Treatment of Achalasia
For type I and II achalasia, pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) are equally effective first-line options, but for type III (spastic) achalasia, per-oral endoscopic myotomy (POEM) is definitively the preferred treatment. 1, 2
Diagnostic Workup Required Before Treatment
Before any intervention, confirm the diagnosis and subtype with:
- Upper endoscopy with careful retroflexed examination to exclude pseudoachalasia from occult malignancy, identify frothy retained secretions, and assess the puckered gastroesophageal junction 1, 2
- Timed barium esophagram to confirm outflow obstruction, document structural changes, and assess severity with a 13-mm barium tablet 1, 2
- High-resolution manometry (HRM) as the gold standard to confirm diagnosis and define achalasia subtype (I, II, or III) according to Chicago Classification—this is crucial as it directly impacts treatment selection 1, 2, 3
Treatment Algorithm by Achalasia Subtype
Type I and II Achalasia
Choose between three equally effective options based on shared decision-making:
Pneumatic Dilation (PD):
- Start with 30 mm balloon, then progress to 35 mm at 2-28 days, with cautious consideration of 40 mm if needed 1
- Achieves 90% success at 1 year, 86% at 2 years, and long-term success of 97% at 5 years and 93% at 10 years 1, 2
- Lower upfront morbidity and cost compared to surgery, but anticipate repeat dilations over years 1, 2
- Perforation risk 2-4% (mostly during first dilation), mortality <1% 1, 4
- Initiate PPI therapy post-procedure as 10-40% develop symptomatic GERD or ulcerative esophagitis 1, 2
Laparoscopic Heller Myotomy (LHM) with Partial Fundoplication:
- Provides 90% symptom relief with lower reflux rates when combined with fundoplication (8.8% vs 31.5% without) 5
- Requires 2 days hospitalization, 1-2 weeks return to work 4
- Higher upfront cost but fewer repeat procedures needed 2
- Post-operative GERD risk significantly reduced with fundoplication (OR 6.3 for GERD without fundoplication) 5
POEM (if expertise available):
- Should be considered comparable to LHM for type I and II achalasia 1
- Highly efficacious in RCTs versus PD with 92-97% symptom improvement 1
- Requires 20-40 procedures to achieve competence—only perform at high-volume centers 1, 2
- Highest reflux risk (up to 58% on pH-metry)—patients must accept potential indefinite PPI therapy and surveillance endoscopy 1, 2
Type III (Spastic) Achalasia
POEM is the definitive preferred treatment:
- Allows unlimited proximal extension of myotomy tailored to the spastic segment imaged on HRM or thickened segment on EUS 1
- Calibrate myotomy length to the proximal extent of esophageal body spasm—this is critical for optimal outcomes and cannot be achieved laparoscopically 1, 2
- Type III has the poorest response to all other treatments 3
Critical Post-Treatment Management
All patients require:
- Strong consideration for PPI therapy, particularly after POEM which has the highest reflux risk 1, 2
- Post-POEM patients should be counseled about potential indefinite PPI therapy and surveillance endoscopy before undergoing the procedure 1
- Monitor for perforation signs: pain, breathlessness, fever, or tachycardia 2
- Water-soluble contrast swallow after dilation may screen for perforation but is not essential 1
Special Considerations and Pitfalls
End-stage disease (severe dilation, sigmoidization):
- Most published trials excluded these cases—insufficient data on POEM efficacy 1
- Esophagectomy should be considered for stage 4 achalasia with severe dilation and sigmoid deformation 6
EGJ outflow obstruction (not true achalasia):
- Many cases resolve spontaneously—image the EGJ with EUS or CT to rule out obstruction 1
- POEM should only be considered case-by-case after less invasive approaches exhausted 1
Anticoagulation management:
- Low-risk patients: discontinue anticoagulants with preprocedure PT 2
- High-risk patients: transition to IV heparin, stop 4-6 hours before, resume 4-6 hours after 2
Botulinum toxin injection: