What is the best management approach for achalasia?

Management of Achalasia

Per-oral endoscopic myotomy (POEM) should be considered 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

Diagnosis and Classification

Accurate diagnosis and classification are essential for optimal treatment selection:

• High-resolution manometry (HRM) is the gold standard for diagnosis and subtyping
• Achalasia subtypes include:
  • Type I: Absent contractility
  • Type II: Panesophageal pressurization
  • Type III: Spastic contractions
• Complementary tests include:
  • Timed barium esophagram
  • Endoscopy
  • Functional luminal impedance planimetry (FLIP)

Treatment Options Based on Achalasia Subtype

Type I and II Achalasia

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

• POEM:

  • Success rate comparable to LHM
  • Minimally invasive with no abdominal incisions
  • Higher risk of post-procedure reflux (requires PPI therapy)
  • Rapid recovery
  • Should be performed by experienced physicians in high-volume centers (20-40 procedures needed for competence) 2, 1

• Laparoscopic Heller Myotomy (LHM):

  • Success rate of 84-94%
  • Lower post-procedure reflux rates when combined with partial fundoplication
  • More invasive, requires general anesthesia
  • Limited ability to extend myotomy proximally 1

• Pneumatic Dilation (PD):

  • Effective in 90% of patients in first year
  • Long-term success rates of 97% at 5 years with repeat dilations
  • Performed under endoscopic or fluoroscopic control
  • Typically starts with 30mm balloon, progressing to larger sizes if needed
  • May require multiple sessions 2, 1
  • Procedure: Balloon positioned at esophagogastric junction, inflated for 1-3 minutes 2

Type III Achalasia

• POEM is clearly superior due to ability to perform longer myotomy extending into the esophageal body
• Reported 92% response rate in type III achalasia 2, 1
• Myotomy can be calibrated to the spastic segment imaged on HRM 2

Special Considerations

• End-stage achalasia: POEM has been used successfully but adverse events may double in patients with sigmoid esophagus 2, 1
• Post-procedure reflux: All treatments can cause reflux, but POEM has highest risk
  • Management includes PPI therapy and surveillance endoscopy 2, 1
• Recurrent dysphagia: May require repeat intervention
  • For PD, consider repeat dilatation to maintain symptom response 2
  • Up to one-third of patients may have recurrence of symptoms during 4-6 years of follow-up 2

Procedure-Specific Details

POEM Procedure

• Create submucosal tunnel 10-15 cm proximal to LES
• Extend 2-4 cm onto gastric cardia
• Perform circular muscle myotomy within tunnel 1

Pneumatic Dilation Protocol

• First session: 30mm balloon
• Second session: 35mm balloon (2-28 days later)
• Third session: Consider 40mm balloon if symptoms persist (Eckardt score >3) 2
• Monitor for at least 2 hours post-procedure 2

Post-Procedure Care

• PPI therapy after dilation due to 10-40% rate of symptomatic GERD 2
• Diet instructions and contact information for on-call team
• Monitor for complications: pain, breathlessness, fever, tachycardia (signs of perforation) 2, 1

Treatment Algorithm

1. Confirm diagnosis and subtype with HRM and complementary tests
2. For Type III achalasia: POEM is preferred treatment
3. For Type I and II achalasia: Choose based on:
   • Local expertise availability
   • Patient preference regarding invasiveness and reflux risk
   • Presence of complicating factors (hiatal hernia, sigmoid esophagus)
4. Post-procedure: Implement appropriate monitoring and acid suppression therapy

This approach ensures optimal outcomes by matching treatment modality to achalasia subtype while considering patient-specific factors and local expertise.