Laparoscopic Heller's myotomy or botulinum toxin injection for management of esophageal achalasia. Patient choice and treatment outcomes.
BACKGROUND
Esophageal achalasia is a rare disease in which degenerating parasympathetic innervation of the lower esophageal sphincter (LES) leads to unopposed sympathetic tone and failure to relax on deglutition, resulting in a range of symptoms for the patient, most notably dysphagia, chest pain, regurgitation, and weight loss. Laparoscopic Heller's esophagomyotomy (Lap-HM) and botulinum toxin (BoTox) injection into the LES are two recently described methods for treating achalasia. No comparison of laparoscopic Heller's myotomy and botulinum toxin has yet been presented.


METHODS
A total of 22 patients (15 men, 7 women; mean age, 57.9 years) diagnosed with idiopathic esophageal achalasia were given a choice of treatment modality: Lap-HM or BoTox. Patients were prospectively assessed before and after treatment with esophageal manometry, barium swallow roentgenography, and dysphagia score. Patients' preferences and treatment efficacy were evaluated.


RESULTS
Of the 22 patients, 18 (81.8%) chose BoTox and 4 (18.2%) chose Lap-HM. Five patients in the BoTox group opted for Lap-HM a mean of 565 +/- 212 days after the first injection, having received a median of four (range, 3-5) injections. Both BoTox and Lap-HM were effective in improving dysphagia score: before BoTox (median, 7; range, 0-10) and 2 months afterward (median, 2; range, 0-6) (p < 0. 01); before Lap-HM (median, 9; range, 7-10) and 6 months afterward (median, 1.5; range, 0-4) (p < 0.05). Both methods also effectively reduced lower esophageal sphincter (LES) nadir pressure: before BoTox (mean mmHg, 22 +/- 9) and 2 months afterward (mean mmHg, 15 +/- 7) (p < 0.05); before Lap-HM (mean mmHg, 24 +/- 10) and 6 months afterward (mean mmHg, 3 +/- 4) (p < 0.05). However, only Lap-HM produced a significant reduction in LES basal pressure before (mean mmHg, 34 +/- 7) and afterward (mean mmHg, 3 +/- 3) (p < 0.01) and increased esophageal barium clearance (mean percentage of barium retained in esophagus at 5 min before (97% +/- 6%) and afterward (23% +/- 45%) (p < 0.05).


CONCLUSIONS
BoTox injection and Lap-HM both significantly reduce achalasia symptoms, but only Lap-HM improves esophageal clearance of barium. BoTox injection is the most popular treatment method from a patient perspective, although symptom recurrence or failure rates are high. Lap-HM is favored by younger patients and is equally effective after BoTox therapy failure.
Andrews
C N
CN
Department of Surgery, St. Joseph's Hospital, McMaster University, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
Anvari
M
M
Dobranowski
J
J
D000328:Adult; D000368:Aged; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage / Q000627:therapeutic use*; D004931:Esophageal Achalasia / Q000188:drug therapy* / Q000601:surgery*; D004943:Esophagogastric Junction; D005260:Female; D005773:Gastroscopy; D006801:Humans; D015552:Injections, Intralesional; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009465:Neuromuscular Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D017060:Patient Satisfaction; D016896:Treatment Outcome
D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A