Does illness severity matter? A comparison of laparoscopic esophagomyotomy with fundoplication and esophageal dilation for achalasia

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Abstract
There is scarce evidence regarding optimal treatment options for achalasia in patients with varying illness severity risk. The objective of this study was to evaluate and compare outcomes with laparoscopic esophagomyotomy with fundoplication (LM) and esophageal dilation (ED) for hospitalized patients with different illness severity. The University HealthSystem Consortium (UHC) is an alliance of more than 100 academic medical centers and nearly 200 affiliate hospitals. UHC’s Clinical Data Base/Resource Manager (CDB/RM) allows member hospitals to compare patient-level risk-adjusted outcomes for performance improvement purposes. The CDB/RM was queried for patients with achalasia who underwent LM (n = 1,390) or ED (n = 492) during a 3-year period between 2006 and 2008. Overall esophageal perforation rates were significantly higher for ED (0.4% LM vs. 2.4% ED; p < 0.001). Patients undergoing LM with minor/moderate illness severity showed higher morbidity (9.42% LM vs. 5.15% ED; p < 0.05). However, LM patients in this illness severity group showed significantly lower 30-day readmission rate (0.38% LM vs. 7.32% ED; p < 0.001) and length of stay (2.23 ± 1.78 LM vs. 4.88 ± 4.42 days ED; p < 0.001), but comparable cost ($9,539 LM vs. $8990 ED; p > 0.05). In the major/extreme illness severity group mortality was comparable (1.37% LM vs. 2.44% ED; p > 0.05). Overall morbidity was significantly greater in LM (50.48% LM vs. 19.57% ED; p < 0.001). However, the length of stay was significantly increased in the ED group (8.96 ± 7.86 LM vs. 11.72 ± 11.05 days ED; p = 0.04). In hospitalized patients with minor/moderate illness severity, laparoscopic myotomy for achalasia showed comparable or better outcomes than ED. For major/extreme illness severity, dilation showed comparable or better profile for hospitalized achalasia patients. These results highlight the importance and impact of illness severity on outcomes of achalasia patients.