title: Efficacy and safety of pneumatic dilatation for achalasia in the treatment of post-myotomy symptom relapse.
abstract: OBJECTIVE
  There is no consensus on how best to treat symptom recurrence following previous therapy with Heller myotomy. Our aim was to determine the safety and the short and long-term efficacy of pneumatic dilatation to treat symptomatic recurrence in patients previously treated with Heller myotomy for idiopathic achalasia.
  
  
  METHODS
  We identified 27 eligible patients treated with pneumatic dilatation, for symptom recurrence following Heller myotomy as their initial or secondary treatment, from a prospectively acquired database of 450 patients with a diagnosis of achalasia seen between 1995 and 2010. Our treatment protocol involved sequential, graded pneumatic dilatations (30-35-40 mm) over a 2-6 week period until an initial therapeutic response was achieved. The subsequent relapse rate, defined as the need for any subsequent therapy, was determined. Relapsers were offered further pneumatic dilatation "on demand". A cross-sectional analysis was also performed using a validated achalasia severity questionnaire to determine the overall long-term remission rate.
  
  
  RESULTS
  Of 27 eligible patients, 25 (93%) complied with the institutional dilatation protocol. The two drop-outs did so after the initial 30 mm dilatation and were deemed treatment failures. One additional patient did not respond despite protocol compliance. Therefore, 24 of 27 (89%) patients were responders on intention to treat analysis at 12 months, while the per protocol response rate was 24 of 25 (96%). Among the 24 responders 16, 25, and 42% relapsed at 2, 3 and 4  years, respectively. Overall long-term remission, with on demand dilatations as required, was 95% (median follow-up 30 months). There were no perforations in a total of 50 dilatations in 27 patients.
  
  
  CONCLUSIONS
  In treating symptom recurrence, following prior Heller myotomy, pneumatic dilatation is safe and yields an excellent short-term response rate. Although the long-term relapse rate is substantial, subsequent on demand pneumatic dilatation in this population is highly effective with a long-term remission rate of 95%. These data also highlight the need to keep these patients under long-term review.
authors: Department of Gastroenterology & Hepatology, University of New South Wales, Sydney, New South Wales, Australia.
authors: Vivek
authors: V
authors: Kumbhari
authors: Jason
authors: J
authors: Behary
authors: Michal
authors: M
authors: Szczesniak
authors: Teng
authors: T
authors: Zhang
authors: Ian J
authors: IJ
authors: Cook
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D004106:Dilatation / Q000009:adverse effects; D018572:Disease-Free Survival; D004931:Esophageal Achalasia / Q000601:surgery / Q000628:therapy*; D005260:Female; D006801:Humans; D057194:Intention to Treat Analysis; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires; D013997:Time Factors; D055815:Young Adult