From the Guidelines
Treatment for achalasia should be individualized, with peroral endoscopic myotomy (POEM), laparoscopic Heller myotomy (LHM), and pneumatic dilation (PD) being effective options, and the choice among these modalities should be based on shared decision making, taking into account patient and disease characteristics, patient preferences, and local expertise. The most recent and highest quality study 1 suggests that POEM may be superior to PD for patients with failed initial POEM or LHM.
Treatment Options
- POEM: a minimally invasive procedure that cuts the muscle fibers of the lower esophageal sphincter (LES) endoscopically, and is considered the preferred treatment for type III achalasia 1.
- LHM: a surgical procedure that cuts the LES muscle fibers, often combined with a partial fundoplication to prevent reflux.
- PD: an endoscopic procedure where a balloon is inflated inside the LES to stretch and weaken it.
Considerations
- Patient age, overall health, and preferences should be taken into account when choosing a treatment option.
- Local expertise and the risk of post-procedural reflux should also be considered.
- A comprehensive evaluation, including repeat esophagogastroduodenoscopy, high-resolution manometry (HRM), and timed barium esophagram, should be performed for patients with persistent or recurrent symptoms after initial treatment.
Recommendations
- POEM should be considered as primary therapy for type III achalasia 1.
- POEM should be considered as a treatment option comparable to LHM for any of the achalasia syndromes 1.
- Patients should be advised of the management considerations, including potential indefinite proton pump inhibitor therapy and/or surveillance endoscopy, before undergoing POEM 1.
From the Research
Treatment Options for Achalasia
The primary goal of achalasia treatment is to alleviate symptoms such as dysphagia, regurgitation, coughing, or choking by enabling the patient to eat without difficulty 2. The treatment options for achalasia include:
- Pneumatic dilation (PD): a procedure that involves the mechanical disruption of the lower esophageal sphincter fibers to reduce the functional obstruction 3.
- Botulinum toxin (BTX) injection: a treatment that provides relief of symptoms in many patients but requires periodic reinjection 2, 4.
- Laparoscopic Heller myotomy (LHM): a surgical procedure that involves the disruption of the lower esophageal sphincter fibers to alleviate symptoms 2, 5.
- Peroral endoscopic myotomy (POEM): a newer endoscopic modality that represents a scarless endoscopic approach to Heller myotomy 4, 5.
Efficacy and Safety of Treatment Options
The efficacy and safety of these treatment options have been extensively studied:
- Pneumatic dilation has a high success rate, with a mean success rate of about 80% in the short term, and a low complication rate, with esophageal perforation occurring at a mean rate of about 2.5% 6, 3.
- Botulinum toxin injection provides some relief of symptoms in many patients but requires periodic reinjection, which may provide progressively less benefit over time 2, 5.
- Laparoscopic Heller myotomy and peroral endoscopic myotomy are safe and effective therapies for the treatment of achalasia, with marked symptom improvement in most patients 5.
Factors Influencing Treatment Choice
The choice of treatment depends on various factors, including:
- Patient preference: the patient's personal preference for a particular treatment option 5.
- Achalasia subtype: the specific subtype of achalasia, which may influence the choice of treatment 5.
- Local expertise: the availability and expertise of healthcare professionals in performing specific treatment options 5.