A Controversy That Has Been Tough to Swallow: Is the Treatment of Achalasia Now Digested?

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux

The influence on outcome of indications for antireflux surgery

Background: Patients with gastroesophageal reflux referred for fundoplication present with different symptom patterns. Previous studies have not analyzed the clinical outcome after fundoplication in patients stratified according to symptom patterns. Methods: Five hundred eighteen patients undergoing laparoscopic fundoplication were stratified according to reflux symptom patterns: group 1, regurgitation; group 2, poorly controlled reflux; group 3, regurgitation and poor reflux control (combination of 1 and 2); and group 4, symptoms well controlled but patient does not want to continue taking medication. Clinical outcomes (heartburn control, dysphagia, satisfaction) were assessed prospectively using a standardized questionnaire at early (6 months to 2 years) and late (3–5 years) follow-up intervals. Results: Preoperative demographic data for the four groups were similar, except for age and the frequency of esophagitis (patients in group 4 were younger and more likely to have esophagitis). Perioperative morbidity was similar for the four groups. Eighty-seven percent of the overall study group was satisfied at early follow-up and 88% at late follow-up. Early clinical outcomes were similar for all subgroups, except dysphagia scores were higher in early follow-up in groups 1 and 3 (P = 0.001). At late clinical follow-up, there were no significant differences in clinical outcome between any groups. Conclusions: At early follow-up (6 months to 2 years), patients who had reported regurgitation as the primary indication for surgery had a less favorable clinical outcome for the side effect dysphagia. However, at later follow-up, the type of preoperative reflux symptoms did not influence the clinical outcome.Urs Zingg, Lorelle Smith, Nicky Carney, David I. Watson and Glyn G. Jamieso