What are the treatment options for achalasia?

Treatment Options for Achalasia

Pneumatic balloon dilatation (PD), per-oral endoscopic myotomy (POEM), and laparoscopic Heller myotomy (LHM) are the primary effective treatment options for achalasia, with POEM being the preferred first-line treatment for type III achalasia due to its ability to provide longer myotomy extending into the esophageal body. 1

Treatment Selection Based on Achalasia Subtype

Treatment selection should be guided by the specific achalasia subtype:

Type I (Classic) and Type II Achalasia

• Pneumatic balloon dilatation (PD):

  • Start with 30 mm balloon in first session 2
  • Perform second dilatation 2-28 days later with 35 mm balloon 2
  • Consider third session with 40 mm balloon if symptoms persist (Eckardt score >3) 2
  • Effective in 90% of patients in the first year, 86% in the second year 2
  • Long-term success rates up to 97% at 5 years and 93% at 10 years with repeat dilations 2

• Laparoscopic Heller Myotomy (LHM):

  • Consider with partial fundoplication to reduce reflux risk 1
  • Particularly beneficial for patients with large hiatal hernia 1
  • Success rates of approximately 85% 3

Type III (Spastic) Achalasia

• POEM is the preferred treatment due to ability to perform longer myotomy 2, 1
• Allows for myotomy extending into the esophageal body to address spastic contractions 1
• Weighted pooled response rate of 92% in type III achalasia 2

Procedural Considerations

Pneumatic Dilatation

• Perform under endoscopic or fluoroscopic control based on clinician's preference 2
• Position balloon at esophagogastric junction and inflate for 1-3 minutes 2
• Consider proton pump inhibitor (PPI) therapy after dilatation due to 10-40% rate of reflux 2
• Consider water-soluble contrast swallow after dilatation to screen for perforation 2

POEM

• Should be performed by experienced physicians in high-volume centers 2, 1
• Requires 20-40 procedures to achieve competence 2, 1
• Higher risk of post-procedure reflux (up to 58% of patients) 1
• Requires post-procedure PPI therapy and surveillance endoscopy 1

Alternative Treatment Options

For Patients Not Suitable for Primary Interventions

• Botulinum toxin injection:

  • Reserved for elderly patients and those at high surgical risk 2, 4
  • Long-term results are modest and repeated injections often required 2
  • Not recommended as first-line therapy 4

• Pharmacologic therapy:

  • Calcium channel blockers and nitrates 4
  • Offer only mild, transient improvement at best 5
  • Used only in patients who are not candidates for other interventions 4

Management of Treatment Failure

• If Eckardt score remains >3 after three sessions of pneumatic dilatation, treatment is considered to have failed 2
• For recurrent dysphagia after myotomy:
  • POEM shows higher success rates (67%) compared to repeat pneumatic dilation (50%) 6
  • Patients undergoing PD may require more subsequent procedures 6
• For end-stage achalasia with megaesophagus, esophagectomy may be required 3

Post-Treatment Monitoring

• Monitor for at least 2 hours after procedure 2
• Provide clear diet instructions and contact information for on-call team 2
• Prescribe PPI therapy, especially after POEM due to high risk of reflux 2, 1
• Consider surveillance endoscopy to monitor for reflux-related complications 1

Complications to Watch For

• Perforation: Suspect if patient develops pain, breathlessness, fever, or tachycardia 2
• Gastroesophageal reflux: Common after all treatments, particularly POEM 1
• Recurrent dysphagia: May require repeat intervention 2, 6

Treatment of achalasia should be performed at centers with expertise in these procedures to ensure optimal outcomes and minimize complications.