Heller myotomy is superior to dilatation for the treatment of early achalasia.

Objectives: To study the pretreatment characteristics that predispose a patient to rupture and to compare the outcome after dilatation with the outcome after surgical myotomy.

Design: A survey of all patients treated for achalasia at the Creighton University Medical Center, Omaha, Neb, during a 16-year period. Clinical examination and testing of consenting patients at 12 months and longer after treatment.

Setting: Tertiary referral center.

Patients: Of the 61 patients, 55 were treated with dilatation. Esophageal rupture developed in 8 patients (14.5%) with achalasia after pneumatic dilatation; these patients underwent surgery for the rupture. Dilatation failed in 8 other patients; these patients underwent a surgical myotomy. Six patients underwent a primary surgical myotomy.

Main Outcome Measures: Duration of symptoms, weight loss, lower esophageal sphincter resting pressure and relaxation, amplitude and quality of distal esophageal contractions (assessed by manometry), 24-hour esophageal pH, and maximal esophageal diameter (assessed by barium swallow examination).

Results: Surgical myotomy at a mean (+/-SEM) of 44.9 +/- 18.6 months alleviated dysphagia in 13 (93%) of the 14 patients compared with only 12 (39%) of the 31 patients after dilatation at a mean (+/-SEM) of 55.0 +/- 11.7 months (P < .001). Of the 14 patients who underwent surgical myotomy, 13 (93%) were able to return to a normal diet compared with only 2 (7%) of the 31 patients who underwent dilatation (P < .001). Compared with patients without perforations, patients with perforations after pneumatic dilatation had pretreatment characteristics consistent with "early" disease: shorter symptom duration (20.1 +/- 5.4 vs 68.9 +/- 4.9 months, P < .001), less weight loss (4.7 +/- 1.2 vs 10.3 +/- 0.8 kg, P < .001), a less dilated esophagus (24.0 +/- 1.8 vs 45.6 +/- 3.0 mm, P < .005), lower lower esophageal sphincter resting pressures (19.3 +/- 2.6 vs 34.2 +/- 1.3 mm Hg, P < .001), a greater percentage of lower esophageal sphincter relaxation (47.6% +/- 4.9% vs 20.7% +/- 2.1%, P < .001), and a lower percentage of synchronous contractions in the distal esophageal body (66.2% +/- 4.9% vs 85.3% +/- 2.3%, P < .005). (All data given as the mean [+/-SEM].) All patients with pneumatic perforations were successfully treated by thoracotomy and surgical repair.

Conclusions: Surgical myotomy provides a better long-term outcome. The early disease stage is associated with perforation after pneumatic dilatation. Surgical myotomy rather than balloon dilatation should be considered in patients with early achalasia.