Practice Short cuts

Patients with achalasia often need repeat procedures, usually balloon dilatation

BMJ 2006; 333 doi: (Published 16 November 2006) Cite this as: BMJ 2006;333:1065

Achalasia is a rare disorder of oesophageal motility that causes obstruction at the lower end of the oesophagus, resulting in dysphagia, regurgitation, and chest pain. The main treatment options are pneumatic dilatation, which is done as a day case, and surgical myotomy, which requires a general anaesthetic and a short period in hospital. There's little decent evidence to help patients choose between them, so researchers took a look at what happened in the long term to unselected patients who had one or other procedure. A substantial proportion of both groups needed at least one repeat intervention during a follow-up of five years: 56% of those who had a pneumatic dilatation and 30% of those treated initially with myotomy (adjusted hazard ratio for pneumatic dilatation 2.37; 95% CI 1.86 to 3.02). Pneumatic dilatation was the commonest repeat intervention for both groups. The difference between initial myotomy and initial pneumatic dilatation persisted after adjustments for age, sex, other illnesses, and income, which suggests (but doesn't prove) it was due to the treatment, not the characteristics of the patients selected for each procedure.

The authors used Ontario's administrative health databases, which don't include information on symptoms or quality of life, so they can't say much about the effectiveness of either treatment. But it does seem clear that when patients have a procedure for achalasia, particularly dilatation, they have a good chance of eventually needing another one.


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