title: Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than heller myotomy alone.
abstract: OBJECTIVE
  Heller myotomy has been shown to be an effective primary treatment of achalasia. However, many physicians treating patients with achalasia continue to offer endoscopic therapies before recommending operative myotomy. Herein we report outcomes in 209 patients undergoing Heller myotomy with the majority (74%) undergoing myotomy as secondary treatment of achalasia.
  
  
  METHODS
  Data on all patients undergoing operative management of achalasia are collected prospectively. Over a 9-year period (1994-2003), 209 patients underwent Heller myotomy for achalasia. Of these, 154 had undergone either Botox injection and/or pneumatic dilation preoperatively. Preoperative, operative, and long-term outcome data were analyzed. Statistical analysis was performed with multiple chi and Mann-Whitney U analyses, as well as ANOVA.
  
  
  RESULTS
  Among the 209 patients undergoing Heller myotomy for achalasia, 154 received endoscopic therapy before being referred for surgery (100 dilation only, 33 Botox only, 21 both). The groups were matched for preoperative demographics and symptom scores for dysphagia, regurgitation, and chest pain. Intraoperative complications were more common in the endoscopically treated group with GI perforations being the most common complication (9.7% versus 3.6%). Postoperative complications, primarily severe dysphagia, and pulmonary complications were more common after endoscopic treatment (10.4% versus 5.4%). Failure of myotomy as defined by persistent or recurrent severe symptoms, or need for additionally therapy including redo myotomy or esophagectomy was higher in the endoscopically treated group (19.5% versus 10.1%).
  
  
  CONCLUSIONS
  Use of preoperative endoscopic therapy remains common and has resulted in more intraoperative complications, primarily perforation, more postoperative complications, and a higher rate of failure than when no preoperative therapy was used. Endoscopic therapy for achalasia should not be used unless patients are not candidates for surgery.
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA. csmit27@emory.edu
authors.forename: C Daniel
authors.initials: CD
authors.lastname: Smith
authors.forename: Alessandro
authors.initials: A
authors.lastname: Stival
authors.forename: D Lee
authors.initials: DL
authors.lastname: Howell
authors.forename: Vickie
authors.initials: V
authors.lastname: Swafford
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D004931:Esophageal Achalasia / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D004945:Esophagoscopy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009130:Muscle, Smooth / Q000601:surgery; D011300:Preoperative Care