J Gastrointest Surg (2013) 17:1547–1549 DOI 10.1007/s11605-013-2252-z
2012 SSAT OTHER
What is the Best Primary Therapy for Achalasia: Medical or Surgical Treatment? Who Owns Achalasia? Marco E. Allaix & Marco G. Patti
Received: 24 April 2013 / Accepted: 10 June 2013 / Published online: 19 June 2013 # 2013 The Society for Surgery of the Alimentary Tract
Abstract This article reviews the medical and surgical modalities for the treatment of esophageal achalasia. It compares and critically analyzes the short- and long-term outcomes of pneumatic dilatation and laparoscopic Heller myotomy. Today, laparoscopic Heller myotomy is considered in most centers to be the procedure of choice for the treatment of achalasia. Nevertheless, the success of either procedure is based on the careful selection of the patients and on the surgeon’s and gastroenterologist’s level of expertise. Keywords Achalasia . Botulinum toxin . Pneumatic dilatation . Laparoscopic Heller myotomy
Esophageal achalasia is a primary motility disorder characterized by lack of esophageal peristalsis and failure of the lower esophageal sphincter (LES) to relax properly in response to swallowing. The most common symptoms are dysphagia, regurgitation, heartburn, and chest pain. Aspiration of undigested food can lead to respiratory symptoms, such as cough, hoarseness, wheezing, and episodes of pneumonia. Because the pathogenesis of achalasia is still unknown, treatment is palliative and aims to improve patient’s symptoms and esophageal emptying by decreasing the functional obstruction at the level of the gastroesophageal junction. This goal can be accomplished by either medical therapy or by surgery. Medical options include (1) medications, such as calcium channel blockers and long-acting nitrates, (2) botulinum toxin injection, (3) pneumatic dilatation, and (4) per-oral endoscopic esophageal myotomy (POEM). Because of short duration, decreased efficacy with long-term use, and systemic side effects, the role of medications in the treatment of achalasia is limited and should be reserved for patients at high risk for other treatment modalities. M. E. Allaix : M. G. Patti (*) Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 5031, Room G-207, Chicago, IL 60637, USA e-mail:
[email protected]
Endoscopic botulinum toxin injection locally inhibits the release of acetylcholine from the presynaptic cholinergic nerve endings, thereby lowering LES pressure. While it is a safe procedure, symptom relief progressively declines over time (30 to 40 % at 12 months). Moreover, intramural inflammation and fibrosis may occur at the level of the gastroesophageal junction, making a myotomy more challenging and the results less predictable. Therefore, botulinum toxin injection should be reserved for patients with contraindications to more effective treatment modalities, such as pneumatic dilatation and laparoscopic Heller myotomy.1 Pneumatic dilatation (PD) is considered the most effective nonsurgical treatment modality for achalasia. This procedure has been standardized with the introduction of Rigiflex balloons (Boston Scientific Corporation, MA, USA). Under fluoroscopic or endoscopic guidance, a balloon is gradually inflated at the level of the gastroesophageal junction to disrupt the muscle fibers while leaving the mucosa intact. While in the 1970s, 1980s, and early 1990s PD was widely considered the main treatment modality for patients with achalasia and surgery had a secondary role in the case of PD failure, with the advent of minimally invasive surgery, esophageal myotomy has progressively gained wide acceptance among patients and physicians. This has led to a gradual shift in the treatment algorithm of achalasia, and today, PD is increasingly used as treatment of the few failures of Heller myotomy.2 While the myotomy was initially performed through a left thoracoscopic approach, the possibility of getting better exposure of the gastroesophageal junction and to perform a
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fundoplication (thereby reducing the risk of postoperative gastroesophageal reflux (GER) around 60 % after myotomy alone) has made laparoscopic Heller myotomy (LHM) the treatment of choice in most centers. LHM consists of the controlled section of muscle fibers (myotomy) of the lower esophagus (6 cm) and the proximal gastric wall (2.5–3 cm) followed by a partial fundoplication. Although no significant differences in terms of control of GER are evident between partial anterior (Dor) and partial posterior (Toupet) fundoplication, the former is often preferred because it is simpler to perform, and it covers the exposed esophageal mucosa. A LHM is associated with minimal postoperative pain, short hospital stay (1 to 2 days), and fast recovery (2 weeks). Long-term results show that symptoms are improved in 90 to 95 % of patients at 5 years and in 80 to 90 % at 10 years. Most LHM failures present within the first 2–3 years of follow-up and may reflect fibrosis of the distal edge of the myotomy that can be successfully treated in most cases with PD. Previous endoscopic treatment, such as botulinum toxin injection or PD, may compromise the clinical outcome of LHM, while increased age and esophageal diameter are not associated with adverse outcomes. Therefore, LHM should be performed in patients with a dilated and sigmoid esophagus, while esophagectomy should be considered only when LHM fails. Postoperative GER occurs in about 25 % of patients, and it is usually controlled by acid-reducing medications. The answer to the question “Who owns achalasia?” should be based on large prospective randomized studies. Recently, the results of a multicenter, randomized trial comparing PD (95 patients) to LHM with Dor fundoplication (106 patients) for untreated esophageal achalasia were reported.3 The perforation rate during PD and LHM was 4 and 12 %, respectively. Therapeutic success was defined as a drop in Eckardt score below 3. The study showed comparable success rates after LHM (90 %) and PD (86 %) over a 2year follow-up period. A further analysis reported significantly higher success rates at 2 years in type II patients than in types I and III patients according to the Chicago classification, 4 irrespective of the type of treatment. However, this trial has raised some concerns: &
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The 12 % perforation rate during LHM is much higher than reported in the largest prospective series of untreated patients, raising questions about the experience of some of the surgeons involved in the study. The myotomy was extended 1–1.5 cm only below the gastroesophageal junction, and no specific information was provided about the technical aspects of the Dor fundoplication (such as separation of the muscle edges
J Gastrointest Surg (2013) 17:1547–1549
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