American Board of Internal Medicine (ABIM) Certification Practice Exam

What is the risk associated with perforation in achalasia treatment?

1. Low risk, typically less than 1%

2. Moderate risk, ranging from 1-3%

3. High risk, above 5%

4. Controllable risk with medications

The correct answer is: Moderate risk, ranging from 1-3%

In the context of treating achalasia, the risk of perforation during interventions such as pneumatic dilation or surgical myotomy is classified as moderate, typically ranging from 1-3%. This risk is an important consideration for patients and clinicians alike, particularly given the potential complications that can arise from a perforation, such as mediastinitis or leakage of esophageal contents into the thoracic cavity. The reason this risk falls into the moderate category rather than being considered low or high is related to both the nature of the procedure and the underlying disease. Achalasia treatment involves manipulating the esophagus, which can be fragile due to its abnormal motility and distensibility, thus increasing the likelihood of an adverse event like perforation. Furthermore, while perforation can occur, advancements in technique and equipment have helped to keep the risk relatively contained within this moderate range. Recognizing that this risk is not something manageable solely with medications emphasizes the need for careful patient selection and surgical planning. While medication can aid in managing symptoms and preparation for procedures, the inherent risks of surgical intervention, such as perforation, require more than just pharmaceutical control. Essential preoperative evaluations and intraoperative techniques play critical roles in minimizing complications.