Management of Achalasia in the 21st Century: A Suggested Approach

The esophageal motility disorder termed achalasia has been known for many decades and treatment approaches extend at least back to 1674 when Willis reported dilation of the cardiac sphincter with a whale bone (1). The combination of a poorly relaxing lower esophageal sphincter (producing an obstructive component) plus the absence of peristalsis in the smooth muscle portion of the esophagus (producing a lack of propulsive activity) results in the extreme dysphagia, regurgitation and weight loss found in these patients. There have been two accepted definitive therapies for many years; these include either forceful dilatation or direct myotomy in the region of the lower esophageal sphincter (LES). Much has been written regarding which technique is preferable for both immediate and long term effectiveness. The advent of a laparoscopic approach to the myotomy has markedly changed the controversy since the prior morbidity associated with thoracotomy has been eliminated. However, the basic pros and cons of the two procedures remain relatively constant: Pneumatic dilatation (PD) involves only a short outpatient encounter with the possibility of esophageal perforation being a concern. When performed by a well experienced “esophagologist”, this risk is, in fact, only 1% or less. PD carries the advantage of a lower incidence of gastroesophageal reflux. In contrast, myotomy can be expected to provide profound relief of the patient’s dysphagia resulting from the controlled destruction of the LES with the trade-off of a high likelihood of reflux. Hence, most surgeons will perform a variation of a fundoplication to control the myotomy induced reflux. As we enter the 21st century, it is appropriate to revisit the published comparisons of these two procedures. Although Achalasia was first described and treated by physicians in the 17th century, our understanding of what constitutes best practice and the long-term effects of our interventions is lacking. At least part of the explanation for this is the low prevalence of the disease, it is difficult to accumulate experience with a disease occurring 10 in 100,000 persons. However, even at terA SPECIAL ARTICLE