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BACKGROUND:
Swallowing deteriorates over time in some patients after transthoracic esophagomyotomy for achalasia. Causes of decline are poorly understood.
METHODS:
We report a retrospective analysis of transthoracic esophagomyotomy for achalasia. Symptom relief, patient satisfaction, and reintervention were determined during short-term (2-6 months) and long-term (1-31 years) follow-up. Logistic regression was performed to identify predictors of long-term outcome.
RESULTS:
From 1962 to 1999, 65 patients aged 12 to 79 years underwent transthoracic esophagomyotomy. Sigmoid esophagus was present in 12 (18%). Fundoplication was omitted in 50 patients (group A) and added in 15 (group B). Follow-up was complete in 86% (56/65); median follow-up was 11 years. Short-term results were good to excellent in 91% (51/56) and long-term in 63% (33/52) (p<0.0005). Four patients (group A 2/38 [5%]; group B 2/14 [14%]) developed late peptic stricture with poor long-term outcome. Fewer patients had reflux symptoms after fundoplication (group A, 16/38 [42%]; group B, 4/14 [29%]). Late dysphagia was not reduced (group A, 13/38 [34%]; group B, 5/14 [36%]). Two patients in group B (11%) and none in group A had esophagectomy (p<0.0005). Early (<6 months) recurrence of symptoms predicted late poor outcome (p<0.001), whereas sigmoid esophagus, fundoplication, or early postoperative reflux did not.
CONCLUSIONS:
Early good results after esophagomyotomy for achalasia deteriorate over time. Recurring dysphagia early after operation predicts late failure, while myotomy for sigmoid esophagus does not. Fundoplication may reduce reflux, but poor results requiring esophagectomy were increased. These data should be considered in the evaluation of newer, minimally invasive procedures.