Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response

Abstract

Achalasia is a motor disorder characterized by esophageal aperistalsis and failure of lower esophageal sphincter relaxation. The cardinal symptoms are dysphagia, food regurgitation and weight loss. The most effective treatments are pneumatic dilation (PD) of the cardia and Heller esophageal myotomy with partial fundoplication. There is still controversy regarding which treatments should be initially done. The aims of this study were to evaluate clinical response and the variables related to good results in both treatments. Ninety-two patients with achalasia diagnosed by esophageal manometry were randomized to receive either PD or laparoscopic Heller myotomy with partial fundoplication. After the procedure, patients were followed up clinically and submitted to esophageal manometry and pH monitoring. Three months after treatment, 73% of the patients from PD group and 84% of the surgery group had good results (P = 0.19). After 2 years of follow-up, 54% of the PD group and 60% of the surgery group (P = not significant) were symptom free. Variables related to a good response to PD were a 50% drop in lower esophageal sphincter pressure (LESP) or a LESP <10 mmHg after treatment. Patients over 40 years old with LESP ≤32 mmHg before treatment and a drop in LESP >50% after treatment significantly achieved better responses after surgical treatment when compared with PD. The reflux rate was significantly higher in the PD group (27.7%) compared with the surgery group (4.7%), P = 0.003. We concluded that surgical treatment and PD for achalasia are equally effective even after 2 years of follow-up. The choice of treatment for achalasia should be based on the following parameters: treatment availability, rate of good results, complication rates, variables related to good responses and also the patient's wish.

Evaluating the reliability and construct validity of the Eckardt symptom score as a measure of achalasia severity

“…and follow treatment outcomes 2–5 . While these tests are also used to monitor treatment response, a self-reported measure of symptom severity is often the primary outcome in clinical studies and is often the principal factor that drives clinical management decisions 2, 6–8 .…”

Effect of peroral endoscopic myotomy in achalasia patients with failure of prior pneumatic dilation: A prospective case–control study

“…Despite of the excellent short‐term success rate that was achieved in more than 90% of patients undergoing PD, recurrence of symptoms could occur in approximately 20% in 2 years, 30% in 5 years and about 40% in 10 years after the procedure . Controversy regarding the therapy for achalasia patients with failed PD still exists.…”

Is Heller Myotomy Better than Balloon Dilation? A Meta-Analysis

“…In 4 other studies, symptom evaluation was based on various dysphagia scores. In the studies by Hamdy et al [23] and Borges et al [18] the primary outcome was the successful symptomatic improvement, which used the Demeester's or Vantrappen and Hellemans dysphagia score. In the studies by Persson et al [24] and Kostic et al [25] the primary end point was the cumulative number of treatment failures.…”

“…The analysis included 360 patients in the balloon dilation group and 389 in the Heller myotomy group. One study (Borges et al) [18] reported significant differences in the patients' ages between the two treatment groups, but in the other 7 studies no significant difference was found in this regard. The data published in 8 studies assessing the distribution of genders showed no difference between the two groups.…”

“…The major outcome of the study of Borges et al [18] was the clinical improvement of the Vantrappen and Hellemans dysphagia score. Good responders mean excellent results (asymptomatic) or good results (dysphagia less than once a week, no weight loss or food regurgitation).…”