Achalasia: what is the best treatment?

Achalasia is an infrequent primary motility disorder of the esophagus. Because of uncertain etiology, treatment is only palliative and is directed at decreasing lower esophageal sphincter pressure, improving esophageal emptying and relieving the symptoms of achalasia. Current treatment options include pharmacological, endoscopic and surgical. We undertook a systematic literature review of the management strategies currently available for achalasia.

A Medline, PubMed and Cochrane database search was conducted using reference manager 11. Original articles and reviews published in the English literature on the management of achalasia were reviewed. Emphasis was placed on articles published in the last ten years on randomized controlled trials comparing the various forms of treatment.

Esophageal manometry is the standard diagnostic evaluation for achalasia. Accurate diagnosis can also be made based on clinical findings and barium esophagogram. Medical treatment with nitrates or calcium channel blockers has variable results in alleviating the symptoms of achalasia but long-term results are disappointing because of tolerance and side effects. Intrasphincteric injection of botulinum toxin, pneumatic dilatation and surgical myotomy are variably effective at controlling the symptoms of achalasia but each modality has specific strength and weaknesses which make their choice suitable in a particular group of patients. While pneumatic dilatation is superior to botulinum toxin injection surgical myotomy provides the best long-term control of symptoms in patients with achalasia.

Laparoscopic myotomy should be the initial treatment for most patients with achalasia. Pneumatic dilatation is the most cost-effective alternative but its long-term efficacy is less than that of surgical myotomy. Endoscopic botulinum toxin injection can be considered when other forms of treatment are contraindicated.