Management strategies for achalasia

M. F. Vela

Research output: Contribution to journalReview article

14 Scopus citations

Abstract

Treatment options for achalasia include oral pharmacologic therapy, endoscopic injection of botulinum toxin, pneumatic dilation, and myotomy (conventionally by laparoscopy, but more recently by an endoscopic approach). Oral pharmacologic agents have fallen out of use because of insufficient efficacy and frequent side effects. Endoscopic injection of botulinum toxin is safe and has good short-term effectiveness, but as the effect invariably wears off after a few months, this treatment is reserved for patients who are not candidates for more definitive treatments. Pneumatic dilation and surgical myotomy are currently considered the most effective treatments, with similar effectiveness in randomized controlled trials with follow-up of up to 2 years. The risk/benefit ratio and choice of therapy depend on patient characteristics (age, comorbidities, disease stage, prior treatments), patient's preference, and locally available expertise. Treatment of patients who fail or relapse after initial therapy is challenging and the success rate of pneumatic dilation or myotomy in this group is lower compared with previously untreated patients. The recently developed peroral endoscopic approach to myotomy has achieved excellent results in early uncontrolled studies, but high-quality randomized trials are needed to ensure widespread adoption is reasonable. Finally, retrospective data suggest that achalasia subtypes as defined by high-resolution esophageal pressure topography may guide treatment choice, but confirmation in prospective outcome studies is awaited. Proposed algorithm for the management of achalasia. Patients without prior treatment who are not surgical candidates because of age or comorbidities can be treated by botulinum toxin injection (Botox), with repeat injections as needed. Those who are good surgical candidates can have initial treatment with either graded pneumatic dilation or laparoscopic Heller myotomy. Some studies suggest that young males (i.e., less than 40 years old) may achieve higher success rate with myotomy. Patients who fail initial therapy or relapse following initial success should undergo repeat treatment at a center with achalasia expertise. These patients can be treated with either pneumatic dilation or myotomy; those with end-stage disease may need esophagectomy. Patients who previously failed myotomy or dilation and are no longer good surgical candidates can be treated with botox.

Original languageEnglish (US)
Pages (from-to)1215-1221
Number of pages7
JournalNeurogastroenterology and Motility
Volume26
Issue number9
DOIs
StatePublished - Sep 2014

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Keywords

  • Achalasia
  • Botulinum toxin injection
  • Heller myotomy
  • Peroral endoscopic myotomy
  • Pneumatic dilation

ASJC Scopus subject areas

  • Physiology
  • Endocrine and Autonomic Systems
  • Gastroenterology

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