The course of achalasia one to four decades after initial treatment

Background: Most follow-up studies of achalasia are limited to <5 years. Aim: To study the long-term efficacy of pneumatic dilation (PD) and myotomy in achalasia at least 10 years after treatment. Methods: We performed a retrospective cohort study of achalasia patients with >10 years follow-up after initial myotomy or pneumatic dilation. Symptom recurrence which required repeat dilation or surgery was compared between pneumatic dilation and myotomy. Results: One hundred and fifty patients (112 myotomy, 38 pneumatic dilation) of similar characteristics were studied. The mean duration of follow-up after initial treatment was 17.5 ± 7.2 years (10–40 years). Symptoms recurrence rate was 60.7% (100% pneumatic dilation patients vs. 47.3% myotomy), hazard ratio 0.24 demonstrating a lower need for repeat dilation or surgery with myotomy than pneumatic dilation (P = 0.008). All pneumatic dilation patients underwent myotomy in 4 ± 4 (0–16 years). Forty of 53 myotomy patients had symptom recurrence prompting further treatment: 16 pneumatic dilation, 11 myotomy and 13 both. The mean time to repeat procedure was 6.9 years (0–40). The myotomy group required fewer dilations and/or surgeries than the pneumatic dilation group (1.6 vs. 3.6, P < 0.001). 13 patients (10.1%) progressed to end-stage achalasia (five myotomy, eight pneumatic dilation) over 40 years. At last follow-up, 57/62 (92%) patients had absent or mild dysphagia, 53/62 (85%) patients had regurgitation less than once per week and 37 (60.7%) had heartburn episodes <1/week similar for pneumatic dilation and myotomy (P = 0.27). Conclusion: Although the majority of patients treated for achalasia do well after decades of treatment, most patients may need a series of endoscopic and/or surgical procedures to maintain effective symptom control.