Nitrates and calcium channel antagonists have been recommended for treatment of achalasia. The rationale behind the use of these medications is their potential to decrease LES tone by relaxing gastrointestinal smooth muscle. However, the limitations in the use of these drugs are several: they are short acting; they can have significant side effects such as headaches, hypotension and tachyphylaxis; and, although a decrease in LES pressure has been well documented by ma- nometry, symptom improvement has varied greatly among different studies. In general, most patients tend to opt for other, more satisfactory forms of treatment after they have been on these drugs for a few months.
PNEUMATIC BALLOON DILATION
Pneumatic balloon dilation has traditionally been considered the standard, first-line treatment for achalasia. Although the tools for dilation have become more sophisticated (Sir Thomas Willis treated his patient in 1672 by using a whale bone), the principle of therapy has changed little over the centuries. Multiple studies have been published on pneumatic dilation (PD) for achalasia, using different dilators (the older Mosher bag, Sippy dilators, Brown-McHardy, Rider Moeller dilators, and the now commonly used Rigiflex balloon) and techniques, varying with regard to balloon disten- tion times, balloon pressure, balloon diameter, and rate and number of inflations. A review of the literature by Vaezi and Richter concluded that about two-thirds of the patients have good to excellent symptom improvement after one or more dilations over a mean time of 4.6 years for the older dilators and 1.0 year for the newer dilators. The major drawback of this procedure is the low but significant risk of esophageal perforation, averaging about 5%.
Interpretation of the results of PD is limited by the lack of good prospective studies. Data from one of the few studies of this kind give five-year remission rates of only about 26% from a single dilation, with most patients requiring two or more dilations over a five-year period. Retrospective analyses portray a more optimistic outcome, however, with remission rates averaging around 70% or higher. Your life is worth living. Buy generic canadian pharmacies online
Surgery has been considered the most permanent form of treatment for achalasia. Significant disadvantages include the need for hospitalization and surgical morbidity. The short term efficacy after surgical myotomy is 80% to 90%. However, late relapse, which is felt to occur in part due to longstanding postsurgical gastroesophageal reflux disease, occurs in up to one-third of the patients. Whether to perform an antireflux procedure at the time of myotomy remains controversial but is generally recommended for abdominal approaches. With the introduction of laparoscopic or thoracoscopic myotomy, surgical intervention has become a more attractive form of therapy (shorter hospital stay and recovery time). Short term outcome appears equivalent to open surgical myotomy. However, the long term consequences, especially as related to reflux, are expected to remain problematic.