italy

    Francesco Cavallin

  4. Unità Operativa Complessa Chirurgia Generale, University of Padova Department of Surgery, Oncology and Gastoenterology, ULSS 12, Venice, Italy

    Giovanni Zaninotto

Authors
  1. Renato Salvador
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  2. Mario Costantini
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  3. Francesco Cavallin
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  4. Lisa Zanatta
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  5. Elena Finotti
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  6. Cristina Longo
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  7. Loredana Nicoletti
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  8. Giovanni Capovilla
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  9. Romeo Bardini
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  10. Giovanni Zaninotto
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Corresponding author

Correspondence to Giovanni Zaninotto.

Additional information

Discussant

Dr. Stanley Ashley (Boston, MA, USA): Thank you Dr. Salvador for a great presentation. I want to congratulate you and your group on such a large series with such excellent outcomes. It is clear from your data that the Heller-Dor can be an effective approach to achalasia irrespective of the patient's age. I believe however that this was a select group that was referred for surgery. Can you tell us what percentage of all patients and what percentage of the group over 70 with achalasia at your institution underwent surgery?

I also wonder why you chose to exclude patients who had previously been treated—either with dilatation or botox? For many of us, this group represents a significant percentage of referrals and the question of whether to proceed with surgery or repeat the endoscopic treatment is always there, particularly in the elderly. Did this group do as well with operation?

Finally in group C, the type III patients, have you altered your approach because of the higher recurrence rate and need for dilatations?

Closing Discussant

Dr. Renato Salvador: At our department, laparoscopic Heller-Dor has become the treatment of choice for patients with esophageal achalasia over the last 20 years because, in our experience, it is less invasive and affords a better outcome. The percentage of patients undergoing surgery is very high, >90 %. If we consider only patients over 70 years old, the percentage decreases to around 60 % and our choice of therapy depends on the patients' surgical risk.

We decided to exclude patients who had already had other treatments for esophageal achalasia from the study in order to have more homogeneous groups of patients and clearer data for assessing the manometric findings (LES residual and resting pressure, manometric pattern, …) and the radiological findings. In 2008, our group published our global experience in the Annals of Surgery (Zaninotto et al. Four Hundred laparoscopic myotomies for esophageal achalasia: a single-center experience). In that study, we saw that previous endoscopic treatment(s) did not generally affect the chances of success of laparoscopic myotomy.

The answer is a longer myotomy. Before starting to assess the manometric pattern, we thought that a myotomy extending into the chest might be the answer for the spastic subtype. But when we analyzed our data, we found that the spastic type coincided with a longer LES, so we decided to perform a longer myotomy on the gastric side. The answer is therefore probably a longer myotomy on both sides. On the other hand, we saw in the European randomized trial comparing dilations with laparoscopic myotomy (in which our group took an active part) that the success rate in type III patients was higher after laparoscopic Heller Dor than after pneumatic dilations, reaching 86 and 40 %, respectively (Rohof W, Salvador R, et al. Treatment outcome of achalasia depends on the manometric subtype. Gastroenterology, December 2012).

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Salvador, R., Costantini, M., Cavallin, F. et al. Laparoscopic Heller Myotomy Can Be Used As Primary Therapy for Esophageal Achalasia Regardless of Age. J Gastrointest Surg 18, 106–112 (2014). https://doi.org/10.1007/s11605-013-2334-y

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  • DOI: https://doi.org/10.1007/s11605-013-2334-y

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