This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (116)  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Topic Collections  • Review  • Alert me on articles by topic  Social Bookmarking   What's this?

From Whalebone to Laparoscope

Anita E. Spiess, MD; Peter J. Kahrilas, MD

JAMA. 1998;280:638-642.

Objective.— To review the pathophysiology and management of achalasia.

Data Sources.— Peer-reviewed publications located via MEDLINE using the search term esophageal achalasia (subheadings: complications, drug therapy, epidemiology, etiology, physiopathology, surgery, and therapy) published in English from 1966 to December 1997.

Study Selection.— Of 2632 citations identified, 4.5% were selected for inclusion by authors' blinded review of the abstracts. New developments in the understanding of achalasia or reports of therapeutic efficacy in either controlled trials or uncontrolled consecutive series involving 10 patients or more observed for a year or longer were reviewed in detail.

Data Extraction.— All 6 controlled therapeutic trials were included, and therapeutic efficacy in uncontrolled series was assessed by the authors extracting the patients with a good-to-excellent response from each study and calculating a pooled estimate of response rate with individual studies weighted proportionally to sample size.

Data Synthesis.— Achalasia results from irreversible destruction of esophageal myenteric plexus neurons causing aperistalsis and failed lower sphincter relaxation. The only therapies that adequately compensate for this dysfunction for a sustained time are pneumatic dilation and Heller myotomy. The single controlled trial comparing these treatments found surgery superior to dilation (95% vs 51% nearly complete symptom resolution, P<.01). In uncontrolled trials pneumatic dilation (weighted mean [SD]) is 72% (26%) effective vs 84% (20%) for Heller myotomy. The limitation of dilation is a 3% risk of perforation; thoracotomy morbidity has been the major limitation of myotomy. Surgical morbidity has been sharply reduced by laparoscopic techniques.

Conclusions.— Both pneumatic dilation and surgical myotomy are effective therapies for achalasia; laparoscopic Heller myotomy is emerging as the optimal surgical therapy.

From the Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Medical School, Chicago, Ill.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Minimally-Invasive Esophagomyotomy in 200 Consecutive Patients: Factors Influencing Postoperative Outcomes
Schuchert et al.
Ann. Thorac. Surg. 2008;85:1729-1734.
ABSTRACT | FULL TEXT  

Laparoscopic Heller Myotomy for Achalasia: A Review of the Controversies
Litle
Ann. Thorac. Surg. 2008;85:S743-S746.
ABSTRACT | FULL TEXT  

Pneumatic dilatation and surgical myotomy for achalasia.
Lopushinsky and Urbach
JAMA 2006;296:2227-2233.
ABSTRACT | FULL TEXT  

Laparoscopic Esophageal Myotomy for Achalasia: Factors Affecting Functional Results
Deb et al.
Ann. Thorac. Surg. 2005;80:1191-1195.
ABSTRACT | FULL TEXT  

Minimally invasive surgery
Jaffray
Arch. Dis. Child. 2005;90:537-542.
ABSTRACT | FULL TEXT  

Long-term results and quality of life after surgery for oesophageal achalasia: one surgeon's experience
Mineo and Ambrogi
Eur. J. Cardiothorac. Surg. 2004;25:1089-1096.
ABSTRACT | FULL TEXT  

Achalasia Treatment: Improved Outcome of Laparoscopic Myotomy With Operative Manometry
Chapman et al.
Arch Surg 2004;139:508-513.
ABSTRACT | FULL TEXT  

Improved Outcome After Extended Gastric Myotomy for Achalasia
Oelschlager et al.
Arch Surg 2003;138:490-497.
ABSTRACT | FULL TEXT  

Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment
Vaezi et al.
Gut 2002;50:765-770.
ABSTRACT | FULL TEXT  

Outcomes after minimally invasive esophagomyotomy
Luketich et al.
Ann. Thorac. Surg. 2001;72:1909-1913.
ABSTRACT | FULL TEXT  

Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia: Analysis of Successes and Failures
Patti et al.
Arch Surg 2001;136:870-877.
ABSTRACT | FULL TEXT  

Cardiomyotomy
Patti et al.
SURG INNOV 1999;6:186-193.
ABSTRACT