SpringerLink
Log in

Botox, dilation, or myotomy? Clinical outcome of interventional and surgical therapies for achalasia

  • Original Article
  • Published:
Langenbeck's Archives of Surgery Aims and scope Submit manuscript

Abstract

Purpose

Achalasia is a rare, but well-defined primary esophageal motor disorder. Classic therapeutic approaches include botulinum toxin injection, balloon dilation, and surgical myotomy of the lower esophageal sphincter. This report summarizes our experience with different treatment modalities for achalasia.

Methods

Forty-three patients with achalasia treated in our hospital were subdivided according to therapeutic strategy: endoscopic botulinum toxin injection into the lower esophageal sphincter (EBTI; n = 7), endoscopic esophageal balloon dilation (EBD; n = 16), surgical myotomy after failed esophageal balloon dilation (EBD-HM; n = 14), and first-line surgical myotomy (HM; n = 6). Therapeutic efficiency was evaluated comparing standardized symptom scores preoperatively and at follow-up.

Results

There was no mortality and no significant difference between the groups for age, sex, or morbidity. The mean follow-up was at 9, 35, 38, and 17 months. At follow-up, recurrent or persistent symptoms were found in 71.4%, 6.3%, 35.7%, and 16.7% in EBTI, EBD, EBD-HM, and HM, respectively. Considering EBD-HM patients as failures of esophageal dilation, the total rate of recurrent or persistent symptoms after EBD was 50%. Poor symptomatic outcome was correlated to a low esophageal sphincter pressure during pretherapeutic manometry (p = 0.03) and to sigmoid-shaped esophageal dilatation (p = 0.06).

Conclusion

Surgical myotomy is the most reliable first-line therapy for achalasia, particularly in patients with a high sphincter pressure and moderate esophageal dilatation. Botox injection has a high failure rate and should be reserved for exceptional cases. Endoscopic dilation provides about 50% of patients with long-term symptomatic relief; in most cases, failure can be successfully treated surgically.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Germany)

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Campos GM, Vittinghoff E, Rabl Ch, Takata M, Gadenstätter M, Lin F, Ciovica R (2009) Endoscopic and surgical treatments for achalasia. A systematic review and meta-analysis. Ann Surg 249:45–57

    Article  PubMed  Google Scholar 

  2. Nguyen NQ, Holloway RH (2005) Recent developments in esophageal motor disorders. Curr Opin Gastroenterol 21:478–484

    PubMed  Google Scholar 

  3. Gottstein G (1908) Über Pathologie und Therapie des Cardiospasmus. All Med Centr Z 77:563

    Google Scholar 

  4. Heller E (1914) Extramuköse Kardiaplastik beim chronischen Kardiospasmus mit Dilatation des Ösophagus. Mitt Grenzgeb Med Chir 27:141

    Google Scholar 

  5. Shimi S, Nathanson LK, Cuschieri A (1991) Laparoscopic cardiomyotomy for achalasia. J R Coll Surg Edinb 36:152–154

    PubMed  Google Scholar 

  6. Pasricha PJ, Ravich WJ, Hendrix TR, Sostre S, Jones B, Kalloo AN (1995) Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 332:774–778

    Article  PubMed  Google Scholar 

  7. Eckardt VF (2001) Clinical presentation and complications of achalasia. Gastrointest Endosc Clin N Am 11:281–292

    PubMed  Google Scholar 

  8. Zaninotto G, Costantini M, Rizzetto C, Zanatta L, Guirroli E, Portale G, Nicoletti L, Cavallin F, Battaglia G, Ruol A, Ancona E (2008) Four hundred laparoscopic myotomies for esophageal achalasia: a single centre experience. Ann Surg 248:986–993

    Article  PubMed  Google Scholar 

  9. Csendes A, Braghetto I, Burdiles P, Korn O, Csendes P, Henríquez A (2006) Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months. Ann Surg 243:196–203

    Article  PubMed  Google Scholar 

  10. Allescher HD, Storr M, Seige M, Gonzales-Donoso R, Ott R, Born P, Frimberger E, Weigert N, Stier A, Kurjak M, Rösch T, Classen M (2001) Treatment of achalasia: botulinum toxin injection vs. pneumatic balloon dilation. A prospective study with long-term follow-up. Endoscopy 33:1007–1017

    Article  PubMed  Google Scholar 

  11. Hulselmans M, Vanuytsel T, Degreef T, Sifrim D, Coosemans W, Lerut T, Tack J (2010) Long-term outcome of pneumatic dilation in the treatment of achalasia. Clin Gastroenterol Hepatol 8:30–35

    Article  PubMed  Google Scholar 

  12. Zaninotto G, Annese V, Costantini M, Del Genio A, Costantino M, Epifani M, Gatto G, D'onofrio V, Benini L, Contini S, Molena D, Battaglia G, Tardio B, Andriulli A, Ancona E (2004) Randomized controlled trial of botulinum toxin versus laparoscopic Heller myotomy for esophageal achalasia. Ann Surg 239:364–370

    Article  PubMed  Google Scholar 

  13. Csendes A, Braghetto I, Henríquez A, Cortés C (1989) Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut 30:299–304

    Article  PubMed  Google Scholar 

  14. Wang L, Li YM, Li L (2009) Meta-analysis of randomized and controlled treatment trials for achalasia. Dig Dis Sci 54:2303–2311

    Article  PubMed  Google Scholar 

  15. Anselmino M, Perdikis G, Hinder RA, Polishuk PV, Wilson P, Terry JD, Lanspa SJ (1997) Heller myotomy is superior to dilatation for the treatment of early achalasia. Arch Surg 132:233–240

    PubMed  Google Scholar 

  16. Suárez J, Mearin F, Boque R, Zanón V, Armengol JR, Pradell J, Bermejo B, Nadal A (2002) Laparoscopic myotomy vs endoscopic dilation in the treatment of achalasia. Surg Endosc 16:75–77

    Article  PubMed  Google Scholar 

  17. Eckardt VF, Gockel I, Bernhard G (2004) Pneumatic dilation for achalasia: late results of a prospective follow up investigation. Gut 53:629–633

    Article  PubMed  Google Scholar 

  18. Gockel I, Junginger Th, Bernhard G, Eckardt VF (2004) Heller myotomy for failed pneumatic dilation in achalasia. How effective is it? Ann Surg 239:371–377

    Article  PubMed  Google Scholar 

  19. Smith CD, Stival A, Howell DL, Swafford V (2006) Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than Heller myotomy alone. Ann Surg 243:579–586

    Article  PubMed  Google Scholar 

  20. Torquati A, Richards WO, Holzman MD, Sharp KW (2006) Laparoscopic myotomy for achalasia: predictors of successful outcome after 200 cases. Ann Surg 243:587–593

    Article  PubMed  Google Scholar 

  21. Rosemurgy AS, Morton CA, Rosas M, Albrink M, Ross SB (2010) A single institution's experience with more than 500 laparoscopic Heller myotomies for achalasia. J Am Coll Surg 210:637–645

    Article  PubMed  Google Scholar 

  22. Portale G, Costantini M, Rizzetto C, Guirroli E, Ceolin M, Salvador R, Ancona E, Zaninotto G (2005) Long-term outcome of laparoscopic Heller–Dor surgery for esophageal achalasia: possible detrimental role of previous endoscopic treatment. J Gastrointest Surg 9:1332–1339

    Article  PubMed  Google Scholar 

  23. Arain MA, Peters JH, Tamhankar AP, Portale G, Almogy G, DeMeester SR, Crookes PF, Hagen JA, Bremner CG, DeMeester TR (2004) Preoperative lower esophageal sphincter pressure affects outcome of laparoscopic esophageal myotomy for achalasia. J Gastrointest Surg 8:328–334

    Article  PubMed  Google Scholar 

  24. Guardino JM, Vela MF, Connor JT, Richter JE (2004) Pneumatic dilation for the treatment of achalasia in untreated patients and patients with failed Heller myotomy. J Clin Gastroenterol 38:855–860

    Article  PubMed  Google Scholar 

  25. Pasricha PJ, Hawari R, Ahmed I et al (2007) Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 39:761–764

    Article  PubMed  Google Scholar 

  26. Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, Satodate H, Odaka N, Itoh H, Kudo S (2010) Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 42:265–271

    Article  PubMed  Google Scholar 

  27. Gutschow CA, Hölscher AH (2010) Myotomy for esophageal achalasia—laparoscopic versus peroral endoscopic approach. Endoscopy 42:318–319

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Mrs. Marlies Janson for her helpful assistance in data acquisition and Mr. David Peters for careful revision of the manuscript.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of General-, Visceral-, and Cancer Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany

    Christian Alexander Gutschow, Jessica Leers, Hartmut Schäfer, Klaus Ludwig Prenzel & Arnulf H. Hölscher

  2. Department of Gastroenterology and Hepatology, University of Cologne, Cologne, Germany

    Ulrich Töx

Authors
  1. Christian Alexander Gutschow
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ulrich Töx
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jessica Leers
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hartmut Schäfer
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Klaus Ludwig Prenzel
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Arnulf H. Hölscher
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Christian Alexander Gutschow.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Gutschow, C.A., Töx, U., Leers, J. et al. Botox, dilation, or myotomy? Clinical outcome of interventional and surgical therapies for achalasia. Langenbecks Arch Surg 395, 1093–1099 (2010). https://doi.org/10.1007/s00423-010-0711-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00423-010-0711-5

Keywords

Search

Navigation