eMedicine Specialties > Radiology > Gastrointestinal

Achalasia: Follow-up

Author: Michael AJ Sawyer, MD, Consulting Staff, Department of Surgery, Southwestern Medical Center; Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Inc
Coauthor(s): Thomas F Murphy, MD, Chief of Abdominal Imaging Section, Department of Radiology, Tripler Army Medical Center
Contributor Information and Disclosures

Updated: Oct 30, 2009

Intervention


No radiologic interventions are currently indicated for achalasia.{Ref56}23,24

Treatment options for achalasia include pharmacologic, mechanical, botulinum toxin, and surgical-based therapies.

Pharmacologic therapy for achalasia relies on agents that relax the smooth muscle of the distal esophagus and lower esophageal sphincter (LES). Four main classes of drugs have been used for this purpose and include the following:

  • Calcium channel blockers - Nifedipine and verapamil
  • Anticholinergic agents - Cimetropium bromide
  • Nitrates - Isosorbide dinitrate
  • Opioids - Loperamide

These agents all have demonstrated effectiveness in decreasing LES pressure in patients with achalasia; however, they frequently fail to relieve symptoms, or they are associated with significant adverse effects. For many patients, the effectiveness is only transient.

Mechanical therapy for achalasia consists of esophageal dilation, the object of which is to disrupt muscle fibers of the LES, effecting a decrease in LES pressure. Dilation is most commonly performed by using pneumatic balloons. The therapy is successful in decreasing LES pressure in 60-80% of patients; however, this change does not always translate into the relief or improvement of symptoms. Approximately one half of patients experience recurrent symptoms within 5 years. In most of these patients, the disease responds well to repeated dilation therapy. Long-term results do not appear to be as durable as results achieved with surgical esophageal myotomy.

Botulinum toxin therapy works by inhibiting the release of acetylcholine from presynaptic nerve terminals. An endoscopist injects botulinum toxin into the LES. The use of botulinum toxin has a good therapeutic index. As many as 33% of patients treated with botulinum toxin do not realize any benefit.

Esophageal (Heller) myotomy is a surgical procedure that is performed with minimally invasive techniques. The laparoscopic approach appears to be most appropriate.25,26,27,28 The results are as durable as those with an open approach and, according to Ancona and colleagues, laparoscopic surgery is associated with shorter recovery periods and more rapid discharge from the hospital.29 Laparoscopy offers the surgeon the opportunity to perform an antireflux operation, whereas thoracoscopy does not.

Several series of laparoscopic esophageal myotomy with concomitant partial fundoplication have been reported. Good-to-excellent results have been achieved in 88% of patients, according to Hunter et al30 and in 98% of patients according to Rosati.31

Gaissert and colleagues published their series of patients treated with transthoracic Heller myotomy.32 They demonstrated good early results in 91% of patients. In patients undergoing long-term follow-up, results described as good to excellent decreased to 63%. Early postoperative recurrence of symptoms was a significant factor portending less than satisfactory long-term results.

Torquati and coworkers described their results in 200 consecutive patients with achalasia treated by laparoscopic Heller myotomy.33 The primary endpoint was the change in the patient's dysphagia score. Excellent relief was afforded to 85% of the study population. The strongest predictor of a good postoperative outcome was a high preoperative LES pressure. Patients with a preoperative LES pressure greater than 35 mm Hg were much more likely to attain excellent postoperative dysphagia relief.

Csendes and coinvestigators reported very long-term follow-up data on a cohort of 67 patients who had undergone Heller myotomy plus Dor fundoplication for achalasia.34 Patients were divided into 3 groups based on duration of follow-up: group I (80-119 m, n = 15), group II (120-239 mo, n = 35), and group III (>240 mo, n = 17).

Three patients developed squamous cell esophageal carcinomas within 15 years of surgery. Nine developed Barrett esophagus with up to 30 years of follow-up. A progressive deterioration in esophageal mucosa was noted. LES pressure remained low. Esophageal peristaltic activity was not improved. Acid reflux, as determined by 24-hour pH monitoring, tended to increase with time. The authors stated that good-to-excellent results persisted in 73% of the study group. Carcinoma had developed in 4.5%. They conceded treatment failures over the long term in the remaining 22.4%, citing reflux esophagitis as the main reason for failure. In their conclusion, the authors stated that initially good clinical surgical results progressively deteriorated with time. This deterioration is mainly due to an increase in esophageal acid exposure, with development of significant reflux esophagitis and Barrett esophagus.

Medicolegal Pitfalls

  • Radiologic features of achalasia may be obvious, or they may be difficult to demonstrate, especially early in the disease process.
  • Regardless, if achalasia is clinically or radiologically suspected, the diagnosis must be confirmed by means of esophageal manometry.
  • Upper endoscopy with an analysis of biopsy specimens may also be indicated.
 


More on Achalasia

Overview: Achalasia
Imaging: Achalasia
Follow-up: Achalasia
Multimedia: Achalasia
References
Further Reading
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Keywords

achalasia, esophageal motor disorder, cardiospasm, primary achalasia, secondary achalasia, LES relaxation, lower esophageal sphincter relaxation, failure of LES relaxation, dysphagia, pseudoachalasia, esophageal distention, bird beak deformity, atonic esophagus, primary achalasia, secondary achalasia

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Contributor Information and Disclosures

Author

Michael AJ Sawyer, MD, Consulting Staff, Department of Surgery, Southwestern Medical Center; Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Inc
Michael AJ Sawyer, MD is a member of the following medical societies: American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Thomas F Murphy, MD, Chief of Abdominal Imaging Section, Department of Radiology, Tripler Army Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

David Andrew Nicholson, MBBS, FRCR, Honorary Lecturer, Department of Radiology, University of Manchester; Consultant Gastrointestinal Radiologist, Department of Radiology, Hope Hospital, Salford Royal Hospital NHS Trust, UK
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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