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A Multidisciplinary Approach Is Essential for the Treatment of Esophageal Achalasia.
Ciro Andolfi*1, Robert T. Kavitt2, Vani J. Konda2, Marco G. Patti1
1Department of Surgery, University of Chicago, Chicago, IL; 2Gastroenterology, University of Chicago, Chicago, IL
Background: Pneumatic dilatation (PD) or laparoscopic Heller myotomy (LHM) provide good relief of symptoms for patients with achalasia. Some patients, however, may experience recurrent symptoms and require additional treatment. Given the challenging nature of the management of these patients, we hypothesized that patients with achalasia require multidisciplinary expertise to avoid an esophagectomy.
Objective: To evaluate the results of a multidisciplinary approach to esophageal achalasia.
Design: Retrospective review of prospectively maintained database.
Setting: Multidisciplinary esophageal team consisting of radiologists, gastroenterologists, and surgeons in a quaternary care center.
Patients: Between May 2008 and April 2015, 147 patients with achalasia underwent LHM and partial fundoplication. Eight patients also had an epiphrenic diverticulum.
Main outcome measures: Symptom evaluation based on the Eckardt score (ES).
Results: Seventy-nine patients were men; mean age was 48 years. Patients were symptomatic for an average of 66 months. Sixty-two patients (42%) had been treated preoperatively with pneumatic dilatation (PD) and/or botulinum toxin (BT). Before surgery patients underwent barium swallow, endoscopy, manometry, and often pH monitoring. Mean preoperative ES was 6.4. Heller myotomy was completed laparoscopically in 145 patients (98.7%). Laparotomy was performed on 2 patients: one for bleeding and the other because of severe intraperitoneal adhesions. Five patients had an intraoperative mucosal perforation which was repaired laparoscopically without sequelae. Median length of stay was 23 hours. Postoperatively, 128 patients (87%) did well and required no further treatment (ES 0.1) during a median follow-up of 22 months. The remaining 19 patients (13%) during this follow-up period had recurrence of symptoms and required further treatment: 12 were treated with PD and improved (ES 0.7); 4 were treated with PD and BT and improved (ES 1.3); and 3 failed PD (ES 4.3). Of the 3 patients that failed PD, 2 underwent esophagectomy and are now asymptomatic and 1 refused further treatment. These 3 patients had been treated with multiple sessions of PD and BT before the myotomy. Overall, 144 patients (98%) were doing well with surgery (87%) and surgery and endoscopic treatment (11%).
Conclusions: The results of this study show that: 1) LHM is an effective treatment modality; 2) PD improved symptoms in the majority of patients with recurrent dysphagia after myotomy; and 3) preoperative PD and BT may cause failure of LHM, with consequent need for esophagectomy. These data support our hypothesis that patients with achalasia should be treated in a quaternary care center by a multidisciplinary team.
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