Outcomes of pneumatic dilatation and Heller’s myotomy for achalasia in England between 2005 and 2016

Abstract

IntroductionAchalasia is a disorder characterised by failed relaxation of the lower oesophageal sphincter. The aim of this study was to examine, at a national level, the long-term outcomes of achalasia therapies.MethodsHospital Episode Statistics include diagnostic and procedural data for all English National Health Service–funded hospital admissions. Subjects with a code for achalasia who had their initial treatment between January 2006 and December 2015 were grouped by treatment; pneumatic dilatation (PD) or surgical Heller’s myotomy (HM). Procedural failure was defined as time to a further episode of the same therapy or a change to a different therapy. Up to three PDs were permitted without being considered a therapy failure.Results6938 subjects were included; 3619 (52.2%) were men and median age at diagnosis was 59 (IQR 43–75) years. 4748 (68.4%) initially received PD and 2190 (31.6%) HM. The perforation rate following PD was 1.6%. Mortality at 30 days was 0.0% for HM and 1.9% for PD, and <8% after perforation following PD. Factors associated with increased mortality after PD included age quintile 66–77 (OR 4.55 (95% CI 2.00 to 10.38), p<0.001), >77 (9.78 (4.33 to 22.06), p<0.001); Charlson comorbidity score >4 (2.87 (2.08 to 3.95), p<0.001); previous HM (2.47 (1.33 to 4.62), p<0.001); and repeat PD 1–3 (1.58 (1.15 to 2.16), p=0.005), >3 (1.97 (1.21 to 3.19), p=0.006). Durability of up to 3 PD and HM over 10 years of follow-up was 86.2% and 81.9%, respectively (p<0.001).DiscussionThe efficacy of PD for achalasia appears to be greater than HM over 10 years. There was no mortality associated with HM, but 1.9% of subjects died within 30 days of PD. Mortality was associated with increasing age, comorbidity, previous HM and repeat PD.

Mortality rate after pneumatic dilatation for achalasia

“…In this study, the mortality rate 30 days after PD was surprisingly high with a staggering 1.9% 1. This is contradictory to previous recent literature, in which the mortality rate after pneumatic dilatation was generally 0% 2–4.…”

“…With great interest we have read the article ‘Outcomes of pneumatic dilatation and Heller’s myotomy for achalasia in England between 2005 and 2016’ of Harvey et al 1 In this retrospective study, the efficacy and complication rate were compared between pneumatic dilatation (PD) and Heller’s myotomy (HM) over 10 years. The Hospital Episode Statistics (HES) database of England was used to include achalasia patients treated with PD or HM.…”

Achalasia: what to do in the face of failures of Heller myotomy

“…20 In 2019, Harvey et al reported that durability of up to three PDs and surgical HM over 10 years of a follow-up was 86.2% and 81.9%, respectively, in a large national database study involving 6938 subjects. 21 Long-term treatment effects of PD over 10 years seem better than HM in this largest study of the outcomes of achalasia therapy, but perforation occurred in 1.6% of 4748 patients who underwent PD and in none of 2190 patients who underwent HM. Mortality at 30 days was 1.9% for PD and there were no deaths in the HM group.…”

“…Mortality at 30 days was 1.9% for PD and there were no deaths in the HM group. 21 In 2019, Werner et al reported on a multicenter, randomized trial comparing POEM with LHM + Dor fundoplication in the treatment of symptomatic achalasia. 22 At a 2-year follow-up, clinical success was similar in both groups (83.0% in the POEM group and 81.7% in the LHM group) and reflux esophagitis was present in 44% of POEM patients and 29% of LHM patients.…”

“…Banbury et al 86 32 TH (21) and TT (11) Stomach 69 3 42 Devaney et al 87 93 TH (87) and TT (6) Stomach 91Colon (2) 30 2 38Hsu et al 88 9 LTA Colon 22 0 72 Gockel et al 89 8 TH (6) and TT 2 esophagectomy were recurrent and disabling symptoms; in three patients, the resection was necessary because of the finding of SSC, and in the other two patients, a small focus of carcinoma was incidentally detected in the resected specimen. Esophagectomy was performed through a transthoracic (78.7%) or a transhiatal (21.3%) approach.…”