What is the best treatment for achalasia?

Best Treatment for Achalasia

Per-oral endoscopic myotomy (POEM) is the preferred treatment for achalasia, 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, 2

Diagnosis and Classification

Before selecting treatment, proper diagnosis and classification are essential:

• High-resolution manometry (HRM) is the gold standard for diagnosis and subtyping achalasia
• Endoscopy, esophagram, and functional luminal impedance planimetry (FLIP) should be used to confirm diagnosis
• Achalasia is classified into three subtypes:
  • Type I: Classic achalasia with absent contractility
  • Type II: Achalasia with panesophageal pressurization
  • Type III: Spastic achalasia with premature contractions

Treatment Algorithm Based on Achalasia Subtype

Type I and Type II Achalasia

All three main interventions are effective, with selection based on:

• POEM:

  • Advantages: Minimally invasive, no abdominal incisions, rapid recovery
  • Disadvantages: Higher risk of post-procedure reflux (requires PPI therapy)
  • Success rate: Comparable to LHM 1

• LHM with partial fundoplication:

  • Advantages: Lower post-procedure reflux rates
  • Disadvantages: More invasive, requires general anesthesia
  • Success rate: 84-94% 1

• Pneumatic Dilation:

  • Advantages: Non-surgical, outpatient procedure
  • Disadvantages: May require multiple sessions, 2% risk of perforation
  • Success rate: 90% in first year, 93-97% with repeat dilations 2

Type III Achalasia

POEM is clearly superior for type III achalasia due to:

• Ability to perform longer myotomy extending into esophageal body
• Reported 92% response rate in type III achalasia 1, 2
• Better targeting of the spastic contractions in the esophageal body 1

Special Considerations

• Age and surgical risk: For elderly or high-risk patients who cannot undergo POEM or LHM, botulinum toxin injection can be considered, though effects are temporary 3

• Presence of hiatal hernia: LHM may be preferred when significant hiatal hernia is present 2

• Sigmoid esophagus: POEM has been used successfully in end-stage achalasia, but adverse events may double in patients with sigmoid esophagus 1

• Post-procedure reflux management: All patients should be monitored for reflux, especially after POEM, with PPI therapy and surveillance endoscopy 2

Procedural Details

POEM Procedure

• Mucosal incision 10-15 cm proximal to LES
• Submucosal tunnel extending 2-4 cm onto gastric cardia
• Circular muscle myotomy within tunnel
• Should be performed by experienced physicians (20-40 procedures needed for competence) 1

LHM Procedure

• Laparoscopic approach with division of phrenoesophageal ligament
• Myotomy of LES extending 2-3 cm onto stomach
• Combined with partial fundoplication (Toupet or Dor) to prevent reflux
• Typically requires 2 days hospitalization 1

Pneumatic Dilation

• Performed under endoscopic or fluoroscopic control
• Balloon positioned at esophagogastric junction
• Inflated for 1-3 minutes
• Starting with 30 mm balloon, progressing to larger sizes if needed 2

Complications and Management

• Reflux: Most common after POEM, requiring PPI therapy and surveillance
• Perforation: Risk of 2% with pneumatic dilation, requires immediate recognition and management
• Recurrent dysphagia: May require repeat intervention, with POEM showing higher success rates for retreatment 2

POEM represents the most significant advancement in achalasia treatment in recent years, offering excellent outcomes with minimal invasiveness, particularly for type III achalasia where it should be considered the first-line therapy 1, 2.