From the Guidelines
The most effective treatment for achalasia is peroral endoscopic myotomy (POEM), which has been shown to be superior to pneumatic dilation (PD) in patients with failed initial POEM or laparoscopic Heller myotomy (LHM) 1.
Treatment Options for Achalasia
The recommended treatments for achalasia include both non-surgical and surgical options.
- Pneumatic dilation is often considered as a first-line treatment, involving the insertion of a balloon into the lower esophageal sphincter (LES) to forcibly stretch and tear the muscle fibers, reducing pressure.
- Laparoscopic Heller myotomy, a surgical procedure that cuts the LES muscle fibers, is highly effective and often combined with a partial fundoplication to prevent reflux.
- Botulinum toxin (Botox) injections into the LES can provide temporary relief for 3-6 months by relaxing the sphincter, making it useful for elderly patients or those unfit for more invasive procedures.
- Medications like calcium channel blockers (nifedipine 10-30 mg) or nitrates (isosorbide dinitrate 5-10 mg) taken before meals can help relax the LES but offer limited effectiveness.
Considerations for Treatment Choice
Treatment choice depends on patient age, overall health, and disease severity, with more definitive procedures like POEM or Heller myotomy typically providing longer-lasting relief than temporary measures like Botox or medications.
- POEM has been shown to be a safe and effective approach for patients with previously failed LHM or POEM, with a notable higher success rate compared to PD 1.
- The decision between treatment modalities should be individualized, taking into account the etiology for the failed myotomy, local expertise, patient characteristics, and preferences.
Post-Treatment Surveillance
Long-term postprocedure surveillance is encouraged to monitor for progression of disease and complications of GERD, with endoscopic surveillance strongly considered for all patients post POEM to monitor for disease progression and to identify potential complications from asymptomatic GERD 1.
From the Research
Treatment Options for Achalasia
The recommended treatments for achalasia include:
- Pneumatic dilation (PD)
- Laparoscopic Heller myotomy (LHM)
- Peroral endoscopic myotomy (POEM)
Efficacy of Treatment Options
Studies have shown that:
- PD and LHM are equally effective in treating achalasia, with similar success rates and complication rates 2, 3, 4
- POEM is a safe and effective treatment for patients with achalasia who have previously undergone Heller myotomy 5
- The choice of treatment should be based on factors such as treatment availability, rate of good results, complication rates, and patient preference 3
Comparison of Treatment Options
Comparative studies have found that:
- LHM may be more effective than PD for type 3 achalasia, while PD may be superior for type 2 achalasia 4
- POEM can be an effective treatment for patients with achalasia who have persistent or recurrent symptoms after HM 5
- The risk of gastroesophageal reflux is similar between PD and LHM 4
Complications and Safety
Studies have reported that: