Results of surgical treatment of achalasia of the esophagus.

Surgical treatment of patients with achalasia of the esophagus results in dramatic and permanent relief in almost 90% of the patients. The abdominal approach seems to produce more reflux than the thoracic route. There is evidence that extending myotomy more than 10 mm onto the stomach increases reflux. The length of the hypertensive gastroesophageal sphincter is almost 4 cms and an anterior esophagomyotomy of 5 to 6 cms is long enough in these patients. Extending the section 7 to 10 cms proximally would seem to be unnecessary and may provoke more reflux. The mortality rate of the surgical procedure is very low--less than 0.2%. Postoperative complications can occur in almost 4% of them, esophageal leakage being the most dangerous. The most frequent late complication is gastroesophageal reflux, which can occur symptomatically in 10% of the cases and by objective studies in almost 20% of the patients. The addition of antireflux surgery is controversial. If performed, it must be ensured that no obstruction can occur; esophageal emptying in an aperistalsic esophagus can be seriously delayed. Comparative studies suggest that the addition of antireflux surgery gives better results than myotomy alone. Surgeons performing this operative technique should be specialized digestive tract surgeons and familiar with manometric studies.