Can esophageal achalasia recur after treatment?

Recurrence of Esophageal Achalasia After Treatment

Yes, esophageal achalasia can recur after treatment, with up to one-third of patients experiencing symptom recurrence within 4-6 years of initial treatment. 1

Recurrence Rates by Treatment Modality

Pneumatic Dilation (PD)

• Initial success rate: 90% in first year, decreasing to 86% in second year 1
• Long-term recurrence: Up to one-third of patients experience symptom recurrence during 4-6 years of follow-up 1
• With repeat dilations: Success rates can reach 97% at 5 years and 93% at 10 years 1
• Very long-term outcomes: 100% of patients initially treated with PD eventually required myotomy in one study with 17.5-year follow-up 2

Laparoscopic Heller Myotomy (LHM)

• Lower recurrence rate compared to PD: 47.3% vs. 100% over long-term follow-up (10-40 years) 2
• Timing of recurrence after myotomy:
  • Insufficient myotomy: Symptoms typically recur within 12.4 months (range 3-30 months) 3
  • Periesophageal scarring: Symptoms recur within 18.8 months (range 6-28 months) 3

Per-Oral Endoscopic Myotomy (POEM)

• Short-term efficacy: 89-97% in multiple large case series 1
• Long-term data: Still limited as POEM is a newer procedure 1
• Particularly effective for type III achalasia compared to other treatments 4

Mechanisms of Recurrence

1. Inadequate initial treatment:

   • Insufficient myotomy length or depth 3, 5
   • Incomplete pneumatic dilation 1
   • Periesophageal scarring after myotomy 3

2. Progressive disease:

   • Continued degeneration of esophageal neurons 6
   • Development of end-stage achalasia (occurs in approximately 10% of patients over 40 years) 2

3. Treatment complications:

   • Post-treatment reflux causing esophagitis (10-40% after PD or POEM) 1
   • Development of strictures or fibrosis 3

Management of Recurrent Achalasia

1. After initial PD:

   • Repeat dilation with same or larger balloon size 1
   • Consider progression to myotomy if multiple dilations fail 2

2. After initial myotomy:

   • Repeat myotomy for insufficient initial procedure 5
   • Consider PD as a salvage therapy 2
   • POEM may be performed for recurrence of dysphagia following myotomy 1

3. Post-treatment monitoring:

   • Regular follow-up to detect symptom recurrence
   • Consider PPI therapy to prevent reflux complications 1
   • Long-term endoscopic surveillance, particularly after 5 years 3

Treatment Selection for Recurrent Disease

• Type I and II achalasia: Both repeat PD and surgical options are effective 4
• Type III achalasia: POEM may be particularly advantageous due to ability to perform longer myotomy 1, 4
• Presence of megaesophagus: May require more aggressive intervention 7

Important Caveats

• Most patients with achalasia will require multiple procedures over their lifetime to maintain symptom control 2
• The risk of progression to end-stage achalasia exists despite treatment 2
• Post-treatment reflux requires monitoring and management with PPIs 1
• Treatment should be performed at centers with expertise in achalasia management 1, 4

In summary, while initial treatment success rates are high for achalasia, recurrence is common across all treatment modalities, with the highest rates seen after pneumatic dilation and lowest after surgical myotomy. Most patients will require additional interventions throughout their lifetime to maintain symptom control.