Surgery for achalasia is an anachronism.

John C. Dugal Jr. MD

Outline:

• Overview of achalasia• Traditional surgical treatments

– Heller ±fundoplication• Less invasive treatments

– Nitrates/Ca channel blockers– Botulism toxin– Pneumatic dilation

• Defile my opponent• Local experience• Bottom line

Achalasia

• 1-6/100,000• Failure of the esophagus to empty properly• Presents as dysphagia to solids then liquids,

66% regurgitation, 10% chest pain• Cause unknown, destruction of Aurbach’s

plexus

Workup

• EGD• Manometry• Barium esophagram

Manometry

• Elevated resting pressures in esophageal body

• Wide mirrorlike, weak tertiary waves• Complete absence of peristalsis• LES resting pressure normal to elevated,

incomplete or absent relaxation

• Barium esophagram:– Grade 1 <4cm– Grade 2 4-6cm– Grade 3 >6cm– Grade 4 Sigmoid

Development

• Sir Thomas Willis 1672• Ernest Heller 1913

– Anterior and posterior• JH Zaaijer 1923

– Anterior only• Shimi 1991 lap• Pellegrini 1992 VATS

Dor Toupet

Drawbacks:

• Reflux• Dysphagia• Perforations

Reflux

• Peters 2001 J GI Surg 40-60% failure• Richards 2004 Ann Surg 47.6% failure

Dysphagia

• Luketich 2001 ATS 38% failure– 3 re-do, 5 dilation, 3 esophagectomy

Perforations

• Rakita 2005 J GI surgery: 6-10%• Believed to be highly under-reported

Nitrates/Ca channel blockers

• Wen 2008 Cochrane: transient at best, recommended only in trial setting

Botulism toxin injection

• Andrews 1999 Surg Endoscopy: similar decrease in dysphagia score, not durable – 77% reintervention at 324d – only 25% conversion to Heller

• Zaninotto 2004 Ann Surg: RCT similar decrease in dysphagia score, not durable – 34% symptom free at 2yrs– 2004 Surgical Endoscopy cheaper at 2yrs

Dilation

Dilation

• Kadakia 1993 Am J Gastroenterology: 27/29 – 93.1% success

• 16 one dilation• 5 two dilations• 6 three dilations

Dilation

• Katz 1998 Dig Dis & Sciences: • 72pts mean f/u 6.5yrs

– 80% single dilation success– 85% successful with 2 dilations– One 25yr single dilation success

Dilation

• Katsinelos 2005 W J Gastroenterology: • 39pt mean f/u 9.5yr 13(1) 17(2) 9(3)

dilations– 78% 5yr– 61% 10yr– 58% 15yr

Dilation

• Perforation rate 0.1-0.4% ASGE 2006

Surgery long term

• Malthaner 1994 Ann Thor Surg: Heller +Belsey mark IV: – 95% 1yr – 77% 5yr– 68% 10yr– 67% 20yr

Patient Preference:

• Andrews 1999 Surg Endoscopy: 18/22 chose botulism toxin injection

• Katsinelos 2005 W J Gastroenterology: 39/39 chose dilation

Local experience

• Stephen R. Freeman MD– 1-2 new dysphagia patients/month– Avg. 1 dilation per month– 1 perforation, 1 failure of dilation– Only 3 pts. preferred surgery first line

Cost

• O’Connor 2002 Dig Dis and Sciences– Botox $7011 5yr QALY– Dilation $7069 5yr $1348– Lap Heller $21,407 5yr $5,376,750

Cost

• Karanicolas 2007 Surg Endoscopy:– Dilation $5315 at 5yrs– Lap Heller $10,789 at 5yrs– “initial LM is a more costly management

strategy under all clinically plausible scenarios”

Summary

• Dilation has nearly equivalent results, cheaper, preferred by both patients and providers.

• Specializing in:– Lord procedures– Belsey Mark IV– Billroth 1 and 2– Open cholecystectomy– Heller myotomy– McVay and Bassini hernia repair– Vineberg procedure

References• Willis T. Pharmaceutica Rationalis. Sive Diatribe de Medicamentorum Operationibus in Humano

Corpore. London: Hagae Comitis; 1674

• Heller E. Extramukose cardioplastik beim chronischen cardiospasmus mit dilation des oesophagus. Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie. 1913:141-9

• Peters, JH An antireflux procedure is critical to the long term outcome of esophageal myotomy for achalasia. J Gastrointestinal Surgery 2001;5(1):17-20

• Richards, WO Heller myotomy vs Heller myotomy with Dor fundoplication for achalasia. Ann Surgery 2004;240(3): 405-415

• Shuchert, MJ Minimally invasive esophagomyotomy in 200 patients: factors influencing postoperative outcomes. Ann Thor Surg 2008;85:1729-34

• Rakita, S Esophagotomy during laparoscopic Heller myotomy cannot be predicted by preoperative therapies and does not influence long term outcome. J of Gastrointestinal Surgery 2005;9(2) 159-164

References• Wen, ZH Nitrates for achalasia (review). Cochrane collaboration 2008.

• Andrews, CN Laparoscopic Heller’s myotomy or botulinum toxin injection for management of esophageal achalasia. Surgical Endoscopy 1999;13:742-6

• Zaninotto, G Randomized controlled trial of botulinum toxin vs laparoscopic Heller myotomy for esophageal achalasia. Ann Surgery 2004;239(3):364-70

• Malthaner, RA Long term results in surgically managed achalasia. Ann Thor Surgery 1994;58:1343-6

• Kadakia, SC Graded pnuematic dilation using rigiflex achalasia dilators in patients with primary esophageal achalasia. Am J Gastroenterology 1993;88(1):34-8

• Katz, PO Pneumatic dilation is effective long term treatment for achalasia. Dig Dis and Sciences 1998;43(9):1973-7

References• Katsinelos, P Long term results of pneumatic dilation for achalasia: A 15years’ experience. W J

Gastroenterology 2005;11(36):5701-5

• O’Connor, JB The cost effectiveness of treatment strategies for achalasia. Digestive Diseases and Sciences 2002;47(7):1516-25

• Karanicolas, PJ The cost of laparoscopic myotomy vs pneumatic dilation for esophageal achalasia.Surgical Endoscopy 2007;21:1198-206

• Stephen R. Freeman MD- personal communication 4/30/2008.

• www.ASGE.org UGI dilation guidelines 2006