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Heller myotomy is the optimal index procedure for esophageal achalasia in adolescents and young adults

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Abstract

Background

There is limited and conflicting data on the optimal intervention for the treatment of achalasia in adolescents and young adults (AYA), Heller myotomy (HM), esophageal dilation (ED) or botulinum toxin injection (botox). The goal of this study is to determine the most appropriate index intervention for achalasia in the AYA population.

Methods

We completed a longitudinal, population-based analysis of the California (2005–2010) and New York (1999–2014) statewide databases. We included patients 9–25 years old with achalasia who underwent HM, ED or botox. Comparisons were made based on the patients’ index procedure. Rates of 30-day complications, long-term complications, and re-intervention up to 14 years were calculated. Cox regression was performed to determine the risk of re-intervention, adjusting for patient demographics.

Results

A total of 442 AYAs were analyzed, representing the largest cohort of young patients with this disease studied to date. Median follow-up was 5.2 years (IQR 1.8–8.0). The overall rate of re-intervention was 29.3%. Rates of re-intervention for ED and botox were equivalent and higher than HM (65.0% for ED, 47.4% for botox and 16.4% for HM, p < 0.001). Ultimately, 46.9% of ED and botox patients underwent HM. The overall short-term complication rate was 4.3% and long-term, 1.9%. There was no difference in the short-term and long-term complication rates between intervention groups (p > 0.05). On adjusted analysis, ED and botox were associated with increased risks of re-intervention when compared to HM (HR 5.9, HR 4.8, respectively, p < 0.01). Black patients were found to have a risk of re-intervention twice that of white patients (HR 2.0, p = 0.05).

Conclusions

HM has a similar risk of complications but a significantly lower risk of re-intervention when compared to ED and botox. Based on our findings, we recommend HM as the optimal index procedure for AYAs with achalasia.

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Authors and Affiliations

  1. Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA

    Ya-Ching Hung, Maggie L. Westfal, David C. Chang & Cassandra M. Kelleher

  2. Department of Pediatric Surgery, MassGeneral Hospital for Children, Boston, MA, USA

    Maggie L. Westfal & Cassandra M. Kelleher

  3. Pediatric Surgery, Massachusetts General Hospital, 55 Fruit St. WRN-11, Boston, MA, 02114, USA

    Cassandra M. Kelleher

Authors
  1. Ya-Ching Hung
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  2. Maggie L. Westfal
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  3. David C. Chang
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  4. Cassandra M. Kelleher
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Contributions

Dr. Kelleher conceptualized the study, critically reviewed the data and drafted the initial manuscript, and reviewed and revised the final manuscript. Dr. Hung and Dr. Chang conceptualized the study, collected the data and carried out the initial data analysis, critically reviewed the data and drafted the initial manuscript, and reviewed and revised the final manuscript. Dr. Westfal critically reviewed the data, reviewed and revised the initial and final manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Cassandra M. Kelleher.

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Disclosures

ML Westfal is financially supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (Award Number: T32 DK007754) and by the Massachusetts General Hospital Department of Surgery Marshall K. Bartlett Fellowship. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Y-C Hung, DC Chang, CM Kelleher have no conflicts of interest or financial ties to disclose.

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Hung, YC., Westfal, M.L., Chang, D.C. et al. Heller myotomy is the optimal index procedure for esophageal achalasia in adolescents and young adults. Surg Endosc 33, 3355–3360 (2019). https://doi.org/10.1007/s00464-018-06625-6

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  • DOI: https://doi.org/10.1007/s00464-018-06625-6

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