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A Current Perspective

Loie Sauer, MD; Carlos A. Pellegrini, MD; Lawrence W. Way, MD

Arch Surg. 1989;124(8):929-932.

Abstract
• We analyzed the course of 79 adult patients treated for achalasia between 1977 and 1988. Sixty-six patients (84%) had pneumatic dilatation as the primary therapy. Fifty-three patients (80%) had immediate improvement in swallowing. Three patients required immediate redilatation, 2 developed pulmonary aspiration, and 8 (12%) suffered esophageal perforation. Esophageal perforation was treated by closure plus Heller's myotomy in 3 patients, closure only in 3, chest tube in 1, and antibiotics and nasogastric suction in 1. At 4 years' follow-up, 50% of patients who had dilatation remained asymptomatic, 30% had symptoms of gastroesophageal reflux, and 20% had persistent dysphagia. Eight Heller myotomies were performed, with excellent results in 7 and 1 postoperative death from respiratory failure. Seven additional patients with disabling esophageal symptoms after multiple operations for achalasia were ultimately treated by esophagectomy (n 5), hemigastrectomy and Roux-en-Y gastrojejunostomy (n =1), and repeated myotomy (n= 1). All recovered and are able to eat solid food. Thus, our experience indicates that pneumatic dilatation remains unperfected (ie, the line between undertreatment and overtreatment is finer than generally recognized), and unless improvements can be made, the role for surgery may need to be reexpanded.

(Arch Surg. 1989;124:929-932)

Author Affiliations
From the Surgical Service, Veterans Administration Medical Center, and the Department of Surgery, University of California, San Francisco (Drs Sauer, Pellegrini, and Way).

Footnotes
Accepted for publication April 21, 1989.

Read before the 96th Annual Meeting of the Western Surgical Association, San Diego, Calif, November 16, 1988.

Reprint requests to Veterans Administration Medical Center (112), 4150 Clement St, San Francisco, CA 94121 (Dr Pellegrini).

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