Complications
This results from aspiration of retained material in the oesophagus, with nocturnal aspiration being a particular problem.
In the US, approximately 10% of people with achalasia in hospitals have pulmonary complications.[13]
GORD is the most common cause for post-surgical treatment failure.
In one 10-year follow-up study, 14 of 67 patients (21%) developed severe reflux disease oesophagitis despite a partial anti-reflux procedure.[56] The severity of reflux disease increased with increasing duration of follow-up. In one series, 9 patients (13%) developed Barrett's oesophagus.[56] Rarely, a peptic stricture can result.[73] In one trial, reflux oesophagitis was reported in 7% of patients who underwent pneumatic dilatation for newly diagnosed achalasia.[50] Gastro-oesophageal reflux following pneumatic dilatation is usually mild and responds well to acid suppression.
The incidence of GORD is higher after a peroral endoscopic myomectomy (POEM). Many patients may require long-term proton pump inhibitor therapy for symptomatic reflux or erosive oesophagitis following POEM.
There may be an increased risk of squamous cell oesophageal carcinoma in patients with achalasia.[78] One systematic review and meta-analysis reported an incidence of 312.4 cases per 100,000 patient-years at risk.[79]
One large UK study reported that oesophageal cancer was 5 times more likely in patients with achalasia than in matched controls, presenting on average 15 years after diagnosis.[9]
Squamous cell oesophageal carcinoma is thought to result from chronic injury to the oesophageal mucosa due to retained ingested food and other noxious compounds.[80] The diagnosis is often made late, because patients already have a degree of dysphagia and any obstructing lesion has to be much larger to cause symptoms in a dilated oesophagus.[78][80]
The outcome is therefore poor; however, endoscopic surveillance is not standard practice.[80]
In a survey of physicians who treat achalasia, 82% felt that achalasia incurred an increased lifetime risk of carcinoma and 89% endorsed routine screening every 2-5 years.[81]
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