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

Heller myotomy Local treatment patterns A total of 38 patients underwent laparoscopic Heller myotomy at the Montreal General Hospital, Montreal, Quebec from June 1999 to April 2004. Overall, 47% (18 of 38) of the patients had one or more endoscopic interventional procedures before referral for laparoscopic myotomy. Botulinum toxin injection alone was used in six patients, 10 had pneumatic dilation alone and two had both. The proportion of patients having endoscopictreatment before surgery declined from 70% in the first 10 patients (seven of 10) to 39% (11 of 28) subsequently (P=0.19). buy asthma inhalers

Regional treatment patterns
One hundred eighty-five patients were identified in the RAMQ database to have undergone a Heller myotomy from 1997 to 2002 (Table 1). The number of procedures per year remained stable over this period (prelaparoscopy = 28.7/year, postlaparoscopy = 33/year). Patients were older in the postlaparoscopy period. The proportion of patients undergoing preoperative endoscopictreatment did not significantly differ between prelaparoscopy (29%) and postlaparoscopy (23%) periods (Figure 2); however, the median time interval between the last endoscopictreatment and myotomy decreased from seven to three months. The rate of concurrent fundoplication increased significantly, from 11% to 52% (P<0.01). Seven patients hadtreatment failure severe enough to elicit an additional postoperative endoscopic procedure or a repeat myotomy. A fundoplication was present in two of seven failures (29%), similar to the rate in the overall cohort (60 of 185, 32%).

TABLE 1 Patient characteristics and treatment of 185 patients undergoing surgical myotomy from 1997 to 2002 in Quebec, divided into two groups based on the approximate date of general availability of minimally invasive Heller myotomy (January 1, 2000)

Prelaparoscopy (1997 to 1999) Postlaparoscopy (2000 to 2002) P
n 86 99
Age (years) 46 51 0.04
Sex (male/female) 45/41 47/52 0.51
Prior endoscopic therapy, n (%) 14 23 0.24
Interval (months)* 7 (0.25-57) 3 (0.25-18) 0.04
Concurrent fundoplication, n (%) 9 51 <0.01

*Time from last endoscopic intervention to surgical myotomy


Figure 2) Annual rate of previous endoscopic intervention in all patients undergoing Heller myotomy in Quebec from 1997 to 2002 (P = not significant)

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