Management of achalasia in 2020: Per-oral endoscopic myotomy, Heller’s or dilatation?

Abstract

Achalasia cardia is a rare esophageal motility disorder. Although a primary neurological disorder, the treatment modalities of achalasia are primarily endoscopic or surgical. Pneumatic dilatation (PD) or laparoscopic Heller's myotomy (LHM) have been the mainstay of achalasia management for several decades. With the introduction of third space endoscopy, the endoscopic management of achalasia has revolutionized. Randomized studies have concluded the superiority of per-oral endoscopic myotomy (POEM) over PD. In addition, the short-term outcomes of POEM are similar to LHM. POEM is a relatively new technique and long-term data is eagerly awaited. The main concern after POEM is a high incidence of gastroesophageal reflux disease (GERD) which is found in about half of the patients undergoing this procedure. GERD is higher after POEM when compared to PD and LHM with fundoplication. The management of achalasia should be individualized and based on factors like patient characteristics (age, sex, comorbidities), subtyping on high resolution manometry, patient/doctor preference, and surgical risk of the patient.

Achalasia Cardia: A Comprehensive Review

“…POEM with extended myotomy is recommended for Type III achalasia (Figure 2). 3,70 Upon failure of therapy, either of the three modalities can be used. Oesophagectomy should be reserved for patients with longstanding disease who are fit for surgery and have had repeated failure to various therapies.…”