Advances and caveats in modern achalasia management

Abstract

Achalasia is a rare esophageal motility disorder characterized by the incomplete relaxation of the lower esophageal sphincter (LES) and impaired peristaltic activity. The advent of high-resolution manometry (HRM) and the rapidly evolving role of therapeutic endoscopy have revolutionized the approach to the diagnosis and management of achalasia patients in the last decade. With advances in HRM technology and methodology, fluoroscopy and EndoFlip, achalasia can be differentiated into therapeutically meaningful phenotypes with a high degree of accuracy. Further, the newest treatment option, per-oral endoscopic myotomy (POEM), has become a staple therapy following the last 10 years of experience, and recent randomized trials appear to show no difference between POEM, graded pneumatic dilatation and surgical Heller myotomy in terms of short- and long-term efficacy or complication rate. On the other hand, how treatment outcomes are measured as well as the risk of reflux following therapy remain areas of contention. This review aims to summarize the recent advancements in achalasia testing and therapy, describes the recent randomized clinical trials as well as their potential setbacks, and touches on the future of personalizing achalasia treatment.

Malaysian joint societies' consensus recommendations on diagnosis and management of disorders of esophagogastric junction outflow

“…(6) What are the surgical treatment options? (7) What is treatment failure or relapse, and what are the treatment options after failing initial therapy? And (8) what and how to manage complications post-treatment?…”

“…Traditional procedures, including pneumatic dilatation (PD) and Heller myotomy (HM), and novel procedures, such as peroral endoscopic myotomy (POEM) treatment, have been shown to be effective, with each procedure having its own advantages and disadvantages 7 . However, the equipment and expertise are not widely available, especially in resource‐limited countries, including Malaysia.…”

Outcome of Per Oral Endoscopic Myotomy (Poem) in Sigmoid Achalasia at a Median Follow Up of 17 Months

“…Achalasia cardia (AC) is a uncommon esophageal motility disorder characterized by absent peristaltic activity in the esophageal body with incomplete relaxation of the sphincter mechanism of the lower esophagus (1) . Traditional therapies include pneumatic dilatation (PD) and laparoscopic hellers myotomy (LHM), however, both have their inherent limitations (2,3) .…”

Advances on Neurogastroenterology and Motility Disorders: Pathophysiology, Diagnostics and Management

“…EndoFLIP may further help to measure secondary peristalsis in patients with esophageal symptoms, enabling the diagnosis of achalasia or other major esophageal motility disorders. Advances in fluoroscopy methodology, such as the timed barium swallow protocol and timed barium surface area measurement, have further added to the diagnostic arsenal when assessing a patient with esophageal symptoms [ 13 , 14 ].…”