OGBN P04 Achalasia: A single-centre experience of surgical management over 14 years Free

Achalasia is a rare motility disorder of the oesophagus with likely autoimmune aetiology, characterised by absent oesophageal peristalsis and impaired lower oesophageal sphincter relaxation. Typical symptoms include dysphagia, regurgitation and weight loss. Different treatment modalities are available, predominantly aimed at improving quality of life.

No UK guidelines currently exist for the management of achalasia; the US-based SAGES guidelines (2011) do however provide evidence-based recommendations, albeit of varying strength. A published survey of UK surgeons revealed variation in certain aspects. We sought to explore our institution's experience in management of achalasia, primarily focusing on surgery (laparoscopic Heller’s cardiomyotomy).

An electronic database search was performed to identify all patients either newly diagnosed with achalasia and / or who received treatment for achalasia at our institution between 2009 and 2022. Patients who had already received endoscopic, radiological or surgical treatment prior to 2000, or at another institution at any time were excluded. Demographics, diagnostic investigations, treatment (Botox injection, dilatation, cardiomyotomy) and surgical outcomes were retrospectively recorded in a database and analysed.

128 patients met the inclusion criteria above; 127 were adults, 66 male.

70 patients (54.7%) underwent laparoscopic Heller’s cardiomyotomy with anterior fundoplication. All patients had OGD, 63 (90.0%) barium swallow and 54 (77.1%) high resolution manometry pre-operatively.

Major intra-operative bleeding occurred in one patient from lower oesophageal ulceration. 12 patients had mucosal breaches, repaired intra-operatively. Iatrogenic oesophageal perforations occurred in two patients requiring return to theatre. No mortalities occurred.

31 patients (44.3%) experienced long-term symptom resolution post-operatively. 8 patients (20.5%) with recurrent symptoms had laparoscopic re-do surgery, 11 Botox (28.2%) and 11 dilatation (28.2%) - several had combination of modalities.

Access to regional, then latterly local, high resolution manometry has facilitated full diagnostic assessment, as SAGES strongly recommends all patients undergo along with OGD and barium swallow.

Surgical management of achalasia at our institution over this 14-year period has been very standardised, owing to the operations being performed by two consultant surgeons only.

A good proportion of operated patients had a successful outcome with long-term resolution of symptoms. Serious complications in our cohort were rare; these patients required re-operation and ultimately recovered. Laparoscopic Heller’s cardiomyotomy with anterior fundoplication can be a safe and effective management option for achalasia.