Clinical utility of routine barium esophagram after laparoscopic anterior esophageal myotomy for achalasia

Background: This study aimed to evaluate the clinical utility of routine barium esophagram after laparoscopic anterior esophageal myotomy for achalasia. Methods: The records of 260 consecutive patients who underwent laparoscopic anterior esophageal myotomy for achalasia from May 1996 to August 2007 were reviewed from a prospective institutional review board-approved database. Data are given as mean ± standard deviation. Statistical significance (p < 0.05) was determined using a two-tailed t-test and Fisher's exact test. Results: Routine protocol barium esophagrams performed for 236 patients a mean of 1 ± 0.3 days postoperatively were interpreted for 145 (61.4%) of the patients as normal flow of contrast after esophageal myotomy. There were no false-negative studies in this group, and diet was initiated without incident at a mean of 1 ± 0.2 days. The time to the goal diet was 1.3 ± 0.7 postoperative days, and the mean postoperative time to discharge was 1.5 ± 1 days. Of the 236 patients, 91 (38.6%) had an abnormal barium esophagram (contrast retention or pooling, delayed emptying). For this group, initiation of a diet was delayed for only six (6.6%) patients. Two barium esophagrams (0.9%) interpreted as an esophageal leak were determined to be false-positives after the one patient underwent negative exploratory laparoscopy and the other was observed clinically. In this group, diet was initiated at a mean of 1.1 ± 0.3 days. The time to the goal diet was 1.4 ± 0.7 days, and the mean postoperative time to discharge was 1.8 ± 1.9 days. The mean times to diet initiation, goal diet, and discharge were not significantly different (p ≥ 0.14) between the normal and the abnormal barium esophagram groups. The sensitivity and specificity of an abnormal routine barium esophagram after laparoscopic esophageal myotomy were, respectively, 100% and 62.0%, and the positive and negative predictive values were 2.2% and 100%. Conclusions: Because of its poor positive predictive value, routine barium esophagram after laparoscopic anterior esophageal myotomy should be used selectively in the immediate postoperative period after an uncomplicated procedure.