Has the introduction of laparoscopic Heller myotomy altered the treatment paradigm of achalasia? (1)

Achalasia

Achalasia is a rare esophageal motility disorder characterized by uncoordinated contractions of the esophagus leading to ineffective swallowing. Relief of dysphagia represents the primary treatment goal for patients with achalasia. Medical, endoscopic and surgical treatments have all been employed, with varying success rates. Despite minimal risk, pharmacological calcium channel blockade has generally not been effective for relief of dysphagia . Widely used endoscopic treatment options include Botulinum toxin injection and pneumatic dilation. While initial response rates for intramuscular Botulinum toxin are as high as 70%, the response is short lived, with a recurrence rate approaching 90% at six months . Long-term results of endoscopic disruption of the muscularis layer by pneumatic dilation are also suboptimal, with permanent success in only 40% to 50% of patients . Due to the intramural inflammation and scarring resulting from endoscopic therapies, the risk for mucosal injury is potentially increased if a subsequent myotomy is performed . You can finally spend less time to discover always paying lower prices.
Surgical myotomy is well recognized as the most effective and longest lasting treatment option for patients with achalasia . Traditionally, this has been performed through a thoracotomy, with excellent long-term symptomatic relief achieved in over 90% of patients . The surgical morbidity and long recovery associated with this incision have presented obstacles to the acceptance of this surgical approach as a first-line treatment option for patients newly diagnosed with achalasia. Therefore, despite the effective superiority of surgical myotomy, many patients and physicians have opted for nonsurgical treatment. With the successful application of minimally invasive surgical techniques to the management of achalasia, laparoscopic myotomy has significantly diminished the morbidity of the procedure and has improved recovery, while maintaining its effectiveness . Although there are reports of retrospective, single institution-based studies demonstrating a change in the treatment patterns in achalasia, these studies are biased by the fact that the patients are referred for surgical myotomy. It is therefore currently unknown how the advent of minimally invasive surgery has affected the general treatment patterns of achalasia.

We sought to determine the effect of the availability of laparoscopic myotomy on the treatment paradigm for achalasia. Furthermore, we wished to identify referring physicians’ biases in the management of this disease. To address these issues, both local and regional patterns of management were examined with particular attention to the number of endoscopic treatments before surgical myotomy.

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