title: Botox, dilation, or myotomy? Clinical outcome of interventional and surgical therapies for achalasia.
abstract: OBJECTIVE
  Achalasia is a rare, but well-defined primary esophageal motor disorder. Classic therapeutic approaches include botulinum toxin injection, balloon dilation, and surgical myotomy of the lower esophageal sphincter. This report summarizes our experience with different treatment modalities for achalasia.
  
  
  METHODS
  Forty-three patients with achalasia treated in our hospital were subdivided according to therapeutic strategy: endoscopic botulinum toxin injection into the lower esophageal sphincter (EBTI; n = 7), endoscopic esophageal balloon dilation (EBD; n = 16), surgical myotomy after failed esophageal balloon dilation (EBD-HM; n = 14), and first-line surgical myotomy (HM; n = 6). Therapeutic efficiency was evaluated comparing standardized symptom scores preoperatively and at follow-up.
  
  
  RESULTS
  There was no mortality and no significant difference between the groups for age, sex, or morbidity. The mean follow-up was at 9, 35, 38, and 17 months. At follow-up, recurrent or persistent symptoms were found in 71.4%, 6.3%, 35.7%, and 16.7% in EBTI, EBD, EBD-HM, and HM, respectively. Considering EBD-HM patients as failures of esophageal dilation, the total rate of recurrent or persistent symptoms after EBD was 50%. Poor symptomatic outcome was correlated to a low esophageal sphincter pressure during pretherapeutic manometry (p = 0.03) and to sigmoid-shaped esophageal dilatation (p = 0.06).
  
  
  CONCLUSIONS
  Surgical myotomy is the most reliable first-line therapy for achalasia, particularly in patients with a high sphincter pressure and moderate esophageal dilatation. Botox injection has a high failure rate and should be reserved for exceptional cases. Endoscopic dilation provides about 50% of patients with long-term symptomatic relief; in most cases, failure can be successfully treated surgically.
authors.affiliation: Department of General-, Visceral-, and Cancer Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany. christian.gutschow@uk-koeln.de
authors.forename: Christian Alexander
authors.initials: CA
authors.lastname: Gutschow
authors.forename: Ulrich
authors.initials: U
authors.lastname: Töx
authors.forename: Jessica
authors.initials: J
authors.lastname: Leers
authors.forename: Hartmut
authors.initials: H
authors.lastname: Schäfer
authors.forename: Klaus Ludwig
authors.initials: KL
authors.lastname: Prenzel
authors.forename: Arnulf H
authors.initials: AH
authors.lastname: Hölscher
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D002404:Catheterization; D002648:Child; D004931:Esophageal Achalasia / Q000628:therapy*; D004945:Esophagoscopy; D005260:Female; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D008875:Middle Aged; D009130:Muscle, Smooth / Q000601:surgery*; D019233:Retreatment; D016896:Treatment Outcome
chemical_list: D019274:Botulinum Toxins, Type A