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Are the results of myotomy altered by previous dilatations?
J.C. Chiocca, G.B. Salis (Buenos Aires)
In our exprience [1] on 120 patients with achalasia of the esophagus treated by pneumatic dilatation (PD), 21 had a recurrence of the disease and underwent surgical treatment, 15 because of 2 therapeutic failures, and 6 who refused a second dilatation. There were 10 females (R: 21-58, X 37.6 years) and 11 males (R: 26-68, X 43.5 years). Fourteen patients were subjected to Heller cardiomyotomy, and 7 were treated by Heller's procedure plus partial fundoplication. After an average follow-up of 3.5 years, 20 patients (95.2%) are doing well. One patient who had a Heller cardiomyotomy, developed gastroesophageal reflux disease (GERD) complicated by Barrett's epithelium, and is currently on proton pump inhibitors.
Based on our experience, we conducted a bibliographic search of the last 5 years with the following findings. Pinotti [2] reported on 92 patients who experienced previous pneumatic dilatation failures and were treated thereafter by myotomy and fundoplication with "no statistically significant difference found on comparing the cases with and without previous dilatation (excellent results in 83.9%)". Ferguson [3], in a recent paper on 44 patients with failure from 1 to 3 previous PDs, reports excellent or good results with myotomy and fundoplication in 88% of the cases. Korn [4] shows similar results (good or excellent in 87.5%) with the same combined surgical treatment in 40 achalasia patients with previous failure to a median of 2 pneumatic dilatations. Martins [5] reports on a group of chagasic megaesophagus which presented 30 recurrences of pneumatic dilatation, which were treated by surgery with good results in 23 cases (76.6%). Parkman [6] reported as well, that 15 patients with failure to pneumatic dilatation were submitted to surgical myotomy with good clinical and X-ray results in 100% of the cases. Similar experience has been reported by Maurer [7] on 12 patients with failure to one or more preoperative pneumatic dilatations, who did well after extramucosal myotomy combined with Dor's semifundoplication; and by Tandon [8] in 2 patients (Heller), and Abid [9] in one Heller procedure. On the contrary, Victor's paper [10] was the only one reported in the period mentioned above which addressed the case of "a female aged 46 dilated on 2 occasions with failure, in whom at surgery the muscle fibers were found disrupted, with submucosal adhesions and friable mucosa", precluding Heller's myotomy. She was finally treated by a Mickulicz's procedure.
In conclusion, in the period 1991-1996, 258 failures to 1 or more pneumatic dilatations treated by myotomy alone (63 patients) or combined with fundoplication (195 patients) presented good to excellent results in 83.1% of the cases. Therefore, based on our experience and that of the literature, we believe that the results of myotomy are not altered by previous pneumatic dilatation. Most authors indicate surgical treatment of achalasia of the esophagus after 2 failures of pneumatic dilatation.
We think that this is a reasonable figure, since the repetition of innumerable dilatations may not improve the results, and could eventually lead to such an anatomical damage of the esophagogastric junction that it could eventually tamper a cardiomyotomy. Nevertheless, the Vantrappen group's formidable experience with repeated progressive size balloons, is not to be forgotten [11].
References
1. Salis GB, Chiocca JC, Periss E, Acosta E, Mazure PA. Esophageal achalasia: 20 year's experience with nonsurgical treatment. Acta Gastroent Latinoam 1991;21(1):11-16.
2. Pinotti HW, Aissar Sallum RA, Zilberstein B, Ceconello I, Da Rocha JM, Felix VN. Should failure of balloon dilatation foretell a poor result from surgery?. In: Giuli R, McCallum RW, Skinner DB, eds. Primary motility disorders of the esophagus. Paris: John Libbey Eurotext, 1991:429-430.
3. Ferguson MK, Reeder LB. Long-term results following myotomy and fundoplication for achalasia. Abstracts Volume. Sixth World Congress of The International Society for Diseases of the Esophagus 1995;42.
4. Korn O, Stein HJ, Feussner H, Dittler HJ, Siewert JR. Experience with a step-wise therapeutic strategy for the management of patients with achalasia. Abstracts Volume. Sixth World Congress of The International Society for Diseases of the Esophagus 1995;39.
5. Martins P, Morais BB, Cunha Melo JR. Postoperative complications in the treatment of chagasic megaesophagus. Int Surg 1993;78(2):99-102.
6. Parkman HP, Reynolds JC, Ouyang A, Rosato EF, Eisenberg JM, Cohen S. Pneumatic dilatation or esophagomyotomy treatment for idiopathic achalasia: clinical outcome and cost analysis. Dig Dis Sci 1993;38(1):75-85.
7. Maurer KP, Junginger T, Eckardt V, Zapf S. Surgical therapy of achalasia after previous pneumatic dilatation. Med-Klin 1991;86(11):569-573.
8. Tandon RK, Arora A, Mehta S. Pneumatic dilatation is a satisfactory first line treatment for achalasia. Indian J Gastroenterol 1991;10(1):4-6.
9. Abid S, Champion G, Richter JE, Mc Elvein R, Slaughter RL, Koehler RE. Treatment of achalasia: the best of both worlds. Am J Gastroenterol 1994;89(7):979-985.
10. Victor S, Jayabaul R, Jayanthi V, Chari ST, Mandanagopdan N. Cardiomyotomy after failed pneumatic dilatation for achalasia cardia, operative pitfalls. Trop Gastroenterol 1992;13(1):36-38.
11. Tak J, Janssens J, Vantrappen G. Non-surgical treatment of achalasia. Hepatogastroenterology 1991;38(6):993-997.
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