Efficacy and safety of cardiomyotomy in patients with achalasia after failure of pneumatic dilatation.

In patients with achalasia, it has been suggested that pneumatic dilatation could make cardiomyotomy more difficult to perform, diminishing its efficacy and safety. Our aim was to evaluate the efficacy and safety of elective cardiomyotomy after failure of pneumatic dilatation in achalasia. During 14 years, 32 of 276 consecutive patients with achalasia have been operated on because of failure of dilatation therapy. Twenty patients have been followed-up for at least one year after surgery. After failure of dilatation, Heller's cardiomyotomy and 180 degrees anterior fundoplication were performed. Clinical status was evaluated before and after surgery. Lower esophageal sphincter pressure and esophageal body basal pressure were measured by manometry, esophageal diameter by 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 was absent. Cardiomyotomy improved clinical status in 19 of 20 patients. The results of surgery were considered excellent or good in 16 patients (80%; CI: 56-94%). The pressure of the lower esophageal sphincter was significantly reduced, falling in most patients to under 10 mm Hg. Gastroesophageal reflux appeared after surgery in eight patients, four of them with endoscopic esophagitis, but it was controlled in all patients with medical therapy. In conclusion, cardiomyotomy is a safe and effective therapy in achalasia after failed pneumatic dilatation.