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 treatments for achalasia, with treatment selection depending on achalasia subtype and patient characteristics. 1

Pneumatic Balloon Dilatation (PD)

• Perform dilatation with pneumatic balloons 30-40 mm in diameter, starting with 30 mm in the first session to reduce complications 1
• Schedule a second dilatation session 2-28 days later with a larger 35 mm balloon 1
• Consider a third session with cautious use of 40 mm balloon if symptoms remain (Eckardt score >3) 1
• Perform the procedure under endoscopic or fluoroscopic control based on clinician's preference and expertise 1
• PD is effective in 90% of patients in the first year, with effectiveness decreasing to 86% in the second year 1
• Up to one-third of patients may experience symptom recurrence during 4-6 years of follow-up, but most can be successfully retreated with repeat dilatation 1
• Long-term success rates with repeat dilatations can reach 97% at 5 years and 93% at 10 years 1

Per-Oral Endoscopic Myotomy (POEM)

• POEM should be performed by experienced physicians in high-volume centers, as 20-40 procedures are needed to achieve competence 1
• POEM is the preferred primary therapy for type III achalasia due to ability to perform longer myotomy 1
• For other achalasia subtypes, POEM should be considered as a treatment option comparable to LHM 1
• Post-POEM patients have higher risk of developing reflux esophagitis and may require indefinite proton pump inhibitor therapy and/or surveillance endoscopy 1
• Short-term efficacy appears excellent, with a meta-analysis showing 92% response rate in type III achalasia 1

Laparoscopic Heller Myotomy (LHM)

• LHM with partial fundoplication provides excellent symptom relief (90%) with low complication rates (6.3%) 2
• Adding fundoplication to LHM significantly reduces post-operative gastroesophageal reflux (31.5% without vs. 8.8% with fundoplication) 2
• LHM may be more effective in adolescents and younger adults, especially men 3
• Patients typically require 2 days of hospitalization and can return to work in 1-2 weeks 4

Other Treatment Options

• Botulinum toxin injection into the LES provides short-term relief and is most effective in elderly patients or those who cannot undergo PD or surgery 5, 4
• Smooth muscle relaxants (nitrates and calcium channel blockers) can improve dysphagia when taken before meals, but side effects and drug tolerance are common 4

Treatment Selection Based on Achalasia Subtype

• Type I (classic achalasia): Both PD and LHM are effective options 1
• Type II (achalasia with panesophageal pressurization): Best outcomes with either PD or surgical approaches 1
• Type III (spastic achalasia): POEM is preferred due to ability to perform longer myotomy 1

Common Pitfalls and Caveats

• Perforation occurs in approximately 2% of pneumatic dilations but can usually be managed conservatively or surgically 4, 6
• Post-treatment gastroesophageal reflux is more common after POEM than after PD or LHM with fundoplication 1
• Achalasia cannot be cured, but excellent symptom relief is achievable in over 90% of patients 4, 3
• Patients should understand that intermittent "touch-up" procedures may be required over time 3
• Patients with end-stage achalasia or sigmoid esophagus may have higher complication rates with POEM 1