From the Guidelines
The most effective treatment for achalasia is peroral endoscopic myotomy (POEM), which should be considered the preferred treatment for type III achalasia, and a viable option for type I and II achalasia, based on shared decision making with the patient and physician, taking into account patient and disease characteristics, patient preferences, and local expertise 1.
Treatment Options
The primary treatments for achalasia are:
- Pneumatic dilation, which involves stretching the lower esophageal sphincter using a balloon, typically requiring multiple sessions
- POEM, an endoscopic procedure that cuts the inner circular muscle fibers of the esophagus
- Laparoscopic Heller myotomy, which surgically cuts the muscle fibers, usually combined with a partial fundoplication to prevent reflux
Considerations
When choosing a treatment, the following factors should be considered:
- Patient age and overall health
- Disease characteristics, such as the type of achalasia
- Patient preferences
- Local expertise and availability of treatment options
Additional Recommendations
- Patients with failed initial POEM or laparoscopic Heller myotomy may benefit from POEM as a subsequent treatment option 1
- Patients undergoing POEM should receive pharmacologic acid suppression in the immediate post-procedure setting to reduce the risk of post-procedure reflux and esophagitis 1
- Long-term post-procedure surveillance is encouraged to monitor for progression of disease and complications of gastroesophageal reflux disease 1
From the Research
Treatment Options for Achalasia
The treatment options for achalasia include:
- Pneumatic dilation (PD)
- Laparoscopic Heller myotomy (LHM)
- Peroral endoscopic myotomy (POEM)
- Botulinum toxin injection
Pneumatic Dilation
Pneumatic dilation is a commonly used treatment for achalasia, with a mean success rate of about 80% in the short term 2. The aim of dilation is a controlled disruption of circular muscle fibres of the lower esophageal sphincter to reduce the functional obstruction. A graded approach starting with a 30-mm dilation, followed by an elective 35-mm dilation and 40 mm when there is insufficient symptom relief, is considered the most efficient and safe method 3.
Surgical Options
Laparoscopic Heller myotomy (LHM) is a surgical option for achalasia, which can be combined with antireflux surgery 4. Peroral endoscopic myotomy (POEM) is a newer endoscopic modality that represents a scarless endoscopic approach to Heller myotomy 5.
Other Treatment Options
Botulinum toxin injection is another treatment option for achalasia, which can provide some relief of symptoms in many patients, but requires periodic reinjection 6, 4.
Comparison of Treatment Options
Each treatment has a specific constellation of risks, benefits, and recurrence rate 6. The choice of treatment depends on patient preference, achalasia subtype, and local expertise. Pneumatic dilation is still considered the first-line treatment by most physicians, but laparoscopic myotomy and POEM are increasingly attractive options in certain patients 6, 4.