Heller Myotomy for Failed Pneumatic Dilation in Achalasia
Heller Myotomy for Failed Pneumatic Dilation in Achalasia
Objectives: This long-term prospective study describes the effect of myotomy in patients who fail to respond to repeated pneumatic dilations and compares their clinical course with that of patients responding to dilation therapy.
Methods: Nineteen consecutive patients who had never reached a clinical remission after repeated pneumatic dilation underwent myotomy. Their clinical course was compared with that of patients who had reached a clinical remission after a single (n = 34) or multiple (n = 14) pneumatic dilation(s). Symptoms were graded with a previously described symptom score ranging from 0 to 12. Remission was defined as a score of 3 or less persisting for at least 6 months. Duration of remission was summarized using Kaplan Meier survival curves. Association between baseline factors and the need for surgery was evaluated using logistic regression.
Results: Complete follow-up was obtained for 98.5% of the patients. The median duration of follow-up was similar in patients treated by myotomy (10.0 years), in patients reaching a clinical remission after a single dilation (10.6 years), but differed in patients undergoing repeated dilations (6.9 years). The 10-year remission rate was 77% (95% CI 53-100%) in patients undergoing myotomy, 72% (95% CI: 56-87%) in patients "successfully" treated with a single pneumatic dilation and 45% (95% CI: 16-73%) in patients undergoing several dilations. Among all baseline factors investigated, young age was associated with an increased need of surgery.
Conclusions: Myotomy is an effective treatment modality in patients with achalasia who have failed to respond to pneumatic dilation. Young patients may benefit from primary surgical therapy.
Controversy exists with regard to the most optimal therapy for achalasia. None of the available therapeutic methods can reverse the neurologic abnormalities, consisting of a marked reduction or lack of ganglionic cells in Auerbach's plexus, a Wallerian degeneration of extraesophageal nerve fibers and perhaps fewer neurones in the dorsal vagal nucleus. Therefore, any type of therapy for these patients is strictly palliative. Currently, only 2 treatment modalities promise a long-term relief from dysphagia and regurgitation, namely pneumatic dilation and Heller myotomy. Both methods have different characteristics: pneumatic dilation may cause a too low reduction of lower esophageal sphincter (LES) pressure and only little improvement in symptoms, and myotomy may have the opposite effect, leading to a higher frequency of gastroesophageal reflux. The results of a single randomized controlled study suggest that surgery may be more effective than myotomy in the long-term management of patients with achalasia. However, this study has been criticized for its less than optimal method of pneumatic dilation. Thus, at the present time, the optimal therapy for patients with achalasia remains to be determined.
An even greater therapeutic challenge arises in patients who fail to respond to either one of these treatment modalities. There is no prospective controlled study that investigates the effect of surgical myotomy in patients not responding to repeated pneumatic dilation. In fact, it remains unclear whether patients who had previously undergone pneumatic dilation are more difficult to treat surgically. While Patti et al encountered no difficulties when dissecting the different anatomic planes in patients who had previously been treated by pneumatic dilation, others emphasized that surgery is technically more demanding in this situation and occasionally leads to mucosal perforation. Furthermore, there is almost no information on the long-term outcome in patients who have been treated by dilation and subsequently required surgery.
In 1980, we began a prospective long-term observation in patients with achalasia with the aim to determine their long-term clinical course. The current analysis is aimed at answering the following questions. (1) What is the long-term clinical course in patients undergoing surgery after failed pneumatic dilations in comparison with that of patients showing an "optimal response" to a single dilation therapy? (2) Does a preceding pneumatic dilation adversely affect the performance of a Heller myotomy and does it increase perioperative morbidity? (3) Does clinical information obtained at initial presentation allow one to predict the eventual requirement of surgery?
Objectives: This long-term prospective study describes the effect of myotomy in patients who fail to respond to repeated pneumatic dilations and compares their clinical course with that of patients responding to dilation therapy.
Methods: Nineteen consecutive patients who had never reached a clinical remission after repeated pneumatic dilation underwent myotomy. Their clinical course was compared with that of patients who had reached a clinical remission after a single (n = 34) or multiple (n = 14) pneumatic dilation(s). Symptoms were graded with a previously described symptom score ranging from 0 to 12. Remission was defined as a score of 3 or less persisting for at least 6 months. Duration of remission was summarized using Kaplan Meier survival curves. Association between baseline factors and the need for surgery was evaluated using logistic regression.
Results: Complete follow-up was obtained for 98.5% of the patients. The median duration of follow-up was similar in patients treated by myotomy (10.0 years), in patients reaching a clinical remission after a single dilation (10.6 years), but differed in patients undergoing repeated dilations (6.9 years). The 10-year remission rate was 77% (95% CI 53-100%) in patients undergoing myotomy, 72% (95% CI: 56-87%) in patients "successfully" treated with a single pneumatic dilation and 45% (95% CI: 16-73%) in patients undergoing several dilations. Among all baseline factors investigated, young age was associated with an increased need of surgery.
Conclusions: Myotomy is an effective treatment modality in patients with achalasia who have failed to respond to pneumatic dilation. Young patients may benefit from primary surgical therapy.
Controversy exists with regard to the most optimal therapy for achalasia. None of the available therapeutic methods can reverse the neurologic abnormalities, consisting of a marked reduction or lack of ganglionic cells in Auerbach's plexus, a Wallerian degeneration of extraesophageal nerve fibers and perhaps fewer neurones in the dorsal vagal nucleus. Therefore, any type of therapy for these patients is strictly palliative. Currently, only 2 treatment modalities promise a long-term relief from dysphagia and regurgitation, namely pneumatic dilation and Heller myotomy. Both methods have different characteristics: pneumatic dilation may cause a too low reduction of lower esophageal sphincter (LES) pressure and only little improvement in symptoms, and myotomy may have the opposite effect, leading to a higher frequency of gastroesophageal reflux. The results of a single randomized controlled study suggest that surgery may be more effective than myotomy in the long-term management of patients with achalasia. However, this study has been criticized for its less than optimal method of pneumatic dilation. Thus, at the present time, the optimal therapy for patients with achalasia remains to be determined.
An even greater therapeutic challenge arises in patients who fail to respond to either one of these treatment modalities. There is no prospective controlled study that investigates the effect of surgical myotomy in patients not responding to repeated pneumatic dilation. In fact, it remains unclear whether patients who had previously undergone pneumatic dilation are more difficult to treat surgically. While Patti et al encountered no difficulties when dissecting the different anatomic planes in patients who had previously been treated by pneumatic dilation, others emphasized that surgery is technically more demanding in this situation and occasionally leads to mucosal perforation. Furthermore, there is almost no information on the long-term outcome in patients who have been treated by dilation and subsequently required surgery.
In 1980, we began a prospective long-term observation in patients with achalasia with the aim to determine their long-term clinical course. The current analysis is aimed at answering the following questions. (1) What is the long-term clinical course in patients undergoing surgery after failed pneumatic dilations in comparison with that of patients showing an "optimal response" to a single dilation therapy? (2) Does a preceding pneumatic dilation adversely affect the performance of a Heller myotomy and does it increase perioperative morbidity? (3) Does clinical information obtained at initial presentation allow one to predict the eventual requirement of surgery?
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