DefinePK

Abstract

Madam, We appreciate the thorough review and comments on our article, "Achalasia in a Gastroenterology Unit of Karachi" by Mr. M. Hanif Shiwani and Mr. Chris Whitfield. One should not be disappointed by looking at scientific data which has unexpected results or do not coincide with our impressions drawn by experience. It is also obvious that older studies cannot be compared with recent ones and the advance techniques cannot be compared with the older and conventional procedures.
As we have mentioned earlier that this is a retrospective data which obviously had some limitations but a sincere effort was made to provide the correct information as it was documented. Regarding the preoperative preparation, all the patients who came with the obstructive symptoms like Dysphagia, vomiting, reflux or regurgitation of food and having dilated esophagus and narrow lower esophageal sphincter on barium swallow studies were further evaluated for achalasia by esophageal transit time, esophageal manometry and upper GI Endoscopy. Post dilatation barium swallow to obtain and compare the barium height and width as compared to base line was not done in this study. Only symptomatic evaluation and endoscopic examination was done at one month and then six monthly intervals after dilatation and post surgery to evaluate the success of procedure or any evidence of complication. Duration of follow up ranged from one year to three years with a mean of 2 years. Most of our cases had standard Heller Myotomy only four cases had fundoplication and fundal wrapping. Out of these four two patients developed post operative dysphagia and required dilatation.
The last sentence of our article gives the advantages of Laproscopic Heller Myotomy rather than negating the advantages of recent advancements as has been stated by the worthy reviewer The authors are well aware of the impressive results of the Laproscopic Heller Myotomy but since this particular study did not deal with that group it was not discussed in detail. Prior endoscopic dilatation may worsen subsequent surgical outcome, is a well known fact which should have been discussed and explained to the patients prior to the decision making and during informed decision making process which was over looked in this study, we are grateful for the critical review and guidance. As far as the final conclusion is concerned it was drawn on the basis of long term follow up results. Statistical analysis shows the difference was not significant P> 0.05 (P value = 0.802).
This is an ongoing controversy which will continue for years to come, as physicians will favour dilatation whereas surgeons will support surgical myotomy. It seems this debate will end with the excellent results of Laproscopic Heller Myotomy which is emerging as a gold standard in literature.

Waquaruddin Ahmed, Huma Qureshi,
Mumtaz Maher*, Ambreen Arif
Pakistan Medical Research Council, Research Centre
and *Department of Surgery, Jinnah Postgraduate Medical Centre, Karachi.