Achalasia: new diagnostic tests and treatments

Abstract

Introduction: The past several years have seen exciting breakthroughs leading to a better understanding of the pathogenesis of achalasia, classifying the disease more accurately by high-resolution manometry (HRM), defining better predictors of achalasia treatment success and to the introduction of exciting new treatments.

Areas covered: PubMed and the Cochrane library were searched with no date limits for ‘achalasia’ and appropriate treatment modalities. This review summarizes the current state-of-the-art treatment and technology in achalasia. Emphasis is placed on the role of HRM with detailed assessment of lower esophageal sphincter function and peristalsis making it possible to classify achalasia into three subsets. These subsets seem to predict treatment success: type II achalasia does best with any form of treatment, whereas type III may respond better to surgery. The multicenter, randomized controlled European Achalasia Trial now gives us confidence that either pneumatic dilation or surgical myotomy are equivalent treatments for achalasia over a 2-year period. Finally, the novel endoscopic technique of peroral endoscopic myotomy is a promising new incision-less treatment for achalasia, although troubling acid reflux is a potential drawback.

Expert opinion: These are exciting times in the diagnosis and treatment of achalasia, which will definitely improve patient treatment outcomes. However, achalasia is never cured, re-treatment may be required over time and there is a slight risk of developing esophageal squamous cancer, particularly in those patients with megaesophagus.

Keywords:

• achalasia
• botulinum toxin
• high-resolution manometry
• laparoscopic myotomy
• peroral endoscopic myotomy
• pneumatic dilation
• timed barium esophagus

Declaration of interest

The author has 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.

Notes

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