Is pneumatic dilatation still needed for the treatment of achalasia?

The uncertainty regarding its long-term effectiveness and perforation rates sometimes reaching 4% have led centers to abandon pneumatic dilatation (PD). We evaluated the efficacy and safety of a treatment strategy based on stepwise pneumatic dilations (30, 35 ± 40 mm) in real-world practice among patients with achalasia.

This was a retrospective study including consecutive, treatment naive, achalasia patients treated with PD at a single center. The study was based on a prospectively maintained database. The primary endpoint was the rate of clinical remission, defined as an Eckardt score < 3 at the end of follow-up.

We included 132 patients with achalasia between 2018 and 2023. Achalasia was classified as type I in 44 patients (33%), type II in 83 patients (63%), and type III in 5 patients (4%). Ninety-nine patients (75%) underwent a series of two dilations at 30 and 35 mm, 7 patients (5%) underwent a single 30-mm dilation, and 26 patients (20%) received three dilations at 30, 35, and then 40 mm. The clinical success rate at the first 3-month follow-up was 88%, with no statistically significant difference between subtypes. The median follow-up duration was 40 months. At the end of follow-up, 66 patients (65%) were in clinical remission without additional treatment. Three of the 317 procedures (1%) were complicated by perforation.

Pneumatic dilation provides sustained symptomatic improvement in 65% of patients, with a severe complication rate of 1%. It therefore remains a valuable option to treat achalasia, particularly for frail patients.