Achalasia: Dilation, injection or surgery? INJECTION

The results of a double-blind trial of intrasphincteric in­jection of botulinum toxin compared with placebo showed that 66% of patients remained in remission six months after treatment, and the mean duration of a favourable response was 1.3 years. After a median follow-up of 2.4 years, only one-third of the patients were still in remission despite multiple injections. The response rate among patients older than 75 years was 75%, while it was 27% among individuals younger than 50 years. The short term safety and effec­tiveness of the procedure have been confirmed in a French multicentre study.

Based on these early results it seems reasonable to con­sider the use of the toxin in the elderly patients and in those at risk for more invasive procedures. It remains to be clarified how long the effects of the injection will last and whether re­peated injections will prove to be safe in the long term.

SURGERY

Extramucosal myotomy of the distal esophagus and cardia has been shown to achieve good symptomatic relief in about 95% of patients with idiopathic, previously untreated acha- lasia. When dissection of the cardia is minimal and an ante­rior antireflux procedure is added, gastroesophageal reflux is rare.

The advent of minimally invasive surgery in the manage­ment of benign esophageal disease, by lessening the surgical trauma to the chest and abdominal wall, has made surgery a more attractive option as a primary treatment. It has been shown that an extramucosal myotomy of the esophagus and cardia combined with a Dor fundoplication can be per­formed safely and effectively through laparoscopy, with clinical and functional results similar to that obtained with the open approach.

The operation is performed through a five-port access. Careful attention to technical details of the procedure is critical for a good surgical outcome. The incision of the lesser omentum is performed taking care to preserve the he­patic branch of the vagus nerve. Dissection is limited to the anterior surface of the esophagus and of the diaphragmatic crura to prevent postoperative reflux by preserving the ana­tomical relationships of the cardia.

The myotomy is started on the distal esophagus using an L-shaped hook until identification of the submucosal plane, and then continued with the Sugarbaker pericardiotomy scissors. Intraoperative endoscopy helps to identify the sub- mucosal plan, to evaluate the length of the myotomy and to divide residual muscle fibres; additionally, it allows de­tection of possible mucosal tears that may be safely sutured laparoscopically. The incision is carried out for about 6 cm on the esophagus and 2 cm on the gastric side including the oblique fibres. An incomplete myotomy on the stomach rep­resents the most common reason for a failed operation. The cardia is not mobilized except in patients with sigmoid esophagus; in such circumstances, it is preferable to reduce the redundancy in the abdomen and to close the crura poste­riorly. The anterior fundic wall is then sutured to both the muscle edges of the myotomy and cranially to the crura. The addition of an anterior antireflux repair sutured to the mus­cle edges aids in preventing postoperative reflux and healing of the myotomy. After an uneventful Heller myotomy and Dor fundoplication, a gastrographin swallow study is per­formed on the first postoperative day. The patient is then al­lowed to drink and to have a soft diet, and is discharged the following day.
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