Laparoscopic Heller's myotomy or botulinum toxin injection for management of esophageal achalasia - Patient choice and treatment outcomes

Background: Esophageal achalasia is a rare disease in which degenerating parasympathetic innervation of the lower esophageal sphincter (LES) leads to unopposed sympathetic tone and failure to relax on deglutition, resulting in a range of symptoms for the patient, most notably dysphagia, chest pain, regurgitation, and weight loss. Laparoscopic Heller's esophagomyotomy (Lap-HM) and botulinum toxin (BoTox) injection into the LES are two recently described methods for treating achalasia. No comparison of laparoscopic Heller's myotomy and botulinum toxin has yet been presented. Methods: A total of 22 patients (15 men, 7 women; mean age, 57.9 years) diagnosed with idiopathic esophageal achalasia were given a choice of treatment modality: Lap-HM or BoTox. Patients were prospectively assessed before and after treatment with esophageal manometry, barium swallow roentgenography, and dysphagia score. Patients' preferences and treatment efficacy were evaluated. Results: Of the 22 patients, 18 (81.8%) chose BoTox and 4 (18.2%) chose Lap-HM. Five patients in the BoTox group opted for Lap-HM a mean of 565 +/- 212 days after the first injection, having received a median of four (range, 3-5) injections. Both BoTox and Lap-HM were effective in improving dysphagia score: before BoTox (median, 7; range, 0-10) and 2 months afterward (median, 2; range, 0-6) (p < 0.01); before Lap-HM (median, 9; range, 7-10) and 6 months afterward (median, 1.5; range, 0-4) (p < 0.05). Bath methods also effectively reduced lower esophageal sphincter (LES) nadir pressure: before BoTox (mean mmHg, 22 +/- 9) and 2 months afterward (mean mmHg, 15 +/- 7) (p < 0.05); before Lap-HM (mean mmHg, 24 +/- 10) and 6 months afterward (mean mmHg, 3 +/- 4) (p < 0.05). However, only Lap-HM produced a significant reduction in LES basal pressure before (mean mmHg, 34 +/- 7) and afterward (mean mmHg, 3 +/- 3) (p < 0.01) and increased esophageal barium clearance (mean percentage of barium retained in esophagus at 5 min before (97% +/- 6%) and afterward (23% +/- 45%) (p < 0.05). Conclusions: BoTox injection and Lap-HM both significantly reduce achalasia symptoms, but only Lap-HM improves esophageal clearance of barium. BoTox injection is the most popular treatment method from a patient perspective, although symptom recurrence or failure rates are high. Lap-KM is favored by younger patients and is equally effective after BoTox therapy failure.