Abstract
This article reviews current trends in management of esophageal achalasia, highlighting short-term outcome and cost comparisons of three treatments: botulinum toxin injection, pneumatic dilation, and laparoscopic myotomy. The quality of life resulting from these palliative treatments is also discussed, as are long-term outcomes.
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References and Recommended Reading
Massey BT, Hogan WJ, Dodds WJ, Dantas RO: Alteration of the upper esophageal sphincter belch reflex in patients with achalasia. Gastroenterology 1992, 103:1574–1579.
Sonnenberg A, Massey BT, McCarty DJ, Jacobsen SJ: Epidemiology of hospitalization for achalasia in the United States. Dig Dis Sci 1993, 38:233–244.
Sandler RS, Nyren O, Ekbom A, et al.: The risk of esophageal cancer in patients with achalasia: a population-based study. JAMA 1995, 274:1359–1362.
Ali GN, Hunt DR, Jorgensen JO, et al.: Esophageal achalasia and coexistent upper esophageal sphincter relaxation disorder presenting with airway obstruction. Gastroenterology 1995, 109:1328–1332.
Eckardt VF, Kohne U, Junginger T, Westermeier T:Risk factors for diagnostic delay in achalasia. Dig Dis Sci 1997, 42:580–585.
Goldblum JR, Rice TW, Richter JE: Histopathologic features in esophagomyotomy specimens from patients with achalasia. Gastroenterology 1996, 111:648–654.
Coccia G, Bortolotti M, Michetti P, Dodero M: Prospective clinical and manometric study comparing pneumatic dilation and sublingual nifedipine in the treatment of oesophageal achalasia. Gut 1991, 32:604–606.
Bortolotti M, Mari C, Lopilato C, et al.: Effects of sildenafil on esophageal motility of patients with idiopathic achalasia. Gastroenterology 2000, 118:253–257.
Traube M, Dubovik S, Lange RC, McCallum RW: The role of nifedipine therapy in achalasia: results of a randomized, double-blind, placebo-controlled study. Am J Gastroenterol 1989, 84:1259–1262.
Holloway RH, Dodds WJ, Helm JF, et al.: Integrity of cholinergic innervation to the lower esophageal sphincter in achalasia. Gastroenterology 1986, 90:924–929.
Massey BT, Arndorfer RC, Hofmann C, et al.: Treatment of achalasia by pneumatic dilation produces a cholinergic neuropraxis of the lower esophageal sphincter [abstract]. Gastroenterology 1996, 110:A714.
Bulat R, Chen Y, Fachnie B, et al.: Pharmacologic effects of intrasphincteric botulinum toxin on the lower esophageal sphincter response to CCK, atropine and edrophonium in achalasia [abstract]. Gastroenterology 1998, 114:A728-A729.
Pasricha PJ, Ravich WJ, Hendrix TR, et al.: Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 1995, 332:774–778.
Vaezi MF, Richter JE, Wilcox CM, et al.: Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial. Gut 1999, 44:231–239. This report from an important randomized trial of two treatment modalities shows that initial symptomatic response is similar but that relapse occurs more frequently with botulinum toxin. Better improvement was also seen in objective parameters of esophageal function with pneumatic dilation.
Andrews CN, Anvari M, Dobranowski J: Laparoscopic Heller's myotomy or botulinum toxin injection for management of esophageal achalasia: patient choice and treatment outcomes. Surg Endosc 1999, 13:742–746.
Annese V, Basciani M, Perri F, et al.: Controlled trial of botulinum toxin injection versus placebo and pneumatic dilation in achalasia. Gastroenterology 1996, 111:1418–1424.
Muehldorfer SM, Schneider TH, Hochberger J, et al.: Esophageal achalasia: intrasphincteric injection of botulinum toxin A versus balloon dilation. Endoscopy 1999, 31:517–521. Report from a randomized trial showing that the response to pneumatic dilation is more durable than that of botulinum toxin.
Spiess AE, Kahrilas PJ: Treating achalasia: from whalebone to laparoscope. JAMA 1998, 280:638–642.
Panaccione R, Gregor JC, Reynolds RP, Preiksaitis HG:Intrasphincteric botulinum toxin versus pneumatic dilatation for achalasia: a cost minimization analysis. Gastrointest Endosc 1999, 50:492–498. This cost analysis based on Canadian costs and outcomes indicates that there is an economic advantage to pneumatic dilation unless life expectancy is less than 2 years.
Gordon JM, Eaker EY: Prospective study of esophageal botulinum toxin injection in high-risk achalasia patients. Am J Gastroenterol 1997, 92:1812–1817.
Wehrmann T, Kokabpick H, Jacobi V, et al.: Long-term results of endoscopic injection of botulinum toxin in elderly achalasic patients with tortuous megaesophagus or epiphrenic diverticulum. Endoscopy 1999, 31:352–358.
Patti MG, Feo CV, Arcerito M, et al.: Effects of previous treatment on results of laparoscopic Heller myotomy for achalasia. Dig Dis Sci 1999, 44:2270–2276.
Horgan S, Hudda K, Eubanks T, et al.: Does botulinum toxin injection make esophagomyotomy a more difficult operation? Surg Endosc 1999, 13:576–579.
Bonavina L, Incarbone R, Antoniazzi L, et al.: Previous endoscopic treatment does not affect complication rate and outcome of laparoscopic Heller myotomy and anterior fundoplication for oesophageal achalasia. Ital J Gastroenterol Hepatol 1999, 31:827–830.
Schiano TD, Fisher RS, Parkman HP, et al.: Use of highresolution endoscopic ultrasonography to assess esophageal wall damage after pneumatic dilation and botulinum toxin to treat achalasia. Gastrointest Endosc 1996, 44:151–157.
Nair LA, Reynolds JC, Parkman HP, et al.: Complications during pneumatic dilation for achalasia or diffuse esophageal spasm: analysis of risk factors, early clinical characteristics, and outcome. Dig Dis Sci 1993, 38:1893–1904.
Gideon RM, Castell DO, Yarze J: Prospective randomized comparison of pneumatic dilatation technique in patients with idiopathic achalasia. Dig Dis Sci 1999, 44:1853–1857.
Vaezi MF, Richter JE: Diagnosis and management of achalasia. Am J Gastroenterol 1999, 94:3406–3412.
Parkman HP, Reynolds JC, Ouyang A, et al.: Pneumatic dilatation or esophagomyotomy treatment for idiopathic achalasia: clinical outcomes and cost analysis. Dig Dis Sci 1993, 38:75–85.
Vantrappen G, Hellemans J: Treatment of achalasia and related motor disorders. Gastroenterology 1980, 79:144–154.
Swedlund A, Traube M, Siskind BN, McCallum RW: Nonsurgical management of esophageal perforation from pneumatic dilatation in achalasia. Dig Dis Sci 1989, 34:379–384.
Burke CA, Achkar E, Falk GW: Effect of pneumatic dilation on gastroesophageal reflux in achalasia. Dig Dis Sci 1997, 42:998–1002.
Imperiale TF, O'Connor JB, Vaezi MF, Richter JE: A cost-analysis of alternative treatment strategies for achalasia [abstract]. Gastroenterology 1998, 114:A19.
Beckingham IJ, Callanan M, Louw JA, Bornman PC: Laparoscopic cardiomyotomy for achalasia after failed balloon dilatation. Surg Endosc 1999, 13:493–496.
Ponce J, Juan M, Garrigues V, et al.: Efficacy and safety of cardiomyotomy in patients with achalasia after failure of pneumatic dilatation. Dig Dis Sci 1999, 44:2277–2282.
Schwartz HM, Cahow CE, Traube M: Outcome after perforation sustained during pneumatic dilatation for achalasia. Dig Dis Sci 1993, 38:1409–1413.
Ferguson MK, Reeder LB, Olak J: Results of myotomy and partial fundoplication after pneumatic dilation for achalasia. Ann Thorac Surg 1996, 62:327–330.
Shimi S, Nathanson LK, Cuschieri A: Laparoscopic cardiomyotomy for achalasia. J Royal Coll Surg Edinburgh 1991, 36:152–154.
Dempsey DT, Kalan MM, Gerson RS, et al.: Comparison of outcomes following open and laparoscopic esophagomyotomy for achalasia. Surg Endosc 1999, 13:747–750.
Patti MG, Arcerito M, De Pinto M, et al.: Comparison of thoracoscopic and laparoscopic Heller myotomy for achalasia. J Gastrointest Surg 1998, 2:561–566.
Stewart KC, Finley RJ, Clifton JC, et al.: Thoracoscopic versus laparoscopic modified Heller myotomy for achalasia: efficacy and safety in 87 patients. J Am Coll Surg 1999, 189:164–169.
Patti MG, Pellegrini CA, Horgan S, et al.: Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg 1999, 230:587–593. Largest minimally invasive series published to date, highlighting the immediate outcomes and complications. The authors present data justifying their switch in preference from a thoracoscopic to a laparoscopic approach.
Topart P, Deschamps C, Taillefer R, Duranceau A: Long-term effect of total fundoplication on the myotomized esophagus. Ann Thorac Surg 1992, 54:1046–1051.
Banbury MK, Rice TW, Goldblum JR, et al.: Esophagectomy with gastric reconstruction for achalasia. J Thorac Cardiovasc Surg 1999, 117:1077–1084.
Katz PO, Gilbert J, Castell DO: Pneumatic dilatation is effective long-term treatment for achalasia. Dig Dis Sci 1998, 43:1973–1977.
Meshkinpour H, Haghighat P, Meshkinpour A: Quality of life among patients treated for achalasia. Dig Dis Sci 1996, 41:352–356.
Eckardt VF, Stauf B, Bernhard G: Chest pain in achalasia: patient characteristics and clinical course. Gastroenterology 1999, 116:1300–1304. This report is from an important observational study regarding the clinical course of the symptom of chest pain in achalasia patients. It emphasizes that treatment to relieve dysphagia does not help this symptom, which nevertheless tends to diminish with time and is more common in younger patients.
Pellegrini C, Wetter LA, Patti M, et al.: Thoracoscopic esophagomyotomy: initial experience with a new approach for the treatment of achalasia. Ann Surg 1992, 216:291–296.
Eckardt VF, Aignherr C, Bernhard G: Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology 1992, 103:1732–1738.
Ellis FH Jr: Oesophagomyotomy for achalasia: a 22-year experience. Br J Surg 1993, 80:882–885.
Malthaner RA, Tood TR, Miller L, Pearson FG: Long-term results in surgically managed esophageal achalasia. Ann Thorac Surg 1994, 58:1343–1346.
Di Simone MP, Felice V, D'Errico A, et al.: Onset timing of delayed complications and criteria of follow-up after operation for esophageal achalasia. Ann Thorac Surg 1996, 61:1106–1110.
Torbey CF, Achkar E, Rice TW, et al.: Long-term outcome of achalasia treatment: the need for closer follow-up. J Clin Gastroenterol 1999, 28:125–130.
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Massey, B.T. Management of idiopathic achalasia: Short-term and long-term outcomes. Curr Gastroenterol Rep 2, 196–200 (2000). https://doi.org/10.1007/s11894-000-0061-5
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DOI: https://doi.org/10.1007/s11894-000-0061-5