What are the treatment options for achalasia?

From the Guidelines

Treatment for achalasia should be individualized, with peroral endoscopic myotomy (POEM), laparoscopic Heller myotomy (LHM), and pneumatic dilation (PD) being effective therapies, 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, LHM, and PD are effective therapies for type I and type II achalasia, and POEM should be considered the preferred treatment for type III achalasia.

Treatment Options

• POEM: a newer, minimally invasive endoscopic procedure that cuts the muscle fibers of the lower esophageal sphincter (LES)
• LHM: the gold standard surgical treatment, often combined with a partial fundoplication to prevent reflux
• PD: an endoscopic option where a balloon is inflated inside the LES to stretch and weaken it
• Medications: calcium channel blockers (nifedipine 10-30 mg before meals) or nitrates (isosorbide dinitrate 5-10 mg before meals) can provide temporary relief, but their effectiveness is limited and side effects are common

Considerations

• Patient age, overall health, and preferences should be taken into account when choosing a treatment
• Younger patients may benefit more from definitive surgical approaches, while elderly or higher-risk patients may be better candidates for less invasive options
• Local expertise and availability of treatments should also be considered
• The risk of gastroesophageal reflux disease (GERD) or ulcerative oesophagitis after treatment should be considered, and proton pump inhibitor (PPI) therapy may be necessary after dilatation 1

Recent Studies

• A recent study 1 found that POEM, LHM, and PD are effective therapies for type I and type II achalasia, and POEM should be considered the preferred treatment for type III achalasia
• Another study 1 found that POEM is a safe and effective treatment for achalasia, with a high success rate and minimal adverse events
• A multicenter randomized controlled trial 1 compared POEM to PD in patients with treatment-naïve achalasia and found that POEM was more effective than PD in relieving dysphagia, but was associated with a higher incidence of pathologic reflux.

From the Research

Treatment Options for Achalasia

The treatment options for achalasia include:

• Pneumatic dilation (PD)
• Laparoscopic Heller's myotomy (LHM)
• Botulinum toxin (BTX) injection
• Open surgical myotomy

Pneumatic Dilation

Pneumatic dilation is a common first-line therapy for achalasia, with a mean success rate of about 80% in the short term 2. The goal of PD is to reduce the functional obstruction by disrupting the circular muscle fibers of the lower esophageal sphincter. The procedure involves using a balloon to dilate the lower esophageal sphincter, and it can be repeated if necessary. However, PD carries a risk of esophageal perforation, which occurs at a mean rate of about 2.5% 2.

Laparoscopic Heller's Myotomy

Laparoscopic Heller's myotomy is a surgical procedure that involves cutting the muscle fibers of the lower esophageal sphincter to relieve the obstruction. This procedure has been shown to have a higher response rate compared to PD, with a cumulative response rate of 86% at 1 year 3. LHM also has a lower rate of major adverse events, such as esophageal perforation, compared to PD.

Botulinum Toxin Injection

Botulinum toxin injection is a minimally invasive procedure that involves injecting BTX into the lower esophageal sphincter to relax the muscle fibers. This procedure has been shown to have excellent short-term efficacy, but its long-term efficacy is still being studied 4. BTX injection is often used as a treatment option for patients who are considered high-risk for more invasive procedures.

Comparison of Treatment Options

A multicenter, randomized clinical trial compared the effectiveness of PD and LHM with partial fundoplication in improving achalasia-specific quality of life 5. The study found that both treatments similarly improved disease severity at 1 year, and there were no significant differences between treatments in improvement of symptoms, general and gastrointestinal quality of life, or measures of esophageal physiology. However, the study also found that patients who received LHM had a lower incidence of retreatment compared to those who received PD.

Key Findings

• Pneumatic dilation and laparoscopic Heller's myotomy are the most common treatment options for achalasia 4, 2, 3.
• Botulinum toxin injection is a minimally invasive procedure that can be used as a treatment option for high-risk patients 4.
• The choice of treatment depends on the individual patient's needs and preferences, as well as the experience of the treatment center 6.
• Both PD and LHM have been shown to be effective in improving achalasia-specific quality of life, but LHM may have a lower rate of major adverse events and a lower incidence of retreatment 3, 5.