What is the best management approach for achalasia cardia?

Management of Achalasia Cardia

Per-oral endoscopic myotomy (POEM) should be considered the primary treatment for achalasia cardia, particularly for type III achalasia, while POEM, laparoscopic Heller myotomy (LHM), and pneumatic dilation (PD) are all effective options for types I and II achalasia. 1

Diagnosis and Classification

Before treatment, proper diagnosis and classification are essential:

• High-resolution manometry (HRM) is the gold standard for diagnosis and subtyping
• Complementary tests include:
  • Timed barium esophagram
  • Endoscopy
  • Functional luminal impedance planimetry (FLIP)

Achalasia is classified into three subtypes:

• Type I: Absent contractility
• Type II: Panesophageal pressurization
• Type III: Premature spastic contractions

Treatment Algorithm Based on Achalasia Subtype

Type III Achalasia

• First-line: POEM - Offers superior outcomes with 92% response rate 1, 2
• Advantage: Allows for longer myotomy extending into the esophageal body
• LHM is less effective for this subtype

Type I and Type II Achalasia

• Options (all effective):

  1. POEM
  2. Laparoscopic Heller myotomy (LHM) with partial fundoplication
  3. Pneumatic dilation (PD)

• Decision factors:

  • Local expertise availability
  • Patient preference regarding invasiveness
  • Risk of post-procedure reflux
  • Presence of hiatal hernia (favors LHM with fundoplication)

Specific Treatment Details

POEM Procedure

• Success rate >90% in multiple studies 1
• Involves creating a submucosal tunnel 10-15 cm proximal to LES
• Extends 2-4 cm onto gastric cardia
• Circular muscle myotomy performed within tunnel
• Important considerations:
  • Should be performed by experienced physicians in high-volume centers
  • Requires 20-40 procedures to achieve competence 1, 2
  • High post-procedure reflux rate (up to 58% of patients) 1
  • Patients need long-term PPI therapy and surveillance endoscopy

Laparoscopic Heller Myotomy (LHM)

• Typically combined with partial fundoplication (Toupet or Dor)
• Advantages:
  • Lower post-procedure reflux rates compared to POEM
  • Preferred in patients with large hiatal hernia
• Disadvantages:
  • More invasive than POEM
  • Limited ability to extend myotomy proximally (important for type III)

Pneumatic Dilation (PD)

• Effective in 90% of patients in first year 2
• Long-term success rates: 97% at 5 years, 93% at 10 years with repeat dilations
• Procedure:
  • Performed under endoscopic or fluoroscopic control
  • Balloon positioned at esophagogastric junction
  • Inflated for 1-3 minutes
  • Start with 30 mm balloon, consider larger balloons for subsequent dilations if needed

Post-Treatment Considerations

Reflux Management

• All treatments can cause reflux, but POEM has highest risk
• Management:
  • Proton pump inhibitor therapy
  • Surveillance endoscopy to monitor for complications

Complications to Monitor

• Perforation: Watch for pain, breathlessness, fever, tachycardia
• Recurrent dysphagia: May require repeat intervention
  • POEM shows higher success rates for recurrent dysphagia compared to repeat PD 2

Special Situations

Esophagogastric Junction Outflow Obstruction (EGJOO)

• Requires comprehensive evaluation with correlation of symptoms
• POEM should only be considered after less invasive approaches have failed 1

End-Stage Achalasia with Sigmoid Esophagus

• POEM can be effective but carries doubled risk of adverse events 1
• Consider esophagectomy in select cases of end-stage disease

Treatment Selection Pitfalls to Avoid

1. Treating based on symptoms alone without proper manometric classification
2. Performing POEM without adequate experience (at least 20-40 procedures needed)
3. Failing to counsel patients about high risk of post-POEM reflux
4. Not tailoring myotomy length to achalasia subtype (especially for type III)
5. Overlooking the need for long-term acid suppression and surveillance

The management of achalasia cardia has evolved significantly with the introduction of POEM, which has strengthened the therapeutic options available. Treatment selection should be guided by achalasia subtype, with POEM being particularly valuable for type III achalasia due to its ability to perform longer myotomies.