Which of the following statement(s) is/are true concerning the management of this patient?

a.The risk of perforation of the esophagus associated with balloon dilatation may be as high as 10%

e.Prospective randomized studies and retrospective data appear to support a surgical approach for achalasia

The mainstay of treatment in achalasia is either balloon dilatation or surgery. Balloon dilatation has an advantage that it can be performed as an outpatient and has minimal recovery time. It is less likely to be effective than surgical treatment, and frequently needs to be repeated. The risk of perforation of the lower esophagus is higher with this procedure than with any other form of esophageal instrumentation and varies from 2–10%. The risk of gastroesophageal reflux following dilatation is not known, but symptomatically the risk appears to be low.

All surgical procedures employ a variant of Heller’s myotomy, in which the circular muscle of the lower esophagus is divided. In the United States, most myotomies are carried out through the chest, but the abdominal approach is favored in Europe. Regardless of the route chosen, four key principles are important, namely: 1) adequate myotomy, 2) minimal hiatal disturbance, 3) anti-reflux protection without creation of obstruction, and 4) prevention of rehealing. The advent of minimally invasive surgery has led to the development of thorascopic and laparoscopic myotomy, and these are now being extensively performed with comparable results to open surgery. There is broad agreement that if a myotomy is performed through the abdomen, an anti-reflux procedure should be added, and that a full Nissen wrap, however floppy, leads to longterm failure. When approached through the chest, there is controversy about the need for an anti-reflux procedure, as it is claimed that less hiatal disturbance and more limited myotomy is possible by this route. Thoracoscopic myotomy, with enhanced view, enables a more precise determination of the distal myotomy and therefore may not require a anti-reflux procedure.

A single pneumatic dilatation achieves adequate relief of dysphasia and pharyngeal regurgitation in about 60% of patients. Repetitive dilatations increase this figure to about 70%. Only one controlled randomized study comparing the two modes of therapy has ever been performed. The results of this study as well as a number of retrospective studies would appear to support operative myotomy as the initial treatment of choice.