Health-related quality of life after laparoscopic Heller myotomy and Dor fundoplication for achalasia

doi:10.1016/j.surg.2016.10.023

Surgery

Volume 161, Issue 4, April 2017, Pages 977-983

https://doi.org/10.1016/j.surg.2016.10.023 Get rights and content

Background

In addition to symptom scores, a person's perception of health and quality of life assessment is an important indicator of quality of treatment and can provide an efficient index to compare different therapeutic modalities in chronic disease states. Only a few studies have investigated quality of life comprehensively in patients with achalasia, and therefore the controversy regarding the best treatment algorithm continues. The primary study outcome was pre- and postoperative quality of life in patients with achalasia undergoing laparoscopic Heller myotomy and Dor fundoplication.

Methods

The study is a retrospective, observational cohort. The hospital registry and the updated research database were reviewed to identify all patients who were treated for achalasia between 2010 and 2015. Patients were eligible for the study if they had a minimum 1-year follow-up and had pre-and postoperative Eckardt, Short Form-36, and Gastro-Esophageal Reflux Disease Health-Related Quality of Life scores. Patients with previous operative and/or endoscopic treatments for achalasia were excluded.

Results

One-hundred and eighteen patients were identified. The median follow-up was 40 months (interquartile range 27). The proportion of patients with Eckardt stage II–III decreased from 94.9–13% (P < .001). The mean Eckardt score decreased from 6.9 ± 1.9 to 1.7 ± 1.2 (P < .001); the mean Short Form-36 scores significantly increased in all 8 domains; the mean Gastro-Esophageal Reflux Disease Health-Related Quality of Life score decreased from 13.9 ± 5.7 to 5.5 ± 5.4 (P < .001). Finally, 88% (confidence interval 81–93) of patients were satisfied regarding their present condition.

Conclusion

Quality of life assessed with generic and disease-specific validated instruments significantly improved after laparoscopic Heller myotomy combined with Dor fundoplication.

Section snippets

Methods

This study examines a retrospective, observational cohort. The hospital registry and the continuously updated research database were reviewed to identify all patients who were treated for achalasia at our institution between 2010 and 2015. Patients were eligible for the study if they had a minimum 1-year follow-up, had the Eckardt score recorded, and completed the Short Form-36 (SF-36) and the Gastro-Esophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaires pre- and

Results

Between January 2010 and December 2015, 199 consecutive patients underwent laparoscopic Heller myotomy and Dor fundoplication. Of these, 139 patients had a minimum 1-year follow-up. Eighteen subjects were excluded because underwent previous endoscopic pneumatic dilation (n = 13) or an antireflux repair other than an anterior fundoplication (n = 5). Of the remaining 121 patients, 3 did not have both pre- and postoperative Eckardt score and the SF-36 and GERD-HRQL questionnaires and were

Discussion

This study shows a sustained improvement in quality of life after laparoscopic myotomy and Dor fundoplication for achalasia at a median follow-up of 40 months. All SF-36 domains significantly improved after operation and reached clinical significance, with the exception of the vitality domain. The most marked improvements were noted on the role-physical domain, followed by the social function and bodily pain. Also, the summary measures of SF-36 physical and mental components significantly

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Cited by (21)

Laparoscopic Heller myotomy and anterior Dor fundoplication for achalasia cardia in Malaysia: Clinical outcomes and satisfaction from four tertiary centers
2021, Asian Journal of Surgery
Citation Excerpt :
At the moment, there is also limited long-term data regarding its efficacy and durability. At present, LHM remains the preferred surgical intervention with a low complication rate,1 good efficacy without the need for an additional therapy1,2 and a proven long-term resolution of dysphagia8 with improved quality of life.9,10 Nevertheless, the surgery is essentially palliative, aiming at lowering the LES resting pressure, resulting in improved esophageal emptying and symptomatic relief of dysphagia.8
To evaluate the clinical outcomes and satisfaction of patients following laparoscopic Heller myotomy for achalasia cardia in four tertiary centers.
Fifty-five patients with achalasia cardia who underwent laparoscopic Heller myotomy between 2010 and 2019 were enrolled. The adverse events and clinical outcomes were analyzed. Overall patient satisfaction was also reviewed.
The mean operative time was 144.1 ± 38.33 min with no conversions to open surgery in this series. Intraoperative adverse events occurred in 7 (12.7%) patients including oesophageal mucosal perforation (n = 4), superficial liver injury (n = 1), minor bleeding from gastro-oesophageal fat pad (n = 1) & aspiration during induction requiring bronchoscopy (n = 1). Mean time to normal diet intake was 3.2 ± 2.20 days. Mean postoperative stay was 4.9 ± 4.30 days and majority of patients (n = 46; 83.6%) returned to normal daily activities within 2 weeks after surgery. The mean follow-up duration was 18.8 ± 13.56 months. Overall, clinical success (Eckardt ≤ 3) was achieved in all 55 (100%) patients, with significant improvements observed in all elements of the Eckardt score. Thirty-seven (67.3%) patients had complete resolution of dysphagia while the remaining 18 (32.7%) patients had some occasional dysphagia that was tolerable and did not require re-intervention. Nevertheless, all patients reported either very satisfied or satisfied and would recommend the procedure to another person.
Laparoscopic Heller myotomy and anterior Dor is both safe and effective as a definitive treatment for treating achalasia cardia. It does have a low rate of oesophageal perforation but overall has a high degree of patient satisfaction with minimal complications.
Dor versus Toupet fundoplication after Laparoscopic Heller Myotomy: Systematic review and Bayesian meta-analysis of randomized controlled trials
2020, Asian Journal of Surgery
Citation Excerpt :
Current therapy aim to relieve the distal esophageal functional obstruction and related symptoms such as dysphagia and regurgitation. Laparoscopic Heller Myotomy (LHM) has become the treatment of choice with significant improvement of patient symptoms and quality of life.3,4 Postoperative Gastroesophageal Reflux Disease (GERD) may occur after myotomy without fundoplication and may be cause of treatment failure.5
Laparoscopic Heller Myotomy (LHM) with partial fundoplication has become the treatment of choice for esophageal achalasia. However, the choice of the partial fundoplication is debated. The aim of this study was to compare outcomes for Dor and Toupet fundoplication after LHM. A systematic search of randomized controlled trials comparing Dor and Toupet fundoplication was performed using PubMed, EMBASE and Web of Science. Three studies met the inclusion criteria. Overall, 174 patients were included in the analysis. The postoperative abnormal acid reflux [pooled Risk Ratio 0.98 (95% HPD 0.54–1.80)] and dysphagia [pooled Risk Ratio 1.03 (95% HPD 0.51–2.05)] were similar comparing Dor and Toupet fundoplication. The % total time pH ≤ 4 [estimated pooled mean difference −0.08 (95% HPD −1.04–0.90)] and DeMeester score [estimated pooled mean difference 0.51 (95% HPD −0.90–1.94)] were comparable. Additionally, the operative time [estimated pooled mean difference 0.02 (95% HPD −0.53–0.52)] and iatrogenic esophageal perforation [pooled Risk Ratio 1.05 (95% HPD 0.52–2.10)] were similar in the two groups. Dor and Toupet fundoplication after laparoscopic Heller myotomy seem comparable in term of postoperative abnormal acid exposure and dysphagia. The choice of the partial fundoplication should be left to surgeon experience and tailored on each patient.
Surgical Management of Gastroesophageal Reflux Disease in Patients with Severe Esophageal Dysmotility
2019, Journal of Gastrointestinal Surgery
Gastroesophageal reflux disease (GERD) and esophageal dysmotility are often disqualifying criteria for fundoplication due to dysphagia complications. A tailored partial fundoplication may improve GERD in patients with severe esophageal motility disorders. We evaluate this approach on GERD improvement in non-achalasia esophageal dysmotility patients.
A single-institution prospective database was reviewed (2007–2016), with inclusion criteria of GERD, previous diagnosis of non-achalasia esophageal motility disorder, and laparoscopic partial fundoplication. Diagnosis of previous achalasia diagnosis or diffused esophageal spasm was excluded. Motility studies, pre- and post-upper gastrointestinal imaging (UGI), esophageal symptom scores, antacid, and PPI use were collected pre-op, 6 months, 12 months, and long-term (LT). Statistical analysis was made using SPSS v.23.0.0, α = 0.05.
Fifty-two patients met the inclusion criteria. A total of 17.3% had esophageal body amotility, 79.6% had severe esophageal dysmotility. A total of 65.9% women (mean age 64 ± 15.7), mean peristalsis 45.3 ± 32.6%, and failed peristalsis 36.0 ± 32.2%. Mean LES residual pressure was 15.0 ± 18.0 mmHg, and 40.7% had hypotensive LES. Mean follow-up time was 25 months [1–7 years], with significant improvement in symptoms and reduction in PPI and antacid use at all time-points compared to pre-op. A total of 74% had UGI studies at 12 months; all showed persistent dysmotility. Six patients had radiographic hiatal hernia recurrence, with only one being clinically symptomatic postoperatively. Three required dilation for persistent dysphagia.
A tailored partial fundoplication may be effective in symptom relief for non-achalasia patients with esophageal motility disorders and GERD. Significant symptom improvement, low HHR, and PPI use clearly indicate this approach to be effective for this population.
Laparoscopic Heller Myotomy vs Per Oral Endoscopic Myotomy: Patient-Reported Outcomes at a Single Institution
2018, Journal of the American College of Surgeons
Although laparoscopic Heller myotomy (LHM) has been the standard of care for achalasia, per oral endoscopic myotomy (POEM) has gained popularity as a viable alternative. This retrospective study aimed to compare patient-reported outcomes between LHM and POEM in a consecutive series of achalasia patients with more than 1 year of follow-up.
We reviewed demographic and procedure-related data for patients who underwent either LHM or POEM for achalasia between January 2011 and May 2016. Phone interviews were conducted assessing post-procedure achalasia symptoms via the Eckardt score and achalasia severity questionnaire (ASQ). Demographics, disease factors, and survey results were compared between LHM and POEM patients using univariate analysis. Significant predictors of procedure failure were analyzed using univariate and multivariate analysis.
There were no serious complications in 110 consecutive patients who underwent LHM or POEM during the study period, and 96 (87%) patients completed phone surveys. There was a nonsignificant trend toward better patient-reported outcomes with POEM. There were significant differences in patient characteristics including sex, achalasia type, mean residual lower esophageal pressure (rLESP), and follow-up time. The only univariate predictors of an unsatisfactory Eckardt score or ASQ were longer follow-up and lower rLESP, with follow-up length being the only predictor on multivariate analysis.
There were significant demographic and clinical differences in patient selection for POEM vs LHM in our group. Although the 2 procedures have similar patient-reported effectiveness, subjective outcomes seem to decline as a result of time rather than procedure type.
Long-term outcomes of laparoscopic Heller’s myotomy with angle of His accentuation in patients of achalasia cardia
2024, Surgical Endoscopy
Post-Surgical Quality of Life After Laparoscopic Heller Myotomy with Fundoplication for the Treatment of Achalasia
2023, Indian Journal of Surgery

View all citing articles on Scopus

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EsophagusHealth-related quality of life after laparoscopic Heller myotomy and Dor fundoplication for achalasia

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Gastroenterology

J Gastrointest Surg

Am J Surg

Treating achalasia: from whalebone to laparoscope

JAMA

Primary treatment of esophageal achalasia. Long-term results of myotomy and Dor fundoplication

Arch Surg

Minimally invasive surgery for achalasia: an 8-year experience with 168 patients

Ann Surg

The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up

Surg Endosc

Minimally invasive surgery for esophageal achalasia

World J Gastroenterol

Long-term results of the European achalasia trial: a multicenter randomized controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy

Gut

The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience

Surg Endosc

Assessment of quality-of-life outcomes

N Engl J Med

Gastrointestinal quality of life before and after laparoscopic Heller myotomy with partial fundoplication

Ann Surg

Evaluation of quality of life after laparoscopic surgery

Surg Endosc

Esophagus
Health-related quality of life after laparoscopic Heller myotomy and Dor fundoplication for achalasia