Relationship between subjective and objective data in achalasia patients after laparoscopic Heller-Dor procedure

Abstract

Goal of surgery – to relieve dysphagia without inducing gastroesophageal reflux. Whether postoperative reflux and dysphagia can be assessed by questionnaires, obviating the need of 24-h pH-testing and manometry is unknown. Aim of study was to assess how subjective evaluation correlates with objective data after Heller-Dor procedure for different morphologic types of achalasia. Laparoscopic Heller-Dor procedure was performed in 47 patients: in 24 spindle type, Sp, patients; in 16 flask type, Fk, patients; and in 7 sigmoid type, Sig, patients. Subjective evaluation was done preop and postop using Dysphagia four-point rating scale and Gastroesophageal Reflux Disease Health-Related Quality of Life scale. Every patient preop and postop was asked to undergo objective evaluation with manometry, 24-h pH testing, endoscopy and barium swallow. Mean follow-up was 4 years (range 1 – 10). The results of laparoscopic procedures were also assessed in operation time, intraoperative and postoperative complications and postoperative hospital stay. There were no conversions to open surgery. Mean operation time was 110±23 min. Median postoperative hospital stay was 5.5±2.2 days. Intraoperative and postoperative complications included 2 cases (4.2 %) of mediastinal emphysema and 1 case (2.1 %) of pneumonia. Degree of dysphagia relief was excellent in 39 (83 %) patients, good in 7 (14.9 %) patients and moderate in 1 patient (2.1 %). Mean lower oesophageal sphincter (LOS) resting pressure decreased from 25.2 mmHg (range 17.3 – 39.1) to 14.1 mmHg (range 11.2 – 18.0). There was poor correlation between median postoperative dysphagia score and median postoperative LOS pressure (r = 0.17) and also no correlation between median change in dysphagia score from preop to postop and median change in LOS pressure (r = 0.03). Median De Meester score decreased from 15.1 (range 3.1 – 94.4) to 5.9 (range 2.9 – 49.3). There was poor correlation between GERD-HRQL score and De Meester score (r = 0.25). Laparoscopic Heller-Dor procedure is an effective treatment of achalasia. Subjective evaluation can document symptomatic relief and health-related quality of life but does not accurately reflect postoperative reflux and LOS pressure, including the different morphologic types. 24-h pH study is required to assess gastroesophageal reflux adequately.