Achalasia is an uncommon problem, with an incidence of 1 per 100 000 persons. This means that many medical centers will not have experience in treating the condition, as is the situation with the group reporting in this article. The 14.5% incidence of perforation might seem high, and the 39% alleviation of dysphagia low, but the results probably reflect the situation as it exists away from large and specialized referral centers; I think the authors are to be commended on providing such data.
Eight patients who sustained a perforation seemed to have less advanced achalasia than the patients who did not have a perforation. This is an interesting finding, and the authors reasonably advocate caution in treating patients with early achalasia by bag dilatation. The surgical results achieved were excellent because there were few primary myotomies and most surgical procedures were performed for short- or long-term failure of bag dilatation.