EFFECT OF PREVIOUS TREATMENT ON SURGICAL OUTCOME
Patients unsuccessfully treated by endoscopic dilation or in- trasphinteric botulinum toxin injection are often referred for surgery. Transient tissue damage in the mucosa-submucosa layer has been documented by high resolution endoscopic ultrasonography, but it is unknown whether previous endoscopic treatment may cause histopathological changes leading to periesophageal inflammation, difficult identification of the circular or sling fibres, or difficult dissection of the submucosal plane. Recently, it has been found that patients who previously responded to botulinum toxin show a marked fibrotic reaction at the gastroesophageal junction leading to a higher rate of intraoperative mucosal tears and postoperative dysphagia.
The increase in technical difficulties encountered at operation after injection therapy can be offset by adequate surgeon’s experience; however, these preliminary observations suggest that injection of botulinum toxin should be reserved to patients who are not candidates for pneumatic dilation or laparoscopic Heller myotomy.
Pneumatic dilation and Heller myotomy are the two best established therapeutic options in achalasia. Which is the initial approach of choice is still matter of controversy. Although the efficacy of surgery is more predictable, in the absence of a large multicentre, controlled trial, it seems reasonable to state that when expertise in both procedures is available the patient should be clearly informed about the potential risks of each procedure and should make his or her own decision.
The impact of minimally invasive surgery in the treatment of achalasia has been almost as profound as in the treatment of cholelithiasis. The results of laparoscopic Heller my- otomy combined with a partial fundoplication show equal efficacy and markedly reduced morbidity compared with the open surgical approach. It is for this reason that, in the near future, laparoscopy could emerge as the initial therapeutic approach of choice in achalasia.
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