Achalasia: management, outcome and surveillance in a specialist unit

AIMS: The management and surveillance of achalasia remains controversial at the present time. The aim of this study was therefore to evaluate the results of endoscopic management and subsequent surveillance of patients with achalasia presenting to a specialist unit. METHODS: A prospective cohort of 40 patients with a radiological and manometric diagnosis of achalasia who presented to this unit between 1991 and 1998 were studied; the male : female ratio was 1 : 1 and the median age 38 (range 15-84) years. Twenty-one patients presented de novo, seven had previously undergone cardiomyotomy and 12 were referred following unsuccessful dilatation. RESULTS: Some 36 patients were treated with balloon dilatation (Microvasive achalasia balloon, 35/40 mm). Results were graded 1-4 (1, asymptomatic; 2, symptomatic but significantly improved; 3, symptomatic with no change; and 4, symptomatic but worse); 29 of 36 patients were grade 1 at subsequent follow-up and the remaining seven were grade 2 (median follow-up 17 (range 5-96) months). There was a single complication of oesophageal perforation which was treated conservatively with full recovery. Following intervention, patients were enrolled in a prospective surveillance programme of chromoendoscopy at 2-year intervals; in a total of 74 patient-years' follow-up, two superficial squamous cell carcinomas (SCCs) and one adenocarcinoma (following cardiomyotomy) were detected, giving a relative risk of one cancer in 25 patient-years. CONCLUSIONS: Balloon dilatation is a safe and effective treatment for achalasia even in patients who have had previous unsuccessful dilatations or cardiomyotomy. There is a high risk of SCC and the adenocarcinoma may have resulted from previous refluxogenic therapy, so all patients with achalasia should be followed up with surveillance endoscopy.