Esophagomyotomy for achalasia Clinical results 1 to 16 ½ years after 158 consecutive operations

Between 1970 and 1988, 158 esophagomyotomies were performed on 156 patients at the Lahey Clinic. Two patients required reoperation. Of these patients, 78 had undergone previous definitive treatment, 52 by forceful dilation and 26 by an esophageal surgical procedure, usually esophagomyotomy. No postoperative deaths occurred, but complications developed in 14 patients (9%), including four patients with retained bronchial secretions, four patients with urinary tract infection, three patients with wound infection, two patients with spontaneous pneumothorax, and one patient with postoperative paraesophageal hiatus hernia requiring surgical correction. Clinical evaluation of the results of operation was possible in 147 patients; eight patients were lost to follow-up, and three patients were operated on too recently for evaluation. The follow-up interval ranged from 1 to 16 ½ years, averaging 7 ½ years. Of the 147 patients, 129 (88%) were improved by operation. The improvement rate for patients undergoing a primary procedure was 92% whereas for patients undergoing reoperation, it was 67%, a statistically significant difference. The cause of the poor results was gastroesophageal reflux in eight patients, an inadequate myotomy in five patients, megaesophagus in three patients, and recurrent dysphagia in two patients. A comparison of early and late results suggests a slight decrease in the rate of improvement with the passage of time. The improvement rate was in the 90+% range for the first five to six years but only 81 % for patients followed up for an average of 10 ¾ years. We conclude that limited esophagomyotomy without an antireflux procedure is the treatment of choice for patients with esophageal achalasia. An improvement rate of 90% or better can be expected after primary operations, at least for the first five years or more after operation. The suggestive decline in the percentage of improved results after longer follow-up intervals requires further study.