Heller Myotomy Is Superior to Dilatation for the Treatment of Early Achalasia

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Abstract
Objectives: To study the pretreatment characteristics that predispose a patient to rupture and to compare the outcome after dilatation with the outcome after surgical myotomy. Design: A survey of all patients treated for achalasia at the Creighton University Medical Center, Omaha, Neb, during a 16-year period. Clinical examination and testing of consenting patients at 12 months and longer after treatment. Setting: Tertiary referral center. Patients: Of the 61 patients, 55 were treated with dilatation. Esophageal rupture developed in 8 patients (14.5%) with achalasia after pneumatic dilatation; these patients underwent surgery for the rupture. Dilatation failed in 8 other patients; these patients underwent a surgical myotomy. Six patients underwent a primary surgical myotomy. Main Outcome Measures: Duration of symptoms, weight loss, lower esophageal sphincter resting pressure and relaxation, amplitude and quality of distal esophageal contractions (assessed by manometry), 24-hour esophageal pH, and maximal esophageal diameter (assessed by barium swallow examination). Results: Surgical myotomy at a mean (±SEM) of 44.9±18.6 months alleviated dysphagia in 13 (93%) of the 14 patients compared with only 12 (39%) of the 31 patients after dilatation at a mean (±SEM) of 55.0±11.7 months (P<.001). Of the 14 patients who underwent surgical myotomy, 13 (93%) were able to return to a normal diet compared with only 2 (7%) of the 31 patients who underwent dilatation (P<.001). Compared with patients without perforations, patients with perforations after pneumatic dilatation had pretreatment characteristics consistent with "early" disease: shorter symptom duration (20.1±5.4 vs 68.9±4.9 months, P<.001), less weight loss (4.7±1.2 vs 10.3±0.8 kg, P<.001), a less dilated esophagus (24.0±1.8 vs 45.6±3.0 mm, P<.005), lower lower esophageal sphincter resting pressures (19.3±2.6 vs 34.2±1.3 mm Hg, P<.001), a greater percentage of lower esophageal sphincter relaxation (47.6%±4.9% vs 20.7%±2.1%, P<.001), and a lower percentage of synchronous contractions in the distal esophageal body (66.2%±4.9% vs85.3%±2.3%, P<.005). (All data given as the mean [±SEM].) All patients with pneumatic perforations were successfully treated by thoracotomy and surgical repair. Conclusions: Surgical myotomy provides a better long-term outcome. The early disease stage is associated with perforation after pneumatic dilatation. Surgical myotomy rather than balloon dilatation should be considered in patients with early achalasia. Arch Surg. 1997;132:233-240