Effects of previous treatment on results of laparoscopic Heller myotomy for achalasia

Until recently, pneumatic dilatation and intrasphincteric injection of botu linum toxin (Botox) have been used as initial treatments for achalasia, wit h myotomy reserved for patients with residual dysphagia. It is unknown, how ever, whether these nonsurgical treatments affect the performance of a subs equent 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 patie nts), 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, CI, and C2, respectively, were: anatomic planes identified at surgery (% of patient s)-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%. T hese results show that: (1) previous pneumatic dilatation did not affect th e results of myotomy; (2) in patients who did not respond to botulinum toxi n, the myotomy was technically straightforward and the outcome was excellen t; (3) in patients who responded to botulinum toxin, the LES muscle had bec ome fibrotic (perforation occurred more often in this setting, and dysphagi a was less predictably improved); and (4) myotomy relieved dysphagia in 91% of patients who bad not been treated with botulinum toxin. These data supp ort a strategy of reserving botulinum toxin for patients who are not candid ates for pneumatic dilatation or laparoscopic Heller myotomy.