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Achalasia Treated With Open Cardiomyotomy AJS 03

Achalasia Treated With Open Cardiomyotomy AJS 03

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Scientific paper
Gastroesophageal reflux, quality of life, and satisfaction in patients withachalasia treated with open cardiomyotomy and partial fundoplication
Marta Ponce, M.D.
, Vicente Ortiz, M.D.
, Manuel Juan, M.D.
, Vicente Garrigues, M.D.
,Concepcio´n Castellanos, M.D.
, Julio Ponce, M.D.
Gastroenterology Unit, La Fe University Hospital, Valencia, Spain
Surgery Unit, La Fe University Hospital, Valencia, Spain
Servicio de Medicina Digestiva, Hospital Universitario La Fe, Avda. Campanar, 21, 46009 Valencia, Spain
Manuscript received June 5, 2002; revised manuscript December 28, 2002
 Cardiomyotomy, often associated with an antireflux technique, is effective in the management of achalasia, althoughgastroesophageal reflux (GER) may occur after the procedure. Patient-centered measures, ie, health-related quality of life (HRQoL) andsatisfaction, should be included in the evaluation of the patients.
 A study was made of the incidence of GER (symptoms, upper endoscopy and 24-hour pH monitoring), HRQoL (Short Form-36Health Survey), and satisfaction after open-access cardiomyotomy and 180-degree anterior fundoplication in 28 consecutive patients, witha minimum postoperative follow-up of 12 months.
 Mean age was 45 years (range 15 to 80) and 68% were female. In 8 subjects (all with heartburn) GER morbidity was present (4with esophagitis and 4 with positive pH study), and 6 patients required proton pump inhibitors. Short Form-36 scores after surgery weresimilar to those found in the general population. Patient satisfaction was high and was more related to the absence of dysphagia than to thepresence of GER symptoms.
 Gastroesophageal reflux is relatively frequent after cardiomyotomy and partial fundoplication, although the efficacy of protonpump inhibitor treatment minimizes its clinical significance. © 2003 Excerpta Medica, Inc. All rights reserved.
 Gastroesophageal reflux; Achalasia; Heller myotomy; Fundoplication; Quality of life; Patient satisfaction
Therapeutic options for achalasia are directed toward relieof symptoms by reducing the pressure of the lower eso-phageal sphincter (LES). Pneumatic dilatation and cardio-myotomy have been shown to be the most effective tech-niques [1,2], and are presently the treatment options of choice. In this context, a sequential approach is oftenadopted, ie, reserving cardiomyotomy for those patientswho fail to respond to dilatation [3,4]. However, the result-ing decrease in sphincter tone implies a risk of morbiditydue to gastroesophageal reflux (GER). This has led to theaddition of an antireflux technique (usually partial fundo-plication) to cardiomyotomy [5–7]. Few studies to date haveobjectively evaluated the incidence of GER after cardio-myotomy.The principal aim of the present study was to investigatethe incidence of GER in patients with esophageal achalasiasubjected to cardiomyotomy and partial fundoplication.Secondary aims were the assessment of patient health-re-lated quality of live (HRQoL) and satisfaction after surgicaltreatment.
Through a 9-year period, a total of 43 patients withesophageal achalasia were operated on because of failure of pneumatic dilatation (median 3 sessions; range 3 to 5). Allsurgical procedures were performed by one of us (MJ) usinga technique previously described [4]. Briefly, a cardiomyo-tomy and 180-degree anterior fundoplication (Dor tech-nique) was performed using an open (laparotomy) surgicalapproach. The present prospective study involves 28 pa-tients followed up for at least 1 year after surgery. Asregards the remaining 15 patients, 2 were lost to follow-up,
* Corresponding author. Tel.:
34-961973065; fax:
 E-mail address:
 jponce@doymanet.esThe American Journal of Surgery 185 (2003) 560–5640002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved.doi:10.1016/S0002-9610(03)00076-X
3 were incompletely evaluated, and 10 had a follow-upduration of less than 1 year; these subjects were thereforenot included in the study. The response to pneumatic dila-tation was evaluated according to clinical criteria
failurebeing de
ned as the presence of grade II or III dysphagia(Table 1).Gastroesophageal re
ux-associated morbidity after sur-gery was evaluated according to subjective (symptoms) andobjective criteria at least 1 year after the operation or earlierif the patient noted GER symptoms. A structured clinicalquestionnaire was used to evaluate the symptoms, recordingthe presence and severity of heartburn and dysphagia-foodregurgitation (Table 1). Objective assessment was based onthe evaluation of esophagitis by endoscopy and 24-hourambulatory pH monitoring to evaluate acid exposure of theesophagus. The pH-metric study was conducted accordingto the conventional technique, and was considered to bepositive when the total time with pH under 4 exceeded 5%[8]. Esophageal manometry was performed in all patients atthe time of the diagnosis of achalasia, and both before andafter (1 year or more) surgery.Patient satisfaction was determined by a 5-point Likertscale (none, little, medium, much, total), while the HRQoLwas assessed by the Medical Outcomes Study ShortForm-36 Health Survey (SF-36) [9] in its Spanish version[10]. This survey comprises 36 items grouped into 8 cate-gories (physical function, physical role, emotional role, so-cial function, mental health, pain, vitality and generalhealth); higher scores correspond to improved function andwell-being. A proton pump inhibitor (PPI) was prescribedfor GER, administering conventional doses, evaluating re-sponse, and adjusting the dosage as required.Quantitative variables are expressed as the mean andstandard deviation (SD) and/or maximum and minimumvalues. The Student
 test was used to compare quantitativevariables. Statistical signi
cance was considered for
 lessthan 0.05.
Of the 28 patients included in the study, 19 were female(68%) and 9 were male (32%), with a mean age of 45
19years (range 15 to 80). The duration of follow-up aftersurgery was 33
 25 months (range 12 to 108). Sixteenpatients (57%) exhibited no GER manifestations (Tables 2and 3). Of the remaining 12 patients, 10 reported heartburn(grade I in 5, grade II in 4, and grade III in 1). Esophagitiswas identi
ed in 4 patients, and pH study showed abnormalacid re
ux in 9.Esophagitis was symptomatic in 4 patients, and pH studywas positive in 3 of them. In 2 patients who reportedheartburn, both endoscopy and pH study were normal, whilein another 2 cases pH study was positive in the absence of either GER symptoms or esophagitis. All patients withpositive pH study recorded at least one GER episode with aduration of more than 20 minutes (range 23 to 312), and 6of these subjects also had four or more GER episodeslasting more than 5 minutes.Lower esophageal sphincter tone at diagnosis and beforeand after surgery was 28
13 mm Hg (range 8 to 65 mmHg), 25
15 mm Hg (range 6 to 70 mm Hg), and 8
4 mmHg (range 3 to 19 mm Hg), respectively. The LES tone of the patients with any manifestation of GER (heartburn,esophagitis, and/or positive pH study) was 8
 4 mm Hg(range 3 to 15), with no signi
cant differences being ob-served with respect to the patients without GER indicators,9
4 mm Hg (range 3 to 19).Dysphagia was reported after surgery by a total of 16patients (57%), corresponding to grade I in 11 (39%) andgrade II in 5 cases (18%). In no case was weight loss or foodregurgitation observed (grade III). The LES tone among thepatients who reported postoperative dysphagia was 8
 5mm Hg (range 3 to 19), similar to that recorded in thesubjects without dysphagia: 9
3 mm Hg (range 3 to 14).Patients scored their satisfaction with surgical treatmentas total in 20 cases, much in 3, medium in 4, and little in 1case. The degree of patient satisfaction was more related tothe absence of dysphagia than to the presence of GERindicators (Fig. 1).
Table 1Criteria for the grading of symptomsHeartburn Dysphagia and food regurgitation0: absence 0: absenceI:
1 episode/week I: dysphagia
1 episode/dayII:
1 episode/day II: daily dysphagia, or with socialIII: daily, or with social and occupational interferenceand occupationalinterferenceIII: weight loss or foodregurgitation or bothTable 2Patients (%) with manifestations of gastroesophageal re
uxCases Heartburn Esophagitis pH (
)Heartburn 10/28 (36)
 4/10 (40) 7/10 (70)Esophagitis 4/28 (14) 4/4 (100)
 3/4 (75)pHmetry (
) 9/28 (32) 7/9 (78) 3/9 (33)
Table 3Patient distribution according to indicators of gastroesophageal re
ux(GER)Symptoms and signs of GER Cases (%)Heartburn 2 (7)Heartburn and esophagitis 1 (4)Heartburn and pH(
) 4 (14)Heartburn, esophagitis and pH(
) 3 (11)pH (
) 2 (7)Esophagitis 0 (0)None 16 (57)561
 M. Ponce et al. / The American Journal of Surgery 185 (2003) 560–564
The HRQoL score as assessed by the SF-36 Survey aftersurgery was 84
24 in the physical function domain, 75
41 in physical role, 72
 28 in body pain, 70
 25 ingeneral health, 67
 23 in vitality, 87
 20 in socialfunction, 74
 42 in emotional role, and 75
 22 in themental health domain (Fig. 2), showing no differences withgeneral population.Proton pump inhibitor antisecretory treatment was pre-scribed in 8 patients with GER symptoms, esophagitis,and/or positive pH study, followed by symptoms remissionat conventional doses, except in 2 patients who requireddoubling of the dose. Six patients required maintenancetherapy. Two patients with heartburn but only very occa-sional symptoms and 2 subjects showing only positive pHstudy received no antisecretory treatment.
Symptoms remission is the aim of all available treat-ments of achalasia. A signi
cant reduction of LES tone [4]is important to achieve this therapeutic goal. In our series,cardiomyotomy was indicated due to a lack of response topneumatic dilatation, which coincided with a lack of effectupon the tone of the LES. The pressure of LES was effec-tively lowered by cardiomyotomy to a similar degree bothin patients whose dysphagia disappeared entirely and inthose who continued to have mild dysphagia.Sphincter low pressure resulting from therapy can pro-voke GER. Few studies to date have objectively evaluatedthe incidence of GER after cardiomyotomy, and the datafound in the literature are dif 
cult to compare owing to theheterogeneity of the surgical techniques employed and thecriteria used to evaluate the existence of GER. In the case of cardiomyotomy performed by an open abdominal approach,the reported incidence of GER is highly variable, with anestimated mean incidence of 22% [1], although it should betaken into account that the criteria used to de
ne GER varygreatly among series. In this context, there is a lack of prospective studies designed to systematically and objec-tively investigate the presence of GER after surgery forachalasia. A number of studies, including one conducted byour group [4
20], have investigated GER after openor laparoscopic cardiomyotomy based on endoscopy or pHstudy, although not in all patients.In our series, more than one third of all patients reportedheartburn, abnormal esophageal exposure to acid was de-tected by pH study in a similar proportion of cases; andesophagitis was observed in only 4 patients, a
gure thatseems to be low considering the existing esophageal func-tional impairment. In fact, the analysis of our pH-metricrecordings suggests that positivity was largely conditionedby a de
cient esophageal clearance of re
uxed acid (Fig. 3),a phenomenon that has been reported elsewhere [15,17].Thus, it may be postulated that some positive pH study
Fig. 1. Patient distribution according to degree of satisfaction, dysphagiagrade, and indicators of gastroesophageal re
ux (GER).Fig. 2. Average Short Form-36 scores of the patients and reference valuesfor the general Spanish population [10].Fig. 3. Study of pH (detail) showing a long acid re
ux episode with pooresophageal clearance in a patient with achalasia after cardiomyotomy.562
 M. Ponce et al. / The American Journal of Surgery 185 (2003) 560

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