Achalasia: treatment options revisited

The aim of all current forms of treatment of achalasia is to enable the patient to eat without disabling symptoms such as dysphagia, regurgitation, coughing or choking. Historically, this has been accomplished by mechanical disruption of the lower esophageal sphincter fibres, either by means of pneumatic dilation (PD) or by open surgical myotomy. The addition of laparoscopic myotomy and botulinum toxin (BTX) injection to the therapeutic armamentarium has triggered a recent series of reviews to determine the optimal therapeutic approach. Both PD and BTX have excellent short term (less than three months) efficacy in the majority of patients. New data have been published that suggest that PD and BTX (with repeat injections) can potentially obtain long term efficacy. PD is still considered the first-line treatment by most physicians; its main disadvantage is risk of perforation. BTX injection is evolving as an excellent, safe option for patients who are considered high risk for more invasive procedures. Laparoscopic myotomy with combined antireflux surgery is an increasingly attractive option in younger patients with achalasia, but long term follow-up studies are required to establish its efficacy and the potential for reflux-related sequelae.