Should Surgery Replace Pneumatic Dilation in Achalasia?

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Ferulano GP, Dilillo S, D'Ambra M, et al. (Systemic Pathology, University of Naples Federico II, Naples, Italy). Short and long term results of the laparoscopic Heller–Dor myotomy. The influence of age and previous conservative therapies. Surg Endosc 2007;21:2017–2023.

Idiopathic achalasia is a primary esophageal motor disorder of unknown etiology characterized by esophageal aperistalsis and abnormal lower esophageal sphincter (LES) relaxation in response to deglutition. Although idiopathic achalasia is a rare disorder, specialized academic centers commonly encounter patients with this disorder presenting with dysphagia to solid and liquids, regurgitation, chest pain, and weight loss. The most effective treatment options for patients with achalasia include surgical myotomy and pneumatic dilation (PD). Other modes of therapy such as botulinum toxin injection and calcium channel blockers or nitrates are less effective and are usually reserved for patients who are not candidates for the more definitive endoscopic PD or surgical myotomy (Am J Gastroenterol 1999;94:3406–3412).

The “expert” decision to perform PD or surgical myotomy in a given patient with achalasia is tainted by their training: surgeons opting for surgical myotomy and esophagologists choosing PD. In recent years the latter group has used esophageal scarring and change of normal anatomy owing to prior therapies to argue for why myotomy should be the treatment option in achalasia. Furthermore, some physicians have used the argument of patient age to discourage surgery. Ferulano et al studied the influence of age and prior conservative therapies on the short- and long-term outcomes of patients with achalasia treated by surgical myotomy. In this retrospective study, 35 patients with idiopathic achalasia who had undergone laparoscopic Heller–Dor myotomy were grouped based on age and prior therapies with PD or botulinum toxin therapy. Patient short- and long-term (5-year) outcomes were assessed by evaluation of a health-related quality-of-life instrument. The study population consisted of 20 patients <70 and 15 patients >70 years old who had mainly moderate to significant esophageal dilation (>60 mm) with near 50% having had prior therapies before undergoing surgical myotomy. The authors report 84% short-term and 77% long-term success with the procedure with a 13%–15% rate of gastroesophageal reflux disease (GERD) on pH monitoring and a 10%–16% rate of dysphagia. Logistic regression analysis did not suggest any influence of patient outcome by age or prior therapies with prior PD or botulinum toxin. The authors concluded that treatment of idiopathic achalasia with a “laparoscopic Heller–Dor myotomy reaches [achieves] a functional recovery of the esophageal function in about 80% of patients regardless of age and previous treatments.”

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Achalasia therapy remains entirely palliative. The objective of the current therapeutic options for achalasia is to reduce LES tone, relieve functional obstruction to the esophageal transit, and facilitate esophageal emptying by gravity. This goal is achieved best by either PD or surgical myotomy. The choice between these 2 definitive treatment options is a point of controversy. Surgeons argue that PD is “barbaric” by design; a large balloon is inflated in the LES region resulting in a “bloody balloon,” that it is indirect, uncontrolled, and less effective than surgical myotomy. They also suggest that, because of the scarring that may result from therapies such as botulinum toxin injection or PD, subsequent surgical myotomy may be less effective. However, the result of the study by Ferulnao et al argue against this contention, finding equal outcomes in their patients despite prior therapies.

But why should we offer PD at all to our patients if surgery is so good? It is important to dissect each aspect of the 2 therapies and discuss the potential risks and benefits before we can answer this question. Are there differences in the effectiveness of the 2 therapies? The answer to this question cannot be answered directly because there are no large-scale, head-to-head randomized trials comparing the 2 therapies. The first randomized trial compared an old dilator (Mosher bag), which is no longer in use, to open myotomy, suggesting better outcomes in the latter group compared with dilation (Gastroenterology 1981;80:789–795). The most recent trial compared the 12-month symptomatic outcome of patients undergoing Rigiflex dilation (n = 26) versus laparoscopic myotomy (n = 25), finding no difference between the groups by the intent-to-treat analysis (P = .09). The per protocol analysis suggested myotomy had significantly less treatment failure (P = .04). However, demographic differences between the PD and surgical myotomy groups may have confounded their results. Patients who had undergone PD were more likely to be male and have higher basal and nadir LES pressures. Because younger males have less robust response to PD (Clin Gastroenterol Hepatol 2004;2:389–394) the findings by per protocol analysis may have been due to confounding by gender. Retrospective comparisons of the 2 modalities suggest equal efficacy in the short and long term (Dysphagia 2008;23:155–160; J Clin Gastroenterol 1998;27:21–35). Thus, from the perspective of efficacy, data are equivocal but tend to favor myotomy if patients are younger males.

How about complication differences between the 2 treatment options? The major complication associated with PD is a 2%–5% perforation risk, which could lead to surgery; surgical myotomy is complicated by development of clinically symptomatic GERD in up to 30% of patients. In the study by Ferulano et al, despite Heller–Dor fundoplication post myotomy, GERD was documented by 13%–15% of patients, who required long-term proton pump inhibitor therapy. Other potential complications of surgery may include pneumonia and wound or urinary tract infections. Given nearly equal efficacy and potential complications of the 2 modalities, one may ask which is most cost effective. In addition to previous cost-effectiveness data concluding superiority of PD over myotomy (Am J Gastroenterol 2005;95:2737–2745; Dig Dis Sci 2002;47:1516–1525), the most recent study conducted by the same group that performed the only randomized trial comparing Rigiflex dilation to myotomy concluded that “the cost effectiveness of pneumatic dilation is superior” (Surg Endosc 2007;21:1184–1189).

In short, myotomy and PD have nearly equal short- and long-term outcomes; myotomy has the edge in overall complication rate, but is less cost effective. Given this scenario, the most important aspect of choosing 1 therapy over the other may be expertise of the institution at which the patient is seeking therapy. Myotomy performed by a surgeon who only does 1 or 2 cases per year is a recipe for adverse an outcome, as is PD offered by a gastroenterologist poorly trained. The suggestion that 1 therapy is superior to the other is often due to “expert” bias and not collective data in the field. Patients should have options in treating their achalasia and physicians should appropriately refer this group of patients to specialty centers with both expertise to improve patient outcome. So when it comes to treating achalasia, myopic views should be replaced by global collaborative approaches.