Multiple preoperative endoscopic interventions are associated with worse outcomes after laparoscopic Heller myotomy for achalasia.
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.
Snyder
Christopher W
CW
Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
Burton
Ryan C
RC
Brown
Lindsay E
LE
Kakade
Manasi S
MS
Finan
Kelly R
KR
Hawn
Mary T
MT
D000293:Adolescent; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004931:Esophageal Achalasia / Q000601:surgery*; D004945:Esophagoscopy / Q000009:adverse effects*; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011300:Preoperative Care / Q000009:adverse effects*; D011788:Quality of Life; D017211:Treatment Failure; D016896:Treatment Outcome