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Background: The Chicago Classification describes three distinct subtypes of achalasia and it appears to be a promising tool in predicting results of treatment with standard Heller Myotomy. The aim of this study is to analyze the outcomes of surgical treatment for achalasia using an extended Heller myotomy for each subtype and to identify additional parameters that may predict the success of therapy., Methods: 72 consecutive patients with achalasia were evaluated at the University of Washington between 2008 and 2013. Symptom duration, patient age, and the degree of esophageal dilation (stage 1-3) as assessed by radiography were determined. We defined treatment failure as no improvement in symptoms and/or need for a second therapy within 1 year. Long-term follow-up data of 25 patients were available in the form of a survey evaluating overall satisfaction with the operation., Results: The distribution of patients according to subtype included 13 with type I, 54 with type II, and 5 with type III. All of the type I patients had some degree of esophageal dilation on radiography, whereas no dilation was found in the type III group. All patients underwent uneventful laparoscopic-extended Heller myotomy. Two patients were classified as failures, including one with type I and one with type II achalasia; however, further investigation revealed the cause of both failures to be the development of peptic stricture. Only one of the 25 patients with long-term follow-up reported dissatisfaction with the treatment result and indicated persistent chest pain without dysphagia., Conclusions: Laparoscopic-extended Heller myotomy is a highly successful treatment for patients with achalasia and outcomes do not appear to vary significantly according to the manometric subtype. Failures may result from reflux in patients who develop esophagitis or stricture. Chest pain is not always responsive to esophagogastric myotomy despite relief of dysphagia.

Background: Randomized trials show that pneumatic dilation (PD) ≥30 mm and laparoscopic myotomy (LM) provide equivalent symptom relief and disease-related quality of life for patients with achalasia. However, questions remain about the safety, burden, and costs of treatment options., Study Design: We performed a retrospective cohort study of achalasia patients initially treated with PD or LM (2009 to 2014) using the Truven Health MarketScan Research Databases. All patients had 1 year of follow-up after initial treatment. We compared safety, health care use, and total and out-of-pocket costs using generalized linear models., Results: Among 1,061 patients, 82% were treated with LM. The LM patients were younger (median age 49 vs 52 years; p < 0.01), but were similar in terms of sex (p = 0.80) and prevalence of comorbid conditions (p = 0.11). There were no significant differences in the 1-year cumulative risk of esophageal perforation (LM 0.8% vs PD 1.6%; p = 0.32) or 30-day mortality (LM 0.3% vs PD 0.5%; p = 0.71). Laparoscopic myotomy was associated with an 82% lower rate of reintervention (p < 0.01), a 29% lower rate of subsequent diagnostic testing (p < 0.01), and a 53% lower rate of readmission (p < 0.01). Total and out-of-pocket costs were not significantly different (p > 0.05)., Conclusions: In the US, LM appears to be the preferred treatment for achalasia. Both LM and PD appear to be safe interventions. Along a short time horizon, the costs of LM and PD were not different. Mirroring findings from randomized trials, LM is associated with fewer reinterventions, less diagnostic testing, and fewer hospitalizations., (Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

The following on achalasia and disorders of the esophageal body includes commentaries on controversies regarding whether patients with complete lower esophageal sphincter (LES) relaxation can be considered to exhibit early achalasia; the roles of different mucle components of the LES in achalasia; sensory neural pathways impaired in achalasia; indications for peroral endoscopic myotomy and advantages of the technique over laparoscopic and thorascopic myotomy; factors contributing to the success of surgical therapy for achalasia; modifications to the classification of esophageal body primary motility disorders in the advent of high-resolution manometry (HRM); analysis of the LES in differentiating between achalasia and diffuse esophageal spasm (DES); and appropriate treatment for DES, nutcracker esophagus (NE), and hypertensive LES (HTLES)., (© 2013 New York Academy of Sciences.)

Background: Esophagectomy has been recommended for patients when recurrent dysphagia develops after Heller myotomy for achalasia. My colleagues and I prefer to correct the specific anatomic problem with redo myotomy and preserve the esophagus. We examined the results of this approach., Study Design: We analyzed the course of 43 patients undergoing redo Heller myotomy for achalasia between 1994 and 2011 with at least 1-year of follow-up. In 2012, a phone interview and a symptoms questionnaire were completed by 24 patients., Results: Forty-three patients underwent redo Heller myotomy. All patients had dysphagia, 80% had had multiple dilations. Manometry confirmed the diagnosis, lower esophageal sphincter pressure averaged 17 mmHg; 24-hour pH monitoring was not useful because of fermentation; patients were divided into 4 groups according to findings on upper gastrointestinal series. Three patients underwent take down of previous fundoplication only, the remainder 40 had that and a redo myotomy with 3-cm gastric extension. Two mucosal perforations were repaired with primary closure and Dor fundoplication. At a median follow-up of 63 months, 19 of 24 patients reported improvement in dysphagia, with median overall satisfaction rating of 7 (range 3 to 10); 4 patients required esophagectomy for persistent dysphagia., Conclusions: The majority of failures after Heller myotomy present with dysphagia associated with esophageal narrowing. Upper gastrointestinal series is most useful to plan therapy and predicts outcomes. With few exceptions, patients improve substantially with redo myotomy, which can be accomplished laparoscopically with relatively low risk. These findings challenge the previously held concept that all myotomy failures need to be treated by an esophagectomy., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

The current state of research into the etiology of achalasia only allows for speculation. To date, several studies have been performed investigating genetic, immune, and infectious disease mechanisms; however, none of these have been conclusive. Further research into this topic is warranted given the severity of the disease, and it may be possible that all of these mechanisms are involved in the pathophysiology of the disease., (© 2009 Copyright the Authors. Journal compilation © 2009, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

This article reviews the changes that have taken place in the treatment of patients with achalasia in the last 20 years. It compares and contrasts treatment preferences in the USA with those of Canada and Europe. It provides a critical analysis of the recent randomized trial between laparoscopic Heller myotomy and pneumatic dilatation that was carried out in several European centers. It supports the use of laparoscopic Heller myotomy as the preferred treatment for the average patient with this disease in the USA.

Achalasia is a primary esophageal motor disorder that results in poor clearance of the esophagus. Although an esophagus filled with debris and undigested food should put these patients at risk for aspiration, the frequency with which the latter occurs has never been documented. In this study, we sought to determine the incidence of respiratory symptoms and complaints in patients with achalasia. A comprehensive symptom questionnaire was administered to 110 patients with achalasia presenting to the Swallowing Center at the University of Washington between 1994 and 2008 as part of their preoperative work-up. Questionnaires were analyzed for the frequency of respiratory complaints in addition to the more typical symptoms of dysphagia, regurgitation, and chest pain. Twenty-two achalasia patients with respiratory symptoms who had also undergone Heller myotomy and completed a post-op follow-up questionnaire were analyzed as a subset. Ninety-five patients (86%) complained of at least daily dysphagia. Fifty-one patients (40%) reported the occurrence of at least one respiratory symptom daily, including cough in 41 patients (37%), aspiration (the sensation of inhaling regurgitated esophagogastric material) in 34 patients (31%), hoarseness in 23 patients (21%), wheezing in 17 patients (15%), shortness of breath in 11 patients (10%), and sore throat in 13 patients (12%). Neither age nor gender differed between those with and those without respiratory symptoms. In the subset of patients with respiratory symptoms who had undergone Heller myotomy, respiratory symptoms improved in the majority after the procedure. Patients with achalasia experience respiratory symptoms with much greater frequency than the approximately 10% that was previously believed. Awareness of this association may be important in the workup and ultimate treatment of patients with this uncommon esophageal disorder., (© 2010 Copyright the Authors. Journal compilation © 2010, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

Introduction: Although patients with achalasia complain mainly of dysphagia, we have observed that they also have a high rate of respiratory problems. We hypothesized that the latter may be due to poor esophageal clearance leading to aspiration. This study examines the effect of Heller myotomy on these symptoms., Methods: We studied the course of 111 patients with achalasia who underwent Heller myotomy between 1994 and 2008 and who agreed to participate in this study. All patients completed a questionnaire postoperatively assessing the preoperative and postoperative prevalence and severity of symptoms using visual analog scales. Patients were divided into two groups: one that included all those with respiratory symptoms (dyspnea, hoarseness, cough, wheezing, sore throat, and/or a history of asthma or pneumonia) prior to myotomy and one that included those without those symptoms., Results: All patients presented with dysphagia as their primary complaint, and 63 (57%) reported respiratory symptoms or disease prior to surgery. There were no significant differences in preoperative characteristics between those with and without respiratory manifestations. After a median follow-up of 71 months (range 9-186 months), 55 (87%) patients reported durable improvement of dysphagia. The frequency and severity of all respiratory symptoms decreased significantly. Twenty-four of the 29 patients (82%) who reported a history of pneumonia prior to surgery did not experience recurrent episodes after Heller myotomy., Conclusions: A Heller myotomy is effective in improving esophageal emptying in patients with achalasia. This results in sustained improvement of dysphagia and associated respiratory symptoms/diseases. This suggests that respiratory symptoms/diseases in these patients are likely caused by esophageal retention of food and secretions, and then aspiration.

Revisional surgery for persistent or recurrent dysphagia following Heller myotomy is rare and should become even more rare if an extended myotomy has been carried out. It is important to work-up patients who experience persistent or recurrent dysphagia in a systematic fashion that includes the determination of the diagnosis of achalasia, the type of operation performed, the results obtained with the primary operation, and to further classify the type of recurrence. Use of adjunctive studies, including upper gastrointestinal study, endoscopy, manometry, and pH monitoring is critical to guiding clinical decision making. This article will review the differential diagnosis, diagnostic workup, and available treatment options for patients with achalasia who present with persistent or recurrent dysphagia following Heller myotomy.

Achalasia, an esophageal motility disorder characterized by aperistalsis and failure of lower esophageal sphincter (LES) relaxation, is most effectively treated by surgical ablation of the LES. In this report, we describe our technique of laparoscopic extended Heller myotomy with Toupet partial posterior fundoplication. The technical details of this procedure include careful division of the longitudinal and circular muscle fibers of the LES anteriorly, including extension of the myotomy 3 cm distal to the esophagogastric junction onto the gastric cardia. The Toupet procedure, involving a posterior wrap of the gastric fundus which is secured to both edges of the myotomy as well as to the crura of the hiatus, is added to prevent post-myotomy gastroesophageal reflux. From a recently published report, mean dysphagia scores remained low (3 out of 10 severity on a visual analog scale) and symptoms of reflux were reported minimally in a series of 63 patients followed for a median of 45 months. This technique provides excellent and durable relief of dysphagia associated with achalasia while minimizing post-myotomy acid reflux symptoms.

Background: The standard Heller myotomy (SM) for achalasia extends 1 to 2 cm on to the stomach. The authors perform an extended myotomy (EM) (>3 cm) with the goal of reducing postoperative dysphagia. This study examines the long-term efficacy and durability of EM compared with SM., Methods: Patients with achalasia who underwent a laparoscopic Heller myotomy were identified from a prospective database that includes symptom evaluation and results of esophageal functional studies. From September 1994 to August 1998, the authors performed SM with Dor fundoplication, and from September 1998 through 2003, they performed EM with Toupet fundoplication. In 2001, they performed a telephone survey of all available patients. This was repeated in 2005 for the EM group. The survey included scales of symptom frequency (0 [never], 1 [once per month], 2 [once per week], 3 [once per day], 4 [more than once per day]) and severity (0 [no symptoms] to 10 [symptoms equal to preoperative state]) as well as the need to undergo postoperative intervention for dysphagia., Results: For this study, 52 patients underwent SM with Dor fundoplication (median follow-up period, 46 +/- 24 months), and 63 patients underwent EM with Toupet fundoplication (median follow-up period, 45 +/- 17 months. Postoperative dysphagia severity was significantly better in the EM group (4.8 +/- 2.3 vs 3.1 +/- 2.6; p < 0.005). There was no significant difference in postoperative heartburn frequency, esophageal acid exposure, or lower esophageal sphincter pressure. In the SM group, 9 patients (17%) required reintervention for dysphagia: 14 endoscopic interventions for 5 patients (10%) and reoperation for 4 patients. Three patients (5%) in the EM group required reintervention for dysphagia: one endoscopic intervention each and no reoperations (p < 0.05). A total of 30 patients in the EM group were contacted in both 2001 (median follow-up period, 19 +/- 11 months) and 2005 (median follow-up period, 63 +/- 10 months). There was no significant change over time in dysphagia severity (2.6 +/- 1.9 vs 3.7 +/- 2.0; p = 0.19)., Conclusions: For the treatment of achalasia, EM with Toupet fundoplication provides excellent durable dysphagia relief that is superior to SM with Dor fundoplication.

Morbid obesity is a disease encompassing multiple, significant comorbidities. The only current, reliable, durable treatment of obesity is surgical intervention, most commonly gastric bypass. Achalasia, a swallowing disorder of esophageal motility and failure of the lower esophageal sphincter (LES) to relax, is rarely seen in the morbidly obese patient. Treatment is directed at disruption of the LES to allow passage of food. As medical management usually fails in both disease processes, surgical treatment is often chosen. The patient with both morbid obesity and achalasia presents an unusual challenge for surgical treatment. The standard surgical approach for each disease does not address the other, and may have deleterious consequences on the other condition if approached unilaterally. We present the first case of a patient treated with a concomitant laparoscopic esophagogastric myotomy (LEM) and laparoscopic Roux-en-Y gastric bypass (LRYGBP).

Surgical therapy (Heller myotomy) is the most effective treatment to relieve dysphagia associated with achalasia. The advent of minimally invasive techniques, specifically the laparoscopic approach, significantly reduced the morbidity of surgical therapy, making it the procedure of choice for most patients who have achalasia. Pneumatic dilatation is a viable alternative, though is associated with inferior results and a higher risk of esophageal perforation than surgical therapy. Pharmacotherapy and Botox provide inferior results and should be reserved for temporizing therapy, or for patients who are deemed too frail for surgical intervention. For best results, a laparoscopic myotomy should be carried at least 3 cm onto the stomach, and a partial fundoplication should be performed to reduce the incidence of postoperative GE reflux.

Hypothesis: There is general agreement that a Heller myotomy should extend 6 to 7 cm above the gastroesophageal junction. Results of most previous studies have recommended that the myotomy extend 1 to 1.5 cm below the gastroesophageal junction. We speculated that the effectiveness of the operation could be improved if a longer, 3-cm myotomy was carried out below the gastroesophageal junction, as it would more completely obliterate the lower esophageal sphincter. We, therefore, changed our technique in 1998. Concurrently, we converted from a Dor fundoplication to a Toupet fundoplication. This study analyzes the results of our new strategy., Design: A case series using a prospectively maintained database., Setting: Tertiary referral center., Patients: One hundred ten consecutive patients with achalasia undergoing laparoscopic Heller myotomy., Intervention: We analyzed the course of 52 patients treated with a standard laparoscopic esophagogastric myotomy (1.5 cm in the stomach) and a Dor fundoplication between September 1, 1994, and August 31, 1998, and 58 treated with an extended gastric myotomy (3 cm below the gastroesophageal junction) and a Toupet fundoplication between September 1, 1998, and August 31, 2001., Main Outcome Measures: Esophageal function testing (esophageal manometry and 24-hour pH monitoring), symptom questionnaire (frequency and severity), and postoperative interventions required., Results: Postoperatively the lower esophageal sphincter pressure was significantly lower after extended gastric myotomy and a Toupet fundoplication vs standard myotomy and a Dor fundoplication (9.5 vs 15.8 mm Hg). Dysphagia was both less frequent (1.2 vs 2.1) and less severe (visual analog scale, 3.2 vs 5.3) after extended gastric myotomy and Toupet fundoplication. In the standard laparoscopic esophagogastric myotomy and a Dor fundoplication group, 9 patients (17%) had recurrent, severe dysphagia, which was treated by dilation in 5 patients and by reoperation in 4 patients. In the extended gastric myotomy and Toupet fundoplication group, 2 patients (3%) developed recurrent dysphagia that resolved with dilatation. There were no reoperations in the extended gastric myotomy and Toupet fundoplication group. No difference was noted in the frequency of heartburn (1.3 vs 1.7), regurgitation (0.3 vs 0.8), and chest pain (0.3 vs 0.6), nor was there a difference between the 2 groups in proximal (1.7% vs 2.3%) and distal (6.0% vs 5.9%) esophageal acid exposure., Conclusion: An extended gastric myotomy (3 cm) more effectively disrupts the lower esophageal sphincter, thus improving the results of surgical therapy for achalasia for dysphagia without increasing the rate of abnormal gastroesophageal reflux provided that a Toupet fundoplication is added.

Esophageal Heller myotomy and a partial antireflux procedure for achalasia are the ideal procedures to benefit from the advances in minimally invasive surgery. The magnified view of the operative field provided by the laparoscope allows precise division of the esophageal muscle fibers with excellent results. Laparoscopic Heller myotomy results in reduced postoperative pain, less morbidity, shorter hospitalization, better resolution of dysphagia, and less postoperative heartburn when compared with the open abdominal and even the thoracoscopic approach. A longer myotomy especially at the distal end, and a loose, well-formed partial fundoplication are the keys to a successful outcome. Superior long-term results after surgical myotomy when compared with nonsurgical interventions argue strongly in favor of surgery in any patient who is fit enough to undergo general anesthesia.

During the last decade, minimally invasive surgery has replaced open surgery in the treatment of esophageal achalasia. This new approach, in fact, determines results similar to the open approach, but is associated to a shorter hospital stay, minimal postoperative discomfort, and faster return to regular activity. Between 1991 and 1998, 168 patients underwent a cardiomyotomy by minimally invasive techniques. Good or excellent results were obtained in 85% of patients after thoracoscopic myotomy, and 93% of patients after laparoscopic myotomy and partial fundoplication. The latter procedure was followed by a lower incidence of postoperative gastroesophageal reflux (60% versus 17%). Laparoscopic Heller myotomy and partial fundoplication has emerged as the procedure of choice for esophageal achalasia, and it should be considered today the primary form of treatment for this disease.

Background: Seven years ago, the authors reported on the feasibility and short-term results of minimally invasive surgical methods to treat esophageal achalasia. In this report, they describe the evolution of the surgical technique and the clinical results in a large group of patients with long follow-up., Patients and Methods: Between January 1991 and October 1998, 168 patients (96 men, 72 women; mean age 45 years, median duration of symptoms 48 months), who fulfilled the clinical, radiographic, endoscopic, and manometric criteria for a diagnosis of achalasia, underwent esophagomyotomy by minimally invasive techniques. Forty-eight patients had marked esophageal dilatation (diameter >6.0 cm). Thirty-five patients had a left thoracoscopic myotomy, and 133 patients had a laparoscopic myotomy plus a partial fundoplication. Follow-up to October 1998 was complete in 145 patients (86%)., Results: Median hospital stay was 72 hours for the thoracoscopic group and 48 hours for the laparoscopic group. Eight patients required a second operation for recurrent or persistent dysphagia, and two patients required an esophagectomy. There were no deaths. Good or excellent relief of dysphagia was obtained in 90% of patients (85% after thoracoscopic and 93% after laparoscopic myotomy). Gastroesophageal reflux developed in 60% of tested patients after thoracoscopic myotomy and in 17% after laparoscopic myotomy plus fundoplication. Laparoscopic myotomy plus fundoplication corrected reflux present before surgery in five of seven patients. Patients with a dilated esophagus had excellent relief of dysphagia after laparoscopic myotomy; none required an esophagectomy., Conclusions: Minimally invasive techniques provided effective and long-lasting relief of dysphagia in patients with achalasia. The authors prefer the laparoscopic approach for three reasons: it more effectively relieved dysphagia, it was associated with a shorter hospital stay, and it was associated with less postoperative reflux. Laparoscopic Heller myotomy and partial fundoplication should be considered the primary treatment for esophageal achalasia.

Malignant pseudoachalasia can be indistinguishable from primary achalasia on routine clinical evaluation, often resulting in a delay in diagnosis. To better define the clinical features and appropriate management of this disease, the course of five patients discovered to have pseudoachalasia after being referred for a minimally invasive Heller myotomy was reviewed, as were 67 cases of pseudoachalasia previously reported in the literature. Patients with an occult malignancy tended to present with shorter durations of symptoms, greater weight loss, and at a more advanced age than patients with primary achalasia. Since contrast radiography and endoscopy frequently failed to differentiate these two diseases, persons with presumed achalasia meeting these criteria who are referred for minimally invasive surgery should undergo additional imaging to rule out an occult malignancy, since this condition cannot be reliably detected during the course of a thoracoscopic or laparoscopic esophagomyotomy.

Background: Some patients with achalasia treated by botulinum toxin injection still require an esophagomyotomy. In this study, we analyzed the impact of botulinum toxin injection on the technical aspects and outcome of esophagomyotomy., Methods: We studied 57 patients, with a mean age of 46 years (range, 12-97) who were treated between January 1995 and March 1998 by esophagomyotomy performed via minimally invasive techniques by one team. Operative reports, videotapes, and clinical outcome were analyzed to define the technical difficulties, perforations, and outcome., Results: Fifteen of the 57 patients had received one or more injections of botulinum toxin (botox group) preoperatively. Difficulties in dissection of the submucosal plane were encountered in eight of the 15 cases (53.3%), and a mucosal laceration (perforation) occurred in two cases (13.3%). Forty-two of the 57 patients had not received any injections (non-botox group). In three patients (7%), difficulties in identifying or following the submucosal plane were encountered, although 29 patients had one or more previous dilations, and perforation occurred in one case (2.4%). All mucosal injuries were repaired laparoscopically, and the patients recovered without obvious sequelae. Dysphagia improved significantly after the operation in both groups (botox group, from preoperative score of 3. 8 to a postoperative score of 0.7; non-botox, from a score of 3.4 preoperatively to 0.5 postoperatively). Regurgitation also improved in both groups (botox, 2.7 preoperatively, 0.92 postoperatively; non-botox group, 2.0 preoperatively, 0.56 postoperatively)., Conclusions: Injection of botulinum toxin significantly increases the technical difficulties and thus the potential risk of esophagomyotomy. The immediate results were equally good for both groups in our series, but the long-term sequelae of repeated injections are unknown. Laparoscopic Heller myotomy is a safe and effective procedure even after unsuccessful treatment with botulinum toxin.

During the course of a laparoscopic Heller myotomy, a patient thought to have primary achalasia was found instead to have an adenocarcinoma of the gastroesophageal junction. Aspects of this patient's clinical course, which are exemplary of malignant pseudoachalasia, are discussed, as are ways in which this not uncommon error in diagnosis can be avoided.

In summary, the authors believe that minimally invasive surgery has added a new dimension to the treatment of achalasia. Thoracoscopic myotomy is feasible, safe, and effective in relieving dysphagia in the great majority of individuals affected with this disease without the many problems associated with dilatation; thus, the authors offer it to patients with achalasia as the initial and preferred form of treatment. Whether an antireflux procedure should be routinely added and whether a laparoscopic rather than a thoracoscopic approach is preferred, remains unanswered questions at this time.

The treatment of esophageal achalasia has been controversial for many years. Even if a myotomy performed through a left thoracotomy gives better results than pneumatic dilatation, the fear of an operation with the associated postoperative pain and disability has kept patients away from this form of treatment. Minimally invasive surgery allows the same results obtained with open surgery, with a short hospital stay, minimal postoperative discomfort, and a fast recovery time. A thoracoscopic or laparoscopic Heller's myotomy should be considered today the primary form of treatment for esophageal achalasia.

We treated 24 patients with achalasia using thoracoscopic (22 patients) or laparoscopic (2 patients) esophagomyotomy. The only operative complications were mucosal lacerations, which occurred in 3 patients and required conversion to an open procedure in 2. Twenty-two (91%) patients were eating by the second postoperative day. Analgesics were only required for the management of pain from the chest tube, which remained in place for a median time of 24 hours. The median postoperative hospital stay was 3 days (range, 20 to 14 days). The myotomy proved to be incomplete in the first 3 patients, who required a second myotomy; this was done laparoscopically in 2. One patient had a paraesophageal hernia repaired 6 months after the myotomy, and 1 patient required an esophagectomy 1 year after the myotomy for a large nonfunctioning esophagus. Late follow-up showed that swallowing was excellent in 17 (71%) and fair to good in 4 (17%). Sixteen (66%) of these 24 patients have regained their original weight. Thus, excellent to good results were ultimately obtained in nearly 90% of the patients. These results suggest that esophageal myotomy performed using minimally invasive techniques appears to be the treatment of choice for achalasia.

We analyzed the course of 79 adult patients treated for achalasia between 1977 and 1988. Sixty-six patients (84%) had pneumatic dilatation as the primary therapy. Fifty-three patients (80%) had immediate improvement in swallowing. Three patients required immediate redilatation, 2 developed pulmonary aspiration, and 8 (12%) suffered esophageal perforation. Esophageal perforation was treated by closure plus Heller's myotomy in 3 patients, closure only in 3, chest tube in 1, and antibiotics and nasogastric suction in 1. At 4 years' follow-up, 50% of patients who had dilatation remained asymptomatic, 30% had symptoms of gastroesophageal reflux, and 20% had persistent dysphagia. Eight Heller myotomies were performed, with excellent results in 7 and 1 postoperative death from respiratory failure. Seven additional patients with disabling esophageal symptoms after multiple operations for achalasia were ultimately treated by esophagectomy (n = 5), hemigastrectomy and Roux-en-Y gastrojejunostomy (n = 1), and repeated myotomy (n = 1). All recovered and are able to eat solid food. Thus, our experience indicates that pneumatic dilatation remains unperfected (ie, the line between undertreatment and overtreatment is finer than generally recognized), and unless improvements can be made, the role for surgery may need to be reexpanded.