Achalasia of the cardia: dilatation or division?

The relative rarity of achalasia dictates that most patients will receive treatment delivered by an enthusiast with a predetermined preference. Mr Beckingham argues strongly in favour of laparoscopic myotomy, emphasising the benefits of division (as opposed to disruption) of the sphincter muscle, under direct vision and the ability to perform sutured repair should a peroration occur. Professor griffin is a confirmed dilator he expounds the advantages of outpatient therapy, without the need for general anaesthesia, the relative ease of treatment repetition and the low risk of inadvertent perforation. With modern digital cameras and flat screen technology, the anatomical details seen by the surgeon are unsurpassed, enabling highly accurate division of the sphincter muscle to be obtained. Last week, I operated on an external referral who had undergone three balloon dilatations, a laparoscopic Heller's myotomy and a further two dilatations postoperatively before undergoing a re-do laparoscopic myotomy nothing appears to be foolproof. It would, however, appear reasonable to choose a treatment enabling immediate repair of any mucosal perforation rather than run the risk (albeit small) of an unseen perforation following dilation. In elderly or unfit patients. Botox or dilation may be suitable, but younger patients may benefit from surgery. As both authors point out, it is highly, unlikely that enough evidence will accrue to provide a definitive answer. Ultimately, local preferences and expertise will dictate the treatment delivered.