An overview of the efficacy, safety, and predictors of achalasia treatments

ABSTRACT

Introduction

Achalasia is a rare esophageal motility disorder characterized by abnormal esophageal peristalsis and the inability of the lower esophageal sphincter to relax, resulting in poor esophageal emptying. This can be relieved by endoscopic and surgical treatments; each comes with certain advantages and disadvantages.

Areas covered

This review aims to guide the clinician in clinical decision making on the different treatment options for achalasia regarding the efficacy, safety, and important predictors.

Expert opinion

Botulinum toxin injection is only recommended for a selective group of achalasia patients because of the short term effect. Pneumatic dilation improves achalasia symptoms, but this effect diminishes over time and requiring repeated dilations to maintain clinical effect. Heller myotomy combined with fundoplication and peroral endoscopic myotomy are highly effective on the long term but are more invasive than dilations. Gastro-esophageal reflux complaints are more often encountered after peroral endoscopic myotomy. Patient factors such as age, comorbidities, and type of achalasia must be taken into account when choosing a treatment. The preference of the patient is also of great importance and therefore shared decision making has to play a fundamental role in deciding about treatment.

KEYWORDS:

• Achalasia
• botulinum toxin injection
• pneumatic dilation
• Heller myotomy
• peroral endoscopic myotomy

Article highlights

• Current treatment options for achalasia are endoscopic botulinum toxin injection, pneumatic dilation, laparoscopic Heller myotomy combined with fundoplication and peroral endoscopic myotomy.

• Botulinum toxin injection should only be considered for patients with a short life expectancy, in whom achalasia diagnosis is inconclusive, who are pregnant or not eligible for other treatment options.

• Pneumatic dilation improves symptoms in the majority of the patients, but repeated dilations are often required to maintain effect.

• Effective long-term treatment options are Heller myotomy combined with fundoplication and peroral endoscopic myotomy.

• Peroral endoscopic myotomy is the most recently evolved minimally invasive procedure and increasingly performed worldwide, but more research on prevention, monitoring, and management of gastro-esophageal reflux after this procedure is warranted.

• Shared decision making is essential when discussing different treatment options with the patient.

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Authorship statement

E Wessels, G Masclee and AJ Bredenoord designed the review. AJ Bredenoord supervised the project. E Wessels wrote the manuscript with input from all authors. All authors approved the final manuscript.

Abbreviations

LES: lower esophageal sphincter; LHM: laparoscopic Heller myotomy; PD: pneumatic dilation; POEM: peroral endoscopic myotomy.

Additional information

Funding

This paper was not funded.