Factors associated with postoperative symptoms after laparoscopic Heller myotomy.
BACKGROUND
Our objective is to ascertain if preoperative and perioperative treatments affect the short- and long-term symptom frequency or symptom scores for dysphagia, regurgitation, and heartburn in patients with laparoscopic Heller myotomy for achalasia.


METHODS
From 1994 to 2008, 261 patients undergoing laparoscopic esophageal myotomy were enrolled prospectively. The diagnosis of classic achalasia was made on clinical history, barium swallow, endoscopy, and manometry. A validated symptom questionnaire and history was taken for each patient at the preoperative visit and at each postoperative visit.


RESULTS
In all, 261 patients had laparoscopic Heller myotomy during the study period. Preoperatively, 137 patients (62.3%) tried medications, 101 (38.7%) were treated with pneumatic dilation, and 29 (11.1%) were treated initially with at least one injection of botulinum toxin into the lower esophageal sphincter. In all, 134 patients (51.3%) received a Dor anterior fundoplication. On multivariate regression controlling for age and sex, preoperative dilation (p = 0.031), injection of botulinum toxin (p = 0.044), and a fundoplication (p = 0.005) were associated with significantly worse early postoperative dysphagia, with odds ratios of 2.11, 2.56, and 2.80, respectively; previous botulinum toxin injection was associated with worse late postoperative dysphagia (p = 0.001), regurgitation (p = 0.031), and heartburn (p = 0.049), with odds ratios of 5.24, 2.87, and 2.52, respectively. There was a trend for no fundoplication to be associated with late postoperative heartburn (p = 0.077) with an odds ratio of 1.80.


CONCLUSIONS
Many patients presenting for Heller myotomy have previously undergone a different form of treatment. Early postoperative dysphagia was affected by dilation, botulinum toxin injection, and fundoplication. Only botulinum toxin injection was associated with late symptoms.
Finley
Christian J
CJ
Division of Thoracic Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Canada. christianfinley@shaw.ca
Kondra
Jennifer
J
Clifton
Joanne
J
Yee
John
J
Finley
Richard
R
D000328:Adult; D000368:Aged; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage / Q000009:adverse effects; D002404:Catheterization / Q000009:adverse effects; D003131:Combined Modality Therapy; D003680:Deglutition Disorders / Q000209:etiology; D004931:Esophageal Achalasia / Q000175:diagnosis / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication; D006356:Heartburn / Q000209:etiology; D006801:Humans; D010535:Laparoscopy; D057045:Laryngopharyngeal Reflux / Q000209:etiology; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011183:Postoperative Complications / Q000209:etiology*; D011379:Prognosis; D011446:Prospective Studies; D012086:Reoperation
D019274:Botulinum Toxins, Type A