Pneumatic Dilation for Achalasia: Obliterate the Waist!

To the Editor: We greatly enjoyed the thoughtful and very informative commentary by Jacobs and Richter carefully summarizing the senior author’s vast experience with pneumatic dilation (PD) as a primary treatment for achalasia (1). It was gratifying to note that as their experience has grown they have incorporated and refined this technique based on many aspects that we learned together as colleagues and now pass on to our junior "esophagologists." The one aspect of the approach to PD, as described that we would challenge, is the actual duration of inflation of the dilating balloon. Over the years that this procedure was evolving, we changed from holding the balloon through two steps to only one step of a full 60 s of inflation, an approach still being used by many experts. However, while watching the fluoroscopic image we wondered whether there was any necessity to leave the balloon inflated once the waist had been obliterated. It would seem that the situation had been accomplished at that point, usually by the early seconds of inflation.