Achalasia – advances in treatment

Abstract

Achalasia is a primary esophageal motility disorder, which shows distinct clinical, manometric, radiologic, and pathologic features. Available treatment strategies are pharmacological, endoscopic or surgical. In the past decades preferred treatment has alternated between surgical myotomy (presently Laparoscopic Heller Myotomy [LHM]) and endoscopic balloon dilation (EBD). While surgical myotomy promises superior long-term results and significantly less retreatment, endoscopic balloon dilation is initially far less invasive and yields comparable results after redilation. Peroral Endoscopic Myotomy (POEM) aims to combine the minimal invasive approach through the mouth with the better long-term results after LHM. Initial findings in the literature point to comparable success-rates after POEM and LHM. In the literature complication rates are similar to those obtained after surgery. This new interventional technique should be subject to randomized controlled trials and compared to EBD and LHM.

Keywords::

• achalasia
• endoscopic balloon dilation
• esophagus
• laparoscopic surgery
• motility disorder
• peroral endoscopic myotomy

Financial & competing interests disclosure

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.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Achalasia is an idiopathic primary esophageal motility disorder, which shows distinct clinical, manometric, radiological and pathological features and has an incidence of 2/100,000.

• High-resolution manometry allows for early diagnosis and distinguishes between achalasia subtypes.

• Both endoscopic balloon dilation (EBD) and laparoscopic Heller myotomy (LHM) are currently the preferred treatments for achalasia.

• Meta-analyses show significantly better sustainable and long-term results after LHM compared to EBD.

• Peroral endoscopic myotomy (POEM) is a new technique that aims to combine the minimal invasive access through the mouth with the principles of creating the myotomy as done during LHM.

• POEM reaches sustainable short-term results similar to LHM.

• Complications and the rate of pathological reflux are comparable to LHM and EBD.

• POEM is still in its nascent stage and should at present only be conducted within institutional review board-approved trials for patient safety.

Notes