Relief of Dysphagia after Laparoscopic Heller Myotomy Improves Long-Term Quality of Life
Background and Objective
Quality of life (QoL) is getting more attention in the medical literature. Treatment outcomes are now gauged by their effect on the QoL along with their direct effect on the diseases they are targeting. The aim of the study was to assess the impact of residual dysphagia on QoL after laparoscopic Heller myotomy for achalasia.
QoL was evaluated using the short-form-36 (SF-36) and postoperative dysphagia was assessed using a dysphagia score. The score (range 0–10) was calculated by combining the frequency of dysphagia (0=never, 1 = < 1 day/wk, 2 = 1 day/wk, 3 = 2–3 days/wk, 4 = 4–6 days/wk, 5=daily) with the severity (0=none, 1=very mild, 2=mild, 3=moderate, 4=moderately severe, 5=severe). Patients were classified in the Nonresponder group when their dysphagia score was in the upper quartile.
Questionnaires were mailed to 110 patients. The overall response rate was 91% with 100 patients (54 female) returning the questionnaires. The average follow-up was 3.3 years. There was a significative inverse correlation between dysphagia score and mental component (P = 0.0001) and total SF-36 (P = 0.001) scores. According to their postoperative dysphagia scores, 77 patients were assigned to the Responder Group and 23 patients to the Nonresponder Group. The two groups were similar in terms of age, gender, rate of fundoplication, and length of follow-up. Mental component and total SF-36 scores were significantly (P < 0.05) higher in the Responder group. Successful relief of dysphagia after Heller myotomy was associated with health-related quality of life scores that were 13 higher in Vitality (P < 0.05), 11 points higher in mental health (P < 0.05), and 12 points higher in General Health (P < 0.05). Overall patient satisfaction with surgical outcome was 92%, with only eight patients not satisfied with the surgery.
Laparoscopic Heller myotomy offers excellent long-term relief of achalasia-related symptoms, namely dysphagia, and this was projected on a significant improvement in quality of life and patient satisfaction.
KeywordsAchalasia Quality of life Laparoscopic Heller myotomy Dysphagia SF-36
Achalasia is a primary motility disorder of the esophagus characterized by loss of peristaltic waveform in the body and failure of the lower sphincter to relax in response to swallowing. The condition is relatively rare, occurring at an incidence of 0.5 to 1.0 in 100,000 of the general population1, and affects any age group2. The etiology of achalasia remains unknown, although in South America many patients have infestation by Trypanosoma cruzi as an underlying pathogenesis. The main symptoms are dysphagia and chest pain, although in the late stages regurgitation of swallowed material may occur. Other common symptoms include heartburn and weight loss.
At present time no treatment can reverse the degeneration of the myenteric plexus and restore normal relaxation of the lower esophageal sphincter (LES) with swallowing3. Therefore, the current treatment strategy is aimed to relief the main symptom of achalasia: the dysphagia. Subjective relief of dysphagia and body weight regain have been the most common endpoints used in studies aimed to evaluate the therapeutic outcome of Heller myotomy or endoscopic dilation. However, Quality of life (QoL) is getting more attention in the medical literature4. Treatment outcomes are now gauged by their effect on the QoL along with their direct effect on the diseases they are targeting.
We hypothesize that successful relief of achalasia symptoms after laparoscopic Heller myotomy is associated with improved QoL. To test this hypothesis, we assessed how residual dysphagia after laparoscopic Heller myotomy for achalasia affects long-term QoL.
Patients and Methods
Patients who underwent laparoscopic Heller myotomy for achalasia were mailed a follow-up survey under an IRB approved protocol. The survey included: a Short Form-36 (SF-36) health status questionnaire, a follow-up structured dysphagia score questionnaire5, and a query regarding long-term satisfaction. All patients who did not return the questionnaires received a second mailing or were allowed to answer the survey over the phone.
The SF-36 questionnaire includes 36 questions that yield an eight-scale profile of scores. Scores range from 0–100, with higher scores indicating better QOL. Scoring is designed so that the average American individual would score on average 50 with 10 points standard deviation. The eight scales of the questionnaire include: 1) general health, 2) physical functioning, 3) bodily pain, and 4) role-physical, which all correlate with the physical health summary measure; and 5) mental health, 6) social functioning, 7) vitality, and 8) role-emotional, all of which correlate with the mental health summary measure.
The dysphagia score (range 0–10) was calculated by combining the frequency of dysphagia (0=never, 1 = <1 day/wk, 2 = 1 day/wk, 3 = 2–3 days/wk, 4 = 4–6 days/wk, 5=daily) with the severity (0=none, 1=very mild, 2=mild, 3=moderate, 4=moderately severe, 5=severe). The cutoff point used to define successful outcome after laparoscopic Heller myotomy was selected at the 75th percentile (upper quartile) of the entire cohort. Patients with dysphagia score falling above the cutoff point were classified into the unsuccessful outcome group (Nonresponders).
Our technique for laparoscopic Heller myotomy has been previously described5. Briefly, after exposure of the anterior gastroesophageal (GE) junction, the myotomy is created by incising the distal 4–6 cm of esophageal musculature. The myotomy is extended 1–2 cm onto the gastric cardia using cautery scissors or an ultrasonic scalpel. Intraoperative endoscopy is performed before and simultaneously with the myotomy to assess the adequacy of the myotomy.
The data are presented as mean ± SD for continuous variables and as counts or proportions (%) for categorical variables. Continuous variable means were compared by appropriate parametric or nonparametric tests. Categorical variables were compared with the Chi-square test. Statistical significance was set at P < 0.05.
Effect of Dor-fundoplication on Dysphagia and SF-36 Scores
Heller myotomy (n = 67)
Heller-Dor (n = 33)
3.8 ± 2.8
2.9 ± 2.8
74.7 ± 18.7
73.8 ± 20.8
68.1 ± 20.8
70.7 ± 21.8
76.5 ± 17.4
72.9 ± 21.1
There was a significant inverse correlation between dysphagia score and mental component (Pearson r = −0.379; P = 0.0001) and total SF-36 (Pearson r = −0.328; P = 0.001) scores.
Demographic and Operative Data of the Two Groups
Responders (n = 77)
Nonresponders (n = 23)
54.9 ± 14.9
50.1 ± 13.2
42 female, 35 male
12 female, 11 male
27 Dor (35%)
6 Dor (26%)
40 ± 22 months
40 ± 22 months
Overall patient satisfaction with surgical outcome was 92%, with only eight patients not satisfied with the surgery.
Our study has demonstrated that laparoscopic Heller myotomy offers excellent long-term relief of achalasia-related symptoms resulting in a significant improvement of health-related QoL and patient’s perceived satisfaction.
Current treatments for achalasia, whether medical or surgical, cannot restore normal esophageal motility. Therefore, all the therapeutic options, including endoscopic botulinum toxin injection and pneumatic dilation of the LES are aimed to improve subjective symptoms6,7. The main drawback of these treatments is their transient effect on dysphagia. Differently, laparoscopic Heller myotomy is a durable and effective treatment for achalasia8,9.
Patients with achalasia are greatly affected by their disease. They commonly experience loss of physical strength, fatigue, frustration, and even strains in personal relationships. Many studies have showed that QoL and gastrointestinal symptoms related to achalasia improve significantly after laparoscopic Heller myotomy4,10, 11, 12, 13, 14. However, our study was the first to assess long-term QoL and to correlate better health-related QoL with successful relief of dysphagia.
The present study finds that dysphagia score is inversely correlated with total and mental health SF-36 scores. This finding confirms the observation previously made by Mineo and collaborators15. In their study, four-year dysphagia score was inversely correlated with postoperative changes in mental health. A plausible explanation for this observation is that the loss of normal swallowing and diet increases depression-related symptoms that directly affect the mental component of the SF-36 score16. Therefore, the finding of higher mean SF-36 mental score in the responder group is not surprising. In this group, the most significant improvements were seen in domains such as mental health and vitality. Similarly, Perrone and collaborators found significant postmyotomy improvements in domains affecting the mental SF-36 score, such as social function, and role limitations due to emotional problems17.
In patients with achalasia, it is very difficult to objectively assess the results of surgery because of the low incidence of the disease and the cost of the postoperative studies. In addition, patients are reluctant to undergo invasive testing, especially when they are satisfied with the surgical outcome. So we often rely on the patient’s assessment of their symptoms in determining the outcome of the surgery. This also has its downside, mainly because patients with achalasia often modify their diet to avoid symptoms of dysphagia, which may overestimate the therapeutic effectiveness of the myotomy. In addition, some studies have found no relationship between objective outcome measures and subjective measures12,18, 19, 20. Therefore, we need to highlight more the importance of instruments aimed to objectively assess surgical outcome from the patient’s perspective. SF-36 is a well-validated instrument that has been already used to evaluate surgical outcome. However, it is desirable to develop a valid and reliable measure of disease-specific health-related QoL. Recently, Urbach et al. developed a 10-item measure of disease-specific health-related QoL that sampled the concepts of food tolerance, dysphagia-related behavior modifications, pain, heartburn, distress, lifestyle limitation, and satisfaction21.
We were unable to implement this new instrument because our study was already ongoing at the time of the publication. However, future studies will benefit from using this disease-specific QoL instrument.
Our study also inquired about patient’s satisfaction. Among the 100 patients enrolled in the study, 92 were satisfied with the surgery and only six will not undergo surgery again. However, only 30 patients think that they were cured by surgery. On the other hand, successful relief of dysphagia, measured by dysphagia score, was observed in 77% of patients. This discrepancy can be explained by the fact that self-perceived outcomes measured by binary endpoints (i.e., yes/not) generally overestimate successful outcome when compared with continuous variable endpoints (i.e., Likert scale).
In conclusion our study demonstrated that successful relief of dysphagia after laparoscopic Heller myotomy for achalasia leads to an overall improvement in health-related QoL.