Pneumatic dilation is the most effective nonsurgical treatment of achalasia. It involves the controlled rupture of LES muscle fibers to dilate the sphincter and allow gravity to move food from the esophagus into the stomach.6 Symptom improvement lasts for 60% of patients at 1 year, 50% at 5 years, and 36% at 10 years. Repeated dilations are possible and sometimes necessary, but have diminishing success rates. The most worrisome complication of pneumatic dilation is esophageal rupture, which occurs 2% of the time.5
Botulinum toxin injection is another accepted nonsurgical therapy and is recommended for patients who would like to avoid more invasive treatment. When injected into the LES, the toxin causes temporary atrophy of the neurons responsible for LES contraction. After the procedure, 70% of patients report improvement in symptoms, with half in remission at 6 months and one-third at 1 year. Patients may require repeat injections every 3 to 4 months, but the toxin’s effectiveness diminishes with each injection.6
The laparoscopic Heller myotomy involves cutting the LES muscle, making it incompetent and allowing food boluses to pass through the LES. Ninety percent of patients experience symptom relief after surgery,5 with 10-year remission rates of 67% to 85%.1 Comparisons to pneumatic dilation do not show significant differences in outcomes over time, although most studies favor myotomy over dilation.
Surgical treatment is indicated for patients who are younger than 40 years of age, those who have failed repeated nonsurgical therapies, and those at high risk of esophageal perforation.5
Patient’s course highlights Tx risks
Due to the severity of the patient’s achalasia, a Heller myotomy was performed. During the postoperative period he had several complications. He ultimately died from an uncontrollable hemorrhage after an esophageal perforation, highlighting the seriousness of this disease and the risks inherent to its treatment.
Correspondence
Drew C. Baird, MD, Department of Family and Community Medicine, D.D. Eisenhower Army Medical Center, 300 Hospital Road, Fort Gordon, GA 30905.