What are the treatment strategies for Achalasia (Esophageal Motility Disorder)?

From the Guidelines

Treatment for achalasia should prioritize peroral endoscopic myotomy (POEM) as the preferred treatment for type III achalasia, while pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and POEM are effective therapies for type I and type II achalasia, with the decision among these treatment modalities based on shared decision making, taking into account patient and disease characteristics, patient preferences, and local expertise 1.

Treatment Approaches

The main approaches for treating achalasia include endoscopic and surgical interventions.

• Pneumatic dilation is often used, involving the insertion of a balloon into the LES under endoscopic guidance, inflated to 30-40 mm for 1-3 minutes to disrupt the sphincter muscle fibers, with a high grade of evidence and strong recommendation to start at 30 mm in the first session and perform a second dilatation session 2-28 days later with a larger size balloon of 35 mm 1.
• POEM is another effective option, where an endoscope is used to create a submucosal tunnel to cut the circular muscle fibers of the LES, with success rates of 80-95% and considered superior to PD and noninferior to LHM in separate multi-center RCTs 1.
• Laparoscopic Heller myotomy, a surgical procedure that cuts the LES muscle fibers, is typically combined with a partial fundoplication to prevent reflux and has excellent long-term outcomes.

Considerations

When choosing a treatment, patient age, comorbidities, achalasia subtype, and local expertise should be taken into account, with the goal of reducing LES pressure to allow better food passage while minimizing complications like reflux.

• For type III achalasia, POEM is preferred due to its ability to provide unlimited proximal extension of myotomy, which is advantageous in treating spastic body contractions capable of luminal obliteration regardless of pressurization 1.
• Proton pump inhibitor (PPI) therapy should be considered after dilatation due to the 10-40% rate of symptomatic gastro-oesophageal reflux disease (GORD) or ulcerative oesophagitis after treatment, with a high grade of evidence and strong recommendation 1.

From the Research

Treatment Strategies for Achalasia

• The primary treatment goal for achalasia is to disrupt the lower esophageal sphincter to improve bolus passage, as there is no curative treatment for the condition 2.
• Available treatment modalities include pneumatic dilation, laparoscopic Heller myotomy, and peroral endoscopic myotomy (POEM) 2.
• Surgical myotomy is considered the most reliable first-line therapy for achalasia, particularly in patients with high sphincter pressure and moderate esophageal dilatation 3.
• Pneumatic dilation provides about 50% of patients with long-term symptomatic relief, and failure can often be successfully treated surgically 3.
• A graded approach to pneumatic dilation, starting with a 30-mm balloon and followed by elective 35-mm and 40-mm dilations as needed, is considered the most efficient and safe method 4.
• Botulinum toxin injection has a high failure rate and is typically reserved for patients who are not candidates for pneumatic dilation or surgery 3, 5, 6.

Comparison of Treatment Outcomes

• A study comparing different treatment modalities found that surgical myotomy resulted in the lowest rate of recurrent or persistent symptoms (16.7%), followed by endoscopic esophageal balloon dilation (6.3%) and botulinum toxin injection (71.4%) 3.
• Pneumatic dilation with a 30-mm or 35-mm balloon resulted in comparable success rates (81% and 79%, respectively), while a series of dilations up to 40 mm had a higher success rate of 90% 4.
• Elective additional dilation in patients with insufficient symptom resolution was found to be more effective than performing a predefined series of dilations (86% vs 75% after 12 months) 4.

Considerations for Treatment Choice

• The choice of treatment depends on patient characteristics, such as age, comorbidities, disease stage, and prior treatments, as well as patient preference and locally available expertise 6.
• Treatment of patients who fail or relapse after initial therapy is challenging, and the success rate of pneumatic dilation or myotomy in this group is lower compared to previously untreated patients 6.
• Achalasia subtypes, as defined by high-resolution esophageal pressure topography, may guide treatment choice, but confirmation in prospective outcome studies is needed 6.