Update on the endoscopic treatments for achalasia

Abstract

Achalasia is the most common primary motility disorder of the esophagus and presents as dysphagia to solids and liquids. It is characterized by impaired deglutitive relaxation of the lower esophageal sphincter. High-resolution manometry allows for definitive diagnosis and classification of achalasia, with type II being the most responsive to therapy. Since no cure for achalasia exists, early diagnosis and treatment of the disease is critical to prevent end-stage disease. The central tenant of diagnosis is to first rule out mechanical obstruction due to stricture or malignancy, which is often accomplished by endoscopic and fluoroscopic examination. Therapeutic options include pneumatic dilation (PD), surgical myotomy, and endoscopic injection of botulinum toxin injection. Heller myotomy and PD are more efficacious than pharmacologic therapies and should be considered first-line treatment options. Per oral endoscopic myotomy (POEM) is a minimally-invasive endoscopic therapy that might be as effective as surgical myotomy when performed by a trained and experienced endoscopist, although long-term data are lacking. Overall, therapy should be individualized to each patient’s clinical situation and based upon his or her risk tolerance, operative candidacy, and life expectancy. In instances of therapeutic failure or symptom recurrence re-treatment is possible and can include PD or POEM of the wall opposite the site of prior myotomy. Patients undergoing therapy for achalasia require counseling, as the goal of therapy is to improve swallowing and prevent late manifestations of the disease rather than to restore normal swallowing, which is unfortunately impossible.

Keywords: Per oral endoscopic myotomy; Dilation; Achalasia; Treatment; Endoscopy; Myotomy; Per oral

Core tip: Achalasia can be classified into three subtypes based on high-resolution manometry, with type 2 being the most responsive to therapy. Since no cure for achalasia exists, early diagnosis and treatment of the disease are critical. Pre-treatment counseling is paramount, as the goal of therapy is to improve swallowing and prevent late manifestations of the disease, rather than to restore normal swallowing and function. Pneumatic dilation and surgical or endoscopic myotomy are efficacious and reasonable first-line treatment options in appropriate candidates. In instances of therapeutic failure or symptom recurrence, different treatment modalities might need to be applied.