Achalasia: current evaluation and therapy.

The current evaluation of and therapy for achalasia are reviewed. Esophageal manometry remains the best means for diagnosing achalasia. Initial therapy can include either pneumatic dilation or esophagomyotomy. Symptomatic improvement occurs in 71% of patients after pneumatic dilation, with a risk of perforation of 1.4%. Eight percent of these patients require subsequent esophagomyotomy. Surgical procedures for achalasia can be performed through either an abdominal or a thoracic incision. Nearly all authors favoring an abdominal approach add an antireflux operation to esophagomyotomy, whereas many authors advocating a transthoracic esophagomyotomy believe that an antireflux wrap is unnecessary. Overall results for the various surgical approaches used as initial therapy are excellent, with symptomatic improvement in 89% of patients, a mortality rate of less than 1%, and development of gastroesophageal acid reflux in less than 10%. Factors governing the choice of initial therapy are discussed.