Acalasia. Controversias del tratamiento

Abstract

The Achalasia is a motor disorder of the esophagus characterized by loss of the esophageal peristalsis with lack in the relaxation or incomplete relaxation of the lower esophageal sphincter (LES) (1). The exact cause of this disease is unknown. The most common symptoms are dysphagia, regurgitation, loss of weight and chest pain (2). The esophageal manometry is the main method diagnosis; showing peristalsis absent of the esophageal body with elevated pressure, lacks or incomplete relaxation of the LES (3, 4). The goal of the treatment is to reduce the pressure of the LES, so that the gravity can to facilitate the esophageal evacuating, since any treatment does not exist to recover muscular activity of the esophagus (6). The treatment includes certain medications, like the nitrates or calcium channels antagonists. They are useful in patients with slight symptoms or previous a more effective invasive procedure or in those who the invasive procedures are contraindicated (7). Another therapeutic option is the positioning by means of injection under endoscopic guide of Botulinum toxin (BT) at level of the zone of higher pressure of the lower esophageal sphincter (5). The results to this drug are not uniform and one third part of these patients relapse 3 months later (5, 6). The goal of the pneumatic dilatation is to produce a controlled tear of fibers muscular of the LES, to lower the obstruction of the distal esophageal and lightening of the symptoms. The pneumatic dilatation has an immediate success of 85% to 95% (7). The technique of the pneumatic dilatation defers in each study and is not clear the number from sessions, like the caliber of the dilator (22). The Open Heller myotomy, has been the surgical treatment widely used in the patients with achalasia, nevertheless the coming of less invasive surgical techniques for the treatment of the same, have changed the handling algorithm (27, 28). The present surgical handling includes the laparoscopic Heller myotomy, which was reported in 1991 (29). Comparative studies that involve the different therapeutic techniques in achalasia are rare (33). More prospective randomized and controlled studies between the different modalities of treatment to achalasia are required to define which one is better.