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Steven R. Lopushinsky, MD, MSc; David R. Urbach, MD, MSc

JAMA. 2006;296:2227-2233.

Context  Pneumatic dilatation and surgical (Heller) myotomy are the 2 principal methods for treatment of achalasia. There are no population-based studies comparing outcomes of these 2 treatments in typical practice settings.

Objective  To compare the outcomes of pneumatic dilatation and surgical myotomy for achalasia.

Design, Setting, and Participants  Retrospective longitudinal study using linked administrative health data in Ontario. A total of 1461 persons aged 18 years or older received treatment for achalasia between July 1991 and December 2002, 1181 (80.8%) of whom had pneumatic dilatation and 280 (19.2%) of whom had surgical myotomy as the first procedure.

Main Outcome Measures  Use of subsequent interventions for achalasia (pneumatic dilatation, surgical myotomy, or esophagectomy) following the first treatment during the study period, subsequent physician visits, and use of gastrointestinal medications among persons aged 65 years or older. We adjusted for confounding variables using regression models.

Results  The cumulative risk of any subsequent intervention for achalasia after 1, 5, and 10 years, respectively, was 36.8%, 56.2%, and 63.5% for persons treated initially with pneumatic dilatation and was 16.4%, 30.3%, and 37.5% for persons treated initially with surgical myotomy (adjusted hazard ratio [HR], 2.37; 95% confidence interval [CI], 1.86-3.02; P<.001). Differences in risk were observed only when subsequent pneumatic dilatation was included as an adverse outcome; there was no statistical difference between the 2 groups with respect to the risk of subsequent surgical myotomy or esophagectomy. Compared with persons treated initially with surgical myotomy, those treated with pneumatic dilatation were not statistically different with respect to subsequent physician visits (adjusted rate ratio, 1.01; 95% CI, 1.00-1.03), or time to use of histamine-2 receptor blockers (adjusted HR, 1.19; 95% CI, 0.79-1.80), proton pump inhibitors (HR, 1.02; 95% CI, 0.70-1.49), and prokinetic medications (HR, 0.92; 95% CI, 0.60-1.41).

Conclusions  Subsequent intervention after the initial treatment of achalasia is common. Although the risk of subsequent interventions among persons treated with surgical myotomy in typical practice settings is higher than previously thought, the risk of subsequent intervention is greater among persons treated with pneumatic dilatation than with surgical myotomy. This difference is attributable to the use of subsequent pneumatic dilatation rather than surgical procedures.

Author Affiliations: Departments of Surgery and Health Policy, Management, and Evaluation, University of Toronto (Drs Lopushinsky and Urbach), Institute for Clinical Evaluative Sciences (Drs Lopushinsky and Urbach), Division of Clinical Decision Making and Health Care, University Health Network (Dr Urbach), and Cancer Care Ontario (Dr Urbach), Toronto, Ontario.

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