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Consider Heller Myotomy In Patients With Achalasia


 

MONTREAL — Surgery should be first-line treatment for achalasia, and those patients with normal or hypotensive lower esophageal sphincter pressure have the strongest indication for this approach, according to Lorenzo E. Ferri, M.D.

“In general, I think everyone should have a laparoscopic Heller myotomy if they have achalasia, but we know that's not the treatment paradigm for most referring physicians in North America,” said Dr. Ferri of McGill University, Montreal.

Although absence of peristalsis is the defining characteristic of achalasia, increased lower esophageal sphincter (LES) pressure and incomplete LES relaxation can compound the problem, he explained in an interview.

The goal in treating achalasia is disruption of this LES mechanism, and Heller myotomy has been demonstrated to be the most effective and longest-lasting method to achieve this goal.

However, a trial with endoscopic pneumatic dilatation is often suggested before surgical treatment, Dr. Ferri said. And although this might temporarily improve symptoms in those patients who have hypertensive LES pressure, those with normal/hypotensive LES pressure will likely gain limited benefit from this approach.

“If significantly symptomatic, these patients [normal/hypotensive LES pressure] should go straight to surgery because we know their margin for clinical improvement is decreased, therefore they should have the procedure that has the greatest chance of improving their symptoms,” he said.

Patients with normal/hypotensive LES pressure have a decreased margin for symptom improvement because they experience fewer and less severe symptoms, compared with patients with hypertensive LES pressure, according to Dr. Ferri's study.

He presented his research at the annual meeting of the Canadian Association of Thoracic Surgeons.

The prospective study compared symptoms in 38 newly diagnosed achalasia patients, 22 with hypertensive LES pressure (defined as greater than 26 mm Hg) and 16 with normal/hypotensive LES pressure (defined as less than or equal to 26 mm Hg).

Patients with hypertensive LES pressure (group A) had higher esophageal tone (43 versus 19 mm Hg) and less relaxation of the sphincter (50% versus 67%) than did patients with normal/hypotensive LES pressure (group B).

The study data showed that group B had less dysphagia to liquids and soft foods, but not to solid foods, compared with group A. The latter group also scored higher (43 versus 30, with 0 being the best score and 67 being the worst) on the Achalasia Symptom Questionnaire, a structured 12-question survey of achalasia symptoms.

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