Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months.
BACKGROUND
Laparoscopic esophagomyotomy is the preferred approach to patients with achalasia of the esophagus, However, there are very few long-term follow-up studies (>10 years) in these patients.


OBJECTIVE
To perform a very late subjective and objective follow-up in a group of 67 patients submitted to esophagomyotomy plus a partial antireflux surgery (Dor's technique).


METHODS
In a prospective study that lasted 30 years, 67 patients submitted to surgery were divided into 3 groups: group I followed for 80 to 119 months (15 patients); group II, with follow-up of 120 to 239 months (35 patients); and group III, with follow-up more than 240 months (17 patients). They were submitted to clinical questionnaire, endoscopic evaluation, histologic analysis, radiologic studies, manometric determinations, and 24-hour pH studies late after surgery.


RESULTS
Three patients developed a squamous cell esophageal carcinoma 5, 7, and 15 years after surgery. At the late follow-up, Visick III and IV were seen in 7%, 23%, and 35%, according to the length of follow-up of each group. Endoscopic examination revealed a progressive nonsignificant deterioration of esophageal mucosa, histologic analysis distal to squamous-columnar junction showed a significant decrease of fundic mucosa in patients of group III, with increase of intestinal metaplasia, although not significant time. Lower esophageal sphincter showed a significant decrease of resting pressure 1 year after surgery, which remained similar at the late control. There was no return to peristaltic activity. Acid reflux measured by 24-hour pH studies revealed a progressive increase, and the follow-up was longer. Nine patients developed Barrett esophagus: 6 of them a short-segment and 3 a long-segment Barrett esophagus. Final clinical results in all 67 patients demonstrated excellent or good results in 73% of the cases, development of epidermoid carcinoma in 4.5%, and failures in 22.4% of the patients, mainly due to reflux esophagitis. Incomplete myotomy was seen in only 1 case.


CONCLUSIONS
In patients with achalasia submitted to esophagomyotomy and Dor's antireflux procedure, there is a progressive clinical deterioration of initially good results if a very long follow-up is performed (23 years after surgery), mainly due to an increase in pathologic acid reflux disease and the development of short- or long-segment Barrett esophagus.
Csendes
Attila
A
Department of Surgery, University Hospital, Santiago, Chile. acsendes@machi.med.uchile.cl
Braghetto
Italo
I
Burdiles
Patricio
P
Korn
Owen
O
Csendes
Paula
P
Henríquez
Ana
A
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001471:Barrett Esophagus / Q000453:epidemiology; D016009:Chi-Square Distribution; D004931:Esophageal Achalasia / Q000175:diagnosis / Q000503:physiopathology* / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000453:epidemiology; D004945:Esophagoscopy; D005260:Female; D005500:Follow-Up Studies; D005745:Gastric Acidity Determination; D006801:Humans; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D011795:Surveys and Questionnaires; D016896:Treatment Outcome