What are the recommended treatment options for achalasia?

Treatment of Achalasia

For types I and II achalasia, choose between pneumatic dilation (PD), laparoscopic Heller myotomy with fundoplication (LHM), or peroral endoscopic myotomy (POEM) based on local expertise and patient factors; for type III achalasia, POEM is the preferred treatment. 1

Diagnostic Workup Before Treatment

Before initiating therapy, comprehensive evaluation is mandatory:

• Esophagogastroduodenoscopy (EGD) with careful retroflexed examination to exclude pseudoachalasia and assess for retained secretions and puckered gastroesophageal junction 1
• High-resolution manometry (HRM) remains the gold standard for diagnosis and is crucial for determining Chicago Classification subtype (I, II, or III), which directly guides treatment selection 1
• Timed barium esophagram to confirm outflow obstruction, assess structural changes, and monitor disease severity 1
• Functional luminal impedance planimetry (FLIP) as a useful adjunct that may confirm diagnosis when HRM is inconclusive, particularly by demonstrating low distensibility index at the esophagogastric junction 1

Treatment Algorithm by Achalasia Subtype

Type I and Type II Achalasia

All three definitive therapies (PD, LHM, POEM) are effective options:

• Pneumatic dilation has demonstrated excellent efficacy in randomized controlled trials with less morbidity and lower cost compared to surgical options, though repeat dilations should be anticipated 1, 2
• Laparoscopic Heller myotomy with partial fundoplication has proven highly efficacious in RCTs with long-term outcome data 1
• POEM has been found superior to PD and noninferior to LHM in separate multicenter RCTs 1
• The 2025 SAGES guideline provides a conditional recommendation for POEM over PD, and supports either POEM with appropriate PPI use or HM with fundoplication as equivalent options 3

Type III Achalasia (Spastic Subtype)

POEM should be considered the preferred treatment:

• Type III achalasia is characterized by spastic body contractions capable of luminal obliteration and requires myotomy tailored to the proximal extent of esophageal body spasm 1
• POEM provides the critical advantage of unlimited proximal extension of myotomy, which cannot be achieved laparoscopically 1, 2
• The 2025 SAGES guideline specifically favors POEM over HM with fundoplication for subtype III 3
• Studies consistently demonstrate that symptoms associated with type III achalasia are best palliated with extended myotomy rather than myotomy confined to the lower esophageal sphincter alone 1

Critical Technical Considerations

POEM-Specific Factors

• Expertise requirement: POEM should only be performed by experienced physicians in high-volume centers, as an estimated 20-40 procedures are needed to achieve competence 2
• Reflux risk: Post-POEM patients are at high risk for developing reflux esophagitis and require counseling about potential indefinite proton pump inhibitor therapy and/or surveillance endoscopy before undergoing the procedure 2
• Adverse events: Adverse event rates range from 0-8% in large uncontrolled trials, with gastroesophageal reflux being the most common complication (up to 58% when systematically studied with pH-metry) 2

Special Populations

• End-stage achalasia with sigmoid deformation: One report suggests a doubling of adverse events with POEM in patients with sigmoid esophagus 2
• Esophagogastric junction outflow obstruction (EGJOO) alone: Patients with EGJOO without clear achalasia should undergo comprehensive evaluation with symptom correlation; POEM should only be considered case-by-case after less invasive approaches are exhausted 1

Common Pitfalls to Avoid

• Do not perform permanent interventions based on EGJOO manometric findings alone without comprehensive clinical correlation, as EGJOO is associated with multiple alternative causes including obesity 1
• Do not overlook achalasia subtype determination before treatment selection, as this directly impacts outcomes—type III requires extended myotomy while types I and II can be managed with any of the three definitive therapies 1, 2
• Do not fail to counsel POEM patients about reflux management before the procedure, as this is a predictable complication requiring long-term management 2
• Do not attempt POEM without adequate training and volume, as competence requires 20-40 procedures 2

Post-Treatment Monitoring

• Esophagram to rule out leak should be performed based on clinical suspicion after any myotomy procedure 1
• Same-day discharge is feasible for select POEM patients 1
• Long-term PPI therapy and surveillance endoscopy should be discussed with all POEM patients given the high reflux risk 2