» Thoracic
» Survey Results

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