A decision analysis of the optimal initial approach to achalasia: Laparoscopic Heller myotomy with partial fundoplication, thoracoscopic Heller myotomy, pneumatic dilatation, or botulinum toxin injection

In the absence of randomized controlled trials that directly compare all of the modern methods of managing achalasia, decision analysis may help deter mine the optimal treatment strategy. Four strategies fur the initial manage ment of achalasia were compared using the following decision model: (1) lap aroscopic Heller myotomy and partial fundoplication; (2) pneumatic dilatati on; (3) botulinum toxin injection; and (4) thoracoscopic Heller myotomy. Pr obabilities of clinical events and utilities of health states were estimate d using review of the medical literature and patient interviews. A recursiv e decision tree (Markov model) was used to simulate all the important outco mes of each initial treatment option, allowing for complications, relapses over time, and transitions between strategies when appropriate. After 10 ye ars, laparoscopic Heller myotomy with partial fundoplication was associated with the longest quality-adjusted survival (quality-adjusted life years [Q ALY] = 7.41). The difference between this strategy and either pneumatic dil atation or botulinum toxin injection was small. Thoracoscopic Heller myotom y was associated with the poorest quality-adjusted survival (QALY = 7.15). Pneumatic dilatation was the favored strategy when the effectiveness of lap aroscopic surgery at relieving dysphagia was less than 89.7%, the operative mortality risk was greater than 0.7%, or the probability of reflux after p neumatic dilatation was less than 19%. In a decision model, laparoscopic He ller myotomy with partial fundoplication is at least as effective as endosc opic approaches for managing achalasia symptoms. However, the differences a re small enough that patient preferences and local expertise should be take n into consideration when tailoring a treatment plan for an individual pati ent.