Evaluating Long-Term Functional and Symptomatic Outcomes of Pneumatic Dilatation in Achalasia: An Experience from Pakistan

Abstract

Background

Achalasia, a rare esophageal motility disorder, is managed with medications, botulinum toxin, pneumatic dilation (PD), or surgery. In resource-limited settings like Pakistan, PD is preferred first-line non-surgical treatment due to its accessibility and cost-effectiveness so we aim to assess remission rates and clinical outcomes of PD.

Methodology

Between 2015 and 2024, 213 achalasia patients were diagnosed via HRM at Center for Liver & Digestive Diseases, Holy Family Hospital, Rawalpindi. 191 patients opted for PD and completed follow-up interviews using Eckardt score and ASQ questionnaire. Data analysis was performed using SPSS.

Results

Among 191 patients (107 males, 84 females), 53% underwent one, 30% two, and 17% three PD session. Success rates were 58% for one, 78% for two, and 87.5% for three sessions, with no severe complications. The cumulative re-dilation rate was 20%, with a 76% success rate for repeat dilations. Multiple PDs significantly outperformed single PDs(p=0.01), reducing mean Eckardt score from 6.7 to 1.9. QoL improved with successful dilations but not in failed cases.

Conclusion

PD provides sustained symptom relief for up to five years, with repeat sessions enhancing long-term success, reinforcing PD as an effective, durable, and accessible treatment option for achalasia in low-resource settings for evidence-based clinical decision-making.

Zusammenfassung

Hintergrund

Achalasie, eine Motilitätsstörung der Speiseröhre, wird mit Medikamenten, Botulinumtoxin, pneumatischer Dilatation (PD) oder Operation behandelt. In ressourcenarmen Regionen wie Pakistan ist die PD aufgrund ihrer Zugänglichkeit und Kosteneffizienz die bevorzugte nicht-chirurgische Erstlinienbehandlung. Daher ist es unser Ziel, die Remissionsraten und klinischen Ergebnisse der PD zu untersuchen.

Methodik

Zwischen 2015 und 2024 wurden 213 Achalasie-Patienten im Zentrum für Leber- und Verdauungskrankheiten Holy Family Hospital in Rawalpindi mittels HRM diagnostiziert. 191 Patienten entschieden sich für eine PD und nahmen an Folgeinterviews mit Eckardt-Score und ASQ-Fragebogen teil. Die Datenanalyse erfolgte mit SPSS.

Ergebnisse

Von 191 Patienten (107 Männer, 84 Frauen) erhielten 53% eine, 30% zwei und 17% drei PD-Sitzungen. Die Erfolgsraten lagen bei 58% für eine, 78% für zwei und 87,5% für drei Sitzungen, ohne dass schwerwiegende Komplikationen auftraten. Die kumulative Wiederdilatationsrate lag bei 20%, die Erfolgsrate für wiederholte Dilatationen bei 76%. Mehrfache PDs waren deutlich leistungsfähiger als einzelne PDs (p=0,01), wodurch sich der mittlere Eckardt-Score von 6,7 auf 1,9 reduzierte. Mehrere PDs übertrafen einzelne PDs signifikant (p = 0,01) und reduzierten den mittleren Eckardt-Score von 6,7 auf 1,9. Die Lebensqualität verbesserte sich bei erfolgreichen Dilatationen, jedoch nicht in fehlgeschlagenen Fällen.

Fazit

PD bietet eine anhaltende Linderung der Symptome für bis zu fünf Jahre, wobei wiederholte Sitzungen den langfristigen Erfolg steigern und PD als wirksame, dauerhafte und zugängliche Behandlungsoption für Achalasie in ressourcenarmen Umgebungen für evidenzbasierte klinische Entscheidungen bekräftigen.

Keywords

Achalasia - Pneumatic dilation - Symptom remission - Pakistan

Schlüsselwörter

Achalasie - Pneumatische Dilatation - Symptomremission - Pakistan

Introduction

Achalasia is a relatively rare disease involving esophageal dysmotility due to ganglionic cell loss, which leads to impaired lower esophageal sphincter (LES) relaxation and peristalsis, resulting in dysphagia (>90%) [1] [2]​. Other symptoms that can co-exist are regurgitation of undigested food and respiratory complications such as nocturnal cough, aspiration, chest pain, heartburn, and weight loss [3]​​. Achalasia affects 1 to 3 individuals per 100000, typically aged 25 to 60. The cause of achalasia is unclear but likely involves autoimmune-mediated damage to the myenteric plexus, targeting inhibitory neurons and leading to nerve fibre degeneration ​[4]​. Genetic predisposition may also play a role in specific populations ​[5]​. If left untreated, achalasia can cause esophageal dilation and increase the risk of esophageal squamous cell cancer in patients ​[1] [5]​.

Diagnosis of achalasia involves barium swallow, high-resolution manometry (HRM), and an endoscopic functional luminal imaging probe (EndoFLIP). At the same time, upper gastrointestinal endoscopy can only rule out any underlying mechanical conditions like esophageal stricture or malignancy. HRM, utilizing at least 21 pressure sensors spaced 1 cm apart, is the gold standard for diagnosis. It not only confirms achalasia but also classifies subtypes – type I (classic achalasia), II (compressive achalasia), and III (spastic achalasia) – guiding treatment decisions [6]. EndoFLIP uses a trans-oral catheter with a distensible balloon, providing a 3D image of the esophageal lumen via impedance and pressure measurements ​[3]. Despite its predictive value, data scarcity and limited availability hinder its use, particularly in developing nations such as Pakistan.

Most treatment modalities focus on reducing esophagogastric junction resistance rather than restoring esophageal motility due to the irreversible nature of neuronal damage. According to Western studies, type II achalasia is associated with a positive treatment response, while type III is correlated with an inadequate treatment response [7] [8] [9]​. This may reflect that each type has a different pathophysiological mechanism, and the subtype might predict the response to the chosen treatment option ​[10]​.

Various treatments exist for achalasia, including pharmacological agents like calcium channel blockers or botulinum toxin injection, which intend to relax the LES, but their efficacy is short-lived. Alternatively, endoscopic or surgical interventions aim to reduce LES pressure, with pneumatic balloon dilation (PD) being the most common, convenient, and non-surgical method. It uses a balloon dilator to expand the LES to a diameter of 30–40 mm, thus lowering LES pressure by tearing the sphincter muscle ​ [11]​. Multiple trials have been done comparing the efficacy of PD with other treatment modalities, particularly with laparoscopic Heller’s myotomy (LHM) [11] [12]. One of these trials demonstrated that PD and LHM have identical efficacy rates. However, 25% of PD patients needed re-dilation during follow-up ​[12]​. Peroral endoscopic myotomy (POEM) is a minimally invasive technique for achalasia, rivalling LHM in short-term efficacy. Studies indicate higher success rates and lower perforation risk than PD ​[13]​. Yet, the scarcity of expertise and availability hampers its use in Pakistan.

Evaluation for extended post-treatment period is essential, yet follow-up for achalasia in low to middle-income countries (LMICs) like Pakistan is hindered by limited resources and insufficient personnel for patient follow-up, especially in rural areas with limited access to clinics or telecommunication. Usually, retreatment is only sought if symptoms recur. Objective measurements often correlate with patient-reported symptom changes. So, for this reason, our primary objective was to evaluate the effectiveness of PD in achieving clinical remission across different achalasia subtypes at a single referral center in Pakistan. Specifically, the success rates of initial and repeat PD sessions were determined, and their impact on symptom relief over time. Our secondary objectives include assessing improvements in patients’ QoL following PD and analyzing long-term remission rates to determine whether patients remained asymptomatic after one or multiple dilations.

Methodology

Patients

Patients diagnosed with achalasia using the results of radiographic, endoscopic, and manometric examinations [14] at the Center for Liver and Digestive Diseases, Holy Family Hospital, Rawalpindi, between December 2015 and February 2024, were consecutively enrolled. This interval was chosen to ensure a maximum follow-up of 5 years. Only patients whose records were available for review during the mentioned period were selected for the study. Out of 213 individuals initially diagnosed with achalasia, four patients had a prior history of LHM or PD and were excluded. Additionally, pre-treatment data from 6 patients were unavailable; five did not choose PD as the first-line treatment, and one patient had a comorbid hiatal hernia, all of whom were excluded. Six patients did not choose to participate in the study for an extended period. Thus, data from 191 patients were retrospectively included in a database, provided informed written consent, and were followed up regularly according to a standard protocol ([Fig. 1]).

Fig. 1 Flowchart demonstrating included patients with achalasia receiving pneumatic balloon dilatation as a first line treatment.

Symptom evaluation

All patients underwent interviews with symptoms assessed using the Eckardt score recorded by attending gastroenterologists at diagnosis, i.e., before and after treatment. The Eckardt score, calculated based on symptom frequency with a maximum score of 12, was the sum of each symptom score for dysphagia, regurgitation, and chest pain (0, absent; 1, occasional; 2, daily; and 3, each meal), and weight loss (0, no weight loss; 1 < 5 kg; 2, 5–10 kg; and 3 > 10 kg). Following PD, Eckardt’s score of 0–1 represents stage 0, and 2–3 indicates stage I, both of which reflect significant symptom relief, and stages II (score 4–6) and III (score of >6) are considered treatment failure [10]​.

Quality of Life Evaluation

QoL was assessed using the Achalasia-specific quality-of-life questionnaire (achalasia-DSQoL or ASQ) before and after treatment. The ASQ is a 10-question validated questionnaire comprising ten items that evaluate various features of health-related quality of life (HRQoL). These items included tolerance of food (item 1: 1–3 points; items 2–4: 3–8 points), behavioural modifications due to dysphagia (item 5: 1–3 points), pain (item 6: 1–4 points), heartburn (item 7: 1–5 points), distress (item 8: 1–2 points), lifestyle limitation (item 9: 1–2 points), and satisfaction (item 10: 1–4 points). The cumulative score ranges from 10 points to the minimum and 31 points to the maximum, respectively, with the cutoff score of ≥15 representing the improvement in QoL and vice versa ​[15]​.

Pneumatic Dilation

Patients were advised to visit with an overnight fast on the day of treatment. The procedure was done on an outpatient basis. A Rigiflex II balloon (Microvasive, Milford, MA) measuring 30 mm in diameter was used for dilation at the start in most patients. Subsequent dilations were performed using a 35–40 mm balloon. Pharyngeal topical anesthesia was administered, and under endoscopic guidance, the balloon was positioned across the LES and inflated for 60 seconds at 5–15 PSI based on patient tolerance. Following the procedure, patients were observed for up to two hours and instructed to drink water.

Study outcomes: success and failure

To assess post-treatment success or failure, the reference standard of employing a questionnaire was applied to all patients after the administration of informed consent. After PD, patients followed up in the center by themselves or were oriented about the research process over the phone at 6, 12, and 24 months up to 5 years to assess symptomatic improvement and relapse. Duration/follow-up time (in months) was measured as a follow-up from the first PD to the interview date. Success was defined as symptom remission for at least one year following initial PD based on the patient’s subjective reporting and Eckardt’s score of less than three and ASQ scores of ≥15. Patients were defined as failures if symptoms recurred within one year. Repeated dilations were offered to all patients who developed symptom scores of >3 or wished to undergo further treatments. Short-term treatment response was evaluated six months after the treatment. Long-term treatment response was assessed in patients 2 to 5 or more than five years after the treatment.

Due to economic issues and patient constraints, repeat esophageal function testing for all patients was impossible, so the primary measure of success of the treatment modality, PD, relied on symptomatic improvement and better QoL. Informed consent was obtained from all patients, and the study was approved by the Institutional Research and Ethics Forum of Holy Family Hospital, Rawalpindi, with protocol approval number 269/IREF/RMU/2022 and the Institutional Ethical Review Board and Bio-Ethical Committee (BEC) of Quaid-I-Azam University, Islamabad, with protocol approval number BEC-FBS-QAU2022–381.

Statistical analysis

Descriptive statistics (mean and standard deviation, and percentages) accounted for both clinical and symptomatic data, where appropriate statistical tests were used to compare these variables across different subtypes of achalasia, involving ANOVA, for continuous and normally distributed data, for the constant and non-normally distributed data, Kruskal-Wallis’s test and categorical variables chi-square test were employed, respectively. PD outcome, differences in one vs. multiple PDs, and duration of effect were analyzed using Fisher’s Exact tests. Cox proportional hazard models were used to assess the influence of factors like age, baseline Eckardt and ASQ scores, and the number of PD sessions on the success rates of the treatment provided to the patients. Moreover, each predictor was presented with a hazard ratio (HR) and a 95% confidence interval (CI). To determine the likelihood of staying symptom-free after PD sessions, Kaplan-Meier survival evaluation was performed, taking treatment failure into account. Failure of therapy was defined as ASQ<15 or Eckardt score >3 within a year of the first PD treatment. In addition, the log-rank test was used to plot the survival function, where differences were drawn in the PD sessions (initial vs multiple). To further evaluate the long-term success of PD, the recurrence-free interval for different patient subgroups (types of achalasia) was also estimated using the Kaplan-Meier method. All the tests were conducted as two-sided, with a significance level of p < 0.05 using SPSS version 25.

Results

The baseline characteristics of the 191 patients are summarized in [Table 1]. There were 118 (61.8%) type I achalasia patients, 58 (30%) type II, and 15 (7.8%) type III, with type III patients being the oldest. The overall male-to-female ratio observed was 107:84, which differed among the subtypes. Type I and type II showed male predominance, while type III was predominantly female (67%). Dysphagia for both solids and liquids was the most commonly reported symptom, while chest pain was the least widely observed in type III. Additionally, weight loss and regurgitation showed no significant differences across the subtypes. The mean ASQ score showed the worst QoL among all types before the treatment.

Table 1 Baseline clinical findings among subtypes of esophageal achalasia.

	Basic Characteristics	Total	Chicago classification			P-Value
			Type I (n=118)	Type II (n=58)	Type III (n=15)
*P < 0.05 is significant * type II vs. type III; ** type I vs. type III; *** type I vs. type II
	Age (mean ± SD)	41.84 ± 16.5	41.90 ± 15.7	39.0 ± 14.1	44.63 ± 19.7	0.261
	Gender (M:F)	107:84	68:48	34:26	5:10	0.131
	Duration of symptoms before diagnosis (in months) (mean ± SD)	48.12 ± 31.04	47.94 ± 40.05	39.10 ± 36.77	41.60 ± 32.15	0.743
Pre-treatment	Dysphagia	186/191 (97%)	115/118 (98%)	56/58 (96%)	15/15 (100%)	0.06
	Weight loss	163/191 (85%)	95/118 (81%)	55/58 (95%)	13/15 (87%)	0.091
	Retrosternal Pain	141/191 (74%)	89/118 (75%)	43/58 (74%)	09/15 (60%)	0.11
	Regurgitation	166/191 (87%)	103/118 (87%)	49/58 (85%)	14/15 (93%)	0.203
	Total Eckardt score	7.2 ± 2.1	7.1 ± 2.5	6.8 ± 2.5	6.7 ± 1.8	0.745
	Total ASQ score	24.4 ± 8.6	23.1 ± 9.5	22.9 ± 7.2	22.1 ± 8.2	0.550
Post-treatment (6 months)	Dysphagia	56/191 (29%)	36/118 (31%)	11/58 (19%)	9/15 (60%)	0.012*
	Weight loss	92/191 (48%)	61/118 (52%)	26/58 (45%)	5/15 (33%)	0.27
	Retrosternal Pain	77/191 (40%)	51/118 (43%)	20/58 (35%)	6/15 (40%)	0.301
	Regurgitation	88/191 (46%)	59/118 (50%)	23/58 (40%)	6/15 (40%)	0.112
	Total Eckardt score	1.4 ± 1.1	1.6 ± 1.7	1.3 ± 1.2	1.2 ± 1.5	0.04**
	Total ASQ score	12.6 ± 4.4	13.2 ± 5.3	12.7 ± 4.1	11.4 ± 5.5	0.01**
Post-treatment (1 year)	Dysphagia	62/191 (32%)	38/118 (32%)	17/58 (29%)	7/15 (47%)	0.015*
	Weight loss	84/191 (44%)	56/118 (47%)	24/58 (41%)	4/15 (27%)	0.810
	Retrosternal Pain	80/191 (42%)	50/118 (42%)	22/58 (38%)	8/15 (53%)	0.061
	Regurgitation	83/191 (43%)	50/118 (42%)	26/58 (45%)	7/15 (47%)	0.43
	Total Eckardt score	2.4 ± 2.2	2.9 ± 1.5	2.8 ± 1.9	2.8 ± 1.6	0.25
	Total ASQ score	17.2 ± 3.1	14.1 ± 3.5	15.5 ± 3.2	14.4 ± 6.5	0.90
Post-treatment (2 years)	Dysphagia	77/191 (40%)	46/118 (39%)	22/58 (38%)	9/15 (60%)	0.05*
	Weight loss	91/191 (48%)	59/118 (50%)	26/58 (45%)	6/15 (40%)	0.809
	Retrosternal Pain	90/191 (47%)	55/118 (47%)	27/58 (47%)	8/15 (53%)	0.09
	Regurgitation	81/191 (42%)	55/118 (47%)	21/58 (36%)	5/15 (33%)	0.042**
	Total Eckardt score	4.2 ± 2.1	4.5 ± 1.1	4.1 ± 2.0	3.9 ± 1.5	0.07
	Total ASQ score	19.5 ± 3.6	20.5 ± 3.5	17.1 ± 2.1	19.3 ± 5.0	0.04***
Post-treatment (5 years)	Dysphagia	74/191 (39%)	44/118 (37%)	20/58 (35%)	10/15 (67%)	0.01*
	Weight loss	92/191 (48%)	59/118 (50%)	24/58 (41%)	9/15 (60%)	<0.001*
	Retrosternal Pain	94/191 (49%)	55/118 (47%)	30/58 (52%)	9/15 (60%)	<0.001**
	Regurgitation	89/191 (47%)	51/118 (43%)	30/58 (52%)	8/15 (53%)	0.02**
	Total Eckardt score	2.4 ± 2.9	2.6 ± 2.5	2.5 ± 1.9	2.8± 2.1	0.1
	Total ASQ score	15.2 ± 1.7	13.9 ± 1.1	13.1 ± 2.5	14.0 ± 2.2	0.07

At the 6-month mark, a notable improvement was evident, characterized by an 80% reduction in total Eckardt scores and a 78% reduction in ASQ scores, as depicted in [Fig. 2], underscoring the immediate benefits of PD. Subsequent observations from month 6 to month 12 revealed minor fluctuations, primarily indicating stability with slight exacerbations. However, at the 2-year follow-up, a significant deterioration in QoL was noted, alongside a worsening trend in Eckardt scores, irrespective of the number of dilations administered. Nevertheless, these adverse effects were alleviated and exhibited improvement during the extensive follow-up assessment, regardless of the repeated dilatations received.

Fig. 2 Average scores of Eckardt and ASQ at different time durations.

Among the 191 patients studied, 101 (53%) underwent one PD session, 58 (30%) had two sessions, and 32 (17%) underwent three sessions. Of these, 79 with type I achalasia, 18 with type II, and 4 with type III were treated with a single PD session. Patient distribution for two PD sessions included 23 with type I, 28 with type II, and 7 with type III. In the cohort receiving three sessions, 16 had type I, 12 had type II, and 4 had type III. Within 12 months, no more than one session was required. Among those with one PD session, 58/101 achieved successful outcomes, while 29% had symptom remission. Of the 58 patients with two sessions, 45/58 (78%) experienced success, while the rest, 13/58, opted for surgery or declined further treatment. Remarkably, 28/32 patients (87.5%) receiving three dilations achieved long-term symptom resolution. Further elucidation is provided in [Fig. 3].

Fig. 3 Outcomes of PD (based on symptom resolution or relapse) sorted by number of PDs in subtypes of achalasia at 1-year.

The cumulative re-dilation rate was 20%, calculated by dividing the total repeat PDs by the total patients. The cumulative re-dilation success rate was 76%, determined by successful repeat PDs over instances of re-dilation (29/38). When comparing one PD to multiple PDs, there was a significant difference between the number of successes and failures (p = 0.01). Overall, a majority of patients found success with PD. The mean Eckardt score changed to 1.9 ± 1.4 from 6.7 ± 2.1 after a successful PD, compared to 6.9 ± 2.3 to 6.1 ± 2.1 with a failed PD. The same was observed with QoL; the average score improved from 21.7 ± 2.3 to 14.9 ± 3.5 in a successful dilatation, but the average ASQ score of failed PD sessions did not improve.

Among the 101 patients receiving a single PD session, 72 (71%) maintained stability at 1-year follow-up, while 29 (29%) experienced symptom relapse (treatment failure). Of these, 58 (80.5%) remained stable at 2 and 5 years, and 17 (58.6%) improved long-term. Of the 58 patients undergoing two sessions, 45 (77.6%) achieved remission initially, with 39 (86.6%) showing long-term improvement. For those needing a third session, 28 (87.5%) were successful initially, and 24 (stable) remained in remission at five years. A detailed tabulation is presented in [Fig. 4].

Fig. 4 Short- and long-term responses of PD (based on symptom resolution or relapse) sorted by number of PDs. (Stable means Eckardt scores 3 or less. Relapse means Eckardt scores more than 3. Persist means the symptom score remains the same. Stable* means symptom improvement either by opting for any other treatment option).

A Cox proportional hazards regression model was fitted to assess the effect of clinical variables on the risk of treatment failure over time, to see how they affect symptom recurrence after PD. The analysis included 191 patients, of whom 76 (40%) experienced symptom recurrence. The predictors included age, baseline Eckardt, and ASQ score, together with the number of PD sessions, which were examined as shown in [Table 2].

Table 2 Cox Proportional Hazards Model.

Predictor	HR (95% CI)	P-value	Interpretation
HR Hazard Ratio, CI Confidence Interval *P < 0.05 is significant
Age	1.0056 (0.98–1.03)	0.6593	No impact on failure risk
Baseline Eckardt Score	1.0148 (0.89–1.15)	0.8240	No significant effect
Baseline ASQ Score	0.9747 (0.94–1.01)	0.2046	Weak protective effect, not significant
Number of PD Sessions	0.7408 (0.52–1.05)	0.0936	Lower failure risk, borderline significant

An essential aspect of this study was assessing how much time the effect of a PD lasted, i.e., the probability of staying in remission after the treatment. The Kaplan-Meier survival curve ([Fig. 5] a) shows that symptom-free survival declined from 90% in 6 months to 40% at 5 years, with the steepest drop occurring within the first two years. Patients who underwent multiple PD sessions had significantly better long-term outcomes than those with a single session (p = 0.01). A separate analysis by achalasia subtype ([Fig. 5] b) revealed that while remission probabilities ranged from 80 to 100% at one year. The remission probability values in the achalasia type I after the first session were around 80% for two years, but around 70–75% for achalasia type II and III. At five years, the cumulative remission percentage after a single session decreases to around 10%, irrespective of type. No significant levels were observed in the probability of remission among subtypes (p = 0.32).

Fig. 5 a Kaplan-Meier survival analysis for time to treatment failure. b Probability of staying in remission after the first pneumatic dilation among subtypes of achalasia by Kaplan-Meier survival analysis.

Discussion

In Pakistan, achalasia management lacks curative options, relying on symptomatic relief methods like pharmacotherapy or structural interventions such as PD or LHM. Treatment efficacy varies and is influenced by factors like patient characteristics and prior interventions. Limited or no access to advanced techniques like POEM complicates care, making PD predominant. LHM was initially thought to be the most successful treatment, but recent studies [11] [16] have shown that PD approaches the success rate of LHM, especially when accounting for the manometric subtype. Also, in LMICs like Pakistan, treatment selection should consider cost, availability, and long-term patient outcomes. PD is the most cost-effective, particularly in resource-limited settings, as it avoids surgical costs and hospital stays, though multiple sessions may be required for sustained remission [11]. LHM offers durable symptom relief, with lower retreatment rates than PD, but it involves higher surgical costs and risks [7]. POEM, despite its minimally invasive nature and superior efficacy, is the most expensive and requires specialized expertise, limiting accessibility in low-resource settings [17] [18]. We aim to evaluate PD’s effectiveness and outcomes across achalasia subtypes in a Pakistani tertiary care setting, addressing the country’s treatment landscape challenges.

In the present study, most patients had type I achalasia (62%), followed by type II and III. Our data show that it is reasonable to expect at least one year of symptom resolution following PD. On the other hand, patients with type I achalasia demonstrated a trend towards a considerably longer remission period following a single PD compared with those patients who had type II achalasia. Apart from that, data from previous studies suggest that achalasia type II is a significant type of achalasia that has a better clinical outcome irrespective of the choice of treatment [10] [19] [20]​. The patients with type III achalasia, despite being smaller in sample size due to late diagnosis and the self-managing nature of the Pakistani cohort, demonstrated to have a least favorable response to the treatment aligned with the previous findings ​[20]​, while on the other hand, those patients reported to have a considerably higher basal LES pressure and esophageal pressure as compared to the patient with type I and type II achalasia, which might suggest the failure of favorable treatment outcomes ​[21] [22].

Moreover, on the statistical parameters, significant advancements were noted in the symptoms of dysphagia, as were identified with Eckardt and ASQ scores, and were observed for six months following the initial PD, contrasted with the pre-treatment levels across all types of achalasia, with a significant decrease in mean Eckardt score from 7.2 ± 2.1 (untreated patients) to 1.4 ± 1.1 (patients following initial PD for six months). In addition, mean ASQ scores were significantly different from 24.4 ± 8.6 to 12.6 ± 4.4 in untreated patients and patients following the initial PD for six months, respectively. Also, there was an initial treatment response of 75.9% (73.3% to 77.5%) as (outlined by an Eckardt of ≤ one year PD), which was observed in all three types of achalasia; however, this study found no such patient who may need an additional PD at or within one year following the initial PD, pertaining their recurrent or symptomatic relapses, which correlates with the previous research [11] [23]​.

Apart from that, the 5-year remission rates for patients without treatment and with single PD was around 57% vs. 82% with those patients who had two or required three PD sessions, where the majority of the patients requiring additional PD sessions after one year of follow-up or between 2 years showed the significant rates of the symptomatic remission vs those who had only one PD done (80% vs 57%). Many contributing factors may explain the failure in treatment and/or clinical outcomes for the patients, including patient characteristics or procedural characteristics, which may exhibit initial relapse of the symptoms​ [10]​. Multiple dilations may lead to progressive esophageal wall remodeling, which can improve symptom relief but also increase the risk of complications such as perforation or persistent esophageal dilation. While our study observed no severe complications, the impact of repeated PD on esophageal compliance and motility remains an important consideration.

About one-third of our patient population ultimately pursued repeat dilation, which was lower than the 25% reported by the European multicenter trial [12] and the 52% rate of repeat intervention reported by Lopushinsky et al [24]. The size and timing of graded balloon dilation are unnecessary for improving symptoms unless there is an apparent disease recurrence. However, our data indicate that a single PD may be sufficient for lasting results. While we acknowledge the standard practices that many practitioners employ, this paper demonstrates a practical approach to treating achalasia in a Pakistani patient with limited resources.

The strength of this study is that a complete patient-oriented symptom assessment was available after treatment for all patients, with a large sample size compared to previous studies. Unfortunately, our study lacked systematic manometric and endoscopic follow-ups. Patients with poorer outcomes or persistent symptoms may have been more likely to discontinue follow-up, potentially leading to an overestimation of treatment success. The study was conducted at a referral center only one present in the region, potentially skewing results toward severe cases and not being representative of the community practice. As a single-center study, the findings may not be fully generalizable to broader populations, and potential patient selection bias cannot be excluded. The absence of a control group or direct comparison with other treatment modalities, such as LHM or POEM, limits the ability to assess the relative efficacy of PD. Additionally, resource constraints in particular settings influenced treatment accessibility, follow-up adherence, and the availability of advanced interventions, which may impact outcomes. Also, the timing of treatment and follow-up period in each patient was different because this is a retrospective study followed by a prospective type of study. However, all the enrolled patients’ symptoms were recorded in the same planned description format. Future multicenter studies with comparative designs will provide a more comprehensive evaluation of achalasia management strategies.

Conclusion

Our results affirm the potential for up to five years of symptom relief in most patients, highlighting the durability of PD as a safe and effective procedure. Our observations underscore the effectiveness of initial dilatation in achieving symptom relief and higher QoL, with repeat dilations for late recurrences promising long-term success rates. Also, our study findings offer valuable insights into the utility of the Eckardt and ASQ questionnaires for assessing post-treatment response in achalasia patients after PD when other confirmatory tests were out of reach. This evidence empowers physicians and patients with a choice of assessment tools, facilitating shared decision-making. While our study had a few treatment failures, our conclusions remain reliable.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Rengarajan A, Bazarbashi AN, Gyawali CP. PATHOPHYSIOLOGY OF ACHALASIA. Digestion 2025;
• 2 Savarino E, Bhatia S, Roman S. et al. Achalasia. Nat Rev Dis Primers 2022; 8: 28
• 3 Rieder E, Fernandez-Becker NQ, Sarosiek J. et al. Achalasia: physiology and diagnosis. Ann N Y Acad Sci 2020; 1482: 85-94
• 4 Lee K, Hong SP, Yoo IK. et al. Global trends in incidence and prevalence of achalasia, 1925–2021: A systematic review and meta‐analysis. United European Gastroenterol J 2024; 12: 504-515
• 5 Jia X, Chen S, Zhuang Q. et al. Achalasia: the current clinical dilemma and possible pathogenesis. J Neurogastroenterol Motil 2023; 29: 145
• 6 Elmakki K, Akhtar TS, Abbas S. et al. Role of High-Resolution Manometry in Diagnosing Esophageal Motility Disorders-A Literature Review in Line with Chicago Classification V4. 0. Biomed J Sci Tech Res 2024; 55: 47081-47096
• 7 Kahrilas PJ, Pandolfino JE. Treatments for achalasia in 2017: how to choose among them. Curr Opin Gastroenterol 2017; 33: 270-276
• 8 Pratap N, Kalapala R, Darisetty S. et al. Achalasia cardia subtyping by high-resolution manometry predicts the therapeutic outcome of pneumatic balloon dilatation. J Neurogastroenterol Motil 2011; 17: 48
• 9 Roman S, Gyawali CP, Xiao Y. et al. The Chicago classification of motility disorders: an update. Gastrointestinal Endoscopy Clinics 2014; 24: 545-561
• 10 Lee JY, Kim N, Kim SE. et al. Clinical characteristics and treatment outcomes of 3 subtypes of achalasia according to the chicago classification in a tertiary institute in Korea. J Neurogastroenterol Motil 2013; 19: 485-494
• 11 Javed AT, Batte K, Khalaf M. et al. Durability of pneumatic dilation monotherapy in treatment-naive Achalasia patients. BMC Gastroenterol 2019; 19
• 12 Moonen A, Annese V, Belmans A. et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65: 732-739
• 13 Cappell MS, Stavropoulos SN, Friedel D. Updated systematic review of achalasia, with a focus on POEM therapy. Dig Dis Sci 2020; 65: 38-65
• 14 Abbas S, Akhtar TS, Chinnam S. et al. Optimizing achalasia diagnosis in the era of high‐resolution manometry: A Pakistani perspective. JGH Open 2025; 9: e70041
• 15 Abbas S, Shah SS, Akhhtar TS. et al. Urdu adaptation and validation of a disease-specific quality-of-life questionnaire in a Pakistani population of Achalasia. PLoS One 2025; 20: e0321933
• 16 Borges AA, Lemme EM de O, Abrahao Jr LJ. et al. Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response. Diseases of the Esophagus 2014; 27: 18-23
• 17 Haisley KR, Swanström LL. The modern age of POEM: the past, present and future of per-oral endoscopic myotomy. Journal of Gastrointestinal Surgery 2021; 25: 551-557
• 18 Müller M, Eckardt AJ, Wehrmann T. Endoscopic approach to achalasia. World J Gastrointest Endosc 2013; 5: 379
• 19 Mari A, Abu Baker F, Pellicano R. et al. Diagnosis and management of achalasia: updates of the last two years. J Clin Med 2021; 10: 3607
• 20 Müller M, Keck C, Eckardt AJ. et al. Outcomes of pneumatic dilation in achalasia: Extended follow-up of more than 25 years with a focus on manometric subtypes. Journal of Gastroenterology and Hepatology (Australia) 2018; 33: 1067-1074
• 21 Rohof WO, Salvador R, Annese V. et al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology 2013; 144: 718-725
• 22 Furrukh M, Akhter TS, Rahman F. et al. Correlation of Balloon Pressure Used for Pneumatic Dilatation in Achalasia with Manometric Findings and Factors Associated With the Need for Repeat Procedure. Cureus 2024; 16
• 23 van Hoeij FB, Prins LI, Smout A JPM. et al. Efficacy and safety of pneumatic dilation in achalasia: A systematic review and meta‐analysis. Neurogastroenterology & Motility 2019; 31: e13548
• 24 Lopushinsky SR, Urbach DR. Pneumatic dilatation and surgical myotomy for achalasia. JAMA 2006; 296: 2227-2233

Publication History

Received: 04 March 2025

Accepted after revision: 22 September 2025

Article published online:
12 January 2026