Treatment of Achalasia
For achalasia treatment, pneumatic dilation (PD), per-oral endoscopic myotomy (POEM), and laparoscopic Heller myotomy (LHM) are all effective primary options, but POEM is the preferred treatment specifically for type III (spastic) achalasia due to its ability to perform longer myotomies, while types I and II can be treated with any of the three modalities based on local expertise and patient factors. 1, 2
Treatment Selection Algorithm by Achalasia Subtype
Type I (Classic Achalasia)
- All three primary treatments (PD, POEM, LHM) demonstrate comparable efficacy, with treatment choice determined by physician expertise and patient preference 1, 2
- Both PD and LHM achieve approximately 90% symptom improvement in the first year 1, 3
Type II (Achalasia with Panesophageal Pressurization)
- Any of the three primary treatments can be used, as this subtype has the most favorable prognosis regardless of treatment modality selected 2
- This represents the most common presenting achalasia subtype 4
Type III (Spastic Achalasia)
- POEM is the preferred primary therapy because it allows for longer myotomy extending beyond the lower esophageal sphincter, achieving 92% response rates 4, 1, 2
- This subtype requires extended myotomy of the distal smooth muscle esophagus, which POEM accomplishes better than other modalities 4
Pneumatic Dilation Technical Protocol
- Start with a 30 mm diameter balloon in the first session to minimize perforation risk (1.0% vs 3.2% with 35 mm initial dilation), then advance to 35 mm at 2-28 days if symptoms persist, with cautious use of 40 mm for refractory cases 1, 3
- Perform under endoscopic or fluoroscopic guidance based on clinician expertise 1
- A graded approach with elective additional dilations achieves 86% success at 12 months versus 75% with predefined series 3
- Long-term success rates reach 97% at 5 years and 93% at 10 years with repeat dilations as needed 1
- Perforation risk is significantly lower with subsequent 35 mm dilations (0.97%) compared to initial 35 mm dilations (9.3%) 3
POEM Technical Considerations
- POEM should only be performed by experienced physicians in high-volume centers, as 20-40 procedures are needed to achieve competence 4, 1, 2
- Technical advantages include no abdominal incisions, ability to perform longer myotomies, avoidance of vagal nerve injury, and no intra-abdominal adhesions 2
- All post-POEM patients are high risk for reflux esophagitis and require 8 weeks of proton pump inhibitor therapy immediately post-procedure, with potential need for indefinite PPI therapy and surveillance endoscopy 4, 1, 5
- POEM is superior to repeat pneumatic dilation for failed initial myotomy (62% vs 27% success rate) 2
Laparoscopic Heller Myotomy
- LHM with partial fundoplication is comparable in efficacy to POEM for types I and II achalasia 1, 2
- The myotomy extends 2-3 cm onto the stomach, with most surgeons combining it with incomplete fundoplication to reduce reflux risk 6
- Requires approximately 2 days hospitalization with return to work in 1-2 weeks 6
Critical Pitfalls and Caveats
- Post-treatment gastroesophageal reflux is significantly more common after POEM than after PD or LHM with fundoplication, requiring prophylactic acid suppression 1, 5
- Patients with sigmoid esophagus deformation may require esophagectomy rather than sphincter-directed therapy, as POEM has a doubling of adverse events in this population 2
- Up to one-third of patients experience symptom recurrence during 4-6 years of follow-up after PD, but most can be successfully retreated with repeat dilation 1
- Patients with achalasia have a 4.6-fold higher risk for esophageal cancer, supporting endoscopic surveillance 2
- Botulinum toxin injection should be reserved only for patients who cannot undergo PD and are not surgical candidates, as it provides only short-term relief 7, 6