Complexities of Managing Achalasia at a Tertiary Referral Center: Use of Pneumatic Dilatation, Heller Myotomy, and Botulinum Toxin Injection

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Abstract
The purpose of this study is to describe the results and complexity of treatment for achalasia patients presenting to a single esophagologist at a tertiary referral center and to make treatment recommendations based on this experience. Retrospective chart review of achalasia patients treated between 1994 and 2002. Symptoms, manometric and timed barium esophagram results, and treatments/outcome at CCF determined. 232 patients (51% male, mean age = 53) were evaluated. Untreated patients (n = 184): Pneumatic dilatation (PD) used in 111 patients. Symptoms and barium emptying improved in 86% and 54%, respectively. Nineteen (17%) patients required subsequent Heller myotomy (HM). Perforation rate: 3/111 (2.7%) patients. 16% required proton-pump inhibitor (PPI) for GERD. HM was used in 72 patients (81% laparoscopic). Symptoms and barium emptying improved in 89% and 44%, respectively. PPI required in 53%. Botulinum toxin (Botox) was used in 39 older patients (mean age = 71); symptom improvement lasted for a mean 6.2 months, with frequent need for repeated injection (mean: 1.7, range: 1–7). About 43% required additional treatment with a different modality. Esophagectomy was done in three patients. Patients with prior surgery (n = 48): PD (n = 10) achieved symptom and barium emptying improvement in 67% and 11%, comparable to redo HM (n = 21) with 57% symptom improvement and 38% improved emptying. Esophagectomy required in eight patients. Successful management of achalasia can be complex and may require more than one treatment modality. PD and HM are presently the best treatments for untreated achalasia with similar efficacy but greater PPI use after surgery. Both are less successful after prior HM.