Introduction Achalasia is a relatively rare primary oesophageal motor disorder characterised by absent peristalsis and failure of relaxation of the lower oesophageal sphincter (LOS).
The standards of treatment for achalasia are pneumatic balloon dilatation and surgical myotomy. Although 85–95% success at 2 years is reported with these procedures, in the longer term, dysphagia may return in over 50%, prompting consideration of re-treatment. The definition of recurrence is often based on symptom evaluation, particularly dysphagia. Treatment of dysphagia in achalasia is targeted at the LOS, but in some patients dysphagia may be multifactorial and may not be improved by attempting to further lower LOS pressure.
We aimed to evaluate the GI physiological findings of patients undergoing studies in our tertiary referral unit to investigate recurrence of dysphagia post-treatment.
Method We interrogated our database for patients undergoing high resolution oesophageal manometry +/- 24-hour pH studies due to dysphagia post-treatment for achalasia between 2010–2014.
We recorded achalasia subtype, LOS relaxation pressure (known as integrated relaxation pressure, or IRP), and reflux study results if performed.
Results 80 eligible patients (38 female; age range 11–83 years, median 46 years) were identified with recurrent dysphagia. All had high resolution oesophageal manometry performed, and 18 patients had 24-hour pH studies due to concomitant heartburn and/or regurgitation. 52 patients had undergone at least one previous pneumatic dilatation, 23 had undergone surgical myotomy, and 5 had no response to Botox injection.
40 patients were found to have type 1 achalasia, 25 had type 2 achalasia, and 6 had type 3 achalasia. 9 patients had normal peristalsis unlikely to be consistent with a diagnosis of achalasia.
22 of the 80 patients had an IRP >15 mmHg (upper range of normal). 10 patients had a very low (<5 mmHg) IRP. 11 patients had pathological oesophageal acid exposure on 24-hour reflux testing.
Conclusion We investigated a large cohort of patients with recurrent dysphagia post-treatment of achalasia. The most frequent achalasia subtype was type 1. Although 28% patients had high residual LOS pressures, a significant proportion of patients had findings not consistent with a need to re-treat with dilatation or myotomy (due to very low LOS pressure, gastro-oesophageal reflux disease, or possible incorrect diagnosis).
These results highlight the need to carefully re-evaluate patients presenting with recurrent dysphagia after achalasia treatment before deciding on repeat therapy.
Disclosure of interest None Declared.
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