Vol.:(0123456789) 1 3 Surgical Endoscopy https://doi.org/10.1007/s00464-020-07541-4 Laparoscopic Heller myotomy or pneumatic dilatation in achalasia: results of a prospective, randomized study with at least a decade of follow‑up Ehsan Sediqi 1  · Alexandros Tsoposidis 1  · Ville Wallenius 1  · Hans Axelsson 1  · Jan Persson 1  · Erik Johnsson 1  · Lars Lundell 2,3  · Srdjan Kostic 1 Received: 6 January 2020 / Accepted: 26 March 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020 Abstract Background and objectives The most efcient long-term treatment strategy for achalasia has yet to be established. This study compared the long-term results (≥ 10 years) after either pneumatic dilatations or laparoscopic myotomy using treatment failure as the primary outcome. Secondary objectives were; the frequency and degree of dysphagia and efects on health- related quality of life (QoL). Patients and methods Out of the 53 patients with achalasia who were initially randomized to either laparoscopic myotomy with a posterior partial fundoplication (LM) or repetitive pneumatic dilatation (PD), 43 remained for scrutiny after a median observation period of 170 months (LM; n = 20 and PD; n = 23). Results At the follow-up of 60 months, 10 patients (36%) in the PD group and two patients (8%) in the LM group were classifed as treatment failures (p = 0.016). At the latest follow-up time point (≥ 10 years), the corresponding numbers were 13 (57%) and 4 (20%), respectively. The Kaplan–Meier analysis of the cumulative incidence of treatment failure revealed a signifcant advantage of LM over the dilatation strategy (p = 0.036)). QoL assessed by the generic instrument PGWB and the more disease-specifc instrument GSRS revealed scores which were similar in the two study groups with no obvious changes over time. Refux was better controlled in the LM group (p = 0.02 regarding PPI consumption). Conclusions After more than a decade of follow-up, laparoscopic myotomy reinforces its superiority over repetitive pneu- matic dilatation treatment strategy in the management of newly diagnosed achalasia. Keywords Heller achalasia · Pneumatic dilatation · Laparoscopic myotomy · Partial fundoplication · Dysphagia · Quality of life · Long-term follow-up Conceptually the pathogenesis of achalasia can be looked upon as a disruption of the balance between the regional excitatory and inhibitory response elicited along the esopha- geal body. Achalasia is associated with functional loss of myenteric plexus ganglion cells in the distal esophagus and lower esophageal sphincter [1–5], the cause of which is unknown. Progressive dysphagia to both solids and liq- uids is the hallmark symptom associated with a diagnosis of achalasia. Although demographic and clinical factors may afect clinical symptoms dysphagia and regurgitation are dominant symptoms among all ages. Hence the diagnosis of achalasia requires recognition of symptoms and appropriate use and interpretation of diagnostic testing, where endos- copy, barium swallow and high resolution manometry are essential components. Historically pneumatic dilatation (PD) has played a cen- tral role in the management of achalasia patients and remains so. Studies using PD as the initial treatment of achalasia have reported excellent long-term symptom control. How- ever, a third of patients will relapse in 4 to 6 years and may require repeat dilation [6–8]. Needless to say that achalasia and Other Interventional Techniques * Ehsan Sediqi ehsan_se@hotmail.com 1 Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden 2 Division of Surgery, CLINTEC, Department of Surgery, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden 3 Department of Surgery, Odense University Hospital, J.B. Winsloews Vej 4, 5000 Odense, Denmark