Supplement Abstracts Submitted for the 73rd Annual Scientific Meeting of the American College of Gastroenterology: ESOPHAGUS
Purpose: Treatment options of esophageal achalasia, such as medical therapies, endoscopic therapy (dilation) or surgical myotomy, are directed at decreasing lower esophageal sphincter (LES) pressure. Literature suggests that medical therapies, although safe, are ineffective for most patients 1. Short term efficacy of endoscopic dilation rivals that of surgical myotomy and is well tolerated 2. We believe there has been a shift in the paradigm of how patients are treated after their diagnosis and that endoscopic dilation has become a less desirable treatment option.
Methods: We retrospectively reviewed records of patients who underwent esophageal manometry from January 2005 to September 2007. Patients diagnosed with achalasia were included in the study and those with questionable diagnosis of achalasia based on manometry, or pseudoachalasia based on endoscopic ultrasound/CT-scan were excluded from the study. Patients were offered three treatment options by the referring gastroenterologist and were divided into three groups based on their treatment choice: group A: surgically treated, group B: pharmacologically treated and group C: endoscopic dilation.
Results: Data was obtained on treatment selection for 33 out of 35 eligible patients (94%). Mean age of patients was 53 years (54% female). Treatment choices were distributed as follows: 19 (54.3%) underwent surgical myotomy (18 laparoscopic and 1 open myotomy); 12 (34.3%) were treated with pharmacological therapies such as calcium channel blockers, nitrates or botox; 2 (5.7%) underwent endoscopic pneumatic dilation; and 2 (5.7%) were lost to follow up.
Conclusion: Despite promising data, endoscopic dilation is being underutilized in comparison with myotomy and pharmacologic therapy. Elderly patients are not often referred for invasive treatments; however, the mean age of our study group was relatively young at 53. Concomitant medical conditions may have precluded referral for an invasive procedure but this data is not available to us. We believe gastroenterologists are concerned about performing pneumatic dilation and may be weary of liability given the 2–6% perforation risk with this modality1. Due to our initial observation we are now involved in a prospective trial to survey gastroenterologists about their reasons for selection of a particular achalasia therapy. 1. Tulman AB, Boyce HW Jr. Esophageal dilation. Gastrointestinal Endoscopy. 1981 Nov; 27 (4):229–234. 2. Cohen S, MD, et al., Pneumatic dilation for achalasia or diffuse esophageal spasm. Analysis of risk factors, early clinical characteristics, and outcome. Dig Dis Sci. 1993 Oct; 38 (10):1893–1904.