Should Surgery Replace Pneumatic Dilation in Achalasia? Reply.

As surgeons dedicated to the repair of upper and lower gastrointestinal tract dysfunction, the main goal of our paper was to evaluate the influence of 2 different conditions on the surgical treatment of patients suffering from achalasia, referred to our outpatient endoscopy service. Historically, both patient age and previous nonsurgical treatments were regarded in the literature as relative contraindications to surgery. Our results did not support these contentions, provided that patients fulfilled the accepted criteria for a surgical procedure. As far as cost effectiveness is concerned (Surg Endosc 2007;21:1184–1189), it seems that the comparison has been done between surgery and a single procedure (pneumatic dilation), but it is accepted that dilation often needs to be repeated 2–3 times to achieve a 90% short-term success rate, which decreases to fewer than half the patients at 5 years follow-up (Am J Gastroenterol 2002;97:1346). The literature suggests that these patients mandate a median of 2 (range, 1–8) sessions of endoscopic dilations (Ann Surg 2002;236:750–758), which could certainly impact the quality of life of these patients. The therapy of achalasia, whether surgical or endoscopic, should be regarded as palliative and consequently a long-term successful outcome after surgery in nearly 80% of our patients seems to be satisfying. Nevertheless, I suggest that it is best to avoid the potential to be caught in the trap of voicing the best option between the 2 very effective therapeutic options. I would like to stress that we perform surgery as well pneumatic dilation with Rigiflex balloons, but based on published literature and the analysis of our patients, I am more confident that dilation, if unsuccessful, will not alter the outcome of a subsequent myotomy.