What are the treatment options for achalasia?

Treatment Options for Achalasia

Per-oral endoscopic myotomy (POEM) should be considered as the primary treatment for achalasia, particularly for type III achalasia, while pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) remain effective alternatives depending on achalasia subtype and patient factors. 1

Treatment Selection Based on Achalasia Subtype

Treatment should be guided by the specific achalasia subtype identified through high-resolution manometry (HRM):

Type I Achalasia (Classic)

• First-line options: POEM, PD, or LHM (all with comparable efficacy)
• PD is effective in 90% of patients in the first year, with long-term success rates up to 97% at 5 years 1

Type II Achalasia (With Panesophageal Pressurization)

• First-line options: POEM, PD, or LHM
• Generally responds well to all treatment modalities

Type III Achalasia (Spastic)

• Preferred treatment: POEM
• POEM shows superior outcomes with a 92% response rate due to ability to perform longer myotomy extending into the esophageal body 2, 1
• Standard myotomy length for type III: approximately 17.2 cm 2

Pneumatic Balloon Dilation (PD)

• Technique:

  • Start with 30 mm balloon in first session
  • Perform second dilation 2-28 days later with 35 mm balloon
  • Consider third session with 40 mm balloon if symptoms persist (Eckardt score >3) 1
  • Performed under endoscopic or fluoroscopic control
  • Balloon positioned at esophagogastric junction and inflated for 1-3 minutes

• Efficacy:

  • 90% effective in first year
  • 86% in second year
  • Up to 97% at 5 years with repeat dilations 1

• Complications:

  • Perforation risk: approximately 2% 3
  • Post-procedure reflux: 10-40% 1

Per-Oral Endoscopic Myotomy (POEM)

• Key advantages:

  • Allows for calibrated, longer myotomy when needed
  • Minimally invasive approach
  • Superior for type III achalasia 2, 1

• Important considerations:

  • Should be performed by experienced physicians in high-volume centers
  • Requires 20-40 procedures to achieve competence 2, 1
  • Higher success rates (67%) for recurrent dysphagia after previous treatment compared to repeat PD (50%) 1

• Major limitation:

  • High post-procedure reflux rate (up to 58% of patients) 1
  • Requires long-term PPI therapy and surveillance endoscopy

Laparoscopic Heller Myotomy (LHM)

• Technique:

  • Cuts the LES and extends 2-3 cm onto the stomach
  • Should be combined with partial fundoplication to reduce reflux risk 1, 3

• Best for:

  • Patients with large hiatal hernia 1
  • Patients concerned about post-procedure reflux

• Efficacy:

  • Similar to POEM for types I and II achalasia
  • Less effective than POEM for type III achalasia 2

Special Considerations

End-Stage Achalasia/Sigmoid Esophagus

• Patients with end-stage achalasia have been treated successfully with POEM 2
• However, one report suggests doubled adverse events with POEM in sigmoid esophagus 2
• Consider surgical options in severe cases

Post-Procedure Management

• Reflux prevention/management:
  • PPI therapy recommended after all procedures, especially POEM 1
  • Surveillance endoscopy to monitor for reflux-related complications

Alternative Therapies for Poor Surgical Candidates

• Botulinum toxin injection:

  • Reserved for patients who cannot undergo PD or surgery 4
  • Most effective in elderly patients
  • Temporary relief (up to 1-2 years) 3

• Pharmacologic therapy (calcium channel blockers, nitrates):

  • Limited efficacy
  • Significant side effects and drug tolerance 3
  • Used only when other options contraindicated

Treatment Algorithm

1. Confirm diagnosis with HRM, endoscopy, and timed barium esophagram
2. Determine achalasia subtype (I, II, or III)
3. Select treatment based on:
   • For Type III: POEM preferred
   • For Types I and II: POEM, PD, or LHM based on:
     • Local expertise availability
     • Presence of hiatal hernia (favors LHM)
     • Patient preference regarding invasiveness and reflux risk
4. Monitor for complications and implement appropriate post-procedure care