Most doctors with any practical experience of achalasia would be willing to admit that the disorder often provides considerable professional satisfaction. Firstly, it can be very satisfying to make the diagnosis. Far too often, patients will have suffered from gradually worsening dysphagia for many years and the diagnosis will have been missed at earlier consultations. The second moment of satisfaction can be enjoyed when the symptoms are relieved immediately after a relatively simple procedure such as pneumatic dilatation.

Malfunction of the lower oesophageal sphincter (LOS) plays a key role in the genesis of dysphagia in achalasia, in which it usually maintains an abnormally high resting tone. More importantly, however, the LOS does not relax sufficiently on swallowing, causing a persistent barrier to food boluses. In addition, the oesophageal body lacks normal propagation of contractions.

Presently there are four therapeutic options in achalasia, all of which are directed at lowering the tone of the LOS.

In what is considered to be the first report on treatment of achalasia, Sir Thomas Willis in 1672 described the successful dilatation of the sphincter using …