Queens Medical Centre, Nottingham. Keywods: achalasia; surgery, operative; endoscopy; dilatation, oesophageal. Summary. A retrospective survey was made ...
708
Journal of the Royal Society of Medicine Volume 79 December 1986
Audit of surgical 'and pneumatic/hydrostatic treatment of achalasia imn'a defined populati'on
H L Smart MHuRcP Queens Medical Centre, Nottingham
J F Mayberry MD MRCP
M Atkinson MD FRCP University Hospital,
Keywods: achalasia; surgery, operative; endoscopy; dilatation, oesophageal
Summary A retrospective survey was made of all the patients resident in the Nottingham area who presented with achalasia between 1959 and 1983. Initial treatment consisted of pneumatic bag dilatation in 26, hydrostatic bag dilatation in one and surgical cardiomyotomy in 22. Those treated by dilatation were older (mean age 52 years) than those treated by cardiomyotomy (mean age 42 years). Seven patients died without receiving active treatment because of old age and infirmity and in 6 this occurred before the introduction of endoscopic dilatation to the area. Initial treatment by cardiomyotomy was associated with a lower recurrence rate than treatment by bag dilatation but with a longer stay in hospital and a higher incidence of complications including empyema, chest infections and oesophageal stricture. Introduction Achalasia is a rare disease of unknown aetiology. Treatment is directed at the lower oesophageal sphincter, which can be disrupted either by a forceful dilatation or a surgical myotomy. There have been a few limited comparisons of treatment types, which on occasions have even involved different centres in different countries. In this study we have compared surgical and endoscopic treatment over a 25-year period in a defined area. Method The case notes of each of the 56 patients from the Nottingham area with achalasia who were treated between 1959 and 1983 were retrieved from the medical records department. Details were noted of each patient's age and year of treatment, types and frequency of treatment and duration of stay in hospital before and after treatment; pretreatment work-up and post-therapeutic convalescence were recorded as separate items. Immediate complications of treatment were also noted. The state of health of patients on 31 December 1984 was determined and a record made of the occurrence of long-term complications as reported in the patients' notes. Results Twenty-two patients underwent a cardiomyotomy between 1959 and 1983. One of these subsequently required an endoscopic pneumatic dilatation for recurrent dysphagia. Twenty-seven patients under0141-0768/86/ went either a pneumatic (26) or hydrostatic (1) dila012708-03/$02.00/0 tation between 1973 and 1983 (Figure 1). The patient 1986 ° treated hydrostatically was admitted in 1973. The The Royal Rider-Moeller pneumatic technique was introduced Society of Medicine to Nottingham in 1977 and used safely after that time
15
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Oo- Cardiomyotomy (n 22) - .-----. Pneumatic/hydrostatic dilataton (n 27)
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1981-83 1975-77 1969-71 1953-65 1957-59 Figure 1. Treatment of achakasia in the Nottingham area by surgical myotomy and forceful dilatation
for endoscopic dilatation. Of the 26 patients so treated, 5 subsequently required a cardiomyotomy (Table 1). However, in one of these cases relief was only temporary and 2 further pneumatic dilatations were undertaken. Only one treatment was required by 41% of cases treated with pneumatic dilatation compared with 86% treated by a cardiomyotomy. However, 19% of cases who underwent a pneumatic dilatation failed to obtain some relieffrom repeated dilatation compared with 9% who underwent a myotomy (Table 1). Pneumatic dilatation requires significantly less convalescence in hospital than a surgical myotomy (Table 2). The procedure was carried out in older people whose mean age was 52 years (range 16-80 years), compared with 42 years (range 16-70 years) for those having a cardiomyotomy (Figure 2). In addition, 6 of the 7 patients who received no treatment were diagnosed before 1977, when pneumatic dilatation became readily available, and they had been judged to be too old (mean age of 80 years) and infirm for operation. Two complications were reported as a result of endoscopic pneumatic dilatation and both were minor - a chest infection and a mucosal tear, both successfully managed conservatively (Table 3). Immediate complications after a surgical myotomy were often serious and accounted for the prolonged convalescence of some patients for up to 162 days. Patients who underwent a cardiomyotomy were followed up for a mean of 11 years (range 4-22 years), during which period 2 patients died. One patient was referred back to hospital because of symptoms of gastro-oesophageal reflux and 2 developed an oesophageal stricture. None of the cases developed an oesophageal carcinoma. Patients who had a pneumatic dilatation were followed up for a mean of 5 years (range 0.2-8 years) during which period 3 patients died. No patient was referred back to hospital because of gastro-oesophageal reflux or stricture formation and none developed an oesophageal carcinoma.
Joumal of the Royal Society of Medicine Volume 79 December 1986 Table 1. Frequency of various types of treatment for achalasia in 49 patients from Nottingham (1959-1988)
No. of treatments
Pneumatic Cardiomyotomy dilatations
1 2
19 1 1
3
110 5 3
Cardiomyotomy with subsequent pneumatic dilatations
Pneumatic dilatation with subsequent cardiomyotomy
0 1
0 0 3 (2 pneumatic dilatations followed by
cardiomyotomy) 0 1(4 pneumatic dilatations followed by
2 1
4 5
cardiomyotomy)
1(4 pneumatic dilatations followed by
7
cardiomyotomy, followed by 2 further pneumatic dilatations)
* In one case endoscopic treatment was by hydrostatic bag dilatation rather than pneumatic Rider-Moeller technique.
Table 2. Duration of hospital stay in patients from Nottingham with achalasia, by initial treatment
Cases treated Mean no. of treatments Age at first treatment (years) Length of stay (days): Pretreatment work-up Post-treatment convalescence: mean (range)E
Cardiomyotomy
Forceful dilatation
22 1.3 42
270 2.3 52 3.7
3
21(7-162)
5 (2-12)
0 26 patients had pneumatic dilatation by the RiderMoeller technique, and one a Hurst-Tucker hydrostatic bag dilatation * P
