Current trends in the management of achalasia

Despite the recent advances in the understanding of the pathophysiology of achalasia, aetiology remains obscure and this primary oesophageal motor disorder is still considered "idiopathic" in nature. As a consequence, the therapeutic approach remains palliative. Since there is little or no chance of improving the motor abnormalities of the oesophageal body, treatment of achalasia is aimed at symptomatic relief of functional lower oesophageal sphincter obstruction. Pharmacologic treatment induces only a limited and brief improvement. It may be used to treat early cases of achalasia without significant oesophageal dilatation and to manage patients exhibiting some but not all the characteristics of achalasia (e.g. transitional forms). In any event, drug therapy should be seen as a short-term measure and be considered as an alternative only in patients unfit to undergo pneumatic dilatation or surgery. Pneumatic dilatation and surgical myotomy (now increasingly carried out through a minimally invasive approach) remain, therefore, the two main approaches which guarantee long-lasting symptomatic relief. Unfortunately, both pneumatic dilatation and Heller cardiomyotomy are only palliative as neither reliably reverses oesophageal aperistalsis not corrects the incomplete postdeglutition relaxation of the lower oesophageal sphincter. They do, however, improve symptoms by lowering lower oesophageal sphincter pressure thus enhancing oesophageal emptying by gravity. Recently a third approach, consisting in perendoscopic injection of botulinum toxin into the lower oesophageal sphincter is gaining acceptance. Indeed, more endoscopists are finding this kind of treatment attractive because it does not carry the risk of perforation that can occur with pneumatic dilatation. However, since symptomatic improvement with botulinum toxin only lasts a few months, either repeated injections are required or the patient must be switched to other therapy. There may be, however, subsets of patients for whom BoTox injection is the preferred approach. They probably include elderly patients or patients with multiple medical problems who are poor candidates for more invasive procedures as well as those unwilling to have either surgery or pneumatic dilatation. Future approaches to achalasia may markedly change from the suggested algorithm depending on the long-term efficacy and safety as well as cost analysis of BoTox injection and of minimally invasive surgery.