Comparison of forceful dilatation and esophagomyotomy in patients with achalasia of the esophagus.

In the present paper we have reviewed the results of forceful dilatation as compared with surgical esophagomyotomy in patients with achalasia. The review of 4 retrospective and uncontrolled studies revealed that in all, surgery produced a more effective late result than dilatation, with minimal side effects and very low or no mortality. In the only prospective randomized study comparing both treatments by the same group, good late results were seen after surgery in 95% of the cases, as compared with 65% after dilatation (p less than 0.001). The resting gastroesophageal sphincter pressure was predictive of the quality of the late results. Reflux occurred in 8% of the dilated and in 19% of the operated group as measured by standard acid reflux test. The old, classical concept that dilatation is the first choice and preferable method of treatment for patients with achalasia should be reviewed, and the idea that surgery should be reserved only for patients in whom dilatation has failed should be abandoned. We propose that surgical treatment should be the initial choice in the majority of patients with achalasia of the esophagus.