Has the introduction of laparoscopic Heller myotomy altered the treatment paradigm of achalasia? DISCUSSION (Part 3)

We assessed the predominant treatmentparadigm for achalasia, from the referring physicians’ perspective, with a six-question survey sent to all gastroenterologists in Quebec. Although the vast majority of respondents agreed that surgical myotomy represented the most effective and longest lasting treatmentfor achalasia, only slightly more than one-third referred newly diagnosed patients for immediate surgery. Rather, patients are offered endoscopic therapies (predominantly pneumatic dilation).Several studies suggest that preoperative endoscopictreatment may adversely affect and complicate a subsequent Heller myotomy. Increased intramural fibrosis from either Botulinum toxin injection or endoscopic dilation may obliterate the natural submucosal plane, potentially increasing the risk for mucosal injury during the myotomy . Indeed, more than 40% of responding gastroenterologists agreed that previous endoscopic therapy increases the risk of mucosal injury in the case of a subsequent surgical myotomy. Quebec gastroenterologists favouring immediate referral for Heller myotomy were more likely to believe that preoperative endoscopic therapy complicates subsequent surgicaltreatment. Reasons cited for nonsurgical primarytreatment of achalasia centred on the perceived morbidity of the procedure for a given patient’s physiological state. This bias likely persists from the open transthoracic era despite several studies demonstrating the safety, low morbidity and rapid recovery of minimally invasive Heller myotomy. Buy Asthma Inhalers Online

We have attempted to detect a shift in thetreatmentparadigm of achalasia over a period encompassing the approximate date of the general availability of minimally invasive Heller myotomy in Quebec. Despite a slight decrease in the threshold for referral for surgical myotomy and an understanding among referring physicians that myotomy represents the most effective therapy for achalasia, no difference in the overall rate of previous endoscopictreatmentoccurred in the period under study. The benefits and minimal risk of minimally invasive Heller myotomy need to be more effectively communicated to the referring gastroenterologists, as they often represent the first-line in thetreatmentof achalasia.

 

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