Esophageal myotomy and risk of esophageal cancer and mortality in achalasia: Real-world cohort study.

Background and study aims: Achalasia is associated with increased risk of esophageal cancer, particularly squamous cell carcinoma. Although esophageal myotomy improves dysphagia, its impact on cancer risk and mortality remains unclear. Patients and methods: We conducted a retrospective cohort study using the TriNetX research network, including adults (≥ 18 years) with achalasia confirmed by esophageal manometry. Patients were categorized based on treatment of those undergoing esophageal myotomy (peroral endoscopic myotomy [POEM] or laparoscopic Heller myotomy [LHM]) and those managed without myotomy. Patients with prior esophagectomy or malignancies associated with increased esophageal cancer risk were excluded. The primary outcome was incident esophageal cancer; secondary outcomes included all-cause mortality. Propensity score matching balanced baseline characteristics. Associations were assessed using adjusted odds ratios (aORs) and Cox proportional hazards models. Overall survival was assessed using Kaplan-Meier analysis and compared with the log-rank test. Results: Among 18,186 patients with achalasia, 3,758 underwent esophageal myotomy and 14,428 were managed without myotomy. After matching, esophageal cancer incidence was low and did not differ significantly between the myotomy and non-myotomy cohorts (0.29% vs 0.27%; aOR 1.1, 95% confidence interval [CI] 0.47-2.6). In contrast, myotomy was associated with significantly lower all-cause mortality (3.25% vs 7.22%; aOR 0.43, 95% CI 0.35-0.54). Independent predictors of esophageal cancer included male sex, older age, and personal history of gastrointestinal malignancy. Conclusions: In short-term follow-up, esophageal myotomy in achalasia was associated with lower all-cause mortality and similar esophageal cancer incidence. These findings suggest benefits beyond symptom control, including a potential survival advantage.