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Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, Room C-879, New York, NY 10021
(Email: floresr{at}mskcc.org).
Achalasia is the most common and best characterized primary esophageal motility disorder with a prevalence of 10 per 100,000 individuals, with an annual incidence of 0.5 cases per 100,000 individuals. The natural pathology of achalasia is such that progressive neural degeneration leads to dysphagia, a defunctionalized esophagus, and eventually end-stage disease that requires an esophagectomy.
Finley and colleagues [1] have investigated the effects of initial nonoperative management in short- and long-term symptoms after myotomy for a 14-year period of study. The most concerning finding was that Botox therapy at initial presentation was associated with a higher rate of dysphagia 1 year after surgical myotomy. A surgical concern with Botox is the development of fibrosis leading to difficulty in submucosal dissection during the myotomy and even possible incomplete myotomy. These findings suggest that initial temporizing procedures are not without consequences.
Every study has its limitations. This article provides useful information, although ascertainment bias is likely present because all subjective data were recorded by the operating surgeon. There must also be some caution used to interpret the initial treatment data because of the neat separation of the three initial treatments (ie, 62.3% medication, 38.7% pneumatic dilation, and 11.1% Botox). There is no description of overlap between the three treatments, which is common to everyday practice.
Half of the patients in this study underwent fundoplication. Many United States' surgeons believe that a myotomy of this extent should be followed by a partial fundoplication to prevent reflux. A prospective randomized trial conducted in the United States on 43 patients demonstrated a lower incidence of reflux without increased dysphagia in patients who underwent myotomy plus Dor compared with myotomy alone [2]. Despite this data, the role of fundoplication remains controversial, especially outside the United States.
The myotomy does not reverse the underlying pathophysiology of neural degeneration, but it does convert the esophagus into a passive conduit dependent on gravity for evacuation. A balance between obtaining a complete myotomy and the avoidance of excessive reflux is the primary goal.
Delay in surgical treatment will only increase the likelihood of long-term sequela (ie, mega-esophagus, thereby leading to esophagectomy for end-stage disease). Finley and colleagues [1] provide additional evidence to support the early treatment of achalasia by surgical intervention rather than exhaustive conservative treatments.
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