Dilation, myotomy produce comparable achalasia outcomes

Last Updated: 2015-12-17

By Will Boggs MD

NEW YORK (Reuters Health) - For achalasia patients, pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) yield comparable long-term outcomes, according to results of the European Achalasia Trial.

It is surprising "that there is no difference between the two treatments, especially as in literature Heller myotomy has always been presented to be superior," Dr. Guy E. Boeckxstaens, from University Hospital Leuven, Catholic University, Leuven, Belgium, told Reuters Health by email. "Our study thus shows that randomized studies are the only objective manner to compare different treatments. The choice of treatment thus should be based on these data, rather than on subjective arguments."

Started in 2003, the European Achalasia Trial is a randomized prospective multicenter trial designed to compare PD and LHM for the treatment of patients with naive achalasia. In the first report, two-year success rates were similar for PD (86%) and LHM (90%).

Now Dr. Boeckxstaens and colleagues report on 128 patients who completed between five and 10 years of follow-up in this trial, out of 201 (105 LHM, 96 PD).

The overall success rate for these patients was 94% for LHM and 90% for PD after one year and 84% for LHM and 82% for PD after five years of follow-up (p=0.92), according to the November 27 Gut online report.

A quarter of the 96 patients in the PD group required redilation during follow-up, not including seven patients who refused further redilation.

After five years, symptoms were reduced to a similar extent after the two treatments, and both groups had similar quality of life as measured by the SF-36 questionnaire.

Irrespective of treatment group, younger age, pre-existing daily chest pain, and an esophageal width <4 cm before treatment predicted treatment failure.

While no factors predicted treatment failure after LHM, age <40 years, pre-existing daily chest pain, and pretreatment esophageal width <4 cm were significant risk factors for failure after PD.

"Our data indicate that either treatment can be proposed as initial treatment for achalasia, but patients have to be informed that PD requires retreatment in 25% of cases," the researchers conclude. "Finally, based on the above, we suggest that the choice between LHM and PD should be based on the expertise available in the respective center."

"The same accounts for the new treatment of achalasia, i.e., POEM (per oral endoscopic myotomy)," Dr. Boeckxstaens said. "This approach receives a lot of enthusiasm and is currently being introduced in many centers. However, we first need objective randomized studies before accepting this as a new alternative to PD or LHM."

Ronan T. Gray, from Queen's University Belfast, UK, previously reported similar quality-of-life outcomes after LHM and PD in a case-control study of achalasia patients (Here: http://bit.ly/1mpO7mv).

He told Reuters Health by email, "The long-term results continue to show no difference in outcomes when LHM is compared with PD, even for those <40. This is important as prior to this some proposed treatment algorithms recommended LHM as first-line treatment in those <40, but in fact, this study confirms that while treatment failure is more likely in younger patients overall, there is actually no difference in outcomes between the treatment groups in younger patients."

"Based on this paper, the clinical factors that should influence physician decision making are the presence of type III (spastic) achalasia and a narrow esophagus, both of which are better served with LHM," Gray said. "Apart from these factors the decision should be made after a fully informed discussion with the patient."

"The vital information to convey is that while PD is less invasive than LHM, achieving the desired outcome can be more time-consuming and may not be suitable to those in employment who are keen to limit the amount of time out of work," Gray added.

"For example," Gray added, "the regimen for PD consists of up to three graded dilatations over a four-week period with a day off work per dilatation. A quarter of patients in the PD arm of this trial required at least one further cycle of dilatations with the protocol allowing up to three of these cycles as long as the third occurred two years from the first cycle. Alternatively LHM is associated with minimal post-operative pain, more rapid resolution of symptoms, and patients are usually discharged one to two days after surgery."

The authors reported no funding or disclosures.

SOURCE: http://bit.ly/1YnsgYB

Gut 2015.