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Background: Controversy still remains as to whether an endoscopic or surgical approach should be primary treatment for patients with achalasia. We report our experience with endoscopic and surgical treatments in patients with achalasia over a 10-year period.

Methods: Retrospective analysis of electronic medical records was gathered from 190 patients with confirmed achalasia between January 1, 2000 and August 9, 2011. Demographics, data from motility studies, peri-operative intervention data, endoscopic intervention data, the use of a proton pump inhibitor (PPI), and presence of symptoms (dysphagia and GERD-related symptoms) throughout their course of treatment from clinical visits were collected.

Results: In our surgical cohort, 72 patients underwent various types of procedures (surgical myotomy with or without a full or partial fundoplication), with 8 (11%) patients having more than one surgical admission for a total of 80 surgical interventions. Thirty-two percent of the surgical patients underwent prior endoscopic treatment. In our endoscopic cohort, 76 patients underwent only endoscopic treatments (balloon dilation, botulinum injection or both) with 53 (70%) patients undergoing multiple treatments for a total of 174 endoscopic interventions. The remaining 42 patients did not have an endoscopic or surgical intervention, or did not have adequate follow up. The endoscopic-only managed patients underwent a mean of 3 (±2) and a median of 2 (range 1-8) interventions. There was no statistically significant difference between groups when comparing BMI, smoking status, pre-intervention mean resting lower esophageal sphincter (LES) pressures, pre-intervention mean lower esophageal sphincter (LES) relaxation pressure, or use of a PPI. Patients in the surgical cohort were significantly younger at 56.3 years versus 72.7 years (P<0.001). Endoscopic-only managed patients had both significantly more dysphagia (42.1% versus 16.7%, P<0.005) and GERD-related symptoms (72.6% versus 15.3%, P<0.005) throughout and after their course of treatment as compared to the surgical group. The mean period between the first and second endoscopic procedures was significantly less at 2.5 (±4.79) years as compared to 16.34 (±15.9) years in between a first and second surgery for achalasia (P<0.05). Patients in the endoscopic cohort had comparable average follow-up course of 7.26 (±6.72) versus 7.35 (±8.47) years compared to the surgical cohort. Thirty-day morbidity in the surgical cohort was 6.9% (5 patients) versus 1.3% (1 patient) and there were no mortalities.

Conclusion: Surgery may offer a more efficacious option for patients with achalasia than endoscopic treatment alone with less need for repeated interventions and significant relief of symptoms.