Long-Term Outcomes Good After Cardiomyotomy for Achalasia

July 05, 2013

By Rob Goodier

NEW YORK (Reuters Health) Jul 03 - Long-term clinical outcomes look promising after laparoscopic surgery of the esophagus to treat achalasia, a new paper says.

The results suggest a need for targeted endoscopic surveillance, but nothing more general, researchers say.

"In this study, only eight patients (12%) had a further endoscopic dilation after myotomy, and only two (3%) required repeat cardiomyotomy," the research team reported May 31 online in Annals of Surgery.

"Based on our study, we would recommend an initial endoscopic evaluation of patients five years following cardiomyotomy. No routine scans are necessary," coauthor Dr. Sarah Thompson at Royal Adelaide Hospital in Adelaide, Australia, told Reuters Health by email.

"Depending on the findings at initial endoscopy, patients should remain on a surveillance protocol every two to five years," Dr. Thompson said.

She and her team reported on endoscopy performed on 68 patients at a mean of 10 years (median eight years) since their surgery.

Most (93%) still had difficulty swallowing after their treatment, but significantly less than before surgery. Overall, the patients reported an average satisfaction score of 7.9 out of 10 and 97% said that the surgery had been a good decision.

Symptoms were mild in 56%, at grades 1 and 2 out of 5 on the Visick scale. Thirteen percent reported moderate symptoms that interfere with their quality of life at grade 4, and one patient reported grade 5 symptoms, meaning worse than before the operation.

Fewer than 10% reported regular reflux; 29% were on acid suppression medication.

"Symptoms of reflux before five years should be treated with antireflux medication, and in our center, we would probably do an endoscopy at this time to ensure symptoms are due to reflux and not regurgitation," Dr. Thompson said.

Endoscopic analysis found tortuosity, dilatation, food residue or some combination of those abnormalities in 67% of the patients. A fundoplication wrap was visible in 53% of the patients.

Forty-four percent suffered inflammation of the lower esophagus and 22% had severe esophagitis. Histologic analysis found chronic inflammation of the distal esophagus in 83%.

Five patients (7%) showed signs of Barrett's esophagus.

None of the patients showed signs of dysplasia or malignancy.

The database search had discovered 171 patients who had undergone cardiomyotomy five or more years prior, and two of them had developed squamous cell carcinoma of the esophagus. Esophageal cancer rates have been higher in past studies, but this new research did not independently assess severe esophageal changes, and the low cancer rate makes it difficult to draw a conclusion, the researchers write.

They conclude, "Our current study supports the evidence from the literature that, at up to 10 years after myotomy, the incidence of esophageal carcinoma is extremely low. Surveillance during this time period is therefore difficult to justify. Follow-up endoscopy at 10 years after onset of achalasia symptoms, or five years after cardiomyotomy, is probably warranted to identify patients at high risk of developing carcinoma."

In comments emailed to Reuters Health, Dr. Lee Swanstrom of the Oregon Clinic in Portland, who wasn't involved with the study, insisted that follow-up endoscopy after achalasia surgery is warranted.

"Indeed, while the risk of cancer is low in this study, it is high in other reports," Dr. Swanstrom said. "More to the point - the authors found a very high incidence of esophageal pathology other than cancer most of which is imminently treatable by endoscopy to the benefit of the patients. They also show that symptoms are very unreliable in determining which patients are harboring problems in their esophagus. My conclusion and our practice, is that patients should be endoscoped every five years after achalasia treatment."

SOURCE: https://1.usa.gov/13mej7b

Ann Surg 2013.


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