[Current Treatment of Achalasia 2019]

Treatment of primary idopathic achalasia, the most common of the rare oesophageal motility disorders, is currently changing. The therapeutic priciple of Heller's myotomy is increasingly accepted as standard. In 1913, the German surgeon Ernst Heller described the cardiomyotomy named after him, faciliating excellent symptom control. Meta-analyses of randomised trials (level 1A evidence) demonstrate superiority of laparoscopic Heller myotomy (LHM) over endoscopic pneumatic dilatation (PD). However, some surgeons still advocate the PD strategy, based on the results of the randomised European Multicenter study PD vs. LHM, suggesting that the two procedures achieve similar symptom control after 2 and 5 years. However, an initial series of PDs was excluded from "intention-to-treat" analysis, as the oesophageal perforation rate was unacceptably high (33.3%). To prevent postoperative gastroesophageal reflux (GER) after LHM, addition of a fundoplication is established as standard. The anterior 180° Dor is the wrap type of choice. This standard (LHM + Dor procedure) has now been challenged: Peroral endoscopic myotomy (POEM) was introduced into clinical practice by Harihiro Inoue in 2010, and has now been intensively investigated in specialised centres worldwide. This allows creation of a "Heller myotomy" through the endoscopic route. Complication rates are low, symptom control is excellent and systematic reviews of published series show similar or slightly superior dysphagia control with POEM than with LHM. Advantages of POEM are the possibility to perform a long-myotomy (of the entire length of the oesophagus if necessary) and the relatively free choice of the localisation of the myotomy (anterior/posterior POEM). The disadvantage is the increased postoperative GER after POEM; however this sequel is managed with PPI in most cases, or a laparoscopic fundoplication, if necessary. Preliminary results of two prospectively randomised trials show the superiority of POEM over PD, as well as the non-inferiority to LHM, but increased postoperative GER. The author uses a tailored approach, with preference of POEM for achalasia type III and type II with chest pain and LHM + Dor for sigmoid achalasia and other associated morphological changes. The procedure in all other patients is depends on individual personal preferences.