title: Heller myotomy for failed pneumatic dilation in achalasia: how effective is it?
abstract: OBJECTIVE
  This long-term prospective study describes the effect of myotomy in patients who fail to respond to repeated pneumatic dilations and compares their clinical course with that of patients responding to dilation therapy.
  
  
  METHODS
  Nineteen consecutive patients who had never reached a clinical remission after repeated pneumatic dilation underwent myotomy. Their clinical course was compared with that of patients who had reached a clinical remission after a single (n = 34) or multiple (n = 14) pneumatic dilation(s). Symptoms were graded with a previously described symptom score ranging from 0 to 12. Remission was defined as a score of 3 or less persisting for at least 6 months. Duration of remission was summarized using Kaplan Meier survival curves. Association between baseline factors and the need for surgery was evaluated using logistic regression.
  
  
  RESULTS
  Complete follow-up was obtained for 98.5% of the patients. The median duration of follow-up was similar in patients treated by myotomy (10.0 years), in patients reaching a clinical remission after a single dilation (10.6 years), but differed in patients undergoing repeated dilations (6.9 years). The 10-year remission rate was 77% (95% CI 53-100%) in patients undergoing myotomy, 72% (95% CI: 56-87%) in patients "successfully" treated with a single pneumatic dilation and 45% (95% CI: 16-73%) in patients undergoing several dilations. Among all baseline factors investigated, young age was associated with an increased need of surgery.
  
  
  CONCLUSIONS
  Myotomy is an effective treatment modality in patients with achalasia who have failed to respond to pneumatic dilation. Young patients may benefit from primary surgical therapy.
authors.affiliation: Deutsche Klinik für Diagnostik Wiesbaden, Germany.
authors.forename: Ines
authors.initials: I
authors.lastname: Gockel
authors.forename: Th
authors.initials: T
authors.lastname: Junginger
authors.forename: Gudrun
authors.initials: G
authors.lastname: Bernhard
authors.forename: Volker F
authors.initials: VF
authors.lastname: Eckardt
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002404:Catheterization; D013505:Digestive System Surgical Procedures; D004931:Esophageal Achalasia / Q000601:surgery* / Q000628:therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013997:Time Factors; D017211:Treatment Failure