Management of Achalasia
Respondents were asked to assume for purposes of this survey that the patient
is a 40 yo male with a 12 month history of symptoms compatible with achalasia.
There is no evidence that he has Chagas’ disease. The diagnosis has been confirmed
with endoscopy, contrast esophagram, and manometry. His esophagus has slight
dilatation but no tortuosity. He does not have symptoms of vigorous achalasia.
His symptoms are present daily as evidenced by regurgitation after every meal.
He has lost 6 kg in the past 6 months.
The results of the survey demonstrate the expected wide variety of management
algorithms for this disease. Most respondents indicated that the most common
initial management of achalasia in their institution is myotomy, although an
appreciable number of institutions still favors pneumatic dilation. Only 2/3
of respondents perform surgery for uncomplicated achalasia. The total number
of respondents for this survey is relatively low compared to prior surveys,
suggesting that surgeons who do not treat achalasia didn’t respond to this
survey. The majority of surgeons performs minimally invasive surgery for achalasia,
primarily via laparoscopy, but 1/3 continue to treat uncomplicated achalasia
using open techniques. There was no agreement about the length of myotomy necessary
for adequate therapy. Most surgeons use a fundoplication as part of the surgical
therapy for this disease. Appropriate therapy for achalasia is not generally
agreed upon, and many approaches make up the standard of care.
| 1. In your institution, what is the most
common initial therapy for this patient? |
| |
Response
Percent |
Response
Count |
|
Pneumatic dilation
|
|
37.7%
|
29
|
|
Botox injection
|
|
14.3%
|
11
|
|
Bougie dilation
|
|
5.2%
|
4
|
|
Surgical myotomy with or without fundoplication
|
|
42.9%
|
33
|
|
|
answered question |
77
|
|
|
skipped question |
1
|
| 2. Do you perform surgery for uncomplicated
achalasia? |
| |
Response
Percent |
Response
Count |
|
Yes
|
|
64.9%
|
50
|
|
No
|
|
35.1%
|
27
|
|
|
answered question |
77
|
|
|
skipped question |
1
|
| 3. Which surgical specialty in your institution
manages uncomplicated achalasia? |
| |
Response
Percent |
Response
Count |
|
Cardiothoracic surgery
|
|
64.0%
|
48
|
|
General (abdominal; GI) surgery
|
|
36.0%
|
27
|
|
|
answered question |
75
|
|
|
skipped question |
3
|
| 4. What is your preferred surgical approach
to uncomplicated achalasia? |
| |
Response
Percent |
Response
Count |
|
Laparoscopy
|
|
51.4%
|
38
|
|
Laparotomy
|
|
12.2%
|
9
|
|
Thoracotomy
|
|
25.7%
|
19
|
|
Thoracoscopy
|
|
10.8%
|
8
|
|
|
answered question |
74
|
|
|
skipped question |
4
|
| 5. What is your preferred surgical therapy
for uncomplicated achalasia? |
| |
Response
Percent |
Response
Count |
|
Short myotomy and fundoplication
|
|
33.3%
|
25
|
|
Long myotomy and fundoplication
|
|
36.0%
|
27
|
|
Myotomy without fundoplication
|
|
30.7%
|
23
|
|
|
answered question |
75
|
|
|
skipped question |
3
|
| 6. In what region is your surgical practice
based? |
| |
Response
Percent |
Response
Count |
|
North America
|
|
54.5%
|
42
|
|
Europe
|
|
27.3%
|
21
|
|
South America
|
|
3.9%
|
3
|
|
Asia
|
|
7.8%
|
6
|
|
Africa
|
|
6.5%
|
5
|
|
|
answered question |
77
|
|
|
skipped question |
1
|
