The Course of Achalasia One to Four Decades After Initial Treatment

T. Sawas; K. Ravi; D. M. Geno; F. Enders; K. Pierce; D. Wigle; D. A. Katzka

Disclosures

Aliment Pharmacol Ther. 2017;45(4):553-560. 

In This Article

Abstract and Introduction

Abstract

Background Most follow-up studies of achalasia are limited to <5 years.

Aim To study the long-term efficacy of pneumatic dilation (PD) and myotomy in achalasia at least 10 years after treatment.

Methods We performed a retrospective cohort study of achalasia patients with >10 years follow-up after initial myotomy or pneumatic dilation. Symptom recurrence which required repeat dilation or surgery was compared between pneumatic dilation and myotomy.

Results One hundred and fifty patients (112 myotomy, 38 pneumatic dilation) of similar characteristics were studied. The mean duration of follow-up after initial treatment was 17.5 ± 7.2 years (10–40 years). Symptoms recurrence rate was 60.7% (100% pneumatic dilation patients vs. 47.3% myotomy), hazard ratio 0.24 demonstrating a lower need for repeat dilation or surgery with myotomy than pneumatic dilation (P = 0.008). All pneumatic dilation patients underwent myotomy in 4 ± 4 (0–16 years). Forty of 53 myotomy patients had symptom recurrence prompting further treatment: 16 pneumatic dilation, 11 myotomy and 13 both. The mean time to repeat procedure was 6.9 years (0–40). The myotomy group required fewer dilations and/or surgeries than the pneumatic dilation group (1.6 vs. 3.6, P < 0.001). 13 patients (10.1%) progressed to end-stage achalasia (five myotomy, eight pneumatic dilation) over 40 years. At last follow-up, 57/62 (92%) patients had absent or mild dysphagia, 53/62 (85%) patients had regurgitation less than once per week and 37 (60.7%) had heartburn episodes <1/week similar for pneumatic dilation and myotomy (P = 0.27).

Conclusion Although the majority of patients treated for achalasia do well after decades of treatment, most patients may need a series of endoscopic and/or surgical procedures to maintain effective symptom control.

Introduction

Achalasia is a rare motor disorder characterised by oesophageal body aperistalsis and ineffective relaxation of the lower oesophageal sphincter (LES).[1,2] The main goal of therapy is to reduce LES pressure and subsequently relieve obstructive symptoms and further oesophageal dilation.[1] The two most effective interventions have been pneumatic dilatation (PD) and oesophageal myotomy. Pneumatic dilation disrupts the mucosa and submucosa through intraluminal high pressure balloons, whereas surgical myotomy dissects the muscularis propria without disrupting the mucosa.[1] Prior to the introduction of laparoscopic myotomy, endoscopic pneumatic dilation was a favoured treatment due to the high short-term success rate of 70–80%.[2,3] The introduction of laparoscopic Heller myotomy combined with anti-reflux procedure has generated at least equal enthusiasm for the surgical approach with a 5-year success rate exceeding 80%.[4–6] Both PD and myotomy have shown to be comparably effective at 5 years.[7] Unfortunately, achalasia is a lifelong disease. We aimed to evaluate long-term efficacy of PD and myotomy and need for reintervention decades after the initial treatment.

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