From the Guidelines
Achalasia cardia should be treated with Peroral Endoscopic Myotomy (POEM) as the preferred treatment option, especially for type III achalasia, due to its excellent outcomes and minimal invasiveness, as supported by recent studies 1.
Diagnosis and Evaluation
A comprehensive diagnostic workup is essential for patients with achalasia cardia, including clinical history, upper endoscopy, timed barium esophagram, and high-resolution manometry, with endoscopic functional luminal impedance planimetry as a useful adjunct test in equivocal cases 1.
Treatment Options
Treatment options for achalasia cardia include medications, endoscopic procedures, and surgery, with POEM being a newer and effective approach, offering excellent outcomes and minimal invasiveness 1.
Management After Failed Initial Myotomy
For patients with failed initial myotomy, POEM may be superior to pneumatic dilation, but the decision between treatment modalities should be based on shared decision making, taking into account risk of post-procedural reflux, need for repeat interventions, patient preferences, and local expertise 1.
Key Considerations
- POEM should be performed by experienced physicians in high-volume centers 1.
- Patients should be considered high risk to develop reflux esophagitis and advised of management considerations before undergoing POEM 1.
- Long-term postprocedure surveillance is encouraged to monitor for progression of disease and complications of gastroesophageal reflux disease 1.
From the Research
Definition and Symptoms of Achalasia
- Achalasia is a primary esophageal motor disorder of unknown cause that produces complaints of dysphagia, regurgitation, and chest pain 2.
- The cardinal symptoms of achalasia are dysphagia, food regurgitation, and weight loss 3.
Treatment Options for Achalasia
- The current treatments for achalasia involve the reduction of lower esophageal sphincter (LES) pressure, resulting in improved esophageal emptying 2.
- Treatment options include pneumatic dilation (PD), laparoscopic Heller myotomy with partial fundoplication, and peroral endoscopic myotomy (POEM) 3, 4, 5.
- Calcium channel blockers and nitrates are used only in patients who are not candidates for pneumatic dilation or surgery, and in patients who do not respond to botulinum toxin injections 2.
Efficacy of Treatment Options
- Pneumatic dilation and laparoscopic Heller myotomy are equally effective in treating achalasia, with symptom improvement in up to 90% of patients 2, 3.
- A study found that 73% of patients in the PD group and 84% of patients in the surgery group had good results after 3 months of treatment 3.
- Another study found that POEM was associated with higher clinical success and shorter operative time, length of stay, and postoperative pain compared to LHM 5.
Variables Related to Good Response to Treatment
- Variables related to a good response to PD include a 50% drop in lower esophageal sphincter pressure (LESP) or a LESP <10 mmHg after treatment 3.
- Patients over 40 years old with LESP ≤32 mmHg before treatment and a drop in LESP >50% after treatment significantly achieved better responses after surgical treatment compared to PD 3.