Does laparoscopic Heller’s myotomy provide superior results compared to endoscopic dilatation for oesophageal achalasia?

Abstract

A best evidence topic was written according to a structured protocol. In [patients with primary oesophageal achalasia] is [laparoscopic Heller Myotomy] superior to [endoscopic dilatation] with respect to [clinical outcomes]. In total 49 papers were found using the reported search, and eight of these represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Existing evidence shows that LHM is associated with improved post-operative symptoms and reduced clinical relapse rates compared to ED. Satisfactory clinical outcomes with ED often require repeat procedures performed over time and are associated with an increased risk of oesophageal perforation compared to LHM. One prospective randomized study showed no significant difference in post-operative outcomes between LHM and ED but this was limited by lack of standardization in the endoscopic dilatation procedure, limited reporting of complications and poor long-term follow up. Current evidence shows oesophageal perforation during LHM may be successfully managed intra-operatively but in ED usually requires further laparoscopic or open operative intervention. Fundoplication during LHM is associated with reduced incidence of post-operative gastro-oesophageal reflux disease. There is an increased risk of clinical relapse regardless of the treatment in patients with a sigmoid-shaped oesophagus or reduced oesophageal sphincter pressure assessed during pre-treatment manometry. Current studies are limited by study design, variations in operative technique and dilatation regimens, and limited follow up times. Further higher power studies matching patients for disease severity and surgical technique with longer follow up may enable greater understanding of differences in outcomes and improved patient selection for different treatment regimens.

Day surgery for achalasia cardia: Time for consensus?

“…This belief has to be tempered by the increased risk of oesophageal perforation with endoscopic dilatation and the frequent need for repeat procedures. 7 Moreover, the mean length of hospital stay (LOS) for LHM reported in previous studies is >1 day. [12][13][14][15] Nevertheless, the safe and effective performance of LHM as a day case lends further credence to surgery as a first-line therapy for achalasia of the oesophagus.…”

“…6 The literature, including a meta-analysis of randomised controlled trials of LHM versus endoscopic pneumatic dilatation, favours LHM as first-line therapy. 7,8 Some endoscopic enthusiasts have suggested that incision-less peroral oesophageal myotomy compares favourably with LHM as the treatment of choice for achalasia. 9,10 However, there is a lack of long-term evidence to support such conclusions.…”

Imaging in the Evaluation of Endoscopic or Surgical Treatment for Achalasia

“…The intervention consists in the longitudinal section of the cardial esophageal smooth musculature for 6-7 cm; then, an antireflux Dor fundoplication is associated, protecting the esophageal mucosa from the gastroesophageal reflux. According to the available literature, good or excellent results may be obtained in up to 90% of the cases [ 21 ].…”