Surgery Should Be Primary Treatment for Achalasia

In the surgical group, 72 patients underwent surgical myotomy with or without a full or partial fundoplication. Eight of those patients (11%) had more than one surgical admission, and 23 patients (32%) had undergone prior endoscopic treatment.

In the endoscopic group, 76 patients underwent only endoscopic treatments, which included balloon dilation, botulinum injection or both; 53 of those patients (70%) had more than one treatment, which came to 174 endoscopic interventions total. The investigators noted no statistically significant differences between the demographics, except that patients in the surgical cohort were significantly younger (56.3 versus 72.7 years).

The results showed that the average time between the first and second surgery was almost seven times longer than that for endoscopic procedures. Patients in the endoscopic group underwent a mean of three interventions and had significantly more dysphagia and gastroesophageal reflux disease (GERD)-related symptoms than the surgical group. The 30-day morbidity rate in the surgical group, however, was more than four times greater than that in the endoscopy group (6.9% versus 1.3% patients, respectively); deaths did not occur in either group. The study was presented at Digestive Disease Week (DDW), held during May 2012 in San Diego (CA, USA).

“Surgery is more efficacious than endoscopy alone because there is better resolution of achalasia and maybe even better treatment of the reflux,” said study investigator Michael Ujiki, MD, a clinical assistant professor of surgery. “If you look at this issue overall, the endoscopic surgeries end up costing more because of all the subsequent repeat interventions that may be required.”

Achalasia is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES). It is characterized by incomplete LES relaxation, increased LES tone, and lack of peristalsis of the esophagus. Achalasia is characterized by difficulty swallowing, regurgitation, and sometimes chest pain. Various treatments are available, although none cures the condition. Certain medications or Botox may be used in some cases, but more permanent relief is brought by esophageal dilatation and surgical cleaving of the muscle.

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