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Multiple Preoperative Endoscopic Interventions Are Associated with Worse Outcomes After Laparoscopic Heller Myotomy for Achalasia

  • 2009 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

The effect of preoperative pneumatic dilation or botulinum toxin injection on outcomes after laparoscopic Heller myotomy (LHM) for achalasia is unclear. We compared outcomes in patients with and without multiple preoperative endoscopic interventions.

Methods

This cohort study categorized achalasia patients undergoing first-time LHM by the number of preoperative endoscopic interventions: zero or one intervention vs. two or more interventions. Outcomes of interest included surgical failure (defined as the need for re-intervention), gastrointestinal symptoms, and health-related quality of life. Logistic regression modeling was performed to determine the independent effect of multiple preoperative endoscopic interventions on the likelihood of surgical failure.

Results

One hundred thirty-four patients were included; 88 (66%) had zero to one preoperative intervention, and 46 (34%) had multiple (more than one) interventions. The incidence of surgical failure was 7% in the zero to one intervention group and 28% in the more than one intervention group (p < 0.01). Greater improvements in gastrointestinal symptoms and health-related quality of life were seen in the zero to one intervention group. On logistic regression modeling, the likelihood of surgical failure was significantly higher in the more than one intervention group (odds ratio = 5.1, 95% confidence interval 1.6–15.8, p = 0.005).

Conclusions

Multiple endoscopic treatments are associated with poorer outcomes and should be limited to achalasia patients who fail surgical therapy.

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Author information

Authors and Affiliations

  1. Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA

    Christopher W. Snyder

  2. School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA

    Ryan C. Burton & Lindsay E. Brown

  3. Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, 1922 7th Avenue South, KB 428, Birmingham, AL, 35294-0016, USA

    Manasi S. Kakade & Mary T. Hawn

  4. Barnes-Jewish Medical Center, St. Louis, MO, USA

    Kelly R. Finan

  5. Center For Surgical, Medical Acute Care Research and Transitions, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA

    Mary T. Hawn

Authors
  1. Christopher W. Snyder
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  2. Ryan C. Burton
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  3. Lindsay E. Brown
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  4. Manasi S. Kakade
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  5. Kelly R. Finan
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Corresponding author

Correspondence to Mary T. Hawn.

Additional information

Discussant

Dr. John G. Hunter (Portland, OR): Over a decade ago, John Dent, a gastroenterologist and an acknowledged “dean” of evidence-based esophagology stated: “...For the otherwise healthy patient, the PRIMARY treatment of choice for achalasia should be laparoscopic Heller myotomy and partial fundoplication,” and yet we continue to see patients who have had several endoscopic treatments before surgical referral. This observational study concludes that Heller outcomes are dramatically worse in patients who have had multiple previous treatments, yet the operation itself is not that much more difficult in patients following endoscopic therapy. Is it possible that:

1. Patients who are symptomatic failures of balloon and/or Botox are more likely to remain symptomatic after any therapy (including Heller) than their counterparts who achieve symptomatic success after primary treatment? Said another way, are unhappy patients likely to stay unhappy, no matter what you do to them? I would suggest that your quality of life data would support this hypothesis.

2. While not statistically significant on univariate analysis and therefore not entered into the regression modeling, it appears that there was more anatomically advanced or functionally atypical disease in group 2. Lumped together, might it be suggested that patients with more advanced or atypical disease at presentation might do worse?

3. And what about gastroparesis? Pan GI motility disorders can be seen in Chaga’s disease, but has not commonly associated with “idiopathic” achalasia. What is the cause? Should we start looking for this in all our achalasia patients?

In closing, I would like to return to the primary finding of this paper: Not only is it more expensive to treat achalasia patients inadequately before surgical referral, it appears that outcome will be MUCH improved if they are referred for surgery immediately after diagnosis. Congratulations Drs. Snyder, Hawn, and team. This paper is a great contribution, and, oh yes, the manuscript is excellent. Read it in JOGS or on the Springer website soon.

Closing Discussant

Dr. Christopher W. Snyder (Birmingham, AL): Thank you very much, Dr. Hunter, for your insightful questions and for taking the time to review our manuscript. Regarding your first question, it is certainly possible that selection bias and unmeasured confounders affected our results.

But I think two things suggest that is not the only thing going on.

One is that these groups were similar preoperatively in terms of quality of life, and two, we saw differences both in subjective outcomes and in the objective outcome of re-intervention. We do not re-intervene just because a patient is unhappy; there has to be objective evidence of recurrent or persistent achalasia.

Two, regarding possible confounding effects of vigorous achalasia and esophageal dilation: We tried forcing those variables back into our regression models even though they did not reach significance, and including them did not change the overall results.

In terms of gastroparesis, I think the answer is unknown. Some histologic studies have shown progression of the neurodegenerative process onto the stomach in achalasia patients, so gastroparesis may just be a progression of disease. It could also be an unrelated comorbidity that is unmasked when you decompress the lower esophageal sphincter, or it could be an iatrogenic byproduct of surgical or endoscopic trauma. We really do not know and it is an interesting hypothesis for further study.

Discussant

Dr. Mario Costantini (University of Padua): I have a question. Did you try and split the group of patients with multiple endoscopic treatments between patients who received Botox and those who underwent dilatations? Are there any difference between the two groups? This is because, in our own experience, the dilatations do not really matter, but Botox does.

Closing Discussant

Dr. Christopher W. Snyder (Birmingham, AL): We would have preferred to stratify our analysis by Botox and dilation. Unfortunately, when we tried, our group sizes got so small that we did not have the statistical power to do a meaningful analysis.

Discussant

Dr. Selwyn M. Vickers (Minneapolis, MN): In your preparation of the manuscript after the study, what is the persistence in the GI literature that supports the interventions that you see by our colleagues with these multiple diseases before pursuing surgery?

Closing Discussant

Dr. Christopher W. Snyder (Birmingham, AL): There are several studies in the GI literature that advocate endoscopic interventions as an initial treatment. One of them was a cost-effectiveness study that compared endoscopic interventions vs. immediate surgery, and they found that overall costs were lower among those that got endoscopic treatments.

Grant Support: Dr. Snyder receives salary support under an educational grant from Olympus America, Inc.

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Snyder, C.W., Burton, R.C., Brown, L.E. et al. Multiple Preoperative Endoscopic Interventions Are Associated with Worse Outcomes After Laparoscopic Heller Myotomy for Achalasia. J Gastrointest Surg 13, 2095–2103 (2009). https://doi.org/10.1007/s11605-009-1049-6

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