Achalasia: Dilation, injection or surgery? EFFECT OF PREVIOUS TREATMENT

16 Jan



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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