Efficacy and Safety of Cardiomyotomy in Patients with Achalasia After Failure of Pneumatic Dilatation

In patients with achalasia, it has beensuggested that pneumatic dilatation could makecardiomyotomy more difficult to perform, diminishing itsefficacy and safety. Our aim was to evaluate theefficacy and safety of elective cardiomyotomy afterfailure of pneumatic dilatation in achalasia. During 14years, 32 of 276 consecutive patients with achalasiahave been operated on because of failure of dilatation therapy. Twenty patients have been followed-upfor at least one year after surgery. After failure ofdilatation, Heller's cardiomyotomy and 180 anteriorfundoplication were performed. Clinical status was evaluated before and after surgery. Loweresophageal sphincter pressure and esophageal body basalpressure were measured by manometry, esophageal diameterby barium meal, and gastroesophageal reflux by endoscopy and 24-hr esophageal pH monitoring.No technical difficulties were found during operation.Postoperative morbidity was infrequent and mortality wasabsent. Cardiomyotomy improved clinical status in 19 of 20 patients. The results of surgerywere considered excellent or good in 16 patients (80%;CI: 56-94%). The pressure of the lower esophagealsphincter was significantly reduced, falling in most patients to under 10 mm Hg. Gastroesophagealreflux appeared after surgery in eight patients, four ofthem with endoscopic esophagitis, but it was controlledin all patients with medical therapy. In conclusion, cardiomyotomy is a safe and effective therapyin achalasia after failed pneumaticdilatation.