Long-term Outcome of Pneumatic Dilation in the Treatment of Achalasia

Background & Aims Achalasia is treated with pneumatic dilation or Heller myotomy, but studies suggest poor long-term outcomes. We analyzed long-term outcomes after initial pneumatic dilation and studied factors associated with failure. Methods A total of 209 patients (111 men; mean age, 51.2 ± 1.4 years) with achalasia who were treated with pneumatic dilation between 1992 and 2002 were followed. Outcomes were correlated with demographics, presenting symptoms, manometric features, and treatment variables by using χ2 and Student t tests. Results All patients were initially treated with consecutive esophageal dilations up to balloon diameters of 3.0 (26%), 3.5 (41%), or 4.0 cm (33%). After dilations, mean lower esophageal sphincter (LES) pressure had decreased from 31.3 ± 1.3 to 14.0 ± 0.7 mm Hg ( P < .0001); dysphagia decreased from 96% to 26%; and 49% had gained an average of 4.6 ± 0.5 kg (weight loss at presentation was 10.6 ± 0.7 kg in 39%). During follow-up, 66% required no additional treatment, whereas 23% underwent repeat dilations after 79 ± 8 months. Patients without recurrence were older (41.2 ± 2.1 vs 56.6 ± 1.6 years; P < .0001) and had lower post-treatment LES pressure (17.8 ± 1.2 vs 12.9 ± 0.6 mm Hg; P < .005). After 70-month follow-up, balloon dilation yielded good or excellent outcomes in 72% of patients. In nonresponders, rescue surgery yielded higher success rates than botulinum toxin therapy (84% vs 44%). Patient satisfaction ranged from good to excellent in 81% of patients. Conclusions Treating achalasia with initial dilation and then surgery for short-term failures yielded good long-term results in more than 70% and treatment satisfaction in more than 80% of patients. Management of dilation failures is more problematic.