Introduction

Achalasia is a rare disorder of the esophageal smooth muscle

characterized by impaired relaxation of the lower esophageal

sphincter (LES) and absent or spastic contractions in the

esophageal body1. The crude prevalence in Medicare of

achalasia per 100,000 persons aged 65 or older was 162.1 in

20152. High-resolution manometry (HRM) is the gold standard

for diagnosis and based on this, this disease is further

categorized into 3 distinct 3 types: type l, type ll and type lll.

Treatment is aimed at relieving symptoms because there is no

cure for achalasia3. This may be achieved through calcium

channel inhibitors, pneumatic dilation of the LES, botox

injections, peroral endoscopic myotomy (POEM), Heller

myotomy and ultimately, esophagectomy.

Aim

This study aims to delineate the natural history of achalasia,

emphasizing the infrequency of esophagectomy as a treatment

outcome, examining the spectrum of therapeutic alternatives

preceding esophagectomy, and establishing a timeline for

disease progression. Another objective of the study is to try to

identify variables may predict therapeutic failure.

Methods

We conducted a retrospective descriptive study of all patients

diagnosed with achalasia between 2019 and 2025 at our

institution. Data was extracted from institutional medical records.

Achalasia was diagnosed using a timed barium swallow (TBS)

study and/or HRM. Patients who had an esophagectomy for any

other diagnosis that was not achalasia, were ruled out of the

study. Statistical significance of the mean of quantitative

variables was measured with paired-t tests and chi square and

Fisher’s test were used for comparison of qualitative values.

Results

A total of 147 patients were included. Five patients underwent

esophagecrtomy for achalasia (3.4%), while 142 patients were

treated with Heller myotomy. Patient demographics, comorbidities,

and presenting symptoms are summarized in Table 1.

In the esophagectomy cohort, four patients had a prior myotomy

before esophagectomy. The average duration of symptoms prior to

esophagectomy was 13 years. Among those with prior myotomy, the

average interval to esophagectomy was 10.5 years. All patients in

this cohort had end-stage achalasia. Procedures were robotic, with

one case requiring an open thoracic portion and one conversion to

open. Two patient developed postoperative leaks, and four

experienced symptom recurrence, with an average time of 145 days

after esophagectomy.

In the Heller myotomy cohort, patients reported an average symptom

duration of 7.5 years prior to intervention. Prior treatments included

Botox injection (32), esophagogastroduodenoscopy (EGD) dilation

(89), POEM (3), and percutaneous endoscopic gastrostomy (PEG)

tube placement (1). At <6 months follow-up, 1.49% of patient

reported worsening symptoms compared with preoperative status. At

last follow-up, 4 patients reported worse symptoms than

preoperatively. Symptom recurrence occurred in 27 patients, with an

average time to management of 383 days after myotomy.

Conclusions

Esophagectomy is a rare outcome in the treatment of achalasia. In

our cohort, Heller myotomy provided excellent symptom control at

six month and at last follow-up. No predictive variables for therapy

failure were identified.