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Treating achalasia; more than just flipping a coin
  1. Peter J Kahrilas
  1. Correspondence to Dr Peter J Kahrilas, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Feinberg School of Medicine, 676 N. St. Clair Street, 14th Floor, Chicago, IL 60611, USA; p-kahrilas{at}northwestern.edu

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Even as the preferred treatment of achalasia migrates towards per-oral endoscopic myotomy (POEM), the relative merits of pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) continue to be argued. In this issue of Gut, the long-term results of the European achalasia trial comparing 201 patients randomised to PD or LHM are presented,1 reporting similar outcomes between therapies. After a minimum follow-up of 5 years, 82% of patients with PD and 84% of patients with LHM had a sustained good response when analysed by intention to treat (or 91% of patients with PD and 82% of patients with LHM when analysed per protocol). The outcomes being similar, the authors conclude that the decision between therapies should be based on available expertise and patient preference. Certainly, this was an important trial and an important result. Equally certain, the medical-surgical debate will continue. Assessing the adequacy of treatment in achalasia has many facets. There are many ways to look at it and, most assuredly, surgeons and gastroenterologists will not look at these data the same way.

The ideal therapy for achalasia would revert swallow function to normal, render the patient symptom-free and not result in pathological reflux. No current therapy achieves this and none on the horizon is likely to do so. Hence, treatment is necessarily a compromise, potentially sacrificing one objective at the expense of another; better dysphagia resolution at the expense of worse reflux being the most obvious trade-off. It follows that when assessing treatment outcome in achalasia, it is important that the instrument(s) of assessment reflect a balance of the likely benefits and consequences of that treatment. The Eckardt score, used in the European trial, equally weighs four domains on a scale of 0–3: weight loss, dysphagia, retrosternal pain and regurgitation. This is a good, simple assessment of the magnitude of the achalasia symptom burden prior to treatment. However, chest pain is known to be poorly responsive to treatment by either PD or LHM2 and reflux is known to be a potential consequence of both treatments. Consequently, when used as an assessment of treatment outcome, the Eckardt score is biased against patients who presented with chest pain and neglects to evaluate a major adverse consequence of treatment—reflux. This distorts the assessment of treatment outcome. Illustrative of this, the presence of chest pain, well known to respond to neither treatment, was reported as a predictor of poor response in the European trial. It is time to move on from the Eckardt score.

Although symptomatic improvement is undoubtedly important, symptom perception is inherently subjective, and what constitutes miraculous improvement to one patient may well be an intolerable failure to another. After all, swallowing function is not normalised after treatment for achalasia; it is only improved. Ablation of the lower oesophageal sphincter only compensates for the combination of sphincter dysfunction and absent peristalsis, it does not correct them. A treated achalasic achieves satisfactory swallowing function by pacing themselves and drinking fluids liberally while eating, maintaining an upright posture, and chewing well. To some, this is achieved subconsciously; to others, it is an ongoing challenge. Hence, an objective assessment of oesophageal function using some combination of a timed barium esophagram, high-resolution manometry, endoscopy and reflux testing is essential in determining the adequacy of a treatment rendered for achalasia and assessing the potential merits of subsequent treatment.3 It is a bit curious that, in this trial, patients were retreated on the basis of a ‘bad’ Eckardt score; I would not encourage that in practice.

Another important consideration in treating achalasia is the increasing recognition of disease heterogeneity,4 now formalised in the Chicago Classification.5 Just as the choice of therapy may be influenced by the symptom array, it may also be influenced by achalasia subtype. Specifically, a growing experience, now reinforced by the long-term European trial outcome data presented in this issue, suggests that type II achalasia is the most responsive to treatment, be that PD or LHM, even approaching 100%. This emphasises the benefit of early treatment with the potential to halt the oesophageal decompensation associated with long-standing disease. No current treatment is known to affect the immunologically driven plexopathy ultimately driving the disease process.6 However, by alleviating the chronic outflow obstruction, the associated progressive oesophageal dilatation and deformation are likely halted. Note that advanced cases of achalasia (oesophageal diameter >7 cm or distal oesophageal diverticuli) were excluded from enrolment in this randomised trial.7 That was done because these patients can be very refractory to these treatments (LHM or PD) which we see to be so effective in earlier phases of the disease. Going forward, it is time to compare therapies within disease subtypes, be that type I, II or III achalasia, as each has unique treatment considerations and each may well have a unique optimal management strategy. Treatment efficacy is unquestionably a very important management consideration, but so are cost, treatment complications and post-treatment reflux. Hence if the efficacy is similar, cost is less and comparative morbidity considerations favour PD,8 ,9 this becomes a very attractive treatment option. In fact, one can easily argue that based on currently available treatment data which have characterised achalasia by Chicago Classification subtype, the optimal initial treatment for type II disease (which accounts for about two-thirds of new diagnoses at our centre) is PD.

Perhaps, the most important message of all coming from this report is the reminder that achalasia is a chronic disease and a chronic disease needs a management plan over time. In the five-plus year experience presented here, the effectiveness of both PD and LHM decreased over time. How great a decrement depends on how you keep score. In this series, 25% of the patients with PD required redilation in the course of the study and yet those were treatment successes. In a previous study reporting sustained favourable 6-year outcome of PD and LHM as 44% and 57%, respectively, retreatment was considered treatment failure. Clearly, no matter which initial treatment option is selected, PD, LHM or POEM, this is not a one-and-done scenario and to ever suggest otherwise is misleading to the patient.

References

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Footnotes

  • Funding US Department of Health and Human Services; National Institutes of Health; National Institute of Diabetes and Digestive and Kidney Diseases (DK079902).

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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