Esophageal Motility Disorders and Strictures

Achalasia

Pneumatic dilation is the initial treatment of first choice in patients with achalasia. To compare different treatment alternatives in patients with achalasia, four different strategies (laparoscopic Heller myotomy with fundoplication, thoracoscopic myotomy, pneumatic dilation, and botulinum toxin injection) were compared using a decision analysis (Markov) model. On the basis of quality-adjusted life years (QALYs), only thoracoscopic myotomy was less effective than the other three strategies, but pneumatic dilation proved to be the most effective for patients with a life expectancy of more than seven years. However, based on these data, an individualized approach to patients with achalasia is recommended [1].

In a large series of 106 patients undergoing laparoscopic Heller myotomy, there was a failure rate of 10 in 106 (9.4 %), mainly due to uncut fibers at the gastric side of the lower esophageal sphincter (six of 10) or at the oral side (one of 10). The preoperative abdominal length of the lower esophageal sphincter (LES) was the main predictor of poor or good outcome [2]. Endoscopic treatment (dilation or botulinum toxin) or surgical treatment not only improved the symptoms (dysphagia, chest pain) but also led to an improvement in the quality of life and social functioning [3]. In a similar approach, three treatment methods were compared using a computer model. The model showed that initial laparoscopic myotomy achieved successful treatment with fewer procedures and fewer complications, but that pneumatic dilation was less costly [4].

The cost-effectiveness of different treatment methods (laparoscopic myotomy, pneumatic dilation, or botulinum toxin injection) in achalasia was analyzed over a five-year period using a computer model (Markov). Pneumatic dilation was the most cost-effective treatment per quality-adjusted life year, and botulinum toxin was preferable in the model under certain assumptions, but laparoscopic myotomy was not cost-effective [5].

Botulinum toxin treatment was associated with a higher cumulative rate of treatment failure when compared with pneumatic dilation in a prospective trial including 39 patients. The estimated Kaplan-Meier one-year retreatment rates were 85 % and 47 %, respectively. The treatment failure rates - unusually defined as relapse after two sessions - were 40 % and 0 %, and two botulinum toxin injections were found to be as effective as a single pneumatic dilation [6].

The experience and results with pneumatic dilation in 173 patients with a mean follow-up of 41.8 months showed good or fair treatment results in 76 % and 8.7 %, respectively, with low post-treatment LES pressure being the only predictor of a good treatment result. The overall complication rate was 5.1 %, with a perforation rate of 3.6 % [7].

The long-term follow-up of patients with achalasia was investigated using a questionnaire sent to 249 patients who had undergone pneumatic dilation. A total of 125 of the 249 responded (50 %), and reported results that were excellent (19 %), good (31 %), moderate (15 %), or poor (35 %). In a subgroup of patients with a mean follow-up of more than 20 years, the outcome was excellent (12 %), good (28 %), moderate (20 %), or poor (40 %), with a mean of four dilations. About 50 % of the patients required a second dilation after a mean of 6.4 years. Of the 32 patients who died during the follow-up, six (19 %) died of esophageal carcinoma, with an interval between first treatment and death of 9.9 years [8].

In four children under the age of two years and seven children older than two who had achalasia, forceful brief dilation with a Rigiflex balloon was found to be a safe technique. In children older than two years, the success rate was almost 100 %, but the results were different in those who were younger than two who underwent dilation using a 20-mm through-the-scope balloon; more dilations were needed, and the responses were poorer [9].

Gastroesophageal reflux is thought to be a rare symptom in patients with achalasia. In 19 of 35 patients with achalasia who underwent thoracoscopic myotomy, a 24-hour pH-metry study was performed. Pathological gastroesophageal reflux was found in six of the 19 (31 %), whereas eight (42 %) showed evidence of esophageal fermentation. Three of five patients who had postoperative reflux had also had preoperative reflux, indicating that patients with preoperative gastroesophageal reflux may have an increased risk for postoperative reflux problems. During a 40-month follow-up period, 83 % of the patients showed good or excellent results [10].

References

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• 2 Zaninotto G, Constantini M, Portale G, et al. Etiology, diagnosis and treatment of failures after laparoscopic Heller myotomy for achalasia.  Gastroenterology. 2000;  118 A1061
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