Aspects on the diagnosis and treatment of patients with achalasia

Abstract

Aim:The primary aim of this thesis was to address the potential usefulness of Timed Barium Esophagogram (TBE) inperioperative management of patients with achalasia and to validate the TBE technique. Further aims of thisstudy was to characterize the clinical profile and health related quality of life of achalasia patients at the time ofthe first diagnosis and to compare short term efficacy of laparoscopic myotomy with pneumatic dilatation withrespect to clinical outcomes and to health economy perspectives.Methods:The present investigation incorporates 50 patients on whom TBE was performed and another 51 patients whowere randomized to laparoscopic myotomy or pneumatic dilatation. Evaluation was done by use of quality oflife, manometry and endoscopy. At TBE, 250 mL low-density barium was ingested and upright films at 1, 2 and5 min pre- and postmyotomy were compared with regard to height and width of the barium column and relatedto symptoms. Pneumatic dilation was performed with balloon diameters of 30-40 mm and at the posterior partialfundoplication was added to the laparoscopic myotomy. Follow ups were scheduled at one, three, six and 12months after inclusion. The patients were interviewed regarding symptoms; their quality of life and healtheconomy was also recorded prospectively.Results:Pre-myotomy regurgitation was more severe the higher the barium column (r-0.4, p<0.007). There was excellentintra and inter-observer agreement for all measured variables. The reproducibility of the static TBE variablesform day to day was good, but not so for the functional assessment of esophageal emptying. Most patientspresented with a long duration of symptoms (54 months). The doctor s delay amounted to 9 months despiteprofound swallowing difficulties (Watson score 30.5 ± 1.7). Quality of life was significantly impaired both whengeneric (PGWB) and disease specific (GSRS) instruments were applied. Surgery relieved symptoms in themajority of patients. Pneumatic dilatation strategy was associated with more treatment failures (p=0.047) duringthe 12 months follow up while overall cost of laparoscopic myotomy was found to be significantly highercompared to pneumatic dilation strategy (p= 0.0002 and p = 0.0019) due to the paramount costs charged duringthe actual operation.Conclusion:Timed Barium Esophagogram has the potential to give objective confirmation and information on the outcomeof respective therapeutic intervention. The inter-observer variability was generally small why TBE could well beincluded in the preoperative evaluation and postoperative follow-up of all patients undergoing therapy forachalasia. Laparoscopic myotomy was found to be clinically superior to endoscopic balloon dilatation but isburdened by high initial costs, why the therapeutic method of choice still is under debate.