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Surveillance Endoscopy at Five or More Years After Cardiomyotomy for Achalasia

Gossage, James A. MS, BSc, FRCS*; Devitt, Peter G. MS, FRCS, FRACS*; Watson, David I. MD, FRACS; Myers, Jennifer C. BSc*; Jamieson, Glyn G. MS, FRCS, FRACS*; Thompson, Sarah K. MD, PhD, FRCSC, FRACS*

doi: 10.1097/SLA.0b013e318297ae28
Original Articles

Objective: To perform long-term histopathological and clinical assessment of patients who have previously undergone cardiomyotomy for achalasia.

Background: There are few studies on long-term outcome for patients treated by cardiomyotomy for achalasia. Recent publications suggest that these patients may be at high risk of both squamous cell carcinoma and adenocarcinoma of the esophagus.

Methods: All patients, in whom at least 5 years had elapsed since laparoscopic cardiomyotomy for achalasia, were identified from a prospective database. Patients were invited to attend for endoscopy and clinical outcome was assessed by questionnaire.

Results: Out of 171 patients identified, 2 had died from esophageal carcinoma. Of the remainder, 68 were recruited [mean age 52 years (range 26–72)]. Fifty-six percent reported minimal symptoms and 6% experienced frequent reflux symptoms. Almost all patients (93%) reported some dysphagia, but dysphagia scores remained significantly lower than preoperatively (P < 0.0001). Quality of life was comparable to normal subjects, and 97% of patients indicated they had made the correct decision to undergo surgery. At endoscopy 83% had evidence of chronic inflammation in the distal esophagus on histopathology, including 22% with moderate to severe esophagitis and 7% with Barrett's esophagus. Five patients showed esophageal candidiasis, and 2 had eosinophilic esophagitis. No dysplasia or malignancy was identified.

Conclusions: The clinical outcome remains excellent in most patients at long-term follow-up after cardiomyotomy for achalasia. Surveillance endoscopy might identify high-risk patients but routine endoscopy in all patients is probably not necessary, particularly early after surgery.

Despite awareness that patients with achalasia may be at increased risk of developing esophageal cancer, little is known about the usefulness of surveillance endoscopy. Sixty-eight patients were recruited from a prospective database and endoscoped at least 5 years after cardiomyotomy. From the study findings, a targeted endoscopic surveillance is proposed.

*Discipline of Surgery, The University of Adelaide, Royal Adelaide Hospital, North Terrace

Department of Surgery, Flinders University, Adelaide, South Australia.

Reprints: Sarah K. Thompson, MD, PhD, FRCSC, FRACS, Professorial Oesophagogastric Unit, Discipline of Surgery, The University of Adelaide, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000. E-mail:

Disclosure: The H. J. Windsor Prize, awarded to J.A.G. in 2011, supported this study. For the remaining authors, none were declared. The authors declare no conflicts of interest.

© 2014 by Lippincott Williams & Wilkins.