Health economic evaluation of therapeutic strategies in patients with idiopathic achalasia: results of a randomized trial comparing pneumatic dilatation with laparoscopic cardiomyotomy

Efficacy and safety of laparoscopic Heller's myotomy versus pneumatic dilatation for achalasia: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVES: Achalasia has several treatment modalities. We aim to compare the efficacy and safety of laparoscopic Heller myotomy (LHM) with those of pneumatic dilatation (PD) in adult patients suffering from achalasia.

METHODS

We searched Cochrane CENTRAL, PubMed, Web of Science, SCOPUS and Embase for related clinical trials about patients suffering from achalasia. The quality appraisal and assessment of risk of bias were conducted with GRADE and Cochrane's risk of bias tool, respectively. Homogeneous and heterogeneous data was analyzed under fixed and random-effects models, respectively.

RESULTS

The pooled analysis of 10 studies showed that PD was associated with a higher rate of remission at three months, one year, three years and five years (RR = 1.25 [1.09, 1.42] (p = 0.001); RR = 1.13 [1.05, 1.20] (p = 0.0004); RR = 1.48 [1.19, 1.82] (p = 0.0003); RR = 1.49 [1.18, 1.89] (p = 0.001)), respectively. LHM was associated with lower number of cases suffering from adverse events, dysphagia and relapses (RR = 0.50 [0.25, 0.98] (p = 0.04); RR = 0.33 [0.16, 0.71] (p = 0.004); RR = 0.38 [0.15, 0.97] (p = 0.04)), respectively. There is no significant difference between both groups regarding the lower esophageal pressure, perforations, remission rate at two years, Eckardt score after one year and reflux.

CONCLUSION

PD had higher remission rates than LHM at three months, one year and three years, but not at two years or five years. More research is needed to determine whether PD has a significant advantage over LHM in terms of long-term remission rates.

Current Approach to Dysphagia: A Review Focusing on Esophageal Motility Disorders and Their Treatment

Background

Dysphagia is a prevalent condition which may severely impact the patient's quality of life. However, there are still lacking standardized therapeutic options for esophageal motility disorders.

Summary

Dysphagia is defined as a subjective sensation of difficulty swallowing which can result from oropharyngeal or esophageal etiologies. Regarding esophageal dysphagia, after excluding structural causes and esophageal mucosal lesions, high-resolution manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM has not only improved the sensitivity for detecting achalasia but has also expanded our understanding of spastic and hypomotility disorders of the esophageal body. The Chicago Classification v4.0 uses a hierarchical approach and provides a standardized diagnosis of esophageal motility disorders, allowing a tailored therapeutic approach. Dysphagia is often a long-term health problem that broadly impacts health and well-being and leads to physical and psychosocial disability, namely, malnutrition and aspiration pneumonia, as well as social isolation, depression, and anxiety. Apart from achalasia, most esophageal motility disorders tend to have a benign long-term course with symptoms of dysphagia and noncardiac chest pain that can improve significantly over time. Patient-reported outcomes (PROs) are self-assessment tools that capture the patients' illness experience and help providers better understand symptoms from the patients' perspective. Therefore, PROs have a critical role in providing patient-centered care.

Key Messages

Motility disorders should be ruled out in the presence of nonobstructive esophageal dysphagia, and treatment options should be considered according to the severity of symptoms reported by the patient.

Correlation of timed barium esophagography with Eckardt score in primary achalasia patients treated with peroral endoscopic myotomy

PURPOSE

The purpose of our study was to evaluate the role of timed barium esophagogram (TBE) in quantitative measurement of improved esophageal emptying in primary achalasia patients treated with POEM. Also, we investigated the correlation of TBE with improvement of clinical symptoms as measured by Eckardt score.

METHODS

This retrospective study included 30 patients who underwent POEM due to primary achalasia. As a baseline study, all patients underwent TBE and were evaluated for clinical status by Eckardt score based on presence and frequency of dysphagia, regurgitation, substernal pain, and weight loss. Follow-up evaluation was performed within 3 months after POEM. Pre- and post-POEM TBE results were compared using a calculated value based on summation of height of the barium columns on 1-, 2- and 5-min delayed images. Also, the correlation of TBE with improvement of Eckardt score was evaluated using Pearson's correlation test.

RESULTS

There was a significant decrease in the calculated value of height between pre- and post-POEM TBE studies (40.5 ± 15.8-17.0 ± 11.6, p < 0.01). Also, the Eckardt score decreased significantly after POEM (6.7 ± 2.0-0.8 ± 1.0, p < 0.01). Pearson's correlation test revealed a positive correlation between improvement of TBE results and Eckardt score (correlation coefficient = 0.56, p < 0.01).

CONCLUSION

TBE is an objective method for quantitative measurement of improved esophageal emptying in primary achalasia patients treated with POEM and shows positive correlation with clinical symptoms evaluated by Eckardt score.

Achalasia: Diagnosis, Management and Surveillance

Achalasia is a rare chronic esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and abnormal peristalsis. This abnormal motor function leads to impaired bolus emptying and symptoms of dysphagia, regurgitation, chest pain, or heartburn. After an upper endoscopy to exclude structural causes of symptoms, the gold standard for diagnosis is high-resolution esophageal manometry. However, complementary diagnostic tools include barium esophagram and functional luminal impedance planimetry. Definitive treatments include pneumatic dilation, Heller myotomy with fundoplication, and peroral endoscopic myotomy.

Insights into the endoscopic management of esophageal achalasia

Achalasia is a primary esophageal motility disorder characterized by the loss of inhibitory neurons in the myenteric plexus, resulting in impaired relaxation of the esophagogastric junction. Achalasia is an incurable disease, and the treatment modalities are aimed at disruption of the esophagogastric junction and vary widely from pharmacological to endoscopic to surgical. Traditional endoscopic therapy includes pneumatic dilation, botulinum toxin injection, and peroral endoscopic myotomy. This review aims to provide an overview of the endoscopic management of achalasia, while focusing on the utilization of peroral endoscopic myotomy and other novel approaches.

Surgical management of achalasia

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.

2019 Seoul Consensus on Esophageal Achalasia Guidelines

Esophageal achalasia is a primary motility disorder characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Achalasia is a chronic disease that causes progressive irreversible loss of esophageal motor function. The recent development of high-resolution manometry has facilitated the diagnosis of achalasia, and determining the achalasia subtypes based on high-resolution manometry can be important when deciding on treatment methods. Peroral endoscopic myotomy is less invasive than surgery with comparable efficacy. The present guidelines (the "2019 Seoul Consensus on Esophageal Achalasia Guidelines") were developed based on evidence-based medicine; the Asian Neurogastroenterology and Motility Association and Korean Society of Neurogastroenterology and Motility served as the operating and development committees, respectively. The development of the guidelines began in June 2018, and a draft consensus based on the Delphi process was achieved in April 2019. The guidelines consist of 18 recommendations: 2 pertaining to the definition and epidemiology of achalasia, 6 pertaining to diagnoses, and 10 pertaining to treatments. The endoscopic treatment section is based on the latest evidence from meta-analyses. Clinicians (including gastroenterologists, upper gastrointestinal tract surgeons, general physicians, nurses, and other hospital workers) and patients could use these guidelines to make an informed decision on the management of achalasia.

Peroral endoscopic myotomy (POEM) for achalasia

Achalasia is an uncommon disorder that results from the degeneration of ganglion cells of the myenteric plexus in the lower esophageal wall. It is manifested by a loss of peristalsis in the lower part of the esophagus and failure of the lower esophageal sphincter (LES) to relax. Peroral endoscopic myotomy (POEM) is a minimally invasive intervention that aims to treat achalasia. It is regarded as the endoscopic equivalent of Heller myotomy. POEM is a form of natural orifice transluminal endoscopic surgery that is completed by creating a submucosal tunnel in the lower part of esophagus to reach the inner circular muscle bundles of the LES to perform myotomy, while preserving the outer longitudinal muscle bundles. The result is decreased resting pressure of the LES, facilitating the passage of ingested material. POEM was initially introduced to treat achalasia by targeting the LES. POEM has expanded to include gastric POEM (G-POEM), myotomy of the pyloric sphincter to treat gastroparesis, and per rectal endoscopic myotomy to treat adult Hirschsprung's disease.

Endoscopic Pneumatic Dilation for Esophageal Achalasia

Pneumatic dilation is a well-established treatment modality that has withstood the test of time. Prospective and randomized trials have shown that in expert hands, it provides results similar to a laparoscopic Heller myotomy with fundoplication. In addition, it should be considered the primary form of treatment in patients who experience recurrence of symptoms after a surgical myotomy.

Incidence and costs of achalasia in The Netherlands

BACKGROUND

Recent reports show increasing incidence of achalasia in some populations. The aim of this study was to estimate incidence, prevalence, and healthcare costs of achalasia in a large cohort in The Netherlands.

METHODS

Data were obtained from the largest Dutch healthcare insurance company (±4.4 million insured). Adult achalasia patients were identified between 2006 and 2014 when having an achalasia diagnosis code registered. A total of 907 achalasia patients were identified and included in our database, along with 9068 control patients (non-achalasia patients), matched by age and gender.

KEY RESULTS

The mean incidence over the 9-year period was 2.2 per 100 000 persons and the mean prevalence was 15.3 per 100 000 persons. Mean age of achalasia patients was 54 (range 18-98) years. Male to female ratio was 1:1. Socio-economic status distribution was similar in achalasia patients and controls. Prior to the diagnosis, 74% of achalasia patients received proton pump inhibitors and 26% received anti-emetic medication. The first year after diagnosis median total direct medical costs of achalasia patients were €2283 (IQR 969-3044) per year. Patients above the 90th percentile of €4717 were significantly older than other patients below the 90th percentile (mean age 63 vs 57); P = .005.

CONCLUSION & INFERENCES

In this large study that used a database comprising about 25% of all inhabitants of The Netherlands, it is confirmed that achalasia affects individuals of both genders and all ages. The costs associated with diagnosis and treatment of new cases of achalasia increase with increasing age.

Economic evaluation of the randomized European Achalasia trial comparing pneumodilation with Laparoscopic Heller myotomy

BACKGROUND

A recent multicenter randomized trial in achalasia patients has shown that pneumatic dilation resulted in equivalent relief of symptoms compared to laparoscopic Heller myotomy. Additionally, the cost of each treatment should be also taken in consideration. Therefore, the aim of the present study was to perform an economic analysis of the European achalasia trial.

METHODS

Patients with newly diagnosed achalasia were enrolled from to 2003 to 2008 in 14 centers in five European countries and were randomly assigned to either pneumatic dilation (PD) or laparoscopic Heller (LHM). The economic analysis was performed in the three centers in three different countries where most patients were enrolled (Amsterdam [NL], Leuven, [B] and Padova [I]) and then applied to all patients included in the study. The total raw costs of the two treatments per patient include the initial costs, the costs of complications, and the costs of retreatments.

RESULTS

Two hundred and one patients, 107 (57 males and 50 females, mean age 46 CI: 43-49 years) were randomized to LHM and 94 (59 males and 34 females, mean age 46 CI 43-50 years) to PD. The total cost of PD per patient was quite comparable in the three different centers; €3397 in Padova, €3259 in Amsterdam and €3792 in Leuven. For LHM, the total costs per patient were highest in Amsterdam: €4488 in Padova, €6720 in Amsterdam, and €5856 in Leuven.

CONCLUSION

In conclusion, the strategy of treating achalasia starting with PD appears the most economic approach, independent of the health system.

Mucosal Perforation During Laparoscopic Heller Myotomy Has No Influence on Final Treatment Outcome

BACKGROUND

The aims of the study were (a) to examine the final outcome in patients experiencing accidental mucosal perforation during laparoscopic Heller myotomy with Dor fundoplication (LHD) and (b) to evaluate whether perforation episodes might influence the way in which surgeons subsequently approached the LHD procedure.

METHODS

We studied all consecutive patients that underwent LHD between 1992 and 2015. Patients were divided into two main groups: those who experienced an intraoperative mucosal perforation (group P) and those whose LHD was uneventful (group NP). Two additional groups were compared: group A, which consisted of patients operated by a given surgeon immediately before a perforation episode occurred, and group B, which included those operated immediately afterwards.

RESULTS

Eight hundred seventy-five patients underwent LHD; a mucosal perforation was detected in 25 patients (2.9 %), which was found unrelated to patients' symptom's score and age, radiological stage, manometric pattern, or the surgeon's experience. The median postoperative symptom score was similar for the two groups as the failure rate: 92 failures in group NP (10.8 %) and 4 in group P (16 %) (p = 0.34); moreover, symptoms recurred in 2 patients of group A (10 %) and 3 patients of group B (15 %) (p = 0.9).

CONCLUSIONS

Accidental perforation during LHD is infrequent and impossible to predict on the grounds of preoperative therapy or the surgeon's personal experience. Despite a longer surgical procedure and hospital stay, the outcome of LHD is much the same as for patients undergoing uneventful myotomy. A recent mucosal perforation does not influence the surgeon's subsequent performance.

Pseudoachalasia: Still a Tough Clinical Challenge

Patient: Male, 81

Final Diagnosis: Pseudoachalasia

Symptoms: Dysphasia

Medication: —

Clinical Procedure: Endoscopy ultrasound

Specialty: Gastroenterology and Hepatology

Laparoscopic Heller myotomy as the gold standard for treatment of achalasia

INTRODUCTION

The recent introductions of novel methods for the treatment of achalasia as well as ongoing controversies about the merits of surgical and endoscopic treatment options have created controversy in identifying the optimal treatment for this condition. This lack of clarity prompted this review of 206 consecutive patients treated with a laparoscopic Heller (LH) myotomy over a 16-year period.

METHODS

A retrospective review of a prospectively collected database was performed of 206 consecutive LH performed by a single surgeon.

RESULTS

In this cohort, 58 % of patients had undergone a prior therapeutic intervention. Over 90 % of patients had relief of dysphagia post-operatively. There was one intraoperative esophageal perforation. There were no mortalities. Only 4/206 patients sustained complications that required either post-op therapeutic intervention or delayed hospital discharge.

CONCLUSION

This paper outlines an operative technique that has yielded outstanding results and may be used as a benchmark against which other therapies can be judged.

Advances in the treatment of achalasia

OPINION STATEMENT

Achalasia, although rare, remains one of the most commonly diagnosed disorders of esophageal motility. It results from an idiopathic loss of ganglion cells responsible for esophageal motility and relaxation of the lower esophageal sphincter (LES). As a result, patients present with worsening dysphagia to both liquids and solids and often suffer from significant regurgitation of retained food in the esophagus. When the diagnosis of achalasia is suspected, patients should undergo evaluation with esophageal motility testing, endoscopic examination, and contrast esophagram. Once the diagnosis of achalasia has been established, options for treatment rely on controlling patient symptoms. Medical options are available, but their effectiveness is inconsistent. Endoscopic options include injection of botulinum toxin, which can achieve good short-term results, and pneumatic balloon dilation (PBD), considered the most effective non-surgical option. Surgical options, including laparoscopic, open, or endoscopic myotomy, and provide long-lasting results. This chapter will review achalasia and the treatment options available.

Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response

Achalasia is a motor disorder characterized by esophageal aperistalsis and failure of lower esophageal sphincter relaxation. The cardinal symptoms are dysphagia, food regurgitation and weight loss. The most effective treatments are pneumatic dilation (PD) of the cardia and Heller esophageal myotomy with partial fundoplication. There is still controversy regarding which treatments should be initially done. The aims of this study were to evaluate clinical response and the variables related to good results in both treatments. Ninety-two patients with achalasia diagnosed by esophageal manometry were randomized to receive either PD or laparoscopic Heller myotomy with partial fundoplication. After the procedure, patients were followed up clinically and submitted to esophageal manometry and pH monitoring. Three months after treatment, 73% of the patients from PD group and 84% of the surgery group had good results (P = 0.19). After 2 years of follow-up, 54% of the PD group and 60% of the surgery group (P = not significant) were symptom free. Variables related to a good response to PD were a 50% drop in lower esophageal sphincter pressure (LESP) or a LESP <10 mmHg after treatment. Patients over 40 years old with LESP ≤32 mmHg before treatment and a drop in LESP >50% after treatment significantly achieved better responses after surgical treatment when compared with PD. The reflux rate was significantly higher in the PD group (27.7%) compared with the surgery group (4.7%), P = 0.003. We concluded that surgical treatment and PD for achalasia are equally effective even after 2 years of follow-up. The choice of treatment for achalasia should be based on the following parameters: treatment availability, rate of good results, complication rates, variables related to good responses and also the patient's wish.

Laparoscopic Heller myotomy versus endoscopic balloon dilatation for the treatment of achalasia: a network meta-analysis

OBJECTIVE

Comparison of short- and long-term effects after laparoscopic Heller myotomy (LHM) and endoscopic balloon dilation (EBD) considering the need for retreatment.

BACKGROUND

Previously published studies have indicated that LHM is the most effective treatment for Achalasia. In contrast to that a recent randomized trial found EBD equivalent to LHM 2 years after initial treatment.

METHODS

A search in Medline, PubMed, and Cochrane Central Register of Controlled Trials was conducted for prospective studies on interventional achalasia therapy with predefined exclusion criteria. Data on success rates after the initial and repeated treatment were extracted. An adjusted network meta-analysis and meta-regression analysis was used, combined with a head-to-head comparison, for follow-up at 12, 24, and 60 months.

RESULTS

Sixteen studies including results of 590 LHM and EBD patients were identified. Odds ratio (OR) was 2.20 at 12 months (95% confidence interval: 1.18-4.09; P = 0.01); 5.06 at 24 months (2.61-9.80; P < 0.00001) and 29.83 at 60 months (3.96-224.68; P = 0.001). LHM was also significantly superior for all time points when therapy included re-treatments [OR = 4.83 (1.87-12.50), 19.61 (5.34-71.95), and 17.90 (2.17-147.98); P ≤ 0.01 for all comparisons) Complication rates were not significantly different. Meta-regression analysis showed that amount of dilations had a significant impact on treatment effects (P = 0.009). Every dilation (up to 3) improved treatment effect by 11.9% (2.8%-21.8%).

CONCLUSIONS

In this network meta-analysis, LHM demonstrated superior short- and long-term efficacy and should be considered first-line treatment of esophageal achalasia.

ACG clinical guideline: diagnosis and management of achalasia

Achalasia is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. This results in patients' complaints of dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. Endoscopic finding of retained saliva with puckered gastroesophageal junction or barium swallow showing dilated esophagus with birds beaking in a symptomatic patient should prompt appropriate diagnostic and therapeutic strategies. In this ACG guideline the authors present an evidence-based approach in patients with achalasia based on a comprehensive review of the pertinent evidence and examination of relevant published data.

Minimally invasive myotomy for the treatment of esophageal achalasia: evolution of the surgical procedure and the therapeutic algorithm

Achalasia is a rare disease of the esophagus, characterized by the absence of peristalsis in the esophageal body and incomplete relaxation of the lower esophageal sphincter, which may be hypertensive. The cause of this disease is unknown; therefore, the aim of the therapy is to improve esophageal emptying by eliminating the outflow resistance caused by the lower esophageal sphincter. This goal can be accomplished either by pneumatic dilatation or surgical myotomy, which are the only long-term effective therapies for achalasia. Historically, pneumatic dilatation was preferred over surgical myotomy because of the morbidity associated with a thoracotomy or a laparotomy. However, with the development of minimally invasive techniques, the surgical approach has gained widespread acceptance among patients and gastroenterologists and, consequently, the role of surgery has changed. The aim of this study was to review the changes occurred in the surgical treatment of achalasia over the last 2 decades; specifically, the development of minimally invasive techniques with the evolution from a thoracoscopic approach without an antireflux procedure to a laparoscopic myotomy with a partial fundoplication, the changes in the length of the myotomy, and the modification of the therapeutic algorithm.

Laparoscopic calibrated total vs partial fundoplication following Heller myotomy for oesophageal achalasia

AIM: To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia.

METHODS: Fifty-six patients (26 men, 30 women; mean age 42.8 ± 14.7 years) presenting for minimally invasive surgery for oesophageal achalasia, were enrolled. All patients underwent laparoscopic Heller myotomy followed by a 180° anterior partial fundoplication in 30 cases (group 1) and calibrated Nissen-Rossetti fundoplication in 26 (group 2). Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication. A 6-mo follow-up period with symptomatic evaluation and barium swallow was undertaken. One and two years after surgery, the patients underwent symptom questionnaires, endoscopy, oesophageal manometry and 24 h oesophago-gastric pH monitoring.

RESULTS: At the 2-year follow-up, no significant difference in the median symptom score was observed between the 2 groups (P = 0.66; Mann-Whitney U-test). The median percentage time with oesophageal pH < 4 was significantly higher in the Dor group compared to the Nissen-Rossetti group (2; range 0.8-10 vs 0.35; range 0-2) (P < 0.0001; Mann-Whitney U-test).

CONCLUSION: Laparoscopic Dor and calibrated Nissen-Rossetti fundoplication achieved similar results in the resolution of dysphagia. Nissen-Rossetti fundoplication seems to be more effective in suppressing oesophageal acid exposure.

Outcomes in achalasia from a surgical unit where pneumatic dilatation is first-line therapy

The management of achalasia remains controversial, with little consensus on the optimal patient treatment pathway. In our own esophageal unit, we offer pneumatic dilatation as the initial therapy in most patients as first-line therapy. In this study, we aimed to examine the safety and efficacy of our own approach to the management of patients with a diagnosis of achalasia, examining symptomatic outcomes, patient satisfaction, and need for further intervention, as well as examining patient factors associated with treatment failure. Sixty-seven consecutive patients underwent pneumatic dilatation as first-line therapy (53% male, mean age 46 years). All attended regular outpatient follow-up (mean 37, range 3-132 months). Twenty-five percent of patients required a second intervention because of symptom recurrence, at a median period of 4.5 months. Symptomatic outcomes were excellent or good in 80%. Significant predictors of treatment failure and poor symptom score included a younger age at the time of diagnosis and increased esophageal diameter on barium swallow. This study suggests that pneumatic dilatation is a safe and effective approach as first-line therapy in patients with newly diagnosed achalasia.

Meta-analysis of randomized and controlled treatment trials for achalasia

Pharmacological therapy, botulinum toxin injection, pneumatic dilatation, and surgical myotomy are the primary therapeutic modalities for achalasia, for which laparoscopic myotomy is recommended as state-of-the-art therapy. However, its efficacy and safety remain unclear compared with other approaches in the treatment of achalasia. We searched electronic databases (MEDLINE, EMBASE, Cochrane Central Registry of Controlled Trials, LILACS-Latin American, Caribbean health science literature, and Science Citation Index Expanded) for randomized controlled trials to evaluate which therapeutic measures are temporary and reversible and which measures are definitive and effective by pooling data including remission rate, relapse rate, complications, and adverse effects. Seventeen studies with 761 patients met our inclusion criteria. There was better remission rate in pneumatic dilation than in botulinum toxin injection for initial intervention [relative risk (RR) 2.20, 95% confidence interval (CI) 1.51-3.20], Pneumatic dilation had lower relapse rate than did botulinum toxin injection (RR 0.12, 95% CI 0.04-0.32). Compared with pneumatic dilation, laparoscopic myotomy further increased remission rate (RR 1.48, 95% CI 1.48-1.87), and reduced clinical relapse rate (RR 0.14, 95% CI 0.04-0.58), and there was no difference in complication rate (RR 1.48, 95% CI 0.37-5.99). Based on limited randomized and controlled trials, laparoscopic myotomy is the preferred method for patients with achalasia. Future trials should investigate whether laparoscopic myotomy combined with different modalities of fundoplication is superior to isolated laparoscopic myotomy.

Oesophageal achalasia: an argument for primary surgical management

INTRODUCTION

Achalasia is a primary oesophageal motility disorder resulting from damage to the ganglion cells of the myenteric plexus. Impaired relaxation of the lower oesophageal sphincter and aperistalsis causes its cardinal symptoms of dysphagia, chest pain and reflux-type symptoms. Management is somewhat controversial, with options including systemic and local pharmacotherapy, dilatation and oesophagomyotomy. We review the presentation, investigation and management of oesophageal achalasia and make an argument for primary surgical management.

METHODS

We performed a Medline search of the term 'achalasia', limiting the search to clinical trials and meta-analyses. We then selected articles based on their abstracts using four main criteria: previously unreported findings, previously unreported techniques, size of patient cohort and journal impact factor. References in selected articles were manually searched for other relevant articles.

FINDINGS

Achalasia has been managed using a variety of techniques including systemic and local pharmacotherapy, forced dilatation and oesophagomyotomy. Success rates vary widely between techniques. Mechanical disruption ofthe lower oesophageal sphincter is most successful.

DISCUSSION

In achalasia, mechanical disruption of the lower oesophageal sphincter using forced dilatation or surgical myotomy offers the only realistic prospect of long-term symptom relief. Recent evidence suggests that previous medical treatment or dilatation makes oesophagomyotomy more difficult and increases the risk of complications. As the morbidity associated with surgery continues to decrease with improvements in minimal access techniques, the argument for primary management of achalasia with oesophagomyotomy becomes more compelling.

Esophageal motility disorders: medical therapy

Symptoms of chest pain and dysphagia are common in the adult population. Most patients initially undergo an evaluation to exclude anatomic causes (ie, esophagitis, stricture) and cardiovascular disease as the etiology of these symptoms. Patients with persistent symptoms may then be referred for specialized testing of the esophagus, including esophageal manometry. Disorders of esophageal motility, which include achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive lower esophageal sphincter, and ineffective motility are often identified in these patients. Unfortunately, the etiology of these disorders has not been well characterized and the treatment has not been standardized. This review will briefly discuss the impact, etiology, and diagnosis of esophageal motility disorders, and then focus on the medical management of these disorders using evidence from well-designed, prospective studies, where available.