Modern management of achalasia

Abstract

The goals in the treatment of achalasia are threefold: 1) relieving the symptoms, particularly dysphagia and bland regurgitation; 2) improving esophageal emptying by disrupting the poorly relaxing lower esophageal sphincter (LES); and 3) preventing the development of megaesophagus. Although achalasia cannot be permanently cured, excellent palliation is available in over 90% of patients, especially those with pneumatic dilation and laparoscopic Heller myotomy. The efficacy for short- and long-term therapy seems to be similar when performed by experts. Pneumatic dilation done as an outpatient surgery disrupts the LES muscle from within by using balloons of progressively larger diameter (3.0, 3.5, and 4.0 cm). Repeat dilations may be required; secondary severe gastroesophageal reflux disease (GERD) is rare, but approximately 2% of patients will have an esophageal perforation. A surgical Heller myotomy is now being done laparoscopically through the abdomen that cuts the LES and extends the myotomy 2 to 3 cm onto the stomach. Usually 2 days of hospitalization is required, and patients can normally return to work in 1 to 2 weeks. Severe GERD with esophagitis and peptic stricture is a common complication; therefore, most surgeons combine the myotomy with an incomplete fundoplication. Medical therapy is much less effective than these invasive procedures. Smooth muscle relaxants (nitrates and calcium channel blockers) taken immediately before meals improve dysphagia, but side effects and drug tolerance are common. The injection of botulinum toxin (100 to 200 units) endoscopically into the LES gives short-term relief of symptoms and improves esophageal emptying. This treatment is most effective in the elderly, as symptom relief can last up to 1 to 2 years with a single injection. Several studies suggest the most cost-effective management of achalasia is initial treatment with pneumatic dilation.

Association Between Gastroesophageal Reflux Disease After Pneumatic Balloon Dilatation and Clinical Course in Patients With Achalasia

“…2,16 As such, each treatment aims to reduce the pressure gradient across the LES. 1,[8][9][10]17 Both PD and surgical myotomy are well-recognized modalities to disrupt LES for treatment in achalasia with comparable effectiveness. 18,19 Recently developed POEM is also effective in lowering LES pressure, but requires longer follow-up and needs to be compared with PD or surgical myotomy.…”

“…[4][5][6][7] All these treatment options aimed at reducing the elevated pressure of LES. 1,[8][9][10] However, the LES hypertonicity returns over time and repeated interventions are needed. Gastroesophageal reflux disease (GERD) may occur due to disrupted LES after PD as well as after surgery and POEM.…”

Correlation of esophageal clearance and dysphagia symptom assessment after treatment for achalasia

“…[1][2][3][4] However, symptomatic relapse after treatment of achalasia occurs in 32% of patients after balloon dilation and in 10% of patients after Heller myotomy within the first year. 5,6 In young patients the recurrence rate after 10 years may rise to as high as 72%.…”

Association Between Gastroesophageal Reflux Disease After Pneumatic Balloon Dilatation and Clinical Course in Patients With Achalasia

“…The incidence of GERD after PD has been reported to range from 4% to 35%. 9,11,12,24,26 This wide range of incidence seems to stem from various different definitions used to make a diagnosis of GERD. In a prospective study by Novais and Lemme, 24 they reported the incidence of gastroesophageal reflux (GER) of 31% using 24-hour pH tracing analysis to distinguish true GER patterns from other findings due to esophageal food fermentations.…”