Until recently, pneumatic dilatation and intrasphincteric injection of
botulinum toxin (
Botox) have been used as initial treatments for
achalasia, with
myotomy reserved for patients with residual
dysphagia. It is unknown, however, whether these nonsurgical treatments affect the performance of a subsequent
myotomy. We compared the results of
laparoscopic Heller myotomy and Dor
fundoplication in 44 patients with
achalasia who had been treated with medications (group A, 16 patients), pneumatic dilatation (group B, 18 patients), or
botulinum toxin (group C, 10 patients). The last group was further subdivided according to whether there was (C2, 4 patients) or was not (C1, 6 patients) a response to the treatment. Results for groups A, B, C1, and C2, respectively, were: anatomic planes identified at surgery (% of patients)--100%, 89%, 100%, and 25%;
esophageal perforation (% of patients)--0%, 5%, 0%, and 50%;
hospital stay (hrs)--26+/-8, 38+/-25, 26+/-11, and 72+/-65; and excellent/good results (% of patients)--87%, 95%, 100%, and 50%. These results show that: (1) previous pneumatic dilatation did not affect the results of
myotomy; (2) in patients who did not respond to
botulinum toxin, the
myotomy was technically straightforward and the outcome was excellent; (3) in patients who responded to
botulinum toxin, the LES muscle had become fibrotic (perforation occurred more often in this setting, and
dysphagia was less predictably improved); and (4)
myotomy relieved
dysphagia in 91% of patients who had not been treated with
botulinum toxin. These data support a strategy of reserving
botulinum toxin for patients who are not candidates for pneumatic dilatation or
laparoscopic Heller myotomy.