贲门失弛缓症内镜下注射肉毒毒素与气囊扩张术疗效比较的系统评价

目的 系统评价内镜下注射肉毒毒素与气囊扩张治疗贲门失弛缓症的有效性和安全性.方法 应用国际Cochrane协作网系统评价方法进行评价.结果 共纳人12个试验包括559例患者.Meta分析显示:(1)短期总有效率内镜下气囊扩张治疗优于内镜下注射肉毒毒素治疗(83.21%比71.27%,P<0.01).(2)长期总有效率内镜下气囊扩张治疗优于内镜下注射肉毒毒素治疗(54.59%比27.60%,P<0.01).(3)临床复发率内镜下注射肉毒毒素治疗高于内镜下气囊扩张治疗(55.66%比18.84%,P<0.01).(4)副作用及并发症发生率内镜下气囊扩张治疗高于内镜下注射肉毒毒素治疗(13.01%比1.35%,P<0.01).结论 目前的证据表明:内镜下注射肉毒毒素与气囊扩张均有较好的短期疗效和安全性,内镜下气囊扩张治疗在长期疗效上更优于内镜下注射肉毒毒素.     

Use of botulinum toxin as a diagnostic/therapeutic trial to help clarify an indication for definitive therapy in patients with achalasia

OBJECTIVE: Intrasphincteric injection of botulinum toxin is useful in achalasia but is limited by its short term efficacy. The aim of this study was to evaluate the use of botulinum toxin in selected patients in whom its short duration of action may be useful in guiding therapy before considering more invasive procedures that might not be indicated. METHODS: Over a 3 yr period, botulinum toxin was injected into the lower esophageal sphincter in patients with: 1) symptoms consistent with achalasia but insufficient manometric criteria to make the diagnosis; 2) complex clinical situations in which there were factors in addition to achalasia that may be contributing to the patient's symptoms and that required different treatment; 3) atypical manifestations of achalasia; 4) advanced achalasia in which it was unclear that sphincter-directed therapy (vs esophagectomy) would be of benefit; and 5) after Heller myotomy. Clinical response was assessed mostly by symptom improvement, but in some patients follow-up barium swallow or radioscintigraphy was available. RESULTS: Eleven patients were identified. Ten had complete symptomatic response to the injection. Two patients have undergone subsequent successful pneumatic dilation, one a successful laparoscopic myotomy, and another currently scheduled for surgical myotomy. The only patient without response had advanced achalasia requiring esophagectomy. CONCLUSIONS: Intrasphincteric injection of botulinum toxin into the lower esophageal sphincter is a useful and safe means of guiding therapy in those patients with a variant of achalasia, atypical achalasia, or complex achalasia in which it is unclear that more invasive procedures such as pneumatic dilation or surgical myotomy are the correct therapy.     

Botulinum toxin injections for achalasia symptoms can approximate the short term efficacy of a single pneumatic dilation: a survival analysis approach

OBJECTIVE: Botulinum toxin injection can induce a temporary symptomatic remission in some patients with achalasia, but the comparative utility of the approach is not fully known. This study used survival analysis methods to better understand the ability of single or repeated botulinum toxin injections to postpone the need for other treatments. METHODS: The response to botulinum toxin in 42 patients with idiopathic achalasia who had not received prior treatment was compared with the outcome in 26 consecutive patients who underwent initial treatment with pneumatic dilation. Survival analysis methods were employed using time to retreatment as the principal outcome measure. RESULTS: Retreatment (any type) was required in 50% of subjects at 265 days (0.73 yr) after the first botulinum toxin injection. In contrast, retreatment after initial pneumatic dilation was required in <40% of patients after 2 and 5 yr of follow-up. The curves became significantly separated (p < 0.05) within 1 yr after initial treatment. Of those treated solely with botulinum toxin injections, repeated as needed, only 46% required pneumatic dilation or surgery by 2 yr. Survival analysis curves for repeated injections and initial pneumatic dilation did not differ statistically at 1 or 2 yr (p = 0.5 and p = 0.4, respectively). Correlational analyses indicated that, of the clinical parameters tested, only the degree of dysphagia for liquids was useful in selecting the better responders to botulinum toxin injections, with lesser symptoms predicting longer time to retreatment. CONCLUSIONS: Botulinum toxin injections, repeated as needed, can approximate the benefits of a single pneumatic dilation for < or = 2 yr from the standpoint of usual factors that drive further management.     

Pneumatic dilation in achalasia.

Pneumatic dilation is the most common first-line therapy for the treatment of achalasia. The aim of dilation is a controlled disruption of circular muscle fibres of the lower esophageal sphincter to reduce the functional obstruction. Several types of dilators and different dilation techniques are used, but the achieved results are similar. The mean success rate is about 80% in the short term, but some patients need redilation in the further course (particularly young patients). Best long term results are obtained if the lower esophageal sphincter pressure can be reduced below 10 mmHg. Major complications are rare after pneumatic dilation; the most serious complication is esophageal perforation, which occurs at a mean rate of about 2.5%. Considering the pros and cons of other effective forms of treatment of achalasia (esophagomyotomy and intrasphincteric injection of botulinum toxin), pneumatic dilation is still the treatment of choice in the majority of patients with achalasia.     

Achalasia: diagnosis and management.

Achalasia is a primary esophageal motor disorder of unknown cause that produces complaints of dysphagia, regurgitation, and chest pain. The current treatments for achalasia involve the reduction of lower esophageal sphincter (LES) pressure, resulting in improved esophageal emptying. Calcium channel blockers and nitrates, once used as an initial treatment strategy for early achalasia, are now used only in patients who are not candidates for pneumatic dilation or surgery, and in patients who do not respond to botulinum toxin injections. Because of the more rigid balloons, the current pneumatic dilators are more effective than the older, more compliant balloons. The graded approach to pneumatic dilation, using the Rigiflex (Boston Scientific Corp, Boston, MA) balloons (3.0, 3.5, and 4.0 cm) is now the most commonly used nonsurgical means of treating patients with achalasia, resulting in symptom improvement in up to 90% of patients. Surgical myotomy, once plagued by high morbidity and long hospital stay, can now be performed laparoscopically, with similar efficacy to the open surgical approach (94% versus 84%, respectively), reduced morbidity, and reduced hospitalization time. Because of the advances in both balloon dilation and laparoscopic myotomy, most patients with achalasia can now choose between these two equally efficacious treatment options. Botulinum toxin injection of the LES should be reserved for patients who can not undergo balloon dilation and are not surgical candidates.     

Intrasphincteric botulinum toxin versus pneumatic dilatation for achalasia: a cost minimization analysis.

BACKGROUND: Pneumatic dilatation or intrasphincteric botulinum toxin injection provide effective symptom relief for patients with achalasia. Although intrasphincteric botulinum toxin injection is simple and safe, its efficacy may be short-lived. Pneumatic dilatation lasts longer, but esophageal perforation is a risk. We compared treatment costs for pneumatic dilatation and intrasphincteric botulinum toxin injection using a decision analysis model to determine whether the practical advantages of intrasphincteric botulinum toxin injection outweigh the economic impact of the need for frequent re-treatment. METHODS: Probability estimates for intrasphincteric botulinum toxin injection were derived from published reports. Probability estimates for the pneumatic dilatation strategy were obtained by retrospective review of our 10-year experience using the Rigiflex dilator. Direct, "third-party payer" costs were determined in Canadian dollars. RESULTS: Intrasphincteric botulinum toxin injection was significantly more costly at $5033 compared with $3608 for the pneumatic dilatation strategy, yielding an incremental cost of $1425 over the 10-year period considered. Sensitivity analysis showed that pneumatic dilatation is less expensive across all probable ranges of costs and probability estimates. The intrasphincteric botulinum toxin injection strategy is less costly if life-expectancy is less than 2 years. CONCLUSIONS: Intrasphincteric botulinum toxin injection is more costly than pneumatic dilatation for the treatment of achalasia. The added expense of frequent re-treatment with intrasphincteric botulinum toxin injection outweighs the potential economic benefits of the safety of the procedure, unless life-expectancy is 2 years or less.     

Treatment of symptomatic nonachalasia esophageal motor disorders with botulinum toxin injection at the lower esophageal sphincter

The purpose of this study was to determine if botulinum toxin injection at the lower esophageal sphincter improves symptoms in patients with nonachalasia spastic esophageal motility disorders. Fifteen patients with nonachalasia spastic esophageal motility disorders (diffuse esophageal spasm, nonspecific esophageal motility disorders, and lower esophageal sphincter dysfunction) unresponsive to medical therapy underwent endoscopic injection of botulinum toxin at the level of the gastroesophageal junction. Symptoms were scored (0=no symptoms, 1=mild, 2=moderate, 3=severe and 4=very severe) before treatment, at seven days and every 30 days after treatment. There was significant improvement in chest pain, dysphagia, and regurgitation at 7, 30, 60 and 90 days after treatment. At one month after treatment, 11 of 15 (73%) patients had a good or excellent response to treatment. At the last patient interview (mean follow-up of 10.6 months), five (33%) patients continued to have a good to excellent response, whereas 10 (67%) underwent subsequent treatment with repeat botulinum toxin, pneumatic dilation, or bougienage. We conclude that botulinum toxin injection at the gastroesophageal junction leads to significant symptom improvement in patients with nonachalasia esophageal motility disorders. These results suggest that botulinum toxin may be an effective treatment option in some of these patients not responsive to conventional medical therapy.     

Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial

Background—Intrasphinctericinjection of botulinum toxin is a new treatment option for achalasia.
Aims—To compare the immediate andlong term efficacy of botulinum toxin with that of pneumatic dilatation.
Methods—Symptomatic patients withachalasia were randomised to botulinum toxin (22 patients, median age57 years) or pneumatic dilatation (20 patients, median age 56 years).Symptom scores were assessed initially, and at one, three, six, nine,and 12months after treatment. Objective assessment includedoesophageal manometry initially and at one month, and bariumoesophagram initially and at one, six, and 12 months post-treatment.
Results—Pneumatic dilatationresulted in a significantly (p=0.02) higher cumulative remission rate.At 12 months, 14/20 (70%) pneumatic dilatation and 7/22 (32%)botulinum toxin treated patients were in symptomatic remission(p=0.017). Failure rates were similar initially, but failure over timewas significantly (p=0.01) higher after botulinum toxin (50%) thanpneumatic dilatation (7%). Pneumatic dilatation resulted insignificant (p<0.001) reduction in symptom scores, and loweroesophageal sphincter pressure, oesophageal barium column height, andoesophageal diameter. Botulinum toxin produced significant reduction insymptom scores (p<0.001), but no reduction in objective parameters.
Conclusions—At one year pneumaticdilatation is more effective than botulinum toxin. Symptom improvementparallels objective oesophageal measurements after pneumatic dilatationbut not after botulinum toxin treatment for achalasia.

Keywords:achalasia; pneumatic dilatation; botulinum toxin; barium oesophagram

     

Achalasia treatment in the elderly: is botulinum toxin injection the best option?

BACKGROUND : Achalasia treatment in elderly patients is a matter of controversy. Botulinum toxin injection has been proposed as the best option in this group of patients as it is a safe procedure. However, concern persists regarding its short-term effect. AIMS : To analyse the clinical and economic effectiveness of botulinum toxin injection in the treatment of achalasia patients who are elderly. METHODS : Seventeen consecutive achalasia patients older than 65 years were treated with 80 units of botulinum toxin. Clinical follow-up at 1, 6 and 12 months was performed. Control manometry when symptoms recurred was carried out. Results were compared with those of an historical control group of 16 achalasia patients also older than 65 years and who had been treated with endoscopic dilation. The costs of both procedures were compared. RESULTS : Twenty-nine botulinum toxin injections were performed in the 17 patients of the botulinum toxin group (follow-up, 12-36 months). In the dilation group only two patients had to be retreated (follow-up, 12-108 months). No major complications were observed in either group. The average duration of symptom alleviation was 48 +/- 33 months for endoscopic dilation and 13.8 +/- 9.5 months for botulinum toxin injection. Maintaining a patient free of symptoms cost E348.31 per year for botulinum toxin injection, whilst if endoscopic dilation was chosen the cost was only E117.47 per year. CONCLUSIONS : The effect of botulinum toxin injections wanes with time in elderly patients, necessitating repeated injections to keep the patients symptom-free. Due to the required repeated injections this procedure is more expensive than endoscopic dilation.     

贲门失弛缓症的治疗

贲门失弛缓症是一种病因尚未明确、累及食管平滑肌和下食管括约肌（LES）的动力障碍性疾病。以吞咽时食管体部蠕动消失、LES松弛障碍为特征。本病的治疗方式包括药物、注射肉毒杆菌毒素、气囊扩张术和肌切开术,旨在降低LES压力,促进食管排空,多数患者可获得较理想的结局。本文就贲门失弛缓症的治疗现状作一综述。     

Long-term efficacy of Botulinum toxin in classical achalasia: a prospective study

OBJECTIVE: We sought to examine the long-term efficacy of intrasphincteric Botulinum toxin A injection in a prospective cohort study of 30 patients with achalasia. METHODS: Thirty patients with classical achalasia were treated with intrasphincteric Botulinum toxin A injection. Follow-up consisted of clinical assessment, symptom scoring, and postinjection manometry. RESULTS: Symptomatic improvement for >3 months was seen in 23 of 30 patients (77%). Of the 23 initial responders, seven (30%) experienced a sustained symptomatic response after a single Botulinum toxin injection (mean follow-up, 21 months). The remaining 16 initial responders (70%) eventually relapsed (mean initial response, 11 months). Nine received a 2nd Botulinum toxin injection, and seven experienced an ongoing response (mean duration, 9 months); two patients eventually required a 3rd injection with good effect (mean duration, 22 months). The remaining seven patients who relapsed after Botulinum toxin opted for pneumatic dilation or surgical myotomy. Five of the seven patients who had no initial response received a 2nd injection but again did not respond. A residual lower esophageal sphincter pressure <18 mm Hg after the first Botulinum toxin injection predicted a good response to Botulinum therapy (single or multiple injections, p < 0.002, positive predictive value = 0.71, negative predictive value = 1.0). Neither initial nor sustained response to Botulinum toxin could be predicted based on gender, age, duration of illness, previous pneumatic dilation, or esophageal motility before treatment. CONCLUSIONS: We found that 77% of patients with classical achalasia experienced a good symptomatic response after Botulinum toxin and 30% of initial responders achieve sustained symptomatic relief after a single treatment with Botulinum toxin. The initial responders who relapsed did well with subsequent Botulinum toxin A. Lack of an initial symptomatic response and residual lower esophageal sphincter pressure > or =18 mm Hg after Botulinum toxin are associated with a poor response.     

Modern management of achalasia

Opinion statement The goals in the treatment of achalasia are threefold: 1) relieving the symptoms, particularly dysphagia and bland regurgitation; 2) improving esophageal emptying by disrupting the poorly relaxing lower esophageal sphincter (LES); and 3) preventing the development of megaesophagus. Although achalasia cannot be permanently cured, excellent palliation is available in over 90% of patients, especially those with pneumatic dilation and laparoscopic Heller myotomy. The efficacy for short- and long-term therapy seems to be similar when performed by experts. Pneumatic dilation done as an outpatient surgery disrupts the LES muscle from within by using balloons of progressively larger diameter (3.0, 3.5, and 4.0 cm). Repeat dilations may be required; secondary severe gastroesophageal reflux disease (GERD) is rare, but approximately 2% of patients will have an esophageal perforation. A surgical Heller myotomy is now being done laparoscopically through the abdomen that cuts the LES and extends the myotomy 2 to 3 cm onto the stomach. Usually 2 days of hospitalization is required, and patients can normally return to work in 1 to 2 weeks. Severe GERD with esophagitis and peptic stricture is a common complication; therefore, most surgeons combine the myotomy with an incomplete fundoplication. Medical therapy is much less effective than these invasive procedures. Smooth muscle relaxants (nitrates and calcium channel blockers) taken immediately before meals improve dysphagia, but side effects and drug tolerance are common. The injection of botulinum toxin (100 to 200 units) endoscopically into the LES gives short-term relief of symptoms and improves esophageal emptying. This treatment is most effective in the elderly, as symptom relief can last up to 1 to 2 years with a single injection. Several studies suggest the most cost-effective management of achalasia is initial treatment with pneumatic dilation.     

Esophageal pharmacology and treatment of primary motility disorders

Swallowing is a complex mechanism based on the coordinated collaboration of tongue, pharynx and esophagus. Disturbances of this interplay or disorders of one or several of these components lead to dysphagia, non-cardiac chest pain or regurgitation. The major primary esophageal motility disorders--achalasia, diffuse esophageal spasm, hypercontractile esophagus ('nutcracker esophagus') and non-specific motility disorder--are of unknown etiology. Other esophageal diseases, such as cervical diverticula or gastroesophageal reflux disease, might also be caused by a primary esophageal motility disorder. Medical treatment of esophageal disorders with esophageal hyper- or dysmotility requires agents that reduce esophageal contractile force (anticholinergic agents, nitrates, calcium antagonists). Despite the beneficial effect of the various drugs on esophageal motility parameters, the clinical benefit of medical treatment of esophageal motility disorders is rather disappointing. Calcium channel antagonist, alone or in combination with anticholinergics or nitrates, can be used as a medical trial, especially in mild achalasia. However, medical therapy is clearly inferior to pneumatic balloon dilation therapy. Recently, botulinum toxin injection was suggested as a therapeutic option in achalasia patients with good results on lower esophageal sphincter pressure (LESP) and symptom scores that were similar to the results achieved by pneumatic balloon dilation. Hypercontractile esophagus shows a good manometric response to calcium channel antagonists, but only little clinical effect in terms of improvement of symptoms. Diffuse esophageal spasm is a relatively rare disease and few clinical studies are available. The use of calcium channel antagonists can be beneficial, at least in some patients with diffuse esophageal spasm. From clinical and epidemiological studies, there is some evidence of a 'psychological' component in the pathogenesis or perception of esophageal symptoms. There is some clinical benefit from centrally acting drugs such as benzodiazepines or antidepressants. With the exception of botulinum toxin for achalasia, medical therapy of primary esophageal motility disorders is rather limited and the clinical results are poor. Further understanding of esophageal pathophysiology as well as development of new receptor-selective drugs might increase our chances of a successful treatment of primary esophageal motility disorders.     

内镜下三种方法治疗贲门失弛缓症后下食管括约肌及体部动力学比较

目的 比较分析内镜下单纯扩张术、扩张加肉毒杆菌毒素注射术及支架扩张术治疗贲门失弛缓症后下食管括约肌(LES)及食管体部动力学变化情况.方法 将99例临床确诊的贲门失弛缓症患者分为扩张组、扩张注射组和支架组,分别进行内镜下单纯扩张术、扩张加肉毒杆菌毒素注射术及支架扩张术治疗,并于治疗前、治疗后1周、治疗后6个月及治疗后12个月分别检测LES静息压、松弛率及食管体部顺行性收缩比例、非协调性收缩比例、LES上10 cm处的收缩幅度,比较分析治疗前后各项指标的变化值.结果 治疗前,各组LES静息压、食管体部非协调性收缩比例、收缩幅度均较正常值显著升高,LES松弛率及食管体部顺行性收缩比例则均显著降低,3组间差异无统计学意义.治疗后1周,3组间各项检测指标与术前比较的变化值差异均无统计学意义.治疗后6个月,扩张注射组和支架组LES静息压、LES松弛率、食管体部收缩幅度的改善情况均优于扩张组,P值分别为0.041、0.006、0.037和0.029、0.004、0.033,但扩张注射组和支架组间比较差异无统计学意义(P值均＞0.05).治疗后12个月,支架组LES静息压、LES松弛率、食管体部顺行性收缩比例、食管体部收缩幅度的改善情况均优于扩张组,P值分别为0.035、0.028、0.008、0.007,扩张注射组与扩张组比较则差异均无统计学意义(P值均＞0.05).结论 内镜下单纯扩张术、扩张加肉毒杆菌毒素注射术及支架扩张术是治疗贲门失弛缓症的有效方法 ,近期疗效显著,远期复发率随时间延长均呈上升趋势,但支架扩张术的远期疗效相对优于其他两种方法 .     

Manometrically-guided endoscopic injection of botulinum toxin for esophageal achalasia: a pilot trial

AIMS: Some patients gained only short-term response (< 6 months) after botulinum toxin (BTX) injection for achalasia. This may be due to an incorrect site of injection when targeting the lower esophageal sphincter by using endoscopic landmarks only. PATIENTS AND METHODS: 7 elderly patients (4 females, 67 +/- 20 years) with classical achalasia received manometrically-guided botulinum toxin injection by means of a double-channel endoscope. Thereafter, they were clinically re-evaluated at 6 weeks and later on at bi-monthly intervals. RESULTS: The mean symptom score decreased 6 weeks after the manometrically-guided BTX-treatment from 12 +/- 2 (before BTX) to 6 +/- 2 points (p = 0.02). However, according to the study criteria one patient did not respond to BTX-injection and underwent subsequent cardiomyotomy. The LES-resting pressure was found not to be altered in this patient (6 weeks after BTX-injection) but manometry revealed a marked decrease of the LES-tone in 3 other patients who benefitted from BTX-injection. 5 of the 6 patients, who initially benefited from BTX-injection, relapsed 10 months (range, 6-13 months) after their initial BTX-treatment. They all were treated with repeated BTX-injections. At completion of the study (1.5-year follow-up) the mean symptom score of the 6 patients was still significantly lower (6 +/- 2 points) than before study entry (p = 0.03). CONCLUSION: Manometrically-guided endoscopic BTX-injection is a simple, safe and highly effective (during 1.5-year follow-up) technique for treatment of esophageal achalasia. With the manometrically-guided injection technique one may obtain a longer lasting symptomatic response than with the traditional method of BTX-application.     

Recent trends in endoscopic management of achalasia

Esophageal achalasia is a chronic and progressive motility disorder characterized by absence of esophageal body peristalsis associated with an impaired relaxation of lower esophageal sphincter(LES) and usually with an elevated LES pressure, leading to an altered passage of bolus through the esophago-gastric junction. A definitive cure for achalasia is currently unavailable. Palliative treatment options provide only food and liquid bolus intake and relief of symptoms. Endoscopic therapy for achalasia aims to disrupt or weaken the lower esophageal sphincter. Intra-sphincteric injection of botulinum toxin is reserved for elderly or severely ill patients. Pneumatic dilation provides superior results than botulinum toxin injection and a similar mediumterm efficacy almost comparable to that attained after surgery. Per oral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and further objective and long-term follow up. This article will review different endoscopic treatments in achalasia, and summarize the short-term and long-term outcomes.     

Endoscopic dilation for treatment of esophageal motility disorders

Esophageal dilation is an important therapeutic strategy in patients with esophageal motility disorders. Patients with achalasia have for many years benefited from pneumatic dilation as a definitive form of therapy, which is superior to botulinum toxin injection and equivalent in efficacy to surgical myotomy. Optimal performance of pneumatic dilation ensures maximum efficacy and reduced complication of perforation. Esophageal dilation also plays a crucial role in esophagogastric junction outflow obstruction due to strictures or prior surgical interventions as well as in esophageal hypercontractile states such as spastic disorders or in those with nonobstructive dysphagia. In this section, we will review the clinical evidence of esophageal dilation in achalasia, esophagogastric junction outflow obstruction, esophageal spastic disorders and in patients with dysphagia and nonobstructive dysphagia. We will outline specific techniques currently recommended and employed in esophageal dilations for these disorders and provide relative efficacy to other forms of therapy.     

Meta-Analysis of Randomized and Controlled Treatment Trials for Achalasia

Pharmacological therapy, botulinum toxin injection, pneumatic dilatation, and surgical myotomy are the primary therapeutic modalities for achalasia, for which laparoscopic myotomy is recommended as state-of-the-art therapy. However, its efficacy and safety remain unclear compared with other approaches in the treatment of achalasia. We searched electronic databases (MEDLINE, EMBASE, Cochrane Central Registry of Controlled Trials, LILACS-Latin American, Caribbean health science literature, and Science Citation Index Expanded) for randomized controlled trials to evaluate which therapeutic measures are temporary and reversible and which measures are definitive and effective by pooling data including remission rate, relapse rate, complications, and adverse effects. Seventeen studies with 761 patients met our inclusion criteria. There was better remission rate in pneumatic dilation than in botulinum toxin injection for initial intervention [relative risk (RR) 2.20, 95% confidence interval (CI) 1.51–3.20], Pneumatic dilation had lower relapse rate than did botulinum toxin injection (RR 0.12, 95% CI 0.04–0.32). Compared with pneumatic dilation, laparoscopic myotomy further increased remission rate (RR 1.48, 95% CI 1.48–1.87), and reduced clinical relapse rate (RR 0.14, 95% CI 0.04–0.58), and there was no difference in complication rate (RR 1.48, 95% CI 0.37–5.99). Based on limited randomized and controlled trials, laparoscopic myotomy is the preferred method for patients with achalasia. Future trials should investigate whether laparoscopic myotomy combined with different modalities of fundoplication is superior to isolated laparoscopic myotomy.     

Assessment of esophageal emptying post-pneumatic dilation: use of the timed barium esophagram

OBJECTIVES: The reported success rate of pneumatic dilation in patients with achalasia varies from 50% to 93%. This wide variability may be due to using symptom relief post-dilation as the only assessment of success. There are no studies comparing subjective symptom improvements to objective improvement in esophageal emptying after pneumatic dilation. METHODS: Patients with achalasia undergoing pneumatic dilation from 1995 to 1997 were evaluated. Pre- and post-dilation symptoms were recorded using a standardized scoring system. Barium column height was measured 1 min and 5 min after upright ingestion to assess esophageal emptying. Based on percentage of total symptom and barium height improvement post-dilation, patients were grouped according to one of nine outcomes; the association between subjective and objective parameters of improvement was tested. RESULTS: A total of 37 patients underwent 53 pneumatic dilations. There was a significant association (p < 0.001) between improvement in patient symptoms and barium height. In 38 of 53 (72%) pneumatic dilations, the degree of symptom and barium height improvement was similar. Near complete symptom resolution was reported after 26 dilations. In eight of 26 (31%) patients however, there was < 50% improvement in barium height (group A). Compared with the 16 patients with 91-100% improvement in both symptoms and barium height (group B), forward stepwise regression identified age as the only difference between the two groups, with group A patients being significantly (p = 0.04) older. CONCLUSIONS: Objective assessment of esophageal emptying pre- and post-dilation identifies an important subset of patients with poor esophageal emptying who report near complete symptom resolution. This group may benefit from any early repeat pneumatic dilation.