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Management of treatment-naïve achalasia: choosing the right therapeutic option

Achalasia is the most common motility disorder of the oesophagus. This condition, characterized by failed relaxation of the lower esophageal sphincter (LES) and absence of peristalsis results in progressive dysphagia to both solids and liquids, leading to malnutrition and poor quality-of-life. There is currently no cure for achalasia with available treatments aimed at symptomatic palliation through reducing LES pressure. The therapeutic landscape for achalasia is dynamic and evolving, with treatment options ranging from medical (nitric oxide donors and calcium channel blockers), endoscopic [botulinum toxin injection, pneumatic balloon dilatation, stenting, and peroral endoscopic myotomy (POEM)], to surgery (Heller’s cardiomyotomy and oesophagectomy). Here, we will review the different therapeutic options for achalasia, and discuss the important factors to consider when tailoring the right treatment modality for patients with treatment-naïve disease.