Surgery Should Be Primary Treatment for Achalasia
By HospiMedica International staff writers
Posted on 22 Aug 2012
Surgery should be the primary treatment for patients with achalasia, despite higher morbidity than observed with endoscopy, according to a new study.Posted on 22 Aug 2012
Researchers at the University of Chicago (IL, USA) conducted a retrospective study in which they analyzed electronic medical records (EMRs) from 148 patients with achalasia between January 1, 2000, and August 9, 2011, to determine the efficacy of endoscopic versus surgical treatments. In the surgical group, 72 patients underwent surgical myotomy with or without a full or partial fundoplication. Eight of those patients (11%) had more than one surgical admission, and 23 patients (32%) had undergone prior endoscopic treatment.
Image: The operation to relieve the symptoms of achalasia involves opening up the esophageal sphincter muscle. When the muscle is properly opened, it will allow food to pass forward. In order to help prevent acid from refluxing backward, causing esophageal reflux or GERD, a partial fundoplication is usually performed at the end of the procedure (Photo courtesy of Laparoscopic.md).
In the endoscopic group, 76 patients underwent only endoscopic treatments, which included balloon dilation, botulinum injection or both; 53 of those patients (70%) had more than one treatment, which came to 174 endoscopic interventions total. The investigators noted no statistically significant differences between the demographics, except that patients in the surgical cohort were significantly younger (56.3 versus 72.7 years).
The results showed that the average time between the first and second surgery was almost seven times longer than that for endoscopic procedures. Patients in the endoscopic group underwent a mean of three interventions and had significantly more dysphagia and gastroesophageal reflux disease (GERD)-related symptoms than the surgical group. The 30-day morbidity rate in the surgical group, however, was more than four times greater than that in the endoscopy group (6.9% versus 1.3% patients, respectively); deaths did not occur in either group. The study was presented at Digestive Disease Week (DDW), held during May 2012 in San Diego (CA, USA).
“Surgery is more efficacious than endoscopy alone because there is better resolution of achalasia and maybe even better treatment of the reflux,” said study investigator Michael Ujiki, MD, a clinical assistant professor of surgery. “If you look at this issue overall, the endoscopic surgeries end up costing more because of all the subsequent repeat interventions that may be required.”
Achalasia is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES). It is characterized by incomplete LES relaxation, increased LES tone, and lack of peristalsis of the esophagus. Achalasia is characterized by difficulty swallowing, regurgitation, and sometimes chest pain. Various treatments are available, although none cures the condition. Certain medications or Botox may be used in some cases, but more permanent relief is brought by esophageal dilatation and surgical cleaving of the muscle.
Related Links:
University of Chicago