Iatrogenic achalasia. A case series

Between 1984 and 1992, 14 cases of "secondary" achalasia were diagnosed at our institution, five due to malignancy and nine as a result of esophageal or paraesophageal surgery. Preoperative manometry had excluded preexistent achalasia in eight of nine of the latter patients. Dysphagia developed immediately postoperatively in all. Esophagram and subsequent manometry were consistent with achalasia. All failed conventional dilation sessions and eight of nine underwent pneumatic dilation: Five were cured by this alone, two required surgery (one for iatrogenic perforation), and one was lost to follow-up. This achalasia-like picture appears to be the result of a tight antireflux repair that impairs the ability of the lower esophageal sphincter to completely relax, creating a functional obstruction with proximal dilation and stasis. Such secondary achalasia appears to be a distinct clinical entity and was more common than that associated with neoplasia in our institution. Therapeutically, pneumatic dilation was required and probably causes partial disruption of a tight surgical repair.