What is the diagnosis and treatment for achalasia of the cardia (esophageal achalasia)?

From the Guidelines

Achalasia cardia should be treated with peroral endoscopic myotomy (POEM) as the preferred treatment for type III achalasia, and as a treatment option comparable to laparoscopic Heller myotomy for other achalasia subtypes, based on shared decision making and patient-specific factors. The treatment of achalasia cardia involves various options, including endoscopic and surgical approaches. Pneumatic dilation is often considered, involving balloon dilation of the lower esophageal sphincter to disrupt the muscle fibers. However, POEM has emerged as a newer, minimally invasive endoscopic procedure that cuts the inner circular muscle layer of the esophagus, offering advantages such as lack of abdominal incisions, more rapid recovery, and the option of avoiding general anesthesia with airway intubation 1.

Key Considerations

• POEM should be performed by experienced physicians in high-volume centers, as an estimated 20–40 procedures are needed to achieve competence 1.
• The choice of treatment depends on patient factors, including age, comorbidities, and surgical risk, as well as the severity of esophageal dilation and sigmoid deformation, the presence of hiatus hernia, and the presence of a significant epiphrenic diverticulum 1.
• Patients considering POEM should be advised beforehand that they might require lifelong proton pump inhibitor therapy for symptomatic reflux or erosive esophagitis 1.
• The length of myotomy can be gauged by high-resolution manometry (HRM), esophageal wall thickening on endoscopic ultrasound, or intraoperative functional luminal imaging probe, and can be extended if desired, potentially involving the entire smooth muscle esophagus 1.

Treatment Outcomes

• POEM has been found to be superior to pneumatic dilation and noninferior to laparoscopic Heller myotomy in separate multi-center randomized controlled trials, with a reported success rate of >90% in multiple uncontrolled studies 1.
• The procedure is effective in reducing symptoms of dysphagia, regurgitation, chest pain, and weight loss, and can be repeated if necessary to maintain symptom response 1.
• However, POEM is associated with a high rate of gastroesophageal reflux, and patients should be advised of the potential need for lifelong proton pump inhibitor therapy 1.

From the Research

Definition and Diagnosis of Achalasia Cardia

• Achalasia cardia is a motility disorder of the esophagus characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis in the smooth muscle esophageal body 2.
• The diagnosis is suggested by barium swallow and endoscopy, and confirmed by manometry, which shows a failure of the lower esophageal sphincter to relax upon swallowing 3.

Treatment Options for Achalasia Cardia

• There are several treatment options available for achalasia cardia, including pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM) 2, 3.
• Each treatment has its own advantages and disadvantages, and the choice of treatment depends on patient preference, achalasia subtype, and local expertise 2.
• Pneumatic dilation is a less invasive procedure that can be performed on an outpatient basis, while laparoscopic Heller myotomy is a more invasive procedure that requires a hospital stay 4.
• Peroral endoscopic myotomy (POEM) is a relatively new procedure that has been shown to be effective in treating achalasia cardia, with the advantage of being less invasive than Heller's myotomy and allowing for adjustment of the length and orientation of esophageal myotomy according to the type of achalasia 5.

Efficacy and Safety of Treatment Options

• Studies have shown that pneumatic dilation and laparoscopic Heller myotomy are equally effective in treating achalasia cardia, with similar success rates and complication rates 6, 4.
• Peroral endoscopic myotomy (POEM) has also been shown to be effective and safe in treating achalasia cardia, with high success rates and low complication rates 5, 2.
• The choice of treatment should be based on individual patient factors, including age, achalasia subtype, and patient preference, as well as the availability and expertise of local healthcare providers 6, 2.